Womens Reproductive Health across the Lifecourse Implications for Public Policy

Report of a Conference organised by The Royal Society of Edinburgh 2728 February 2013

Contents
Acknowledgements..4 Conference Programme..6 Executive Summary.9 Key Messages....10 Overview..12 Day 115 Day 231 Chair & Speaker Biographies..49
Rapporteurs: Emma Doyle Sarah Elizabeth Jeavons Emily Ross The Royal Society of Edinburgh: October 2013 ISBN: 978 0 902198 96 8 Requests to reproduce all or part of this document should be submitted to: The Royal Society of Edinburgh 22-26 George Street EDINBURGH EH2 2PQ Tel: 0044 (0)131 240 5000 www.royalsoced.org.uk

Opinions expressed in this report do not necessarily represent the view of The Royal Society of Edinburgh, nor its Fellows.

The Royal Society of Edinburgh wishes to acknowledge the support of HRA Pharma; Pfizer; The Edinburgh Family Planning Trust; PregLem (educational grant); School of Clinical Sciences, School of Molecular, Genetic and Population Health Sciences, Centre for Research on Families and Relationships, University of Edinburgh

and thanks the Organising Committee:

Professor Alice Brown CBE FRSE (Then) General Secretary, The Royal Society of Edinburgh Professor John Coggins OBE FRSE Chairman, RSE Scotland Foundation Professor Hilary Critchley FRSE FMedSci Professor of Reproductive Medicine Professor Sarah Cunningham-Burley AcSS Professor of Medical and Family Sociology, University of Edinburgh Professor Anna Glasier OBE Honorary Professor, University of Edinburgh Professor Neva Haites OBE FRSE Vice-Principal for Development, University of Aberdeen

Conference Programme
Day 1 Wednesday 27 February
10.00 10.30 Registration with tea/coffee Welcome Professor Sir Ian Diamond FBA FRSE Principal and Vice-Chancellor, University of Aberdeen Introductory Session Reproductive Health: Women, Work and Care Chair: Professor David Baird CBE FRSE Emeritus Professor of Reproductive Endocrinology, University of Edinburgh Raising issues: recent trends and implications for policy Professor Sarah Cunningham-Burley AcSS Professor of Medical and Family Sociology, University of Edinburgh 11.00 Life expectancy and reproduction Professor Tom Kirkwood CBE Director of Newcastle Initiative on Changing Age (NICA), Newcastle University Work and health: contemporary issues and future prospects Professor Linda McKie Professor of Sociology, Durham University Panel Discussion Participants: Speakers and Chair from morning session Lunch Session 1 Family Formation Chair: Dr Catherine Calderwood Medical adviser for maternity and womens health, Scottish Government Debate: When should a woman have a baby? Who benefits from women delaying childbearing? Professor Susan Bewley Professor of Complex Obstetrics, Kings College London Fertility decisions are complicated and contextual Professor Sarah Cunningham-Burley Professor of Medical and Family Sociology, University of Edinburgh

10.35

11.30

12.00 12.30 13.30

14.30

Presentations with questions and answers: Combining work and family perspectives from experience Professor Susan Wray Department of Molecular and Cellular Physiology, University of Liverpool Does policy and legislation meet womens needs? Clare Simpson Project Manager, Parenting across Scotland An employers perspective Dr Stewart Irvine Director of Medicine, NHS, Education for Scotland

15.30 16.00

Tea / coffee Panel Discussion Policy implications of afternoon session Chair: Professor Alice Brown CBE FRSE (Then) General Secretary, Royal Society of Edinburgh Participants: Speakers and Chair from afternoon session, plus: Dr Marion Slater Co Chair, Trainees and Members Committee, Royal College of Physicians, Edinburgh

17.00

Concluding remarks Professor Sir Ian Diamond FBA FRSE

Day 2 Thursday 28 February

09.00 09.30 Arrival with tea/coffee Session 2 The Reproductive Years Chair: Professor Iain Cameron Dean of the Faculty of Medicine, University of Southampton Presentations with questions and answers: Epidemiological evidence and socio-economic costs of reproductive problems in UK Professor Siladitya Bhattacharya Professor of Reproductive Medicine, University of Aberdeen Menstruation and cycle-related problems Professor Hilary Critchley FRSE Professor of Reproductive Medicine, University of Edinburgh

The maternal body in the workplace: a focus on breastfeeding experience and practices Dr Caroline Gatrell Director of Doctoral Programmes, Senior Lecturer, Department of Management Learning and Leadership, Lancaster University 11.00 11.30 Tea/coffee Sex and health Professor Kaye Wellings Head of SEHR and Professor of Sexual & Reproductive Health Research, London School of Hygiene and Tropical Medicine Fertility regulation changing policy to improve access Professor Anna Glasier Honorary Professor, University of Edinburgh and London School of Hygiene and Medicine 12.30 13.30 Lunch Session 3 Post-Reproductive Years Chair: Professor Jonathan Seckl FMedSci, FRSE Vice-Principal (Planning, Resources and Research Policy) The Queens Medical Research Institute, University of Edinburgh Presentations with questions and answers: A lifecourse approach to womens health and ageing Professor Rebecca Hardy Professor of Epidemiology and Medical Statistics, University College London and Programme Leader, MRC Unit for Lifelong Health and Ageing The menopausal transition: its effect on lifestyle and health Professor Anna Glasier OBE Honorary Professor, University of Edinburgh and London School of Hygiene and Medicine 15.00 15.30 Tea / coffee Panel discussion - Overall policy implications Chair: Professor Neva Haites OBE FRSE Vice-Principal for Development, University of Aberdeen Participants: Chairs from Day 1 and Day 2 of the Conference Closing remarks Professor Alice Brown CBE FRSE Close of meeting

16.30 16.45

Executive Summary
This two-day conference explored an important public policy topic requiring both medical and social scientific evidence. The research presented during the conference emphasised the need to focus on the social context in which womens reproductive health decisions are made, as well as taking into account the biological constraints and possibilities that influence such decisions. Speakers therefore demonstrated that a multidisciplinary approach to womens reproductive health is required. Speakers highlighted that the medical technologies available to women and their partners are developing rapidly, and that changing social expectations of mens and womens roles in society, as well as an increase in life expectancy, have changed the context in which womens reproductive decision making occurs. However, as several presenters stressed, the time points at which a womans fertility is optimal, and when fertility begins to decline, have remained static. Though IVF is often lauded as a cure all for couples who delay childbearing, the risks of over-reliance upon IVF to treat infertility were highlighted by several speakers. The importance of a lifecourse approach to womens reproductive health was recognised in this conference, with presentations focusing on womens working lives, as well as on the reproductive health of older women. Talks exploring womens reproductive health during childbearing years included those discussing how women balance a career with family life and the barriers they face; for example, factors deterring women from breastfeeding or from expressing milk in the workplace. The personal and economic costs of menstruation and cycle-related problems were also considered, along with the complex and contextual nature of womens reproductive decisions. The reproductive health of women in later life was explored in presentations discussing the effect of the menopause on lifestyle and wellbeing, and the sexual health of older people. It was noted that the issue of womens reproductive health is neglected both in research funding and in public policy, despite there being many areas in which progress could be made. This may be remedied by a more holistic approach to womens reproductive health, as opposed to the issue being spread across sexual health, maternal and child health, and obstetrics and gynaecology. Areas for potential changes to policy and legislation include improving the education of young people about reproductive health as relevant across the lifecourse, including the realities of infertility. This may include the use of social media, and could help to encourage a culture where these issues are talked about, rather than seen as taboo. The need for a move away from masculinist work practices, towards a culture in which women and men can balance their employment and family life more easily, was also highlighted. Other areas for potential policy change include the availability of oral contraceptives, and a call for public health approaches to the sexual health of older people.

Key Messages from the Conference

Womens reproductive health is an important policy issue
Womens reproductive health has implications for social and economic policy. However, the conference highlighted the relative invisibility of some of the issues raised in terms of public policy debates. There is a need to raise the visibility of women's reproductive health as something relevant across the lifecourse, and to support health-promoting workplaces.

Womens reproductive wellbeing has implications for Scotlands economy

Reproductive health has a significant impact on work, social and domestic activities for women at all stages of the lifecourse. Examples include the impact of menstrual disorders on days lost from the workforce, or the challenge of maintaining breastfeeding for women returning to work. The inevitable decline in fertility with age may require a reconsideration of career structures for both women and men. The extension of life expectancy means that womens working lives have expanded beyond reproductive life into the post-menopausal years. The health-related needs of older women in the workforce need to be recognised.

Womens work, in private but also public spheres, remains relatively invisible
Though women form a large part of the workforce, they also often perform the uneconomic but vital social task of birthing, breast feeding and caring for children, as well as caring for their partners and, increasingly, for their ageing parents. A cultural shift is required in terms of how we view child rearing, which almost invariably falls to women. It is seen as low-status and low-skill, which has huge implications for a womans confidence and status, not only in the workplace but also in wider society. There is a relative paucity of data exploring the experiences of how women take on roles and responsibilities that in the past have been carried out exclusively by men (for example, women in combat roles in the military). Increased recognition of women as major contributors to the workforce may consequently raise awareness of the challenges women face in dealing with their reproductive health, caring for children, but also elderly parents, especially at a time when they are also building their careers and taking on leadership roles.

Gender inequality persists in the workplace and domestic sphere

In many ways, it is still a mans world whereby women work more in the home and family, earn less and have to juggle (and hide) the difficulties they face, especially when related to their reproductive health. Interdisciplinary, cross-policy dialogue and action are required to achieve change in gender relations at work and at home.

A multidisciplinary and lifecourse approach to womens health is required

Womens reproductive health has many dimensions, and strategies to address the scope for improvement need to take account of these in a fully integrated way. There is a need to understand womens health and reproduction within the context of society, and to recognise that in todays world, social, economic and personal factors tend to dominate choice over reproductive timing, such that the hard realities of biological constraints tend to be neglected. Perhaps there is a need for a holistic focus on women's health, as opposed to the current approach which separates this topic into different areas, such as sexual health and maternal health. This would lend itself to a more integrated and life course approach to problem management. More research is required to explore fully the social and economic costs of reproductive health in general and reproductive decision making in particular, for women across the lifecourse, and to ameliorate any negative effect on women themselves. There is also a need to extend the concept of sexual and reproductive health to include not only adverse reproductive health outcomes, but also wellbeing and satisfaction.

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Improved education and advice regarding reproductive ageing is required

Improved education on reproductive ageing is essential, as is research into the social influences underpinning current behaviour in terms of decisions on timing of child bearing. There is a need to accept, at an individual level and in policy and practice, the biological constraints on reproductive choice and wellbeing. Men and women have newly enhanced expectations of choice in relation to sexual behaviour, partnering and parenting, but the need to accommodate the impact of nature as well as nurture in relation to these experiences is often neglected. Women need to be better educated about the consequences of putting off fertility decisions, including the success rates of treatments such as in vitro fertilisation (IVF). Such education should also draw attention to pre-conception health, and must take place at an earlier stage in the lifecourse. Society needs to ensure women (and couples) receive appropriate advice and support to ensure that reproductive issues can be satisfactorily balanced with a working life.

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Overview of the Conference

Day 1
Professor Cunningham-Burleys discussion highlighted that although progress has been made through efforts to improve womens health and working lives, policies and legislation in this area leave much to be achieved, and still do not challenge masculinist work practices and career trajectories. She also emphasised the importance of social context in discussions of womens reproductive health. The key messages from her talk were that gender inequality persists in the labour market and in the home, and that managing work and family life can impact on women's health generally and reproductive health specifically, with other family members health needs taking priority. Professor Kirkwood drew attention to the role of womens biology in shaping their experiences of reproductive health. Despite a global increase in life expectancy, the time at which a womans fertility begins to decrease, and when they experience the menopause, has remained constant. A key message from Professor Kirkwoods talk was that intrinsic ageing of the body as a whole is driven by the gradual accumulation of cellular defects. The ovary is not immune to such defects and this most likely explains why so many thousands of eggs are lost over the 50 years from birth to menopause. Apart from the rather small number that is involved in ovulation, the missing eggs are lost to stringent quality control. As the ovary becomes depleted with the passage of years, even the best quality control seems unable to prevent the age-related increase in birth defects, in spite of the general increase in womens life expectancy. A second key message was that the underpinning biology of female reproductive ageing needs to be understood in terms of the evolutionary forces that have acted on the body. Special factors particular to human reproduction (e.g. the large brain size of the human neonate; the protracted dependency of human infants; and complex multi-generational family structures) are likely to have combined to bring about the menopause. Professor McKies talk demonstrated that the emphasis on a linear form of career does not fit with the patchwork of womens experiences, which include caring for elders and family life. She also emphasised the fact that employers often do not enact the spirit of the policies they claim to support. Professor Bewley argued that reproductive ageing must be placed on the public health agenda. Policy must focus on educating young people regarding the biological facts of fertility and the context of their life choices. Reliance on reproductive technologies, such as IVF, is not the answer. Rather, social factors impacting on delayed pregnancy should be addressed. Professor Jamieson, in a paper presented by Professor Cunningham-Burley, noted that fertility decision making is the result of the complex interplay between individuals, couples and the wider society. Consideration of the trend in delayed childbearing must, therefore, include acknowledgement of factors including the economic recession, delayed partnering, and prohibitive work commitments which are likely to shape such decisions. Professor Wray argued that popular images of the 'super mum', who achieves success in both career and family life, have created expectations of perfection which women are expected to reach. It is vital that future policy is supportive of part-time, flexible hours, allowing women to succeed in their chosen careers without having to compromise with regard to family life. Through her key messages, she encouraged women not to be afraid to do what they think will work best for their family, and emphasised the importance of supporting and networking with others juggling the lifework tightrope.

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Ms Simpson focused on policy, arguing that the normative distinction between so-called 'women's policy' and 'other policy' has served to make womens issues a lower priority in policy formulation. It is imperative that future policy becomes integrated, whilst still allowing for acknowledgment of the complex needs of women. Her first key message was that a lack of affordable childcare is a major barrier for women returning to work; delaying their return to work has impact on women in terms of poverty, child poverty and poverty in later life. A comprehensive childcare strategy is therefore essential. Her second key message was that issues generally not regarded as womens issues need to be looked at in terms of womens lived experience, so that their impact on women is assessed and accounted for within policy making. Dr Irvine spoke of the 'dark art' of predicting accurately the NHS workforce. Women comprise the majority of 'in-training' personnel within the NHS. Furthermore, of those trained women, many work part-time hours within specialist fields such as obstetrics and paediatrics. Predicting the workforce is a complex undertaking, not least because of the 'life choices' individuals make. Dr Slater, contributing to the afternoon discussion panel, highlighted that robust financial modelling and workforce planning are essential. This could include various models of less-than-full-time work, or strategies to balance work with caring or other duties. There is a need to encourage a more realistic perspective from employers, society and ourselves, recognising the limitations (and possibilities) of combining work with other responsibilities.

Day 2
Professor Bhattacharya explained that IVF should not be relied upon to remedy infertility. Despite the celebrity success stories we are often presented with, in reality IVF is associated with low success rates and high economic and social costs. Professor Critchley drew attention to the changing experience of menstruation. This has entailed a need for more research in the area of menstrual pain, heavy bleeding and cycle-related issues, which can have high economic and personal costs. Such research needs to pay attention to womens individual experiences. Her first key message was that clinical research is required in the field of problems related to the menstrual cycle, to understand the mechanisms of menstruation and heavy bleeding in women with or without fibroids. Such studies will underpin the development of treatment strategies to avoid surgical intervention. Her second key message was that increased awareness is needed of the wider impact of gynaecological symptoms such as pain and bleeding and the impact on the individual family, workplace and society. Dr Gatrell explained that the portrayal of breastfeeding as natural, and as the normative standard for infant feeding, does not always match the realities of womens experiences, especially when they must balance breastfeeding with paid employment. Her key messages were that breastfeeding can be challenging and hard work, especially if women have more than one child and are employed, and that health promotion policies on breastfeeding need to take into account womens social and economic circumstances.

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Professor Wellings highlighted the recent increase in interest that has been paid to the sexual lifestyles of older people, which has hitherto been lacking. The research that does exist suggests that the sexual health of older people should be considered as a social, rather than a biomedical issue, and therefore may be subject to improvement through public health policies. The first of her key messages was that though sexual health remains important to the majority of older people, the focus shifts to sexual satisfaction and fulfilment. The second was that research has shown an increase in the frequency of sexual activity over time. This reflects changing social attitudes towards older people and, in particular, acceptance of their sexuality. With this in mind, attention should be paid to the impact of stigmatising images of older people and sexuality in advertising and the media, and efforts made to counter the notion that ageing equates with sexual inactivity. Professor Glasier argued that simple changes in policy could improve access to the most commonly used methods of contraception; this would allow GPs to concentrate on provision of long-acting methods. Her key message was that it is time to give serious consideration to making both combined and progestogen-only oral contraception available as pharmacy medicines. This will reduce unnecessary barriers to access and use and, thereby, lessen the burden carried by women related to contraceptive use throughout their reproductive years. Such a policy alone will not result directly in a reduction in the abortion rate, due to the complex social causes. Professor Hardy suggested that early-life risk factors influence reproductive health at all stages across the lifecourse. Therefore, a unified and woman-centred approach to health promotion, disease prevention and management is required. A view of women's health as related to the circumstances of the family, rather than simply to individualised biology, also allows long-term and cross-generational health gain. Professor Glasier explained that symptoms experienced during menopausal transition might influence risk factors for illnesses related to BMI, such as cardiovascular disease and cancer. Overall, menopausal symptoms affect wellbeing negatively, particularly if severe. Professor Glasiers key message was that the physiological and social changes taking place at this time have the potential to influence health outcomes, and the peri-menopause could therefore be a sensible opportunity to review lifestyle and make health promoting changes.

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Day 1 Welcome
Professor Sir Ian Diamond FRSE Principal and Vice-Chancellor, University of Aberdeen Sir Ian said that it was a privilege to be part of this conference, which focuses on an absolutely critical topic within reproductive health. For the past three decades, the subject of womens reproductive health across the lifecourse has existed in the shadows. Today in the UK, with Scotland leading the way, the central importance of this issue has been recognised, and responded to with good quality research. Research in the field of womens reproductive health is characterised by a multidisciplinary approach, and rightly so. As an example, Sir Ian discussed the decline in maternal mortality over the past centuries, which can be attributed to factors as broad as improvements in infrastructure and transport, changes in demography, and sociocultural shifts. It is important to recognise that many of the patterns we see today in womens experiences of reproductive health reflect social inequalities. For example, the ratio of teen births between the lowest income quintile and the highest income quintile is 10:1, and that of abortion rates is 5:1. Policy can have a real impact on reducing these inequalities, but requires a long-term commitment to the field of reproductive health. Sir Ian congratulated the Scottish Government in particular for its efforts to reduce inequality. However, policy must also focus on the implications of the changes to reproductive practices; for example, the issue of increasing numbers of people with both ageing parents and school-aged children. Changes to the current landscape of contraception may help to improve womens experiences of reproductive health, but in this area there is a long way to go. Any changes to policy require evidence from multidisciplinary sources, many of which are represented in this two-day conference.

Introductory Session Reproductive Health: Women, Work and Care

Chair: Professor David Baird CBE, MB, ChB, FRSE Emeritus Professor of Reproductive Endocrinology, University of Edinburgh

Raising Issues: recent trends and implications for policy

Professor Sarah Cunningham-Burley Professor of Medical and Family Sociology, University of Edinburgh Professor Cunningham-Burley described several of the social trends providing a backdrop to the reproductive health decisions made by women and families. She recognised that some may question why a focus on womens working lives and their reproductive health is needed, when changes to legislation have resulted in policies supporting working women, and improved medical services attending to their reproductive lives. Such improvements have contributed to what can be seen as an optimistic account of womens working lives and their health. For example, women now make up a considerable proportion of the Scottish workforce, and the gender pay gap has noticeably decreased since the 1980s. Improved employment rights have also meant that though the glass ceiling remains in place, cracks have begun to appear. Many professions, notably medicine, have also seen a considerable increase in female participation. This has been aided by family-friendly policies and equality legislation such as maternity and paternity leave, and a wider range of childcare.

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Furthermore, medical technologies and care now provide women with greater choice regarding their reproductive lives. These include improved methods of contraception and abortion, regular screening and control over how and where they give birth. A less optimistic account can also be summoned when discussing womens reproductive health and working lives. Though womens participation in the contemporary labour market is relatively high, this is largely constituted of part-time work. Furthermore, in efforts to balance paid and domestic work, many women may take on jobs for which they are over-qualified. Womens and mens experiences of work are therefore quite distinct. Due to normative expectations regarding the contribution women can make to the workplace, and the impact of interruption to their working lives due to child bearing and rearing, the gender pay gap remains intractable. There also remains stark inequality in the domestic division of labour; women continue to carry out most domestic work, especially in relation to childcare. This occurs whether women are simultaneously engaged in paid work or not. Policy developments that might aim to reduce this inequality, and wider cultural change in relation to equality, have therefore not had the impact that might be expected in this sphere. There is also a concern that some measures to provide women with increased flexibility at work may have entrenched gender inequality at work and at home. Professor Cunningham-Burley then turned to the impact of womens working lives on their health. Women may compromise their health if they down-play their own sickness in order to minimise its effect on paid work; an experience commonly reported in qualitative studies. As women progress through the lifecourse, their participation in paid work may reduce due to the demands of motherhood, something referred to as the motherhood penalty. Though maternity leave is universally available, the way in which it is used reflects underlying socioeconomic inequality. Those who take the longest periods of leave are likely to be in managerial and professional occupations, where they have more control over their working lives and access to more resources. Access to childcare is also an important factor in womens participation in the labour force, which again reflects socioeconomic inequality. It is often those with higher incomes who make use of formal childcare, demonstrating that efforts to provide subsidised childcare are not yet sufficient. Furthermore, unexpected situations, such as a childs sickness, are more easily managed if women have familial support. This may be lacking for women without a partner, or for older mothers without the support of their parents. Social context is central to discussions of womens health. Expectations of womens behaviour at home and in the workplace influence how women use health services, and how they manage their own sickness. This is supported by qualitative data, which has demonstrated the stress and tension that reconciling work and family life may cause women. Professor Cunningham-Burley called for challenges to the masculine work practices and career trajectories that currently exist, for familyfriendly policies which target these practices, and for incentives to promote gender equality at work and in the home. However, she also expressed the need for reflection when promoting womens reproductive health, so that we may avoid essentialising womens bodies. Emphasising any of the biological differences between men and women, especially in relation to reproductive health, has the potential to reinforce gender equality, rather than tackling the masculinist policies and practices which reinforce such inequality. Questions and comments In response to questions, Professor Cunningham-Burley asserted that the female contribution to the workforce is fundamentally devalued because of normative expectations of what women can achieve, and surrounding their reproductive trajectories. However, though womens work is generally not valued in the same way as mens work, this may not be true for all women in all work contexts. In some spheres, the contribution of characteristics broadly associated with women, such as caring and emotion, has been recognised in medicine, amongst other professions. Attitudes towards the presence of women in professional careers such as medicine and teaching are changing.

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Other countries, notably in Scandinavia, have more family-friendly policies and maintain a respect for professions associated with a female workforce, such as teaching. We have a lot to learn from other nations, especially from Nordic countries, where childcare is easy to access and characterised by practitioners who are highly qualified. This sends out a clear signal that bearing and raising children is highly valued and supported by society. References Airey, L. 2005. Women in their Fifties. Centre for Research on Families and Relationships Research Briefing 24. Bradshaw, P., Jamieson, L. & Wasoff, F. 2008. The use of informal support by families with young children. Growing up in Scotland Research Briefing 2. Cunningham-Burley, S., Backett-Milburn, K. & Kemmer, K. 2006. Constructing Health and Sickness in the Context of Motherhood and Paid Work. Sociology of Health and Illness 28(4), 385409. Graham, H. 2012. Capable of change? The impact of policy on the reconciliation of paid work and care in couples with children. PhD Thesis, University of Edinburgh. McKie, L., Bowlby, S., Hogg, G. & Smith, A. 2009. Workplace policies and practices of care. Centre for Research on Families and Relationships Briefing 45.

Life expectancy and reproduction

Professor Tom Kirkwood Director of Newcastle Initiative on Changing Age (NICA), Newcastle University Professor Kirkwood emphasised that the issue of womens reproductive health is hugely important, and that there is a need to combine the life sciences and the social sciences to generate evidence. He pointed to the fact that though womens life expectancies are lengthening, in line with global trends, the female reproductive span is not. The increase in life expectancy seen in most parts of the world is a remarkable achievement, and United Nations forecasts for life expectancy are continually being revised upwards. Life expectancies were not anticipated to increase beyond the second half of the 20th Century, once the gains that had been made through reducing deaths in early and middle life had mostly been accomplished. It was expected that life expectancy would thereafter reach a ceiling, reflecting the effects of intrinsic ageing which was assumed to be biologically programmed. However, the increase in life expectancy did not slow and is now driven by declining death rates at older ages, pointing to greater malleability of human ageing than was expected. This has coincided with improved scientific understanding of the ageing process. In order to understand why ageing is not programmed, it is helpful to recognise that ageing is rarely seen in natural animal populations, other than humans, as the vast majority of animals die young from extrinsic factors such as accidents, predation and starvation. In accordance with the disposable soma theory, bodies are not genetically programmed to age; they are programmed for survival but when life is curtailed by extrinsic mortality, there can be little selection pressure for the body to invest in better maintenance than is needed to get through the years of greatest reproductive potential in good physical shape. Ageing, therefore, entails lifelong accumulation of cellular defects. This leads to the age-related frailty, disability and disease that are seen in the modern world, where most of us are spared from premature death. This understanding of ageing reveals how social and biological factors interact; social factors include diet, lifestyle and adverse consequences of socioeconomic disadvantage. Ageing can therefore reflect social inequalities.

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In terms of reproduction, ageing has stark consequences for women. Women are born with 12 million eggs, yet none are left by the time of menopause, even though the number used up through ovulation might be less than 500. It appears that the vast majority of eggs are deleted through quality assurance systems that seek to prevent transmission of acquired molecular defects associated with ageing. As is well known, fertility declines and the frequency of genetic abnormalities increases with age, consistent with the idea that the remaining stock of potential eggs is challenged by effects of intrinsic ageing. In addition to the direct effects of ageing on fertility, which is probably shared across the species range, human female reproduction also features the phenomenon of menopause. Unlike other female primates, which can retain fertility throughout almost the entire lifespan, a womans fertility does not continue until the end of life. That women experience the menopause is puzzling, as it seems contrary to evolutionary principles. Professor Kirkwood described two hypotheses to explain the menopause. The first is that in humans, neonatal brain size is restricted by the maternal pelvis, which explains why babies and young children require a great deal of assistance until they are fully developed. It may therefore be better for women to look after their existing children, rather than attempt to give birth to more, which entails greater risk as they age. The second hypothesis is that as young children require a great deal of support, womens life expectancies have evolved to extend beyond their reproductive years in order to assist their adult daughters with childrearing. In this way a womans genes are propagated through her grandchildren without the risk of maternal mortality entailed by bearing children later in life. Though Professor Kirkwood described how neither hypothesis is convincing on its own, he also showed that the two combined provide a sound explanation for the menopause. Understanding the origins of the menopause is important, because social and technological advances now render largely ineffective the factors that might have driven its evolution. Social support for children removes the absolute dependence on kin, while improved obstetric care can mitigate many of the original risks associated with giving birth later in life. In an era when the possibilities are emerging to make reproduction feasible beyond the normal age of menopause, it is advisable to understand the biology with which such technologies might be interacting. Professor Kirkwood also pointed to the theory that there is a trade-off to be made between fertility and longer life. Based on a study of female aristocrats, he explained how historical records show that women who survived to the oldest ages showed a statistical likelihood to have had fewer children and to have had their first children at later ages, suggestive of compromised fertility. There is some indication that this association might be linked with a mechanistic trade-off involving the innate immune system. An immune profile associated with impaired fertility is also less susceptible to fatal infectious disease. This raises the intriguing possibility that as the selection pressure imposed by historical patterns of infectious-disease mortality shifts, through modern medical interventions, future generations may experience corresponding adjustments to factors affecting fertility. Though human life expectancy has continued to improve, the period during which women experience the menopause has remained the same. This may be because though mechanisms in the body have adjusted to better care for ordinary cells, egg cells have already been receiving the best treatment, and so their maintenance cannot be further improved. This has consequences for womens reproductive health. The harsh biological reality relating to the ageing of the ovary must be recognised, and assisted fertility treatment must account for the biological processes associated with molecular damage. Though we are living, learning and working for longer, some biological realities are not changing; we must therefore think about womens reproductive health in the context of increased longevity. Questions and comments In response to questions, Professor Kirkwood acknowledged that it is important to recognise the Barker hypothesis in discussions of female reproduction. This hypothesis asserts that malnutrition in

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the womb will prime the foetus for adversity after birth, and this means that once born, a child will be more susceptible to poor health in later life. It is therefore important to remember that the health trajectory of an individual begins at fertilisation. It was acknowledged that varying cultural practices and systems will also influence a womans fertility. For example, the reason that fertility is not higher for older women in countries with poor contraception provision may be due to the social status of grandparenthood. References Kirkwood, T. B. L. 2001. BBC Reith Lectures The End of Age. Lecture 3 Sex and Death. Sourced from: (http://www.bbc.co.uk/radio4/reith2001/lecture3.shtml). Kirkwood, T. B. L. & Shanley, D. P. 2010. The connections between general and reproductive senescence and the evolutionary basis of menopause. The Annals of the New York Academy of Sciences 1204, 2129. Shanley, D. P. & Kirkwood, T. B. L. 2001. Evolution of the human menopause. BioEssays 23, 28287 Shanley, D. P., Sear, R., Mace, R. & Kirkwood, T. B. L. 2007. Testing evolutionary theories of menopause. Proceedings of the Royal Society,Series B 247, 294349 Westendorp, R. G. J. & Kirkwood, T. B. L. 1998. Human longevity at the cost of reproductive success. Nature 396,74346. Westendorp, R. G. J., van Dunne, F. M. & Kirkwood, T. B. L. 2001. Human fertility and survival. Nature Medicine 7, 873.

Work and health: contemporary issues and future prospects

Professor Linda McKie Professor of Sociology, Durham University Professor McKies presentation drew on research from a decade of collaboration with colleagues in Finland. The data result from interviews with women managers in Scotland and Finland between the ages of 30 and 60. These interviews considered various aspects of their working and reproductive lives. Scotland and Finland have geographical and political similarities which make them suitable for comparison. They have a similar population sizes, with most of the population congregated around a central belt. Both countries have large hinterlands, and similar components of national identity. However, there are striking differences between the two countries in their approaches to women and employment. Finland has a strong maternity care system, providing up to three years of paid maternity leave, which can be split between mothers and fathers. Womens working lives take place in a context of fuzzy boundaries between family and employment. Women may decide to take time out of work to increase the time spent with family; however, this can impose psychological barriers on women in their middle careers, as they are caught between different spaces and places. Professor McKies study therefore attempted to understand how women experience career in mid-life, and the choices they make. Data were collected from 44 women managers, 25 of whom took part in one-to-one interviews, and the remainder in four focus groups. Women from both Scotland and Finland took part in the study, representing both the private and the third sector. The issues discussed with women included organisational policies, worklife balance, support networks and futures. The women interviewed acknowledged that a different value was put on their time as compared with other workers and other members of their family. For example, work colleagues presumed that women would work better when working with others. However, their workplaces largely tried to divorce themselves from interdependence, apart from where it was of value; for example, regarding emotional

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labour or customer care. Women also discussed the tensions that result from balancing work with their reproductive lives, which were seen as in need of control. Reproductive and family lives deviate from the linear notion of a career, and the women interviewed found it hard to mould themselves to this. Gender discrimination was also experienced by some of the women interviewed. Those in Finland spoke of a sauna culture, whereby men would discuss opportunities and promotions in spaces away from women. Similar stories were told of Scottish corporate environments, occurring on the golf course or at sports matches. The realities of day-to-day caring work were also invoked; for example, for elders or taking children to appointments. Despite policies enabling flexible working hours to account for this, women would go to great lengths to avoid using these. This was because they feared being perceived as less committed to the workplace, and for fear of being seen as less able to cope with both their family and their working lives. In contrast, those who were able to opt in and opt out of the workplace at different times, largely those who were self-employed, found that they were empowered, and had more control over their lives. Professor McKie concluded that current policies often focus on large employers, and though corporate cultures are happy to tick the boxes when it comes to legislation, they often do not enact the spirit of these policies. There is a need to recognise the interdependence of individuals across generations, and integrate this into the world of work, which often divorces care relationships from the workplace. In order for women to achieve a sense of control over their space and time, it is necessary to move away from the ideal type of the linear career, and recognise the patchwork of experiences that comprise womens home and working lives. Questions and comments Comments made included the observation that though there may be a need for a change in legislation, measures must also be put in place to make sure such changes are enacted. Initiatives such as the Athena SWAN charter for women in science may be needed to take a step beyond simply having policies. We also need to monitor and evaluate these policies to make sure they are successful. In response to questions, Professor McKie asserted that the women in the study were happiest when they had greater control over their lives. Those who were older also felt more control, and explained that the best time is now, due in part to the fear that employers would be wary of younger women who may leave to have children. Finland has allocated rights to fathers as well as mothers. However, only around a third of them take up their paternity leave entitlement. This is perhaps because of the gender segregation visible in Finnish workplaces, where women are largely employed in caring professions. Men may find it difficult to use their leave if outwith the public sector. There may be negative outcomes of such family-friendly policies. However, these can be negated if communication is maintained with women during their period of leave, and if women are encouraged to come back to their original place of work. References Bowlby, S., McKie, L., Gregory, S. & MacPherson, I. 2010. Interdependency and care over the Lifecourse. London: Routledge. Burrows, G. 2013. Men Can Do it. Croydon: NGO Media. Jones, B. (ed.) 2012. Women Who Opt Out. The Debate over Working Mothers and Work-Family Balance. New York: New York University Press. Jyrkinen, M. & McKie, L. 2012. Gender, Age and Ageism: Experiences of Women Managers in Two EU Countries in Work. Employment and Society 26, 6177.

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McKie, L., Biese, I. & Jyrkinen, M. 2013. The Best Time is Now! The Temporal and Spatial Dynamics of Women Opting in to Self-Employment, Gender, Work and Organization 20(2), 18496. Wolf, A. 2013. The XX Factor. How Working Women are Creating a New Society. London: Profile Books.

Session 1 Family Formation

Chair: Dr Catherine Calderwood Medical adviser for maternity and womens health, Scottish Government

Who benefits from women 'delaying' childbearing?

Professor Susan Bewley Professor of Complex Obstetrics, Kings College London During her thirty years as an obstetrician, Professor Bewley has witnessed the increasing trend in reproductive ageing in the United Kingdom. There are clear links between reproductive ageing and pregnancy complications. These complications include: 1. 2. 3. 4. Infertility Miscarriage and ectopic pregnancy Stillbirth and neonatal death Maternal death and morbidity

Reproductive ageing must be understood as an issue of relevance not only toindividual women, but also to society as a whole. With increasing numbers of women delaying pregnancy decisions into their late thirties and early forties, reproductive ageing is a concerning trend. Rates of infertility increase with age, and IVF cannot manage to meet the demands of women who find themselves to be infertile once they try to conceive. Furthermore, the failure rates of IVF increase with age. Professor Bewley commented that when IVF fails, it is women who absorb the failure as their own. This is not the desired outcome, as it is the science and hype of IVF, combined with high reproductive age, which should be questioned. The natural end to fertility occurs approximately ten years prior to onset of the menopause. This means that women in their early 40s can expect to be at a high risk of infertility. This reality, however, is something that few young people are aware of. Whilst we are dedicated to teaching young people about contraception, we fail to inform them about the biological realities of fertility cessation. Reproductive ageing is linked with increased risk for the mother. Rates of maternal death are rising in several rich countries, including the USA, the Netherlands, Canada, Norway, the UK, Denmark and Austria. This rise is maternal death can be related to the increased reproductive age of women living in these societies. Postpartum haemorrhage (PPH) is another concern, as rates of such a complication have almost doubled over the past decade. Noting that the increase in PPH and other associated complications may also be linked to other issues such as obesity and migration, Professor Bewley nevertheless stated that the rises are predictable indicators of reproductive ageing. The increasing incidence of reproductive ageing has links to wider social factors. Asking 'who can afford children?', Professor Bewley noted that concerns over debt, employment and childcare impact on pregnancy decision making, as does the pay gap between the genders. Individuals and couples want to have children, and yet, delayed childbearing must be regarded as an inadvertent decision, resulting from womens struggles to find the security they feel necessary for starting a family.

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We live in a society that discourages young women from having children. There is an emphasis on waiting, and establishing a career first. This message is one which can result in heartache, with women delaying pregnancy for so long that their fertility wanes before having any children. Commenting on some of the reproductive options for women who are infertile, Professor Bewley noted that egg freezing is not the answer, but a distraction. This 'experimental technology' does not deal with the social issues at the heart of the problem of infertility. In addition, egg-freezing cannot militate against somatic ageing, and is often unsuccessful. Who, then, benefits from women delaying pregnancy? We must consider the role of: 1. 2. 3. 4. 5. 6. 7. Infertility Clinics Counsellors Lawyers Pharmaceutical companies Scientists Charities Alternative therapists

None of these people or services can guarantee pregnancy to women who are above the normal age range for fertility. Social context is of importance to the question of reproductive ageing. If women felt that they would be supported, and accepted, by the wider society, by their workplace and by their peers, would they choose to become pregnant earlier? Professor Bewley suggested that a 'we' (rather than me) approach to medicine must be designed. This 'we' medicine would include calls for: 1. 2. 3. 4. 5. 6. Better education Childcare Employment protection More women scientists End to sexual and gender-based violence End to the exploitative and unsafe commercial exploitation of women's bodies

Summarising her presentation, Professor Bewley noted that contraceptive choices have had a significant impact on women's pregnancy decision making and the increase in maternal age. Stating that there are pressures on women in modern society which prove 'toxic' to realising pregnancy at a younger age, Professor Bewley reiterated her main points: 1. Reproductive complications increase with age. 2. IVF and 'experimental technology' do not address social norms regarding pregnancy, and do not mitigate against somatic ageing. 3. We must look at the issue of reproductive ageing through a public health lens. References Arnett, J. 2001. Conceptions of the transition to adulthood: Perspectives from adolescence through midlife. Journal of Adult Development 8(2), 13343. Bewley, S., Ledger, W., Nickolou, D. & Kehoe, S. (eds) 2009. Reproductive Ageing. London: RCOG Press. Cooke, A., Mills, T. A. & Lavender, T. 2010. Informed and uninformed decision makingWomens reasoning, experiences and perceptions with regard to advanced maternal age and delayed childbearing: A meta-synthesis.. International Journal of Nursing Studies 47, 131729.

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Daly, I. 2011. Explaining the trend towards older first time mothers A life course perspective. In Ebtehaj, F., Herring, J., Johnson, M. H. & Richards, M. (eds) Birth Rites and Rights, 25570. Oxford: Hart. Everywoman, J. 2013. Cassandras prophecy: why we need to tell the women of the future about agerelated fertility decline and delayed childbearing. Reproductive Biomedicine Online. [In press.] Faddy, M. J., Gosden, R. G., Gougeon, A., Richardson, S. J. & Nelson, J. F. 1992. Accelerated disappearance of ovarian follicles in mid-life: Implications for forecasting menopause. Human Reproduction 7(10), 134246. Frejka, T., Sobotka, T., Hoem, J. M. & Toulemon, L. 2008. Summary and general conclusions: childbearing trends and policies in Europe. Demographic Research 19(2), 514. Leridon, H. 2004. Can assisted reproduction technology compensate for the natural decline in fertility with age? A model assessment. Human Reproduction 19(7), 154853. te Velde, E., Habbema, D., Leridon, H. & Eijkemans, M. 2012. The effect of postponement of first motherhood on permanent involuntary childlessness and total fertility rate in six European countries since the 1970s. Human Reproduction 27(4) 117883. Woodroffe J. 2009. Not having it all: How motherhood reduces womens pay and employment prospects. London: The Fawcett Society.

Fertility decisions are complicated and contextual

Professor Lynn Jamieson [Presented by Professor Sarah Cunningham-Burley] Professor of Medical and Family Sociology, University of Edinburgh Presenting the work of Professor Lynn Jamieson, Professor Cunningham-Burley noted that we must critically engage with the idea of fertility decision making. Rather than regarding fertility decisions as consciously made, it is helpful to conceptualise them as incorporating non-decisions and downplayed decisions, in addition to assertive choices. Understanding fertility decisions as complicated and contextual in all instances is of utmost importance. Fertility, and the decision to become pregnant, is a private issue, and yet fertility decisions must nevertheless be considered as intimately linked to the wider society. Individuals' decisions are both shaped by, and shape, others decisions. Consequently, we must understand that 'stories of reproduction' are socially shaped, and that fertility is not only a personal issue, but also a public one. One such social factor of reproduction is delay in finding a partner which, sometimes, results in delayed pregnancy. For those without partners, it can be challenging to find the partner with whom to have children. Pursuing potential partners in an assertive manner can be stigmatising, as it can be interpreted as desperate behaviour. Therefore, the decision to have a baby is often constrained by the realities of single life. Partnering is not the only contributing factor to fertility decision making. Of central importance is the economic recession, which has negatively impacted on housing, employment and income. These structural issues contribute to feelings of insecurity and, consequently, may impact on decision making regarding reproduction. The 'right' circumstances for having children are not being met and, coupled with reduced public spending on childcare services, individuals are delaying their reproductive futures. Referring to a 1999 study by Jamieson and Anderson, focused on young people's ambitions for the future in relation to economic insecurities, Cunningham-Burley cited findings which suggested that, at the time, young people spoke of ambitions for their lives, in relation to housing and work prospects, and yet they were reticent to plan in terms of future fertility decision making. Planning for child bearing was not included in the ambitions stated by these young people. This highlights that fertility decisions are not always assertively made, or planned.

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Other social influences also work to shape fertility decisions. Culturally determined normative understandings of the 'best' time for reproduction have a significant impact on the 'private' decision making of individual women or couples. In addition, the influence of friends and relatives with children must be appreciated. Couple dynamics and the extent to which agreement, coordinated action or delay plays a role in deciding whether to conceive or not, are also relevant for analysis regarding fertility decision making. Finally, it is important to consider how cultural or social worlds may be more or less child-friendly. For example, men's social worlds tend to involve less experience with children, and may be regarded as less child-friendly, than the social worlds in which women live. Another interesting point is that women are more likely than their partners to downgrade their employment status in order to have children. This is an issue which requires further consideration, in light of discussions regarding more flexibility for women in the workplace. Questions and comments Following both Professor Bewley and Professor Cunningham-Burleys presentations, it was noted that Professor Bewley's work points to the risks in delaying pregnancy, based on fundamental biological realities which cannot reliably be mitigated against using new reproductive technologies. Professor Lynn Jamieson's work provides an alternate lens for analysis, highlighting the complex interplay between personal and social factors in relation to fertility decision making. A comment from the audience suggested that in addition to thinking about the influence of employment and care responsibilities as fundamental structural factors impacting on fertility decision making, perhaps we should be raising the issue of education as well; should we be trying to enable the raising of family whilst in tertiary education? Action could be taken to make sure that future policy is focused on educating the next generations about the biological limits of fertility. However, care must be taken to inform and educate young people about fertility in terms of the biological facts, while remaining mindful of the impact of the social context in shaping women's reproductive decision making. In response to questions, Professor Bewley noted that two curricula exist which inform young people about reproduction. There is the official curriculum, focused on contraception and safe sexual practice, and then there is the 'hidden' curriculum, found in pornography, young people's magazines and popular culture. Neither of these curricula provides accurate information regarding fertility and negotiating trade-offs. Therefore, policy must address this gap in knowledge and give young people the appropriate skills with which to better make fertility decisions. Cultural norms within society impact on women's reproductive decision making; women from more advantaged backgrounds are more likely to gain a higher education, and embark upon a career, before having children. These entrenched expectations should be challenged if we are to respond sufficiently to the concerning trend of reproductive ageing. Referring to a survey conducted in Edinburgh which focused on women over the age of 37 seeking contraception, Professor Glasier noted that a common assertion made by the women was that they had not partnered successfully to date. Maybe the difficult search for Mr Right sometimes results in women waiting too long, and losing their chance to conceive naturally. References Anderson, M., Bechofer, F., McCrone, D., Jamieson, L., Yaojun L. & Stewart, R. 2005. Timespans and Plans among Young Adults. Sociology 39(1), 13955. Sobotka, T., Skirbekk, V. &Philipov, D. 2011. Economic Recession and Fertility in the Developed World. Population and Development 37(2), 267306.

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Combining work and family perspectives from experience

Professor Susan Wray Department of Molecular and Cellular Physiology, University of Liverpool Professor Wray delivered a personal account which documented her experiences of life as a mother with a professional career. She spoke briefly of early frustrations, as a young researcher who was never chosen for a tenured lectureship, and the eventual move from London to Liverpool, with her family, where she has remained since. Today, extensive sources of information exist for women wanting to succeed in their careers whilst also raising a family. Contemporary sources of information for women include: self-help guides to motherhood; books and magazines on motherhood; and internet plans documenting the varying 'types' of mother a woman could aspire to be. However, notwithstanding all of this information, women are faced with complex decisions, such as: whose career (in the partnership) should lead; what 'type' of mother to be; and how to best organise childcare through formal and informal networks, whilst remaining on track for a successful career. In short, life is more complex for women. It is often harder for women to achieve the right work/life balance, when managing a career alongside motherhood, housekeeping, caring for elderly relatives, and maintaining one's own interests. In addition, there is often great pressure on women to achieve 'super mum' status. This modern expectation demands that women look good, are successful in their careers and are good mothers. The emphasis, then, is on perfection. This 'super mum' status is obviously very hard, if not impossible, to achieve as women struggle to manage all of their responsibilities. This can leave mothers feeling guilty about pursuing their careers. Professor Wray revealed that she had experienced these pressures and feelings of guilt. This emphasis on the role of the mother, and the responsibilities that women must juggle as they strive to succeed in life and work, is a discussion which often ignores the father. Indeed, Professor Wray noted that there exists in the public realm very little consideration of the father's presence in the home, what 'type' of father he may be, and the hours he works. This represents a gendered imbalance regarding role expectations. In order to assist women in achieving their goals for life as both professionals and mothers, older women must become mentors for younger women, in order to help inspire, support and guide them through the challenges posed by the work/life balance and familial responsibilities. By way of suggestion, Professor Wray referred to a Royal Society document entitled Mothers in Science 64 ways to have it all, urging everyone to read it as a fantastic example of the diversity of ways of managing and doing life/ career/ child-rearing (http://royalsociety.org/uploadedFiles/Royal_Society_Content/about-us/equality/2011-06-15-Mothersin-Science.pdf). Returning to the issue of the 'super mum', which praises perfection and success, Professor Wray argued that women must see success as subjective. Women must not judge themselves against the successes of other women and, instead, women must decide what success means to them, in their own personal contexts. By extension, women must not judge others or the alternative ways in which other women choose to manage their lives, careers or familial responsibilities. Professor Wray stressed the point that women must be supportive of each other. In conclusion, Professor Wray noted that women must support each other to achieve their own, best suited work/life balance. Older women should mentor the young in order to foster a supportive

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environment for women to succeed. Professor Wray argued that women should apply for funds from corporate sponsors in order to implement supportive networks for women in the workplace, mentioning Athena SWAN as an example (http://www.athenaswan.org.uk/). Questions and comments Comments from the audience highlighted that managing the work/life balance as successfully as Professor Wray has done is something which can be challenging for women without social networks, support systems, financial stability or good health. Professor Wray responded to this issue and agreed, noting that there remain significant structural barriers. It was suggested that policy could be improved to ensure that women on maternity leave do not compromise their careers. Employers should perhaps provide a 're-entry package' to women returning from maternity leave. This would enable women to reintegrate into their work role and regain their competitive edge within the workforce. This, according to Professor Wray, would be beneficial both to the individual woman and to the employer. Professor Wray argued that there needs to be a change in work culture, which would support women in having both a career and a family, through the provision of flexible, part-time hours which allow for family life. Taking from her own experience of employing part-time researchers in her own laboratory, Professor Wray reiterated her point that flexible, nonexploitative hours provide a model for women seeking to achieve both career and family goals.

Does policy and legislation meets women's needs?

Ms Clare Simpson Project Manager, Parenting across Scotland Ms Simpson introduced her presentation by arguing, in response to the title, that policy and legislation does not sufficiently meet women's needs, and questioning whether it is social impetus or legislation that creates change. Providing context to the discussion, Ms Simpson referred the audience to a selection of legislation, implemented with the aim of changing women's lives for the better. These include: 1. 2. 3. 4. 5. 6. 1881 Married Women's Property Act 1918 Votes for women 1945 Family Allowance Act 1970 Equal Pay Act 1975 Sex Discrimination Act 2010 Equality Act

Whilst this legislation has led to significant changes, in many cases the issues that it sought to address continue to be problematic today, in spite of the legislation. Ms Simpson asserted that, whilst there have been significant achievements made, there are still profound problems. Indeed, legislation does not always result in actual change and, as such, women still face challenges in their daily lives as the result of (among other issues): 1. 2. 3. 4. 5. 6. Pay gap Maternity discrimination, which is illegal but, nevertheless, exists Higher risk of poverty for women than men Childcare as a barrier to work Carer responsibilities, with women making up 66 % of unpaid carers in Scotland The falling numbers of women in powerful positions (The Sex and Power Report, Equality and Human Rights Commission 2011)

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These issues require an integrated policy approach that simultaneously retains a specific focus on women. At present, there exists a conspicuous division between so-called 'women's policy' and 'other policy'. Issues of childcare, flexible working hours, and parental leave tend to be considered 'women's' issues, whilst policy relating to planning, transport, housing and employment are considered under the remit of the latter, although they have a significant and differentiated impact on womens lives. This distinction is not sufficient, as it normalises certain concerns as 'women's issues', rather than viewing childcare, and elder care, as collective issues. This division of policies serves to ghettoise women's issues. Policy must be integrated, allowing for employment, transport, housing, childcare, elder care, parental leave and other concerns to be collectively addressed with an awareness of the gendered realities of life. Infrastructure is as much a women's issue as childcare and, therefore, it is detrimental for the division between policy groupings to remain. Furthermore, through merging policy, concerns relevant to women's everyday lives would be taken more seriously, rather than side-lined as less important to society. It is vital that the gendered realities of life are acknowledged in policy, but the present normative division is highly problematic. Ms. Simpson observed that the majority of people working on so-called 'women's policy' are women, and the majority of those working on 'other policy' are male. This division has clear implications for policy, and must be critically addressed. Looking to the future, we must all critically consider the gender role assumptions that exist in society, and which are held by individuals, employers and communities. In addition, women's experiences must be conceptualised as heterogeneous, with acknowledgement of the complexities of lived experience identifiable in future policy. Women's civic engagement should be better facilitated and, crucially, all policy should be formulated using a gendered lens, rather than maintaining the distinction between 'women's policy' and 'other policy'.

An employer's perspective
Dr Stewart Irvine Director of Medicine, NHS Education for Scotland Dr Irvine opened his presentation by noting that the NHS is the world's fourth largest employer, after the US and Chinese military and McDonalds. Responsible for education and training, Dr Irvine spoke of the complexities inherent to predicting the NHS workforce into the future, with emphasis awarded to the impact of 'life choices' and of the overwhelmingly female workforce on such concerns. The linear career path for an individual embarking upon medical training spans more than a decade, with training comprised of medical school, foundation years and specialist training, prior to reaching what Dr Irvine referred to as the 'trained workforce'. The ability to accurately assess the decisions that each individual might make throughout their training, in terms of life choices, so as to estimate the future workforce, is an on-going challenge. Employers within the NHS see 'life choices' as having a potentially significant impact on the future workforce. Individuals on their career path are understood as likely to formulate decisions regarding their future careers based on choices relating to family and personal ties. In addition, individuals are increasingly opting for careers within the NHS in locations which they find acceptable, a preference which sometimes is of more significance to the individual than the career opportunities available in the desired locale. Furthermore, gaining and maintaining a desired work/life balance is becoming more important to those embarking on the medical career. Taken together, these influencing factors serve to make predicting and managing the NHS workforce over the long term a significant challenge.

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Doctors in training make up a large percentage of the medical workforce in Scotland, and of this intraining workforce, the majority are women. In contrast, the majority of consultants who have completed their training are men. Of the female consultants, part-time working is more common than it is amongst male counterparts. Referring to a BMA 2006 cohort study, Preferred choice of specialty by gender, Dr Irvine noted that specialty preferences are highly gendered, with obstetrics and gynaecology and paediatrics representing an overwhelmingly female intake. With consultant participation rates differing across genders, it is possible to argue that such choices relating to women, such as part-time hours, have a significant impact on planning the future workforce, and on individual women's careers within medicine. Indeed, progression to a chosen 'final career destination' is significantly impacted by less-than-full-time working. With these issues in mind, Dr Irvine pointed to the Royal College of Physician's Women and Medicine report. This report, according to Dr. Irvine, raises many important issues and is of relevance today. However, there is still further need for research into the challenges women face in reaching their final career destination in medicine, not least because of the issue of part-time work and the negative impact this has on the linear career path. References Health Policy and Economic Research Unit. 2012. Preferred choice of specialty by gender. Sixth report of the BMA cohort study of 2006 medical graduates. London: British Medical Association. Royal College of Physicians. 2009. Women and Medicine: The Future. Summary of findings from Royal College of Physicians research. London: RCP.

Panel discussion policy implications of afternoon session

Chair: Professor Alice Brown (Then) General Secretary, Royal Society of Edinburgh. The panel was comprised of Dr Calderwood, Professor Bewley, Professor Cunningham-Burley, Professor Wray, Clare Simpson, Dr Irvine and Dr Slater. Professor Brown invited all speakers to summarise their main points, commencing with Professor Bewley. Professor Bewley noted that it is vital to put reproductive ageing onto the public health map. It is imperative that young people are informed about the realities of reproductive ageing. Tackling the deeper social influences of reproductive ageing is a complex task. Professor Cunningham-Burley considered how it would be possible to bring biology into the debate without pressurising or frightening women, and without normalising certain 'right' practices over other alternative methods/time frames. Ms. Simpson argued that childcare issues and flexible working hours are crucial. Encouraging employers to allow women to have a better work/ life balance is important. In addition, so called 'women's policy' must become incorporated into wider policies. Professor Wray asserted that it is vital for women to mentor their younger counterparts, through implementing support networks and creating incentives for better working conditions for working mothers. Professor Wray raised Athena SWAN as an example for future models. Dr Irvine noted that there needs to be a change in reliance upon doctors in training to a reliance on a workforce that is fully trained.

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Dr Slater suggested that the issues raised need further consideration, using economic modelling. Employers need to be encouraged to make changes. Dr Slater also noted that there needs to be an awareness of the realities of what is possible, with regard to juggling career and family, noting the shift as akin to a feeling of 'flying high to getting by'. Dr Calderwood pointed to key messages she would take back to the Scottish Government. She noted an awareness of the need for continued communication and integration of work across medical, social and political spheres, in order to adequately address issues pertaining to women's experiences of reproduction over the lifecourse. Dr. Calderwood argued that happier women raise happier and healthier children and, as such, women's concerns must be addressed head-on. Questions and comments Professor Glasier, arguing devil's advocate, asked the panel how they imagined that part-time, flexible hours, and the accommodation of women's diverse reproductive requirements, could be integrated into a successful business strategy. By way of response, Professor Bewley admitted that there is a pressing need to consider all of the concerns raised throughout the day through an economic lens. Professor Baird, attending, argued that in fact, women in the workforce are a strong business model and that there simply needs to be the implementation of protected part-time hours and the cultivation of normalised social acceptance of such a work/life balance. An audience member asked how scientists could help rectify the problems spoken of throughout the day, namely the link between the economic recession and subsequent feelings of insecurity regarding starting a family. The woman commented that in her native Greece, she has witnessed similar trends, with the onset of recession. Professor Cunningham-Burley responded by stating that academics and professionals must engage in the public debate, and speak out on policy within the public realm. Clare Simpson added that flexible hours should be on offer, and that they should be held to standards of fairness and be nonexploitative. Professor Wellings, attending, raised the issue of social stigma attached to young mothers. She argued that popular preconceptions have constructed young mothers as irresponsible. What is the impact of this social construction of the 'bad' young mother? Professor Cunningham-Burley responded to this point by suggesting that individuals could become less 'private' regarding their reproductive decisions and, in so doing, engender acceptance of the range of reproductive choices that are made by women. This speaking out may serve to counteract normative judgments regarding the 'right' and 'best' time to have children, and the ideal mother. In addition, and by way of encouraging non-judgmental attitudes towards young mothers, Professor Cunningham-Burley suggested that the provision of childcare for students should be pursued.

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Concluding remarks
Professor Sir Ian Diamond Sir Ian concluded the day's sessions by celebrating the multidisciplinary nature of the discussion, and the collective engagement in issues covered. It is evident that we must work to better communicate biological realities of fertility to the general population, and to make explicit through public engagement the limitations that reproductive ageing asserts on our reproductive abilities. Sir Ian suggested that we are experiencing a planned pregnancy era, which has resulted in some women delaying for too long, due to personal and social contributing factors. Trends point to a bimodal distribution of fertility decision making, and Sir Ian noted the high rates of early pregnancy in women from communities with lower socio-economic capabilities, compared to high rates of reproductive ageing among women from middle- and upper-class backgrounds. Policy of the future must address employment, care responsibilities, education and the work/life balance, in order to encourage a culture of childbirth which can also be profitable for the economy. In conclusion, Sir Ian argued for a 'holistic' approach to addressing the issues raised throughout the day, and that this inclusive formulation must engage with men.

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Day 2 Session 2: The Reproductive Years

Chair: Professor Iain Cameron Dean of the Faculty of Medicine, University of Southampton

Epidemiological evidence and socio-economic costs of reproductive problems in the UK Professor Siladitya Bhattacharya Professor of Reproductive Medicine, University of Aberdeen
Professor Bhattacharya asserted that since publication of the revised National Institute for Clinical Excellence (NICE) guidelines regarding IVF at the end of February 2013, the UK has seen a renewed interest in assisted reproduction. In their recommendations, NICE acknowledge the influence of age, and have been more flexible regarding the use of IVF when there is an obvious reason for infertility. Infertility is an important issue for health services to address, as up to one in five women experience difficulties in conceiving. Various explanations are given for infertility in women. These include complications associated with pelvic surgery, chemotherapy, chronic health problems and chlamydia. It is important to recognise that infertility can often be accompanied by concomitant morbidities, such as high BMI. If we were to believe media reports, it would seem that there is currently an epidemic of infertility. However, data from the US suggest that rates of infertility there have not changed significantly since 2002. On a global scale, rates of infertility have remained somewhat constant between 1990 and 2010. Predictions of population growth in Europe have broadly been divided into two categories: countries that will see an increase in population, which includes the UK; and those that will see a decline, many of which are in southern and eastern Europe. Factors associated with declining fertility rates include decreasing fecundity, reproductive delay, desire for smaller family size, lack of support for child-rearing and access to and uptake of fertility services. This discussion will focus on the latter. In terms of reproductive delay, the majority of countries show a trend of increasing age at first birth between 1980 and 2005. In Aberdeen, for example, between 1990 and 1991, the average age at first delivery was around 26. By 2009, this had risen to almost 28. The time it takes for a woman to achieve a pregnancy increases with age. At 30, there is a 75 % chance that she will conceive within 12 months; but at 40, this decreases to 44 %. This is due to a reduction in the number of ovarian follicles and a decrease in the number of healthy eggs possessed by a woman as she ages. However, current definitions of infertility ignore the influence of age, categorising infertility by a one size fits all 12 months of unsuccessful attempts to conceive. In Aberdeen, the age at which women present to the fertility clinic is increasing. In 1989, women presented at an average age of 29 years. This has increased, and around a quarter of the women now attending the clinic are over 40 years of age. Reasons for delaying reproduction include work or other training, and relationships. Many women felt that they had postponed a pregnancy until their circumstances were different. Although there is an expectation that IVF can overcome the effect of delay, in reality the outcome of treatment is strongly affected by a womans age.
In Europe, where population sizes are expected to decline, strategies to increase fertility include income support, work-related policies (seen especially in pro-natalist countries such as France) and assisted reproduction. However, it is important to be realistic about the effectiveness of IVF, both in the UK and abroad. IVF success rates are low, especially for older women. At the age of 44, the chances of a live birth stand at less than 5 %. Age is also correlated with spontaneous miscarriage, so even with a successful course of IVF, for women over the age of 40, their chance of miscarriage stands at 50 %.

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The UK is one of the largest consumers of IVF in Europe. This has had consequences for the economy, as children born following IVF treatment require larger amounts of resources than those born without, especially twins and higher-order multiples, who have a higher risk of premature birth and long-term health problems. Risks in pregnancy increase with a prospective mothers age. It is also important to consider the hidden costs of IVF worldwide. Though we are often presented with celebrity success stories, assisted reproduction also brings with it the possibility of children being made orphans at a young age, and also opportunities for the exploitation of women in developing countries, who may be used as wombs for rent. Questions and comments Responding to questions, Professor Bhattacharya asserted that the recent changes to NICE guidelines were appropriate, given the need to update them; however, more effort should be invested not only in detecting and treating infertility, but also in its prevention. The increased uptake of intra-cytoplasmic sperm injection (ICSI) may reflect a decrease in sperm counts across the world. However, though ICSI is now the default for many countries, it is important to assess its effectiveness, as it does not always produce better outcomes than IVF. Following a comment from the audience, Professor Bhattacharya explained that there is currently a lack of research surrounding the impact of the current economic climate on the uptake of IVF, and also surrounding the rates of natural conception following failed cycles of IVF.

Menstruation and cycle-related problems

Professor Hilary Critchley Professor of Reproductive Medicine, University of Edinburgh Professor Critchleys discussion focused on areas of unmet need in menstrual cycle-related complaints and menstruation. Calls for attention to these issues reflect the fact that women are experiencing an increased number of periods over their reproductive lifecourse. In the past, women spent much of their lives not menstruating. Larger family sizes, which are also seen today in many developing countries, meant a large proportion of a womans life was spent either pregnant or breastfeeding. However, in many developed countries, contraception is now readily available, providing choice and enabling women to have families later in life, and also to increase the length of time between having each of their children. The ways in which populations can be affected by menstruation are becoming increasingly recognised; this has been allowed in part due to a more open attitude towards discussion of this topic. The teenage years, and the menopausal years, are times when periods can pose particular difficulties for women. Common problems include heavy bleeding, whereby some women can lose up to 450 ml of blood during menstruation (equivalent to a pint of blood), pain and cycle-related issues, and these can not only affect an individuals quality of life, but also family and the economy through workplace absence. Some of the common complaints related to menstruation may be a sign of fibroids or endometriosis. However, to improve diagnosis and treatment, there is a need to understand the mechanisms of menstruation itself, as well as those mechanisms underpinning the development of fibroids and endometriosis. Such understanding could lead to availability of medical reversible treatments, as alternatives to surgery, and the ability to adjust treatments to different ages and experience. Progress has also been hampered by confused descriptions and classifications. Terms generally used to describe menstrual conditions include menorrhagia, dysfunctional uterine bleeding (DUB) and heavy menstrual bleeding (HMB). These can also differ cross-culturally. Professor Critchley presented a new classification system recently endorsed by the Fdration Internationale de

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Gyncologie et d'Obsttrique (FIGO), a universal system for defining menstrual disorders which allows practitioners to more easily identify the cause of an individuals symptoms. There is a definite need for action to improve diagnosis and service provision in the field of menstruation. Professor Critchley drew attention to the cost to the US economy resulting from loss of working hours by women with menstrual disorders. At present, the most effective treatments for such disorders are often surgical, which has associated risks such as loss of fertility. Those treatments which do not involve surgery are often stopped before completion, due to side effects or ineffectiveness. The most effective treatment for a guarantee of no bleeding remains hysterectomy, a major operation with consequences which may be unacceptable to women, especially to those who have not yet started a family. Some of the current areas of work at the University of Edinburgh hope to better understand the complexity of the menstrual cycle, throughout which the uterus undergoes repeated episodes of physiological injury and repair. Better understanding of these processes, and the causes of specific menstrual disorders, will help to improve diagnosis. Work is also being undertaken to search for more effective treatments than presently exist. Researchers in Edinburgh are currently exploring differences in the womb lining (endometrium) in women with and without heavy bleeding. There is evidence that the activity of glucocorticoids within the endometrium of these women may be deficient, and this may impact on the structure of blood vessels of the womb lining. The research hopes to demonstrate that treatments already in common use for other conditions may have a beneficial effect on women requiring treatment for heavy bleeding, thereby offering a new line of treatment strategy. Another condition, fibroids, also requires attention. Uterine fibroids are thickened areas of tissue in the muscle of the womb and, though common, fibroids can cause painful and heavy menstrual periods. The condition is also associated with infertility and miscarriage. Improved imaging techniques have contributed to an increased understanding of fibroids, and research at a cellular level has also demonstrated that not only oestrogen, but also progesterone, drives the growth of fibroid tumours. Such research has the potential to improve available treatments, and quality of life, for those who suffer with this very common condition. Professor Critchley also drew attention to endometriosis. In a global study of womens health, it was found that it can take up to a year for women to attend a consultation after first noticing symptoms of endometriosis, and up to seven years until a final diagnosis is made. The condition not only affects women in mid-life, but also young women, and can have a negative effect on their working lives. Research is needed to assess the success of potential treatments. A recent local example is an ongoing trial to assess the effectiveness of the drug Gabapentin to manage chronic pelvic pain. The changing experience of menstruation, which was once a rare occurrence for women, perhaps requires a new approach to the management of womens monthly cycles. The question has been raised should periods be optional and convenient? Such questions require attention to the opinions and experiences of women themselves, whose preferences may differ from those of health professionals. Professor Critchley suggested that a lifecourse approach to womens reproductive health is needed, which enables personalised care. Menstruation may appear to be a small item on the agenda, but healthy and happy women are more likely to have healthy pregnancies and children. Questions and comments Following questions, Professor Critchley explained that there are many barriers to progress in this area of womens health, including little understanding of the mechanisms of menstruation, and previously poor classification systems to help with careful characterisation of patients. This is an

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essential step for future clinical studies across diverse populations. Novel therapeutic treatments have also faced opposition due to their association with therapeutic compounds that play a role in termination of pregnancy. This has hampered the attainment of support and funding and, thus, progress in the field of management of heavy menstrual bleeding and associated conditions such as fibroids. Gynaecological health is also a neglected area of research, and attention to this area would vastly improve quality of life for women. Professor Critchley asserted that, to date, if a woman should wish to never see another period, there remains a place for hysterectomy as a treatment option. However, this may be an unacceptable option for many women. There has been an explosion of research into surgical treatments. However, more research should be focused on understanding the underlying causes of menstrual disorders and identifying effective medical (non-surgical) treatment options, and on preventing these conditions. An audience member commented that perhaps a contributor to the lack of research in this area is the fact that within the Scottish Government, womens reproductive health is incorporated into maternal and child health or sexual health policy and legislation. Perhaps a focus on womens health would allow for a holistic and lifecourse approach to this issue? References Cardozo, E. R., Clark, A.D., Banks, N. K., Henne, M.B., Stegmann, B. J. & Segars, J.H. 2012. The estimated annual cost of uterine leiomyomata in the United States. American Journal of Obsterics and Gynecology 206(3), 21119. Chwalisz, K., Perez, M. C., Demanno, D., Winkel, C., Schubert, G. & Elger, W. 2005. Selective progesterone receptor modulator development and use in the treatment of leiomyomata and endometriosis. Endocrine Review 26(3), 42338. Frick, K. D., Clark, M. A., Steinwachs, D. M., Langenberg, P., Stovall, D., Munro, M. G. & Dickersin, K. 2009. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Womens Health Issues 19(1),7078. Munro, M. G., Critchley, H. O., Broder, M. S. & Fraser, I. S. 2011. FIGO classification system (PALMCOEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynaecology and Obstetrics 113(1), 313. National Collaborating Centre for Women's and Children's Health. 2007. Heavy Menstrual Bleeding. London: Royal College of Obstetricians and Gynaecologists Report CG44. www.nice.org.uk Nnoaham, K. E., Hummelshoj, L., Webster, P., d'Hooghe, T., de Cicco Nardone, F., de Cicco Nardone, C., Jenkinson, C., Kennedy, S. H. & Zondervan, K. T. 2011. (World Endometriosis Research Foundation Global Study of Women's Health consortium.) Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertility and Sterility 96(2), 36673. e8. RCOG. 2011a. Lifecourse Approach to Women's Health Care? RCOG Scientific Impact Paper 27. http://www.rcog.org.uk/womens-health/clinical-guidance/life-course-approachwomen%E2%80%99s-health-care-why-should-we-consider-sac RCOG. 2011b. High Quality Women's Health Care: a proposal for change. RCOG Expert Advisory Group Report, July 2011. http://www.rcgp.org.uk/news/2011/october/~/media/Files/News/HighQualityWomensHealthcarePr oposalforChange.ashx Simoens, S., Dunselman, G., Dirksen, C., Hummelshoj L., Boker, A., Brandes, I., Brodszky, V., Canis, M., Colombo, G. L., DeLeire, T., Falcone, T., Graham, B., Halis, G., Horne, A., Kani, O., Kier, J. J., Kristensen, J., Lebovic, D., Mueller, M., Vigano, P., Wullschleger, M. & DHooghe, T. 2012. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Human Reproduction 27(5),129299. Stratton, P. & Berkley, K. J. 2011. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. Human Reproduction Update 17(3), 32746.

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Warner, P., Critchley, H. O., Lumsden, M.A., Campbell-Brown, M., Douglas, A. & Murray, G. 2001. Referral for menstrual problems: cross sectional survey of symptoms, reasons for referral, and management. BMJ 323(7303), 2428.

The maternal body in the workplace; a focus on breastfeeding experience and practices
Dr Caroline Gatrell Department of Management Learning and Leadership, Lancaster University Dr Gatrell proposed that breastfeeding should be understood as a form of work in the context of paid work. She explained that in the last decade, women have come under increasing pressure to breastfeed; breast milk is often positioned as liquid gold, with the power to improve the health of both mothers and their children. However, breastfeeding is simultaneously seen to be a normative responsibility, which is often discounted as work in medical discourse. Dr Gatrells discussion considered the pressures and experiences discussed by women on internet forums, as well as ethnographic observations, in the context of medical discourse which sees breastfeeding as a maternal responsibility. Today, the pressure on mothers to breastfeed is increasing. Breast milk is construed as the normative standard for infant feeding, with formula milk simultaneously positioned as inferior. It has been claimed that breastfeeding improves a childs health throughout the lifecourse, providing protection against chronic illness, and that it can benefit mothers; for example by decreasing their risk of osteoporosis. In the US, literature has even correlated breastfeeding with a healthy economy. Programmes to communicate the health benefits of breastfeeding, and allocating this responsibility to mothers, have been very effective, with many mothers holding extensive knowledge of the advice which encourages breastfeeding. There have been many attempts to theorise the work of breastfeeding; however, what counts as work is difficult to identify. This is perhaps due to the fact that forms of labour which are classified as womens work are often discounted. Dr Gatrell outlined three ways in which breastfeeding may be identified as work: breastfeeding as a project of maternity; breastfeeding as an embedded form of work; and breastfeeding as maternal body work. Advice often frames breastfeeding as an assignment for which women are responsible, and as an integral part of the project of bearing and rearing a child. Devices have even been created through which women can quantify and monitor their success with breastfeeding, such as charts which record details including duration and time at which breastfeeding takes place. However, Dr Gatrell has observed conversations in Internet forums which demonstrate the anxiety that such monitoring can provoke. Discourses that see breastfeeding as integral to the maternal project can incite worry and distress, when women find that they are unable to perform this natural task. Advice on breastfeeding also seeks to demonstrate the ease with which breastfeeding can become embedded into womens lives; for example by suggesting ways in which women can breastfeed whilst simultaneously carrying out other forms of domestic work. However, forum conversations observed by Dr Gatrell highlighted the exhaustion that some women felt when trying to incorporate breastfeeding into their lives. The advice regarding breastfeeding is often universalised, ignoring the many commitments that women must juggle in their day-to-day lives, such as paid employment or the care of other children. When in paid employment, women may attempt to prioritise breastfeeding in response to medical advice, but at the same time must balance this with their commitment to their employment. Narratives of ease and routine are often offered in advice regarding breastfeeding while working, and women are advised to find time and space to express breast milk. However, it may be difficult for women, especially those in low-income jobs, to negotiate the time and space needed for this. Even when

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space is available, special equipment is often needed to express breast milk. Such advice, therefore, neglects the need to carry equipment to work, including bottles and spare clothes, and the practicalities involved in expressing within the workplace; for example where to store expressed milk. Other challenges include the attitudes of co-workers. A general antipathy exists towards pregnant and post-pregnant bodies, and occasions when aspects of these bodies spill over into the workplace. Despite breastfeeding policies in the workplace, other employees may begrudge women for taking time out of the day to perform breastfeeding activities. Breastfeeding women themselves have also voiced concern about being seen as slacking. Where these hostile attitudes exist, it may be difficult for women to talk to their co-workers about breastfeeding in efforts to make the activity more acceptable. It is, therefore, clear that there are tensions for women in fulfilling the project of breastfeeding and the labour of paid work. There is a clear need to understand the work involved in breastfeeding, as the presentation of breastfeeding as normative and natural may not translate to womens experiences. Much of the existing research in this area sees breastfeeding or not breastfeeding as black and white; however, more research is required to understand how women may move between breast- and formula feeding. For example, performing the work of breastfeeding at night, whilst formula feeding during the day, may decrease some of the tensions experienced when juggling breastfeeding with paid work. Questions and comments An audience member commented that breastfeeding could become paid work, in the same way that some initiatives incentivise smoking cessation. However, Dr Gatrell explained that this could increase pressure on women to breastfeed, especially for those who are unable to. The tensions which exist between womens desires to manage breastfeeding, and to carry on with their paid employment, are complex and often characterised by tension. An audience member asserted that women must be presented with the facts about breastfeeding. Recent publications have demonstrated that the evidence in favour of breastfeeding is not that persuasive, and that any differences in the health of children who have been breastfed and those that have not may be due to social factors. There is a need to provide clear evidence which allows women to choose which option is best for them.

Sexual lifestyles in older people

Professor Kaye Wellings Head of SEHR and Professor of Sexual and Health Research, London School of Hygiene and Tropical Medicine There has been a recent surge in interest in the sexual lifestyles of older people, despite research traditionally being focused on those of young people. This can be attributed to a number of factors. First, there are greater numbers of older people than ever before. In addition, the traditional notion that sexual activity takes place predominantly in the reproductive years, an increase in life expectancy, and opportunities for intimacy that are provided when children leave home, have meant that couples are more able to have sexual relationships later in life. Another contributing factor to the increase in interest in this area is that many researchers are older people. Those who were researching HIV research and sexual behaviour in the 1980s are now interested in how sexual health research can benefit those of a similar age to themselves. The final factor is that today, more opportunities exist for intervention. Where research in the field of sexual health once focused on those who were experiencing poor health, such as sexually transmitted infections (STIs), research now relates to the general population. Indeed, the World Health Organisations definition of sexual health now includes sexual function. Recently, attention was drawn to the rise in STI rates among older people, which has

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resulted from an increase in sexual activity amongst this demographic. However, it is important to also consider the more positive side of these relationships; if safeguarded, sexual lifestyles in older people can prevent marriage dissolution and relationship breakdown. Professor Wellings asserted that research into the lives of older people has often omitted discussion of their sexual lifestyles. For example, the National Service Framework for Older People made no mention of their sexual lifestyles. Similarly, studies in sexual health have so far neglected older people; the age range in the most recent National Survey of Sexual Attitudes and Lifestyles stops at 44. The invisibility of older people in such research has meant that it is unclear which aspects of their sexual relationships could benefit from changes to policy and practice. In recent years, data on the sexual lives of older people have begun to emerge. Research from the US has demonstrated that amongst men and women between the ages of 57 and 64, the majority of men are sexually active. Sexual activity for women declines more steeply with increasing age. However, existing surveys often focus on functional aspects of sexual activity. There is a need for research which also asks whether older people are concerned about their levels of sexual activity. There are many influences on sexual activity in later life. Physiological factors can influence ones ability and desire to engage in sexual relationships; for example, a decrease of oestrogen may lead to vaginal dryness and atrophy for women. Testosterone levels also decline for men, though this occurs at a slower rate. However, changes can impact positively on sexual relationships; for example, as couples age, they also have freedom from fears of unwanted pregnancy. An individuals general health and wellbeing will also impact on the number of sexually active years they can expect to experience. This has been found to be high for men who are in excellent health, though lower for women. Representations of older people can also shape their experience of sexual relationships; sexuality is generally associated with a young and healthy body. Though attitudes towards older bodies are varied, there is a notion that if older people want to engage in sexual activity, they must look and act youthfully. There are also many negative stereotypes associated with older people and sexual activity. However, the belief that sex becomes less important with age is not supported by survey data. Due to their longer life expectancy, and the fact that widows are less likely than widowers to find a partner, women have a higher likelihood of being without a partner later in life. Men also have more sexually active years of life left than women as they get older. It is difficult to investigate the causes of these differences, due to an absence of cohort or time-point cross-sectional studies. Research from Sweden suggests that though positive attitudes towards sex increased with age for both men and women, these were higher in older men. However, different responses to this Swedish research from different sections of the population demonstrate that there is heterogeneity in older peoples attitudes towards sexual satisfaction. That there is variation suggests that sexual satisfaction is a social, not a biomedical issue, which may therefore be subject to change through public health policies and legislation. It is important to recognise however, that having a partner is the predominant factor in ensuring healthy sexual relationships in older people. Questions and comments An audience member asked about the implications of an ageing population and changing social behaviour for public health policy. Professor Wellings stated that we have to establish sexual health as a public health issue of importance. She doubts that there is ignorance about STIs and sexual health amongst the older population, as they lived through the 80s and could not be unaware of sexual health messages and warnings; this is not the most important focus regarding older peoples sexual health.

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In response to a question about whether or not sexual health services are fit for purpose for older people, Professor Wellings said that work on STI/family planning clinic integration has shown that older people are not too keen on attending STI services for sexual health advice. References Beckman, N., Waern, M. & Gustafson, D. 2008. Secular trends in self-reported sexual activity and satisfaction in Swedish 70 year olds: Cross sectional survey of four populations, 19712001. BMJ 337, a279. Beutel, M. E., Stobel-Richter, Y. & Brahler, E. 2007. Sexual desire and sexual activity of men and women across their lifespans: Results from a representative German community sample. British Journal of Urology International 101, 7682. Brody, S. 2010. The relative health benefits of different sexual activities. Journal of Sexual Medicine 7, 133661. DeLamater, J. & Moorman, S. 2007. Sexual behavior in later life. Journal of Aging and Health 19, 92145. Hinchcliff, S.,& Gott, M. 2008. Challenging social myths and stereotypes of women and aging: Heterosexual women talk about sex. Journal of Women and Aging 20, 6581. Lindau, S. T., Schumm, L. P., Laumann, E. O., Levinson, W., OMuircheartaigh, C. & Waite, L. 2007. A study of sexuality and health among older adults in the United States. New England Journal of Medicine 357, 76274.

Fertility regulation- changing policy to improve access

Professor Anna Glasier Honorary Professor, University of Edinburgh and London School of Hygiene and Tropical Medicine The United Kingdom has a high rate of unintended pregnancy and also a high rate of abortion (a measure of unintended pregnancy). All modern methods of contraception are very effective if used perfectly, with failure rates (for most) of less than 1 %. However when used typically, short-acting methods, such as condoms and the contraceptive pill, have much higher failure rates. Women are more likely to stop using these short-acting methods within one year. The very long-acting methods such as the contraceptive implant or the IUD are much less commonly used, but have lower failure rates and women are likely to continue to use them for longer. In a 2001/2002 Lothian study, 360 women who were having abortions were interviewed. Higher rates of short-acting contraception use were reported by these women than are reported amongst the general population. Of those who hadnt used any contraception, 10 % gave the reason as running out of supplies. This shows a need for better and easier access to contraception. The American College of Obstetricians and Gynaecologists has recently recommended the removal of unnecessary barriers to allow women to access over-the-counter oral contraception. Professor Glasier outlined the rules for drug availability that pertain in the UK. Medical products must be prescribed if they are likely to present a danger, either directly or indirectly, if used without medical supervision; if they are frequently or widely used incorrectly, leading to danger; if they contain substances the effects of which need investigation; or if they have to be administered into a muscle or vein. Of these criteria, Professor Glasier argued that only the first is relevant to oral contraceptives. However, the contra-indications to oral contraceptives are almost all conditions that women would be able to identify themselves and present to their GP with. The only exception in the case of the combined pill is high blood pressure, and this could easily be checked by a pharmacist. The only contra-indication in the case of the progestogen-only pill is breast cancer, and doctors prescribing the pill dont routinely do breast examinations. The risk of venous thromboembolism in pill use is not as

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high as the risk of venous thromboembolism in pregnancy, and therefore prevention of pregnancy is more important as a preventative measure of this serious condition. Depo Provera is administered as an intra-muscular injection every 12 weeks, butt is inconvenient for women to have to go to a GP or family planning clinic every 12 weeks. A new formulation called Sayana Press has been developed and will soon be available. The drug is delivered by a Uniject device, which would allow pharmacists to administer the injectable contraceptive, or allow women to self-administer long-lasting contraception. In a pilot study of home self-administration of Depo Provera by 64 women, 99 % gave their own injections, 80 % of injections were given on time, and none were given more than two weeks late. There are strong arguments for better access to oral contraception; however, this wouldnt necessarily reduce abortion rates and may make the pill, which is not the most effective contraception method, the method of choice for more women. Long-acting contraception is more effective for reducing abortions; however, a nanny state is undesirable, and women should have access to all methods and choice about which they use. Professor Glasier concluded by stating that simple changes in policy could improve access to the most commonly used methods of contraception, and may also allow GPs to concentrate on providing the more effective methods which require skill to administer. She believes that the UK colleges should call for the over-the-counter availability of the contraceptive pill. She also suggested that a push from pharmaceutical companies could be effective in bringing about change. Questions and comments In response to questions, Professor Glasier replied that no action has been taken in the United States since the ACOG made its statement, as the US policy and social context is not friendly to contraception. The pill is not currently available over-the-counter in the rest of Europe; it is available in some developing countries, but their data collection is not currently good enough to allow for analysis. She suggested a credit card system could be used for women in the UK. Another question was about whether or not women should have to see a GP at all before taking oral contraceptives, as it is not always easy to access a GP. Professor Glasier replied that as a first step towards policy change, women could see a GP in order to start the pill for the first time, but obtain the pill from a pharmacist thereafter. An audience comment suggested that a call from groups of experts, rather than a push from pharmaceutical companies, would be a more effective way of creating an impetus for policy change in the Scottish Government. References American College of Obstetricians and Gynecologists. 2012. Over-the-counter access to oral contraceptives. Committee Opinion No. 544. American College of Obstetricians and Gynecologists. Obstetrics and Gynecology 120, 152731. Cameron, S. T., Glasier, A. & Johnstone, A. 2012. Pilot study of home self-administration of subcutaneous depo-medroxyprogesterone acetate for contraception. Contraception 85, 45864. Lader, D, 2009. Contraception and Sexual Heath, 2008/09. Office for National Statistics, Opinions Survey Report 41. London, England: Office for National Statistics. Lakha, F. & Glasier, A. 2006. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. The Lancet 368, 178287. Rose, S. B., Lawton, B. A. 2012. Impact of long-acting reversible contraception on return for repeat abortion. American Journal of Obstetrics and Gynecology 206, 3741.

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Schunmann, C. & Glasier, A. 2006. Measuring pregnancy intention and its relationship with contraceptive use among women undergoing therapeutic abortion. Contraception 73, 52024. World Health Organization. 2009. Medical Eligibility Criteria for Contraceptive use. 4th Edition. Geneva, Switzerland: WHO.

Session 3: Post-Reproductive Years

Chair: Professor Jonathan Seckl Vice-Principal (Planning, Resources and Research Policy) Queens Medical Research Institute, University of Edinburgh

A lifecourse approach to womens health and ageing

Professor Rebecca Hardy Professor of Epidemiology and Medical Statistics, MRC Unit for Lifelong Health and Ageing A lifecourse approach to epidemiology takes account of the long-term effects on chronic disease risk and ageing of physical and social hazards during all stages of the lifecourse, and also intergenerational effects. Definitions of healthy ageing take into account survival to old age; delay in onset of chronic diseases or disorders; optimal functioning for the maximum length of time; remaining active; quality of life; and wellbeing. The MRC National Survey of Health and Development (NSHD), also known as the 1946 British birth cohort study, follows a nationally representative sample of 5,362 people. So far they have been followed up 23 times. In the NSHD, when assessed at age 6064 for disorders requiring medical supervision, there was an average of two disorders per person; one sixth of the sample were without a severe or moderate disorder; only one third were without a severe disorder. One in five individuals had a high probability of cardio-metabolic disorders, and were twice as likely as others to have been in the poorest health at age 36, pointing towards a lifecourse effect. However, healthy ageing is not simply about morbidity, but about maintaining optimal functioning and wellbeing and quality of life. Measures of biological function (e.g., lung and muscle) develop during childhood, reach a peak in early adulthood and then decline into older age. The level of peak function in early adulthood, as well as the rate of later agerelated decline, influences the absolute level of functioning in older age; therefore, determinants of gain in early life influence a persons ageing and health in later life. Early-life risk factors influence reproductive health at all stages across the lifecourse. Early menarche is associated with increased risk of breast cancer, and there is some evidence that it is also associated with increased risk of coronary heart disease and Type 2 diabetes. This may be mediated by adiposity, though the mechanism is unclear; is adiposity a result of or a trigger of early menarche? It is clear that BMI tracks across the lifecourse, particularly after menarche. This was demonstrated in the NSHD, as the age at which a person becomes overweight ranks BMI in later life; but it is unclear if childhood adiposity has an effect on later health over and above adult adiposity. Longer duration of overweight in adulthood has been linked to multiple health outcomes; for example, to a higher risk of severe incontinence in women.
In relation to childbearing and pregnancy, higher parity and earlier age at first parenthood are associated with decreased risk of breast cancer and increased risk of coronary heart disease. However, it is important to consider confounders and mediators, to distinguish between a biological effect of pregnancy and confounding with lifestyle associated with child rearing. In the NSHD, the effects in women are removed when adjusted for confounders such as early life socioeconomic position. This suggests a need to look at the lifestyles of families, rather than focusing on the biological impact of pregnancy of the woman.

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A systematic review has shown that women who have had pre-eclampsia have a higher risk of later ischaemic heart disease. Gestational diabetes, hypertension, low birth weight and pre-term delivery are all associated with later disease risk in women. It has been suggested that pregnancy may be considered as a stress-test that can reveal subclinical disease trajectories. Early menopause is associated with decreased risk of breast cancer, but increased risk of early mortality and ischaemic heart disease. Risk factors for early menopause include genetic factors, but also cigarette smoking, lower socioeconomic position and having no children. In the NSHD, it has been found that more early-life factors, in particular early stress, are associated with age at menopause than later life factors. There also seems to be an association between menopause and cognitive ability; those who had lower cognitive ability at age eight in the NSHD had a lower age at menopause. Maintaining cognitive capability is a key concern for older people, and multiple studies have shown that post-menopausal women have lower cognitive function than pre-menopausal women. In the NSHD, search-speed tests of cognitive function have shown post-menopausal women to have lower cognitive function than pre- or peri-menopausal women. However, there is an attenuation of this result when adjustment is made for pre-menopausal cognitive function. This has implications for womens health at menopause, in suggesting that menopause does not necessarily have a direct detrimental impact on cognitive function. In a study of menopausal women, many factors influenced the presence of psychological symptoms, both concurrent factors and early-life factors. Nine percent of women seemed to have a peak of psychological symptoms at menopause, but others seemed to have symptoms right across the period, not correlated to menopause. This could have implications for the management of symptoms during the menopause, as different treatment may be required depending on whether symptoms are menopause-related or not. Recent evidence suggests that vasomotor symptoms during menopause may be revealing underlying conditions and risk factors, but the effects may be modified by HRT. This could have implications for policy regarding the use of HRT. The implications of this evidence are that understanding womens health and ageing requires a lifecourse perspective. It is important to start prevention early, as risk factors and consequences may be more difficult to modify in later life. Pregnancy and menopause may offer opportunities for screening and prevention. A lifecourse approach offers a more unified and woman-centred approach to health-promotion and disease prevention and management, with implications for long-term and cross-generational health gain. Questions and comments Questions from the audience related to the 1946 birth cohort, and the types of impairments the women experienced at 36 which had an effect in their 60s. Professor Hardy observed that there was some continuation, such as high blood pressure developing into worse hypertension; however, they were mainly self-reported illnesses and the data from age 36 is not specific enough to show if they were particularly female health complaints. The effect on the health of the cohort of being questioned 23 times has not been tested or controlled for in analyses, but the cohort is obviously more aware of health messages than the general population. Audience comments related to the idea of pregnancy and menopause as screening opportunities. There was some wariness around this; young mothers who are more likely to experience adverse outcomes in later life may already be less likely to seek help. Using times of vulnerability such as pregnancy and menopause for screening raises concerns; we need to be critical about overindividualising health.

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References Bellamy, L., Casas, J-P., Hingorani, A. D. & Williams, D. J. 2007. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. British Medical Journal 335, 974. Hardy, R. & Kuh, D. 2002. Menopause and gynaecological disorders: a life course perspective. In Kuh, D. & Hardy, R. (eds) A life course approach to women's health, 64-85. Oxford: Oxford University Press. Hardy, R. & Kuh, D. 2005. Social and environmental conditions across the life course and age at menopause in a British birth cohort study. BJOG: An International Journal of Obstetrics and Gynaecology 112, 346-54. Hardy, R., Lawlor, D. A., Black, S., Wadsworth, M. E J. & Kuh, D. 2007. Number of children and cardiovascular risk factors at age 53 years in men and women. BJOG: An International Journal of Obstetrics and Gynaecology 114, 72130. Hardy, R., Lawlor, D. A., Black, S., Mishra, G. D. & Kuh, D. 2009. Age at parenthood and coronary heart disease risk factors at age 53 years in men and women. Journal of Epidemiology and Community Health 63, 99105. Hardy, R., Potischman, N. & Kuh, D. 2013. Life course approach to research in womens health. In Goldman, M., Rexrode, K. & Troisi, R. (eds) Women and Health. Second edition. London: Academic Press. Kok, H. S., Kuh, D., Cooper, R., van der Schouw, Y. T., Grobbee, D. E., Wadsworth, M. E. J. & Richards. M. 2006. Cognitive function across the life course and the menopausal transition in a British birth cohort. Menopause 13, 1927. Kuh, D. & Hardy, R. (eds) 2002. A life course approach to womens health. Oxford: Oxford University Press. Kuh, D. 2011. New Dynamics of Ageing (NDA) Preparatory Network. A life course approach to healthy aging, frailty and capability. Journal of Gerontology A 62, 71721. Kuh, D., Cooper, R., Hardy, R., Richards, M. & Ben-Shlomo, Y. In press. A life course approach to healthy ageing. Oxford University Press: Oxford. Mishra, G., Hardy, R. & Kuh, D. 2007. Are the effects of risk factors for timing of menopause modified by age? Results from a British birth cohort study. Menopause 14, 71725. Mishra, G., Hardy, R., Cardozo, L. & Kuh, D. 2008. Body weight trajectories and the risk of urinary incontinence in middle aged women: results from a British prospective cohort. International Journal of Obesity 32, 141522. Mishra, G. D. & Kuh, D. 2012. Health symptoms during midlife in relation to menopausal transition: British prospective cohort study. British Medical Journal, Feb 8, 344, e402. doi: 10.1136/bmj.e402. Pierce, M., Silverwood, R. J., Nitsch, D., Adams, J. E., Stephen, A. M., Nip, Wing, Macfarlane, P., Wong, A. , Richards, M., Hardy, R. & Kuh, D.(on behalf of the scientific and data collection teams). 2012. Clinical disorders in a post war British cohort reaching retirement: evidence from the first national birth cohort study. PLoS One 7(9): e44857. doi:10.1371/journal.pone.0044857 Rich-Edwards, J. W., McElrath, T. F., Karumanchi, S. A. & Seely, E. W. 2010. Breathing life into the lifecourse approach. Pregnancy history and cardiovascular disease in women. Hypertension 56, 33134. Richards, M., Kuh, D., Hardy, R. & Wadsworth, M. 1999. Lifetime cognitive function and natural menopause in a national UK birth cohort. Neurology 53, 30814. Sattar, N. & Greer, I. A. 2002. Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening? British Medical Journal 325, 15760. Scientific Advisory Committee of the Royal College of Obstetricians and Gynaecologists. 2011. Why should we consider a life course approach to women's health care? RCOG Opinion Paper 27. London: Royal College of Obstetricians and Gynaecologists.

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Thurston, R. C., Sutton-Tyrrel,l K., Everson-Rose, S. A., Hess, R. & Matthews, K. A. 2008. Hot flashes and subclinical cardiovascular disease: findings from the Study of Women's Health Across the Nation Heart Study. Circulation 118, 123440. Wadsworth, M. E/ J/, Kuh, D/, Richards, M. & Hardy, R. 2006. Cohort profile: the 1946 national birth cohort (MRC National Survey of Health & Development). International Journal of Epidemiology 35, 4954.

The menopausal transition: its effect on lifestyle and health

Professor Anna Glasier Honorary Professor, University of Edinburgh and London School of Hygiene and Tropical Medicine Menopause is a time of dramatic hormonal and often social changes for women. The menopausal transition, or peri-menopause, is the time from onset of menopausal symptoms to the last menstrual period. The mean age of onset is 47.5 years and the mean age of menopause is 51. Professor Glasiers presentation focused on how symptoms experienced during the menopausal transition might influence risk factors for illnesses related to BMI, such as cardiovascular disease and cancer. The peri-menopause can influence lifestyle as a result of physiological or hormonal changes and social changes (and the consequences of such changes). Physiological symptoms potentially impacting on lifestyle include vasomotor symptoms such as hot flushes and night sweats; musculoskeletal problems; urinary problems; and mood changes. Joint aches and stiffness and urinary incontinence are amongst the symptoms most commonly reported by women. These symptoms could be expected to impact on exercise levels. However, a study of Australian-born women aged 5565 in Melbourne found that 50 % of women took adequate or more than adequate amounts of exercise, and levels were consistent over time. In this study, the perimenopause did not seem to have an effect on exercise levels. Mood changes during menopause appear to be related to whether or not a woman has symptoms, especially vasomotor symptoms, and how bad they are. A womans attitude to menopause seems to affect how symptoms, particularly vasomotor symptoms, are experienced. The Whitehall study asked questions about symptoms and menopause; women with severe vasomotor symptoms and/or depression had greater functional decline.
Social changes common at the time of menopausal transition include changes in family structure; relationships; roles (such as work roles); and responsibilities (such as caring). Children may be leaving home, and sometimes returning, and women may take on caring roles for ageing relatives around this time. In the Melbourne study. 2739 % of the women experienced a change in their household structure each year over eight years. The factor of children leaving home appears to be associated with better wellbeing outcomes; however, the impact of relationship changes can be detrimental. Menopausal symptoms can impact on work, family and relationships, particularly sexual relationships. There is also a lifecourse effect of relationship changes, as women living alone in mid-life have around twice the risk of developing Alzheimers disease in their 70s. The risk is threefold if they are widowed. Overall, menopausal symptoms affect wellbeing negatively, particularly if severe. Social changes around mid-life are considerable. Both physiological and social changes have the potential to influence lifestyle; however, there is little evidence of considerable lifestyle changes at this time. Questions and comments A question from the audience concerned how many of the symptoms are also present in men of a similar age. The vasomotor and urinary symptoms are not experienced by men, though they do experience similar wellbeing and musculoskeletal problems. There were also questions about the impact of depression on physical symptoms and the effects of HRT on symptoms. Joint problems are genuinely shown to be

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worsening around the age of menopause, but clearly everything is worsened by low mood or depression. The benefit of HRT is clear regarding vasomotor symptoms, and this also improves sleep, which allows better functioning.

Regarding the policy relevance of the evidence around worse outcomes for women who live alone in midlife, Professor Glasier pointed out that there are now more options for women to find new partners, such as internet dating. A final question regarded the definition of early menopause. Professor Rebecca Hardy replied that it hasnt been categorised in the birth cohort study, but it is often defined as occurring under the age of 45. References Ayres, B., Forshaw, M. & Hunter, M. S. 2010. The impact of attitudes towards the menopause on womens symptom experience: A systematic review. Maturitas 65, 2836. Defey, D., Storch, E., Cardozo, S., Diaz, O. & Fernandez, G. 1996.The menopause: womens psychology and healthcare. Social Science & Medicine 42, 144756. Dennerstein, L., Dudley, E. & Guthrie, J. 2002. Empty nest or revolving door? A prospective study of womens quality of life in midlife during the phase of children leaving and re-entering the home. Psychological Medicine 32, 54550. McKinlay, S. M. 1996.The normal menopause transition: an overview. Maturitas 23, 13745. Netz, Y., Guthrie, J. R., Garamszegi, D. & Dennerstein, L. 2002. Attitudes of middle-aged women to ageing : contribution of the Reactions to Ageing Questionnaire. Climacteric 4, 30613. Sternfield, B., Wang, H., Quesenberry CP Jr., Abrams, B., Everson-Rose, S. A., Greendale, G. A., Matthews, K. A., Torrens, J. L. & Sowers, M. 2004. Physical activity and changes in weight and waist circumference in midlife women: findings from the study of Womens Health Across the Nation. American Journal of Epidemiology 160, 91222.

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Panel Discussion Overall policy implications

Chair: Professor Neva Haites Vice-Principal for Development, University of Aberdeen The panel members were Professor Bhattacharya, Professor Critchley, Dr Gatrell, Professor Glasier and Professor Wellings. Professor Haites commented that the panel discussion provided an opportunity to look at what had been learned over the two days of the conference and what needs to be done to improve health and wellbeing for women. She said she was impressed by the forceful policy statements that had been made and hoped the discussion would help the organisers to make policy recommendations. She then invited questions from the floor. Question: Should we be identifying invisible health areas when exploring the impact of events in later life? Professor Rebecca Hardy responded that the 1946 British birth cohort data is open to researchers to use, and that there is a system in place to apply to use it. The study did not collect comprehensive data about womens reproductive characteristics or health during the reproductive years, though ages at childbirth and some information about menstrual cycles were collected. However, better data about the peri-menopausal stage were obtained when annual postal questionnaires were sent to women in the study. There has been an attempt to collect data on menstrual characteristics and gynaecological disorders retrospectively, but this is obviously subject to recall bias. This recalled data has hardly been used and Professor Hardy encouraged people to apply to use the birth cohort data. Question: Should we have a more holistic approach to womens health, rather than obstetrics and gynaecology being somewhat separate? Professor Glasier replied that yes, we should. This has been tried in the service she used to lead. When women came to ask about contraception, they were asked about other health concerns and offered screening. This meant that issues were picked up which otherwise might have been missed. Professor Haites asked how we should then take this forward. Professor Critchley replied that a recent RCOG document about managing womens health across the lifecourse begins to capture it; however, it requires the involvement of health boards and managers, working across primary and secondary care. A lot of stakeholders need to be on board. Professor Glasier noted that women may be better off in terms of a holistic approach in other European countries, where women often have a gynaecologist they can self-refer to and stay with throughout life, rather than a GP who may or may not refer a woman to a specialist, but may know little about gynaecology. Professor Bhattacharya said that more service delivery and organisational research is needed. There is a danger of sending mixed messages; for example, providing contraception but telling women that it may damage their long-term fertility. Professor Glasier referred to a policy in the clinic she used to lead whereby if a woman aged 35 or over requested contraception, they were asked about wanting children in the future and offered a leaflet about the risks of declining fertility. An audience member commented that whilst holistic care is a trendy phrase, caring about all of the needs of each individual does not have to equate with being able to cater to all such needs. Another audience member commented that holistic is not the same as lifecourse, and that understanding the links across the lifecourse does not mean that every clinician needs to be multiply specialist or

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generalist. Professor Critchley responded that nobody was suggesting that all clinicians be generalists, but rather that experts need to work much more closely together and in an integrated way. Question: In the data about sexual activity amongst older people, the figures for men and women dont match. Does this suggest that men are not having sex with women of their own age group or their partners? Are older women unwilling or unable to have sex? What are the policy implications of this? Professor Wellings suggested that one explanation is that older men are partnering with younger women. Data on this will be available in the future. It may be that men have multiple partners, but age-mixing is a more likely explanation. She also cautioned that there has been an attitudinal shift from its ok to have sex later in life to we must have sex later in life, and there is a need to remove normative expectations that everyone is sexually active. Instead, we should acknowledge other ways of being active and engaging in relationships. A further question asked how much of this is likely to be transactional sex, to which Professor Wellings replied that she suspects it is a small proportion. Professor Glasier stated that, in a menopause clinic, she has found that quite a few women claim to be uninterested in sex. This may sometimes be due to changes associated with vaginal atrophy, but it may also be more complex and cant always just be solved with oestrogen. GPs are often not great at dealing with sexual problems. An audience member commented that there may be a culture change in the next few years, as the baby-boomer generation has expectations of an active sex life into older age, which is likely to lead to more of them presenting at sexual problems clinics. This is a good thing for women, as long as it is what they want. Question: In considering the need to educate young women, could better use be made of interactive technologies, to educate rather than browbeat? Specifically in educating young women about fertility and declining fertility. Dr Gatrell suggested that if health agencies decide to promote things, they do invariably use social media to promote them, and if health authorities dont already use social media, they are missing a trick. However, as with other media, the information can be very partial and she would have reservations about how it might be used. The decision to have a child is not just based on age and peak fertility; there are many other social factors which mitigate the decision. The social acceptability around being a mother is very tight; it has to be the right woman, at the right age and the right time. Professor Bhattacharya commented that there are numerous forums used by sub-fertile couples, and there is a huge amount of online chat about clinics and IVF, for example. There is much less information about what happens prior to that stage, so the message that gets out is flawed. Professor Sarah Cunningham-Burley pointed out that analysis of social media is very useful in developing information, as it allows us to find out what peoples main concerns are and what they are saying to each other, which enables the delivery of responsive education. Question: How do we improve womens attitudes to health without alienating and demoralising them? How can we use the sort of data that has been presented constructively? Professor Bhattacharya suggested that there are teachable moments when people are receptive to health messages. It is important to emphasise the positives of behaviour change. We need to provide a concerted message and turn the data from studies into messages that people understand.

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Dr Gatrell added that advice has to be linked to the realities of what people are actually doing. There needs to be flexibility and targeting of messages, as a one size fits all approach wont work. Health messages are not always appropriate to the population they are aimed at. One individualised approach is to have experts online who can answer questions. An audience member commented that another approach might be to target 1314 year-olds, as in the Southampton Life Lab project, which allows children to visit a hospital in order to learn about biology and to understand pregnancy and childbirth from a younger age. Question: If 22 % of the population in Scotland has literacy difficulties, maybe were not looking at the health inequalities agenda. How do we look at how we influence those who are most disadvantaged? For example, in social media, cartoons may be better than forums. Dr Gatrell agreed that there are poor literacy rates across the health and education systems. Professor Haites referred back to Dr Duftys presentation, which noted that education doesnt always transfer into behavioural change. Professor Bhattacharya noted that in most countries around the world, health messages are being developed for those with poor literacy, and that we could learn from looking sideways. Dr Critchley suggested that it is about having a culture where these topics are talked about and are not taboo. They need to be on the curricula not only in primary schools but also in the culture more openly. An audience member asked if we should be starting with babies, putting the money into childcare, so that the next generation has a way out. Professor Cunningham-Burley replied that we need to focus on the determinants of inequalities; there is a focus on the early years, but we should not forget all of the other structural factors which continue to affect gender inequalities. She expressed concern that policy agendas shouldnt become too focused on individually targeted policies.

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Closing remarks
Professor Alice Brown Professor Brown said that she had enjoyed engaging with the topic over the two days of the conference. The discussions had led her to reflect on the influence of policies on her own reproductive health across her life-course. She was struck by the extent to which the issue of women's reproductive health is neglected in research funding and public policy. There are many opportunities for progress, and she hoped the conference has sparked ideas. She added that much of the data presented highlights the gaps in our knowledge, and also the differences between developed and developing countries in terms of the pressures on reproductive health and, for example, approaches to fertility and breast-feeding. Some key messages which Professor Brown identified included the idea that there is a risk of 'exchanging one imperative for another', as the information available, policy 'fashions', 'images' of women and 'messages' given to women change over time. There is a need for more honest debate and open discussion around issues such as IVF and breastfeeding. There is also a need for recognition of the inter-relationship between biology, society (including public attitudes) and the economy. This has implications not only for individual women, but also for public policy, where a more holistic approach to women's reproductive health across the life-course is required. She stressed the need for a strategy that involved Government, employers, universities, Royal Colleges and Societies, and others working together, to address the issues raised at the conference. Professor Brown concluded the conference by thanking all of the speakers, the chairs, the organising committee, the sponsors and the RSE, and the audience for their contributions and participation.

Conclusion
This conference provided an opportunity for people from a wide range of academic and professional backgrounds to engage in discussion and debate about key ideas relating to womens reproductive health. A number of themes emerged prominently over the course of the two days. Foremost amongst them was the need for a lifecourse approach to womens reproductive health, acknowledging the integration of concerns about education, employment and ageing with decisions about fertility, childbearing and health. It was emphasised that information about the realities of fertility needs to be shared in an open and honest way with women, to allow them to make informed decisions about family planning. However, it was also stressed that fertility is not the only factor which influences decisions about childbearing and reproductive health, and that social structures, policies and economic realities must also be factored in. An emphasis on the individual biology of women risks minimising the very real impact of social and economic constraints. Policy changes or education messages are rarely effective in bringing about change, unless they are relevant and targeted to meet the specific needs of different groups of women. There is clearly room for far more research into this neglected area of policy, but a number of positive and useful messages have emerged from this conference.

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Chair and Speaker Biographies

Professor David Baird CBE FRCOG FRCP FmedSc FRSE Emeritus Professor of Reproductive Endocrinology, University of Edinburgh Professor David Baird is Emeritus Professor of Reproductive Endocrinology, University of Edinburgh, and Honorary Consultant Gynaecologist, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh. Past appointments: Professor and Chairman, Obstetrics and Gynaecology, University of Edinburgh; Medical Research Council Clinical Research Professor, Centre for Reproductive Biology, University of Edinburgh; Director, Contraceptive Development Network of Department for International Development (DFiD). Life-time clinical practice in gynaecology and research into reproductive endocrinology, including infertility, contraception and abortion. Over 400 original research articles in peer reviewed journals, including over 100 on various aspects of medical abortion. In 1980, he established in Edinburgh, and supervised for 20 years, one of the first clinics in the world providing medical abortion as a clinical service for women with unwanted pregnancies. Professor Baird and his team reported the first randomised controlled trial comparing the induction of abortion with mifepristone alone or in combination with prostaglandins gemeprost (1986) and with misoprostol (1991), which form the basis of the current licensed method of medical abortion. From 1986 to 1992 he was Chairman of the WHO Task Force on post-ovulatory methods of contraception, which conducted many of the pivotal studies on the use of antigestogens for medical abortion. Previous or current consultant and advisor to Population Council (USA), DfiD, Rousell, UCLAF, Schering AG, HRA Pharma. Professor Susan Bewley Professor of Complex Obstetrics, Kings College London Professor Susan Bewley was the first female maternal foetal medicine-trained specialist in the UK, and also has a degree in law and ethics. She practised high-risk obstetrics as a consultant and clinical leader at Guys and St Thomas Hospitals for nearly 20 years and is now the honorary Clinical Director of Obstetrics for NHS London. Her research interests focus particularly on severe maternal morbidity. She was a member of the NICE fertility guideline group and presently chairs the Intrapartum Care group. In 2005, she authored a BMJ editorial Which career first? The most secure age for childbearing remains 2035. Professor Siladitya Bhattacharya FRCOG Professor of Reproductive Medicine, University of Aberdeen Professor Siladitya Bhattacharya is Professor of Reproductive Medicine, University of Aberdeen and Honorary Consultant, NHS Grampian. Current post: Head of Division of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen. Main research interests include reproductive epidemiology and evaluation of clinical and cost effectiveness of interventions in reproductive medicine. In addition to infertility, areas of interest include early pregnancy, caesarean section, heavy menstrual bleeding, pelvic pain and endometriosis. Professor Alice Brown CBE FRSE (Then) General Secretary, Royal Society of Edinburgh Professor Alice Brown is Emeritus Professor of Politics at the University of Edinburgh and served as General Secretary of the Royal Society of Edinburgh from 2011 to 2013. She was appointed Chair of the Scottish Funding Council in October 2013. She was formerly Head of Department of Politics and a Vice-Principal at the University and Co-Director of its Institute of Governance. Alice was appointed as the first Scottish Public Services Ombudsman in 2002, a post she held until her retirement in 2009. She is also Chair of the Lay Advisory Committee to the Royal College of Physicians of Edinburgh and a Trustee of the David Hume Institute. She has served on numerous public bodies, including the Committee on Standards in Public Life, the ESRC and the Scottish Funding Council.

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Professor Sarah Cunningham-Burley AcSS Professor of Medical and Family Sociology, University of Edinburgh Professor Sarah Cunningham-Burley is Professor of Medical and Family Sociology, based in the Centre for Population Health Sciences at the University of Edinburgh (www.cphs.mvm.ed.ac.uk). She is currently Head of the School of Molecular, Genetic and Population Health Sciences in the College of Medicine and Veterinary Medicine. She is also co-Director of the Centre for Research on Families and Relationships (www.crfr.ac.uk). Her research interests include: families, relationships and health; social issues in relation to new technologies; and health and public engagement in medical science. She has conducted research on womens experiences of caring and providing, funded by the Joseph Rowntree Foundation, on how families negotiate the work/family interface and, most recently, on how young people in their twenties anticipate partnering and parenting (both funded by the Economic and Social Research Council). She is also involved in examining social and ethical issues around largescale data linkage for health research (funded by The Wellcome Trust, MRC and others) and in a major Wellcome Trust Strategic Award in Biomedical Ethics: The Human Body, its scope, limits and future. She was elected to the Academy of Social Sciences in 2012. She chairs the Editorial Board of the recently launched journal Families, Relationships and Societies (The Policy Press). Dr Catherine Calderwood MBChB, MRCOG, FRCP Edin Medical adviser for maternity and womens health, Scottish Government Dr Catherine Calderwood is currently a medical adviser for Scottish Government covering acute specialties, maternity and womens health, cancer and screening programmes. She is clinical adviser for the maternity patient safety programme and she chairs the Scottish Governments Stillbirth Working Group. She works as an obstetrician in NHS Lothian and continues to run a regular high-risk antenatal clinic. Undergraduate training at Cambridge University, 19871990; clinical training at Glasgow University, 19901993; obstetrics and gynaecology training in southeast Scotland, MRCOG 2001; obstetric medicine training at St Thomass Hospital, London, 20032004; Consultant Obstetrician and Gynaecologist with an interest in obstetric medicine NHS Lothian, appointed 2006; Medical Advisor for Women and Childrens Health, CMO directorate, Scottish Government, February 2009 to April 2012, when portfolio expanded to current. Professor Iain Cameron Dean of the Faculty of Medicine, University of Southampton Professor Iain Cameron FRCOG, FRCP Edin is Dean of the Faculty of Medicine and Professor of Obstetrics and Gynaecology at the University of Southampton. After graduating in Medicine at the University of Edinburgh, he underwent postgraduate clinical and research training in obstetrics and gynaecology, and reproductive medicine in Edinburgh, Melbourne and Cambridge. He held the Regius Chair of Obstetrics and Gynaecology at the University of Glasgow from 1993 and moved to Southampton in 1999. His main clinical and research interests are reproductive endocrinology, the treatment of sub-fertility and investigation of the impact of the maternal environment on early pregnancy. Iain is a member of the Scientific and Ethical Review Group, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organisation; Deputy Chair of Medical Schools Council, the national body representing all UK medical schools; and a member of the Boards of the UK Clinical Research Collaboration (UKCRC) and the UK Research Integrity Office (UKRIO). Iain is a member of the University of Southampton Executive Group and a Non-Executive Director of the University Hospital Southampton NHS Foundation Trust. As Dean of Medicine, Iain heads a team of 800 education, research and enterprise professionals. The Faculty of Medicine leads innovative learning and discovery for better health across the lifecourse, building upon three distinctive features: a strong partnership with the local National Health Service to deliver translational research and equip the next generation of doctors to work in a rapidly-changing environment; collaborations at the life sciences interface with engineering, mathematics, computing, chemistry and nanotechnology; and the application of enterprise and innovation, including strong links with industry, to maximise the impact of the Facultys education and research.

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Professor Hilary Critchley FRSE FMedSci Professor of Reproductive Medicine, University of Edinburgh Professor Hilary Critchley is Professor of Reproductive Medicine and Head of the School of Clinical Sciences at the University of Edinburgh. She is a clinical Consultant in Obstetrics and Gynaecology at the Royal Infirmary, Edinburgh. Her laboratory-based research studies focus upon local uterine mechanisms involved in menstruation, implantation and interruption/loss of early pregnancy. Her clinical areas of study include assessment and development of novel treatment strategies for abnormal uterine bleeding and novel imaging of the uterus. Professor Sir Ian Diamond FBA FRSE AcSS Principal and Vice-Chancellor, University of Aberdeen Professor Sir Ian Diamond is Principal and Vice-Chancellor of the University of Aberdeen, an appointment he has held since 1 April 2010. He was previously Chief Executive of the Economic and Social Research Council. He was also Chair of the Research Councils UK Executive Group (2004 2009), the umbrella body that represents all seven UK Research Councils. Before joining the ESRC, Sir Ian was Deputy Vice-Chancellor at the University of Southampton, where he had been for most of his career. Sir Ian is Chair of the Lloyds TSB Foundation for England and Wales and a Trustee of the World Wildlife Fund UK and the Iona Cathedral Trust. He is Chairman of the Universities UK Research Policy Network Committee, Chair of the Universities UK Group on Efficiency, and a member of the Scottish Science Advisory Council, the Council of CBI Scotland and the British Council Scotland Advisory Committee. Sir Ian was elected to the UK Academy of Social Sciences in 1999, is a Fellow of the British Academy (2005), a Fellow of the Royal Society of Edinburgh (2009) and holds honorary degrees from the universities of Cardiff and Glasgow. Sir Ian was Knighted in the New Years Honours 2013. Dr Caroline Gatrell Director of Doctoral Programmes, Senior Lecturer, Dept. Management Learning and Leadership, Lancaster University Dr Caroline J Gatrell is Senior Lecturer at Lancaster University Management School, where she is also Director of Doctoral Programmes. Carolines research centres on sociologies of health, work and family. Carolines primary research interests focus on how the reproductive labour of parenting interconnects with the productive labour of employment. From a sociological perspective she explores how working parents (both mothers and fathers) manage their health, their work-life balance, and the health and nutrition of babies and infant children. Carolines work has been published in a number of journals, including Social Science and Medicine, the International Journal of Management Reviews, the International Journal of Human Resource Management and Gender, Work and Organization. She currently serves on the editorial boards of the International Journal of Management Reviews and the British Journal of Management. Professor Anna Glasier OBE Honorary Professor, University of Edinburgh and London School of Hygiene and Medicine Professor Anna Glasier trained in obstetrics and gynaecology in Edinburgh. She became a clinical scientist in the MRC Unit of Reproductive Biology, then Director of Family Planning & Well Woman Services for Lothian from 1990 until 2010. She is an Honorary Professor at the London School of Hygiene and Tropical Medicine and University of Edinburgh. Her research career has been in reproductive health, particularly in contraception and abortion. She is active in the field of contraceptive development but also in work on understanding contraceptive behaviour and different models of service delivery. Her research was instrumental in the deregulation of emergency contraception. She works with a number of international organisations, including the Population Council in New York and the World Health Organisation.

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Professor Neva Haites OBE FRSE Vice-Principal for Development, University of Aberdeen Professor Neva Elizabeth Haites is originally from Australia, where she studied Biochemistry and obtained a PhD. She studied Medicine in Aberdeen and completed her training in the UK. She is the Professor in Medical Genetics at the University of Aberdeen, formally Head of the College of Life Science and Medicine and now Vice-Principal for Development and an Honorary Consultant Clinical Geneticist at Aberdeen Royal Infirmary. She is a member of the UK Equality Challenge Unit and is Chair of the Scottish DNA Diagnostic Consortium Steering group. She has a special interest in inherited predisposition to cancer. As a Clinical Geneticist, she sees individuals and families with a history of cancer and provides counselling, genetic testing and services for surveillance where appropriate. Professor Rebecca Hardy Professor of Epidemiology and Medical Statistics, University College London and Programme Leader, MRC Unit for Lifelong Health and Ageing Professor Rebecca Hardy is Professor of Epidemiology and Medical Statistics at University College London and Programme Leader at the MRC Unit for Lifelong Health and Ageing. The Unit is responsible for the MRC National Survey of Health and Development, a cohort study of men and women born in Britain in 1946 and followed up ever since. Rebeccas programme of research investigates risk factors from across the life course on cardiovascular ageing, primarily using data from the NSHD. Her research has particularly focused on how prenatal development, childhood growth and adult body size trajectories influence later cardiovascular function and ageing. She has a longstanding interest in womens health, having investigated life course influences on age at menopause and the impact of reproductive characteristics on cardiovascular ageing. Dr Stewart Irvine Director of Medicine, NHS Education for Scotland Dr Stewart Irvine graduated from the University of Edinburgh and completed postgraduate training in obstetrics and gynaecology in Edinburgh and Aberdeen. Held academic training posts in the University of Edinburgh and Aberdeen, followed by a clinical consultant post within the MRC Human Reproductive Sciences unit in Edinburgh, with clinical and research interests in the field of reproductive medicine particularly issues affecting male reproductive health. Held posts as RCOG College Tutor and Regional College Advisor, before assuming the responsibility of Associate Postgraduate Dean in southeast Scotland Deanery, responsible for training in the surgical specialties. From 2008, was Deputy Director of Medicine for NHS Education for Scotland a special health board responsible for the education and training needs of all staff within NHS Scotland. With respect to postgraduate medical education, the four Scottish postgraduate deaneries are an integral part of NES. Dr Irvine had particular responsibility for quality management of PGME across Scotland, and for the performance management of the Medical ACT funding used to support undergraduate medical students in clinical placements. As a General Medical Council (GMC) Associate, he sits on the GMC Quality Scrutiny Group, and has been extensively involved as a GMC Visitor to medical schools and postgraduate deaneries elsewhere in the UK. Appointed Director of Medicine for NES from April 2012. Professor Tom Kirkwood CBE, FMedSci Director of Newcastle Initiative on Changing Age (NICA), Newcastle University Professor Tom Kirkwood leads Newcastle Universitys Initiative for Changing Age, having previously been Director of the Institute for Ageing and Health from 2004 to 2011. His research is focused on the basic science of ageing and on understanding how genes, as well as non-genetic factors such as nutrition, influence longevity and health in old age. He led the Foresight project on Mental Capital Through Life, and was Specialist Adviser to the House of Lords Science & Technology Select Committee inquiry into Ageing: Scientific Aspects. His books include the award-winning Time of Our

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Lives: The Science of Human Ageing, Chance, Development and Ageing (with Caleb Finch) and The End of Age based on his BBC Reith Lectures in 2001.

Professor Linda McKie Professor of Sociology, Durham University Professor Linda McKie is Professor of Sociology, Durham University and an Associate Director of the Centre for Research on Families and Relationships, University of Edinburgh. Her research concerns the working lives of women and the implications for families, relationships and workplace morale. In recent years she has worked with colleagues at the University of Helsinki and the Swedish School of Economics, Helsinki, to examine the working lives of women managers in Finland and Scotland. She has also completed research on morale and wellbeing for call centre workers in a major energy company. Linda is a Trustee for the Institute for Rural Health and a member of the editorial board of the journal Work, Employment and Society. Professor Jonathan Seckl FRSE Vice-Principal (Planning, Resources and Research Policy), The Queens Medical Institute, University of Edinburgh Professor Jonathan Seckl (MBBS UCL, PhD ICL) is a clinical endocrinologist and former Wellcome Trust Senior Clinical Research Fellow. Funded by four successive Wellcome Trust programme grants, his research focuses on local tissue metabolism of glucocorticoids by 11-hydroxysteroid dehydrogenases as a cause of and therapeutic target for age-related memory impairments and the metabolic syndromediabetesobesity continuum. His group advanced the glucocorticoid hypothesis of foetal programming and has elucidated molecular and epigenetic mechanisms whereby this causes disorders in adult life. He has written ~300 peer-reviewed scientific papers (career citations>25,000; h=81) and has spoken widely in conferences, to lay audiences and to the media on stress, obesity, developmental programming and ageing. 39 of Seckls students have gained PhDs. He is currently Vice-Principal for research at the University of Edinburgh. Clare Simpson Project Manager, Parenting Across Scotland Clare Simpson has worked in policy in the third sector for many years, with a variety of client groups including people with mental health problems, homeless people and asylum seekers. In 2007, she took up position as Project Manager of Parenting across Scotland, a partnership of voluntary organisations focusing on parenting in Scotland. She represented Scotland in the development of the National Occupational Standards for Working with Parents. She was a member of the parenting group of the Early Years Taskforce, and has been integrally involved in the development of Scotlands National Parenting Strategy. She is currently sitting on Scottish Government committees relating to childcare, play and culture, and fathers, and a joint Scottish Government/Scottish Prison Service group on parents in prison. Dr Marion Slater Co.Chair, Trainees and Members Committee, Royal College of Physicians, Edinburgh Dr Marion Slater was born in Aberdeen. Graduated MB ChB from University of Edinburgh, 1999. House jobs in Glasgow Royal Infirmary before returning to Aberdeen and has worked in Aberdeen Royal Infirmary since. After obtaining MRCP UK in 2003, commenced training in cardiology; however changed track. Currently specialty registrar in Clinical Pharmacology on maternity leave. Appointed to position of consultant Geriatrician in Aberdeen on return from second maternity leave this autumn. First son born January 2011; second born September 2012. Chose to work full-time between periods of maternity leave due to pressures to succeed! Elected to RCPE Trainees and Members Committee in 2008 and took on role of Chair in 2011. Currently co-chairing for a final year.

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Professor Kaye Wellings Head of SEHR and Professor of Sexual & Reproductive Health Research, London School of Hygiene and Tropical Medicine Professor Kaye Wellings is a social scientist with a public health perspective. Her main area of interest, and one in which she has worked for more than 20 years, is sexual and reproductive health. She was one of the founders, in 1987, of the National Survey of Sexual Attitudes and Lifestyles (Natsal) in Britain and a Principal Investigator on the first (1990), second (2000) and third (2010) surveys. She lead a team of academics researching sexual and reproductive risk behaviour and risk reduction practice, including contraception, at national and international level. She also has a strong interest in evaluation research, particularly in relation to preventive intervention, and her team have assessed major national and international sexual health programmes, including AIDS preventive strategies in European countries and the English governments Teenage Pregnancy Strategy. Much of her working life has been spent researching sensitive topics, including not only sexual behaviour, but also risk practices relating to drug use and in prison populations. She is an honorary Fellow of the Faculty of Public Health, the Royal College of Obstetricians and Gynaecologists (ad eundem), and the Faculty of Sexual and Reproductive Health. Professor Susan Wray FMedSci, FRCOG, MAE Department of Molecular and Cellular Physiology, University of Liverpool Professor Susan Wray is a physiologist with a lively reputation in her field, the uterus. She is passionate about obtaining basic research to improve labour outcomes. To this end she is the Director of the Centre for Better Births. BSc and PhD from UCL, where she worked until appointed lecturer in Liverpool in1990. She gained her Chair in 1996 and was appointed Head of Department in 2003. She is a Fellow of the Academy of Medical Sciences, FRCOG ad eundem and Editor-in-Chief of Physiological Reports. She enjoys mentoring junior colleagues, especially those with families. Her three children have flown the nest and she is menopausal.

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