Does a public online IVF prediction tool help set patient expectations? A mixed methods evaluation study.

STUDY QUESTION: Does a public online IVF success prediction calculator based on real-world data help set patient expectations? SUMMARY ANSWER: The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool and one quarter (26%) had their expectations of IVF success confirmed. WHAT IS KNOWN ALREADY: Several web-based IVF prediction tools exist worldwide but have not been evaluated for their impact on patient expectations, nor for patient perceptions of usefulness and trustworthiness. STUDY DESIGN, SIZE, DURATION: This is a pre-post evaluation of a convenience sample of 780 online users of the Australian YourIVFSuccess Estimatorhttps://yourivfsuccess.com.au/ between 1 July and 31 November 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were eligible if they were over 18 years of age, Australian residents, and considering IVF for themselves or their partner. Participants filled in online surveys before and after using the YourIVFSuccess Estimator. MAIN RESULTS AND THE ROLE OF CHANCE: The response rate of participants who completed both surveys and the YourIVFSuccess Estimator was 56% (n = 439). The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool (20% increased, 30% decreased), bringing their predictions in line with the YourIVFSuccess Estimator, and one quarter (26%) had their IVF success expectations confirmed. One in five participants claimed they would change the timing of IVF treatment. The majority of participants found the tool to be at least moderately trustworthy (91%), applicable (82%), and helpful (80%), and would recommend it to others (60%). The main reasons given for the positive responses were that the tool is independent (government funded, academic) and based on real-world data. Those who did not find it applicable or helpful were more likely to have had a worse-than-expected prediction, or to have experienced non-medical infertility (e.g. single women, LGBTQIA+), noting that at the time of evaluation the Estimator did not accommodate these patient groups. LIMITATIONS, REASONS FOR CAUTION: Those who dropped out between the pre- and post-surveys tended to have a lower education status or have been born outside of Australia or New Zealand, therefore there may be issues with generalizability. WIDER IMPLICATIONS OF THE FINDINGS: With consumers demanding increasing levels of transparency and participation in decisions around their medical care, public-facing IVF predictor tools based on real-world data are useful for aligning expectations about IVF success rates. Given differences in patient characteristics and IVF practices internationally, national data sources should be used to inform country-specific IVF prediction tools. STUDY FUNDING/COMPETING INTEREST(S): The YourIVFSuccess website and evaluation of the YourIVFSuccess Estimator are supported by the Medical Research Future Fund (MRFF) Emerging Priorities and Consumer Driven Research initiative: EPCD000007. BKB, ND, and OF have no conflicts to declare. DM holds a clinical role at Virtus Health. His role did not influence the analysis plan or interpretation of results in this study. GMC is an employee of the UNSW Sydney, and Director of the UNSW NPESU. UNSW receives research funding on behalf of Prof Chambers from the MRFF to develop and manage the Your IVF Success website. Grant ID: MRFF Emerging Priorities and Consumer Driven Research initiative: EPCD000007. TRIAL REGISTRATION NUMBER: N/A.

Double jeopardy-pregnancy and birth during a catastrophic bushfire event followed by a pandemic lockdown, a natural experiment.

BACKGROUND: From November 2019 to January 2020, eastern Australia experienced the worst bushfires in recorded history. Two months later, Sydney and surrounds were placed into lockdown for six weeks due to the COVID-19 pandemic, followed by ongoing restrictions. Many pregnant women at this time were exposed to both the bushfires and COVID-19 restrictions. OBJECTIVE: To assess the impact of exposure to bushfires and pandemic restrictions on perinatal outcomes. METHODS: The study included 60 054 pregnant women who gave birth between November 2017 and December 2020 in South Sydney. Exposure cohorts were based on conception and birthing dates: 1) bushfire late pregnancy, born before lockdown; 2) bushfires in early-mid pregnancy, born during lockdown or soon after; 3) conceived during bushfires, lockdown in second trimester; 4) conceived after bushfires, pregnancy during restrictions. Exposure cohorts were compared with pregnancies in the matching periods in the two years prior. Associations between exposure cohorts and gestational diabetes, preeclampsia, hypertension, stillbirth, mode of birth, birthweight, preterm birth and small for gestational age were assessed using generalised estimating equations, adjusting for covariates. RESULTS: A decrease in low birth weight was observed for cohort 1 (aOR 0.81, 95%CI 0.69, 0.95). Conversely, cohort 2 showed an increase in low birth weight, and increases in prelabour rupture of membranes, and caesarean sections (aOR 1.18, 95%CI 1.03, 1.37; aOR 1.21, 95%CI 1.07, 1.37; aOR 1.10 (1.02, 1.18) respectively). Cohort 3 showed an increase in unplanned caesarean sections and high birth weight babies (aOR 1.15, 95%CI 1.04, 1.27 and aOR 1.16, 95%CI 1.02, 1.31 respectively), and a decrease in gestational diabetes mellitus was observed for both cohorts 3 and 4. CONCLUSION: Pregnancies exposed to both severe climate events and pandemic disruptions appear to have increased risk of adverse perinatal outcomes beyond only experiencing one event, but further research is needed.

Patterns of psychiatric admission in Australian pregnant and childbearing women.

PURPOSE: The early postnatal period is a time of increased risk for psychiatric admission. However, there is scope to further examine if this increase in risk extends to the entire perinatal period (pregnancy and first postnatal year), and how it compares to admission outside of the perinatal period. METHODS: Data were linked across birth and hospital admission registers from July 2000 to December 2009. The study cohort, consisting of all pregnant and childbearing women with a psychiatric history, was divided into two groups: case women (at least one perinatal principal psychiatric admission in the study period) (38%) and comparison women (no perinatal principal psychiatric admissions) (62%). Outcomes were admission rate and length of stay adjusted for diagnosis, socio-demographic factors and timing of admission. RESULTS: Antenatal and postnatal admissions rates were both higher than non-perinatal admission rates for case women for all diagnoses. There was little evidence that women with perinatal admissions were at an increased risk of admissions at other times. Socially disadvantaged women had significantly fewer and shorter admissions than their respective counterparts. CONCLUSIONS: The entire perinatal period is a time of increased risk for admission across the range of psychiatric disorders, compared to other times in a woman's childbearing years. Reduced admission rate and length of stay for socially disadvantaged women suggest lack of equity of access highlighting the importance of national perinatal mental health policy initiatives inclusive of disadvantaged groups.

Inter-hospital and inter-disciplinary variation in planned birth practices and readiness for change: a survey study.

BACKGROUND: How the application of evidence to planned birth practices, induction of labour (IOL) and prelabour caesarean (CS), differs between Australian maternity units remains poorly understood. Perceptions of readiness for practice change and resources to implement change in individual units are also unclear. AIM: To identify inter-hospital and inter-professional variations in relation to current planned birth practices and readiness for change, reported by clinicians in 7 maternity units. METHOD: Custom-created survey of maternity staff at 7 Sydney hospitals, with questions about women's engagement with decision making, indications for planned birth, timing of birth and readiness for change. Responses from midwives and medical staff, and from each hospital, were compared. FINDINGS: Of 245 completed surveys (27% response rate), 78% were midwives and 22% medical staff. Substantial inter-hospital variation was noted for stated planned birth indication, timing, women's involvement in decision-making practices, as well as in staff perceptions of their unit's readiness for change. Overall, 48% (range 31-64%) and 64% (range 39-89%) agreed on a need to change their unit's caesarean and induction practices respectively. The three units where greatest need for change was perceived also had least readiness for change in terms of leadership, culture, and resources. Regarding inter-disciplinary variation, medical staff were more likely than midwifery staff to believe women were appropriately informed and less likely to believe unit practice change was required. CONCLUSION: Planned birth practices and change readiness varied between participating hospitals and professional groups. Hospitals with greatest perceived need for change perceived least resources to implement such change.

Exploring variation in the performance of planned birth: A mixed method study.

OBJECTIVE: Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback. DESIGN: A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation. SETTING AND PARTICIPANTS: Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives. RESULTS: Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%-42%) and planned CS (adjusted rate 15.4%-22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time). KEY CONCLUSIONS: Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases. IMPLICATIONS FOR PRACTICE: At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.

Factors associated with women's birth beliefs and experiences of decision-making in the context of planned birth: A survey study.

OBJECTIVE: In many high-income countries, approximately half of all births are now planned regarding timing, either by elective Caesarean Section (CS) or induction of labour (IOL). To what degree this is explained by women's birth beliefs and preferences, and in turn, factors such as parity and ethnicity that may influence them, is contentious. Within a broader study on Timing of Birth by planned CS or IOL, we aimed to explore the association between demographic and pregnancy factors, with women's birth beliefs and experiences of planned birth decision-making in late pregnancy. DESIGN: Survey study of women's birth beliefs and experiences of planned birth decision-making. Both univariate analysis and ordinal regression modelling was performed to examine the influence of; parity; cultural background; continuity of pregnancy care; CS or IOL; and whether CS was "recommended" or "requested", on women's stated birth beliefs and decision-making experience. SETTING: 8 Sydney hospitals PARTICIPANTS: Women planned to have an IOL or CS between November 2018-July 2019. MEASUREMENT: The survey included four statements regarding birth beliefs and ten statements about experiences of decision-making on a 5-item Likert scale, as well as questions about demographic and pregnancy factors that might influence these beliefs. FINDINGS: Of 340 included surveys, 56% regarded IOL and 44% CS. Women indicated strong belief both that they should be supported to make decisions about their birth and that their doctor/midwife knows what is best for them (over 90% agreement for both). Regarding decision-making, over 90% also agreed they had trust in the person providing information, understood it, and had sufficient time for both questions and decision-making. However only 58% were provided written information, 19% felt they "didn't really have a choice", and 9% felt pressure to make a decision. On both univariate and multivariate analysis, women having CS (versus IOL) expressed more positive views of their experience and involvement in decision-making, as did women experiencing a pregnancy continuity-of-care model. Women identifying as from a specific cultural or ethnic background expressed more negative experiences. On modelling, the studied factors accounted for only a small proportion of the variation in responses (3-19%). CONCLUSIONS: Continuity of pregnancy care was associated with positive decision-making experiences and cultural background with more negative experiences. Women whose planned birth was IOL versus CS also reported more negative decision-making experiences. IMPLICATIONS FOR PRACTICE: Attention to improving quality of information provision, including written information, to women having IOL and women of diverse background, is recommended to improve women's experiences of planned birth decision-making.

Women's experiences of decision-making and beliefs in relation to planned caesarean section: A survey study.

BACKGROUND: The caesarean section (CS) rate is over 25% in many high-income countries, with a substantial minority of CSs occurring in women with low-risk pregnancies. CS decision-making is influenced by clinician and patient beliefs and preferences, and clinical guidelines increasingly stipulate the importance of shared decision-making (SDM). To what extent SDM occurs in practice is unclear. AIMS: To identify women's birth preferences and SDM experience regarding planned CS. MATERIAL AND METHODS: Survey of women at eight Sydney hospitals booked for planned CS. Demographic data, initial mode of birth preferences, reason for CS, and experiences of SDM were elicited using questions with multiple choice lists, Likert scales, and open-ended responses. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Responses of women who perceived their CS as 'requested' vs 'recommended' were compared. RESULTS: Of 151 respondents, repeat CS (48%) and breech presentation (14%) were the most common indications. Only 32% stated that at the beginning of pregnancy they had a definite preference for spontaneous labour and birth. Key reasons for wanting planned CS were to avoid another emergency CS, prior positive CS experience, and logistical planning. Although 15% of women felt pressured (or were unsure) about their CS decision, the majority reported positive experiences, with over 90% indicating they were informed about CS benefits and risks, had adequate information, and understood information provided. CONCLUSIONS: The majority (85%) of women appeared satisfied with the decision-making process, regardless of whether they perceived their CS as requested or recommended.

The Medicines Intelligence Centre of Research Excellence: Co-creating real-world evidence to support the evidentiary needs of Australian medicines regulators and payers.

Regulators and payers play a pivotal role in facilitating timely and affordable access to safe and efficacious medicines. They use evidence generated from randomised clinical trials (RCTs) to support decisions to register and subsidise medicines. However, at the time of registration and subsidy approval, regulators and payers face uncertainty about how RCT outcomes will translate to real-world clinical practice. In response to this situation, medicines policy agencies worldwide have endorsed the use of real-world data (RWD) to derive novel insights on the use and outcomes of prescribed medicines. Recent reforms around data availability and use in Australia are creating unparalleled data access and opportunities for Australian researchers to undertake large-scale research to generate evidence on the safety and effectiveness of medicines in the real world. Highlighting the critical importance of research in this area, Quality Use of Medicines and Medicine Safety was announced as Australia's 10th National Health Priority in 2019. The National Health and Medical Research Council, Medicines Intelligence Centre of Research Excellence (MI-CRE) has been formed to take advantage of the renewed focus on quality use of medicines and the changing data landscape in Australia. It will generate timely research supporting the evidentiary needs of Australian medicines regulators and payers by accelerating the development and translation of real-world evidence on medicines use and outcomes. MI-CRE is developing a coordinated approach to identify, triage and respond to priority questions where there are significant uncertainties about medicines use, (cost)-effectiveness, and/or safety and creating a data ecosystem that will streamline access to Australian data to enable researchers to generate robust evidence in a timely manner. This paper outlines how MI-CRE will partner with policy makers, clinicians, and consumer advocates to leverage real-world data to co-create real-world evidence, to improve quality use of medicines and reduce medicine-related harm.

Women's experiences of decision-making and attitudes in relation to induction of labour: A survey study.

BACKGROUND: Rates of induction of labour have been increasing globally to up to one in three pregnancies in many high-income countries. Although guidelines around induction, and strength of the underlying evidence, vary considerably by indication, shared decision-making is increasingly recognised as key. The aim of this study was to identify women's mode of birth preferences and experiences of shared decision-making for induction of labour. METHOD: An antenatal survey of women booked for an induction at eight Sydney hospitals was conducted. A bespoke questionnaire was created assessing women's demographics, indication for induction, pregnancy model of care, initial birth preferences, and their experience of the decision-making process. RESULTS: Of 189 survey respondents (58% nulliparous), major reported reasons for induction included prolonged pregnancy (38%), diabetes (25%), and suspected fetal growth restriction (8%). Most respondents (72%) had hoped to labour spontaneously. Major findings included 19% of women not feeling like they had a choice about induction of labour, 26% not feeling adequately informed (or uncertain if informed), 17% not being given alternatives, and 30% not receiving any written information on induction of labour. Qualitative responses highlight a desire of women to be more actively involved in decision-making. CONCLUSION: A substantial minority of women did not feel adequately informed or prepared, and indicated they were not given alternatives to induction. Suggested improvements include for face-to-face discussions to be supplemented with written information, and for shared decision-making interventions, such as the introduction of decision aids and training, to be implemented and evaluated.

The Attitudes and Beliefs of Australian Midwives and Obstetricians About Birth Options and Labor Interventions.

INTRODUCTION: The global rise in the rate of induction of labor and cesarean birth shows considerable unexplained variation both within and between countries. Prior research suggests that the extent to which women are engaged in the decision-making process about birth options, such as elective cesarean, induction of labor, or use of fetal monitoring, is heavily influenced by clinician beliefs and preferences. The aim of this study was to investigate the beliefs about labor interventions and birth options held by midwives and obstetric medical staff from 8 Sydney hospitals and assess how the health care providers' beliefs were associated with discipline or years of experience. METHODS: This is a survey study of midwives and obstetric staff that was distributed between November 2018 and July 2019. Modified from the previously validated birth attitudes survey for the Australian context, survey domains include (1) maternal choice and woman's role in birth, (2) safety by mode or place of birth, (3) attitudes toward cesarean birth for preventing urinary incontinence, (4) approaches to decrease cesarean birth rates, and (5) fears of birth mode. Responses were compared between professions and within professions by years of experience using Mann-Whitney U testing. RESULTS: A total of 217 midwives and 58 medical staff completed the survey (response rate, 30.5%). Midwifery staff responses generally favored a physiologic approach to birth, versus beliefs more in favor of intervention (particularly cesarean birth) among medical staff. There was interprofessional discrepancy on most items, particularly regarding safety of mode or place of birth and approaches to decrease cesarean birth rates. Within disciplines, there was more variation in medical staff attitudes than within the midwifery staff. No clinically important differences in beliefs by years of experience were noted. DISCUSSION: Clinicians need to be aware of their own beliefs and preferences about birth as a potential source of bias when counselling women, particularly when there are a range of treatment options and the evidence may not strongly favor one option over another. As both groups had similar perceptions about the importance of women's autonomy, shared decision-making training could help bridge belief gaps and improve care around birth decisions.

Core outcome set for studies on pregnant women with vasa previa (COVasP): a study protocol.

INTRODUCTION: Vasa previa is a condition where fetal blood vessels run unprotected in the membranes, outside the umbilical cord, and cross the internal opening of the cervix. During rupture of membranes, these vessels can rupture and put the baby at serious risk of severe blood loss and death. Numerous studies are being conducted to improve diagnostic modalities and establish clear management plans to improve pregnancy outcomes. However, the lack of a standardised set of outcomes for studies on vasa previa makes it difficult to compare study findings and draw meaningful conclusions. Through this project, we will be developing a core outcome set for studies on pregnant women with vasa previa (COVasP). METHODS AND ANALYSIS: The development of COVasP will involve five steps. The first will be a systematic review, in which we will generate a long list of outcomes based on published studies in pregnancies complicated with vasa previa. The second will involve in-depth interviews with current and former patients, their family members and healthcare providers who care for these patients. This will be followed by a two-round Delphi survey, which will aim to narrow down the long list of outcomes into those considered important by four groups of 'stakeholders': (1) patients, family members and patient advocates/representatives, (2) healthcare providers, (3) researchers, epidemiologists and methodologists and (4) other stakeholders directly or indirectly involved in the management of these pregnancies such as administrators, guideline developers and policymakers. The fourth step will involve a face-to-face consensus meeting using a nominal group approach to establish a finalised core outcome set. The final step will involve measuring and defining the identified outcomes using a combination of systematic reviews and Delphi surveys. ETHICS AND DISSEMINATION: This study as well as consent forms for stakeholder participation have received approval from the Mount Sinai Hospital Research Ethics Board (REB number 18-0173-E) on 05 September 2018 and the Human Research Ethics Committee at The University of Technology Sydney, Australia on 30 July 2019 (UTS HREC reference number ETH19-3718). All progress will be documented on the international prospective register of systematic reviews and Core Outcome Measures in Effectiveness Trials databases. REGISTRATION DETAILS: http://www.comet-initiative.org/studies/details/1117.

A validation study of the Australian Maternity Care Classification System.

BACKGROUND: The Maternity Care Classification System is a novel system developed in Australia to classify models of maternity care based on their characteristics. It will enable large-scale evaluations of maternal and perinatal outcomes under different models of care independently of the model's name. AIM: To assess the accuracy, repeatability and reproducibility of the Maternity Care Classification System. METHOD: All 70 public maternity services in New South Wales, Australia, were invited to classify three randomly allocated model case-studies using a web-based survey tool and repeat their classifications 4-6 weeks later. Accuracy of classifications was assessed against the correct values for the case-studies; repeatability (intra-rater reliability) was analysed by percent agreement and McNemar's test between the same participants in both surveys; and reproducibility (inter-rater reliability) was assessed by percent agreement amongst raters of the same case-study combined with Krippendorff's alpha coefficient for a subset of characteristics. RESULTS: The accuracy of the Maternity Care Classification System was high with 90.8% of responses correctly classified; was repeatable, with no statistically significant change in the responses between the two survey instances (mean agreement 91.5%, p>0.05 for all but one variable); and was reproducible with a mean percent agreement across 9 characteristics of 83.6% and moderate to substantial agreement as assessed by a Krippendorff's alpha coefficient of 0.4-0.8. CONCLUSION: The results indicate the Maternity Care Classification System is a valid system for classifying models of care in Australia, and will enable the legitimate evaluation of outcomes by different models of care.

Societal preferences for fertility treatment in Australia: a stated preference discrete choice experiment.

Objective: To investigate preferences for fertility treatment from the Australian general population with the aims of calculating the willingness to pay in tax contribution for attributes (characteristics) that make up treatment and for an "ideal" fertility treatment program. We also assessed whether willingness-to-pay varies by the relationship status or sexual orientation of the patient.Methods: A stated preference discrete choice experiment was administered to a panel of 801 individuals representative of the Australian general population. Seven attributes of fertility treatment under three broad categories were included: outcome, process, and cost. Attributes were identified through published literature, focus group discussions, expert knowledge, and a pilot study. A Bayesian fractional experimental design was used, and data analysis was performed using a generalized multinomial logit model. Further analyses included interaction terms and latent class modeling.Results: Six of the seven attributes influenced the choice of a treatment program. Under process attributes, individuals preferred: continuity of care of clinic staff, where patients are seen by the same doctor but different nurses at each visit; "alternative" treatments being offered to all patients; and onsite clinic counseling and peer-support groups. Personalization and tailoring of the treatment journey were not important. Among outcome attributes, the improved success rate of having a baby per cycle and significant side-effects were considered important. Cost of treatment also influenced the choice of treatment program. Individual preferences for fertility treatment were not associated with patients' relationship status or sexual orientation. Latent class modeling revealed sub-groups with distinct fertility treatment preferences.Conclusion: This study provides important insights into the attributes that influence the preferences of fertility treatment in Australia. It also estimates socially-inclusive willingness-to-pay values in tax contributions for an "ideal" package of treatment. The results can inform economic evaluations of fertility treatment programs.

Improving, but could do better: Trends in gestation-specific stillbirth in Australia, 1994-2015.

BACKGROUND: Stillbirth remains a public health concern in high-income countries. Over the past 20 years, stillbirth rates globally have shown little improvement and large disparities. The overall stillbirth rate, which measures risk among births at all gestations, masks diverging trends at different gestations. This study investigates trends over time in gestation-specific risk of stillbirth in Australia. METHODS: Analytical epidemiological study using nationally reported gestational age data for births in Australia, 1994-2015. Average annual change in gestation-specific prospective risk of stillbirth (per 1000 fetuses at risk [FAR]) was calculated among births in 1994-2009 and 2010-2015 at term (37-41 weeks) and for preterm gestational age subgroups: 28-36, 24-27, and 20-23 weeks. RESULTS: The decline in risk of stillbirth at term from 2010 to 2015 from 1.43 to 1.16 per 1000 FAR was more rapid than from 1994 to 2009; for preterm gestations from 24 to 27 weeks, there were no discernible trends; from 28 to 36 weeks, the decline between 1994 and 2009 was not sustained; among births from 20 to 23 weeks, the risk of stillbirth plateaued in 2010-2015, fluctuating around 3.3 per 1000 FAR. CONCLUSIONS: Improvement in the stillbirth rate from 28 weeks' gestation aligns with changes in other high-income countries, but more work is needed in Australia to achieve the levels of reduction seen elsewhere. Gestation-specific risk of stillbirth is more informative than the overall stillbirth rate. The message that the overall risk of stillbirth is not changing disregards gains at different stages of pregnancy.

Assessment of the societal and individual preferences for fertility treatment in Australia: study protocol for stated preference discrete choice experiments.

INTRODUCTION: In Australia, societal and individual preferences for funding fertility treatment remain largely unknown. This has resulted in a lack of evidence about willingness to pay (WTP) for fertility treatment by either the general population (the funders) or infertile individuals (who directly benefit). Using a stated preference discrete choice experiment (SPDCE) approach has been suggested as a more appropriate method to inform economic evaluations of fertility treatment. We outline the protocol for an ongoing study which aims to assess fertility treatment preferences of both the general population and infertile individuals, and indirectly estimate their WTP for fertility treatment. METHODS AND ANALYSIS: Two separate but related SPDCEs will be conducted for two population samples-the general population and infertile individuals-to elicit preferences for fertility treatment to indirectly estimate WTP. We describe the qualitative work to be undertaken to design the SPDCEs. We will use D-efficient fractional experimental designs informed by prior coefficients from the pilot surveys. The mode of administration for the SPDCE is also discussed. The final results will be analysed using mixed logit or latent class model. ETHICS AND DISSEMINATION: This study is being funded by the Australian National Health and Medical Research Council (NHMRC) project grant AP1104543 and has been approved by the University of New South Wales Human Research Ethics Committee (HEC 17255) and a fertility clinic's ethics committee. Findings of the study will be disseminated in peer-reviewed journals and presented at various conferences. A lay summary of the results will be made publicly available on the University of New South Wales National Perinatal Epidemiology and Statistics Unit website. Our results will contribute to the development of an evidence-based policy framework for the provision of cost-effective and patient-centred fertility treatment in Australia.

More than a name: Heterogeneity in characteristics of models of maternity care reported from the Australian Maternity Care Classification System validation study.

BACKGROUND: Without a standard terminology to classify models of maternity care, it is problematic to compare and evaluate clinical outcomes across different models. The Maternity Care Classification System is a novel system developed in Australia to classify models of maternity care based on their characteristics and an overarching broad model descriptor (Major Model Category). AIM: This study aimed to assess the extent of variability in the defining characteristics of models of care grouped to the same Major Model Category, using the Maternity Care Classification System. METHOD: All public hospital maternity services in New South Wales, Australia, were invited to complete a web-based survey classifying two local models of care using the Maternity Care Classification System. A descriptive analysis of the variation in 15 attributes of models of care was conducted to evaluate the level of heterogeneity within and across Major Model Categories. RESULTS: Sixty-nine out of seventy hospitals responded, classifying 129 models of care. There was wide variation in a number of important attributes of models classified to the same Major Model Category. The category of 'Public hospital maternity care' contained the most variation across all characteristics. CONCLUSION: This study demonstrated that although models of care can be grouped into a distinct set of Major Model Categories, there are significant variations in models of the same type. This could result in seemingly 'like' models of care being incorrectly compared if grouped only by the Major Model Category.

The development of a classification system for maternity models of care.

BACKGROUND: A lack of standard terminology or means to identify and define models of maternity care in Australia has prevented accurate evaluations of outcomes for mothers and babies in different models of maternity care. OBJECTIVE: As part of the Commonwealth-funded National Maternity Data Development Project, a classification system was developed utilising a data set specification that defines characteristics of models of maternity care. METHOD: The Maternity Care Classification System or MaCCS was developed using a participatory action research design that built upon the published and grey literature. RESULTS: The study identified the characteristics that differentiate models of care and classifies models into eleven different Major Model Categories. CONCLUSION: The MaCCS will enable individual health services, local health districts (networks), jurisdictional and national health authorities to make better informed decisions for planning, policy development and delivery of maternity services in Australia.

Vasa Praevia: a descriptive review of existing literature and the evolving role of ultrasound in prenatal screening.

Introduction: Literature addressing the feasibility of prenatal detection of vasa praevia during the mid-trimester morphology ultrasound scan is scarce, as is a lack of consensus about the appropriate management of pregnancies once it is detected. Method: The following descriptive review will provide historical context about the clinical significance, epidemiology, diagnosis and outcomes of pregnancies complicated by vasa praevia. It will also examine the role of ultrasound in the diagnosis of vasa praevia, and will examine current evidence surrounding this debate of whether routine screening for vasa praevia is possible, beneficial, or cost-effective. Conclusion: Finally, it will highlight the need for increased research into effective management of pregnancies at high risk of, or affected by vasa praevia to reduce fetal mortality and maternal and fetal morbidity associated with the condition.