I have thoroughly enjoyed my responsibilities as a Deputy Editor-in-Chief over the last 15 months. Only now can I appreciate how demanding the Editor-in-Chief’s role is, especially before having the support of three deputies. BJOG’s new editorial team structure with three deputies has allowed faster turnaround times for papers, so that we can let submitting authors know whether their papers will be accepted (or rejected) as quickly as possible on our first assessment. We also give detailed constructive feedback on all papers when we make our final decisions following peer review. All editors are continuously indebted to referees for their contributions to the peer review process. I would like to thank everybody who has helped to review papers for BJOG. Over the last 2 years, I have mentored two trainee editors and I am delighted that both Emma Crosbie and Vanessa Harry have now graduated to being full Scientific Editors for the journal.

This month’s issue demonstrates how BJOG has firmly established its place as a truly international journal held in high esteem by authors and readers globally. This issue contains contributions from Australia, Netherlands, UK, Norway, Italy, USA, and even a collaborative project on outcomes from 13 European countries. The papers cover all aspects of obstetrics and benign and oncological gynaecology, reflecting our broad subject coverage. There are four papers from Dutch university hospitals in this issue demonstrating how our journal is now held in high regard in European countries. BJOG’s high standards are reflected in a steady increase in the journal’s performance over the last decade. Its impact factor, 5-year impact factor, article influence and immediacy index have all been rising (Figure 1). These changes were particularly significant during Philip Steer’s tenure as Editor-in-Chief.


Figure 1. BJOG bibliometrics. Impact Factor is calculated by dividing the number of current year citations by the number of articles published in that journal during the previous 2 years. Five-year Impact Factor is calculated as above but over a 5-year period. Immediacy index is the average number of times that an article published in a specific year within a specific journal is cited over the course of that same year. Article Influence measures the average influence, per article, of the papers in a journal.

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Philip expanded the number of UK and international editors overseeing the peer review process of submitted papers. He also established the culture whereby a panel of editors discuss reviewed papers before the handling editor reaches a definitive decision. This input from a range of experts ensures that authors receive highly valued, comprehensive and constructive feedback on their work, even if the decision is to reject. I believe that the papers I have selected for comment in this month’s Editor’s choice reflect the true international aspect and quality of BJOG papers.

Impact of ‘one-to-one’ midwifery antenatal care

In a randomised controlled trial by McLachlan et al. (page 1483) from Australia the effect of continuity of ‘one-to-one’ antenatal care in low-risk women is compared with traditional medical and midwifery care. Many previous randomised controlled trials have evaluated midwifery antenatal care provided by a team of midwives as opposed to care provided by a single health professional. The conclusions from Cochrane Reviews are therefore biased towards the team approach as opposed to ‘one-to-one’ care. Women assigned to ‘one-to-one’ midwifery care had a significantly lower rates of caesarean section, epidural and episiotomy, shorter postpartum inpatient stays and a higher spontaneous vaginal delivery rate in a unit that had a relatively high caesarean section rate. The lower caesarean section rate was primarily a result of fewer emergency caesarean sections. The potential explanation for the better outcomes is that women are more confident when they have care by a known midwife and are therefore better equipped to deal with labour.

In the era of austerity and cost-cutting, providers of midwifery or obstetric care should be mindful that a patient-centred approach to care inevitably improves outcomes. Reductions in midwifery staffing levels to reduce costs might lead to poorer clinical outcomes for low-risk women.

Trends in intrauterine death in women with hypertensive disorders in pregnancy

In a retrospective study from Norway of 2 337 775 consecutive births over a 39-year period ending in 2006, the stillbirth and perinatal death rates were determined for all women and for those with pre-eclampsia, gestational hypertension and chronic hypertension. Hypertensive disorders affect 5 – 10% of all pregnancies and the rate of stillbirth is elevated in these pregnancies. The overall reduction of intrauterine death was 44% but, impressively, reduction in pre-eclampsia, gestational hypertension and chronic hypertension was 80, 49 and 57%, respectively (Figure 2). The impressive reduction of fetal death in relation to pre-eclampsia particularly reflects antenatal screening for disease. These impressive statistics should be a reminder for all clinicians of the value of antenatal surveillance for hypertensive disease. It is easy to become blasé about screening and management for hypertensive disease in modern obstetric practice and this study is an excellent reminder of its importance.


Figure 2.  Comparison of fetal death rates among women who are normotensive and with pre-eclampsia, chronic hypertension, gestational hypertension for two periods: 1967–1976 and 1997–2006.

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Fatal cases of gestational trophoblastic neoplasia over four decades in the Netherlands

Further evidence of improved health outcomes over the last four decades is illustrated by a retrospective study by Lybol et al. (page 1465) from the Netherlands. Twenty-six women died as a result of gestational trophoblastic neoplasia—with 50% dying in the first decade of the study between 1971 and 1980 and a subsequent steady decline in the death rate. The majority of deaths were after the diagnosis of post-term gestational neoplasia and the most common cause of death was haemorrhage; either uterine or secondary to metastatic disease. Many of the women who died in the first decade would have received more aggressive chemotherapy if diagnosed in the last couple of decades.

The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service

In contrast to the last two retrospective studies, an English study looking at the rates of vesicovaginal or urethrovaginal fistula after hysterectomy between 2000 and 2008 by Hilton and Cromwell (page 1447) demonstrates a deterioration in outcomes reflected by an increase in fistula rate of 48% over time. The overall fistula rate was 1 in 788. As one might expect, the fistula rate was highest after radical hysterectomy (1 in 87) and lowest after vaginal hysterectomy for prolapse (1 in 3861). The authors attribute this increased fistula rate to the reduction in the number of ‘straightforward’ hysterectomies, because more conservative treatments are available for dysfunctional uterine bleeding, and the reduction in surgical experience of UK trainees. Surgical experience in gynaecology is being compromised by the reduction in the length of training, and the reduction in number of hours that junior doctors can work in line with the European working time directive, as well as the dilution of surgical opportunities because of the increased number of trainees.

Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for vaginal hysterectomy

In this randomised controlled trial by Lakeman et al. (page 1473) from the Netherlands, the investigators have evaluated whether modern electrosurgical sealing and division is more effective than traditional division and suturing of pedicles. The authors discuss the theoretical advantage of using new electrosurgical devices as they allow division of tissue closer to the uterus and as a result might lead to fewer innervation problems related to the bladder and consequently a decrease in the incidence of postoperative urinary dysfunction. There are some minor limitations to this study, but it clearly demonstrated that immediate postoperative pain and operative time are reduced and there were no other short-term or long-term differences in outcomes including micturition or defecation symptoms. Individual healthcare economies will have to decide if the shortened operative time and possible reduction in patient stay actually translate into a genuine cost saving bearing in mind the extra cost of the vessel-sealing equipment.

Pregnancy-associated acquired haemophilia A: results from the European Acquired Haemophilia (EACH2) registry

Finally, I have chosen this paper by Tengborn et al. (page 1529) because it demonstrates the value of international multicentre studies in determining the outcomes of rare conditions. Acquired haemophilia A (AHA) is an extremely rare severe bleeding disorder caused by autoantibodies directed against coagulation factor VIII. The condition is known to be associated with pregnancy, where it typically presents with no family or personal history of abnormal bleeding. Forty-two women were identified with pregnancy-associated AHA. The collective data from all the 117 European haemophilia centres in 13 countries provides information for future early recognition of this rare but potentially life-threatening disease in pregnancy.