Official Opening Of The Xviith Asian And Oceanic Congress Of Obstertrics And Gynaecology

09 Jul 2000

By Mr Lim Hng Kiang

Theme : The Challenges of Declining Fertility and an Ageing Population

Prof Ratna Samil, President of the Asia and Oceania Federation of Obstetrics and Gynaecology, distinguished guests, ladies and gentlemen

It gives me great pleasure to open today's Congress, which has aptly chosen "Obstetrics and Gynaecology in the Next Millennium" as its theme. This Congress will comprehensively explore the state-of-the-art in many aspects of women's health, ranging from Reproductive Medicine and Care during Pregnancy to the prospects of gene therapy in the treatment of Cancers in Women. This Congress provides excellent opportunities for an exchange and engagement, sharing knowledge and expertise, so crucial if we want to keep up with rapidly developing areas of medicine.

Maternity care has been a key area of interest throughout the history of the development of health services because it affects the health of both mother and child. There have been many advances made in the care of mothers and newborns, which will be actively discussed during this Congress. Despite this, it is estimated that half a million women still die each year from complications of pregnancy, many of which occur in developing countries.

In Singapore, we are fortunate to have overcome some of the basic problems in maternity and infant care. Our infant mortality rate at 3.6 per 1000 live-births is comparable to the best in the world. The health of our mothers and infants is generally good. This is in part due to the resources devoted to this area. We have more than 200 obstetricians and gynaecologists and more than 140 paediatricians in Singapore. Obstetricians and gynaecologists constitute the single largest group of specialists among the 35 specialities in Singapore. Paediatricians form the third largest group.

While we may have overcome some of the basic problems, with socio-economic advancement however, we face challenges of a different order and magnitude. Singlehood and late marriages have become increasingly prevalent. Couples are opting for smaller families and starting their family later. The consequent rapid decline in fertility rates coupled with the ageing of the population places new strains on our society.

Fertility rates have remained well below replacement level in Singapore since the mid-seventies, as young people reoriented their aspirations and values with socio-economic advancement. Recent survey data show that many Singaporeans do still want to get married and have children. A 1995 study of students in upper secondary and tertiary institutions showed that 96% wanted to get married and 93% to have children. Unfortunately getting married and having children remained unfulfilled desires for many young Singaporean men and women. In a 1996 study on singles, marriage and parenthood only ranked 5th and 6th in the ranking of their life goals over the next 5 years, after career, finance, housing and education. Even if they do find the right marriage partner, young couples often delay marriage. The median age at marriage has increased. The age at first marriage is almost 27 years for brides and 29 years for grooms. The median age at first birth for mothers has also increased gradually from 27.5 years in 1990 to 28.5 years in 1998.

As experts, you would no doubt be discussing advances in reproduction arising from the effects of delayed childbearing and low fertility. Complications such as the higher risk of decreased fertility as mothers advance in age and of developing chronic conditions such as diabetes and hypertension which pose added threats to maternal health, the health of the foetus and at delivery. The risk of fetal abnormality is also well known to be associated with the rising age of the mother. Such information needs to be widely and persuasively disseminated to young couples so as to motivate them to focus their priorities in their life goals, to accept and value the many intangible but important benefits of family and children. Many developed countries have explored innovative initiatives to encourage marriage and childbearing, making it easier and more flexible to raise children. In the final analysis, however, no matter what is offered, the essence of the family, and the desire to have children, must come from enlightened awareness and social consciousness of young adults to make the right choice. The medical fraternity can help our community leaders, parents and sociologists to educate, persuade and facilitate our young adults to marry earlier and start their family earlier. Acknowledging that the trend of later marriages and later childbirths is likely to persist, we should also try to make delayed childbearing safer and more successful.

The health problems of older women have also received relatively little attention. On the World Health Day in 1999, WHO called upon its Member States to recognise and acknowledge the elderly as a valuable national resource. According to WHO's estimates, the global population of persons aged 60 years and above, which currently number 380 million, will rise to 1 billion by year 2020. Three-quarters of these elderly will live in developing countries. To quote the Director-General of WHO, "developed countries faced this problem after they became rich, but developing countries face the problem before they become rich, adding greater burdens on them".

With improving life expectancies, women can now live some 30 years or nearly one-third of their lives, after menopause. The pattern of health problems the older woman faces, tends to reflect her earlier life experience - her nutrition, education, number of children borne, income and occupational history. With the loss of the protective effects of the female hormones after menopause, heart disease, stroke, cancers, including breast, cervical, uterine and ovarian cancers, and osteoporosis cause an additional heavy toll on the health of older women. Mental health particularly depression, dementia and Alzheimer disease also become important because growing numbers of older women become increasingly socially isolated and inadequately cared for.

Although our evaluation of the health of older Singaporean women shows that it is generally good, there are some areas where their health can be improved. Important among these are breast cancer and osteoporosis.

Breast Cancer

Breast cancer is the leading cancer among Singapore women and is on the rise. Breast cancer occurs mainly among older women. What is important is that survival from breast cancer can be improved through early detection of breast cancer by mammography. Many older women however are not aware of the risk they face from breast cancer and how they can be protected from it. My Ministry will educate women about breast cancer. Mammography costs about $100/- per examination. To make mammography more affordable, subsidised mammography is now provided at government polyclinics. Women aged between 50 to 64 years need pay only $50 for mammography once every 2 years at the polyclinics. Currently, 3 polyclinics ie. IOH, Tampines and Yishun Polyclinics, provide this service. My Ministry will extend mammography service eventually to all our polyclinics.

Osteoporosis

Osteoporosis is a global health problem. It affects mainly older women, predisposing them to fractures, an important cause of morbidity and disability in the elderly. Between 1992 to 1996, more than 7000 hip fractures were managed in Singapore, giving an average of about 1500 hip fractures occurring each year. This was more than double the number of hip fractures seen in 1987.

With the rapid ageing of the Singapore population, it is important to introduce preventive measures to reduce osteoporosis. Bone mass increases during childhood and adolescence, peaks at around 35 years of age and declines progressively thereafter. Insufficient calcium intake reduces peak bone mass formation. It is therefore important to have an adequate calcium intake right from young and throughout life.

The National Nutrition Survey conducted in 1998 showed that 32% of men and 42% of women do not meet the Recommended Daily Allowance for calcium intake. Singaporeans need to consume more high calcium foods such as green leafy vegetables, bean curd(tofu), dairy products, nuts and small fish such as ikan bilis. Regular exercise helps strengthen bone and reduce bone loss. Exercise also improves muscle strength and in so doing, reduces the risk of fractures. Smoking has been shown to significantly increase the risk of rapid bone loss with ageing. In all therefore, the risk of osteoporosis can be significantly reduced by a well-balanced diet rich in calcium, regular physical exercise and not smoking. These lifestyle practices are well within the ability and control of individuals and can be easily practised.

I have spoken about the challenges faced by Singapore to deal with declining fertility and improving the health of our older women. As representatives from Asia and Oceania, you come from countries that have the potential for rapid socio-economic development in the coming years. My guess is that you would face similar problems, sooner rather than later. These are some of the more intractable challenges facing Obstetrics and Gynaecology in the Next Millennium.

I am confident that you will have a stimulating and fruitful meeting over the next few days. I wish you success in your endeavours to improve the health of women. It is my pleasure now to declare the Congress open.