Effectiveness and cost-effectiveness of an electronic mindfulness-based intervention to improve maternal mental health in the peripartum: study protocol for a randomised controlled trial.

BACKGROUND: Perinatal women are highly vulnerable to developing mental health issues and particularly susceptible to a recurrence of psychiatric illness. Poor mental health during the perinatal period can have long-term impacts on the physical and psychiatric health of both mother and child. A potentially useful strategy to improve women's mental health is through a mobile application teaching mindfulness, an evidence-based technique helping individuals focus on the present moment. METHODS: A mixed method, prospective randomised controlled trial. The study group comprise women aged 18 years and over, who are attending the public and private maternity clinics at Mater Mothers' Hospital. A sample of 360 prenatal women will be randomised into the intervention group (with the use of the mindfulness app) or usual care. Participants will remain in the study for 11 months and will be assessed at four timepoints for changes in postnatal depression, mother-infant bonding, and quality of life. A cost-effectiveness evaluation will also be conducted using quality-adjusted life year (QALY) calculations. A random selection of intervention participants will be invited to attend focus groups to give feedback on the mindfulness app. DISCUSSION: Previous studies have found mindfulness interventions can reduce stress, anxiety, depression, and sleep disturbances in a prenatal population. The risks of the intervention are low, but could be of significant benefit for women who are unable to attend face-to-face appointments due to geographical, financial, or time barriers; during endemic or pandemic scenarios; or due to health or mobility issues. TRIAL REGISTRATION: This study was approved by the Mater Misericordiae Human Research Ethics Committee (83,589). Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622001581752 ( https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385107&isReview=true ). Registered on 22 Dec. 2022.

Induction of labor using balloon catheter as an outpatient versus prostaglandin as an inpatient: A cost-effectiveness analysis.

OBJECTIVE: The aim of this work was to assess the cost-effectiveness of induction of labor with outpatient balloon catheter cervical priming versus inpatient prostaglandin vaginal gel or tape. STUDY DESIGN: Economic evaluation alongside a multi-centre, randomized controlled trial at eight Australian maternity hospitals. The trial reported on 448 women with live singleton term pregnancies, undergoing induction of labor for low-risk indications between September 2015 and October 2018. An economic decision tree model was designed from a health services perspective from time of induction of labor to hospital discharge. Sensitivity and subgroup analyses were performed to test the robustness of model outcomes. We estimated resource use, collected data on health outcomes (using EQ-5D-3 L questionnaire) and reported cost (Australian Dollars) per quality-adjusted life year gained, incremental cost-effect ratio and net monetary benefit. RESULTS: Deterministic analysis showed lower mean costs ($7294 versus $7585) in the outpatient-balloon (n = 205) compared to the inpatient-prostaglandin group (n = 243), with similar health outcomes (0.75 vs 0.74 quality-adjusted life years gained) and overall higher net monetary benefit ($30,054 vs $29,338). In probabilistic analyses outpatient-balloon induction of labor was cost-effective in 55.3 % of all simulations and 59.1 % for women with favourable cervix (modified Bishop score >3) and 64.5 % for nulliparous women. CONCLUSIONS: Outpatient-balloon induction of labor may be cost-saving compared to inpatient induction of labor with prostaglandin and is most likely to be cost-effective for nulliparous women, but more research is warranted in other settings to explore the generalisability of results.

Is that realistic? The development of a realism assessment questionnaire and its application in appraising three simulators for a gynaecology procedure.

INTRODUCTION: There is no standard approach to determining the realism of a simulator, valuable information when planning simulation training. The aim of this research was to design a generic simulator realism questionnaire and investigate the contributions of different elements of simulator design to a user's impression of simulator realism and performance. METHODS: A questionnaire was designed with procedure-specific and non-procedure-specific (global) questions, grouped in subscales related to simulator structure and function. Three intrauterine contraceptive device (IUCD) simulators were selected for comparison. Participants were doctors of varying experience, who performed an IUCD insertion on each of the three models and used the questionnaire to rate the realism and importance of each aspect of the simulators. The questionnaire was evaluated by correlation between procedure-specific and global items and the correlation of these items to overall realism scores. Realism scores for each simulator were compared by Kruskal-Wallis and subsequent between-simulator comparison by Dunn's test. RESULTS: Global question scores were highly related to procedure-specific scores. Comparison revealed global item subscale scores were significantly different across models on each of the nine subscales (P < 0.001). Function items were rated of higher importance than structure items (mean function item importance 5.36 versus mean structure item importance 5.02; P = 0.009). CONCLUSIONS: The designed questionnaire was able to discriminate between the models for perceived simulator realism. Findings from this study may assist simulator design and inform future development of a generic questionnaire for assessing user perceptions of simulator realism.

The Art of Scientific Performance.

Humanity builds upon scientific findings, but the credibility of science might be at risk in a 'postfactual' era of advanced information technologies. Here we propose a systemic change for science, to turn away from a growth paradigm and to refocus on quality, characterized by curiosity, surprise, discovery, and societal relevance.

Simulation training in obstetrics and gynaecology: What's happening on the frontline?

BACKGROUND: Despite evidence supporting simulation training and awareness that trainee exposure to surgery is suboptimal, it is not known how simulation is being incorporated in obstetrics and gynaecology (O&G) training across Australia and New Zealand. AIM: To investigate the current availability and utilisation of simulation training, and the attitudes, perceived barriers and enablers towards simulation in Australia and New Zealand. METHOD: A survey was distributed to O&G trainees and fellows in Australia and New Zealand. The survey recorded demographic data, current exposure to simulation and beliefs about simulation training. RESULTS: The survey returned 624 responses (24.3%). Most trainees had access to at least one type of simulation (87%). Access to simulators was higher for trainees at tertiary hospitals (92% vs 76%). Few trainees had a simulation curriculum, allocated time or supervision for simulation training. 'Limited access' was the highest rated barrier to using simulation. Lack of time, other training priorities and cost were identified as further barriers. More than 80% of respondents believed simulation improves surgical skills, skills transfer to the operating theatre, and the addition of simulation to the RANZCOG curriculum would benefit trainees. However, a minority of respondents believed simulator proficiency should be shown prior to performing surgery. The need for a curriculum and supervision were highlighted as necessary supports for simulation training. CONCLUSIONS: Despite simulator availability, few trainees are supported by simulation training curricula, allocated time or supervision. Participants believed that simulation training benefits trainees and should be supported with a curriculum and teaching.

Induction of labor using prostaglandin vaginal gel: cost analysis comparing early amniotomy with repeat prostaglandin gel.

BACKGROUND: In a randomized controlled trial of two policies for induction of labor (IOL) using Prostaglandin E2 (PGE2) vaginal gel, women who had an earlier amniotomy experienced a shorter IOL-to-birth time. OBJECTIVE: To report the cost analysis of this trial and determine if there are differences in healthcare costs when an early amniotomy is performed as opposed to giving more PGE2 vaginal gel, for women undergoing IOL at term. STUDY DESIGN: Following an evening dose of PGE2 vaginal gel, 245 women with live singleton pregnancies, ≥37+0 weeks, were randomized into an amniotomy or repeat-PGE2 group. Healthcare costs were a secondary outcome measure, sourced from hospital finance systems and included staff costs, equipment and consumables, pharmacy, pathology, hotel services and business overheads. A decision analytic model, specifically a Markov chain, was developed to further investigate costs, and a Monte Carlo simulation was performed to confirm the robustness of these findings. Mean and median costs and cost differences between the two groups are reported, from the hospital perspective. RESULTS: The healthcare costs associated with IOL were available for all 245 trial participants. A 1000-patient cohort simulation demonstrated that performing an early amniotomy was associated with a cost-saving of $AUD289 ($AUD7094 vs $AUD7338) per woman induced, compared with administering more PGE2. Propagating the uncertainty through the model 10,000 times, early amniotomy was associated with a median cost savings of $AUD487 (IQR -$AUD573, +$AUD1498). CONCLUSIONS: After an initial dose of PGE2 vaginal gel, a policy of administering more PGE2 when the Modified Bishop's score is <7 was associated with increased healthcare costs compared with a policy of performing an amniotomy, if technically possible. Length of stay was the main driver of healthcare costs.

Maternity Care Plans: A retrospective review of a process aiming to support women who decline standard care.

BACKGROUND: All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP). AIM: To review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation. METHODS: Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs. FINDINGS: MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without). CONCLUSIONS: MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.

Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial.

BACKGROUND: Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. METHODS: In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. FINDINGS: Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. INTERPRETATION: Our results show that for women of any risk, caseload midwifery is safe and cost effective. FUNDING: National Health and Medical Research Council (Australia).

Criteria for solid recovered fuels as a substitute for fossil fuels--a review.

The waste treatment, particularly the thermal treatment of waste has changed fundamentally in the last 20 years, i.e. from facilities solely dedicated to the thermal treatment of waste to facilities, which in addition to that ensure the safe plant operation and fulfill very ambitious criteria regarding emission reduction, resource recovery and energy efficiency as well. Therefore this contributes to the economic use of raw materials and due to the energy recovered from waste also to the energy provision. The development described had the consequence that waste and solid recovered fuels (SRF) has to be evaluated based on fuel criteria as well. Fossil fuels - coal, crude oil, natural gas etc. have been extensively investigated due to their application in plants for energy conversion and also due to their use in the primary industry. Thereby depending on the respective processes, criteria on fuel technical properties can be derived. The methods for engineering analysis of regular fuels (fossil fuels) can be transferred only partially to SRF. For this reason methods are being developed or adapted to current analytical methods for the characterization of SRF. In this paper the possibilities of the energetic utilization of SRF and the characterization of SRF before and during the energetic utilization will be discussed.