SILENT EPIDEMIC Vol. 19 No. 4 | Summer 2017

a RANZCOG publication The College

5 From the President Vol. 19 No. 4 Summer 2017 Steve Robson O&G Magazine Advisory Group Dr Gillian Gibson Fellows Rep, New Zealand 9 From the CEO Dr Bernadette White Fellows Rep, VIC Dr Will Milford Young Fellows Rep, QLD Alana Killen Dr John Schibeci Diplomates Rep, NSW Dr Brett Daniels Fellows Rep, TAS Dr Fiona Langdon Trainees Rep, WA Silent epidemic O&G Magazine Editors 11 Editorial Sarah Ortenzio Angela Jay Lisa Westhaven 12 Tackling family violence: a system-wide approach Layout and Production Editor Sarah Ortenzio Jane Hooker

Designers 14 Family violence in New Zealand Shay Colley Whitehart Linda Haultain

Editorial Communications 16 Violence against women in Australia O&G Magazine Advisory Group Brett Daniels RANZCOG 254–260 Albert Street East Melbourne, VIC 3002 Australia 18 Insights into the migrant and refugee communities (t) +61 3 9417 1699 Carol Kaplanian (e) [email protected] 20 Routine enquiry for DFV in healthcare settings Advertising Sales Bill Minnis Kathleen Baird Minnis Journals (t) +61 3 9836 2808 23 The case against routine screening for DFV (e) [email protected] Deborah Walsh Jonathon Tremain Tremain Media 26 Clinical assessment of sexual assault (t) +61 2 9988 4689 (e) [email protected] Miranda Howlett

Printer 29 Does FGM/C still matter in our clinical practice? Southern Colour (t) +61 3 8796 7000 Wemi Oyekanmi, Natalija Nesvadba and Bernadette White

O&G Magazine authorised by Ms Alana Killen 31 Assisting women seeking refuge © 2017 The Royal Australian and New Zealand Margaret Bell and Alexandra Brown College of Obstetricians and Gynaecologists (RANZCOG). All rights reserved. No part of this publication may be reproduced or copied in any form or by any means without the written 33 Misogyny in reproductive health permission of the publisher. The submission of Helen Paterson articles, news items and letters is encouraged.

For further information about contributing to O&G 35 Sexual harassment in the workplace Magazine visit: ogmagazine.org.au Gary Pinchen and Alyssandria Lim

The statements and opinions expressed in articles, letters and advertisements in O&G Magazine are those of the authors and, unless specifically stated, are not necessarily the views of RANZCOG.

Although all advertising material is expected to conform to ethical and legal standards, acceptance does not imply endorsement by the College.

ISSN 1442-5319

Cover art ©RANZCOG Women’s health RANZCOG Regional Committees New Zealand 37 Q&A: Is NovaSure endometrial ablation the safest Dr Ian Page Chair surgical treatment for heavy menstrual bleeding? Jane Cumming Manager Prathima Chowdary, L Ellet and P Maher Level 6 Featherson Tower 23 Waring Taylor Street/ PO Box 10611 Wellington 6011, New Zealand 40 Case report – Ogilvie’s syndrome with caecal (t) +64 4 472 4608 (f) +64 4 472 4609 perforation post caesarean section (e) [email protected] Dennis Gong, Victor Chin, Josephine Woodman, B Bikshandi, R Wescombe and R Pegram Australian Capital Territory Dr John Hehir Chair Lee Dawson Executive Officer 42 Case report – Extraovarian endometriosis- (e) [email protected] associated neoplasms New South Wales Marilyn Boo and Nasser Shehata A/Prof Gregory Jenkins Chair Lee Dawson Executive Officer 46 The leg-up Suite 2, Ground Floor, 69 Christie Street Nicole Woodrow and Vinay S Rane St Leonards, NSW 2065 (t) +61 2 9436 1688 (f) +61 2 9436 4166 (e) [email protected] 48 From the editor’s desk Queensland Caroline de Costa Dr Carol Breeze Chair Karen Young Executive Officer 50 Journal Club Unit 22, Level 3, 17 Bowen Bridge Road HERSTON, Qld 4006 Brett Daniels (t) +61 7 3252 3073 (e) [email protected] 51 How we talk about drinking alcohol during pregnancy South Australia/Northern Territory Dr Amita Singla Chair Susan Hickson Tania Back Executive Officer Level 1, 213 Greenhill Road Eastwood 5063 The College (t) +61 8 8274 3735 (f) +61 8 8271 5886 (e) [email protected] 52 Letters to the Editor Tasmania 54 Winners of 2017 Liam & Frankie Davison Award Dr Lindsay Edwards Chair Mathew Davies Executive Officer Delwyn Lawson College House 254–260 Albert Street 56 New FGM module East Melbourne, Vic 3002 (t) +61 3 9412 2998 Nesrin Varol and Angela Dawson (e) [email protected]

Victoria 58 Just another day in Jahun paradise? Dr Alison Fung Chair Jared Watts Mathew Davies Executive Officer College House 254–260 Albert Street 60 Catalysts for change East Melbourne, Vic 3002 (t) +61 3 9412 2998 Pushpa Nusair (e) [email protected]

Western Australia 63 RANZCOG Women’s Health Foundation: Dr Robyn Leake Chair 2018 scholarships and fellowships Carly Moorfield Executive Officer 44 Kings Park Road PO Box 1645, West Perth, WA 6872 64 Notice of deceased Fellows (t) +61 8 9322 1051 (f) +61 8 6263 4432 (e) [email protected]

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists College House 254–260 Albert Street East Melbourne, Vic 3002 (t) +61 3 9417 1699 (f) +61 3 9417 0672 (e) [email protected] (w) www.ranzcog.edu.au

Vol. 19 No. 4 Summer 2017 | 3 Violence against women This issue of O&G Magazine is devoted to the critically important From the issue of prevention of violence against women. It is easy for us to underestimate the enormous toll that violence against women takes in our communities. As we have become better at managing the deadly complications of pregnancy – bleeding, infection, President hypertension, and thrombosis – violence against women remains a tremendous and deadly challenge we must face.

Many of you will remember the shocking attack against RANZCOG Trainee, Dr Angela Jay. The violence against Dr Jay made front-page news around the country and internationally. Dr Jay has come through the highly public and near-fatal attack with dignity and resilience, and has demonstrated an incredible determination to harness the emotion and publicity to benefit women everywhere. She has joined me in putting prevention of violence against women at the forefront of College advocacy. As the new MBS maternity item numbers support screening for violence, it has become a personal mission of mine – supported with incredible energy and focus by Dr Jay. Prof Steve Robson President

Summer is now with us, and I hope all of you will have the opportunity for some rest and relaxation over the festive season. I spent some time with the senior leadership of one of the large medical indemnity organisations recently and one of their messages was clear: rest and time away from clinical work are good for our patient care. Significant to the profile of a number of practitioners who are involved in medico-legal claims is overwork and lack of down time. So even the workaholics among us must take some time off to clear our heads, rest our bodies, and make sure we have the physical and mental resources to provide the level of care women Video regarding changes to MBS obstetric item numbers available on deserve. So… take a break! the College website. Enmeshed… Since my last column, I have had the ‘pleasure’ of appearing before the Senate Inquiry into transvaginal mesh. The College had made a detailed submission to the Inquiry, an effort driven by Chair of the Urogynaecology Subspecialty Committee, Dr Peta Higgs and her team. I am extremely grateful for her wisdom, experience and hard work in drawing together a sometimes diverse body of opinion in writing the submission.

Along with Urogynaecology Subspecialty Committee Deputy Chair A/Prof Chris Benness, and College CEO Ms Alana Killen, I appeared before the inquiry at Parliament House in Canberra. The appearance was very intimidating, as we knew that an enormous amount of unwarranted criticism had been levelled at the College and our handling of the issue. We spent a great deal of time preparing for the appearance, and I need to acknowledge Dr Agnes Wilson and Ms Jacqueline Maloney for the hard work they did behind the scenes. The report from the Senate Inquiry is due for release in November, and might well be out by the time you read this.

The College President and CEO, and A/Prof Christopher Benness appeared before the Senate Inquiry in September.

Private practice in Australia Many Fellows and GP obstetricians have a private practice component to their work, and in Australia private care is fundamental to both obstetrics and gynaecology practice. Almost one third of births occur in private hospitals, and the majority of gynaecological operations and procedures take place in private settings. In Australia, a healthy balance between the public and private systems seems fundamental to the provision of good care for women.

One of the key drivers of the uptake of private health insurance with hospital cover is maternity. Young couples commonly take out private cover to start a family. The experience of private maternity care affects whether they continue with lifetime private health insurance, and even friends and family visiting them after birth get some sense of private care. The data tell us that many couples are relinquishing private cover, and this has the potential for a severe adverse downstream effect for the whole private health system.

In response to this, I have convened round-table meetings at College House with key figures and organisations from across the spectrum of private health in Australia. Participants come from the Anaesthetic College and Society, the AMA, NASOG, private health insurers and hospitals, Private Health Australia, indemnity providers, as well as Government and the opposition. Focus groups are being run in most Australian capital cities. I am hoping to provide a detailed report on recommendations and actions from these activities early in the new year.

Going global… It has always been a core College activity to support women’s health for our Pacific neighbours. The largest Pacific country, Papua New Guinea (PNG), is a short flight from Australia, yet has some of the worst health outcomes for women in the world, owing to a combination of factors. PNG has a high-skilled and dedicated women’s health workforce and the College is absolutely committed to supporting them. I had the privilege of attending the PNG Medical Symposium in September – along with the Presidents of RACS and ANZCA – and met with the Prime Minister and Health Minister of PNG, as well as senior officials from the Australian High Commission, to discuss access to safe care.

The College has just released a major overview of Pacific women’s health that outlines key challenges and solutions, which can be found here: www.ranzcog.edu.au/Womens-Health/global/What- we-do. While the College’s resources are limited, we have an excellent ability to advocate for Pacific health and to partner with governments and NGOs. Ms Killen and I met with the Minister for Pacific Development to discuss opportunities to work together. Also, for the first time, RANZCOG has signed an historic letter of intent with the American College of Obstetricians and Gynecologists (ACOG) to work together on women’s health issues in the Pacific.

And the rest… Before I became President – even when I was on the College Board – I had little idea about the enormous workload going on at College House. Some issues you will hear about next year are: the College House redevelopment; revalidation; Aboriginal and Torres Strait Islander women’s health; rural workforce; responses to procedural training issues; a new National Maternity Framework; the cervical screening renewal and changes to C-QuIP; the new College maternity app; the National Women’s Health Summit… Since there is clearly a large workload ahead of us all next year, I prescribe a restful summer break for everyone.

Prof Robson speaking at the PNG Medical Symposium about the critical importance of resourcing women’s health. Within medicine, there exist multiple subcultures; each with its own set of values, beliefs and attitudes that influence the behaviours of From the CEO its members. However, common themes have emerged from the research conducted over the past decade and these themes were reflected in RANZCOG’s own survey into bullying and harassment conducted in 2016.

The survey was sent to 2149 Fellows and 701 trainees; of this number, 659 Fellows (approximately 30 per cent) and 265 trainees (approximately 40 per cent) responded. Of the total responses received, 60 per cent (522) indicated that they had been bullied in the O&G workplace – most often when in the role of a trainee, but with 34 per cent indicating that they had experienced this behaviour while working as a consultant.

Consistent with findings from other surveys, the reasons given for not reporting or challenging the behaviour were related to a fear of compromising career prospects or fear of making the situation Alana Killen worse. In terms of what form the bullying and harassment took, CEO the common themes were humiliating and belittling behaviour generally perpetrated in the presence of others, including patients. What was not investigated at that time was the incidence of sexual discrimination in the workplace nor the gender of those who had experienced bullying.

Supporting Respectful Workplaces – Update What is RANZCOG doing? Reports of bullying, harassment and discrimination in medicine have As a result of the survey and in acknowledgement of the growing been the subject of much discussion over the past few years; across need to provide greater support to our trainees (and supervisors), the entire spectrum from medical student to consultant.1-10 a new Training Support Unit has been established. This Unit was formally launched at the ASM in New Zealand and the Trainee While the problem is widely acknowledged, effective strategies to Liaison Senior Coordinator has already commenced in her role address the situation have been difficult to identify. Medicine is a and is quickly becoming familiar with the RANZCOG programs and complex domain that involves ‘a loose coalition of high-achieving, processes. This role will be the primary point of contact for trainees competitive individuals belonging to numerous workplaces and (or supervisors) seeking support and assistance. The College associations, each with its own internal hierarches and cultures’.8 will shortly finalise an agreement with Converge International (www.convergeinternational.com.au) who are experienced in the Mentoring provision of expert advice and assistance. This organisation employs Medicine is a demanding profession, making the wellbeing and specialists in psychology, mental health and wellbeing and can support of doctors, especially those in their first years of medicine, provide confidential support over the phone or face-to-face to of significant importance. Trainees face a multitude of external trainees in times of difficulty. pressures, including heavy workloads, shift work and long hours, as well as significant internal pressures, such as the ongoing drive to RANZCOG is also pleased to launch the Train-the-Trainer ‘Supporting achieve career goals and finding work-life balance. SIMGs face even Respectful Workplaces’ workshop, which is being run in a number of greater challenges as they attempt to balance not only career and regions and will be progressively rolled out over the coming months. training pressures, but also the challenges associated with navigating The workshop has been developed for trainees, SIMGs and Fellows the Australian health workplace. involved in the FRANZCOG training program and aims to develop and consolidate the skills and knowledge essential for safe and The 2013 beyondblue survey of medical students and doctors respectful practice in O&G and to help ensure training environments provided sobering insight into the health of the medical profession. are free from bullying, harassment and discrimination. Alarming findings included that 47.5 per cent of doctors aged 30 years and younger reported emotional exhaustion. These findings prompted the recommendation for increased support for younger doctors, including strengthened mentor and mentee relationships. To address this, the College has developed a mentoring workshop that will assist in developing supportive relationships and provide a formalised program for mentors to enhance and develop their skills. This mentoring program will also be open to trainees.

What can I do? Advanced trainees and Fellows who would like to take the lead in delivering these workshops are encouraged to attend a T3 workshop. The workshops are free of charge and attract CPD points. The T3 workshops include didactic and small group teaching methods as well as roleplay and simulation. Those who are interested should contact [email protected].

References 1. Askew D, et al. Bullying in the Australian medical workforce: crosssectional data from an Australian e-Cohort study. Australian Health Review. 2012;36(2):197-204. 2. Cheema S, et al. Bullying of junior doctors prevails in Irish health system: a bitter reality. Irish Medical Journal. 2005;98:274-5. 3. Paice E, et al. Bullying among doctors in training: cross sectional questionnaire survey. BMJ. 2004;329:658-9. 4. RANZCOG. Bullying and Sexual Harassment Survey. 2016. 5. Rutherford A, Rissel C. A survey of workplace bullying in a health sector organisation. Australian Health Review. 2004;28:65-72. 6. Shabazz T, et al. Consultants as victims of bullying and undermining: a survey of Royal College of Obstetricians and Gynaecologists consultant experiences. BMJ Open. 2016;6(6). 7. Timm A. ‘It would not be tolerated in any other profession except medicine’: survey reporting on undergraduates’ exposure to bullying and harassment in their first placement year. BMJ Open. 2014;4(7). 8. Ivory KD. Listen, hear, act: challenging medicine’s culture of bad behaviour. MJA. 2015;202:563-4. 9. RACS. Expert Advisory Group on Discrimination, Bullying and Sexual Harassment. 2015. 10. Jamieson J, et al. Bullying and harassment of trainees: an unspoken emergency? Emergency Medicine Australasia. 2015;27(5):464-7. SILENT EPIDEMIC

If you If you 3 three in Vol. 19 No. 4 Summer 2017 | 11 Vol. In fact, intimate In fact, intimate 2 amily Violence, Summary and New Zealand and New Zealand * eau of Statistics, Personal Safety Survey. 2012. Survey. Personal Safety Statistics, eau of 4 te Standing Committees on Finance and Public te Standing amily Violence Death Review Committee (2014) Fourth Annual Review Committee (2014) amily Violence Death Australian Bur Victorian Royal Commission into F F Health Wellington, Report: January 2013 to December 2013. Commission. Quality and Safety Sena Report: InquiryAdministration, into domestic violence in Australia. 2015 www.abs.gov.au/ausstats/[email protected]/mf/4906.0. www.rcfv.com.au/MediaLibraries/ 2016. Recommendations. RCFamilyViolence/Reports/RCFV_Full_Report_Interactive.pdf.

on average per year on average partner violence is the leading risk factor for partner violence is the leading risk factor for disability and illness burden death, preventable even in women aged 15 to 45 years; contributing morbidity than smoking or obesity. greater believe your friends, family, colleagues and patients colleagues and patients believe your friends, family, sadly you are untouched by this tragedy, are survivors and victims all are There misinformed. such is why ending the silence about us. That around a taboo topic is vitally important. As obstetrics and gynaecology doctors, we are uniquely well placed to identify and support our most must rise to the challenge We vulnerable patients. as leaders in women’s health and become powerful we can work toward for change. Together, advocates can a world in which all women, men and children I for one am so privileged to still have a live in safety. voice, and I will never let it be silenced. in memory the 13 of Written 71 Australian women murdered in 2016 in acts of in 2016 in acts of 71 Australian women murdered domestic violence. women will experience sexual and/or physical women will experience sexual and/or physical violence during their adult lives. * References 1. 2. 3. 4. shower of petrol. It ran down my face and through It ran down my face and through petrol. shower of it burned my eyes and filled my ears, and I my hair, me. It was that coughed as the fumes began to choke – waiting to be lit on indescribable horror moment of into overdrive and, kicked my adrenaline – that fire courage to run for my life. I found the somehow, Leading up to the one-year anniversary the day of my life almost ended, it has become a poignant silence. One the impact of of reminder – known ever more – known ever more 1 ‘I tell my story, not because it is unique, but because tell my story, ‘I it is not.’ Nobel Lecture 2014 — Malala Yousafzai, relationship a brief after On 3 November 2016, in my on fire and set ended, I was almost murdered 11 times own home. During the assault, I was stabbed fleeing for my life. before and doused in petrol remember I vividly the attack, In the weeks preceding I emotions – fear and shame. my predominant how a seemingly successful couldn’t comprehend a and intelligent person could possibly become domestic violence. Feeling embarrassed victim of I found to find myself in such a vulnerable position, me. While it impossible to open up to those around I waited for the police to serve the Apprehended I constantly felt Violence Order I had applied for, in my to sleep nervous and sick. I was too afraid sleeping in my car or the home, and considered work instead. Suspecting my at room registrar was stalking me, I was always on edge perpetrator and looking over my shoulder to check whether I was being followed. Meanwhile, I continued to care clinics and performed attended for my patients, smile. – all with a forced procedures I could see the knife I was attacked, On the afternoon I was being that and my brain started to comprehend and saw the wound on stabbed. I fell to the ground my skin beneath my left thigh, I could see the fat my fingers even and it was bleeding heavily around learn that I would later when I tried to apply pressure. was in fact not one, but six stab wounds in that there thigh, with one extending all the way into my femur. this point passed at only a few seconds had sure I’m I remember Yet and my mind was buzzing frantically. having one distinct thought – I was about to become by a the 1–2 women per week murdered one of in Australia or ex-partner current Dr Angela Jay trainee FRANZCOG Shore Hospital North Royal Editorial as a mere statistic. statistic. as a mere I would die that I felt sinking despair as I realised all alone, and never get the chance then and there, to see my friends or family again. I think I even briefly I eventually found the strength fate. accepted that only to be met by a the ground, to pick myself off SILENT EPIDEMIC a system-wide approach a system-wideapproach Tackling familyviolence: professionals are inauniqueposition toidentify Research showsthat hospitalandmedical health of women.” but are justassignificant tothe violence maybeless obvious, associated withintimate partner controlling behavioursthat are psychological,sexualand “The requests fortermination of pregnancy. infections, pregnancy andcomplications, and control, increased rates of sexuallytransmitted They mayalsopresent withreduced reproductive during sexualintercourse andsexualdysfunction. tractinfections, fistulas,painpelvic disorders,urinary vaginal andanalbleedinginfections, chronic higher rates of gynaecologicalissues,including of ways.Forexample,womenmaypresent with to thistypeof violencecanpresent inamultitude The varietyof physicalhealthissuesthat are related violence anditsconsequencesacross allitsservices. Melbourne, commonlyseesintimate partner The RoyalWomen’s Hospital(theWomen’s), in and NewZealand. and, accordingtoresearch, isincreasing inAustralia affects womenacross socialandculturaldivides community. Itisacomplex,pervasiveissuethat their families,healthcare workers andthebroader impact issignificant,notonlyonpatients, butalso physical, psychologicalandemotionalhealth.The detrimental effects of violenceagainstwomenon There ismuchdata, research andevidenceonthe The Royal Women’s Hospital,Melbourne,Victoria Prevention ofViolenceAgainstWomen Registered nurseandprogramleader Jane Hooker

Safety Victoria. dedicated solelytofamilyviolencereform: Family July 2017, itestablishedVictoria’sfirst-everagency family violenceinthe2017/18Victorianbudget.In the commitmentof $1.91 billiontowardsaddressing Royal CommissionintoFamily Violence, whichledto 2015, Victoriawasthefirststate inAustraliatoholda significant investmentinprevention. InFebruary for theVictorianGovernment,whichhasmade Since 2015, familyviolencehasbeenapriorityarea of violence-related incidentsanddeaths. women inVictoriahasincreased followinganumber years, asthefocusonaddressing violenceagainst history, butnevermore sothanoverthepastfew has beenapriorityfortheWomen’s throughout its of reducing theeffect of violenceagainstwomen Tackling thecomplexandmultifactorialchallenge within thefamilyviolencesector. social supportandimprove servicesandprograms to strengthen theevidencebaseforclinicalcare and it isactivelyparticipating in,andpromoting, research hospitals andthefamilyviolencesector. Inaddition, government, academia,thecommunity, other family violence.Ithasfostered partnershipswith capacity across thewholehealthsystemintackling collaborating withotherhealthservicestobuild As astate-wide leaderinVictoria,theWomen’s is their children from tosafety violence. andrecovery positioned forearlyinterventiontoassistwomenand women’s andmaternity hospital,itisuniquely against womenasahealthissueand,specialist The Women’s istakingaleadinaddressing violence The roleoftheRoyal Women’s Hospital use (Figure 1). deal withthisissuehasbeendevelopedforpublic healthcare professionals andhospitalseffectively women experiencingviolence.Atoolkittosupport andsupportingunderstand theirrole inidentifying medical professionals involvedinwomen’shealth and theWomen’s isworkingtoensure that all and supportpeopleat riskof familyviolence http://haveyoursay.thewomens.org.au/shrfv-project. Violence project websitewith toolkit. Figure 1.Strengthening HospitalResponsestoFamily SILENT EPIDEMIC

Vol. 19 No. 4 Summer 2017 | 13 Vol. to better support staff experiencing violence, and experiencing violence, to better support staff family violence leave to help of the introduction individuals to manage issues and appointments with family violence. associated for Family The hospital also established a Centre a hub for researching Violence Prevention, early tools, interventions, including identification assist to intervention and therapeutic responses, women experiencing family violence. In 2016, Prof Kelsey Hegarty was appointed Australia’s Hegarty was appointed Australia’s Kelsey Prof a joint Violence Prevention, Family of first chair and the University appointment by the Women’s Melbourne. of Dr Sue Matthews, CEO, Women’s the Early in 2017, to was appointed the hospital representative Committee, Steering Violence Victoria’s Family specialist advice on the which provides policies, of development and implementation family seek to address that and programs strategies has also recently violence in Victoria. The Women’s four Victorian hospitals been appointed as one of for family violence in an screening to trial routine setting. antenatal “The Women’s believes that believes that “The Women’s and intervention of prevention violence against women should business to all health be core professionals.” The goal for the next four years is to continue to develop and implement a sustainable, whole-of- to violence against women right hospital response Victoria. This will be achieved by aligning across women and wellbeing of and prioritising the safety or personally and exposed to violence professionally to and supporting health professionals educating capability and confidence enhance their capacity, to practice sensitive inquiry into violence and refer. appropriately violence is a complex issue, but we encourage Family the a look at to take professionals all healthcare has been developed by the Women’s, toolkit that hospitals to Bendigo Health and other respected practical support and tools. provide Figure 2. SHRFV model. e safe and welcoming e safe y and respond to family violence, y and respond raining staff on how to have the confidence raining staff environments. to be Supporting and mentoring other hospitals able to identif a toolkit of the creation particularly through training information, contains a host of that material, adaptable marketing programs, concerning the and policy and procedures violence against women and of prevention hospitals. This toolkit has been of the role specifically developed to be adaptable to any setting. hospital and applicable in any healthcare T on refer to and respond and skills to identify, violence. risk of women experiencing or at Ensuring physical sites ar • is that the SHRFV project tenets of the key One of not expected to become are professionals healthcare it aims Rather, in family violence prevention. ‘experts’ to health workers to encourage and give confidence and support so they feel able to sensitively enquire violence, and risk of, women experiencing, or at them for further support. to refer know where Beyond the SHRFV project continues to contribute to the The Women’s violence against women in other ways, of prevention or of, at risk who may be such as by supporting staff experiencing, violence; supporting managers; and into family violence. undertaking research support it implemented a workplace In 2016, by family violence. for employees affected program includes training for colleagues and The program policies and procedures managers, human resources • The Women’s, along with Bendigo Health, was one was one Health, with Bendigo along The Women’s, develop family hospitals in Victoria to the first of services. The and response violence prevention has meant the Royal Commission support following has now this area as a leader in role the Women’s its model to enabling it to expand been formalised, Victoria’s across activity coordinated foster greater public hospitals. to Family Responses The Strengthening Hospital Violence project commenced the Victorian Government In 2014, Hospital Responses to funding the Strengthening Violence (SHRFV) led by the Women’s Family project, Health. This innovative in conjunction with Bendigo and implement a framework work aims to develop Victorian hospitals the practice for embedding within identifying systematically of to and responding violence. experiencing family patients covers all elements of The SHRFV project developing and supporting a whole-of-hospital to implementing a family violence approach Based in any hospital setting in Victoria. program best practice, the SHRFV model on international five principles and 2) has two overarching (Figure elements. It aims to deliver a implementation key achieve to violence and response whole-of-hospital families and better outcomes for women, children in Victoria. and welcoming a safe to SHRFV is creating Core who might physical space for women and staff right the be experiencing violence, and providing to enable training, tools, support and structures to identify hospital staff and sensitively enquire about family violence. program the SHRFV the practical aspects of Some of include the following: • SILENT EPIDEMIC violence andchildmaltreatment. is alsobeingmadebetweenintimate partner New Zealand Family violencein developed world. some of thehighestrates of domesticabuseinthe many NewZealanders, withevidenceindicating Family violenceisthebrutalreality forfartoo all DHBat theircore, isthepremise that healthcare of Healthin2016,Ministry andimplementedacross and intimate partnerviolence. Assessment andInterventionGuideline: Childabuse program isarticulated intheupdated Family Violence clinical environment. Thecurrent iteration of this training, supportandauditof theprogram inthe coordinators across allDHBs.Theirrole istoprovide a national VIPmanagerandfamilyviolence In 2007anextensiontotheprogram resourced domestic violence. facilitate effective responses tothoseexperiencing and regular evaluation, theprogram aimstohelp and education. Combinedwithinformation systems of trainingforhealthprofessionals, publicpolicy approach, theprogram nowincludestheprovision alcohol abuse. suicide, domesticviolence,andchild,drug to ourcountry, reflected inthehighrates of youth Commissioner, maintainedwehavea‘darkside’ homicide, JudgeBecroft, NewZealand’s Children’s evidence at therecent inquestregarding achild and PartnerAbuse. Family ViolenceInterventionGuidelines:Child of Healthprograms supportedbythe2002Ministry District HealthBoards(DHB)establishedpilot asweknowittodaybeganin2001.Selected (VIP) programs, theViolenceInterventionProgramme of Health’sflagshipDescribed asoneof theMinistry Policy andprogramdevelopment to helpaddress thesedisturbingfigures? steps havebeentaken byhealthservicesinaneffort against womenandchildren inNewZealand, what Allied Health Services Social Work ProfessionalLeader Women andChildrens Allied Health Director PhD Dr LindaHaultain 3 Giventhesehighrates of violence 1 Increasingly, theconnection 4 Favouring apopulation health 5 Publishedbythe 2 Givingexpert New Zealanders.’ that isof fundamentalimportancetothehealthof longer acceptableforusnottorespond toanissue referral source linkswehavebuiltmeanthat itisno ‘the clinicalknowledge,healthsystemsupportand anddevelopment,thatof program delivery argues that muchhasbeenlearnedduringtheyears The foreword tothe2016guidelinepersuasively professionals assessandintervenecompetently. health servicesobtainearlysupportandthat health people affected byfamilyviolencewhoare using aim of theprogram istomake sure that those response toaddressing theseissues.Theoverall child abuse,theguidelinespromote anintegrated 2. 1. following six-step process: autonomy andjustice,theguidelinedescribes (to dogood),non-malfeasancenoharm), support allhealthcare practice,suchasbeneficence Founded onfundamentalethicalprinciplesthat support of thosethat haveexperiencedviolence. professionals tointervenesafely andeffectivelyin aims toprovide aworkabletooltoassisthealth Similar tothe2002expectations, the2016guideline people affected bydomesticabuse. brief interventions,supportandreferral onwardsto well positionedtoprovide timelyidentification, suffering abuse,healthprofessionals are potentially violence seekhealthcare more often thanthosenot Given that thosesufferingtheeffects offamily the population intocontactwithhealthproviders. pregnancy, orillness,bringsthemajorityof injury provision of routine healthcare, suchasduring This assertionismadeonthebasisthat the violence, inclusiveof childabuse. providers are wellplacedtohelpvictimsof domestic New Zealand policemade78,915 referrals toNew The availabledata from June2012 indicate that the Emphasising theco-occurr 6. 5. 4. 3. in theirlifetime. 55 percentof womenreport havingexperienced IPV psychological abuseisincluded in thestatistics, When and/or sexualintimate partnerviolence (IPV). in NewZealand describehaving experiencedphysical One-in-three (35percent)of ever-partnered women for 41percentof afrontline policeofficers’ time. investigations byNewZealand police, accounting following: in2016there were 118,910 familyviolence Prevalence data publishedinJune2017indicate the Data summary silent epidemic? New Zealand continuestoface inrelation tothe does theavailabledata tellusaboutthechallenges Documentation Referral andfollow-up Sa Health andriskassessment V Routine inquir alidation andsupport fety planning 6 5 Giventheprogram’s aims,what y (identification) ence of partnerabuseand

SILENT EPIDEMIC SOCIAL MEDIA @RANZCOG facebook.com/RANZCOG Vol. 19 No. 4 Summer 2017 | 15 Vol. [email protected] [email protected] +61 3 9417 1699 Ph: +61 3 9419 0672 Fax: Email: www.ranzcog.com.au my.RANZCOG.edu.au my.RANZCOG.edu.au ton N, Gulliver P, Fanslow J. Understanding the Understanding J. Fanslow Gulliver P, ton N, AUSTRALIA College House, 254-260 Albert Street East Melbourne, Victoria 3002, Australia. . Moko inquest: Children’s Commissioner on inquest: Children’s . Moko , Eruera M. Kaupapa Maori wellbeing framework: The y of Health. Family Violence Intervention Guidelines. Child Health. Family y of ealand Government. Family violence risk assessment and ealand Government. Family Summaries: Violence Clearing House Data ealand Family McLain J, Giddings L, Rameka M, Fyfe E. Intimate partner Giddings L, Rameka M, Fyfe E. Intimate McLain J, e you ok website. areyouok.org.nz/family-violence/statistics/. e you ok website. areyouok.org.nz/family-violence/statistics/. Change of address? Visit the your member portal to update details today. oziol-McLain J, McLean C, Garret N. Hospital responsiveness responsiveness Hospital N. McLean C, Garret J, oziol-McLain anslow JL, Kelly P. Family Violence Assessment and Intervention Violence Family P. anslow JL, Kelly Silva M, Whitehead A, Robinson E. Pregnancy anslow J, Guideline: Child abuse and intimate partner violence (2nd ed). Guideline: Child abuse and intimate Ministry Health. of Wellington: 2016. Ministry Social Development. of 2017. Dobbs T F in New Zealand. partner violence outcomes and intimate ANZJOG. 2008;48(4):391-7. K 2013. to family violence: 108 month follow-up evaluation. Auckland. Centre. Research Interdisciplinary Trauma Kziol- New Z to screening, approach management framework. A common Copyright. Available Crown 2017. assessing and managing risk. www.justice.govt.nz/assets/Documents/Publications/ from: family-violence-ramf.pdf. Murphy C, Pa intimate Child maltreatment, connections and relationships: Violence Family New Zealand partner violence and parenting. April 2013. 3. Clearinghouse. Issues Paper Savage J NZ Herald. 3 Oct 2017. New Zealand. the ‘dark side’ of www.nzherald.co.nz/nz/news/article.cfm?c_ from: Available id=1&objectid=11929178. Ministr www.moh.govt.nz/ from: and Partner Abuse. 2002. Available notebook/nbbooks.nsf/0/C1A20FAA3DCAA762CC256C8B00697 3A9/$file/family-violence.pdf. F New Z Snapshot June 2017. Ar and intervention. Newbasis for whanau violence prevention April 2014. Violence Clearinghouse. Issues Paper 6. Family Zealand women and brief intervention: Experiences of violence screening settings. J Midwifery health care in two New Zealand Womens 2008;53(6):504-10. Health.

6. 8. 10. 11. References 1. 2. 3. 4. 5. 7. 9. Local literature suggests that women are supportive supportive are women suggests that literature Local context and in a health being asked the questions of will professionals health that have an expectation way, non-judgmental non-directive, engage in a women the situation complexity of the appreciating individually tailored an need to provide face, and the we must develop all health sectors Across response. effectively to those who are our capability to respond us to step forward, to actively risk. This will require at and our capacity, to increase seek out opportunities the responsibility of up our share fully take to more silent epidemic. the to help to address

1 8 Despite this 9 A number of A number of 10 2 Like other indigenous other Like 7 The final part of this article The final part 10 populations, Māori are disproportionately represented represented disproportionately Māori are populations, family violence. of as both victims and perpetrators explores why this may be the case. explores the questions Asking ourselves Why is this? Is it because we don’t understand the part we must play? Do we think this is someone too busy? Are we are else’s job? Do we perceive we a wound that ripping the scab off of we afraid to? Do we have a lack feel ill equipped to respond respond intended to in the program confidence of to domestic violence? Do we fear causing offence, we uncertain about Are off? or scaring the patient I invite all health to whom and how to refer? to ask ourselves these questions, professionals to the active steps to attend and then to take specific barriers we identify our preventing are that of active engagement with this critical area more practice. healthcare organisational, clinical and public perceptions are are clinical and public perceptions organisational, figure. when we consider this reflection worthy of the sustained investment by the Ministry Firstly, clear professional of Health and the provision of More obligations. clear our makes guidelines that the demonstrate that research than two decades of to domestic violence of exposure damaging affects and poor health outcomes for women. for children compelling contextual background, more than half more compelling contextual background, continue to shy away the time health professionals in relation responsibility our clearly articulated from to domestic violence. How are we doing? above, the process Summarised in the six-step having attended professionals for health expectations a is to undertake program, an eight-hour training for all home inquiry at routine their safety regarding years. If a positive disclosure women aged over 16 referral is made, the brief intervention follows. The a DHB health social to include either is likely pathway or a local specialist domestic violence service. worker meeting this basic obligation? us are How many of cent of (95 per progress, positive signs of are There an efficient DHBs do have systems in place to support to domestic violence); however, response and safe internal DHB audit identifies the most recent the eligible women receiving only 45 per cent of enquiryroutine above. mentioned Almost half of all homicides committed in New all homicides committed of Almost half who has been identified by an offender as are Zealand period (2009–2012) In a four-year a family member. killed as and 10 men were 13 women nine children, family violence. of a result Zealand’s statutory on the agency child protection Zealand’s This was to family violence. exposure of grounds requiring policy change in 2004 a national after police to notify present are children the agency when callouts. family violence at In the women’s health context, there is an established is an established In the women’s health context, there spontaneous link between IPV and increased pregnancy. of abortion and termination SILENT EPIDEMIC PhD, MBBS,FRANZCOG Dr BrettDaniels households. Interviewswere conductedprivately, 17,050 randomlyselectedmembersof Australian toDecember2012.Thissurveyinterviewed February 2012 PersonalSafety Survey(PSS),conductedfrom obtained from theAustralianBureau of Statistics’ prevalence of violenceagainstwomencanbe In Australia,recent reliable estimates of the women inAustralia Violence against violence from apartnerornon-partner. of womenhadexperiencedphysicaland/orsexual systematic review byWHOreported that 35percent affecting millions of peopleeachyear. A2013 Violence againstwomenisaworldwidephenomenon Figure 1.Women’s experienceof violence duringthelast12months,from ABSPersonal Safety Survey, 2012. 1

2005) survey (from 7.1 percentin1996to5.8 percentin experienced violenceinthe12monthspriorto of womenaged18yearsandoverwhohad decrease from 1996to2005intheproportion and 2005. Whilethere wasastatistically significant violence withresults from previous surveysin1996 The 2012PSSresults compared theprevalence of Changes inprevalenceofviolence 1.2 percentexperiencedsexualviolence. 4.6 percentexperiencedphysicalviolenceand greater than18reported experiencingviolence, the survey, 5.3 percentof Australianwomenaged PSS data indicate that inthe12monthspriorto prevalence estimate results of thePSS. The2012 Figure 1reproduces aflowchartsummarisingthe Women’s experienceofviolenceinthepastyear any timesincetheageof 15. experiencing violenceinthepast12months,orat the survey. Data were collectedbothintermsof of womenagedgreater than18at thetimeof estimates of thepercentages andtotalnumbers The results from thissurveyare expressed as potential tobesensitiveandtraumatic disclosures. with interviewerstrainedspecificallyforwhat hadthe in 2012. months priortointerview, compared to5.3 percent of allwomenhadexperiencedviolenceinthe12 to thesurvey. In2005, anestimated 5.8 percent had experiencedviolenceinthe12monthsprior from 2005to2012intheproportion of womenwho 2 , there wasnostatistically significantchange 2 2 SILENT EPIDEMIC Vol. 19 No. 4 Summer 2017 | 17 Vol. 2 3 eau of Statistics. 2013. 4906.0 - Personal 4906.0 2013. Statistics. eau of , Department of Reproductive Health and Research, Health and Research, Reproductive , Department of x, P. Violence against women in Australia: Additional analysis x, P. WHO Medicine, South African Hygiene and Tropical London School of of estimates Council. Global and regional Medical Research of and health effects violence against women: prevalence partner violence and non-partner sexual violence. intimate Geneva, 2013. WHO, Australian Bur Australia, 2012. www.abs.gov.au/ausstats/[email protected]/ Safety, Latestproducts/4906.0Main%20Features12012?opendocument&t abname=Summary&prodno=4906.0&issue=2012&num=&view=. Co Survey, Personal Safety Statistics’ of the Australian Bureau of 2015. Sydney. 2012. ANROWS,

at some time in that relationship. Of these women, these women, Of relationship. time in that some at violence experiencing per cent reported 21.7 women, these and of pregnant, were while they for the first time experienced violence 61 per cent during pregnancy. Conclusion violence against women in of While the prevalence the data ascertain, Australia is impossible to precisely in this summary presented of highlight the high rates women of violence against women, with 40 per cent 15. of experiencing violence since the age reporting far more violence against women are of Perpetrators to be known to them than be strangers, with likely women being the victim of a substantial number of and missing work pregnant violence while they were to be should alert readers it. These data because of violence occurring to the vigilant to the possibility of women they have contact with in their personal and lives. professional References 1. 2. 3. The same paper also reported data on 768,000 on 768,000 data also reported The same paper violence during women who experienced cohabiting partners, with previous relationships some time in that at also pregnant and were per cent 53.9 Of these women, relationship. violence while they were experiencing reported with relationships, in these previous pregnant they that reporting these women 47 per cent of for the first time while they experienced violence pregnant. were Time off work women who the number of The 2012 PSS reported in the 12 months following their work took time off domestic violence. Of the experience of most recent experiencing sexual assault by women who reported per cent 10.9 15, since the age of a male perpetrator work in the 12 months following their took time off per cent did not work assault, while 29.6 most recent necessarily could not time, although that all in that at to the violent incident/s. The standard be attributed sexual assaults on women regarding in the data error too large to be reliable. by women was considered women experiencing physical assault In the case of 19 per cent 15 by a male perpetrator, since the age of paid work in the 12 months following took time off per cent did not assault and 29.6 the most recent females experiencing all. In the case of work at the physical violence by female perpetrators per cent and 5.1 numbers were corresponding per cent respectively. 34.2

29.8 40.8 4.4 19.4 34.4 2,606.8 Females ‘0005,174.8 % 59.2 3,560.6 386.9 1,696.1 1,118.4 12.8 3,006.1 1,494.0 17.1 2 Sexual threat Total Physical threat Total Sexual assault

Physical assault Whether experienced Whether experienced 15 the age of violence since Did not experience violence 15 since the age of since Experienced violence 15 the age of Experience of violence by women any time since Experience of violence by women any time the age of 15 cent 41 per that estimated The PSS 2012 results Australian women aged 18 and over (3,560,000 of and/ women in 2012) had experienced physical Physical 15. or sexual violence since the age of women violence was experienced by 30 per cent of had been while 17 per cent (1,494,000) (2,608,000) 15. sexual assault since the age of the victim of to perpetrator of violence Relationship either sexual experiencing who reported Women 15 were or physical violence since the age of to be assaulted by a person likely much more of In the case known to them than by a stranger. who had experienced women of the 19.4 per cent to the was known sexual violence, the perpetrator women and a stranger per cent of victim in 16.4 per cent) or previous (4.9 Current in 5.3 per cent. cent) partners, or boyfriend/girlfriend (4.4 per reported the highest per cent) were (5.9 or date being per cent reported while 3.7 relationships sexually assaulted by an acquaintance or neighbour per cent by a work colleague. and 1.6 of the 34.4 per cent physical violence, of In the case of experiencing physical violencewomen who reported per cent the perpetrator in 8.4 15, since the age of was per cent the perpetrator was a stranger and 29.6 or previous (2.6 per cent) known to them. Current per cent) partners, or boyfriend/girlfriend or(13.3 again the highest reported per cent) were (6.8 date being physically reported 3.9 per cent relationships. assaulted by an acquaintance or neighbour and 0.8 per cent by a work colleague. Violence in pregnancy in Australia in 2015 reported the PSS data A further analysis of women experienced 180,000 approximately that pregnant partner and were violence by a current Estimated prevalence of women women of prevalence 1. Estimated Table violence since physical or sexual experiencing Safety ABS Personal from extracted 15, the age of 2012. Survey, SILENT EPIDEMIC minimised and very limited. minimised andvery and domesticviolenceintheCaLDcommunityis reiterate that information ontheprevalence of family available. Furthermore, Morgan and Chadwick littletonoevidenceand refugee women,withvery prevalence of familyviolenceagainstimmigrant notably fewstudiesthat specificallyexaminethe community. Theyacknowledgedthat there are ANROWS publishedastudyonFDV intheimmigrant Women andNewbornHealth Service Directorate Women’s Health, GeneticsandMentalHealth Women’s Health StrategyandPrograms FGM andFDV (CaLD)Research ProjectOfficer Dr CarolKaplanian communities migrant andrefugee Insights intothe rate, ifnothigher, intheCaLDcommunity. know isthat domesticviolenceoccursat thesame linguistically diversecommunity(CaLD).What wedo case, Iamspecifically referring totheculturallyand different tothoseweworkwith.Inthisis canbevery that ourperception andunderstandingof what FDV status. However, asprofessionals, weoften forget culture, religion, ethnicity, skincolourandmigration acknowledged that FDV isaglobalissuethat spans Itcanbeissue of familyanddomesticviolence(FDV). literature andresearch has beenconductedonthe In thelastfewyears,anoverwhelmingamountof Australia. death, disabilityandillnessinwomen aged15–44in intimate partnerviolenceisstillthe leadingcauseof views, includingviolence.We alsocannot ignore that stagnating people’sperception around certainworld that culture playsanintegralrole inshiftingand/or on what FDV is.We simplycannotignore thefact the notionsurrounding perception andknowledge why information issolimited,andfurtherexamine response toourclients andpatients. enable ustoprovide amore culturallysensitive which encapsulate theperception of violence, will 3 Understanding suchcomplexconcepts, 2 Thisarticlewillexamine 1 In2015, their prescribed roles. women shouldtheydeviate from what isseenas to usephysicalabuseasoneform of disciplineof observed that itisculturallyacceptableformen immigrant communitiesintheUnited States have argues that studiesamongAsianandMiddleEastern physical abuse. descriptions of familyviolencefocusedmainlyon in Australia,Ogunsijietalreported participants’ undertaken withWest African womennowliving other formsof abuse.Forexample,inresearch perceived asphysical,withoutencapsulating any In manycultures, familyviolencemayonlybe heterosexism, andthelike’. such asracism,colonialism,economicexploitation, mediated through structuralformsof oppression, communities’ culturalexperiencesof violenceare culture. Rather, wemustaddress howdifferent violence, wecannotrest onsimplisticnotionsof crucial tounderstandingandcombating domestic diverse cultures’. Theyfurtherstress that ‘culture is the ‘real differences amongbattered womenfrom view of culture bystressing that wecannotdeny FDV ispivotal.Sokoloff andDupontadoptamacro Widening ourunderstandingof culture inrelation to family violenceinwaysthat emphasiseaggression. immigrant andrefugee womentoconceptualise In 2009, Fishernotedthat there isreluctance among in thesamelightasweperceive ithere inAustralia. In manycultures around theworld,FDV isnotseen different culture. a Western understandingof violencetothat of a to FDV. Thisisoneof thecore differences between women, andultimately judgewomen’sresponses turn reinforce patriarchal valuesaboutthestatus of such ascommunityandreligious leaders,whoin partners, extendedfamilyorothersof influence, and relationships betweenwomenandtheirintimate of language oppression emergefrom theeveryday sense, onecanfurtherarguethat structuralforms women insomecommunities.From an enculturated patriarchal values,predominantly aboutthestatus of to help-seekingbyCaLDwomen,resting upon of thecauseof domesticviolencecreates barriers more micro viewof thisissuebyarguingthat much predominantly contributetoFDV. social dissonanceandpsychological stress that of FDV, itisthestructurallybasedinequalities, while culture andpatriarchal values actascauses may meantoher. Gilletal woman’s experienceof abuseandwhat that abuse that culturalbeliefsplayanintegralrole inshapinga what constitutesFDV inWestern societyisalsooften cases, theirwivesaswell. viewed asmen’sdutytowardschildren, andinsome women from theAfricancommunity, ‘discipline’was research, Fisherillustrated that accordingtosome relationship notmentionedat all.Additionally, inher violence, withsexualviolenceinanintimate partner and verbalabusewere notrecognised asfamily 7 Controlling behaviours,financial 9 ReesandPeasealludethat 8 Furthermore, Tonsing 5 however, take ona 4 Onecantherefore argue 10 Thecauseof 6

SILENT EPIDEMIC oles and Vol. 19 No. 4 Summer 2017 | 19 Vol. f violence: measuring the burden f violence: measuring the burden . Key issues in Domestic Violence: issues in Domestic Violence: . Key Trauma, Violence & tor domestic violence. Trauma, tion of the nature and understanding of and understanding of the nature tion of Piatkowski B. Supporting women from Supporting women from B. Piatkowski , Hagu G. ‘Honour’-based violence in , Hagu G. ‘Honour’-based . Family violence including crimes of honor violence including crimes of . Family printstore.ranzcog.edu.au , Wilkes L, Jackson D, Peters K. Suffering and smiling: L, Jackson D, , Wilkes Piatkowski B, Anne S. Issues in good pratctice: Issues in good pratctice: Anne S. B, Piatkowski , Pease B. Domestic Violence in Refugee Families in Domestic Violence in Refugee Families , Pease B. Written by experts. Written Odeh L. Honour killings and the construction of gender Odeh L. Honour killings and the construction of oloff N, Dupont I. Domestic violence at the intersections at the intersections violence I. Domestic N, Dupont oloff onsing JC. Domestic Violence: Intersection of Culture, Culture, onsing JC. Domestic Violence: Intersection of of disease caused by intimate partner violence: a summary disease caused by intimate of of of Human Services. Department Melbourne: findings. 2004. Forum. International Studies Communities. Women’s Kurdish 2012;35:75-85. communities background domestic violence in African refugee post-settlement in Perth, Australia. Violence Against Women. 2013:19(7):833-47. Minority Health. and Immigrant Gender and Context. Journal of 2016;18(2):442-6. . 2007:5(2):1- and Refugee Studies Immigrant Australia. Journal of 19. Araji SK, Carlson J seriousness. Violence of and perceptions in Jordan: Correlates . 2001:7(5):586-621. Against Women Abu- . Law Comparitive in Arab societies. American Jounral of 2010;58:911-52. Salter M. Multiperpetra Abuse. 2014;15(2):102-12. Allimant A, Ostapiej- sexual violence: of victims/survivors who are CALD backgrounds challenges and opportunities for practitioners. 2011. Australian Sexual Assault. of for The Study Centre Ostapiej- in responding cultures multicultural identity and working across and Domestic Violence to violence. Australian Family Clearinghouse Newsletter. 2009;36:4-5. V women in refugee against immigrant and to violence responses 2015. The ASPIRE Project. Australia: regional and metropolitan Sydney. ANROWS. Morgan A, Chadwick H Criminology (AIC). Institute of Australian Summary paper. Canberra. 2009:7. VicHealth. The health costs o Sok and contributions to race, class, and gender: challenges of in diverse women marginalized understanding violence against . 2005:11(338):38-64. communities. Violence Against Women Gill A, Begikhani N Fisher C. The explora with the Sudanese, Somailan, family and domestic violence Liberian and Sierra Leonean communities and Ethiopian, and community its impact on individuals, family relations for Perth: Association 2009. report. settlement: Research Survivors. Trauma and Services to Torture Ogunsiji O partner intimate immigrant women’s experience of African West Clinical Nursing. 2012:21(11-12):1659-65. violence. Journal of Fisher C. Changed and changing gender and family r T Rees S RANZCOG RANZCOG Patient Information Pamphlets

4. 6. 9. 10. 11. 12. 13. 14. 15. References 1. community-led A,etal.Promoting aughan C,DavisE,Murdolo 2. 3. 5. 7. 8. identity. Taking all of the above into consideration into consideration the above of all Taking identity. effectively work with us to sensitively and will enable backgrounds. cultural different women from

15 It can It can 12 These These 1,13 11 In such clashes of cultural In such clashes of 14 then be stated that migrant and refugee women women migrant and refugee that then be stated may and will experience family violence from notion due to the collective multiple perpetrators This can include in-laws or community identity. of the case for women members. This is often considered wives are communities where from or for maintaining the family unity, responsible collectivism or subordination norms of where or the family the individual to the demands of of the family is seen as normal. the head of Another pivotal point to note is the effect culture has has to note is the effect culture Another pivotal point In many migrant identity. of on developing our sense identifycommunities, individuals with a collective to an individual one. identity as opposed sense of an ‘through that elucidates Abu Odeh succinctly and prohibitions, commands system of elaborate a very at girls “learn” their performance young age. against possible violations guards itself The culture are that by devising sanctions less violent than death spatial it, such as physical abuse, meant to preclude gossip the institution of entrapment, segregation, a girl, people “because you are and reputation, women will talk if you do this”, is rhetorically how subjectivity’. their gendered come to acquire attributed to structural inequalities between men and men between inequalities to structural attributed the societies around is the case for most women. This perception for the CaLD community, world; however, differs. Araji strongly gender roles about ingrained by extrapolating support this argument and Carlson society’s how supportive determines culture ‘a that who it considers the family violence and it will be of abuse, of and recipients administrators appropriate men wherein patriarchal, are most known societies of privilege, and control power, given greater are are In these societies, parents women and children. over children’. also awarded authority To effectively work with women from different different effectively work with women from To it is important to understand their world cultures, factors that It is equally important to note view. employment and status, such as their immigration financial independence, their family and community the law and knowledge of ties, their limited level of hinder them from all barriers that their own rights are women highly value seeking support. Additionally, is in a way that and reputation status their honour, tied to their family due to their collective notion of understanding, practitioners report not knowing understanding, practitioners report CaLD backgrounds to women from how to respond experiencing violence. This is due to the who are to maintain cultural sensitivity. practitioner’s desire factors have a consequential impact on CaLD factors have a consequential impact on CaLD means and is FDV what of women’s interpretation and culture to women’s unique context of linked In turn, in a collective society. attitudes patriarchal to a critical barrier for women these factors provide the seek help, as they themselves do not categorise being subjected to as FDV. they are violence that of This is due to their cultural and social perception constitutes violence. If women only perceive what domestic violence, physical violence as a form of violence in a they may be enduring other types of their collective of normalised manner as a result identity. notion of all walks As practitioners working with women from life, it can be difficult to understand someone of may not support our perception as else’s world view, This can also be compounded by the patient. of that obligation many women hold a sense of the fact that and due to religious to stay in a relationship/marriage ingrained were that traditional beliefs as attitudes an early age. from SILENT EPIDEMIC death. postnatal depression andmaternal andperinatal membranes, premature birth,lowbirthweight, with placentalabruption,premature rupture of woman, butalsotoherunborn fetus.Itisassociated as theviolencenotonlyposes a threat to the during pregnancy shouldbeof specialconcern health problems. However, domesticviolence woman’s lifecanresult inamultitudeof harmful Experiencing domesticviolenceat anytimeina Domestic violenceduringpregnancy children. the healthandwellbeingof women,younggirlsand Domestic violenceisabroad conceptthat affects The natureofdomesticviolence behaviours andreduced capacitytoparent. opportunities, increased uptake of riskyhealth including educational achievementandeconomic to negative consequencesinmanyspheres of life, experiencing domesticviolenceandabusecanlead as wellcontrolling behaviours.Indisputably, includes physical,sexualandemotionalabuse, of arelationship of acohabitingcoupleand domestic violenceoccurswithinthecontext in healthcare settings forDFV Routine enquiry on thelivesof survivors. and culturalgroups, havingadevastating effect society andpervadesallsocio-economic,gender a globalpublichealthissue;itisembeddedin Domestic violenceandabuseagainstwomenis known detrimental effectshas resulted inhealth repeated abortionsandgynaecologicalproblems. including HIV, aswellunintendedpregnancies, report higherrates of sexuallytransmittedinfections, non-abused women,thoseinabusiverelationships self-harm andsubstanceabuse.Incomparisonto suicide, socialwithdrawalandeating disorders, traumatic stress disorder, depression, sleepdisorders, example, psychologicaldisorderssuchaspost- death, aswellindirect healthconsequences;for SaPS, GoldCoastUniversity Hospital Women’s andNewbornChildren’sServices andNursingEducation Director ofMidwifery RM, PhD, MAEd,PGDipHE,BSc(Hons) Dr KathleenBaird 6 Thehighrates of domesticviolenceand its 2 Itcanleadtosevere injury, disabilityand 1 Inmostsituations, 1

3-5

domestic violenceandabuse. women andchildren haveorare experiencing andrespond appropriately to on howtoidentify health organisations haveissuedclinicalguidelines for theirinjuries.Inresponse, manyprofessional frequently accesshealthservicesastheyseekhelp Women whoexperiencedomesticviolencewill professionals? What dowomenfindhelpfulfromhealth measure anoverallreduction inabuse. to even beamore meaningfulmeasure thantrying discussions maybemore achievableandmay of theirexperienceandincreased safety planning outcomessuchasdisclosure, validation primary experiencing domesticviolence,intermediate the effectiveness of interventionsforwomen an idealsettingtocommunicate withwomenwho but maternity andwomen’shealthservices provide violence maynotbeappropriate inallhealthsettings, fordomestic to acknowledgethat routine enquiry violence tobebelievedandvalidated. Itisimportant judgemental. Theywanttheirexperiences of health professional iscaring,sensitiveand non- health settingsacceptable,providing that the previously, incertain womenfind routine enquiry nothing usefulcanbedoneabouttheirsituation. their children removed, orsimplybecausetheythink being believed,judgedandstigmatised, having violence, theyare reluctant todiscloseforfearof not unless womenare asked of directly aboutahistory not. more likely toseekhealthcare thanthosewhoare Those experiencingdomesticviolenceare much fordomesticviolence enquiry Current debatearoundtheeffectivenessofroutine pregnancy isendorsed. for domesticviolenceduringandfollowing the UK,USA,CanadaandAustralia,where screening policy developmentsinmanycountries,including domestic violence. and resources ondealingwiththeconsequencesof recently, healthserviceshavefocusedtheirenergy has proved tobeachallenge.Indeed,untilvery supporting womenexperiencingdomesticviolence or safety. referrals, reduces abuseorimproves women’shealth there islimitedevidencetodate that itincreases is evidencethat screening increases identification, several systematic reviews indicate that whilethere in allhealthcare settingsiskeenly contestedand fordomesticviolence Conducting routine enquiry professionals asapotentialsource of support. healthcare domestic abuseconsistentlyidentify and education. Incontrast,womenexperiencing positive disclosure and,mostof all,alackof training anxiety andnervousnessaboutdealingwitha their professional remit, fearof offending thewoman, isnotwithin believing that domesticviolenceenquiry has beenpoorforavarietyof reasons, suchas healthcare settingsandamonghealthprofessionals 1 However, engaginghealthcare professionals in 9-12 However, perhapswhenassessing 7 Proactive identification within 1 Asmentioned 7,8 Yet, 7

SILENT EPIDEMIC e Vol. 19 No. 4 Summer 2017 | 21 Vol. ovide support and ovide y/screening in this article refers in this article y/screening e professionals who provide care who provide e professionals cia-Moreno C, Pallitto C, Devries K, et al. Global and Regional cia-Moreno Estimates of Violence against Women: Prevalence and Health Prevalence Violence against Women: of Estimates Sexual Partner Violence and Non-Partner of intimate Effects Geneva. Health Organization, World Violence. 2013. W WHO Clinical and Violence and Sexual Violence Against Women: Geneva. Health Organization, World Policy Guidelines. 2013. Baird K, T Mitchell. Using feminist phenomenology to explor in pregnancy. domestic violence women’s experiences of Br J Midwifery. 2014;22(6):418-26. Gar ongoing domestic violence education ongoing domestic and training Healthcar of aware should be and children to women services they agencies and the local support can provide Routine enquir standardised a set of to asking all adult women questions about a history domestic violence of such as maternity, health services nominated at alcohol services, mental health, drug and departments, sexual accident and emergency women clinics, assault services and well including gynaecology. Health services should pr services Health

References 1. Partner RespondingtoIntimate orld HealthOrganization. 2. 3. • • • Domestic Violence Helpline hours, – 1800 737 732 (Australia) 24 1800 RESPECT 7 days a week. Victoria have developed of The AMA and Law Council Violence: Experiencing Family Supporting Patients here: for medical practitioners, available a resource ama.com.au/article/ama-family-violence-resource. f safety

13 t she would like you to do t she would like tions should have robust 7 esponse could be the catalyst to esponse could be the catalyst e system has a significant role e system has a significant ovide her with the option to talk to a community domestic violence agency ell her you believe her Thank her for telling you T Ask her wha Pr Perform a risk assessment to assess her level o eassured that their information will be their information that eassured 2. 3. 5. Accurate and contemporaneous record keeping of a domestic violence disclosure is imperative. Safe Safe is imperative. a domestic violence disclosure of keeping and contemporaneous record Accurate never be in hand-held is critical and should pertaining to a positive disclosure any information storage of to It is also important to acknowledge the limitation visible to the perpetrator. are notes or any notes that a health professional that regard to any information in provided and a clear explanation confidentiality, to minimise the risk to sharing should be carried out safely Information may be legally obliged to share. the woman and her family. for obligations safety and long-term is the immediate following a disclosure An important consideration needs as well as the emotional that Risk assessments should ensure both the woman and her children. communities may have different from Women considered. are women and children the physical risks of leave Women should never be encouraged to language difficulties and isolation. unique needs because of plan put in place safety until a full risk assessment has been performed and a robust a violent relationship both her and her children. to protect with other agencies Working response. Responding to domestic violence should never be a one-agency woman and being able to support the manner is an essential component of and appropriate in a safe her children. It is important to ask women about domestic violence in a confident and professional manner. The manner. professional and violence in a confident It is important to ask women about domestic and in a safe does not pose judgement and should only be asked question should be framed in a way that partner or a child who is able to the of in front be asked The question should not environment. private to another person. the conversation repeat and appropriate as well as safe health guidelines and protocols of must be aware professionals Healthcare If a woman discloses domestic violence, follow to women’s community organisations. pathways referral these five simple steps: 1. 4. shared in a safe and appropriate manner and appropriate in a safe shared domestic violence policies and guidelines. safety and recoverysafety and children for women experiencing domestic violence All women disclosing domestic violence should be r All health organisa The healthcar A supportive r to play in a multisectoral response to violence to play in a multisectoral response against women 3 documentation and accurate Safe 4 planning Risk assessment and safety 5 and working in collaboration Referral Asking about and responding to a positive disclosure to domestic and family violence to a positive disclosure Asking about and responding 1 Asking about domestic violence 2 to a positive disclosure Responding • • Key messages Key • • Five simple steps to assist healthcare professionals to ask about domestic and family violence and respond appropriately. appropriately. to ask about domestic and family violence and respond professionals 1. Five simple steps to assist healthcare Table are experiencing domestic violence. Though, to be to be Though, domestic violence. experiencing are is essential it and effectively, this safely able to do specialist receive professionals healthcare that in a sensitive be able ask the question to education a to appropriately to be able to respond manner and professionals a woman. Healthcare from disclosure to provide and supported must be educated advice and help to women and accurate appropriate of aware they are that It is important and children. and be familiar with responsibilities their professional while acknowledging pathways, referral appropriate 1) (Table role. their of the limitations Routine enquiryabuse can for domestic violence and have not been previously many women who reach to disclose their history with an opportunity provided a visible healthcare violence. Most importantly, of of disclosures promote will not only response a but also communicate women, violence from domestic violence that message to society; strong is no longer acceptable. and abuse in any form SILENT EPIDEMIC 9. 8. 7. 6. 5. 4.

professionals screen womenfordomesticviolence?Systematic Ramsay J routine. 2013;29:1003-10. enquiry. Midwifery Bristol pregnancy domesticviolenceprogramme topromote Baird K,SalmonD . 2015;16(1)15-8. News difference. AustralianMidwifery Baird K,GambleJ Health. 2015;1:100-6. during pregnancy: maternal andneonatal outcomes.JWomens Alhusen JL,RayE,SharpsP Australian women.AustNZJPublicHealth. 2007;31(2):135-42. partner violenceandotherfactorsinanational cohortof young T 2017;26:(15-6):2399-408. and pregnancy intentions:aqualitative Study. JClinNurs. Baird K,Cr A PracticalGuide Assessing FetalWellbeing: Paperback availablefrom theFSEPonlinestore. eBook availablefrom iTunes, GooglePlay, Amazon andKobo. aft AJ, Watson LF. Termination of pregnancy: associations with , RichardsonJ, CarterY, etal,Shouldhealth eedy D, MitchellT. Intimate partnerviolence . Domesticviolence:midwivescanmake a , WhiteP. Afiveyearfollow-upstudy of the , etal,Intimate partnerviolence www.fsep.edu.au 13. 12. 11. 10. special circumstances. surveillance andfetal surveillance in the antenatal CTG, intrapartumfetal the physiologyof fetal surveillance, interpretation. Bookcontent features by detaileddescriptionsandguided (1cm/min) are provided, supported Over 60examplesof real CTGs labour. the care of womeninpregnancy and resource for allcliniciansinvolved in An easytoread andclinicallyfocused 2014;385(9977):1567-79. health-systems response toviolenceagainstwomen.Lancet. Gar T Feder G,RamsayJ Nelson H Database Syst Rev.2013;(4):CD007007. intimate partnerviolenceinhealthcare settings.Cochrane Health Technol Assess.2009;13(16):iii-iv, xi-xiii, 1-113, 137-34. reviews of nineUKNational Screening Committeecriteria. settings meetcriteriaforascreening programme? Systematic women fordomestic(partner)violenceindifferent health-care Ann Intern Med.2004;140(5):387-96. of theevidenceforUSPreventive ServicesTaskforce. elderly adultsforfamilyandintimate partnerviolence:areview review. BMJ.2002;325:314-36. aft A,O’DohertyL,HegartyK,etal.Screening womenfor cia-Moreno C,HegartyK,Lucasd’OliveiraAF, etal.The , Nygren P, McInernyY, etal.,Screening womenand , DunneD, etal,Howfardoesscreening SILENT EPIDEMIC

19 20

13-15 11,12 and Meyer 19

13 Vol. 19 No. 4 Summer 2017 | 23 Vol. 10 there is no evidence of any is no evidence of there 21 Despite the claims that Despite the claims that 17 Irwin and Waugh, reporting on a reporting Irwin and Waugh, 16-18 When exploring the barriers to help seeking, Fugate Fugate When exploring the barriers to help seeking, women felt the violence they were et al found that didn’t experiencing was not serious enough, they think any help would be useful, it was nobody’s embarrassed they were reprisal, business, they feared being judged or criticised. In addition, or they feared would be an if they disclosed there women felt that they would have to leave the partner that expectation and so they felt they needed and end the relationship the relationship. the partner to preserve to protect effective interventions that will improve women’s will improve effective interventions that early intervention will eliminate violence and early intervention will eliminate women’s lives, improve screening program in NSW, found that of the 11 per of found that in NSW, program screening positive for DFV only 30 per cent cent who screened assistance. to some sort of agreed While I believe the motives behind screening are well are While I believe the motives behind screening on two based they are meaning, I will argue here equals help disclosure false assumptions: one, that her seeking and with support the woman will leave and, two, to violence exposure partner thus reducing in will be improvements leaving there of as a result the woman’s safety. Disclosure does not equal help seeking DFV of the results Several studies have explored and have consistently found programs screening violence. of disclosures increases screening that As screening became popular, there were some who were there became popular, As screening in Australia. implementation cautious about its were cautioned against the use of As an example, Taft problematic felt these were tools as she screening complex to address attempting strategies as DFV. psychosocial issues such routine who argued that advocates were There and efficient way to was an effective screening violence and reassure of acknowledge the gravity it was not acceptable behaviour. that patients In my own practice of some 20 years working in the In my own practice of they loved that stated women frequently of DFV, field the partner and didn’t want to leave, but they wanted the violence and abuse to stop. I have found that time and takes that help seeking is a complex process will occur when women have exhausted all their own relationship. to end the abuse and fix the resources if the physical violence is escalating alternatively, Or, then women will leave, particularly if or is severe, et al Fugate they fear for the children. However, it appears that there is little evidence there it appears that However, in help seeking increase to show a corresponding once identified. found that if a woman’s tolerance threshold has not if a woman’s tolerance threshold found that to end the not prepared or they were been reached then women will not seek help. So, relationship, the numbers of may increase while DFV screening women who identify violence, it does not mean they will actively help seek. So why screen? element in justifying a key Feder et al describe that will be an effective there is that programs screening intervention available. In the In the 3-5 As a result, many many As a result, 6 and approximately and approximately

1 4,5 demonstrating the potential demonstrating 2 Many argued to acknowledge Many argued to acknowledge In addition, as many as 38 per cent 1 7-9 indicate that approximately one- approximately that indicate 1 Dr Deborah Walsh GCHEd PhD, MSW, BSW, lecturer Domestic and family violence specialist & Nursing, Midwifery and Social Work of Queensland The University US the Preventive Services Taskforce recommended recommended Services Taskforce US the Preventive settings and counselling in all healthcare screening childbearing age. for women of awareness of DFV affecting women was important women was important DFV affecting of awareness would be seen to be doing and healthcare violence and the cycle of something to break women’s safety. improve catastrophic consequences for women victims. catastrophic domestic and family Considering the gravity of violence (DFV) to intervene early in these an attempt by various health services, was introduced situations for DFV was born. This article screening and routine help seeking is complex behaviour and will argue that may detect DFV in healthcare screening while routine does not equal help seeking disclosure populations, and health nor does it mean women’s safety I will be arguing Therefore, outcomes will improve. the case against screening. emerged data In the 1980s and 90s, as prevalence routinely in favour of recommendations about DFV, women for domestic violence, particularly screening became commonplace. care, in antenatal in-three women have experienced violence, with women have experienced violence, in-three intimate by an the violence perpetrated much of may male partner in a domestic setting. While there that victimised, women who are be one-in-three who men one-in-three are does not mean there but not violent, men are violent. The majority of are have multiple partners. often those who are has been it When the health impact is measured, 30 per found to cause a global disease burden of cent for women. International estimates by the World Health by the World estimates International Organization screening for DFVscreening The case against routine against case The of homicides of women worldwide are committed committed women worldwide are homicides of of partner by a male intimate nursing and health researchers went on to produce went on to produce nursing and health researchers on standardising different data research volumes of tools. screening one woman per week is murdered by a domestic one woman per week is murdered partner in Australia, SILENT EPIDEMIC or fatal. the violentresponse maybesevere, lifethreatening violent partnerhaslostcontrol of theirpartnerand and duringthefirst12monthspost-separation isthe The key factorfortheincrease inriskat separation children toongoingabuseandviolence. frequently occursat childhandover, exposingthe biological children findthat ongoingvictimisation Women whoseparate from violentpartnersandshare separation, jealousyandrage. losing control, suspicionsof infidelity, involuntary who killfoundthat theydescribeexperiencesof any waypossible.Research undertaken withmen frequently resort topunishingherforleavingin escalates. Ifthat failstogetthepartnerbackthey to counsellingandifthat doesn’tworktheviolence tobeniceandpromise tochangeorgo first try change interventionprograms, menreport that they reduce violence. leave theviolencewillimprove healthoutcomesand who willthenhelpseekand,two, that supportto victims challenged. One,that screening willidentify is basedontwoassumptionsthat havebeen In summary, routine screening inhealthsettings ends, evenafter theviolentmanre-partners. may decrease overtime,forotherstheviolencenever some womentheexperienceof abusepost-separation services generallyorinspecificclinicalsettings support DFVscreening programs eitherinhealth concluded that there isinsufficientevidenceto has detectedDFV. Two systematic reviews have health andincrease women’ssafety oncescreening women. being ariskfactorinthedomestichomicideof if thewomanleavesrelationship, withseparation Numerous studieshavefoundthat violenceescalates the dangerinvolvedwhenleavingaviolentpartner. at domesticviolenceservicewebsiteshighlights glance leaves therelationship, butevenacursory It isacommonmyththat DFVendswhenthevictim doesnot equal safety Leaving DFV DFV doesnotmeananincrease insafety. is aproblem asthenextsectionwillshow–leaving victim issupportservicestohelpherleaveandthat detect violencetheonlyoptionwecanoffer the than there are forscreening becausewhenwedo are farmore compellingargumentsagainstscreening the violenceisnotthat bad.Itismyviewthat there potential toreinforce theirsilenceorthefeelingthat violence and,inmyview, screening forDFVhasthe already minimiseanddenytheirexperiencesof of coercive controlling behaviours.Women victims and broken bones,negating otherdamagingforms to reinforce thenotionthat DFVisaboutblackeyes assault, sexualviolenceandfearhasthepotential about violencethat relies onquestionsaboutphysical untested) concernisthat routinely askingwomen In additiontotheresearch findingsabove,my(yet victimised women. reduces violenceorimproves healthoutcomesfor they foundnorobust evidencethat DFVscreening risk of lethalviolence. is consistentlyfoundtobeassociated withhigher pregnancy… Separation isarelationship factorthat tochoke pets, trying thevictim,andabuseduring as wellthreats tokillthevictim,children or obsessive jealousy, stalking,andsexualassault, high risk.Theseincludecontrolling behaviour, forms of violencecanbe‘red flag’indicators of tocommonperceptions, non-physical Contrary 26 22-24 Inmyexperiencerunningbehaviour McKenzie etal 25 notethat: 27-29

25,30,31 While for Whilefor 17,18 as resources canbemade. women are ready toseekhelp,linksthose resources availableiscriticaltoensure that when does ornotdo.To haveup-to-date community fact herpartnermaynotchangenomatter what she experience willhelphertocometermswiththe timing intermsof disclosure andlisteningtothe providing avaluableintervention.Respectingher to listenandbelievewithoutjudgmentare infact about what ishappeningat home,are prepared seeking. Professionals whorespond tocues,ask to endtherelationship before theyengageinhelp reached theirtolerancethreshold andare prepared Women willhaveexhaustedallotheroptions, frequently comesat theendof alongprocess. only optionsforwomen.Thedecisiontoseparate staying withthepartnerorseparating are the With thecurrent responses toDFVinAustralia, 20. 19. 17. 16. 15. 14. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. orld HealthOrganization. Respondingtointimate partner 1. References 18. 13.

Against Women . 2005;11(3):290-310. violence help-seeking:implications forintervention.Violence 2014;348:2913. Cochrane systematic review andmeta-analysis. BMJ. intimate partnerviolenceinhealthcare settings:abridge Interventions%20to%20Reduce%20Violence.pdf. Available from: www.endvawnow.org/uploads/browser/files/ controlled evaluations. 2005. London:Departmentof Health. women whoexperiencepartnerabuse:asystematic review of and promote thephysicalandpsychosocialwell-beingof review. SocSciMed.2011;72(6):855-66. settings: evidencegenerated from arealist-informed systematic intimate partnerviolencescreening programs inhealthcare Department. responding todomesticviolence.2003. NSWHealth pilot-evaluation.pdf. kidsfamilies/protection/Publications/unless-they-are-asked- Department. Available from: www.health.nsw.gov.au/ for domesticviolenceinNSWHealth.2001.Health Australia. Key Centre forWomen’s HealthinSociety. 1998. Melbourne, 2001;10:41-6. Women AgainstViolence: AnAustralianFeministJournal Med. 1998;30(7):508-12. violence screening toolforuseinafamilypracticesetting.Fam 1993;4(3):350-62. hope. AWHONNS ClinIssuesPerinat Womens Health Nurs. Scale. Women’s Health. 1995;1(4):273-88. development of theWomen’s Experiencewithbattering (WEB) 478-86. recommendation statement. AnnIntern Med.2013;158(6): of vulnerable adults:U.S. preventive servicestaskforce Moyer Emerg Med.1996;27(6):741-53. Domestic ViolenceVictimsinanEmergencyDepartment.Ann Roberts GL,O’T 1986;86(8):910-3. Helton A.Ba department. AustJPublicHealth. 1995;19(3)293-9. experienced bywomenattending anaccidentandemergency Ba no 23. 2015. Canberra:AustralianInstituteof Criminology. National HomicideMonitoringreport. Monitoringreport series Br policy guidelines.2013. Geneva,Switzerland. violence andsexualagainstwomen.WHOclinical W Meyer S F O’Doherty LJ Health Technol Assess.2009;13(16):iii-iv, xi-xiii, 1-113, 137-47 reviews of nineUKNational Screening Committee criteria. settings meetcriteriaforascreening programme? Systematic women fordomestic(partner)violenceindifferent health-care Feder G,RamseyJ Ramsey J O’Campo P NSW Health.Policyandpr Irwin J Conference Proceedings. 2000. Melbourne,Australia. Way Forward:Children, Young PeopleandDomesticViolence S Lawler V T Sherin KM,Sinacor McF Hall- aft, A. To screen ornottoscreen –isthistherightquestion? ugate M,LandisL,Riordan,K,etal.Barriersto domestic tratigos S. Domesticviolencescreening andpregnancy. The yant W, CussenT. HomicideinAustralia:2010–11to2011–12: tes L,RedmanS, Brown W, HancockL.Domesticviolence arlane J. Abuseduringpregnancy: thehorror andthe Smith P, EarpJA, DeVellis, R.Measuringbattering: , VA. Screening forintimate partnerviolenceandabuse , Waugh F. asked: Unless they’re routine screening . Respondingtointimate partnerviolencevictimisation: . DomesticViolence:acaseforroutine screening. , RivasC,FederG.Interventionstoreduce violence , KirstM,Tsamis C,etal.Implementingsuccessful ttering duringpregnancy. AmJNurs. , Taft A,HegartyK,etal.Screening womenfor oole BK,Raphael,B. Prevalence Study of , Dunne,D, etal.Howfardoesscreening e JM,LiXQ, etal.HITS: Ashortdomestic ocedures for identifying and ocedures foridentifying . SILENT EPIDEMIC Vol. 19 No. 4 Summer 2017 | 25 Vol. f masculine violence. 1994. 1994. f masculine violence. eport on OG response to Ph: +61 3 9417 1699 +61 3 9419 0672 Fax: Email: [email protected] www.ranzcog.com.au ealand House of . 1993;8(1):3-16. , Hotton T. Losing control: Homicide risk in Homicide Losing control: , Hotton T. , Stuckless N, Smith C. Marital separation and lethal and lethal separation Smith C. Marital N, , Stuckless eseredy WJ, Dragiewicz M, Schwartz, MD. Abusive Endings: Schwartz, MD. Dragiewicz M, WJ, eseredy tient information eoli AM, Rivera EA, Sullivan CM, Kubiak S. Post-Separation Post-Separation S. Kubiak eoli AM, Rivera EA, Sullivan CM, epresentatives R epresentatives domestic violence. 2015. Abingdon, Oxon, Routledge, Routledge, Oxon, Abingdon, 2015. domestic violence. Press. University Cambridge New York: Wilson M, Daly M. Spousal homicide risk and estrangement. M. Spousal homicide risk and Wilson M, Daly Violence Vict Johnson H kill: scenarios o Polk K. When men Dek Z Boundary their Children: and setting and Women Abuse of Mothers. J Fam among Victimized Court Utilization Family Violence. 2013;28(6):547-60. Ellis D Homicide Studies. relationships. intact intimate estranged and 2003;7(1):58-84. Oakland 2017. Violence Against Women. and Divorce Separation California Press. of California, University the New Z R Surgical Mesh

AUSTRALIA College House, 254-260 Albert Street East Melbourne, Victoria 3002, Australia. 27. 30. 26. 28. 29. 31. • The RANZC • College Communiqués • Pa te OG submission tion tements ranzcog.edu.au/mesh-resources . Intimate partner violence, parental violence, parental partner . Intimate , Allen NE. Findings from a community- from , Allen NE. Findings , Sharps PW, et al. Intimate partner partner Intimate et al. , Sharps PW, y and supporting to the Australian Sena Inquir documenta A video explainer enzie M, Kirkwood D, Tyson D. Out of Character? Legal Out of D. Tyson enzie M, Kirkwood D, • • College Sta • The RANZC Pelvic mesh information information Pelvic mesh your patients for you and RANZCOG has created a new page on the College website to new page on the College website to a created has RANZCOG mesh. Find it on the home page answer questions about pelvic or visit: Health under Women’s ffe PG, Crooks CV, Poisson SE. Common misconceptions in Poisson SE. Common CV, ffe PG, Crooks responses to intimate partner homicides by men in Victoria to intimate responses Victoria. Centre Domestic Violence Resource 2016. 2005–2014. homicide: review and implications of research and police. research of and implications homicide: review . 2007;8:246-69. Violence and Abuse Trauma GH Hardesty JL, Chung for intervention and future and child custody: directions divorce, . 2006;55(2):200-10. Relations Family research. Ja in child custody disputes. Juvenile domestic violence addressing Journal. 2003:57-68. Court and Family McK rends and Issues in Crime Issues in Crime Trends and help-seeking. options for effective . 2010;389:1-6. and Criminal Justice DI Sullivan CM, Bybee Glass N Campbell JC, based program for battered women and their children. and their children. women for battered based program . 2002;17(9):915-36. Violence J Interpers

23. 24. 25. 21. 22. SILENT EPIDEMIC Hospital Sexual Health MedicineRegistrar atFremantle Centre, Western Australia Senior MedicalOfficerattheSexualAssault Resource MBBS (Hons),DRANZCOG, FRACGP Dr MirandaHowlett anus. involve sexualpenetration of themouth,vaginaor the termsexualassaultrefers tothosecasesthat of sexualassault Clinical assessment sexual assault. Table 1.Commonmedicalpresentations following and disclosethat theyhavebeenassaulted.Theyalso The sexualassaultvictimmaypresent toyouopenly Taking ahistory Resource Centre (SARC)fordefinitivemanagement. able torefer suchcasestotheirlocalSexualAssault assault. Inmostcircumstances aclinicianwillbe to beconfident responding toadisclosure of sexual Given itsprevalence, itisimportantforallclinicians up approximately 15percentof sexualassaultcases. current orex-partners. Stranger assaultsonlymake victims andahighproportion of perpetrators are perpetrators of sexualassaultare knowntotheir topopularbelief,Contrary themajorityof rising, with2016data revealing aseven-yearhigh. incidence of sexualassaultinAustraliaiscurrently use of violence,coercion orintimidation. carried outagainstthewillof apersonthrough the Sexual assaultisbroadly definedasanysexualact a sexualassaultsinceage15. one-in-25 menovertheageof 18haveexperienced review in2012estimated that one-in-sixwomenand The AustralianBureau of Statistics’ personalsafety Deterioration inworkor school performance Drug oralcoholabuse suicide attempts Psychiatric presentations, self-harm, Memory loss Injury, domesticviolence Reluctance for Papsmears Pelvic pain,sexualdysfunction Unwanted pregnancy STI screen Requesting emergency contraceptionor sexual assault Common medicalpresentations following 2 Sexual assault is very commoninAustralia. Sexualassaultisvery 3 Rather alarmingly, the 1 Legally, 1 3 assault orwitharaisedBMI. women presenting more than72hourspostsexual is nowanoptiontoconsider, especiallyforthose predominantly uselevonorgestrel; however, ulipristal her appropriate emergencycontraception.We is usingreliable contraceptionand,ifnot,tooffer pregnancy. Itisimportanttodetermineifthewoman female sexualassaultvictimsisthat of unwanted forensic examination. Acommonconcernfollowing Medical concernsalwaystake priorityovera 1a. Medicalissues–contraception psychosocial andforensic. There are three key areas toconsider:medical, Assessment andmanagement police andtheirchoiceshouldberespected. However, manypatients willnotwanttoreport tothe the perpetrator from committinganotherassault. responsibility toreport topoliceinorderprevent Some cliniciansfalselybelievethat itisthevictim’s to discusstheoptionsavailablepatient. in Table istaken, 2.Afterthehistory itisimportant willgather theinformationA goodhistory detailed the ageof 18mustbereported. cases of sexualassaultthat occurtoapersonunder state tostate. InWestern Australia,wemustreport all from reporting lawsvary to assessment.Mandatory it isimportanttodiscussthiswiththepatient prior limit toconfidentialityreporting and ismandatory police ortheirfamilywithoutconsent.One aware that theassaultwillnotbediscussedwith confidentiality anditslimits,sothat thepatient is not rushthepatient. Take thetimetoexplain Ideally, take inaprivate area anddo thehistory criminal justicesystem. will report tothepoliceandproceed through the patient feels,itwillalsohelpdeterminewhetherthey assault willnotonlyinfluence howmuchdistress the way inwhichyourespond toadisclosure of sexual and fearthat theywillnotbebelieved.Thus,the Many victimsof sexualassaultexperienceself-blame sexual ormentalhealthproblems (Table 1). sexual assaultwhenapatient presents withinjuries, might present indirectly. Itisimportanttoconsider assault. Azithromycin canbe offered prophylactically infection predated, orwasacquired from, thesexual infection diagnosed.Itisnotalways clearifthe and foundthat chlamydiais themostcommon I conductedanauditonSTIdetection at ourSARC screening, takingwindowperiodsinto account. assess theneedforprophylaxis andarrangeSTI information abouttheirriskof acquiringanSTI; patient. Fortheremaining patients, wemustprovide case of adigitalassault,wecaneasilyreassure the sexual assaultistheriskof acquiringanSTI. Inthe One of themostcommonconcernsfollowinga 1b. Medicalissues–STIs 4 SILENT EPIDEMIC

Vol. 19 No. 4 Summer 2017 | 27 Vol. The clothes worn 8

7 Multiple assailants sex with men Men who have IV drug use Incarceration Receptive anal penetration in the oral/vaginal/anal mucosa Breach particularly gonorrhoea STI, Concurrent From a high-risk country (SE Asia or a high-risk country From Africa) • • • • Assault features • • • Risk factors associated with higher rates of HIV and of with higher rates Risk factors associated B transmission following sexual assault hepatitis Assailant features • Given that many sexual assaults are carried out by carried many sexual assaults are Given that is it is important to assess if the patient a partner, if the and to their accommodation to return safe needs to be involved Child Protection Department of any children. of the safety to ensure 3. Forensic issues of assessment involves documentation The forensic specimens to detectany injuries and collection of DNA and trace evidence. The chance of finding DNA so increases lessens as the time to examination collect should the first clinician to see the patient to the tailored an early evidence kit (EEK). EEKs are first assault, but may include an oral rinse, type of the vulval, penile or wipe of void urine or a gauze WA very EEKs are regions. effective, with a peri-anal were spermatozoa that SARC study demonstrating 42 per cent EEKs versus detected in 35 per cent of examinations. full forensic of Risk factors associated with higher rates with higher rates Risk factors associated 3. Table B transmission following HIV and hepatitis of sexual assault. give the second hepatitis B vaccine if the course if the course B vaccine hepatitis second give the The three- the initial presentation. at was started and serology up involves repeating month follow B vaccination. hepatitis the course of completing issues – injuries 1c. Medical over any priority takes the patient of Medical safety you that so it is imperative investigation, forensic a history to exclude and examine the patient take need to be managed prior that any significant injuries need injuries that of to transfer to SARC. Examples include head SARC review prior to medical review suspected fractures strangulation, injuries, attempted bleeding. and heavy anogenital 2. Psychosocial issues many people experience Following a sexual assault, disturbance, depression, sleep suicidal ideation, It is disorder. stress anxiety and post-traumatic a risk assessment on all patients important to perform for counselling. following a sexual assault and refer regular or one-off Our Perth SARC is happy to offer a counselling to people who have experienced sexual assault. at the time of the assault should also be collected, the time of at should bag. Clothing with each item in a separate still be collected even if it has been washed because DNA may still be obtained. Blood and urine samples assessment if drug should be collected for toxicology sexual assault is suspected. facilitated to should be carried out A top-to-toe examination look for any general body injuries. It is important

5 6 Important features on historyfeatures Important assault of date Time and where) went assault (what of Brief description Condom used Number? assailant: Stranger? Details of IV drug user? Incarcerated? Ethnicity? strangulation) attempted (particularly Violence bleeding Injuries or anogenital use drug or alcohol Preceding contraception Current and any children patient Risk assessment for self or perpetrator) (from (pregnancy? concerns Identifying patient’s STIs? safety?) issues Accommodation Mental health history STI screening is performed at the time of initial the time of is performed at STI screening one month and three and at presentation is for chlamydia, Baseline screening months after. C, HIV and hepatitis B, gonorrhoea, hepatitis a penile-oral or penile- reports syphilis. If a patient the anal assault, one should collect swabs from the one-month follow up oropharynx At or rectum. can also we test for chlamydia and gonorrhoea. We to all victims of sexual assault; however, some sexual assault; however, to all victims of treatment prophylactic to reserve clinicians prefer to high risk or unlikely at who are to those patients for follow up. return gonorrhoea for cases against prophylaxis offer We Knowing we deem the assailant to be high risk. where gonorrhoea will risk factors for, and of, your local rates prophylaxisassist you in deciding whether to provide to your patients. a sexual It is uncommon to contract HIV after easily assault in Australia. This is because HIV is not vaginal sex and unprotected transmitted through HIV in Australia of because the overall seroprevalence HIV transmission per cent). The risk of is low (0.14 penile-vaginal sex with an HIV- receptive after treatment) positive male (who is not on antiretroviral is 1/1250 sex. versus 1/70 penile-anal receptive after We offer post-exposure prophylaxis to those patients to those patients prophylaxis post-exposure offer We and either exposure within 72 hours of who present assault is deemed to be the assailant or the type of 3). high risk (Table B can easily be transmitted hepatitis HIV, Unlike penile-vaginal and penile-anal unprotected through literature deal of is not a great There penetration. against prophylaxis post-exposure regarding against has been vaccinated If the patient B. hepatitis then they B, with hepatitis infected or previously B vaccine a hepatitis offer should be immune. We and who to be immune to anyone who is unlikely B Hepatitis exposure. within two weeks of presents for those cases assessedimmunoglobulin is reserved 3). B transmission (Table as high risk for hepatitis Important features on history. features 2. Important Table SILENT EPIDEMIC in thisfield. Special Interest Group incollaboration withother experts under theauspiceof theSexualand Reproductive Health coordinated thedevelopmentof thiseducational module of ObstetriciansandGynaecologists (RANZCOG) The RoyalAustralianandNew Zealand College MedEduc. 1999;33(1):24-7. Williams L,ForsterG,PetrakJ. Rapeattitudes amongstBritishmedicalstudents. presenting fortreatment.’ influence thelikelihood of victims management of sexualassaultand can haveasignificantimpactonthe attitudes amongsthealthcare staff ‘Better knowledgeandenlightened likely perpetrators inthesecases(30.4%). or severe injuriesandintimate partnersare themost Approximately one-in-fivewomenhavemoderate will havenogeneralbodyinjuriesonexamination. type, colourandsize. Nearlyone-thirdof patients documenting injuriesisSPICS: site,position,injury heal within72hours). amnesia orifexamination isdelayed(mostinjuries less likely tobeseenifthevictimreports sedation or of sexualintercourse (upto52percent).Itis history ispresent andifthere isnoprior general bodyinjury ismore likelyinjury ifthere are multiplepenetrants, consistent withpublisheddata worldwide.Genital of casesof completedvaginalpenetration. Thisis occursin24showed that genitalinjury percent for anogenitalinjuries.Ananalysisof ourdatabase In Perth,weusenaked-eye examination tolook incised wounds. injuries, namely, bruises,abrasions,lacerations or to usethecorrect terminologytodocumentany we canbecontactedon64581828. clinicians, theWA SARCrunsa24-hour serviceand commencing aforensic assessment.ForPerth do nothesitate tocontactyourlocalSARCbefore of arecent sexualassaultiscomplex,soplease the mature minorprincipledonotapply. Assessment consent foraforensic examination, dutyof care and requirements. Itisimportanttonotethat inobtaining examination andhencethere are specificconsent A forensic assessmentisnotatherapeutic tend tobelower. however, there islimitedpublisheddata andtherates also occurduringconsensualvaginalpenetration; Sexual Assault module eLearning 9 9 Ausefulmnemonictousewhen 11 Ofcoursegenitalinjuriescan www.climate.edu.au/course/view.php?id=231 10 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References 7. 6. 5. 4. 3. 2. 1. Topics covered: order, oraccessthetopicsonaneedsbasis. It hasseventopics;youmaynavigate through eachin providing appropriate care to survivorsof sexualassault. prevalence of sexualassaultandtheimportanceof Trainees, FellowsandDiplomates inunderstandingthe This module is designed as a resource to assist RANZCOG

recent sexualassault.ForensicSciInt. 2017;275:195-202. A cross-sectional Australianstudyof 1266womenalleging Zilk women. ForensicSciInt. 2017;279:112-20. injuries: adetailedcross-sectional Australianstudyof 1163 Zilk 2004;190(1):71-76. assault: findings of alargecaseseries.AmJObstetGynecol. Sugar NF 2014;10(3):336-43. urine andotherforensic specimens.ForensicSciMedPathol. assault: anobservational studyof spermatozoa detectionin Smith D assault. BestPractResClinObstetGynaecol.2013;27(1):27-37. Mason F Hepatitis B. Departmentof Health,2017. Immunisation Handbook,10thEd,2017Update. Chapter4.5: Australian GovernmentDepartmento Guidelines, 2ndEd.ASHM,NSW, 2016. and Occupational exposure toHIV: AustralianNational Medicine. Post-Exposure Prophylaxis after Non-Occupational Australasian SocietyforHIV Australian Family Physician.2017;46(5):301-4. Mazza D Canberra: AustralianBureau of Statistics; 2013. Australian Bur Portal/Criminal-offence-descriptions. wa.gov.au/Crime/Crime-Statistics-Portal/Crime-Statistics- Descriptions [CitedSept2017].Available from www.police. W Australia, 2016. Canberra:AustralianBureau of Statistics; 2017. Australian Bur Working with victimssurvivorsof sexualassault Forensic examination Medical responses tosexualassault Childhood sexualassault The impactof sexualassaultonits victims/survivors Sexual assaultandthelaw An introduction estern AustralianPoliceForce (Aus).CriminalOffence ens RR,SmithDA, PhillipsMA,etal.Genitalandanalinjuries: ens RR,SmithDA, Kelly MC.SexualAssaultandgeneralbody A, Webb LG, FennelAI, etal.Earlyevidencekitsinsexual , LodrickZ.Psychologicalconsequencesof sexual . Ulipristalacetate: Anupdate forAustralianGPs. , FineDN, Eckert LO. after sexual Physicalinjury eau of Statistics. PersonalSafety Survey, 2012. eau of Statistics. Recordedcrime–victims, , ViralHepatitis andSexualHealth f Health.TheAustralian SILENT EPIDEMIC Vol. 19 No. 4 Summer 2017 | 29 Vol. : excision of all or part of the clitoris all or part of of ype 1: excision the clitoris and of ype 2: partial or total removal the external genitalia and of ype 3: removal clitoris or labia. of ype 4: pricking, piercing the labia minora the vaginal opening of stitching/narrowing (infibulation) of vaginal tissue, or introduction Scraping of substances into the vagina to cause bleeding, falls within the that or any other procedure above definition T T T T • • • consequences Health FGM/C has no known health stated, As previously are affected by FGM/C Women and girls benefits. various complications suffering from a risk of at can complications their lives. Immediate throughout pain, shock, haemorrhage, tetanus, include severe genital in the open sores sepsis, urine retention, and injuryregion genital tissue. to nearby Long-term consequences can include dysuria, UTIs recurrent cysts, dyspareunia, implantation dysmenorrhoea, pelvic and vaginal infections, difficulties during inflammatory disease, infertility, and childbirth and mental health issues. pregnancy FGM/C may also have long-term effects on the those who psychosexual and psychological health of have undergone the procedure the of to be aware It is critical for health professionals FGM/C can bring health consequences that negative and appropriate early identification and to ensure the same time, it is also important At treatment. to consider the women’s health history and not a all health issues are subscribe that immediately her FGM/C experience. This can be a difficult of result balancing act. Reasons for the practice are complex, arising from a complex, arising from are Reasons for the practice cultural and social traditions belief system based on social acceptance impinge on the woman’s that While her community. and marriageability within religious FGM/C to be part of some people believe not the case. this is in fact requirements, Types of FGM/C four types, depending on FGM/C is classified into the severity: • A special note on terminology girls’ and women’s human rights. of the practice is a violation that is used to reinforce The term mutilation advocacy the act and promotes emphasises the physical, social and psychological consequences of Mutilation the term The use of the community level, this term can be problematic. at the practice. However, to eliminate to forming an in a clinical encounter may have the potential to be counterproductive ‘female genital mutilation’ for of ongoing care and hence detrimental to the provision with the patient relationship effective professional with each you explore terms, so we suggest that communities use different is a sensitive issue. Different what traditional description are of accepted forms terminology they use for the practice. If unsure, individual what this article we use the term FGM/C. throughout For this reason, female cutting or female circumcision. A growing number of migrants and refugees who migrants and refugees number of A growing practice female genital countries that come from (FGM/C) have settled in Australia mutilation/cutting ongoing over the last few decades. This has been an in (and occasional controversy) interest of area article the obstetrics and gynaecology fields. This FGM/C and offers a general overview of provides some practical suggestions on how to appropriately by FGM/C. engage with women and girls affected An overview (2016) Health Organization According to the World involve the that all procedures FGM/C ‘comprises other external genitalia or of partial or total removal injury to the female genital organs for non-medical has no known health benefits.’ The procedure reasons. 200 million women and girls that It is estimated 2016). worldwide have undergone the practice (WHO, in 30 countries in Africa and a fewFGM/C is prevalent countries in Asia (such as, some communities in India, Indonesia, Malaysia and Pakistan) and the Middle East. which it is performed varies accordingThe age at Through to countries, tribes and circumstances. by women and girls affected migration, international FGM/C now live in many countries, including Australia providers all healthcare Therefore, and New Zealand. accessible, quality, to provide have a responsibility to those affected. care culturally safe in our clinical practice? clinical in our Oyekanmi Wemi Liaison FARREP/African Mercy Hospital for Women Does FGM/C still matter matter still FGM/C Does Natalija Nesvadba Services Multicultural Manager, Mercy Hospital for Women Dr Bernadette White FRANZCOG Clinical Director Obstetrics Mercy Hospital for Women The use of the term FGM/C. 1. The use of Box An introduction Sexual assault and the law sexual assault on its victims/survivors The impact of Childhood sexual assault to sexual assault Medical responses examination Forensic sexual assault with victims survivors of Working This module is designed as a resource to assist RANZCOG assist to resource a as designed is module This the in understanding Fellows and Diplomates Trainees, sexual assault and the importance of of prevalence sexual assault. survivors of to care appropriate providing each in through It has seven topics; you may navigate or access the topics on a needs basis. order, covered: Topics 1. 2. 3. 4. 5. 6. 7. www.climate.edu.au/course/view.php?id=231 eLearning Sexual Assault module Sexual Assault ‘Better knowledge and enlightened ‘Better staff amongst healthcare attitudes can have a significant impact on the sexual assault and management of of victims the likelihood influence for treatment.’ presenting amongst British medical students. Rape attitudes Williams L, Forster G, Petrak J. 1999;33(1):24-7. MedEduc. College The Royal Australian and New Zealand Obstetricians and Gynaecologists (RANZCOG) of module this educational the development of coordinated Health the Sexual and Reproductive under the auspice of with other experts in collaboration Group Special Interest in this field. SILENT EPIDEMIC Box 2.Further suggestionstoassistinproviding appropriate care. • • Thematic data analysisidentifiedthefollowing: with thetargetgroup. young womenandthree key stakeholders whowork semi-structured interviewsandfocusgroups with12 appropriate worker wasemployedtoconduct age appropriate. Aculturallyandgenerationally and deliversupportservicesthat are culturallyand communities todeterminewaysdevelop,improve women (18–25yearsold)from FGM/Caffected FGM/C. Ouraimwastoexplore experiencesof young supporting youngwomenwhohaveexperienced In 2014, we conductedasmallqualitative study Providing culturally safe care health professionals inthisarea. affected byFGM/C,aswellbuildingthecapacity of FARREP serviceproviders aimingtosupportwomen Mercy HospitalforWomen inMelbourneisoneof the Reproductive RightsEducation Program (FARREP). Human ServicesinVictoriafundstheFamily and For example,theDepartmentof Healthand consultations. services fortrainingandsecondary professionals canalsoaccessmanyof these useful resources formore information). Health number of FGM/Cspecificsupportservices(see In AustraliaandNewZealand today, there are a health complications from FGM.’ informed recommendations onthemanagementof with anaimto‘provide up-to-date, evidence- health complication from femalegenitalmutilation published thefirstGuidelinesonmanagement of After decadesof workinthisfield,2016, WHO persists insomecommunities. countries. Despitesomeimprovements, FGM/C in thecountriesof originaswellhostmigrant abandon thepracticeinsomeaffected communities Concentrated effortshavebeenmadetoeradicate or The currentstate • • • • • • • Engagement andreferrals: • • • Communication: Tips thatmayassistinprovidingbettercaretowomenaffected byFGM/C • to them. understanding of servicesthat maybeavailable when required other healthprofessionals willoffer support They expr pr The youngwomenwhoparticipated inthe you canassist,suchasbyusing different sizes of instruments this procedure Refer womenwhor Build ar male healthprofessional. Inthiscase,consideroffering afemalechaperone Pr they wouldlik Other significantpeoplemayneedtobeinvolvedinconsultations. Alwayscheckwithawomanifandwho Remind thewomano Pr Engage appr Consider healthliteracy Alter yourappr If childbornisfemale,r For pr oject experiencedalackof awareness and ovide femalehealthprofessionals where possible.Alternatively, toseea explainwhyitmaybenecessary ovide information inthewoman’sfirstlanguage,where available egnant women,explainoptions foraccessingeitherantenatal orintrapartumde-infibulation elationship withyourlocalFGM/Csupportservice essed anexpectation that GPsand opriately qualifiedfemaleinterpreters, if required e tobepresent oach. Forexample,womenaffected byFGM/CmayavoidPaptests.Engageandexplainhow equire de-infibulation tohospitalsthat haveestablishedservices tosupportwomenfor f confidentiality andprivacy emind patient that FGM/C isillegalinAustralia . Forexample,useplainEnglish,avoidmedicaljargon,checkfor understanding shaped by cultural and family values and traditions. shaped byculturalandfamilyvaluestraditions. help-seeking behavioursandhealthliteracyare largely educated inAustralia.However, itappearsthat their wellandhavebeen can speakandwriteEnglishvery a significantpart of theirlife.They report that they Participants inthisproject havelivedinAustraliafor community.’ (Participant#4) experience orfacingthesameissuestothat of my professionals toassumethat Ihavethesame with herownneedsandissuesrather thanfor important tomebetreated like anindividual same experiencesorfacingtheissuessoit’s from aparticularcommunity. We alldon’thavethe rather thanbeingputinagroup becauseyouare is alsoimportanttobetreated like anindividual is difficultfor professionals tounderstandyou.It ‘Better understandingisimportant;sometimesit this isnotconsistentlypractised. this isnotanewfinding,ourexperiencetellsusthat emphasis onprivacy, confidentiality andtrust.While responsive care; accesstobi-culturalworkers; and highlighted theneedforperson-centred, culturally hours of operation andlocation, theparticipants and support.Apartfrom practical,features suchas be importanttothemiftheywere toaccessservices They alsoidentifiedanumber of features that would • Zealand http://fgm.co.nz FGM information forhealthandchildprotection professionals inNew experienced FGM/C.2014. Melbourne,Australia. Mercy PublicHospitalsInc.Supportingyoungwomenwhohave Available from: www.netfa.com.au. The National Education Toolkit forFGM/CinAustralia(NETFA). 2015. fgm/en. reproductivehealth/topics/fgm/management-health-complications- female genitalmutilation. 2016. Available from: www.who.int/ WHO guidelinesonthemanagementof healthcomplications from factsheets/fs241/en. WHO factsheetonFGM.Available from: www.who.int/mediacentre/ Further reading Access toappr information sessions. variety of modes,includingonlineandthrough recommended deliveringinformation ina noted byparticipantsasachallenge.They about FGM/Candsupportsavailablewas opriate, relevant information SILENT EPIDEMIC

3 3,4

6 Vol. 19 No. 4 Summer 2017 | 31 Vol.

7 Of note, the evidence gap is Of note, the evidence gap is 3,4 If recognised for resettlement as a refugee, as a refugee, for resettlement If recognised 3,5 ‘any sexual act, attempt to obtain a sexual act, to obtain a sexual act, sexual act, attempt ‘any or acts unwanted sexual comments or advances, person’s against a or otherwise directed, to traffic, by any person regardless sexuality using coercion, to the victim, in any setting, their relationship of including but not limited to home and work.’ The numbers are inexact and, very likely, and, very inexact The numbers are likely, Poor or non- reasons. for various underestimates, and the ‘normalisation’ collection existent data to the violence in many contexts can be added of many well-documented individual and structural including shame, stigma care, barriers to receiving accessible, and lack of repercussion, and fear of services. appropriate even greater for men than women. for men than women. even greater by a Non-partner violence can be exacerbated factors. Displacement and its push number of a of cause – can be the factors – especially conflict for the victim then carries experience that traumatic years. The global burden 30 per an estimated global averages, In terms of a relationship of women with experience cent of partner violence, while intimate have suffered been victims of women have per cent of 7.2 a non-partner. hands of the sexual violence at Defining sexual violence defines sexual Health Organization The World violence as: This definition is important to MSF and other This definition is important to MSF and other because in some humanitarian organisations, of we work, the legal definition countries where sexual violence means rape only. MSF’s response to sexual violence combines model for sexual violence care MSF’s core as a priority in medical and psychological care care This patient-centred the first consultation. Our in strict confidentiality. for free, is offered can we do for this person that’s impetus is: ‘What their life for them and is going to make appropriate a little bit better?’ our sexual violence patients Over 90 per cent of comprises Our care women and children. are treatment physical injuries; prevention, of treatment such as HIV and against infections and vaccination unwanted and management of STIs and prevention and a large component if appropriate; pregnancy, is psychological support, which can include referral the patient also provide if needed and available. We with a medical certificate. when we have the Beyond the first consultation, further care in a context to provide capacity or are by ourselves or with others, we do. Networking is for the and assistance care to comprehensive key response a holistic individual, and to influencing multiple sectors. across they may carry it all the way to Australia.

2 Our colleague Kate White, Our colleague Kate 1 Alexandra Brown BA, MIPH Communications Department Australia, Sydney Médecins Sans Frontières Margaret Bell GradDipNurse(Infect) RM, PostGradCert(Infect), RN, Medical Unit Australia, Sydney Médecins Sans Frontières seeking refuge refuge seeking Assisting women women Assisting So what can be done for such victims of sexual can be done for such victims of So what What can we provide? care kind of violence; what do we need to know about the hazards the women for the best have faced? How can we adapt our care it? providing we are outcomes in the context where At the time of writing, over half a million people the time of At refuge in have fled violence in Myanmar to seek is yet to abate. that exodus Bangladesh in a dramatic indeed. Predominantly is precarious Their ‘refuge’ trapped in conditions that are women and children and health due to the their safety continue to threaten severe sanitation, settlements, insufficient makeshift arefood shortages and poor security overall. There options in wealthier countries. calls for resettlement medical- In these chaotic circumstances, Médecins Sans Frontières humanitarian organisation dehydration, with severe (MSF) has seen patients by other physical trauma and, in line with reports women showing numbers of growing organisations, sexual violence. signs of emergency coordinator in Bangladesh, has said ‘this emergency coordinator to be out likely are the cases that is a fraction of and we know she’s right. there,’ SILENT EPIDEMIC and thewholecommunity. largescale,reverberating througha very thefamily destabilisation of communities.Itcanbedeployedon strategy for areas, sexualviolenceisalsoamilitary have sexwithme’.More sinisterly, inhigh-conflict as, ‘I’ll giveyoufoodforyourchildren ifyouagree to heard of theterm‘survivalsex’andcoercion such vulnerable tosexualexploitation –youmayhave safety, shelterorbasichealthcare. Thismakes them situations, peopleoften havelimitedaccesstofood, to highlevelsof conflict andinstability. Inthese emergency programs havebeenforced tofleedue Most of thevictimsof sexualviolenceinour A violentjourney reach thedispersedpopulation. We wouldtravel We set upfixed, semi-fixed andmobileclinicsto provision of care. of thisrole wascrucialtohelpingusexpandour most appropriate care. Ourstaff’s positiveembrace them tobeempathetic tothevictimsandprovide the associated withsexualviolence.Thisthenallows common, itisimportanttoeducate staff inall issues staff. Incontextswhere violenceisthe‘norm’or We also undertooksensitisation trainingwithour to, supportedandfollowedupifnecessary. and confidential placewhere theycouldbelistened help. Peopleneededtoknowthat there wasasafe violence, whichoften impedestheirabilitytoseek can betraumatised, scared anddesensitisedto available. Witnesstootherviolenceaswell,victims to talkaboutsexualviolenceandhowcare was appropriate. We created communityoutreach teams and ensuringthat ourserviceswere accessibleand program withanemphasisonraisingawareness Employing mostlyUgandanstaff, wedevelopedour Establishing adedicatedprogram prevention of HIVorunwantedpregnancy. after theattack, missingthedeadlinesforeffective many were notabletoreach care untildaysorweeks attacked ingroups rather thanasindividuals,and soldiers were themostimplicated; thewomenwere rape, mostlyenroute, includingat theborder. Armed vulnerability. Theyhad suffered sexualviolence, often of MSF’spatients confirmed theircollective have endured aslowerjourney. Thetestimonies women withchildren and/orhidingalongtheway of arrivalswere womenandchildren. Typically, Between AprilandMay2017, areported 86percent in 2017. commenced care inbothUgandansettlements or natural disaster, andMSF(nottheonlyresponder) the onsetof ahumanitariancrisis,suchasconflict other sexualandreproductive healthservicesat Care forvictimsof sexualviolencestilllagsbehind opening of anewsettlement,Imvepi. known asBidihadreached capacity, spurringthe outpatient care. ByDecember2016, thesettlement water andsanitation servicesandinpatient and northwest. InitiallyMSFresponded withlarge-scale Sudanese refugees havefledtoUganda,intothe Since mid-2016, more thanonemillionSouth 5

en route. before theylefttheircountry, theothertwo-thirds for agynaecologicalcheck-up: one-thirdassaulted This includedapproximately halfof thewomenseen but predominantly inourwomen’shealthclinics. victims of violenceviamentalhealthassessments, cut, increasing theirvulnerability. MSFidentified healthcare andotherservicesforthemwere severely arrivals betweenAprilandJune.At thesametime, the Mediterranean,there wasahugesurgein Lesbos, aGreek islandandhotspotforcrossing Meanwhile inthenorthernhemisphere on Other pathways tocare care, aswellsecure referral pathways forthem. have suffered sexualviolencebutare yetto receive otherpockets ofto identify peoplethat are likely to organisations, wehavealsobeenabletocontinue each day. Through coordination withother equipment andmedicineneededtosetupafresh for privacyandconfidentiality, andall relevant with ourstaff, ourtentswithmoveablepartitions journey torecovery. andassisttheminstartingtheir their long-heldstory can offer thesupportthat allowsavictimtoshare or yearslater itmaybe,ashealthcare providers we implementation. Yet, howevermanyweeks,months culture, isnotpossiblewithoutcareful planningand Ensuring appropriate care, basedonage,genderor psychosocial needsisoneof thegreatest challenges. provide timelycare toresolve pressing medicaland victims and and displacement.Beingabletoidentify sexual violencecare, especiallyincontextsof conflict There are manyfrustrations andbarriersinproviding Never toolate that couldhelpthemrecover. completely lacked themedicalorpsychologicalcare their firstever. Forweeksandmonths,theyhad 8. 7. 6. 5. 4. 3. 2. 1. References

org/files/msf_lesbos_vulnerability_report1.pdf. Seekers onLesbos.2017. Available from: www.msf.org/sites/msf. Medecins SansF 2015;385(9977):1567-79. systems response toviolenceagainstwomen.Lancet. Gar sc_update_women_at_risk.pdf. from: www.dss.gov.au/sites/default/files/documents/01_2014/ Getting Settled:Women RefugeesinAustralia.2013. Available The AustralianGovernmentDepartmento Available from: www.stoprapenow.org/. UN ActiononSexualViolenceinCon 2014;383:1648-54. of non-partner sexualviolence:asystematic review. Lancet. Abrahams N non-partner sexualviolence.2013. World HealthOrganization. Prevalence andhealtheffects of intimate partnerviolenceand WHO idUSKCN1BZ06X. see-evidence-of-rape-in-myanmar-army-cleansing-campaign- com/article/us-myanmar-rohingya-rape-insight/u-n-medics- army ‘cleansing’ campaign.2017. Available from: www.reuters. Lewis S d/0B0yOtWQMcDpZRzlrQVFCclRFLWc/view and girls.Sep192017. Available from: drive.google.com/file/ and callsformeasures toprotect andassistRohingyawomen Conflict PramilaPatten condemnssexualviolenceinMyanmar Conflict. UNSpecialRepresentative onSexualViolencein Office o cía-Moreno C,HegartyK,d’OliveiraAF, etal.Thehealth- . Globalandregional estimates of violenceagainstwomen: 8 Formany, theirdisclosure toMSFwas , Wilkes T. UNMedicsseeevidenceof rapeinMyanmar f theSpecialRepresentative onSexualViolencein , DevriesK,Watts C,etal. Worldwide prevalence rontieres. ADramatic Deterioration forAsylum flict. Stop RapeNow. 2017. f SocialServices. SILENT EPIDEMIC This 4 Clearly 7 Why is 6 Of those 4 But I imagine a 5 contraception 8 Vol. 19 No. 4 Summer 2017 | 33 Vol.

5 there was a rash of interest in interest was a rash of there 1 this is not respecting the life of women. the life of this is not respecting the is progressive, to think New Zealand like We first country to get the vote for women; but in fact, still don’t have fundamental human women there is based on the Contraception, size rights. Family and Abortion Act 1977, Sterilisation, surveyed, 10 per cent of women experienced sexual of surveyed, 10 per cent identified period. The report assault over a two-year towards women contribute to sexual ‘attitudes that university’. at assault and sexual harassment David Grimes is an American O&G who travels theDavid Grimes is an American O&G who travels which he identifies as world talking about misogyny, neglect, abuse, rape and including disdain, apathy, ASM the RANZCOG in 2009 at femicide. He spoke in me, and on his return on the topic and inspired his country of 2017 he described mourning the death the of rights as a result reproductive with the loss of the rights civil should never assume that election. We society has fought so hard to achieve cannot be lost. not associated abortion laws are restrictive ‘Highly When countries are with lower abortion rates. under which the according to the grounds grouped is 37 abortions per 1000 is legal, the rate procedure it is prohibited childbearing age where women of altogether or allowed only to save a woman’s life, it is available with 34 per 1000 where compared a non-significant difference’. on request, institutional misogyny sets women on their way into institutional misogyny the implicit understanding that with the workforce the eyes of viewed from consent is a perception sexual the establishment or ‘boss’. Just how much you risk harassment should you experience before it? Often it is easier to play by reporting your career become not careful, if you are along and, ultimately, yourself. complicit in the misogynistic environment exposed Surgeons was After the Royal College of by a whistleblower few people thinking ‘is that really a problem?’ Yes, it Yes, a problem?’ really few people thinking ‘is that that confirmed is. Just over 100 people respondents How they had been sexually harassed by their boss. this bullying and sexual many had actually reported per cent. harassment? Only 24 this misogyny? The issue is that the rate of unsafe unsafe of the rate this misogyny? The issue is that abortion access is illegal where abortion increases and death. complications of the rate and with that responsible abortion are unsafe from Complications women each year. 47,000 of for the deaths 51 per cent of students experienced sexual students 51 per cent of almost twice as likely harassment, with women sexually harassed. as men to have been the extent of bullying and sexual harassment in the extent of In 2016, medicine in Australia and New Zealand. to respondents 12 per cent of reported RANZCOG a harassment and bullying survey had experienced per (76.8 those sexual harassment, the majority of a senior O&G consultant. cent) from is not fully funded and abortion is, at best, a is not fully funded and abortion is, at hoops ever-moving jumping through challenge of worst, outright illegal. Most women who and, at determined to be ‘mentally ill’. have an abortion are sit at in Australia and New Zealand rates Caesarean the 3 at least I assume they at 1 We all accept that rape is ‘bad’; all accept that We 2 Helen Paterson Academic Representative, committee NZ RANZCOG Ltd Health Helen Paterson Women’s however, it is pervasive in society. If you watch The If you watch it is pervasive in society. however, a documentaryHunting Ground, about the incidence sexual assault on college campuses in the US, of complexity of the support systems become clear; whoclear; become systems support the of complexity important to the university? The star footballis more player or the raped woman? But I imagine you think of The University is just the US’. Don’t be so sure. ‘that has no sexual assault policy. Otago, to date, Report on Sexual Assault and Sexual The National that reported Australian Universities Harassment at While giving a talk recently on contraception, I asked on contraception, I asked While giving a talk recently contraceptive people thought the most reliable what said a senior O&G consultant. My is. ‘Abstinence’ to this seemed to stun; ‘well, as one-in- response raped in their life, abstinence is not women are three an effective solution.’ really – both the rape and the But is this misogyny? Yes they if girls didn’t have sex subtle judgement that of, Misogyny is the dislike wouldn’t get pregnant. against women. or ingrained prejudice contempt for, by the ingrained prejudice This is an example of common in O&G than weconsultant, and it is more would be to think. Often the perpetrator would like appalled to be called a misogynist. It is worth noting women can be misogynistic much inthough, that the way men can be feminists. Other O&G examples Victorian and Tasmanian farcical include the proposed be should on whether the Mirena 2016 ASM debate compulsory for O&G trainees, reproductive health reproductive Misogyny in in Misogyny weren’t proposing them for men in some way, so I them for men in some way, proposing weren’t too. work there assume misogyny was at women is obviously misogynous. GlobalRape of about that published by WHO indicate estimates (35 per cent) women worldwide haveone-in-three experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime. Looking after self, looking after others Knowing me,knowing you: Register at: www.knowingmeknowingyou.org.au allied health professionals Fellows, Trainees, Diplomates, midwives, medical students, Who’s invited? participate infour days of workshops, education sessionsandpresentations. Don’t missthisopportunityto meet your peers from across Australia and Thursday 26–Sunday 29April2018 Pullman Bunker Bay Resort, Margaret River, Western Australia WA/SA/NT/Provincial Fellows Regional Scientific Meeting Register now! SILENT EPIDEMIC minorities. and NewZealand showhigherrates inethnic Maternal andperinatal mortalitystatistics inAustralia reproductive health,butnotabortion? make decisionstogetheronallotheraspectsof lives. Whydowetrustawomanandherdoctorto would argue,contemptforthevalueof women’s apregnancy toterm.That is,I choose nottocarry is safer thantermbirth,NewZealand womencan’t 25–35 percent, [email protected]. Trainee Liaisonon61394122918orviaemail please contactPaulaFernandez,SeniorCoordinator, bullying, discrimination orharassmentat work, College andwanttomake acomplaintabout If youare aFellow, memberortraineeof the misogynistic behaviour? can Ifightmisogyny, orcanIchangesomeoneelse’s support other’smisogynisticbehaviour?Addthen: this piece?Firstly, think:amIamisogynist?Do healthcare. So,what doIwantyoutotake from we canat leastreduce itinwomen’sreproductive of theseissueswhere misogynyflourishes.Hopefully, reproductive health.There isawholeworldoutside I havelimitedthisarticletothetopicof misogynyin factors intothemix. optimise care forall,weshouldconsiderhowthis well beplayingapartandwhenattempting to complex issues,butIchallengethat misogynymay 11 Nodoubtthisisduetoanumberof 9,10 butdespitethefactthat abortion 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. Veigh, S. ‘Awareness’ won’tstopharassmentof female 1. References

PER 86. Canberra: AIHW. Australia, 1993–2012.2016. Perinatal deaths seriesno1.Cat no AIHW report-FINAL-NS-Jun-2016.pdf. www.hqsc.govt.nz/assets/PMMRC/Publications/tenth-annual- Wellington: HealthQuality &Safety Commission.Available from: Mortality ReviewCommittee:Reportingmortality2014. 2016. PMMRC. T maternityservicesplan-chapter2. publishing.nsf/Content/pacd-maternityservicesplan-toc~pacd- Jul 4]Available from: www.health.gov.au/internet/publications/ Maternity ServicesPlan:thecurrent environment. [cited2017 Australian GovernmentDepartmento publication/report-maternity-2015. of Health.AvailableMinistry from: www.health.govt.nz/ Ministr public/1977/0112/latest/DLM17680.html. 2017 Oct4]Available from: www.legislation.govt.nz/act/ Contraception, S 2016;388(10041):258-67. global, regional, andsubregional levelsandtrends. Lancet. Sedgh G,etal.Abortionincidencebetween1990and201 Killen, A.F UniversityReport.pdf. document/publication/AHRC_2017_ChangeTheCourse_ Available from: www.humanrights.gov.au/sites/default/files/ at Australianuniversities.2017, Sydney. [cited2017Oct4]. National report onsexualassaultandharassment Australian HumanRightsCommission.Changethecourse: Entertainment, Inc.Available from: thehuntinggroundfilm.com. Scully RK,BlavinP fs239/en. Oct 7]Available from: www.who.int/mediacentre/factsheets/ partner andsexualviolenceagainstwomen.2016. [Cited2017 W surgeons/7380536. hack/public-awareness-wont-stop-sexual-harassment-of- Oct 4].Available from: www.abc.net.au/triplej/programs/ surgeons, sayswhistleblower. ABC(AU). 2016[cited2017 Mc orld HealthOrganization. Violenceagainstwomen-Intimate : MonkA,HarrisK,DonnolleyN, etal.Perinatal deaths in y of Health.ReportonMaternity 2015. 2017. Wellington: enth AnnualReportof thePerinatal andMaternal rom theCEO. O&GMagazine.2016;18(3):9-10. terilisation, andAbortionAct1977. [cited , DickK,etal.TheHuntingGround. 2015. Bay f Health.National

4:

SILENT EPIDEMIC Dr Tan’s case is Dr Tan’s 2 Vol. 19 No. 4 Summer 2017 | 35 Vol. an example of the appalling culture in the field, and in the the appalling culture an example of all the need to fight back, whether it is by ensuring training or to simply undergo the appropriate staff raise awareness. Why does it continue to go unreported? If sexual harassment and inequality is such a issue, why does it continue to be prominent that the stark reality Unfortunately, unreported? financial these victims is that burdens many of over their precedence security and job stability takes Particularly in the medical wellbeing and safety. competitive as it is, which is already profession, jeopardising a long, hard-earned career the fear of is terrifying. the case for many single This is often and by the stress troubled – while they are parents this unjust treatment, having to tolerate anguish of debt, or the an exponentially growing the burden of their family needs food on the table, knowledge that important. is more are often those at higher levels. These individuals higher those at often are dentists, bar managers, small business owners, are the distinction where surgeons – all situations and their employee is between a person in authority it is also circumstances, In such clearly delineated. their situation the precarious to these victims clearer as if they do so much as to employment is in, such placed on their thigh. when a hand is protest the medical field Sexual harassment in continues to be increasingly In a field that demanding, it is not competitive, and relentlessly The uncommon for sexual harassment to occur. the are hours is one in which long, tireless profession not as commonplace. norm, and yet complaints are has allegedly this profession that is a culture There any complaints, you are if you make – that cultivated Tan, Dr Caroline Take effectively staining your career. school and was mentored in medical who excelled stay back to began as requests by a surgeon. What assault, to sexual for additional tutelage escalated sexual a complaint of to make Dr Tan prompting harassment with a tribunal. While she did effectively Dr Tan’s was ruined; win this case, her medical career due to a cast aside to hospitals were applications despite her outstanding references ability, lack of on the other hand, Mr The perpetrator and results. was given a formal warning. Xenos, It is therefore critical that employers, critical that It is therefore 1 Issues at home, impact on work violence does manifest in the workplace. Domestic home can often occur behind closed doors at The issues that must do so home often abuse at who must battle Women home, but also in the workplace. issues at not only create to deal with having their employers, or fellow colleagues. Additionally, the hands of work, whether it is at while at impatience instigate and impede work performance, which in turn may home may cause fatigue issues at a host of continually when employers employers. It does not assist the situation unsympathetic from and frustration professionalism home. It is important to maintain meant to be left at home are issues at the notion that reinforce leave, the employer should stress to see a therapist, or take time off work, but if an employee requires at domestic violence. of inequality against victims the cycle of to understand perpetuates this. A failure accommodate Sexual harassment continues to be a prevalent Sexual harassment continues to be a prevalent in the is experienced all too frequently issue that workplace, especially by women. A poll conducted in 2003 by the Australian Human Rights Commission women, along with 28 per cent of that revealed men, experienced sexual harassment in 7 per cent of the workplace. action to proactive along with employees, take harassment in the workplace. prevent What exactly is sexual harassment? as any Sexual harassment is conventionally known that unwanted or unwelcome sexual behaviour While or humiliated. someone feel offended makes sexual this definition appears comprehensive, forms and harassment can come in a variety of kissing Unsolicited consequently goes unrecognised. as would undoubtedly be categorised and caressing the waist can a hand around harassment. However, the shoulder fall under the categoryor a hand around such The test is that sexual harassment? Yes. of actions must be unsolicited. Who sexually harasses? sexual harassment occurs While it is the case that harassment of among employees, the perpetrators Gary Pinchen Principal A Whole New Approach Pty Ltd in the workplace workplacein the Sexual harassment Sexual Alyssandria Lim Commerce/law 2nd year student, Monash University How work is affected by issues at home. by issues 1. How work is affected Box SILENT EPIDEMIC For more information,email:[email protected] developed by RANZCOG. onthe latestinitiatives oftopicandarticles information onavariety Collegiate isthe featuringhelpful College'smonthlye-newsletter, news fromRANZCOG employer assoonyouhaveexperiencedsexual It isimportanttoraiseyourconcernswith harassed orbeingtreatedunfairly What todoifyoufeellike you’rebeingsexually touching shouldbeaddressed. are inappropriate, andanyincidentsof uninvited employers torecognise that certainformsof banter procedures that are inplace.Itisalsothedutyof training andare aware of thestrictpoliciesand to ensure theirstaff undergotheappropriate workplace. Itisobviouslythedutyof theemployer harassment orinequalitythat isoccurringintheir mean that theemployerscanturnablindeyeto However, ifnocomplaintsare raised,itdoesnot harassment andvilification. that measures are putinplacetoprevent further conduct athorough investigation andtoensure to theattention of employers,itistheirdutyto in theworkplace.Whencomplaintsare brought to prevent discrimination, harassmentandinequality their responsibility totake theappropriate action All toooften, employersfailinproperly fulfilling Failure ofemployers You’ve gotmail

2. 1. References (www.humanrights.gov.au). you mayreach outtotheHumanRightsCommission the harassmentordiscrimination doesnotcontinue, fail toenforce anypreventative measures toensure to appropriately address yourconcerns,orifthey the matter properly addressed. Ifyourcompanyfails someone whocandirect yourcomplaintsandhave Alternatively, youmayseektoconsultamanager, or prompt manner, whilemaintainingconfidentiality. resources toinvestigate thesecomplaintsina complaints tothem.Itisthenthedutyof human has ahumanresources department,address your harassment orunfair treatment. Ifyourcompany

hospitals-20150311-141hfi.html. caroline-tan-breaks-silence-over-sexual-harassment-in- 2017]. Available from: www.theage.com.au/victoria/surgeon- harassment inhospitals.TheAge,2015. [cited23September Medew J SHSB_Report2008.pdf. default/files/content/sexualharassment/serious_business/ 2017 Sept17].Available from: www.humanrights.gov.au/sites/ Survey. AustralianHumanRightsCommission;2008[cited Results o . SurgeonCaroline Tan breaks silenceoversexual f the2008SexualHarassmentNational Telephone WOMEN’S HEALTH 8 1,2 1

1 A vacuum pump in Vol. 19 No. 4 Summer 2017 | 37 Vol. 7 Treatment failure is failure Treatment 9,10,22 Institute of Innovation and Institute of Innovation Mercy Hospital for Women MBBS(Hons), FRACGP, FRANZCOG MBBS(Hons), FRACGP, Maher Dr Peter J. Improvement, Waitemata District District Improvement, Waitemata Board, NZ Health MBChB, MEngSt, FRANZCOG MBChB, Dr Lenore Ellett FRANZCOG MBBS, FRCOG, 1 2 Dr Prathima ChowdaryDr Prathima the tissue impedance is continuously monitored the tissue impedance is continuously monitored 50 once a level of terminates and the procedure may varyohms is achieved. Actual treatment up uterine different to 120 seconds to accommodate dimensions and endometrial thickness. Carbon a safe into the uterine cavity at is delivered dioxide the central lumen through and pressure flow rate device. When 50mmHg is achieved the ablation of for four seconds, uterine integrity is confirmed. is not achieved due If this intrauterine pressure the the cervix, or a leak through to a perforation cannot be performed. procedure the RF controller brings the endometrial lining into the RF controller array and simultaneously contact with the electrode the uterine from ablation of byproducts removes techniques, to other ablation Compared cavity. has the shortest treatment procedure NovaSure and can be no uterine pretreatment time, requires any time during the menstrual cycle. performed at NovaSure ablation device. ablation Figure 1. NovaSure What are the success rates? high, are ablation for NovaSure rates Satisfaction 77–96 per cent, amenorrhoea occurs in ranging from life (including pleasure per cent and quality of 14–70 women with HMB are from scores and discomfort) substantially improved. For the broader O&G broader O&G For the readership, Magazine to those answers balanced questions curly-yet-common and gynaecology. in obstetrics defined as; hysterectomy for any benign indication, for any benign indication, defined as; hysterectomy the procedure, within 36 months of ablation repeat with gonadotrophin- synechiolysis or treatment pain or bleeding. hormone for post-ablation releasing One in 20 1,2 Several endometrial The ablation The ablation 7 3,4

5 6 Using the uterine width 7 device is a conformable, bipolar electrode bipolar electrode device is a conformable, and sheath array housed within a protective 1). mounted on an expandable frame (Figure It also contains an intrauterine measuring determines the uterine cavity system that width (cornua–cornua distance). When the within correctly device is seated ablation is withdrawn into the the sheath the cavity, the endocervix endocervical canal to protect thermal injury. from and length, the RF controller calculates the calculates and length, the RF controller complete power output to ensure appropriate the endometrium. During ablation, of ablation How does NovaSure ablation work? a system comprises of The NovaSure device, a radiofrequency disposable ablation (RF), a suction line desiccant and generator canister. a carbon dioxide women suffer from HMB. women suffer from What is the difference between different What is the difference between different generations of endometrial ablation devices? to a series (EA) refers Endometrial ablation in the blind techniques originating of sources which used various 19th century, the to achieve thermal destruction of 20th centuryendometrium. The late brought lens an important paradigm shift when a rod was used together with an hysteroscope permitting EA under direct energy source the early hysteroscopic However, visualisation. training techniques required resectoscopic user- owing to their complexity and more improved friendly techniques with reported now available. are safety Heavy menstrual bleeding (HMB) is one of the Heavy menstrual bleeding (HMB) is one of for most common gynaecological symptoms which women seek medical care. Is NovaSure endometrial ablation the endometrial ablation the Is NovaSure surgical treatment for heavy safest it just a menstrual bleeding or is hysterectomy? delayed difficult techniques are available for treatment, available for treatment, techniques are intracavity abnormalities are that provided devices absent. Modern endometrial ablation high of HMB with effective in the treatment are rates. satisfaction patient WOMEN’S HEALTH hysteroscopic adhesiolysismay berequired. with cervicaldilatation;however, insomecases, Central haematometracanusually betreated respectively). 16.7 per centcompares with9.8 percentP=0.003 compared with10.7 percent,P=0.002 and treatment failure after ablation (21.8 percent pain orobesitywere more likely toexperience Women withpreoperative dysmenorrhea,pelvic aHR 1.5. P=.003. ultrasound features suggestiveof adenomyosis and parity>5aHR1.3–6.0, P<0.001 andfinally, 45 years,adjustedhazardratio (aHR)2.6, P=0.008 Other predictors of failure are ageyoungerthan develops 2–3yearsafter endometrialablation. which hasanincidenceof 6–8percentandusually topost-ablationablation, secondary syndrome, risk factorforhysterectomy after endometrial approximately 2percent. rate; however, theriskof ectopicpregnancy is significant increase overthebaselinemiscarriage reported inamenorrhoeicwomen. cent oronein50,000. Pregnancy hasalsobeen and tuballigation isestimated tobeat 0.002 per pregnancy occurringafter endometrialablation as 12yearspostoperatively. Thechancesof been reported asearlyfiveweeksandlate NovaSure ablation. endometrial ablationandthenewerdevices,suchas has beendemonstratedwithbothresectoscopic uterine contractureandintrauterinescarring.This tissue necrosisandinflammationcanresultin When energyisappliedtotheendometrium, Pain-related obstructedmenses undergone atuballigation. to occurin0.7 percentof womenwhohave of contraception.Pregnancy hasbeenreported Endometrial ablation isnotconsidered aform Pregnancy-related complications What aretheshort-andlong-termcomplications? NovaSure ablation is1:5000. of at ablation. thetimeof Theriskof bowelinjury pre-operative orintra-operative predictor forfailure Of interest, previous caesarean sectionisnota 2.06) andprocedure time<93seconds(aHR2.61). length >6cm(aHR2.06), uterinewidth>4.5cm (aHR sounding length>10.5cm (aHR2.58),uterinecavity Intraoperative predictors of failure are uterine Intraoperative predictors per centcompared with9.0 percent,P=0.0008). of tuballigation (16.4to womenwithoutahistory likely toexperiencetreatment failure compared of tuballigation werewomen withahistory more A paperpublishedin2014 demonstrated that Pre-operative predictors ablation andhasanincidenceof 1–3percent. cervical canalisdamagedatthe timeofendometrial haematometra ismostlikelyto occur whenthe been reportedafterremovalof the tubes. tubal sterilisationsyndrome,symptomreliefhas at thecornualregion.Incasesofpost-ablation of theuterinecavity(centralhaematometra)or can manifestashaematometrawithinthebody can leadtoobstructeddegreesofmenses.This ablation. Contractureandscarringatthefundus persistent endometrialglandsafter are generallylessthan50percent,suggesting clinical studieshaveshownthatamenorrhoearates clinical, imaging, and histologic studies. Randomised endometrial ablationiscommonasevidencedby 11 Tubal ligation isawell-recognised 12 17 Persistentendometriumafter 17 15 Pregnancy has 14 16 There isno 13 Central 18

11 13 13

will be satisfied at theone-year mark. will notexperienceamenorrhoea,yet85percent Most womenwhoundergoendometrialablation is animportantaspectof pre-operative counselling. A discussioncentred around patient expectations Failure tocontrolmenses endometrial cancer were diagnosedwithstage I 75 percentof thewomenwith post-ablation nonpolyposis colorectal cancer. diabetes mellitus,tamoxifen therapyandhereditary include nulliparity, chronic anovulation, obesity, of developingendometrialcancer. Theserisks well studiedinwomenwhoare at increased risk The safety of endometrialablation hasnotbeen with subsequentevaluation of theendometrium. endometrial hyperplasiaorcancerandmayinterfere Endometrial ablation isnotatreatment for unit. helpful at ourendosurgery 30 minutespre-operatively hasbeenfoundtobe vaginal atrophy) and400mμgbuccalmisoprostol prior toprocedure(for postmenopausalpatients with 3mm scope,withvaginalestrogen forafewweeks feasible. Usingasmallerhysteroscope, suchasa be attempted giventhat evidenceshowsthat itis because of cervicalstenosis,hysteroscopy should or difficulttoachieve.Ifunableperformpipelle toconcernsthat diagnosismaybedelayed contrary endometrial cancerorhyperplasiaispossible.This Therefore, inmostcases,preoperative diagnosisof making anoninvasivediagnosischallenging. distortion canalterfeatures at ultrasonography, yield substantialresults. Inaddition,theanatomical because thebasictoolsforevaluation mayfailto endometrial ablation create adiagnosticdilemma into consideration. Patients withbleedingafter an a diagnosisof endometrialcancershouldbetaken caution whenabnormaluterinebleedingoccursand of cervicalstenosisandintrauterineadhesions. biopsy wasnotsuccessfulat presentation because per cent)apreoperative diagnosisof endometrial 18–38 percent. be examinedbya4–5yearre-operation rate of for long-termfailure of endometrialablation may cancer. now enteringtheagegroup at riskforendometrial endometrial ablation inthelasttwodecadesare years; itispossiblethat womenwhohaveundergone approximately 2–3-foldbetweenages50and70 The riskof endometrialcancerincreases by NovaSure ablation Evaluating theuterinecavity andcancerriskafter What ifshehassymptoms? label use. NovaSure ablation andshouldbeconsidered off- ablation wasnotevaluated aspartof theFDA for hysterectomy asthenextstep.Repeat endometrial with endometrialablation, mostcaseseriesreport perform, itremains feasible. of abnormaluterinebleedingmaybedifficultto though endometrialsamplingandinvestigation However, asystematic review foundthat even with abnormaluterinebleeding andpain. with post-ablation endometrialcancer present NovaSure ablation, confirmed that mostwomen endometrial cancersdiagnosed fiveyears after systematic review, publishedin 2011, examining of bleedingfrom theretained endometrium.A completely destroyed, thusallowingdegrees in mostinstancestheintrauterinecavityisnot endometrial carcinoma. However, itappearsthat fear that itmaydelaythediagnosisof asubsequent about thesafety of endometrialablation wasthe 20 These patients shouldbeevaluated with 12 Forpatients whoare notsatisfied 20 Inonlytwocases(11.8 17 Anearlyconcern 19 The evidence 20 Over 21

20

WOMEN’S HEALTH Vol. 19 No. 4 Summer 2017 | 39 Vol. , et al. Intraoperative predictors predictors , et al. Intraoperative eedon DJ, et al. Prediction of of et al. Prediction eedon DJ, er CA, et al. Preoperative uterine uterine er CA, et al. Preoperative amuyide AO. Endometrial cancer after Endometrial cancer after amuyide AO. , Mol B, Bongers M. Ten year follow up of year follow up of Bongers M. Ten , Mol B, ey M. Endometrial destruction techniques for techniques destruction ey M. Endometrial ete oselatt SA o Adam ale o et SA ee o atee elsoe o , Phillip L, Bressman, et al. Radiofrequency endometrial endometrial et al. Radiofrequency , Phillip L, Bressman, , Endometrial Ablation: postoperative complications. complications. postoperative , Endometrial Ablation: , Crane JM, Hogan TG. Successful planned pregnancy Successful planned pregnancy , Crane JM, Hogan TG. J, Hill DJ. Transcervical endometrial resection for endometrial resection Transcervical Hill DJ. J, , Engels R, Bourdrez P, et al. Five year follow up of Five year follow up of et al. P, , Engels R, Bourdrez . Haematometria – a complication of endometrial of – a complication . Haematometria Singh M, Angala P, Seela R, Mathur R. Impact of microwave microwave of R. Impact Seela R, Mathur Singh M, Angala P, ella RR, McLucas B, Ragavendra N, et al. Sonographic Ragavendra N, ella RR, McLucas B, abnormal uterine bleeding--report of 100 cases and review of of 100 cases and review of abnormal uterine bleeding--report ANZJOG. 1990;30(4):357-60. the literature. heavy menstrual bleeding: a Cochrane review. Human Reprod. bleeding: a Cochrane review. heavy menstrual 2002;17(11):2795. J Herman M, Penninx comparing bipolar endometrial trial controlled a randomized for heavy menstrual bleeding. ablation with balloon ablation BJOG. 120;(8):966-70. G, Rak Smithing KR, Savella Am J failure. ablation endometrial and risk of bleeding pattern Obstet Gynecol. 2014;211:556. El Nashar SA, Hopkins MR, Cr Obstet global endometrial ablation. outcomes after treatment Gynecol. 2009;113:97-106. O Sherif AM, Shazly SA, Abimbola ablation. endometrial radiofrequency long-term outcoes after of J Minim Invasive Gynecol. 2016;23(4):582-9. Adkins RT with a history in patient low transverse cesarean ablation of J Minim Invasive Gynecol. 2013;20:840-52. delivery. Pugh CP J Am Assoc laser. with YAG following endometrial ablation Gynecol Laparosc. 2000;7:391-4. Palep- subsequent in the management of endometrial ablation J Minim Invasive Gynecol. 2007;14:365-6. unplanned pregnancy. Sharp HT Am J Obstet Gynecol. 2012;207(4):242-7. Hill DJ J Am Assoc Gynecol Laparosc. 1994;1:S14. ablation/resection. Kleijn J and trial comparing NovaSure controlled a randomized BJOG. 2008;115:193-8. Thermachoice endometrial ablation. AlHilli MM, Hopkns MR, F medical literature. of review systematic endometrial ablation: J Minim Invasive Gynecol. 2011;18(3):393-400. Perr of the endometrium. AJR Am J after surgical ablation findings . 1992;159(6):1239-41. Roentgenol Maher P Lethaby A, Hick Lethaby

9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

20 te. Acta Obstet tion, Center for Devices and essey MP. Do British women Do British women essey MP. V, Blumenthal P, Dubois RW. A systematic review review A systematic RW. Dubois Blumenthal P, V, Y, Bourdrez P, Mol BW, et al. Randomized controlled controlled et al. Randomized Mol BW, P, Bourdrez Y, , Gimpelson R, Laberg P, et al. A randomized, et al. A randomized, , Gimpelson R, Laberg P, , Aarthi C, Arthur M, Vance M. Late-onset endometrial M. Late-onset , Aarthi C, Arthur M, Vance

essey MP, Villard-Mackintosh L, McPherson K, et al. The Villard-Mackintosh essey MP,

undergo too many or too few hysterectomies? Soc Sci Med. undergo too many or too few hysterectomies? 1988;27:987-94. J Minim and Prevention. Treatment – Etiology, abaltoin failure Invasive Gynecol. 2015;22:323-31. US Food and Drug Administra impedence controlled Radiological Health. P020031 NovaSure 2001. September 28, letter. system approval endometrial ablation Cooper J system in of the NovaSure and efficacy safety multicenter trial of . menorrhagia. J Am Assoc Gynecol Laparosco of the treatment 2002;9,418-28. Gynecol Scand. 2003;82:405-22. and life, work impairment, quality of health-related evaluating in abnormal uterine bleeding. costs and utilization health care . 2007;10:173-82. Health Value findings in a large cohort study. hysterectomy: epidemiology of BJOG. 1992;99:402-7. Coulter A, McPherson K, V Bongers M and balloon endometrial ablation bipolar radio-frequency trial of BJOG. 2004;111:1095-102. endometrial ablation. Morris W Oehler MK, Rees MC. Menorrhagia: an upda Oehler MK, Rees MC. Menorrhagia: Liu Z, Doan Q V

5. 7. 8. 2. 3. 4. 6. References 1. endometrial cancer. This is in keeping with the with the is in keeping This cancer. endometrial cancer in endometrial of typical presentation a historywomen without ablation. endometrial of with endometrial most women Furthermore, to have the able remained ablation cancer post or hysteroscopy. sampled by pipelle endometrium Conclusion was procedure NovaSure In the 13 years since the has been significant data by the FDA, approved re- low profile, a good safety provides that generated rates. satisfaction high patient and intervention rates

date Sae te WOMEN’S HEALTH its frequency. reliable national orinternational data tosuggest resolve spontaneously. Furthermore, there isno partlyasmildcasestendto incidence isamystery; OS remains anunder-recognised condition.Itstrue with nomechanicalobstructionof thedistalcolon. scenario of acutemassivedilatation of thecolon caesarean section. report mentionedfourdeaths from OS, allfollowing intoMaternal andChildHealth 2000–2002 Enquiry with metastatic cancer. 1948, followingobservation of twoof hispatients William HeneageOgilviewhofirst reported itin OS carriesthenameof theBritishsurgeonSir perforation orischemia. cause. Theobstructioncanthenleadtobowel obstruction, often withoutanobviousmechanical the phenomenonof anacutecolonicpseudo- Ogilvie’s syndrome (OS).Thissyndrome describes yet important,complication of caesarean section: This casereport highlightsarather uncommon, R Pegram R Wescombe B Bikshandi Dr JosephineWoodman Dr VictorChin Dr DennisGong post-caesarean section with caecalperforation Ogilvie’s syndrome Case reports forceps-assisted delivery. been reported tooccurfollowingvaginal birthand procedure associated withOS, althoughithas also caesarean sectionisnotedtobethe mostcommon to-female ratio of 1.5:1. those withmultiplecomorbidities.Ithasamale- is observedmore often inelderlypatients aswell OS doesnothaveanyagepredilection, althoughit a perforation orischemicbowel. 36–50 percentmortalityrate incaseswhere there is intervention withnocomplications compared to mortality rate inhealthypatients whoreceive early It hasbeensuggestedthat there isa15percent significant direct correlation withmortalityrates. 2 However, delaysindiagnosishavea 7

4 1 Intheobstetricssetting, Hedescribestheclinical 4–6 TheUKConfidential 3 her abdomenwas sodistendedthat shefeltthat but itwasdifferent from hernormal routine and She alsomentionedthat she didopenherbowel, specifically mentionedbilateral shouldertippain. abdominal pain,significantdistension andalso Day 6withrecurrent vomiting,pyrexia, generalised She presented totheemergencydepartment on to bedischargedhomeonday4. further investigations were carriedout.Sherequested 3 and4, shehadopenedherbowelsonday3, sono and distendedabdomenwere documentedondays normal dietbythethirdday. Althoughbowelsound the secondpost-operative day, butwastolerating a experienced abdominaldistensionandmildpainon Post-operatively, wasslow andshe herrecovery was observedintra-operatively. blood losswas500ml.Nobowelorbladderinjury one minuteand9at fiveminutes.Theestimated forceps, weighing4.5kg. TheApgarscore was9at the procedure. Thebabywasdelivered viaWrigley’s electrocoagulation instrumentswere usedduring cavity andpelvicorgansappeared normal.No entered viaJoelCohentechnique;peritoneal Caesarean sectionwentsmoothly, withabdomen caesarean sectionforfailure toprogress wascalled. position. Subsequently, 2emergency acategory the babywasfoundtobeindirect occiput-posterior cervical dilatation withareactive cardiotocographand progress initially, arrest at 8cmof shehadsecondary Following 12hoursof activelabourwithgood asymptomatic sinustachycardia. she waspositiveforGroup BStreptococcus andhad no abnormalrecordings throughout labour. Ofnote, and routine labourmonitoringwascommencedwith liquor. HerlabourwasaugmentedwithSyntocinon showed thepresence of lightmeconium-stained next daybyartificialrupture of membranes,which and wasinducedwith1mgof Prostin gelfollowedthe for inductionof labourduetopost-dates at 41weeks uncomplicated singleton pregnancy. She was admitted We present thecaseof a19-year-old G1P0withan Case report between OSandparalyticileusintheinitialstage. Clinically, itisrather challengingtodifferentiate rare conditionthat requires prompt recognition. performed worldwide,OSremains arelatively Despite therisingrate of caesarean sectionsbeing WOMEN’S HEALTH

10 2 9

11 Neostigmine Neostigmine Vol. 19 No. 4 Summer 2017 | 41 Vol. 12 Physiologically, the Physiologically, 4 The signs and symptoms The signs and symptoms This involves the patient This involves the patient 4 4 In addition, patients may still be still be may In addition, patients 8 Often this is associated with abdominal pain, nausea with abdominal pain, nausea Often this is associated is typically 2–12 days and vomiting. The woman section. post caesarean This finding may help to explain OS post caesarean caesarean This finding may help to explain OS post section, but this is yet to be confirmed. the colon with the thinnest The caecum is the part of it especially which makes wall and largest diameter, This can be explained by vulnerable to perforation. the tension in that Laplace, which states the Law of to proportional a hollow viscus is directly the wall of its radius and intraluminal pressure. parasympathetic system increases the motility of the the motility of system increases parasympathetic system does the exact colon while the sympathetic it OS, of 400 cases opposite. In a large analysis of is a temporary there was suggested that neuropraxia outflow (S2–S4). the sacral parasympathetic of being given nil by mouth and the use of nasogastric being given nil by mouth and the use of analgesics and anti- Any narcotic decompression. cholinergic drugs should be stopped. neostigmine, Medical therapy involves the use of colon motility by inhibiting which promotes acetylcholinesterase. A small trial done in 1999 had an patients 50 per cent of showed that (within 30 minutes; passing of response immediate reduced abdominal distension) and 73 per and flatus (lasted over three cent had a sustained response caecal diameter). hours; reduced may initially mimic paralytic ileus, but bowel ileus, but bowel may initially mimic paralytic to be higher pitched reported often sounds are and hyperactive. Management of OS has been classically divided into Management of and surgical. These options are conservative/medical which in turn dependent upon the caecal diameter, the condition. of is dependent on early recognition less than 10cm can of In general, caecal dilatation are there provided be managed conservatively, perforation. no signs of Patient is usually tachycardic, afebrile (pyrexia might might (pyrexia is usually tachycardic, afebrile Patient sepsis) and may be hypotensive. Laboratory indicate In may not be helpful in the first instance. results is abdominal x-ray the acute setting, a plain erect list down the narrowing most helpful in terms of diagnosis. This may show a typical differential of especially the large bowel dilatation, of picture A CT caecum with or without pneumoperitoneum. the diagnosis to confirm scan can then be requested the caecal to measure importantly, OS and, more of which will aid in the management and diameter, patient. outcome of OS is still poorly understood; The exact aetiology of is an there consensus is that the current however, and parasympathetic sympathetic imbalance of the colon. of innervation the relatively inaccessible locations and associated associated and locations inaccessible the relatively A segmental pulmonary drainage. risks of embolism and being on mechanical despite occurred She was discharged thromboprophylaxis. medication with surgical and days in the hospital 35 home after has been positive up. Her progress obstetric follow since discharge. Discussion abdominal OS is marked of The hallmark symptom over a short timeframe. distension developing able to pass small amounts of fecal fluid and flatus. fecal fluid and flatus. of able to pass small amounts usually manifests as a dull, Abdominal pain in OS no specific localisation, with crampy sensation then hollow viscus distension. This may typical of to localise over the right iliac fossa, progress caecum. of impending rupture indicating Multiple air fluid level seen with possible faecal Figure 1. Multiple air fluid level seen loading. 40 weeks’. Despite these again at she was ‘pregnant and bonding symptoms, she had been breastfeeding well with baby. elevated came back with markedly Her blood results x 109/L. 12.1 612 and white cell count of CRP of small and showed distended loop of Abdominal x-ray of large bowel with positive Rigler’s sign, suggestive on CT scan, which This was confirmed perforation. intra-abdominal showed distended ileum with free fluid and gas collections. was performed through An emergency laparotomy a Pfannensteil incision; however, the previous was necessary midline laparotomy due to the the peritoneal faeculent soiling of extent of caecum was found and a right A perforated cavity. hemicolectomy with ileostomy was performed. of faecal-purulent fluid litres five Approximately left was drained and the abdominal wound was and a dressing (VAC) pressure open with a negative the was performed further washout and full closure colonic segment the resected Histology of next day. and perforation showed full thickness necrosis, findings consistent with caecal pseudo-obstruction. unit (ICU) She was admitted to the intensive care she A few days later, her initial operation. after sepsis. for recurrent laparotomy underwent a repeat was applied over the open abdomen. dressing A VAC to ICU mechanically ventilated, She was returned the The next day, therapy. vasopressor requiring due to purulent Pfannenstiel incision was re-opened discharge and superficial dehiscence. After further abdominal washout, the abdominal fascia was closed a further days later, Three dressing. with a VAC performed. were wound debridement and full closure andA transvaginal ultrasound examination ruled out and curettage with dilatation hysteroscopy ongoing septic shock. Noendometritis as a cause of on blood or wound grown specific organisms were antibiotics so empirical, broad-spectrum cultures with infectious in consultation administered were and intubated diseases specialists. She remained nine days, during for a total of mechanically ventilated critical illnesswhich time she developed anaemia of thrombocytosis blood transfusions, reactive requiring drainage. required pleural effusions that and reactive 15 She was discharged to the surgical ward after to the ICU readmitted but was days in the ICU, Discrete septic features. of twice for recurrence found on a further CT abdominal collections were considering conservatively treated scan, which were WOMEN’S HEALTH young, healthywomaninherreproductive years. preventing acatastrophic outcometoanotherwise importance of earlydiagnosisandinterventionin passage of flatus. Itcannotbestressed enoughthe presence of falselyreassuring bowelsoundsand progressive abdominaldistension,despitethe in thepost-caesarean patient presenting with It isimportanttomaintainahighindexof suspicion and formation of astoma. This usuallyentailslaparotomy withbowelresection bowel perforation warrantsurgicalmanagement. arise intheovary. malignancies. Theseneoplasmsmostcommonly endometriosis willdevelopendometriosis-associated It isestimated that 1percentof womenwith O&G consultant, PalmerstonNorth,NewZealand FRCOG, MRCOG, MRCPI, MD, DDU Dr NasserShehata North ShoreHospital,Auckland, NewZealand FRANZCOG Trainee, MBCHB,BSc Dr MarilynBoo associated neoplasms endometriosis- Extraovarian 2. 4. 3. 1. References a recurrence rate of 40percent. has avariablesuccessrate (61–78percent),with treatment withneostigminefails.This,however, Colonoscopic decompression canbeusednextif is givenintravenouslyat 2.5mgover3–5minutes. consistent withpelvicendometriosis. revealed externalendometrialglands andstroma for pelvicorganprolapse, and histologyof theuterus alsoincludedavaginal hysterectomy surgical history for amid-trimestertermination 42yearsago.Her reported hadbeenpresent since herhysterotomy firm massintherightiliacfossa region that she A 75-year-old woman(G4P3),presented witha4cm Case 1 extraovarian sites. Here wepresent three casesarisingfrom various endometriosis-associated neoplasmsare rare.

a newclinicalsyndrome. BMJ.1948;2:671-3. Series. JClinGynecolObstet.2016;5(1):53-7. Functional BowelObstructionAfterCaesarean Section:ACase www.eMedicine.com/med/topic2699.htm. Carpenter S Ogilvie H Kakarla A,PosnettH Norton- Old KJ, Yuen N, Umstad MP. AnObstetricPerspectiveOn . Largeintestinecolicduetosympathetic deprivation: , HolmstormB. OgilvieSyndrome. Available from: 1,2 Publishedcasesof extraovarian , JainA,etal.ReviewAcuteColonic 13–14 Anysignsof examination, a 5cm smooth, firm posterior vaginal examination, a5cmsmooth,firmposterior vaginal with severe pelvicpainandvaginalbleeding. On A 52-year-old nulliparous womanpresented Case 2 adjuvant treatment wasnotrecommended. this massandnodefinitivesign of metastatic disease, endometriosis wasconfirmed. Givenfull resection of endometrioid adenocarcinoma inabdominalwall and omentectomy. Amoderately differentiated including bilateral salpingo-oopherectomy She underwentawidelocalexcision of themass, CA19-9 were withinnormalrange. evidence of metastatic disease.HerCA-125, CEA and staging process, aCTscanof herchestshowedno was notedwithinthespecimen.To complete the from the gynaecologicaltract;endometriosis primary differentiated adenocarcinoma consistentwitha A core biopsyof themassconfirmed amoderately tumour. (Figure 1) the subcutaneousfat, whichwassuggestiveof a anterior abdominalwallmusculature extendinginto diameter by3.6cm inAPdiameter arisingfrom the enhancing massmeasuring5.8cm intransverse A CTscanof herabdomenandpelvisrevealed an 5. 12. 11. 10. 9. 8. 7. 14. 13. 6.

Gynaecologist. 2006;8:207-13. Pseudo-obstruction AfterCaesarean Section.TheObstetrician& Gastroin Rex DK.Colonoscopyandacutecolonicpseudo-obstruction. Eisen GM,Bar Ponec RJ 1954;621:12-7. Br Rectum. 1986;29:203-10. (Ogilvie’s syndrome). Ananalysisof 400cases.DisColon V London: HodderArnold;2000. p.436-9. Brown EmergencySurgery. S, editors.HamiltonBailey’s 13thed. Munr Can. 2009;31(2):167-71. caesarean section.JObstetGynaecol ileus followingprimary Laskin MD RCOG Press; 2004.232-33. intoMaternal andChildHealth.London: Confidential Enquiry Lewis G,DrifeJ casereport. Intdelivery: JClinPract . 2006Oct;60(10):1303-5. the colon(Ogilvie’ssyndrome) followinginstrumentalvagina Kakarla A,PosnettH Nanni G,GarbiniA,LuchettiP obstruction. Gastrointest Endosc.2002;56:789-92. 1999;341:137-41. treatment of acutecolonicpseudo-obstruction.NEngJMed. Dis Colon Rectum.1982;25:157-66. 1948 toMarch 1980)andreport of fouradditionalcases. colonic pseudo-obstruction):review of theliterature (October avek VW, Al-Salti M.Acutepseudo-obstructionof thecolon ock W. Volvulus of theCecum.West JSurgObstetGynecol. o A.Largebowelobstruction.In:WillsBW. Paterson- test EndoscClinNAm.1997;7:499-508. , SaundersMD, KimmeyMB. Neostigmineforthe , Tessler K,KivesS. Cecalperforation duetoparalytic on TH, DominitzJA, etal.Acutecolonicpseudo- . editors.WhyMothersDie2000-2002. , AshA.Acutepseudo-obstructionof , etal.Ogilvie’ssyndrome (acute WOMEN’S HEALTH 1-6 Vol. 19 No. 4 Summer 2017 | 43 Vol. The majority of endometriosis- The majority of 1-3 . A 0.9x1.7x1.7cm heterogeneous lesion heterogeneous Figure 2. A 0.9x1.7x1.7cm endometrium, suspicious for seen posteriorly in the a possibly may represent endometrial tumour or submucosal fibroid. . A 13.2x11.6x7.4 cm solid/cystic mass seen in cm solid/cystic mass Figure 3. A 13.2x11.6x7.4 the right adnexal region. Aetiology no clear causal present, at Unfortunately, has been identified. One theoryrelationship is and between hyperoestrogenism the association endometriosis. malignancy from development of theoryThe proposed origin a shared involves associated neoplasms are of ovarian origin and only of neoplasms are associated the 25 per cent involve extraovarian sites; mainly the abdominal wall. bowel, but rarely, She was scheduled for a total abdominal salpingo-oopherectomy, bilateral hysterectomy, pelvic abdominal mass, lymph node of removal A mass dissection and partial omentectomy. to the anterior surface and mesenteryadherent colon was seen. However, the recto-sigmoid of either ovaryit did not appear to arise from or 1 a grade fallopian tubes. Histology revealed with focal endometrioid adenofibroma proliferative ectopic ovarian tissue. arising from adenocarcinoma Adjuvant chemotherapy or radiotherapy was given although felt to be unbeneficial considered, disease and ill-defined metastatic no evidence of tumour origin. Discussion is a presence Endometriosis is diagnosed when there the outside of endometrial glands and stroma of uterine cavity.

four years after her index surgery with normal her index surgeryfour years after with normal tumour markers. Case 3 with post- woman (G3P1) presented A 58-year-old 32 and a menopausal bleeding. She had a BMI of use contraindicated hypertension that of background 20 weeks in size Her uterus felt enlarged at HRT. of no adnexal masses found. on examination, a 13.2x11.6x7.4cm A pelvic ultrasound revealed solid/cystic mass seen in mixed heterogonous vascularity seen of the right adnexa with areas an 2). Uterus revealed inside the septae (Figure and in fundus 0.3cm endometrial thickness of lesion posteriorly in heterogeneous 0.9x1.7x1.7cm her abdomen 3). An MRI of the endometrium (Figure and pelvis showed complex cystic mass measuring with a well-defined border arising from 14x13x8cm This mass contained numerous the right ovary. lesion, which within a well-encapsulated septations Her staging CT contained several solid nodular areas. and CEA. her CA-125 scan was normal and so were wall mass was found. A rigid sigmoidoscopy waswall mass was found. A rigid sigmoidoscopy masses.performed up to 18cm, which found no rectal an ovoid 12x11x9cm midline An MRI revealed and pelvic mass, displacing the bladder anteriorly Her CT scan showed a posteriorly. rectosigmoid cystic mass posterior to the bladder with enhancing rectum solid peripheral tissue, which displaced the the distal with associated posteriorly and intimately metastatic was no evidence of sigmoid. There CEA and CA19-9. disease. She also had an elevated historyPrevious a total abdominal showed salpingo-oophorectomy with bilateral hysterectomy and for heavy menstrual bleeding six years previously uterus with dysmenorrhea. Histology showed fibroid on endometriosis and surface endometriosis serosal both ovaries. a pelvic her initial presentation, months after Three and anterior resection posterior exenteration pelvic mass was performed. A hypervascular of and mass invading the terminal ileal loop, rectum Histology vaginal vault was seen during the surgery. Müllerian tumour arising a malignant mixed revealed colon. She endometriosis involving loop of from therapy and underwent pelvic adjuvant radiation and carboplatin). adjuvant chemotherapy (paclitaxel and metastases recurrence of free She remains . CT scan of abdomen. Enhancing mass abdomen. Figure 1. CT scan of abdominal wall extending the anterior arising from which has appearances fat, into the subcutaneous a tumour. suggestive of WOMEN’S HEALTH HRT versus10percentintheothergroups. extraovarian cancers,with62percentreceiving and reported anassociation betweenHRTuseand with extraovariancancersarisinginendometriosis A caseseriesbyModesittetalincluded21patients distinguishing the two. in determiningtheoriginof tumourand,therefore, finally, ishelpful theuse of immunohistochemistry glands lackinginintracellularmucin. Thirdly, and the neoplasticendometroid cellsform tubular occur intheouterwallsof thebowel. Secondly, in distinguishingthetwo.Firstly, thebulkof EAIT are three histologiccharacteristicsthat may assist from poorlydifferentiated coloniccarcinoma. There distinguish high-gradeendometroid carcinoma in therectosigmoid colon,itcanbedifficult to the highestincidenceof endometriosis. the rectosigmoid colon,anarea of thebowelhaving documented intheliterature, 65percentinvolve endometriosis-associated intestinaltumours(EAIT) rectovaginal septumandvagina.Ofthe40casesof changes of endometriosisoccurinthecolon, More than50percentof extraovarianneoplastic Location in caseswithmalignanttransformation. as p53, whichhasbeenreported tobeelevated oncogenes ortumoursuppressor genes,such cells mightundergosomatic mutation involving that someendometrioticconsidering thetheory most endometriosisremains benign,itisworth and hasimmunosuppressive properties. It isapotentinhibitorof Tlymphocytefunction bleaching process usedinmanufacturingtampons. biphenyls. Dioxin isaby-product of thechlorine products, suchasdioxin andpolychlorinated and malignancyincludetheuseof carcinogenic Other speculated linksbetweenendometriosis between 25and30. oestrogen exposure. Allof ourpatients hadBMIs of excessour othertwocaseshadnopasthistory from onecaseinvolvinganulliparous patient, compared to6percentwithout. cent of endometrioticsitesaffected bycarcinoma chromosome 5qisreported toplayarole in25per anomalies suchasthelossof heterozygosity of fashion whenexposedtohormonalstimulation. tissues, therefore bothresponding inasimilar between endometrioticdepositsandendometrial (4.5 percent). sarcoma (25percent)andclearcellcarcinoma endometroid adenocarcinoma (69.1 percent), extraovarian endometriosismalignancyinclude The mostcommonhistologicalsubtypesof Histology 6–20 yearsafter initialabdominalsurgery. presenting at theprevious abdominalincisionsite wall endometriosisisrare intheliterature, often and vagina.Malignanttransformation of abdominal involved amassinvadingtheterminalileum,rectum colon derivingitsbloodsupply, whiletheother adherent totheanteriorsurfaceof therectosigmoid our discussedcasesrevealed aneoplasticmass clear cellcarcinoma. specific toendometriosisco-existingwithovarian are endometroid carcinoma. The majorityof EAITcasesreported intheliterature endometriosis of theabdominalwall. currently intheliterature of malignanttumoursin carcinoma asreported inacasereview of 10cases wall endometriosis,followedbyendometroid accounts forthemajorityof malignantabdominal

2,10 Incontrast,clearcellcarcinoma 8

9,10 2,9 Astheseoften occur 2,3 However, since 3

9,10 2,8 2,3 Thisis Genetic Oneof 3 7 Apart 1,2,7 with aprevious hysterectomy andbilateral presenting withapelvicmass,even in those neoplasms shouldbeconsidered inwomen is uncommonandnotwellunderstood. Such endometriosis, especiallyinextraovarian sites, The diagnosisof malignant transformation of Conclusion and radiotherapy. literature onthecombineduseof chemotherapy on therole of radiotherapynorhasthere been of followup.There hasnotbeenrecent literature patient remained diseasefree after eightmonths to thepelvis,similarourpatient incasetwo. receiving adjuvantexternalbeamradiation therapy retroperitoneal localisedMülleriancarcinosarcoma localised tothepelvis. malignancy arisinginendometriosiswhendiseaseis The useof radiation therapywasdescribedfor agents (cisplatinum orcaboplatinum). often consistsof paclitaxel andoneof theplatinum in endometriosis. documented extragonadalcarcinosarcoma arising the leftureter. Thisisperhapsthemostrecently found intheretroperitoneal compartmentencasing to ourpatient incasetwo.Thismass,however, was salpingoopherectomy forbenignreasons, similar of aprevious hysterectomyand history andbilateral endometriosis inapatient withpresenting complaint carcinosarcomatous masscloselyassociated with septum. setting often arisesfrom thevaginaorrectovaginal involves theovaries,butinextragonadal endometriosis israre and,ifpresent, frequently known asuterinetumours.Theirassociation with as mixed Müllerianmalignanttumours,are best Sarcomas andcarcinosarcomas, alsoreferred to bilateral salpingo-oophrectomy. multiple peritonealbiopsiesand,sometimes, aortic lymphnodedissections,omentectomy, disease canbeperformedwithpelvicandpara- to obtainahistologicaldiagnosis.Staging of the surgical resection of theoffending pelvictumour endometriosis-associated malignancyiscomplete The first-linetreatment forextraovarian Treatment to havewidespread intraperitonealdisease. who, at thetimeof surgicalexploration, were found chemotherapy wasrecommended toallpatients metastatic disease.Inareview byDilsilvestro etal, of ourthree casesasthere wasnoevidenceof adjuvant chemotherapywasprescribed intwoout was notsignificantlyassociated withsurvival. a multivariantanalysis,thetypeof chemotherapy after completionof initialadjuvanttherapy. Using chemotherapy; 74 per centwere thendiseasefree and71percentreceived adjuvant underwent surgery endometriosis-associated cancers.Allpatients factors associated withsurvivalinwomen efficacy. in thosewithendometrialcancershaslimited cancers are chemosensitive,butchemotherapy associated neoplasms.Peritonealandovarian radiation andchemotherapyinendometriosis- reports limitedeffectivenessforpostoperative A review of thescarce literature onthistopic due totherarityof thisdiseaseinextragonadalsites. most appropriate approach toadjuvanttreatments considered. However, itisdifficulttoestablishthe chemotherapy and/orradiation therapycanbe Depending onthehistologyandstaging, 2,6,10 1-3,11 Boothetaldescribeahomologous Modesitt’sseriesof 21casesdescribed 6

1 In2003, Boothdescribeda 1,2

1

1 This 7 No 6 The

WOMEN’S HEALTH Vol. 19 No. 4 Summer 2017 | 45 Vol. V. Endometriosis-associated intestinal Endometriosis-associated V. oom, Maxwell L. Retroperitoneal L. Retroperitoneal oom, Maxwell esford A, Sutton C. Endometrial esford A, Sutton C. Endometrial ortolero-Luna G, Robinson JB, et al. Ovarian and G, Robinson JB, ortolero-Luna , Sekizawa A, Purwosunu, et al. The role of p53 of et al. The role , Sekizawa A, Purwosunu, chand E, Hequet D, Thoury A, Barranger E. Malignant chand E, Hequet D, mullerian carcinosarcoma associated with endometriosis: a case with endometriosis: associated mullerian carcinosarcoma . 2004;93:546-49. Gynecol Oncol repot. Modesitt SC, T . Obstet Gynecol cancer. extraovarian endometriosis-associated 2002;100:788-95. Akahane T J endometriosis. Int arising from carcinomas in the mutation l. 2007;26(3):345-51. Gynecol Patho Jones K, Owen E, Berr the rectosigmoid endometriosis of arising from adenocarcinoma colon. Gynecol Oncol. 2002;86:220-22. Slavin RE, Krum R, Dinh T a 6 cases with study of tumours: a clinical and pathological . 2000;31:456-63. Hum Pathol the literature. of review Mar superficial peritoneal endometriosis lesion. of transformation BMJ Case Rep. 2013;007730. Booth C, Zahn CM, McBr Booth C,

6. 7. 8. 9. 10. 11. , et al. Malignant extraovarian , et al. Malignant ek JS. Malignant neoplasm arising in Malignant neoplasm arising ek JS. o PA, Gold MA, Gould NS. Malignancies arising in MA, Gould NS. Gold o PA, eer NA, Al-Jifree HM, Gari AM. Malignant transformation HM, Gari AM. Malignant transformation eer NA, Al-Jifree Guidance App RANZCOG ts AS, Zafrani Y, Pautier P, et al. Malignant transformation of et al. Malignant transformation Pautier P, Y, Zafrani ts AS, Eur J Surg Oncol. 2006;32(1):6-11. Eur endometriosis: A review. a case to clear cell carcinoma: abdominal wall endometriosis e13-6. . 2008;90(4):1197. Fertil Steril literature. of and review report . 1990;75:1023-28. endometriosis. Obstet Gynecol Bawaz Saudi Med J. hysterectomy. persistent endometriosis after of 2014;35(11):1390-92. DiSilvestr L, Cheynel N Benoit L, Arnould Ba Heaps JM, Nieberg RK, Ber . 1999;6(4):122-24. Ob Gyns. 1999;6(4):122-24. Prim Care Update endometriosis.

3. 4. 5. 1. salpingooopherectomy. Primary is management salpingooopherectomy. of in the role research More resection. by surgical is needed. adjuvant treatment References 2. he go-to app resource app resource he go-to comprehensive library of RANZCOG approved approved RANZCOG of library comprehensive RAN017 GUIDANCE APP ADVERT 02.pdf 1 6/09/2017 3:54:32 PM RAN017 GUIDANCE APP ADVERT 02.pdf 1 6/09/2017 3:54:32 gynaecologists. A fingertips. your and guidelines, at statements for obstetricians and obstetricians for T K Y M C CY CM MY CMY WOMEN’S HEALTH Melbourne MothersandMonashUniversity Royal Women’s, SunshineandNorthernHospitals FFCFM(RCPA), MAICD, MHSM FACLM, MFFLM(Lon),FRANZCOG, FACOG, MBBS, LLB,PDLP, BMedSci(Hons),LLM, A/Prof VinaySRane Women’s Ultrasound Melbourne(WUMe) Royal Women’s Hospital,Melbourne COGU, MBioeth MBBS, MRCOG, FRANZCOG, DDU, Dr NicoleWoodrow 2. 1. grounds eitherorbothof thefollowing: must report topolice,iftheybelieveonreasonable Act requires adultinNorthernTerritory that every Since March 2009, theDomesticandFamily Violence reporting laws. Australian legaljurisdictiontointroduce mandatory violence inNorthernTerritory, itbecametheonly In response tohighrates of familyanddomestic reporting violence: mandatory Legal solutionstodomestic circumstances…’ person that apersonmightreasonably objecttoin with adiseaseandanyphysical contact witha ‘unconsciousness, pain,disfigurement, infection The CriminalCodedefines‘physical harm’toinclude The leg-up ‘…the lifeandsa relationship,’ with whomtheotherpersonisinadomestic cause seriousphysicalharmtosomeoneelse, ‘ committed.’ violence hasbeen,isbeingor abouttobe, serious orimminentthreat becausedomestic Another personhascausedorislikely to fety of anotherpersonisunder

• confidentiality. underpinnings inrespect forautonomyand remains deeplyproblematic withourethical professional. reporting of Mandatory adultwomen her ownchoiceswiththehelpof asupportive circumstances andshouldbeempowered tomake power; that sheisuniquelyaware of herpersonal threatens women’sdignityandtakes awaytheir reportingCriticism hasbeenmadethat mandatory • • • • • on thegrounds: reporting hasbeenvoiced Opposition tomandatory scope of clinicalpractice. issue rather thanaprivate socialmatter outsidetheir encouraged toviewdomesticviolenceasahealth behaviour. Furthermore, healthprofessionals are pathway toincrease prosecutions forviolentcriminal intervention ordersonwomen’sbehalfandthere isa refuge services,policehaveincreased thenumberof services, fundinghasincreased forhospitaland women becomequicklyconnectedtosupport Since instituted,thepositiveshaveincludedthat remain silent.’ be ignored; that we,thecommunity, willnolonger our friendsandneighbours,that abusewillnolonger reporting issendingamessagetothecommunity, to and response toacommunityproblem. ‘Mandatory about thelaws,seeingitasastrong commitment On thewhole,healthcare workers havebeenpositive made forthisoffence. prosecutions orformaloffences haveeverbeen Report 144 assertsthat itisunlikely that any enteringintothecriminaljusticesystem.ALRC – have notthemselvescommittedfamilyviolence including professionals andfamilymemberswho can therefore result inawiderangeof persons– Failure tomake areport isacriminaloffence and the practiceofobstetricsandgynaecology informed oncurrentmedicolegalissuesin Your regularlegalupdatetokeep you despite ourbest efforts. the pastdecadewithinNHS hasremained static, were foravoidablecerebral palsy(CP).Incidence over cost 1.7 billionpoundsandthemostexpensiveclaims In 2016/2017, clinicalnegligenceformaternity care read CTGs,butthesystem can’t Cerebral palsyclaims:wecan migrant andr investiga police donothavethecapacityorwillingnessto perpetra aboutcustodialsentencesfor women worry victims mightbedeterr a significantnumbero ther with real fearsof deportation policeinvolvement vulnerable tomandatory disclosing abuse by childprotection andviolentretribution for seeking medicaltreatment the victims e isnoevidencethat itimproves safety for tors, fearof children beingremoved te allreported cases efugee womenare particularly f victimsare opposedtoit ed orprevented from WOMEN’S HEALTH Vol. 19 No. 4 Summer 2017 | 47 Vol. o M. NHS Resolution. Five years of cerebral palsy claims. A palsy claims. cerebral of o M. NHS Resolution. Five years thematic review of NHS Resolution data. September 2017. NHS Resolution data. of review thematic K injury: white matter of contributions neonatal cumulative of and acute fetal inflammation placental inflammation, chronic Med. 2014;42(6):731-43. inflammatory J Perinat events. postnatal agr

References 1. etal.A“multi-hit”model J, R,Cortez Romero SJ, orzeniewski 2. overrepresented Breech births claims in cerebral palsy why if they’re can’t understand this saying ‘I we not doctors is unskilled, why are of generation birth who gave up-skilling them?’ said a patient ‘We clinic earlier this year. with the hospital’s breech as medicine of our work up-skill in all other fields not like It’s develops, so why is it any different? The Age 7 August 2017, new.’ births are breech Melbourne. Newspaper, cerebral of In the 2016/2017 NHS Resolution data significantly births were palsy claims, breech to the 12 per cent compared at overrepresented per as 0.4–2.7 average (variously reported national with two term births were the breech cent). Four of born out-of-hours All were 34 weeks gestation. at Most undiagnosed in labour. and 85 per cent were without a by an obstetric registrar, delivered were vaginal an attempted All were consultant present. delivery converted to an being with half later section. emergency caesarean was published in 2000, Trial Breech Since the Term babies outcomes for breech improved demonstrating has been section, the trend by caesarean delivered in the NHS vaginal births. The result for fewer breech trainees meant that Australia) has ironically (and likely performing the most with the least experience are undiagnosed and occur in deliveries, since most are This is wholly inadequate an emergency situation. having an that since the evidence is irrefutable is a primaryexperienced practitioner present delivery. criterion for safer scenario, RCOG In an undiagnosed vaginal breech delivery of ‘individualisation based on recommends any additional are whether there labour, stage of risk factors, such as an extended fetal neck, and lies the rub skilled supervision’. Therein availability of – experience a lack of that it needs to be recognised skills for all obstetricians, and the has led to a loss of is for a continuing reduction. trend practitioners to the up-skilling of With respect delivery’, vaginal breech at attempt effortsfor ‘an the number of on decreasing need to concentrate and counselling presentations undiagnosed breech the understanding of a proper women to ensure delivery. mode of risks regarding absolute and relative errors are likely to involve cultural factors related cultural factors related to involve likely are errors of situational lack in risk stratification, to risk: errors and escalation, in decision-making delays awareness, while in isolation interpretation CTG and performing factors. In summary, and fetal risk ignoring maternal occur in isolation. should not interpretation CTG implemented, should be A holistic approach and the timely risk stratification incorporating concerns. of escalation

1 Using claims 2 f the maternal HR f the maternal etation eassurance with an uninterpretable trace eassurance with an uninterpretable thological misinterpr not started when it should have false r contact’ assumed to be ‘loss of was identified as too slow to act once a CTG pa monitoring o • more the underlying causes were However, than to systemic factors rather related often to found RCAs were individual misinterpretation. on be consistently deficient by focusing blame the environmental than looking at individuals rather for allowing factors responsible and organisational theme in errors The recurring to occur. the error or reminding recommending was in using CTGs guidelines and policies. to follow current staff advised to follow policies without Individuals were in not followed as to why they were an examination the first place. ignoring cultural factors in an RCA An example of for a midwife was blamed included an instance where obstetric without escalating a CTG misinterpreting The subsequent analysis by NHS Resolution review. missed opportunities to act were there showed that – hours with no “fresh was abnormal for 3.5 ‘the CTG by a second midwife eyes” assessments, no review the labour despite hospital policy requirements, twice but did not review was in the room coordinator despite was no obstetric review and there the CTG this being a high-risk pregnancy’. These fail-safes more seemed It RCA. the in mentioned even not were to appoint individual blame. palatable obstetric authoritiesDespite, the universality of use in CTG to advocate RCOG) ACOG, (RANZCOG, high risk women or low risk women who subsequently poor obstetricdevelop risk factors to prevent of is poor evidence for reduction outcomes; there interpretation, CTG training improves CP risk. CTG and better agreement gives higher inter-observer not does intrapartum management. This, however, outcomes. No in neonatal an improvement confer in individual fetal outcomessignificant improvement on ST Segment Analysis research has arisen from decision CTG a computerised or the use of (STAN) study). support tool (INFANT use CP risk with CTG of The issues for prevention to be dependent on many factors and proposed are The remedy. and therefore thus hard to measure • data, they reviewed the root cause analyses (RCAs) root the they reviewed data, clinical practice of analysed areas and secondly, common to the claims. were the most with fetal heart monitoring Errors theme in the claimscommon clinical practice (64 per cent) with almost all involving included: using CTGs Errors cardiotocographs (CTGs). • • • It is recognised that the majority of CP cases are not not CP cases are of the majority that It is recognised event in the rare but to medical error, attributable be learned. the case, lessons may this is where the ‘two-hit theory’. has given rise to Recent evidence a ‘hostile CP, of in the development that This suggests with a second is coupled environment’ intrauterine placental abruptionintrapartum (chorioamniotits, event (interventricular neonatal and birth asphyxia) or malacia and sepsis). haemorrhage, periventricular The UK NHS Resolution, a litigation authority, has authority, a litigation The UK NHS Resolution, CP legal claims of review a thematic released recently and 2016. between 2012 occurred that Clinical Guideline Fetal Surveillance (IFS) RANZCOG Intrapartum Incorporatesthe current intrapartum care involved in antenatal and for clinicians and hospitals risk management strategy An educational resource RANZCOG FSEP

WOMEN’S HEALTH oestrogen andprogesterone receptor modulators culminating intherecent developmentof selective onwards, occurred from theearly20thcentury understanding of reproductive endocrinologythat Rod goesontodescribethegreat increase in millions of years‘before sexbecameinteresting’! sex hormones–apparently thesewere around for of in whichhefirstexplores theknownhistory entitled ‘Sexhormones,receptors andmodulators’, fascinating invitededitorialfrom Prof RodBaber, The Augustissueof ANZJOGcommenceswitha desk editor’s From the ANZJOG and

Accredited for CPD points Accredited for assessment tool reliable Includes our valid and Pacific region ZealandNew andthe Throughout Australia, health centres Delivered to morethan250 Workshops Please contact us: (t) +613 9412 2958 (e) [email protected] www.fsep.edu.au 1

health. in particular, ulipristalingynaecologyandwomen’s issue, from Rozenberg etal,ontheuseof SPRMsand, to theimportantreview itcomplementslater inthis practice. Hiseditorialisastimulating introduction (SERMs andSPRMs)that canbeusedinclinical cytology anddetectionof cervicalcancerinwomen gynaecology dealwiththetopicof abnormal Two papersamongtheoriginalarticlesin to manyof ourreaders. FSEP MobileApps Assessment Tools FSEPTeaching and Clinical Guideline RANZCOG IFS OFSEPlus Wellbeing:practical a guide NEW book-Assessing Fetal Online Store 2 Ibelievethisreview willbeof great interest ANZJOG Editor-in-Chief FRANZCOG Prof Caroline deCosta OFSEP OFSEP Online Programs FREE forRANZCOG members Accredited forCPDpoints Certificate ofcompletion Login fee keyenrolment needed NO username, password or FREE prereading LUS WOMEN’S HEALTH 19 Vol. 19 No. 4 Summer 2017 | 49 Vol. while Robson and 18 ett H, et al. SOMANZ guidelines ett H, Finally, in the Opinion section in the Opinion Finally, 17 f age in Queensland, Australia: To what what f age in Queensland, Australia: To , Roman A, et al. Outcomes and predictive tests , Roman A, et al. Outcomes and predictive , Canfell K, Saville M. A new era for cervical screening K, Saville M. A new era for cervical screening , Canfell , Norman RJ. It is ethical to recommend against It is ethical to recommend , Norman RJ. umar S, Beckmann M. Maternal age is a risk factor age is a risk Beckmann M. Maternal umar S, . The future of robotic-assisted laparoscopic laparoscopic robotic-assisted of . The future tkar H, Wearn A, Vnuk A. Medical students’ experience A, Vnuk Wearn tkar H, , Tucker PE, Bulsara MK, Cohen PA. Working hours Working PE, Bulsara MK, Cohen PA. , Tucker el M. How can safe working hours produce a working hours produce el M. How can safe , Brick E, East MC, Johnson N. Endometriosis education Endometriosis education , Brick E, East MC, Johnson N. , R. Sex hormones, receptors and modulators. ANZJOG. and modulators. , R. Sex hormones, receptors em U, Kucukler FK, Togrul C, Gungor T. Anti-Mullerian Anti-Mullerian C, Gungor T. FK, Togrul Kucukler em U, zenberg S, Praet J, Pazzaglia E, et al. The use of selective E, et al. The use of Pazzaglia J, Praet S, zenberg aller KA, Dickinson JE, Hart RJ. The contribution of multiple The contribution of aller KA, Dickinson JE, Hart RJ. erhoef L, Baartz D, Morrison S, et al. Outcomes of women of et al. Outcomes Morrison S, erhoef L, Baartz D, aghavi K, Morell S, Lamb J, et al. Initial observation of CIN2 does CIN2 does of et al. Initial observation Lamb J, S, aghavi K, Morell ucker PE, Cohen PA, Bulsara MK, Acton J. Fatigue and training Fatigue Bulsara MK, Acton J. PE, Cohen PA, ucker remellen K, Wilkinson D, Savulescu J. Should obese women’s Should Savulescu J. K, Wilkinson D, remellen access to assisted fertility treatment be limited? A scientific and access to assisted fertility treatment ethical analysis. ANZJOG. 2017;57(5):569-74. progestin receptor modulators (SPRMs) and more specifically (SPRMs) and more modulators receptor progestin ANZJOG. gynaecology. in the practice of ulipristal acetate 2017;57(4):393-9. Gork women with in infertile variation hormone exhibits a great . 2017;57(4):464-68. ANZJOG reserve patterns. ovarian different W to obstetric overseas fertility treatment from pregnancies Australian tertiary obstetric hospital. services in a Western ANZJOG. 2017;57(4):400-4. Hughes K, Sim S high risk of specialist clinic for women at a dedicated from labour: A ten year audit. ANZJOG. 2017;57(4):405-11. preterm Dunn L, K ANZJOG. labour. section following induction of for caesarean 2017;57(4):426-31. Permez specialist obstetrician & gynaecologist? ANZJOG. safe 2017;57(5):491-2. T obstetrics and gynaecology trainees in Australia and New of ANZJOG. 2017;57(5):502-7. Zealand. Acton J obstetrics and gynaecology trainees in Australia and New of ANZJOG. 2017;57(5):508-13. Zealand. Bhoopa Opportunities and performing female pelvic examinations: of barriers. ANZJOG. 2017;57(5):514-19. Hammond I this space! ANZJOG. 2017;57(5):499-501. in Australia: Watch Nicklin J gynaecologic surgery in Australia – A time and a place for everything. ANZJOG. 2017;57(5):493-8. Bowyer L, Robinson HL, Barr and management sepsis in pregnancy. for the investigation ANZJOG. 2017;57(5):540-51. T Robson SJ a high body for women with treatment assisted reproductive mass index. ANZJOG. 2017;57(5):575-8. Baber 2017;57(4):391-2. Ro Morgan EL, Sanday K, Budd A, et al. Cervical cancer in women under 25 years o cytology? ANZJOG. extent is the diagnosis made by screening 2017;57(4):469-72. T life in women under 25 years of quality of not appear to reduce age. ANZJOG. 2017;57(4):473-8. Bush D an the impact of model examining in schools: A New Zealand symptoms of in schools on early recognition program education suggesting endometriosis. ANZJOG. 2017;57(4):452-7. V trophoblastic for low-risk gestational diagnosed and treated (QTC). Centre the Queensland Trophoblastic neoplasia at ANZJOG. 2017;57(4):458-63.

of the October issue, Tremellen and others argue and the October issue, Tremellen of obese women the access of to against limitations to assisted fertility treatments, 19. 3. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. I wish you all enjoyable reading of these two issues. of reading I wish you all enjoyable References 1. 2. 4. 5. 6. 7. Norman strongly defend the ethical and clinical defend Norman strongly assisted reproductive for withholding reasons with a high BMI. women from treatments is pleased to is pleased ANZJOG obstetrics, of area In the summary the SOMANZ of executive publish the and management for the investigation guidelines guide to a comprehensive sepsis in pregnancy; of all types of diagnosis and management the causes, will be invaluable women that sepsis in pregnant of for all obstetricians.

3 4 The 7 12,13

10 Also of great interest interest great Also of management of low- management of 5 15 and varying levels of

6 16 The authors note a significant 8 and Dunn et al from Brisbane find and Dunn et al from 9 14 in conjunction with two articles looking 11 The October issue of ANZJOG will also be published The October issue of Michael Permezel this. Prof by the time you read O&G has contributed an incisive editorial on current training, In the second paper, from Taghavi et al, the authors Taghavi from In the second paper, CIN2 in women of observation careful conclude that ‘health-related in decreased under 25 does not result psychological stress. life’ or in undue quality of is the review article by Nicklin on robotic-assisted article by Nicklin on robotic-assisted is the review surgery and future, laparoscopic present and its role, in gynaecological surgery. that although advanced maternal age doubles the although advanced maternal that delivery caesarean and risk of in both nulliparous women older women, the majority of multiparous nevertheless do have vaginal births. at RANZCOG trainees’ working hours and reported trainees’ working hours and reported RANZCOG at in this issue. appear later levels that fatigue anti-Müllerian hormone in infertile women. hormone in infertile anti-Müllerian risk trophoblastic neoplasia risk trophoblastic In an important Clinical Perspective, Hammond et al the changes to the account of give an excellent that Program Cervical Screening Australian National The 1 December this year. will be implemented from the concerns that many of authors clearly address by some health professionals have been expressed to these changes; the article should be in regard for all practitioners involved in essential reading health. women’s reproductive Among the obstetrics original articles, Waller et Among the obstetrics original articles, Waller conceived with on multiple pregnancies al report and subsequently overseas fertility treatments managed in the sole tertiary unit in WA; maternity pregnancies all multiple these constituted a third of conceived with ART and managed over a two-year period in the hospital. Also in this issue, Harris et al review 525 cases of 525 cases of et al review Also in this issue, Harris the majority of that vulval pain, reporting chronic disease as the cause these had a dermatological had neuromuscular while a small proportion the authors point out, are conditions; both groups, original articles deal Other gynaecology treatable. with endometriosis education, aged under 25. A paper from Morgan et al concludes et al concludes Morgan from A paper under 25. aged very is a there cervical cancer that low incidence of the age of of irrespective under 25, in women intervals length of or the screening commencing their that state the authors between screening; the forthcoming ‘some support’ to findings lend in Australia. guidelines cervical screening changes in cost to the health system of what is now termed is now what cost to the health system of In other papers, care.’ reproductive ‘cross-border high-risk their dedicated from Hughes et al report preterm of rate Melbourne clinic on a decreased the labour over a ten-year period, and examine for this; reasons editorial examines the shortcomings of the present the present editorial examines the shortcomings of for recommendations some strong and makes system et al training, Bhoopatkar on the topic of change. Still the experiences study of an interesting have reported medical students in South Australia and New of they detail in learning pelvic examination; Zealand both the opportunities available to students, and the to gain in their attempts obstacles they encountered of intimate sufficient experience in the techniques examinations. WOMEN’S HEALTH rate inthispopulation. and easilyavailablementalhealth servicestothesewomenmaybeanimportantfactorinreducing thesuicide women whoare thevictimsof domestic violence,before suicidebecomestheirfinaloption.Provision of prompt or culturalpractices.Whilethismakes research more difficult,itdoes provide avenuesfor providing methods to cases thisassociation maybemediated viamechanismssuchasmental illnessanddepression, socialisolation suicide, butfindsthere isdefinitelyanassociation betweendomestic violenceandsuicideinwomen.Inmany In conclusion,thisreview highlightsthedifficultiesinstudying relationship betweendomesticviolenceand generally men,rather thanwomen,whowere thefocusof thisstudy. more likely toaccurately involvethepsychology of homiciderather thansuicideandthat theperpetrators were While thesecasesmayalmostalwaysincludeevidenceof domestic violence,theauthorsdecidedthat theywere authors excluded somestudieswhere genderwasnotreported. Theyalsoexcluded studiesof murder-suicide. type of studymethodology. Limitations were that onlyEnglishlanguagestudieswere includedandthat the the search terms,geographicallocation, inclusionof studiesof perpetrators of violence andnolimitations on broad inclusioncriteriaintermsofwomen. Despitethis,theyacknowledgeitslimitations. Thestudyhad very As theauthorsstate, at thetimeof writing,theirswastheonlysystematic review of IPV andsuicideamong violence inimmigrantcommunities. means of escape.Suchculturalconsiderations are relevant inothercountries,especiallywithconsideration of may subjectthewomantophysicalandmentalabuse.Inthiscase,somewomenseesuicideastheironly areBangladesh andIran,iftherequirements notmetbythebride’sfamilyhusband’s forthedowry system,suchasIndia,Pakistan,domestic violencehadspecificculturalcontexts.Incountrieswithadowry As thisreview considered studiesfrom across theworldthere were anumberof studiesinwhichsuicideand association betweenviolence,mentalillnessandsuicidehighlightsthedifficultyindeterminingcausality. of depression of orothermentalillness.This domesticviolencealsohadahistory of suicidewithahistory relationship betweeninterpersonalviolenceanddeath bysuicide.Inthat study, 85percentof womendying studies. Onestudyshowedthat after controlling forconfounders suchasmentalillness,there wasnosignificant violence conferred a17–40-foldincrease inriskof death bysuicide.Theseresults were notconsistentacross all suicide rangedfrom 3.5 percentto62.5cent.Alternatively, twostudiesreported that beingthevictimof violence anddeath bysuicide.Thereported lifetimeprevalence of exposure toviolenceinwomendyingfrom Thirty-six of thestudiesreported onthestrength of therelationship betweenbeingthevictimof interpersonal record audits,cohortstudies,psychologicalautopsyandtwoarticlesreviewing mediareports. were publishedbetween1981and2014 and18studiesincludedonlywomen.Study typesincludedretrospective and abstracts320full-textarticles,afinal38articleswere includedintheanalysis.Thearticles sexual violence,death andinjury. Aftersearch andelimination of duplicates andexamination of the5216titles March 2015. Search termsusedencompassedawiderangeof descriptorsof selfharmandsuicide,physical andCriminalJusticeAbstracts.Databases wereof searched Science,CochraneLibrary from theirinceptionto science, publichealthandcriminologydatabases, includingMedline,PsycINFO, EMBASE, CINAHL,Scopus,Web suicide inbothmenandwomenasperpetrators andvictims.Theauthorssearched eightmedical,social MacIsaac etal making itdifficulttodeterminecausality. the presence of domesticviolence.Inmanycases,peoplewhosuicidemayhavemore thanasingleriskfactor, predisposing factorsincludingmentalillness,drugandalcoholissues,regional location, ethnicityandrace and womenunder44yearsof age.Thecausesof suicideare often multifactorialandassociations are seenwith In Australia,more than2000peoplediebysuicideeachyearanditisthemostcommoncauseof death formen Links betweensuicideanddomesticviolence Club Journal WOMEN’S HEALTH 1. Reference Australian andNewZealand Journalof PublicHealth. 2017;41:61-9. MacIsaac MB 1 , Bugeja LC, Jelinek G A.Theassociation between exposure to interpersonalviolence andsuicideamong women: asystematic review. reported asystematic reviewand of therelationship betweeninterpersonalviolence(IPV) mini-reviews byDrBrett Daniels. recent research byreading these journals? Catch uponsome Had timetoread thelatest WOMEN’S HEALTH

2 Vol. 19 No. 4 Summer 2017 | 51 Vol. climate.edu.auclimate.edu.au climate.edu.auclimate.edu.au t women want f Health and Welfare. National Drug Strategy Drug Strategy National f Health and Welfare. tional Health and Medical Research Council. Australian Guide- tional Health and Medical Research ffering support and referral if needed ffering support and having the conversation about alcohol having the conversation consumption tha clear advice about alcohol, based providing on the Australian Alcohol Guidelines o Australian Institute o Available from Household Survey 2016: detailed findings. 2017. www.aihw.gov.au/reports/illicit-use-of-drugs/ndshs-2016-de- tailed. Na Avail- Drinking Alcohol. 2009. lines to Reduce Health Risks from www.nhmrc.gov.au/health-topics/alcohol-guidelines. able from

• • eLearning course RANZCOG and you with the information This course provides tackle the above dilemmas. skills to confidently course attracts the comprehensive Completion of you will be able to importantly, CPD points, but more by pregnancies help women to achieve alcohol-free delivering clear and evidenced-based advice about alcohol during pregnancy. the risks of Alcohol is a teratogen and heavy or binge drinking Alcohol is a teratogen It is not can cause damage to the developing fetus. alcohol is an amount of known if there currently fetus, can be consumed without damage to the that to not drink. hence, the recommendation to Know – alcohol and pregnancy Want Women dilemmas such as the ones outlined can solve You by: here • References 1. 2. Rebecca is consuming alcohol at a level that increases a level that alcohol at Rebecca is consuming and stillbirth, and puts her baby miscarriage her risk of birthweight and fetal birth, low premature risk of at conditions. (FASD) alcohol spectrum disorder risk Australian Alcohol Guidelines and level of Council’s Health and Medical Research The National from Australian Guidelines to Reduce Health Risks are for women who that Drinking Alcohol state not or breastfeeding, planning pregnancy pregnant, option. drinking alcohol is the safest 1 argeted resources aimed at aimed at resources argeted o see omen ealt roessionals lanning a regnanc regnant, are tat or breasteeding. argeted resources aimed at aimed at resources argeted o see omen ealt roessionals lanning a regnanc regnant, o are or breasteeding. CMA CMA ESCES ESCES Surprising to some is the fact that older, more more older, Surprising to some is the fact that likely those more women are and better-off educated to continue to drink during pregnancy. Rebecca has been referred by her GP because she Rebecca has been referred She and her in her first pregnancy. is a 36-year-old Rebecca has no busy professionals. partner are significant past or family history and is in good health feeling She admits to often 18 weeks gestation. at since and says she has cut down on alcohol stressed at 10 weeks, but is still was confirmed the pregnancy wine daily to help her wind down. having a glass of and Following history test results of review taking, Rebecca’s you determine that physical examination, well. is progressing pregnancy dilemma Rebecca’s is not She Drinking alcohol helps Rebecca relax. she can give up without help. She’s received sure having the about the risks of messages mixed She wine now she’s pregnant. occasional glass of that to raise this with you, and hopes feels reluctant the of you will raise alcohol consumption as part consultation. routine dilemma Your with Rebecca about have a conversation need to You or alarm her. her drinking, but don’t want to offend need this. You how to approach not sure You’re her with the risk and provide to assess her level of This will all advice, support or referral. appropriate have a full waiting room. time, and you already take storyRebecca’s is not uncommon women consume In Australia, one-in-four pregnant their pregnancy. knowledge of alcohol after during pregnancy during Susan Hickson Promotion Officer Health and Education Research Foundation for Alcohol drinking alcohol alcohol drinking How we talk about about talk we How THE COLLEGE me’. Manyearlyadolescentswillfindthiseasierand like Ladyof Shalott,realises that ‘thecurseisupon 3, butcanstillbeeffectiveiftaken assoonthegirl, Mefanamic acidisideallytaken from dayminus2or already taking‘thepill’. needs barriercontraception,butislesslikely touseif NSAIDS. Ifayoungadolescentissexuallyactive,she analgesics and/orprostaglandin suppression by those whosesymptomsdonotrespond tosimple young adolescents.COCP shouldbereserved for inappropriate asfirst-linetherapy, especiallyin pills (COCP) maybesound,Iconsideritto suppression bycombinedoralcontraceptive Although thetheoretical basisof ovulation inconvenience. 15 percenttoalevelof seriousdiscomfort and affecting 60–70percent of alladolescents,and level of medicalisation of acommoncondition, in O&GMagazineVol.19;No.3:p.36, proposes ahigh The article,Dysmenorrhoeainadolescents,published FRCOG, FRANZCOG(Hon) Schramm Dr Mary come totheclinic,letalonepay forinvestigations. investigation addstothecost.Many cannotafford to Asia, healthcare isnotfree. Every visitandevery In manylow-incomecountriesin Africaand extremely difficulttoobtainbasic electrolytes). (that is,onlyhaemoglobin,testformalaria,HIVand basicbloodtests blood fortransfusionandvery for another, letaloneanultrasound.There isno x-ray tubeismanydecadesoldwithnofunding At thehospitalinremote westernUganda,the service orrepair equipment. There isalsoapaucityof biomedicalengineersto unreliable, withpowersurgesdamagingequipment. there isnotraininginultrasounduseandelectricity Africa, ultrasoundisnotavailable.Ittooexpensive, Imaging isusefulinureteric fistulas.Inmanyparts of recto-vaginal fistula)byclinicalassessmentalone. of fistulasfrom theurethra/bladder tothevagina(and objectionable. At present, wecandetect100percent The paragraphon‘future directions of OFdetection’is a fistulasurgeon. there at theAddisAbabaFistulaHospital,workingas Ethiopia foroverayear, spendingmostof mytime Uganda asamedicalvolunteer. Ihavelivedin and havejustreturned from remote farwestern and Asiatreating womenwithobstetricfistula(OF), For over20years,IhavespentmuchtimeinAfrica Magazine Vol 19;No3:p60. Re: Obstetricfistula:apublichealthissue,O&G Letters totheEditor FRANZCOG, PhD, CU Prof JudithGohAO risk of fetalanomalies). ‘research’ that linked it,fraudulently, toheightened effects. Itwasdriven off that market around 1980by effective inearlypregnancy withvirtuallynoside like Debendox! (Debendox wasanantiemetic;highly wiped off theslate byexternalforces. Something registrar’s prescribing sins–anothergoodremedy an urgentcallfrom ascandalisedGPabouthisnew learned thisrather late, whenmyconsultantreceived to otheruses,andwere knownas‘purplehearts’.I days, totheUKin1968thesepillswere beingput dysmenorrhoea. WhenImoved,asonedidinthose friends andmypatients rapidrelief from cramping of sodiumamytalinapillthat gaveme,some dexamphetamine wascombinedwithasmalldose As anoteof history, inthe1950sand60s, contraception becauseof sideeffects. have discontinuedCOCP andsoughtalternative forget that, formore thanfivedecades,manywomen more natural thanadailypillregimen. We shouldnot The articlequotesNolsoe healthcare costs. diagnosing afistula.Itdoesnotaddtotheburden of requires littletrainingandextremely accurate in rectum. Thedyetestislowcost,availableanywhere, examination enablesassessmentof thevagina/ clinician tolocate thefistulaand,again,vaginal For the‘pinhole’fistula,adyetestwillallow safer andpreferable togeneral. many low-incomecountriesasspinalanaesthesiais importantin vaginal repair orabdominal.Thisisvery – clinician toassessandplanfortheroute of surgery fistula)andvaginalscarring.Italsoallowsthe urinary other fistulas(rectovaginal ormore thanonegenito- clinician toinspectthevaginaforotherpathology, Clinical hands-onexamination alsoallowsthe therefore easilypalpableorseenonexamination. required forthemajorityasfistulaislargeand +/- dyetestisallthat isrequired. Adyetestisnot andexamination For awomanwithfistula,history of equipmentisnothelpfulinlow-income areas. equipment withlittlescopefortraining orservicing obstetric fistulasandadvocacyforexpensive disagree that ultrasoundisrequired todetect Therefore, asanexperiencedfistulasurgeon,I benefit andonlyaddstothecost of healthcare. examination. Thus,anultrasoundscanisof little obstetric fistulawassurgery, inotherwords,clinical also admitsthat ‘gold standard’ fordiagnosisof the aetiology) totheobstetricfistula.This reference fistula, whichiscompletelydifferent (withdifferent 1. Reference 2013;16(2):45-55. pia –awalktobeautiful:isthere arole forultrasound?AJUM. Nolsoe CP . Campaigntoendfistulawithspecialfocus on Ethio- 1 whodiscussesperianal THE COLLEGE Vol. 19 No. 4 Summer 2017 | 53 Vol. Comprehensive, relevant, patient-focused information. The RANZCOG print store features features print store The RANZCOG functionality. BPAY updated printstore.ranzcog.edu.au Br obstetric fistula. Int J Gynaecol Obstet. of on the formation 2017;138(3):288-92. RANZCOG RANZCOG Patient Information Pamphlets Reference 1. of earlypregnancy Theeffect FodenP. owning A,MbiseF, The author also proposes that ultrasound would be ultrasound that also proposes The author obstetric fistula. This an the diagnosis of valuable in to diagnose, as the A fistula is simple is not the case. All 3x2.8cm. an obstetric fistula is of average size is not available, hand. If that you need is a gloved and removing or tissue in the vagina inserting a gauze with it is soaked see that an hour or so will after is the traditional Or there a fistula. urine, indicating and widely available dye test – a low-technology an ultrasound superfluous. rendering investigation guidelines nor any obstetric Neither FIGO nor WHO as a diagnostic test. fistula text lists ultrasound showed 1 that of those fistula sufferers who become pregnant who become those fistula sufferers of that the obstructed labour occurs in ‘early’ or ‘late’, hinting that their first labour in equal proportions, obstructed labour pelvic maturity, of regardless in equal rates. occurs in the first pregnancy the busiest fistula Northern Nigeria has one of early marriage where services in the world, in an area many arguments are is not the cultural norm. There against early marriage, but obstetric fistula is not early marriage will have a them. Eradicating one of obstetric fistula of impact on the rates if any, minor, obstetric fistula will be The only way that formation. it was in the West, is the same way that eradicated all women have access to safe by ensuring that by and timely obstetric services such as is provided Africa www.barbaramayfoundation.com. Maternity The article by Madeline King that appeared in O&G appeared by Madeline King that The article a public Obstetric fistula: 19;No 3:p 60, Magazine Vol affecting the tragedy us of reminds health issue, in developing countries. about two million women in the live in isolation sufferers fistula The majority of they Africa. Commonly, Sub-Saharan of rural areas disease, anaemia as renal have co-morbidities such and lower limb palsies. obstetric is the cause of obstructed labour Unrelieved of all labours 5 per cent About fistula formation. is solved in the problem become obstructed and But where by assisted delivery. the developed world obstructed labour no obstetric services, are there and delivery death with fetal a usually resolves of diameters. stillborn with reduced pelvis undoubtedly contributes Although a narrow the basic cause is malposition to obstructed labour, the baby’sof flexion, occipito- head, inadequate More posterior position and deep transverse arrest. in the home women deliver at than 90 per cent of Africa, so Sub-Saharan of huge swathes of rural areas assistance for obstructed labour is lacking. Madeline King points to early marriage and pelvis as the prime childbearing with a narrower experienced obstetric fistula. However, cause of Dr Andrew fistula surgeons dispute this. For example, on 6500 fistula who has operated Browning, ‘It is a commonly states and seen 10,000, sufferers early marriage is a risk factor held assumption that The link seems to for obstetric fistula formation. pelvic follow common sense as it is known that menarche.’ some two years after is reached maturity an early at pregnancy Hence, the thought is that labour obstructed age leads to a higher chance of been this has not However, and fistula formation. established in the field and it is hard to find an proven of example, For fistula surgeon who would agree. 2500 consecutive fistula an unpublished series of where Ethiopia, of in the Amhara region patients is the norm, only 45 per menarche marriage before got their injury fistula patients cent of during their is, when their pelvis was immature. that first labour, published paper by Browning A recently Dr David J Browning Dr David OAM FRANZCOG, FRCOG, THE COLLEGE Foundation Coordinator RANZCOG Women’s Health Delwyn Lawson Frankie Davison Award Winners of2017Liam& for studentsandallowsthemtoexplore, in-depth, The awardprovides avaluablelearningexperience he intendstopursueacareer inmedicinehimself. personal connectionashismotherisamidwifeand way of theaward.’Angus’interest stemmedfrom a would begreat tobeablelookdeeperintothat by and thegovernment’sstanceonit,sothoughtit interested inthecircumstances surrounding abortion City policybecauseshesays,‘I was already really for writingandchosetowriteabouttheMexico Gaia entered theawardbecauseof herpassion Council Week inJuly. held at CollegeHouseinMelbourneduringthisyear’s Board andCommitteemembersat apresentation and $1000prize moneyinfront of theRANZCOG The recipients were eachpresented withtheirawards influenced mygeneration’s view of “normal”women’. his submission,‘Early exposure totheinternethas Angus McGregor of St Kevin’s College,Victoria,for her submission,‘Gag Trumps Women’s Rights’,and Melbourne Girls’GrammarSchool,Victoria,with their exceptional submissionswere Gaia Bahaarof Coming inat thetopof thiscompetitivefieldwith in anyof theprevious years. of theentries,withtopscores beinghigherthan most impressed bythetopicsselectedandquality Director of PracticeandAdvocacy. Thejudgeswere New Zealand aswelltheCollege’sCEO and comprising RANZCOG Fellowsfrom Australiaand The awardwasjudgedbyanAward Committee polycystic ovariansyndrome. depression, abortion,genderinequalityand endometriosis, bodyimageconcerns,postpartum submissions were received ontopicsincluding Applications closedon30April2017and20eligible Australia andNewZealand. selection of applications from studentsacross year in2017, andonceagainattracted animpressive offered bytheCollegeforfourthconsecutive writingonanissueinwomen’shealthwas in literary The LiamandFrankie DavisonAward forexcellence and-Frankie-Davison-Award orbycontacting [email protected]. Coordinator andfurtherinformation isavailableonthewebsite:www.ranzcog.edu.au/about/foundation/Liam- science andhealth,tolawpolitics. Theawardisadministered bytheRANZCOG Women’s HealthFoundation level,butalsothosewithaninterest inavarietyofintending tostudymedicineat subjectareas tertiary from will beameaningfullegacyforLiam andFrankie. Theawardisintended tobeof relevance notonlytostudents passion fornurturingandencouraging youngwriters,teachingandgoodliterature, andinthehopethat this a teacherat Toorak Collegeformanyyears.Theawardwasnamedinrecognition of LiamandFrankie’s shared MH17 disaster. LiamDavisonwasavaluedmemberof staff at RANZCOG, responsible foreLearning,and Frankie to theLiamandFrankie DavisonAward followingthetragiclossof LiamDavisonandhiswife, Frankie, inthe of RANZCOG. Thenamewaschangedfrom theRANZCOG Students Women’s SeniorSecondary HealthAward introduced in2014 toincrease levelof awareness therole withintheeducation andwork sectorbelowtertiary schoolinAustraliaandNew Open tostudentsintheirfinalthree years Zealand, theawardwas of secondary About theaward Angus McGregor Prof Robsonpresenting awardstoGaiaBahaarand 31 January andcloseon30April2018.31 January Applications fornextyear’sawardwillopenon about/foundation/Liam-and-Frankie-Davison-Award. section of theCollegewebsite:www.ranzcog.edu.au/ from theRANZCOG Women’s HealthFoundation The winningsubmissionsare availabletodownload and familyinAustraliaNewZealand.’ woman an organisation that hasanimpactonevery and acknowledgmentof myinterest inthisarea from saying, ‘It wasagreat honourtoreceive thisaward College fortheirawards,withAngusMcGregor The recipients were bothdeeplygrateful tothe can really learnfrom.’ that itisonatopicthat cansurpriseyouandthat you important whenyoudoundertake research like this, interested inandIthinkitis a subjectthat Iamvery was anamazingwaytolookbeyondthesurfaceof some areas duetotheMexicoCitypolicy. Theaward topic, often shockingtoseewhat isreally goingonin own view, butalso,consideringthesensitivityof the the evidenceagainstgagruleandstrengthen my researching soitwasincredibly enlighteningtosee few preconceived opinionsaboutmytopicbefore interested in.RecipientGaiaBahaarsays,‘I hada an issuerelated towomen’shealththat theyare . THE COLLEGE To access thecourse, pleasevisitcolp.cquip.edu.auorcontact [email protected] for furtherinformation. Academic Abilitiesdomainfor completion of theCOLP. RANZCOG Fellowscanclaim5CPD, PAR pointsintheself-education component of theClinicalExpertiseor 5. 4. 3. TheNational CervicalScreening Program andrisk-basedscreening 2. anditsrelation Thenatural historyof HumanPapillomaVirus (HPV) tocervical neoplasia 1. The revised topicsinclude: progress andcertificate of completion. Abnormal Vaginal Bleeding(2016Guidelines),itoffers sequential compliance pathway totrackindividual for Managementof Screen DetectedAbnormalities,Screening inSpecific Populations andInvestigation of Recently updated toalignwiththerenewed National CervicalScreening Program (NCSP)policyandGuidelines performing colposcopy. freely availabletheoretical onlineeducation program forprofessionals The ColposcopyOnlineLearningProgram (COLP) isacomprehensive and The treatment of pre-invasive diseaseanditscomplications The fundamentalandpractice of colposcopy Management principleof thepatient withandanabnormalcervical screening result RANZCOG’s education module. education andtrainingonFGMshowcased of twosystematic reviews onhealthprofessional hospital andAngelaDawsonpresented theresults on theobstetricoutcomesof womenat anAustralian presented theresults of arecently publishedpaper modules, represented Australia.NesrinVarol the committeethat developedRANZCOG’s FGM Varol (University of Sydney), key membersof Dawson (University of Technology) andNesrin professional trainingandcurricula.A/Profs Angela evidence andconsensusgapshealthcare and data concerninghealthcare andprevention, Australasia cametogethertoshare experiences program implementersfrom Europe, Africaand and Brussels.Leadingresearchers, cliniciansand Programme andtheUniversities of Geneva,Montreal World HealthOrganization’s HumanReproduction Switzerland. Thesymposiumwassponsored bythe and prevention at theGenevaUniversity Hospitals, an international symposiumonFGMmanagement RANZCOG’s FGMmodulewasrecently presented at New FGMmodule University ofTechnology Sydney Australian CentreforPublic&PopulationHealth PhD,BA(Hons), MA, PGDipHEd,PGDipPubHlth A/Prof AngelaDawson Sydney GynaecologyandEndometriosisCentre Director Sydney MedicalSchool,University ofSydney PhD, MIPH, FRANZCOG, MBBS A/Prof NesrinVarol and prevention. international symposiumonFGMmanagement Angela Dawsonwiththeposterdisplayedat the professional counsellingaide. supported byclinicalguidelinesandahealthcare to clinicalpractice.InNSW, thistraininghasbeen found themoduletoberelevant andapplicable and advocacyisalsoprovided. Anevaluation has FGM mayrequire. Information tosupporteducation clinical supportthat womenwhohaveexperienced consequences of FGMandaddresses thecare and Australia, outlinesthesexualandreproductive health introduces healthprofessionals totheissueof FGMin The onlineRANZCOG module,madeupof fourunits, colp.cquip.edu.au

THE COLLEGE Jahun paradise? Just anotherdayin antenatal care andearlier intheirlabour. this ischanging,withmore womenpresenting for midwives andthehospital’sgrowing reputation, collaboration andtheworkof the MSFoutreach mortality rates intheworld. Thankfully, through the which ispotentiallyoneof thehighestmaternal mortality rate iswellover5000 per100,000 women, staggering stillbirthrate of 15percent.Thematernal local figures innorthernNigeriademonstrating a there isalargedisparityacross thecountry, with mortality rate of 820per100,000 people.However, maternal world togivebirth,withacountry-wide Nigeria isranked asone of the 20worstplacesinthe presenting tothehospitalisoften thelastresort. and treatment from traditionalmedicinepeople,so births withlocalbirthattendants orseekadvice late andunwell.Manywomenstillattempt home majority of womenarriveat thehospitalextremely highacuity,6000 womenayearwithvery asthe wards. Currently, thehospitaldeliversmore than as twotheatres, anICU, andpostnatal anddelivery repairs, aNICUforbabiesbornat thehospital,aswell This includesavesicovaginalfistulawardforfistulae operated JahunGeneralHospital’smaternity unit. of Health.Since2008,the NigerianMinistry MSFhas Jahun Project isacollaboration betweenMSFand Located inJigawaState innorthernNigeria,the It hasalready beenabusydayinJahunHospital. both, Ithink. running. Oh,itisneveragoodsignwhentheycallus just arrivedfrom theUK,already inthecar, engine I canseethedriverandanaesthetist,whohas put onmyscrubs,bootsandheadouttothegate. unceremoniously untanglemyselffrom it.Iquickly about themosquitonet,andhavetodoadance needed. Igotogetoutof bed,onceagainforgetting door andisgentlyknockingtoletmeknowthat Iam the MSFWatchman that hascometomybedroom is that callingme?Ithenremember ‘Oh, Jahun!’Itis a fewseconds,Iamconfused. Where amIandwho ‘Dr Jared, DrJared. You are neededinmaternity.’ For Broome, DerbyandKununurra Hospitals Kimberley Regional Specialist MBBS(Hons) FRANZCOG Dr JaredWatts She isintrouble, bigtrouble. cardiac effusionsandpoorcontractility of theheart. probe, evenwithnotrainingIcanseethepleuraland normally venture outof thepelviswithmyultrasound or otherconfounding problems and,whileIdonot abdomen toensure there are noretained products her saturations, butsheisquicklytiring.Iscanher tohelpherstaysittingupasthishasraised trying to keep hersaturations at 80percent.Thestaff are musclejust accessory positive, andsheisusingevery failure. Herhaemoglobinis35, aspottestformalaria seizures withlikely oedema andcardiac pulmonary one dayagoat home.Shenowpresents after three day. Thismotherisaged21,para3anddelivered four ormore patients presenting withjijigaeach has anextremely highrate of eclampsia,withoften shake’ callseclampsia.Jahun andwhat everyone I sigh.JijigaisthelocalHausawordmeaning‘to sitting at thedesk.Shenodsherhead.‘Not again,’ concentrator settomax.‘Jijiga?’ Iaskthemidwife saturation of 80percent,despitetheoxygen 194/114 andevenmore concerningistheoxygen have three patients. Thebloodpressure shows patient notsharingabedtonight;mostotherbeds attached tothepatient inbedtwo.Sheistheonly I aminstantlydrawntothereadings onamonitor are ward.Asweenter, directed tothepre-delivery On arrivingat thehospital,anaesthetistandI else JahunParadisehasinstore forustonight. with ‘Welcome toJahunParadise!’Iwonderwhat shocked ontheirfirstday, andjokilygreet newstaff local staff are quiteusedtoexpats seemingquite in disseminated intravascularcoagulation (DIC).The a womanwhopresented withaPPHandwasalready ruptured uteri.Sadly, wehavealsohadadeath today: two endinginhysterectomies, andrepaired three have performedeightcaesareans sections,with (PPH), often withhaemoglobinsof lessthan30. I anaemia from malariaorpostpartumhaemorrhages ten womenhavepresented withsymptomsof have lostcountof thenumberof twins.At least supervised sixvaginalbreech deliveries,andwe today Ihavedelivered avaginalbirthof tripletsand been quitebusyandoften seemschaotic.Already With itbeingmalariaseason,thehospitalhas anaesthetist, two scrubnursesandexpat obstetrician. The theatre team,madeupof alocalnurse THE COLLEGE Vol. 19 No. 4 Summer 2017 | 59 Vol. Surprise twins: a common occurrence in Jahun. Surprise twins: a common occurrence Back to that night: I missed the ward round the round the ward I missed night: to that Back up in theatre. as I was caught following morning for the evening I made it to ICU was The next time our ICU shoes As we changed into ward round. in bed five was I noticed the patient and lab coats, familiar. her baby and she looked breastfeeding mask on with a high had an oxygen The patient but seemed to be talking in short respiratory rate, closely, Looking more sentences to her neighbour. the from it was the patient I was surprised to find to not only alive, but appeared She was night before. anaesthetist noticed I think the rapidly. be improving ‘The and whispered, jijiga did my surprise and joy, I also I went over to see her, not win this time.’ As she was talking to in the next the patient recognised with presented who she the uterine rupture bed. ‘Is the ‘Yep,’ and DIC?’ I asked. 21 a haemoglobin of she looks and teased, ‘and anaesthetists smirked glad with that, I had to agree better than you, hey?’ rest. and I could night off, it was now my too that Jahun has been challenging for MSF and in Working but I canand difficult, with even a few tears shed, easily say it has been the most satisfying six weeks you can only do so much, Yes, so far. my career of due to complex social the issues are as many of up for a health, but if you are determinants of tochallenge, want to use your general skills, learn treat findings, and see and on your examination rely be the about, MSF may conditions you have only read appreciated In Australia, you may feel really answer. fine wine tries to give you a bottle of when a patient give you tries to or champagne, but wait till a patient is often for the day as a thank you. It their food ration all they have, and it means they would go without you and what and appreciate realise then food. You a lot I have also received MSF means to these patients. working in Nigeria; friendships, skills, knowledgefrom real knowing I am making a of and the satisfaction theseof in these people’s lives. For many difference stands that it is only MSF and their staff patients, about Jahun joke often We between them and death. it reallyHospital being a paradise, but for the patients is their northern Nigerian desert paradise. I Having been home for about a week, the question go back? Will you is ‘Will you asked am most often already work for MSF again?’ My answer is simple, ‘I have my next placement booked.’ is currently Australia Médecins Sans Frontières looking for O&Gs to deliver medical assistance to must be able to the people who need it most. You commit to a minimum placement of six weeks and be Find out morea resident of Australia or New Zealand. www.msf.org.au/join-our-team/work-overseas. at A rare moment in pre-delivery beds don’t A rare where each. patients have three This follows on from three other cases this week three This follows on from in maternal have resulted eclampsia that severe of Patients aged less than 20. All mothers were deaths. due the disease in advanced stages of present often to wait to having limited transport options, having them for their husband to give permission or escort to hospital, or trying first. The medication traditional other cases had also developed pulmonary oedema in electrolyte which resulted failure, and renal All the cases disturbances and then cardiac arrest. which may traditional medications, so far had taken and herbs actually worsen the outcome as these teas under the own. For this mother, on their appear toxic the anaesthetist, we started frusemide guidance of glyceryl of and moved her and an infusion trinitrate to keep I rang the medical coordinator to the ICU. we may have another maternal think ‘I him abreast. eclampsia and potentially traditional from death again,’ he sighed. This him. ‘Not meds,’ I informed was becoming all too common. I have now been on placement with MSF in Nigeria for a month. Since medical school days, I have always journey started the real but wanted to work for MSF, the FIGO World about two years ago. I was attending and MSF had a booth at in Vancouver Conference to an obstetrician I chatted There, the trade show. MSF’s medical advisors and was verywho was one of with in Sydney surprised to discover she worked other advisors on women’s and child health. She and opportunities process discussed the application to work with MSF. Fellowship, I After completing my RANZCOG and an essay on my motivation submitted my resume for an I was then invited to Sydney to work for MSF. working for MSF and aspects of interview regarding I in humanitarian medicine. Passing the interview, training course in Sydney, a week-long attended working for MSF many topics of which covered I was matched and in developing countries. Finally, with Jahun, and my employer in Australia was very for a supportive. I soon found myself back in Sydney briefing and then flew out to Abuja, the predeparture nerves and excitement. Nigeria, full of capital of THE COLLEGE College ofMedicineNursing&Health Sciences Associate Professor, FijiNational University Pacific Societyfor Reproductive Health President Dr PushpaNusair Catalysts forchange PIC every twoyearsandIencourage membersofPIC every We holdourbiennialconferences inadifferent standard of healthforwomenandtheir families. in thePacificandourcommitment toahigher members isourworkinreproductive sexual health workers. Thecommondenominator forallour researchers, educators andcommunityhealth reproductive healthprogram analystsandmanagers, O&Gs, publichealthspecialists,midwives,nurses, Our membershipincludesacademicandclinical care forthehealthandwellbeingof ourworkforce. disease, casemanagement,clinicalgovernanceand proactive andinformed aboutemergingtrends in women intheirhealthandwellbeing,tobeing from advocacyformeasures that willempower at thebigpicture of sexualandreproductive health, For thoseof usinseniorroles, thisincludeslooking not sowell,inourworkplaces. challenges andupdates onwhat isworkingwell,or collaborating andsharingourexperiences, updates andcreates opportunitiesfornetworking, development of ourmembersthrough educational invaluable opportunitytoenhancetheprofessional workshops, meetingsandeventsprovide an generation of O&GsforourPICs.Oureducational departments responsible fortrainingthenext or PapuaNewGuinea,tothoseworkinginacademic health postsinaremote islandprovince of Vanuatu providers, whorangefrom thoseworkinginsmall PSRH seekstoprovide supportforwomen’shealth the Pacific,Australia,New Zealand andglobally. that thisrole isbeingincreasingly recognised across the PacificIslandCountries(PICs),andweare proud workforce whoprovide theserviceacrossmidwifery women’s healthandsupportforthemedical The Societyhasastrong role inadvocating for to womeninthePacific. leaders andproviders of reproductive healthservices stimulating andthought-provoking timeforusas attended theconference. Itwasabusy, educationally Vila, Vanuatu. More than300 healthprofessionals by thePSRH12thbiennialconference inPort number of educational trainingworkshopsfollowed Society forReproductive Health(PSRH)helda Over aperiodof sixdaysduringJuly2017, thePacific • cancerprevention andcontrolprogram cervical Recommendation 1:Establishacomprehensive Executive of themeetingasfollows: Summary These recommendations are reported inthe next biennium. an actionplantoguidetheworkof theSocietyin recommendations that formthebasisfordeveloping meeting, thePSRHBoardhasidentifiedanumber of fine-tuned through apost-conference strategy wide experienceandexpertiseat theconference, obstetrics, gynaecologyandmidwifery. From the The PSRHforumbringstogetherseniorleadersin Recommendations fromthe Conference CEO) whomanagesoursecretariat inAuckland. (Vanuatu). We alsohaveDrAlecEkeroma (Honorary Tagiyaco Vakaloloma (Fiji)andDrErrollyn Tunga general membersMsNancyPego,(SolomonIslands), Gapirongo, PastPresident (SolomonIslands)and (PNG);MsKathy Secretary Gawin, Honorary Watson, Treasurer Honorary (Australia);Dr Gunzee (NZ); MsPaulaPauwe,VicePresident (PNG);Dr Roy members are DrKaraOkesene-Gafa, VicePresident for theensuingtwo-yearperiod.MyelectedBoard PSRH Board.Iwashonoured tobeelectedPresident The biennialgeneralmeetingelectedmemberstothe newborn healthintheirownsettings. innovative methodsforimproving maternal and allowed midwivestoshowcasebestpracticesand Improvement Marketplace Stalls’ wassetupthat to theconference sessions,asidesession‘Practice health; andleadershipintheworkplace.Inaddition based violence;adolescentsexualandreproductive unmet needs;prevention of cervicalcancer;gender- surveillance andresponse; familyplanningandthe maternal death and gynaecology;midwifery; health; healthworkforce developmentinobstetrics including bestpracticesinmaternal andnewborn The conference discussedanumberof areas, July at theNational ConventionCentre. colposcopy, withthemainconference held15–18 obstetric tears;ultrasoundinmaternity care; and planning; research andclinicalaudit;repair of including earlyessentialnewborncare; family Pacific emergencymaternal andnewborntraining, skills workshopsconductedinparallelsessions: The eventstartedfrom 13–15Julywithsixtechnical period, 2016–2030. to improve healthanddevelopmentinthe15-year of theSustainableDevelopmentGoals,ablueprint progress’. Thisthemeisinlinewiththeglobalagenda Development Goals–catalysts foraccelerating ‘Reproductive HealthandtheSustainable The themeof ourconference thisyearwas: we inhabit. Pacific hospitalityandlearnaboutthe region RANZCOG tocomeourmeeting,share some be prevented ifpre-cancer status isdetected deaths peryearintheregion. These deaths can burden andcausingmor cancer inthePacific,contributing todisease Cervical canceristhemostcommon female e than1500premature THE COLLEGE Vol. 19 No. 4 Summer 2017 | 61 Vol. educing maternal and newborn deaths and newborn deaths and educing maternal effective contraception, people with each more partners to reassess the situation in the Pacific the situation reassess partners to practical are plans that strategic and develop issues. the in addressing and affordable for planning is an effective intervention Family r to couples and promoted should be strongly the essential component of individuals as a key health package. maternal with countries, donors PSRH will collaborate ways to on innovative and development partners r methods of with a focus on long-acting the unmet needs. contraception, and addressing Recommendation 4: Increase contraceptive uptake uptake contraceptive 4: Increase Recommendation family planning in the unmet need for and reduce the region • • many partners it takes As with any large conference, to the deliveryworking together to contribute of PSRH thanks itself. workshops and the conference Pacific the the conference, the main sponsors of Population Nations Community and the United and contribution support for their generous Fund possible, as well as the made the conference that government for its hospitality in hosting the Vanuatu with gratitude also acknowledge We conference. the Australian Society for Cytology the support of Health UPNG, World FNU, and Cervical Pathology, RANZCOG, UNICEF, Nations United Organization, Papua New Guinea Society of Fiji O&G Society, New Zealand Midwives, O&G, Australian College of Midwifery Council, Midwifery Fiji, Societies from the Solomon Islands and Papua New Guinea, and and Australian the governments of assistance from New Zealand. and PSRH looks forward to continuing our strong and its with RANZCOG supportive relationship the of members and we hope to welcome many membership to our next conference. RANZCOG welcome to our next are RANZCOG Members of via in PNG in 2019 and can join PSRH conference psrh.org.nz/apply-online. the online application, welcome always to support our work are Donations psrh.org.nz/donation. at

f health workforce in midwifery in f health workforce y technical working group on y technical working group y segment of the PSRH Board y segment of esources and sponsorship for esources -appropriate guideline on comprehensive -appropriate oblem that hinders the provision of essential of hinders the provision oblem that maternal-newborn care at all levels of the health the all levels of at care maternal-newborn to midwives the numbers of system. Increasing critical to of vacancies is fill in the large number at especially care, in quality of progress make primary level. care Shortage of midwives has been a long-standing Shortage of pr The midwifer will work with governments and development cervical cancer prevention to help countries to help prevention cervical cancer on PSRH will embark problem. this address and key with governments collaborating to pursue this agenda. partners in the region will be coordinated cervical cancer prevention this development of by PSRH to oversee the its progress. and facilitate program and treated early. Primary secondary and early. and treated and effective are that strategies prevention be pursued. PIC settings should practical for in problem and obstetrics is a long-standing of service the quality affects the Pacific and delivery The issue care. in maternal-newborn of needs to be positioned high on the agenda development and in the discussions among governments and development partners. PSRH is well-positioned to engage in advocacy dialogue with donors and development partners to leverage r health institutions (midwiferystrengthening [FNU] and the University schools, Fiji National Papua New Guinea [UPNG]) to of University well-trained numbers of adequate produce obstetricians and gynaecologists for the Pacific region. The shortage o A multi-countr PSRH made strong commitments to develop a commitments strong PSRH made Pacific • • workforce 2: Support health Recommendation and gynaecology development in obstetrics • • • 3: Strengthen the capacity Recommendation of midwifery to produce training institutions increased numbers of midwives to meet national targets • THE COLLEGE Vol. 19 No. 4 Summer 2017 | 63 Vol. Sydney West Advanced Pelvic Surgery Unit West Sydney Dr Poprzeczny is currently enrolled in a PhD at the a PhD at in enrolled is currently Dr Poprzeczny and Trainee is a RANZCOG Adelaide, and of University Hospital. Her McEwin Lyell at senior O&G registrar and fetal and newborn growth will investigate project elevated a normal and distribution in women of fat of of a diagnosis and the additional effects BMI, diabetes on fetal and newborn growth gestational distribution. and fat Committee Trainee NSW Regional RANZCOG Grants, 2018 (ThreeResearch awarded) Dr Amy Goh Recipient: Institution: surgical outcomes Project: The comparison of and Gyrus PK in total laparoscopic using LigaSure hysterectomy. in her fourth year Trainee Dr Goh is a RANZCOG aims Hospital. Her project Westmead training at of surgery laparoscopic two types of to compare the Gyrus PK. system and instruments – the LigaSure surgeryShe will be comparing the outcomes of for hysterectomy women undergoing total laparoscopic these instruments; these outcomes with either of time and blood loss. include operating Shamsa Dr Aiat Recipient: New South Wales of Institution: University with benign in women Project: Novel biomarkers IVF. gynaecological conditions and those undergoing based currently Trainee, Dr Shamsa is a RANZCOG aims Her project the Royal Hospital for Women. at using a blood test the possibility of to investigate – women’s ovarian reserve of as an indication her eggs. This blood the quantity and quality of in women with benign test will be investigated gynaecological conditions such as endometriosis, Such a new test could and women undergoing IVF. potentially help in the diagnosis and management of these women. Dr Daniella Susic Recipient: George Hospital, NSW Institution: St and infancy: in pregnancy Project: The microbiome its composition, and assessment of comprehensive to health and disease. its relationship and year four Registrar Trainee Dr Susic is a RANZCOG Hospital/Royal Hospital for Women. Wollongong at will assess the years, Dr Susic’s project Over three the critical period stages throughout at microbiome to hormonal, in response and infancy pregnancy of metabolic, immune and cardiovascular changes. (faecal, during pregnancy the microbiome Samples of birth (placental, breastmilk, oral and vaginal) and after meconium) will be assessed to determine a link outcome and disease. between pregnancy Research Scholarships Research Arthur Wilson Memorial Scholarship, 2018–2019 Pritchard Dr Natasha Recipient: Melbourne of Institution: University Project: Novel therapeutic agents to treat in obese mice models. pre-eclampsia the Mercy at Trainee Dr Pritchard is a FRANZCOG will Dr Pritchard’s project Hospital for Women. pre-eclampsia. develop an obese mouse model of She will test whether metformin and esomeprazole, in pregnancy, potential and safety two drugs offering in this model to determine pre-eclampsia can treat outcomes for whether these therapies can improve obese women and their offspring. Scholarship, 2018–2019 Fotheringham Research Dr Maya Reddy Recipient: Institution: Monash University pre-eclampsia: Project: The cardiovascular toll of fetal and determining impacts on the maternal, placental vasculature. training FRANZCOG Dr Reddy is in her fourth year of Monash Health. Her study at and is an O&G registrar be conducted over the course will predominately how Monash Health and will explore two years at of the heart and blood vessels change in pregnancies It blood pressure. by elevated complicated are that will then determine whether these changes can be outcomes and long-term pregnancy used to predict heart disease. Scholarship, Norman Beischer Clinical Research 2018–2019 Dr Amanda Poprzeczny Recipient: Adelaide of Institution: University overweight and obesity and Project: Maternal diabetes: effect on fetal growth gestational and adiposity. Each year, the Foundation offers several research andresearch several offers the Foundation Each year, The assessment application. travel scholarships for very was once again process competitive this year, Australia and from received being with 33 applications scholarship for evaluating The process New Zealand. aims to identifyapplications the most promising Research and the RANZCOG researchers early-career Grants Committee, which assesses these applications, of with the high quality impressed was extremely this year. received applications is Health Foundation Women’s The RANZCOG the following applicants pleased to advise that scholarships and fellowships for have been offered and travel in 2018: research Health Foundation Health and fellowships 2018 scholarships RANZCOG Women’s Women’s RANZCOG @RANZCOG SOCIAL MEDIA facebook.com/RANZCOG Ph: +61 3 9417 1699 +61 3 9419 0672 Fax: Email: [email protected] www.ranzcog.com.au A senior colleague (FRANZCOG) with whom A senior colleague (FRANZCOG) two within the previous you have worked the in currently years. Applicants who are must nominate training program FRANZCOG Supervisor as the senior Training their current colleague. applicant the whom with colleagues other Two the last two years. within has worked PLEASE NOTE details of to provide required Applicants are referees. three must be: referees The three • • form to Please email your completed application Subspecialty Committee: the relevant the Chair of [email protected] about these positions For further information Gilliam kgilliam@ranzcog. please contact Kate edu.au or +61 3 9412 2959 about the subspecialty information Further can be viewed on the College training programs www.ranzcog.edu.au/Training/ website at Subspecialist-Training/Apply/National-Selection training for all subspecialty Applications 31 March 2018 positions for 2019 close on Friday AUSTRALIA College House, 254-260 Albert Street East Melbourne, Victoria 3002, Australia. Applications for the following Subspecialties National Selection Process 2018 (2019 2018 Selection Process following Subspecialties National for the Applications * 2018. 31 March and close on entry) 2017, open on 1 December *PLEASE NOTE training subspecialty (CGO) the Gynaecological Oncology for 2017 Applications As of 31 January on 1 October 2017 and close on program opened 2018. The Subspecialties National Selection Process is Selection Process The Subspecialties National eligibility determines that a competitive process but does to commence subspecialty training, not guarantee a training position. to apply pertaining to eligibility The regulations for and eligibility to commence subspecialty Regulations found in the RANZCOG training are available on the Section D: Subspecialty Training applicants College website. It is expected that before they meet eligibility criteria will ensure applying. by conducted Shortlisting and interviews are relevant the a panel comprising the Chair of Subspecialty Committee and a further two subspecialists. APPLICATIONS FOR SUBSPECIALTY FOR SUBSPECIALTY APPLICATIONS POSITIONS TRAINING Applications are invited, through the National through invited, are Applications trainees for the prospective from Selection Process, which subspecialty training programs, RANZCOG subspecialties: of the five in one lead to certification Obstetrical & Gynaecological Oncology (CGO), Fetal Maternal Gynaecological Ultrasound (COGU), Endocrinology and Medicine (CMFM), Reproductive (CU). (CREI) and Urogynaecology Infertility training: Eligibility for subspecialty • • • using the must be submitted All applications entry) Selection Process 2018 (2019 National website form available on the College application www.ranzcog.edu.au/Training/Subspecialist- at Training/Apply/National-Selection THE COLLEGE regeneration inherniasof thevagina. efficacy ofpolycaprolactone asascaffold fortissue Queensland. DrMowat’s studywillevaluate the at theRoyalBrisbaneandWomen’s Hospitalin urogynaecology andiscurrently aurogynaecologist Dr Mowat holdsaRANZCOG certificate in of pelvicorganprolapse inthesheepmodel. tissue engineeringscaffold forthesurgicaltreatment Project: Evaluation of Polycaprolactone (PCL)asa Institution: RoyalBrisbaneandWomen’s Hospital Recipient: DrAlexMowat Research Scholarship,2018 UroGynaecological SocietyofAustralasia(UGSA) compare thesetoself-reported measures of stress. trainingworkshopand surgeons at alivesurgery 12 months,hewillinvestigate thesemarkers in time pressure). Intheotherphase,conductedover stressful environment (forexample,loudnoisesor when there isastress-neutral environment witha markers duringsimulated exercises andcompare phase conductedover12months,hewillmeasure surgeons undertakingstressful activities.Inone investigate possiblemarkers of acutestress in Royal HospitalforWomen inSydney. Heaimsto at the minimally invasivegynaecologysurgery Dr BuddenisaRANZCOG Trainee andFellowin Project: Measuringstress insurgeons. Institution: University of NewSouthWales Recipient: DrAaron Budden Taylor HammondResearch Scholarship,2018 improves painoutcomesandlongevityof relief. anaesthetic fortherapeuticpudendalnerveblocks assess whethertheadditionof hyaluronic acidtolocal outcomes forpatients withchronic perinealpainand Her project aimstoimprove thetreatment and Women’s HealthandResearch Instituteof Australia. Pain Fellowat theRoyalHospitalforWomen & Dr KiteisaFRANZCOG traineeandaGynaecology anaesthetic inpudendalnerveblocks. the efficacy ofaddinghyaluronic acidtolocal Project: Randomisedcrossover trialassessing of Australia(WHRIA) Institution: Women’s HealthandResearch Institute Recipient: DrLauren Kite 2018–2019 Robert Wrigley PainResearch Scholarship, Women inRandwick. Thisfellowshipwillsupport Gynaecology (PAG) Fellow at theRoyalHospitalfor Dr Shortiscurrently aPaediatric andAdolescent Great OrmondStreet Hospital,London Institution: University CollegeLondonHospital/ Recipient: DrAsha-Rhiannon Short Brown CraigTravel Fellowship,2018 different healthsystem. appreciation forhowresearch isconductedina form collaborations withtheunitandgainan George’s Hospital,London,where shehopesto observership intheFetalMedicineUnit at St grant willallowhertoundertakeDr Reddy’s an Institution: St George’sUniversity of London Recipient: DrMayaReddy TravelBeresford Buttery Grant,2018 Travel Scholarships/Fellowships hormone toprotect theovariesduringchemotherapy. Project: Theadministration of anti-Müllerian Institution: University of NewSouthWales Recipient: DrRachaelRodgers 2017–2018 ElizabethCourierResearch Scholarship, Mary Project: Theimpactsof kidneydiseaseinpregnancy. Institution: Westmead Hospital Recipient: DrMonicaZen 2017–2018 Norman BeischerClinicalResearch Scholarship, eclampsia. enhancing theprediction anddiagnosisof pre- Project: Targeting placentalspecificsFLT-1: Institution: MonashUniversity Recipient: DrKirstenPalmer Glyn WhiteResearch Fellowship,2017–2018 pathology andtheircorrelation withpregnancy rates. ultrasound of thejunctionalzone inmyometrial Project: Reproducibility of three-dimensional Institution: MonashIVF Recipient: DrLufeeWong (start datedeferred) Arthur WilsonMemorialScholarship,2016–2017 following projects in2018: The Foundation willalsocontinuetofundthe IN 2018 CONTINUING SCHOLARSHIPS/FELLOWSHIPS of aPAG clinic. multidisciplinary gender, andobservingtherunningorganisation management of adolescentswhoare transitioningin PAG conditions,gainingexposure tothecare and anomalies of thegenitaltract,andcommonbenign Differences of SexualDifferentiation, congenital the objectivesof understandingandmanaging and Great OrmondStreet HospitalinLondonwith Dr ShorttovisitUniversity CollegeLondonHospital +61 394122993. Coordinator, [email protected] or Lawson, theRANZCOG Women’s Health Foundation For donation enquiries,pleasecontactMsDelwyn please gotomy.ranzcog.edu.au/login. myRANZCOG MembersPortal.To loginanddonate, Foundation viathepaymentssectionof the RANZCOG membersare abletodonate tothe and Torres Strait IslanderWomen’s Health. initiatives inglobalwomen’shealthandAboriginal not onlyclinicalandscientific research, butalso well asorganisations, enabletheCollegetosupport Donations totheFoundation, from individualsas supported itsphilanthropicworkinthepastyear. grateful toallthosewhohavesogenerously very The RANZCOG Women’s Health Foundation is Support theFoundation Prof AlanHewson,NSW, 19August2017 Dr RameshVasant,Qld, 10August2017 the followingRANZCOG Fellows: The Collegewassaddenedtolearn of thedeath of Notice ofDeceasedFellows