This O&G Magazine feature sees Dr Nisha Khot in conversation with RANZCOG members in a broad range of leadership positions. We hope you find this an interesting and inspiring read. Join the conversation on Twitter #CelebratingLeadership @RANZCOG @Nishaobgyn

Prof Caroline de Costa

FRANZCOG

As I hold the ultrasound probe to check a fetal presentation in the antenatal clinic, I am reminded that when Prof Caroline de Costa started her career in O&G, ultrasound was not available to perform this simple task that we take for granted today. Prof de Costa’s career has not only spanned great technological advances but has also spanned legal, ethical and societal change. She was the first woman to become Professor of O&G in Australia. She spearheaded the movement to make RU-486/ mifepristone available in Australia. She is the current Editor-in-Chief of ANZJOG and has worked in Ireland, Papua New Guinea, Sydney and Far North Queensland. When our generation of Fellows speaks of standing on the shoulders of giants, Prof de Costa is that giant (although, you wouldn’t guess it when you hear her soft voice). Prof de Costa has recently written a book, The Women’s Doc, so I started my interview with asking her about the book.

Can I start by asking you about your new book?

My book is called The Women’s Doc, published by Allen and Unwin. It was their idea, not mine. They approached me and asked me to write an account of the things I had seen in the practice of obstetrics and gynaecology. Initially I said no, I didn’t think there was anything interesting enough, but they persisted and asked if I would write a few short pieces. So I did that thinking they would agree that they weren’t very interesting. But instead, they said they wanted a book. I worked with a wonderful editor who was very helpful when it came to choosing the right stories to include. It was launched in May this year and is now in bookstores everywhere. I haven’t been able to do as many in-person publicity events owing to Covid, but am hoping to do some once restrictions ease.

Could you please tell me about your days as a medical student?

I was born in Sydney and I started medical school in 1964 in Sydney. I was 16 at the time and wasn’t sure I wanted to be a doctor. So I dropped out of medical school and for the next two and a half years, I travelled. I got a job on a Swedish merchant navy ship as a ‘mess girl’ mostly washing dishes. I got to go to North and South America and finally ended up in Europe. I then re-started medical school in Dublin, Ireland in 1967. The 1960s was a very heady time and I was involved in movements to improve access for women to reproductive healthcare although, at the time, I wouldn’t have known to put it in those words. In Ireland particularly, there was a great need for contraception. Contraception was illegal at the time and it was frowned upon by the Church. There was definitely no abortion and sex was for married couples only! These were topics that were not talked about in polite company in Ireland (and indeed, in many other countries). In 1971, 47 of us women took the train from Dublin to Belfast in Northern Ireland. We planned to buy contraceptives and bring them back with us to Dublin, which was illegal. We announced that we were going to do this because we wanted to get caught to generate publicity. Incidents like this Contraceptive Train instance led to the founding of the Irish Family Planning Association.

At the same time, I became a single mother in my second year of medicine. I was aware that the situation for other women in that position in Ireland was terrible. Most women who got pregnant outside of marriage were hidden away and their babies were forcibly separated from them at birth. My family wasn’t with me in Ireland at the time but they were supportive of my decisions. I was financially precarious since I was a student but I didn’t feel any shame or stigma for being a single mother. I had a lot of friends who were really supportive, although none of us knew much about babies. We barely knew one end of a baby from the other! But everyone was willing to help me care for my baby and so we got through to the end of medical school. I took my baby to all the social events I was going to; he grew up as a very social person. It was a matter of organising time to look after him and also complete my studies.

What led you to choose a career in O&G and how did you go about achieving this?

My experiences in my pre-clinical years and my early activism made me develop an interest in O&G. I felt that not only would I be able to provide care for women but I would also be able to speak up about what women really needed from health services. On my first day in the labour ward as a medical student, I saw a breech birth. It was just a beautiful birth, the baby came out bawling, the mother was delighted to have a girl after three boys. That was it, I was hooked. I could not imagine doing anything other than O&G for the rest of my life.

By the time I finished medical school, I was married and had another son. My husband and I went to Papua New Guinea (PNG) for our internship and from there, we went back home to Sydney. We stayed with my parents for some time and both of us started as house officers. My husband completed his primary exam in surgery, and I did my primary exam in O&G. I applied for registrar jobs in O&G but was told very early that they didn’t train women in O&G in Sydney in 1974. So we went back to Ireland and I started my O&G training. There were no women in training in Ireland either but the men were very supportive, in both the Rotunda and Coombe Hospitals in Dublin, where I did most of my training. They had known me as a medical student. I got a good training job. I worked in the NHS for my basic trainee years and then we went back to PNG where I was senior registrar at Port Moresby Hospital. We had wanted to stay in PNG, but this was very difficult for expatriates after PNG became independent. So we returned to Australia where I set up a practice in Sydney, a mixture of public VMO and private. I was fully qualified and a member of the new college, RACOG (Royal Australian College of Obstetrics and Gynaecology). Women just came pouring through the door because I was the only woman obstetrician. My male colleagues were very supportive in the Western Sydney hospitals I worked in, in both the public hospital and in private practice.

It must have been very difficult and lonely being one of two or three women O&G specialists. What did you do to change this?

There were a couple of other women O&Gs who had also trained overseas and were practicing in Sydney. We decided that we needed to get more women in O&G. We made a concerted effort to find women who were residents or medical students and had an interest in O&G. We encouraged them and mentored them and soon we had a number of women start O&G training and become fully qualified specialists. But it was not until the late 90s that we achieved gender parity amongst O&G trainees. So it took close to 20 years of gradual change to achieve parity. There was opposition from many male obstetricians at the time but there was also plenty of support. You can only get on to training programs, college committees etc if you have the support of those in decision-making positions. Without the support of the men (because it was men who were in these positions), we would not have achieved what we did, and it is important to acknowledge these men. Today we have more than 80% female trainees in the college. But it is equally important to think that anyone who wants to do O&G, is willing to put the hard yards in to training, should feel welcome and not feel like there are barriers to becoming a specialist O&G. We want to look at all barriers and remove them because I am not sure we would want to go to 100% female fellowship. It was not right to have 100% male fellowship either. Men and women should feel equally welcome in O&G. It is also important to remove barriers for women to gain leadership roles in obstetrics and gynaecology. Despite achieving gender parity amongst trainees in the 90s, we have only just this year achieved gender parity in leadership.

What would you describe as the high points of your career; the moments that brought you the most joy?

There are many high points but caring for women in pregnancy has to be the thing that brings the most joy. Especially caring for women who have had some difficulty in conceiving or have had obstetric disappointments, helping them negotiate the pregnancy and birth and have a successful outcome with a healthy baby is a truly joyous experience. This is probably why we all stay in obstetrics despite the challenges of long, unfriendly hours.

What message do you have for medical students wanting a career in O&G?

If you are interested in O&G, you need to look at the pros and cons, do an elective in O&G so you get a taste for it and then get some hands-on experience as a PGY 1–3. O&G allows you to have a variety of different options – a predominantly surgical practice, an academic career, a predominantly ultrasound practice, a medical/physician type practice – so there is a place for many different interests. It is a long road, but if you enjoy it, you should definitely give it a go.

How did you come to be involved with abortion care in Australia?

I moved to Far North Queensland in 2000 and realised that there was an urgent need for access to abortion for women in Queensland. I had not recognised the issues related to abortion care when I was practicing in Sydney because, although the laws were draconian, there were clinics that provided a surgical abortion service and mostly, women could access them and also afford them. I was able to perform some abortions myself in my private practice. But Queensland was very different. I cared for a pregnant woman who had had severe preeclampsia in two of her previous pregnancies at 25–26 weeks. Both her children were alive but had significant disabilities and she was their primary carer. She became pregnant again but lived in a remote location where she had been refused a surgical abortion. At the time, there was no option of medical abortion in Australia because RU-486 was illegal. The inevitable happened and she developed severe preeclampsia at 25 weeks. She was too sick to be transferred so I did her emergency caesarean section in Cairns. Her baby died very soon after birth. When I saw her for her postnatal visit, she said how she would have preferred to have an early abortion instead of having a third operation and losing her baby at 25 weeks. And I had to agree with her. At that point, I felt I had to do something about abortion care for women in Queensland. I was able to use my position as a woman who was a professor of O&G to advocate for abortion. I had known of the existence of mifepristone but had to read up extensively about it to be able to speak with knowledge and authority. There were many people involved in the campaign to get mifepristone widely available and accessible to women all over Australia, including women members of Parliament who came together across party lines to make this possible. I am very proud to have been involved with this work and along the way, helping change the out-of-date abortion laws across Australia. The laws have now, finally, changed in all states and territories. There is still a lot of work to be done to destigmatise abortions and to make access equitable across rural and remote Australia, but we have come a long way since the 70s.

What has been your involvement with refugee women?

While I was practicing in Sydney in the late 90s, I was asked by a refugee organisation if I would provide care for refugee women who were brought to Sydney and I was very happy to do this. I could look after these women as outpatients but when they had to be admitted to hospital either antenatally or for birth, it required a lot of negotiating with hospital administrators to allow them to birth in a public hospital when we knew that they could not afford to pay for it (and were not eligible for Medicare). This was my first experience of the inequities that refugee women faced.

Next, I got involved with an organisation called the National Justice Project writing reports about women in detention (onshore detention at that time) to recommend the best place for their care in pregnancy. I would be agitating for them to be released from detention, but I wasn’t always terribly successful. In 2003, I was asked to go to Nauru to spend a week doing gynaecological surgery, mainly for Nauruan women but I also got to see women in the detention camp on Nauru. I became more and more concerned about these women and their children. I did a lot of lobbying for women to be transferred to Australia from Nauru for medical treatment. I also went to Darwin detention centre and saw the conditions in which the women were kept during pregnancy and postnatally. They were sending women back to Christmas Island from Darwin even though they clearly needed medical attention. Women were only transferred from Christmas Island to Darwin at the last minute. They didn’t speak English and their husbands and children were not allowed to accompany them to Australia, isolating them from their family when they were particularly vulnerable.

One of the women from Nauru, a Palestinian refugee, Dima, was brought to Cairns for her pregnancy care. Most women were transferred to Sydney or Brisbane and I have no idea why she was brought to Cairns instead. She was 37 weeks pregnant and had severe preeclampsia with a breech baby. She was initially told that her husband, Hani, could come with her but at the last minute, he was not allowed to board the flight. She had never been to Australia, and she had no support system here. I met her and became her support person. I never cared for her as her doctor, but I was with her when her son, Mohammed was born by caesarean section. With the help of lawyers, we were able to make sure that she and her son stayed in Cairns. Dima stayed in Cairns for a year supported by the refugee group in Cairns. The lawyers were trying to get the family together because her husband was still on Nauru. Suddenly, the immigration department moved her to North Adelaide where she was given accommodation but did not know anyone. It was much harder for us to help her while she was in Adelaide and she was cut off from the supports she had developed in Cairns. Hani was eventually brought to Adelaide where he was kept in detention. When he first arrived in Adelaide, he had a badly infected foot. I went to Adelaide and met him for the first time. He was on antibiotics but of course, they were useless because he really needed a surgical procedure. I made quite a fuss and was told that he had refused to go to hospital for treatment. On questioning, I found out that he was refusing to go because he would have to be handcuffed to two guards on both sides. He wasn’t going to run away. His wife and son were in Adelaide. Yet, protocol meant that he had to be handcuffed when he was outside the detention centre. It was demeaning and unnecessary. After a lot of discussion with lawyers, the guards finally agreed to hold him by putting a hand on his shoulders so that he wouldn’t be able to escape. Eventually, he got his foot fixed, but it really showed how every decision was designed to make refugees feel less than human.

At that time, I discovered that Dima and her family would never be allowed to settle in Australia. We looked at New Zealand, but this did not work out either. We then found out about a scheme whereby if we raised a certain amount of money and found a local sponsor, they could be resettled in Canada. My oldest son lives in Canada and is a Canadian citizen. He was very happy to be the sponsor. It took about 18 months to arrange, but at the end of that time, in October 2019, the Canadian government paid for Dima, Hani and Mohammed to travel by Air Canada to Toronto where my son was waiting to welcome them. It hasn’t been easy for them since almost as soon as they got to Canada, the pandemic arrived. But they are now permanent residents, Mohammed starts school soon and they will become Canadian citizens next year. I feel really pleased that I could help make this possible.

You were awarded the Member of the Order of Australia (AM) in 2014 which you returned in 2021. What prompted you to do this?

I felt very honoured when I was awarded the Member of the Order of Australia (AM) in 2014 for my service to reproductive healthcare of women, in particular Aboriginal and immigrant women. I was not the only one who had done the work, it was always a team of people and I felt humbled by the offer. There were plenty of other people who were equally worthy of the award. One major reason for accepting the award was the fact that fewer women than men have received one of these awards, at all levels. The framed certificate hung on the wall of my Cairns office for seven years.

At the beginning of this year, I learned that Margaret Court was to be elevated to become a Companion of the Order of Australia (AC). She had already received the award of Officer (AO) in 2007 for her services to tennis. She was an excellent tennis player and had been rightfully recognised as such. But now she was to receive Australia’s highest honour, intended for ‘eminent achievement and merit of the highest degree in service to Australia or to humanity at large’.

But before 2007, and even more since, Margaret Court has made homophobic statements that are harmful to the people who are her targets. As the mother of a gay son, an absolutely wonderful person who does lots of good things all the time, I felt I had to take a stand. The granting of this second award sends a message from the Commonwealth Government of Australia that they are condoning and supporting her homophobic views. I was shocked and disgusted by this decision. I did not want to be associated in any way with these views and so I returned my AM to the Governor General.

What do you see as future challenges in O&G?

When I began in O&G, there was no ultrasound. You placed your hands on the mother’s abdomen and made a diagnosis of presentation, size, liquor volume. Ultrasound revolutionised the information we could get before the baby was born and brought with it the possibility of checking for anomalies. We then developed prenatal testing for genetic disorders. Non-invasive prenatal testing is relatively new but has made a huge difference to how we test for genetic conditions. We also have carrier screening routinely available even before a pregnancy occurs.

Currently, we use these tests largely for medical reasons, but I can imagine a future where these tests will be developed to such an extent that the medical will start to border on the social implications for pregnancy. I envisage a whole bunch of ethically challenging decisions in the future.

What lies ahead for you?

I have decided to write crime fiction. It all started with the long days and nights of obstetric on call. You had to sit around in the tea room waiting for babies and invariably, you would find a book to read so you could stay awake. You had to find something that was page turning but not too intellectually challenging, and crime fiction fit the bill perfectly. I read lots of crime fiction. Over the years and I thought that’s what I would like to do when I retire. I have published three crime fiction books and am looking forward to working on the next one.