Please cite this paper as: Robson S, Daniels B, Rawlings L. Bariatric surgery for women of reproductive age. BJOG 2016;123:171-174. Australia is ranked fifth of all OECD countries for prevalence of obesity in women, 1 and the proportion of young women with obesity is increasing. Over the last decade the estimated prevalence has increased by about 60% in Australian women aged 25-34 years, and by a remarkable 80% in women aged 35-44 years. 2 In 2012 just over 20% of women giving birth in Australia had a body mass index (BMI) of 30 kg/m 2 or greater, and 3% had a BMI of 40 kg/m 2 or more. As the theme of this issue of BJOG attests, obesity has become perhaps the major challenge facing those who provide care to women who are pregnant or seeking to become pregnant in both the developed and, increasingly, the developing world. Obesity is important because it affects all phases of a woman's reproductive life -it makes achieving an ongoing pregnancy more difficult, increases the likelihood of things going wrong during pregnancy and birth, can have important long-term adverse effects for the offspring, and limits the ability of a woman to provide longer-term parental care to her children. For all of these reasons, finding ways to help reproductive-age women return to a healthy weight before they try to become pregnant should be a priority.Losing weight is difficult and while systematic reviews 3 have shown that behavioural treatments and pharmacological therapies, alone or in combination, can bring about weight loss and improve health, the magnitude of change is relatively modest (typically around 3 kg) and the duration of improvement is unclear, with few studies providing follow up for 10 years or more. Nonsurgical approaches to obesity are also resource-intensive and require life-long compliance. They are also least likely to work in adults with the greatest degree of obesity. For these reasons the introduction and subsequent evolution of surgical approaches to the management of obesity have sparked great interest. Bariatric surgical procedures had their genesis in the 1950s, when it was noted that resection and shortening of the small intestine resulted in subsequent malabsorption and weight loss. 4 There are two main types of procedure in common use: 'restrictive' procedures such as adjustable gastric banding and sleeve gastrectomy; and 'malabsorptive' procedures such as the Roux-en-Y gastric bypass or biliopancreatic diversion. Restrictive procedures are technically easier to perform, but adjustable gastric bands that encircle the more proximal portion of the stomach may require frequent adjustment. In addition, food of a soft consistency (ice cream, for example) can easily defeat the band. Malabsorptive procedures, as their name suggests, shorten the effective length of the small intestine and, by an effect at the proximal duodenum, probably alter neuroendocrine function in the gastrointestinal tract as well.Recent systematic review of the evidence for bariatric surgery in nonpregnant adults is very encouraging,...
The COVID‐19 global pandemic has triggered one of the greatest economic shocks in a century. Effective COVID‐19 vaccines have been developed, but a proportion of people either are hesitant or refuse to be vaccinated, facilitated by a global misinformation campaign. If ‘herd immunity’ cannot be achieved, there is potential not only for ongoing surges in infection, but also for development of new strains of the virus that could evade vaccines and precipitate further health and economic crises. We review the economics of vaccination and of vaccine hesitancy and refusal, and their potential effects on the recovery from the COVID‐19 pandemic.
We examined mortality rates in Australian women aged twenty to fifty years during 2001–2016, demonstrating continued disparity by socioeconomic status. Mortality has declined but the reduction occurred in the first decade with no evidence of improved rates since 2010. There have been steady improvements in death rates from causes not considered preventable, while potentially preventable deaths increased in all but the highest socioeconomic quintiles. These rises are particularly alarming in what have been termed “deaths of despair.” As well as the obvious compassionate responses to death in prime aged women, there are important economic considerations that should prompt further research and a policy response.
Decisions regarding surgery are complex and economic influences affect choices made both by patients and their doctors. There is evidence that surgeons' decisions to offer operations are affected by financial incentives, yet we could find no studies addressing whether, once a decision to operate is made and a choice of procedures is available, operations offering greater financial reward are favoured. The choice between endometrial ablation or hysterectomy in heavy menstrual bleeding offers an opportunity to study decision-making. We obtained on all private hospital claims made in Australia for either endometrial ablation or hysterectomy for women aged 30 to 50 years for the five-year period 2012 to 2016 inclusive, according to socioeconomic status. The overall incidence rates and the ratio between hysterectomy and ablation, and the association between socioeconomic factors, were examined using linear regression. We found that the surgery with the greatest economic impact on the patient (hysterectomy) was more commonly performed than ablation, yet hysterectomy became the less dominant choice with increasing socioeconomic status of women. This finding suggests that direct financial costs are a lesser consideration in choice of the procedure with patients, but that surgeons may respond to a financial incentive to perform a more expensive procedure.
Background: There is variation in uptake of in vitro fertilisation (IVF) between countries, and Australia has high incidence rates of IVF due to universal public funding. However, it remains unclear whether there is regional variation and, if present, what might cause this. Objectives: We sought to determine whether regional variations in treatment rates existed and what might influence these. Methods: The number of cycles of fresh IVF and intrauterine insemination (IUI) for women were obtained for the period 2011 until 2014 in two age groups (25 to 34 years and 35 to 44 years) to calculate incidence rates. Proxy indicators that might influence treatment affordability were: unemployment rates; average weekly total earnings; coverage of private health insurance; and, percentage of women in the highest socioeconomic quintile. Measures of accessibility considered were percentage of the population remote from urban areas and average state population density. Linear regressions were performed using log-transformed ratio of IVF and IUI incidence rates. Results: Variations were found in IVF uptake between states with greater differences in older women. There was no significant association between IVF procedures and population density or geographic isolation. Economic factors were not associated with IVF uptake. Conclusion: These findings suggest that factors such as physician preference, clinical practice guidelines, and cryopreservation protocols of ART units might explain the national variation in uptake of IVF.
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