Identification of women at risk of depression in pregnancy: using women's accounts to understand the poor specificity of the Whooley and Arroll case finding questions in clinical practice.

Antenatal mental health assessment is increasingly common in high-income countries. Despite lacking evidence on validation or acceptability, the Whooley questions (modified PHQ-2) and Arroll 'help' question are used in the UK at booking (the first formal antenatal appointment) to identify possible cases of depression. This study investigated validation of the questions and women's views on assessment. Women (n = 191) booking at an inner-city hospital completed the Whooley and Arroll questions as part of their routine clinical care then completed a research questionnaire containing the Edinburgh postnatal depression scale (EPDS). A purposive subsample (n = 22) were subsequently interviewed. The Whooley questions 'missed' half the possible cases identified using the EPDS (EPDS threshold ≥ 10: sensitivity 45.7 %, specificity 92.1 %; ≥ 13: sensitivity 47.8 %, specificity 86.1 %), worsening to nine in ten when adopting the Arroll item (EPDS ≥ 10: sensitivity 9.1 %, specificity 98.2 %; ≥ 13: sensitivity 9.5 %, specificity 97.1 %). Women's accounts indicated that under-disclosure relates to the context of assessment and perceived relevance of depression to maternity services. Depression symptoms are under-identified in current local practice. While validated tools are needed that can be readily applied in routine maternity care, psychometric properties will be influenced by the context of disclosure when implemented in practice.

The bionomic approach to patient safety and its application in gynaecological surgery.

In the past 2 decades, a gradual shift has taken place from the 'person approach' to patient safety (in which the individual clinician at the sharp end is blamed for any accident) to a 'systems approach' (in which causation of accidents is attributed to loopholes in the organisational defences). Increasingly, however, concern has been expressed that the systems approach risks absolving individuals from responsibility for patient safety, and a balance between the systems and person approaches has been sought. In this paper, resolution of the tension between the person and the systems approaches is advocated through the use of a paradigm that places more emphasis on the relationships between the individual at the sharp end and other components of the system. This paradigm, which is adapted from ecosystems, has been labelled the 'bionomic approach'. A bionomic approach to patient safety incorporates principles and concepts of human ecology and applies them to the healthcare system, situating the individual as an intrinsic component of the system rather than an adjunct. It builds on the notion that 'people create safety' and on the recognition that, in some clinical areas, particularly surgery, the individual is the primary defence against patient safety incidents. Skills required for 'error wisdom' are described, and the principles of the bionomic approach are applied to gynaecological surgery, using an illustrative case study.

Risk management in gynaecology: principles and practice.

The majority of gynaecology patients are fit women receiving relatively straightforward care. However, human error is inevitable. Furthermore, new treatments and technologies are constantly emerging, today's trainees are less experienced than their predecessors, and the need for team work is greater than ever. These and other factors pose threats to patient safety. Patient safety can be improved through risk management. This review describes risk management principles and tools applicable to gynaecology and highlights common sources of patient safety incidents in gynaecology clinics, wards and operating theatres. It provides an overview of communication, consent, staff training and supervision, and use of clinical practice guidance. Underlying theoretical principles are amply illustrated by practical examples.

Mind over matter: psychological factors and the menstrual cycle.

PURPOSE OF REVIEW: Increasingly, gynaecologists are becoming aware of the impact of psychosocial factors on women's health generally, and on the menstrual cycle in particular. This review highlights developments in this field in the last triennium. RECENT FINDINGS: Stress impairs the ovarian cycle through activation of the hypothalamus pituitary adrenal axis. The effect of psychological stress on the menstrual cycle is mediated by metabolic factors. Stress-induced impairment of ovarian function may not necessarily manifest as menstrual irregularity, and the effects of stress may persist beyond the cycle in which the stress episode occurred. Response to stress may be determined not so much by the nature of the stress as by the intrinsic neuronal attributes of the individual. SUMMARY: Interventions to address underlying stress should be part of the management regime for women with menstrual cycle abnormalities.