Recent eLetters

Displaying 1-10 letters out of 348 published

  1. BMJ Open Study on Abortion Mortality in Mexico Is Deeply Flawed

    A recent study in the BMJ Open that looked at the effect of abortion laws on maternal mortality in Mexico is egregiously flawed and biased. It poses an unacceptable risk to public health because it could be used to advocate the criminalization of necessary healthcare for women. This letter exposes the study's biases and flaws in detail.

    The study purports to show that Mexican states with more restrictive abortion laws have lower maternal mortality rates than states with more permissive laws. Although the authors refrain from hypothesizing a causal link between criminalized abortion and better maternal health outcomes, that counter-intuitive implication comes through nonetheless. It's even clearer in the authors' press release about the study.

    BMJ Open is an open access journal that offers easier and quicker publication of studies, but its website also states: "Our aim is to provide a home for all properly conducted medical research to be fully reported, after a rigorous and transparent peer review process."

    So what happened? Why did BMJ Open accept this study without subjecting it to greater scrutiny? Some anti-abortion language even slipped through--on page three of the study, the authors characterize the Mexican states' constitutional amendments protecting the "unborn" from conception as "progressive changes."

    Leading author Elard Koch (and various other co-authors) have published previous studies related to abortion (in Chile, Colombia, and Mexico), but the methodology of those studies has been shown to be seriously flawed and biased, rendering their conclusions invalid. My blog has a compendium of rebuttals ( disgraceful-example-of-bad-science.html) of Koch et al.'s previous work from both professional and lay sources.

    For example, in 2012, Ipas-Mexico published an analysis ( of maternal and abortion-related mortality in Mexico from 1998 to 2008, showing that one in 13 maternal deaths were from abortion. Koch and some co-authors then published a rebuttal to this, and Ipas responded with a statement that referred to the Guttmacher Institute's previous rebuttals to Koch et al.'s work. Guttmacher had explained and defended ( critique.pdf) widely accepted scientific methodologies for estimating numbers of illegal abortions and resulting maternal mortality rates--which Koch et al. had grossly underestimated.


    The BMJ Open study concludes that "maternal and abortion-related mortality ratios were lower in states with less permissive abortion legislation compared with states with more permissive legislation." However, this is based on arbitrarily dividing Mexican states into two categories using a variable with little significance for maternal mortality: those that ban abortion for reasons of "serious genetic or congenital conditions" in the fetus, and those that don't. It's worth quoting the authors in full to expose the nature of their error:

    "In exploratory analyses, segregating states by the number of exemptions provided in criminal codes did not result in detectable differences in sensitivity analyses, with the exception of abortion allowed by genetic or congenital fetal malformations. The remaining seven exemptions were distributed differentially in almost every state or very few states, thus offering no discrimination potential. Therefore, to differentiate between states with more or less permissive abortion legislation in subsequent statistical analyses, states allowing pregnancy termination due to serious genetic or congenital conditions were considered more permissive (14 states) while the remaining states were considered less permissive (18 states)."

    In other words, the authors subjected each legal exemption to a "sensitivity analysis"--which checks all the data to look for patterns among variables--until they found a variable that happened to show a detectable difference in maternal mortality. They then presented this as the primary finding. This error is called "data dredging" because chance associations between just about any two things are easy to find if you crunch enough numbers. To make their random association sound more meaningful, the authors manipulated the definition of "states with less permissive legislation" into something it didn't actually mean at all.

    Twelve Mexican states actually have a more liberal exemption allowing abortion in cases of serious risk to the woman's health, yet nine of those states ended up in the study's category of "less permissive." This demonstrates the arbitrariness of the chosen exemption factor of fetal anomaly, and indicates that the study could well have come to the opposite conclusion if the health exemption had been chosen as the dividing criterion instead. (All Mexican states allow abortion in cases of rape. Otherwise, abortion is mostly or completely illegal in all states except Yucatan, where it is allowed for economic or social reasons, and the Federal District of Mexico City, which allows abortion on request up to 12 weeks.)

    The selected exemption for fetal anomaly cannot possibly by itself show any trends or differences in abortion mortality rates between states. That's because abortions due to fetal abnormality are always a tiny minority of abortions in any country. In Britain for example, only 1 percent of abortions are carried out for reasons of fetal anomaly, and the numbers are similarly tiny for other countries. Further, almost all abortions for fetal abnormality occur later in pregnancy because the anomaly cannot usually be detected until then.

    In settings like Mexico, the numbers of abortions for fetal anomaly will likely be far smaller than 1 percent regardless of legality, because of stigma and other obstacles. Indeed, here's a study ( showing that most Mexican geneticists advise against abortion when the fetus has a genetic or chromosomal disorder. And there's no reason to assume that the average Mexican woman would even know that abortion might be legally available for reasons of fetal abnormality, let alone that she would have the means, resources, or courage to pursue that option. In other words, abortions for reasons of fetal abnormality must be very rare throughout Mexico, and cannot possibly serve as a proxy for tracking trends in maternal mortality due to abortion.

    This fatal flaw renders the study meaningless and the conclusion invalid, because it relies solely on a rarely occurring variable that would not have any noticeable statistical effect on maternal mortality.


    Similarly, the study assumes that because about half of Mexican states tightened their already strict laws against abortion after 2007--by passing a constitutional amendment protecting "the unborn" from conception --this would have a measurable effect on death from unsafe abortion. There is absolutely no basis for this assumption. Criminal laws restricting most abortions were already in effect everywhere outside Mexico City, so women would not be driven to unsafe abortion in any greater discernible numbers.

    This helps expose the second major flaw in the study: the authors' assumption that abortion law accurately predicts abortion practice. In reality, few Mexican women actually obtain abortions under the legal exemptions due to fear and stigma, lack of resources or knowledge, and refusals by anti-abortion doctors.

    One study (in Spanish: criminalization-of-abortion-continues-in-mexico/) by the Mexico City-based Group on Reproductive Choice (GIRE) showed that between 2007 and 2012, only 39 women in Mexico actually got a legal abortion under the country- wide rape exemption, out of a total of 120 who had applied for one. Why would so few apply? First, most states lack sufficient administrative mechanisms for seeking out a legal abortion under any of the exemptions, which means there's simply no way to even apply for an abortion. Second, abortion is highly stigmatized in Mexico, and it takes courage to apply for one--or seek medical attention after an illegal abortion. At least 679 women in Mexico were reported or sentenced for having an illegal abortion between 2009 and 2011. Mexico is one of at least seven countries in the world that imprisons women for having illegal abortions. From 2007 to 2012, 127 women were put on trial for abortion in Mexico, and in one particularly conservative state, Guanajuato, dozens of women have been prosecuted for abortion since 2000, with some of them receiving sentences of up to 30 years in prison.

    Oddly, Koch et al. never mention such shocking facts, nor do they mention the deeply rooted stigma and shame surrounding abortion in Mexico, the judgmental attitudes of many healthcare workers, or indeed any of the social, economic, or logistical difficulties that may inhibit women from even attempting to exercise their legal right to abortion in Mexico. Instead, the study's methodology and conclusion depend on the unspoken assumption that legal exemptions for abortion mean that all or most of those exempted abortions are actually taking place as needed. Nothing could be further from the truth.


    Koch et al. fail to acknowledge that "do-it-yourself" medical abortions have increased substantially over the last decade or more, with pills to end pregnancy now widely available in Mexico and most other Latin American countries. In fact, the words mifepristone and misoprostol never appear once in the BMJ Open study, which is a serious oversight. Clandestine use of the drug misoprostol is generally accepted as being much safer than traditional and more dangerous methods (for example, significantly reducing the rate of infection), even when women misuse it or misinterpret its effects because they don't have instructions on how to use it or what to expect.

    In one of Koch's 2012 rebuttals to the Guttmacher Institute, he asserted that "no study currently exists to date that seriously supports a decline in maternal mortality associated with the use of abortifacient drugs such as misoprostol in Chile." But he ignored several studies from countries such as Brazil and Mexico that showed significant declines in the severity and number of abortion-related complications and sometimes mortality over the same periods in which misoprostol use has grown.

    In the BMJ Open study, Koch and his co-authors follow the same pattern as in a previous Koch-led study on Chile ( Advisory.2012.05.23.pdf): They underestimate the number of abortions and associated maternal mortality by relying only on official statistical sources, while failing to consider that large numbers of illegal abortions are not accounted for in these sources, and that related complications and deaths may often be misclassified. In a criminalized and stigmatized environment, many women will not admit to having an abortion, and many health professionals will not officially report complications or deaths as caused by abortion, either through ignorance of the real cause, or out of compassion for women and their families.

    Koch et al. claim there is no reason for healthcare professionals in Mexico to "misreport deaths from a suspected illegal abortion" due to the existence of separate reporting codes for various types of abortions, including for an unknown cause. This overlooks the fact that issues with miscoding ( have become more common with misoprostol-related complications. For example, it can be challenging for doctors to distinguish medical abortion from miscarriage or other obstetrical complications. Further, Koch et al.'s analysis ignores the effects of fear and abortion stigma on how abortion occurs in illegal settings and whether complications or deaths resulting from them are reported as such.


    It's already well established--practically self-evident--that maternal mortality can be significantly reduced by educating women, upgrading health systems, and improving access to contraception, skilled birth attendants, clean water, sanitation, and so on. Yet, this study and previous Koch-led studies seem to treat such factors like their own new discovery that obviates any need to reform abortion laws.

    Unsafe abortion is just one of many factors that affect maternal mortality rates, though it's among the top five causes. An estimated 13 percent of maternal mortality globally is due to unsafe abortion. It is simply not possible to try to take into account a lot of contributing factors to maternal mortality and conclude that restrictive abortion laws have little or no effect, because the other factors can easily swamp the effect of unsafe abortion on maternal mortality rates. Is it possible that the authors of the BMJ Open study are using such factors as a smokescreen to cover up the effect of unsafe abortion on maternal mortality?

    Mexico still has a relatively high maternal mortality rate compared to other countries--about 45 per 100,000 live births, compared to 28 for the United States, 13 for Canada, and four for Sweden. In Latin America, where abortion is mostly illegal, it's 22 for Chile and 69 for both Brazil and Argentina (2013 data). It's likely that the declines Mexico has been seeing in maternal mortality would be even steeper if abortion was safe, legal, and accessible, and the same goes for Chile.

    Estimating the incidence of illegal, unsafe abortion as well as the resulting deaths and complications is of course a challenging task. Such abortions are unreported and usually never come to the attention of authorities, so vital statistics can only provide a fragment of the evidence-based picture. A variety of methods must be used to carefully piece together a picture that is as reliable as possible. These include, for example, surveys of women, surveys of specific healthcare facilities, and interviews with knowledgeable healthcare workers.

    Such methodologies are embodied in the Abortion Incidence Complications Method (AICM), which was developed about 20 years ago. The AICM has been widely used in studies appearing in peer-reviewed journals, and is recognized by experts around the globe, including the World Health Organization. Despite this, Koch has simply tossed out the AICM on the basis that it uses "imaginary numbers." ( critique.pdf) Not only is this dismissal disingenuous and unwarranted, it amounts to a gratuitous slur against the hundreds of reputable scientists and researchers who spend large amounts of time carefully gathering, comparing, and adjusting abortion-related data under challenging circumstances.


    The BMJ Open study has an important focus on maternal mortality, but unfortunately that focus tends to disguise certain facts that never see the light of day in the study:

    * More than a million (1,026,000) abortions take place in Mexico each year, the large majority of them illegal.

    * About 159,000 women were treated at public hospitals for abortion complications in 2009.

    * An estimated 36 percent of all women who have illegal abortions develop complications that need medical treatment.

    * One-quarter of those do not seek treatment, putting them at risk of lasting negative health consequences.

    The question that Koch et al. need to answer is this: Even if the study did demonstrate that restrictive abortion laws are associated with lower maternal mortality, does that make it acceptable to let a million desperate Mexican women, year after year, suffer the distress and trauma associated with risking their lives, health, and freedom to obtain an illegal abortion?

    Koch et al.'s studies, including the current one in BMJ Open, are promoted widely on the Internet by anti-abortion groups and individuals. Because the studies appear professional and are published in reputable journals, there is a real danger that they can be used to influence policy decisions of governments. For example, they may play a role in decisions to decrease or cut funding for reproductive health programs in developing countries--such as what occurred in Canada in 2010--or to further restrict abortion, despite current laws that still kill 47,000 women a year and injure over eight million.

    By rendering those women invisible, such studies become dangerous weapons that threaten to slow down the global decrease in maternal mortality and continue allowing women to suffer and die unnecessarily. The BMJ Open study is the latest contribution to this ideological battle disguised as science, one that poses a grave public health risk to women.

    AUTHOR'S NOTE: I would like to thank the Guttmacher Institute for its past work, cited in this letter, exposing the serious methodological flaws in Elard Koch's work and debunking his false claims.

    (Further sources for this letter can be found at:

    Conflict of Interest:

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  2. Demographics and Pulmonary Function Testing

    To the Editor: It was very interesting to read the work established by Wilson et al. entitled " The effects of maintenance schedules following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomised controlled trial" published in the BMJ Open 2015.

    Authors identified that a maintenance programme of three monthly two hour sessions does not improve outcomes in patients with Chronic Obstructive Pulmonary Disease (COPD) after 12 months. To test the effectiveness of their programs, authors randomised subjects to either receive their maintenance program or standard care as a control. The maintenance program consisted of two hours (an hour of individually tailored exercise training and an hour of an education program) every three months for one year.

    The authors explained the PR program thoroughly and provided clear inclusion and exclusion criteria. Nevertheless, only patients who completed at least 60% of the sessions in the initial PR program were included in the study. The authors stated that the intervention group only contains individuals who have complied with the PR program, whereas the control group consists of individuals who would have complied with the intervention as well as individuals who would not have complied. Providing a table that compares the baseline characteristics of subjects who complied and did not comply with the PR program would be beneficial. Sampling bias would be reduced if there was no statistically significant differences in baseline characteristics of both groups, subjects who complied and did not comply to the PR program.

    The authors focused on using questionnaires to assess the benefits of the PR program. They acknowledged that the use of accelerometer or patient independent devices would have provided more accurate data than that obtained from questionnaires. However, one of the key aspects to assess the long term benefits of a PR program is lung function measurements of the subjects, which has not been discussed in this paper1,2. The use of portable spirometers could be beneficial for this type of research because it requires minimal training and is more affordable than standard laboratory pulmonary function tests. Therefore, the effectiveness of these PR intervention programs would be better evaluated if objective lung measurements were examined.

    References: 1-Incorvaia, C., Russo, A., Foresi, A., Berra, D., Elia, R., Passalacqua, G., . . . Ridolo, E. (2014). Effects of pulmonary rehabilitation on lung function in chronic obstructive pulmonary disease: The FIRST study. European Journal of Physical and Rehabilitation Medicine, 50(4), 419-426. 2-Roberts, C. M., Gungor, G., Parker, M., Craig, J., & Mountford, J. (2015). Impact of a patient-specific co-designed COPD care scorecard on COPD care quality: A quasi-experimental study. NPJ Primary Care Respiratory Medicine, 25, 15017. doi:10.1038/npjpcrm.2015.17; 10.1038/npjpcrm.2015.17

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  3. Financial crisis and suicide mortality in Greece: do we need more evidence to be convinced?

    Dimitrios Anyfantakis 1, Adelais Markaki 2, Emmanouil K Symvoulakis 3

    1 Primary Health Care Centre of Kissamos, Chania, Crete, Greece 2 Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece. 3 Private Family Practice Unit in Heraklion, Crete, Greece.

    The study performed by Rachiotis et al. [1] reporting on the impact of financial crisis on suicide rates in Greece was both timely and intriguing. The researchers reported a significant increase of 35% of the mean suicide rate between 2010 and 2012. Remarkably, an increase of suicide mortality rates from 5.75 (2003-2010) to 7.43/100 000 (2011-2012; p<0.01) was recorded among males [1]. A significant positive association was also reported between rise in suicide rate and unemployment in the group of working-age males [1]. The authors concluded that austerity measures in Greece contributed significantly to the increased suicide mortality [1].

    In alignment with the above findings, previous research suggested a positive association between austerity and rise of suicide rate (17% from 2007 to 2009) as well as adverse effects in various health indicators [2]. Remarkably, a reduction of blood and organ donor supply has also been reported as a side-effect of the severe financial and humanitarian constraints placed on the country's national health system [3].

    However, despite growing debate on austerity's negative effects on health [4], governmental and international agencies have been slow to acknowledge this issue. In the past, some of the country's figures on suicides, attempted suicides, use of antidepressants and need for mental health services were met with skepticism, questioning earlier conclusions on the health consequences of the Greek crisis [5].

    The findings by Rachiotis et al.[1] underscore the impact of the Greek financial crisis on health indicators and death by providing the latest pragmatic data. Report of a 35% increase on the incidence of a deadly outcome within a three-year period is reason for not just domestic but global concern.

    References 1. Rachiotis G, Stuckler D, McKee M, Hadjichristodoulou C. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012). BMJ Open. 2015 Mar 25;5(3):e007295. 2. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet. 2011 Oct 22;378(9801):1457-8. 3. Symvoulakis EK, Markaki A, Morgan M, Jones R. Organ donation during economic hardship: an untold end for Prometheus? BMJ 2011; 342:d982 4. Kentikelenis A, Karanikolos M, Reeves A, McKee M, Stuckler D. Greece's health crisis: from austerity to denialism. Lancet. 2014 Feb 22;383(9918):748-53. 5. Liaropoulos L. Greek economic crisis: not a tragedy for health. BMJ. 2012 Nov 27;345:e7988.

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  4. 'False Witnesses' Publish Deeply Flawed Study on Abortion Mortality in Mexico

    This study has been comprehensively refuted, with fatal errors found that invalidate the conclusion:

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  5. Article titles should be factual not rhetorical questions

    It would have been better if the article titled 'What has happened to suicides during the Greek economic crisis?' had been titled 'Suicide rate increases in Greece during economic crisis'. BMJ Open is a scientific journal not a collection of mystery stories.

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  6. Re: Miedema B, Reading SA, Hamilton RA, Morrison KS, Thompson AE. Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study. BMJ Open 2015,5:e006650.

    To the Editor:

    The rapid acceleration of obesity rates worldwide and its contribution as a major risk factor for many chronic and resource-heavy diseases make it paramount for public health and health care research to explore effective ways to manage it. Miedema et al. appropriately utilized a quasi-experimental design to investigate the effectiveness of a community-based exercise and education programme to treat people who are obese in New Brunswick, Canada. (1) The authors acknowledged that the multidimensional factors contributing to the development of obesity require multidimensional treatment strategies to manage it. (1) The described intervention was certainly appropriate based on current literature, particularly the inclusion of group-mediated cognitive- behavioural intervention (GMCBI). (1)

    One of the study's stated hypotheses was "the intervention programme and the GMCBI would improve the health and well-being of the participants". (1) To assess the effectiveness of the multidisciplinary programme, the authors chose the outcomes of blood pressure, resting heart rate, weight and height (BMI), waist circumference and the mental health scale of the SF-36v2 Health Survey. (1) They reported that they also assessed other outcomes "related to physiological abilities, nutrition knowledge and behaviour" which were not reported in the present paper. (1) The programme was designed to assist people who are obese make the behavioural changes necessary to positively manage their health and well- being. Such multimodal approaches are similarly used in chronic disease management (2) and chronic pain management (3) and are shown to be the most effective in the long term.

    Despite delivering an intervention that sought to change health behaviour and improve overall wellness of people with obesity, the authors chose to include outcomes that measure biomedical and psychological constructs. These are insufficient to capture global latent variables as complex as "health" or "well-being". The World Health Organization defines health as "a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity." (4) The ultimate goal of obesity management is not only weight loss, reduction in blood pressure, and lower degrees of depression; it is also empowerment through self-efficacy, control over health and life, and satisfaction in social life. These all lead to overall increased quality of life. To truly demonstrate that their programme made a lasting positive difference in the participants' overall health, the study team should include measures for overall function, quality of life, behavioural change, and self-efficacy. Tackling a health issue as prevalent and complex as obesity requires a population health approach; interventions and their evaluation should reflect this.

    Bibliography 1. Miedema, B, et al., et al. Can certified health professionals treat obesity in a community-based programme? A quasi-experiemental study. BMJ Open. [Online] 02 2015. 2. National standards for diabetes self-management education and support. Haas, L, et al., et al. 2013, Diabetes Care, pp. S100-S108. 3. Interdisciplinary Chronic Pain Management: Past, Present, and Future. Gatchel, Robert J, et al., et al. 2014, American Psychologist, pp. 119- 130. 4. World Health Organization. WHO definition. World Health Organization Definition. [Online] 1948.

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  7. Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study -The role of motivation

    To the Editor: With great interest I read the paper by Miedema et al. entitled "Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study" published in the BMJ Open 2015. Authors identified that lifestyle interventions administered by trained certified professionals improve health outcomes in obese participants. To show the effectiveness of their programs, authors presented positive results in heart rate, blood pressure, body mass index, waist circumference and mental health among the participants who adhered to the interventions. Their results further validate similar findings from previous studies that diet and exercise are two major contributors to better health and weight loss in obese patients. However, one of the key aspects of this type of lifestyle intervention programs is the motivation which has not been discussed in this paper. Similar to this study, review of existing literature shows that in lifestyle intervention programs including exercise and diet have had a high rate of attrition [1]. Therefore, individuals' motivation is the key to the success of this type of intervention programs [2, 3]. Among the two types of motivation-- namely, autonomous and controlled-- to adhere to the intervention programs, the former one is preferred because it is chosen by and emanating from one's self, while the later one is experienced when they pressured or forced by others [3]. Individuals tend to more competent when they are autonomously motivated to endorse themselves to the intervention programs and develop a strong willingness to do them. Previous studies also show that individuals who perceive the health care providers more autonomy supportive tend to maintain long-term intervention programs, and autonomous supportiveness played a key role in the success of programs for smoking cessation and adapting positive coping strategies for better management of chronic diseases such as diabetes and overweight [4-6]. Therefore, the effectiveness of these non-pharmaceutical intervention programs would be better evaluated if the autonomous motivation is also examined.


    1. Volkmar FR, Stunkard AJ, Woolston J and Bailey RA. High attrition rates in commercial weight reduction programs. Arch Intern Med 1981;141(4): 426-428.

    2. Andersson I, Rossner S. Weight development, drop-out pattern and changes in obesity-related risk factors after two years treatment of obese men. International Journal of Obesity & Related Metabolic Disorders 1997; 21:211-216.

    3. Lantz H, Peltonen M, Agren L, & Torgerson JS. A dietary and behavioural programme for the treatment of obesity. A 4-year clinical trial and a long-term post-treatment follow-up. Journal of Internal Medicine 2003; 254: 272-279.

    4. Williams GC, Grow, VM, Freedman ZR, et al. Motivational predictors of weight loss and weight-loss maintenance. Journal Personality and Social Psychology 1996; 70:115-126.

    5. Williams GC, Cox EM, Kouides R, & Deci EL. Presenting the facts about smoking to adolescents: The effects of an autonomy supportive style. Archives of Pediatrics and Adolescent Medicine 1999; 153:959-964.

    6. Williams GC, Freedman ZR, & Deci EL. Supporting autonomy to motivate glucose control in patients with diabetes. Diabetes Care 1998; 21:1644-1651.

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  8. Re:The volume of complaints against doctors and how they are handled are not necessarily in the best interests of patients and harms doctors. New solutions are needed based on good quality evidence.

    I have specific interest in this article, as my cancer was misdiagnosed by ten to fifteen doctors, across three counties, over a great number of years.

    The backlog of complaints I made to The Department of Health (and later many other health bodies), were either unanswered or answered grossly inappropriately.

    Instead of this complaint being used as the wake-up call it ought to have been, it's (incontrovertible) contents have been rigorously kept under wraps. This has resulted in on-going widespread hardship, excruciating suffering,and loss on many all levels of life.

    It highlights one of the most serious miscarriages of justice, on the health front, in modern times, being meted out to a vast number of physically ill people.

    Therefore doctors across the board, need to take responsibility for the catastrophic errors they are carrying out, even today, on a daily basis.

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  9. Overestimating pregnancy rates after psychosocial interventions for infertile couples

    Frederiksen et al conclude in their very interesting meta-analysis on the efficacy of psychosocial interventions in infertile women and men that psychosocial interventions for couples in treatment for infertility could be efficacious in improving clinical pregnancy rates (1). As presented in figure 2 of their paper, the mean risk ratio of all ten studies analysed is 2,006 for pregnancy rates in favour of the psychosocial intervention groups. Two of these studies (labelled "Domar 2000" and "Sarrel 1985" in figure 2) appear to be outliers with risk ratios about 6 or more. In the study of Domar et al (2), 26 pregnancies resulted in the cognitive- behavioural intervention group (with 47 participants), 26 pregnancies in the support group (with 48 participants), and 5 pregnancies in the control group (with 25 participants). This gives a risk ratio of 2,766 for the first intervention group and of 2,7083 for the second intervention group (both compared to the control group). The combined risk ratio for the two intervention groups is therefore 2,736. The same score was computed in the meta-analysis of Haemmerli and colleagues (3). In the study of Sarrel & DeCherney (4), six pregnancies were reported for the psychosocial intervention group (with 10 participating couples), and one pregnancy in a group of nine couples without a psychosocial intervention. This gives a risk ratio of 5,400, which is also the score reported in the paper of Haemmerli et al. The number of participants in the study of Sarrel & DeCherney is therefore 38 and not 140 as indicated in figure 2 in (1). In my opinion, the mean risk ratio for pregnancy rates in infertile couples after psychosocial interventions is clearly overestimated in this meta- analysis of Frederiksen et al. There are still insufficient systematic studies indicating a rise in pregnancy rates following psychological interventions (5).

    1. Frederiksen Y, Farver-Vestergaard I, Skovgard NG, Ingerslev HJ, & Zachariae R. (2015). Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis. BMJ Open, 5(1) E-Pub.

    2. Domar AD, Clapp D, Slawsby EA, Dusek J, Kessel B, & Freizinger M. (2000). Impact of group psychological interventions on pregnancy rates in infertile women. Fertil Steril, 73(4), 805-811.

    3. Haemmerli K, Znoj H, & Barth J. (2009). The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate. Hum Reprod Update, 15, 279- 295.

    4. Sarrel PM, & DeCherney AH. (1985). Psychotherapeutic intervention for treatment of couples with secondary infertility. Fertil Steril, 43, 897-900.

    5. Wischmann T. (2008). Implications of psychosocial support in infertility - a critical appraisal. J Psychosom Obstet Gynecol, 29(2), 83- 90.

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  10. Re: Patterns and trends in sources of information about sex among young people in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles

    Tanton et al conclude that over the past 20years, young people have increasingly identified school lessons as their main source of information about sex.(1) This is surprising given that the quality and access to sex and relationships education(SRE) continues to give cause for concern.(2) Recent evidence from inspectors found that SRE required improvement in over a third of schools, and that some young people were being left unprepared for the physical and emotional changes they were going to experience.(2)

    The findings from the national surveys support the need for improved SRE in schools alongside greater involvement of parents and health professionals.(1) Some of these important issues were also highlighted in the chief medical officer's report "Our Children Deserve Better: Prevention Pays".(3) Dame Sally Davies recommended that there needs to an improvement in personal, social and health education (PSHE) and especially sex education.(3)

    The recently published Education Committee Report Life Lessons: PSHE and SRE in Schools states that PSHE and SRE should be given statutory status.(4) We fully endorse Graham Stuart, Chair of Education Committee, who states that: "There is an overwhelming demand for statutory sex and relationships education - from teachers, parents and young people themselves. It's important that school leaders and governors take PSHE seriously and improve their provision by investing in training for teachers and putting PSHE lessons on the school timetable. Statutory status will help ensure all of this happens." (4)

    The Government has just announced that there will be new guidance on an element of PSHE: materials on "consent" will be issued later this year.(5) Although this small step is welcome, we feel strongly that this is insufficient. Without statutory change, topics like consent will continue to be taught in some places by untrained teachers and in many schools squeezed from the timetable.

    Until SRE is made a universal entitlement for all young people in schools no matter how they are funded or organised, SRE will continue to be poorly taught and accessible only to a fortunate minority. We believe that children and young people deserve properly planned systematic SRE taught by well trained, confident and competent teachers with appropriate support from health professionals.

    References 1) Tanton C, Jones KG, Macdowall W, et al. Patterns and trends in sources of information about sex among young people in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles. BMJ Open 2015;5:e007834.

    2) Ofsted. Not yet good enough: personal, social, health and economic education in schools. 1 May 2013.

    3) Department of Health. Annual Report of the Chief Medical Officer, 2012, Our Children Deserve Better: Prevention Pays. London: Department of Health 2013.

    4) Life Lessons: PSHE and SRE in Schools. Report of the Education Select Committee 17th February 2015. select/education-committee/news/pshe-sre-report/

    5) Woolf M. Rape classes for 11 year olds. Times on Sunday, page 16: 8th March 2015.

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