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BMJ 2011; 342 doi: (Published 14 February 2011) Cite this as: BMJ 2011;342:d972

Prenatal or postnatal surgery for myelomeningocele?

Myelomeningocele is the most common form of spina bifida. Highly specialised surgeons can repair the defect in utero, and a trial from the US reports some significant benefits, including a better chance of walking unaided at the age of 3 when compared with repair soon after birth (42% (26/62) v 21% (14/67); relative risk 2.01, 95% CI 1.16 to 3.48). Children who had prenatal surgery were less likely to need a ventriculo-peritoneal shunt at the age of 1 year (40% (31/78) v 82% (66/80); 0.48, 0.36 to 0.64).

There were problems, however. Babies repaired in utero were born earlier than controls (34.1 v 37.3 weeks) and had a higher risk of respiratory distress syndrome (21% (16/77) v 6% (5/80); P=0.008). Their mothers had complications including oligohydramnios (21% (16/78) v 4% (3/80); P=0.001), uterine dehiscence at the site of the hysterotomy (8/76), and haemorrhage (risk of blood transfusion at delivery (9% (7/78) v 1% (1/80); P=0.03).

Women considering fetal surgery need detailed counselling about risks, says an editorial (doi:10.1056/mejme1101228). They also need accurate information about their surgeon’s expertise. The 183 women in this trial were carefully selected and treated at three specialist centres. All other centres nationwide agreed to suspend fetal surgery for myelomeningocele for the duration of recruitment, which took seven years. Results may be worse in less experienced hands.

Change in sexual behaviour helps curb HIV in Zimbabwe

The prevalence of HIV has fallen faster in Zimbabwe than in other countries in southern Africa, driven largely by changes in sexual attitudes and practices. During the 10 years spanning the turn of the millennium, extramarital relationships declined, as did casual sex, commercial sex, and the proportion of men reporting multiple concurrent partners. Why?

After a careful review of all available evidence from published research and new in depth qualitative work, observers agreed that the main reason …

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