Background Model development and validation constitute the critical initial steps in the clinical prediction modelling pipeline, where methodological rigour and reporting transparency determine the validity of all subsequent stages. Our systematic review aimed to appraise the methodology and reporting quality of recently published studies that developed or externally validated prediction models for caesarean section at term following induction of labour. Methods MEDLINE, Scopus, Embase, IEEE Xplore and CINAHL Complete databases were searched to identify original research studies published since 2017. Studies that did not report any performance measurement of the prediction model were excluded. No restrictions were applied to study designs, populations, modelling algorithms, type and timing of predictors, and methods of induction. Descriptive analysis was performed to assess heterogeneity across eligible studies. Study risk of bias and model applicability were assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). Study reporting quality was evaluated using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis + Artificial Intelligence (TRIPOD + AI) Statement. Results Among the 14 included studies, 12 developed a single model using logistic or Bayesian regression, and two externally validated included models. All studies reported discrimination performance using the Area Under the Receiver Operating Characteristic (AUROC) curve, and 11 reported calibration performance. However, only one validation-only study assessed clinical utility using decision curve analysis, and none evaluated model fairness. Overall, 12 studies had unclear or high risk of bias, mainly attributable to the selection of predictors through univariate analysis. Three studies raised applicability concerns due to the inclusion of predictors not available before induction. The handling of missing data was not reported in five studies. Conclusions More external validation is needed to assess the clinical utility and fairness of existing models before they can be recommended for the subsequent stages in the clinical prediction pipeline and ultimately support clinical decision-making and improve maternal and neonatal outcomes. Future research should prioritise the inclusion of comprehensive performance measures and strengthen methodological rigour and reporting transparency to improve model reliability and clinical applicability, as emphasised in existing reporting guidelines.

OBJECTIVES:To evaluate the population net health benefit and distributional health impact across socioeconomic subgroups when considering alternative target populations for implementing antenatal lifestyle interventions in Australia. METHODS:Differences in the distributions of health within population subgroups defined by Socioeconomic Index for Areas quintiles were compared for standard care (no routine antenatal lifestyle intervention) versus subsidized provision to (1) all pregnant women, (2) women with body mass index (BMI) ≥ 25, (3) women aged ≥ 30 years, or (4) women giving birth within the public health system. Distributional cost-effectiveness analysis of the alternative implementation strategies was conducted to model the impact on disease incidence (gestational and type-2 diabetes), direct healthcare costs, opportunity costs, mortality and quality-adjusted life-years for socioeconomic subgroups. Data were obtained from national statistics, registries and the literature. Value judgements regarding aversion to social inequality in health were captured using the Atkinson index. Extensive sensitivity analyses were conducted. RESULTS:At an opportunity-cost threshold of AU$31 157 (2024 prices), all implementation strategies improved overall population health and reduced health inequality compared with current standard care. Provision to women with a BMI ≥ 25 generated the highest population net health benefit, whereas provision only within the public health system generated the greatest reduction in health inequality. Sensitivity analyses did not materially change these findings. CONCLUSIONS:Among the targeted strategies evaluated, limiting implementation to women with BMI ≥ 25 is likely to result in the greatest incremental population net health gains and is the preferred strategy when trade-offs between efficiency and health equity are considered.

Background:Gestational diabetes mellitus (GDM) is increasingly common, with short- and long-term health risks. Building on the GooD4Mum pilot, which demonstrated quality improvements in general practice for care after GDM, this project implemented and evaluated a primary care Quality Improvement Collaborative (QIC) program to optimize identification, recall, screening, and referral of patients after GDM. Objective:This study aimed to assess the effectiveness of QIC activities relative to usual practice for improving general practice clinicians' provision of follow-up and screening of patients with a history of GDM to ultimately support the onset of type 2 diabetes. Methods:A 21-month, prospective non-randomized controlled trial (at practice level) was conducted, matching intervention practices 1:1 with controls. The QIC intervention is compared with care-as-usual in general practice to review implementation, effectiveness, and economic outcomes. For 18 months, the intervention practices engaged with the GooD4Mum QIC program, including education, training, resources, and Plan-Do-Study-Act (PDSA) cycles to implement locally relevant improvement activities. A clinical decision support system aided in the identification, screening, and tracking of patients with a history of GDM. Control practices provided care as usual. Primary outcomes are practice-level proportions of women with recorded type 2 diabetes screening, modifiable cardiometabolic risk factors, and referral to a diabetes prevention program. Secondary outcomes examine changes in care processes, adherence to clinical standards, and fidelity of intervention delivery. Outcome analyses use clinical data derived from practices via automated extraction. Baseline comparisons use t tests or chi-square tests. Primary and secondary outcomes are analyzed by repeated-measures ANOVA and/or cluster-adjusted generalized estimating equations, accounting for practice-level clustering, and sensitivity analyses include a per-protocol approach. Implementation outcomes are assessed through longitudinal qualitative interviews with practice leads, support staff, and stakeholders, guided by the CFIR (Consolidated Framework for Implementation Research) and the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework. Cost consequence analysis uses clinical activity and practice-reported data. Results:The program ran in 9 general practices between April 2024 and September 2025, with data collection until December 2025. Practice characteristics and protocol deviation are summarized. Detailed outcome, cost consequence, and implementation process evaluations will be reported elsewhere. Conclusions:The protocol offers a novel quality improvement approach enhanced by clinical decision support and automated data extraction to optimize identification, screening, and provision of lifestyle advice toward reducing type 2 diabetes after GDM. The evaluation is designed to generate actionable insights and a scalable implementation toolkit to improve care after gestational diabetes.

While existing literature has compared the methodological strengths and limitations of randomized controlled trials (RCTs) and real-world data (RWD) in general medical research, two critical gaps remain unaddressed: (1) no prior communication papers have specifically examined this comparison in the context of maternity care where unique ethical and practical considerations exist, and (2) no studies have systematically compared cost-effectiveness analyses derived from RCTs versus RWD approaches-a crucial dimension for value-based maternity care decisions. This article examines how both approaches can strengthen the evidence base and support the delivery of value-based maternity care. We argue that neither RCTs nor RWD should be regarded as inherently superior in guiding decision-making. Each study design offers valuable insights, and their findings must be critically appraised in light of methodological rigor, context, and relevance, particularly when their results diverge.

INTRODUCTION:Nausea and vomiting in pregnancy is highly prevalent and can significantly impact pregnant women's quality of life. Despite this, access to effective pharmacotherapies can be constrained by stringent regulatory controls and socioeconomic barriers. The objective of this study was to examine the socioeconomic distribution of antiemetics (metoclopramide, ondansetron, and prochlorperazine) dispensed to pregnant women through Australia's publicly subsidized Pharmaceutical Benefits Scheme. MATERIAL AND METHODS:We used the Maternity1000 linked administrative dataset to characterize antiemetics dispensed during 297 630 pregnancies in Queensland, Australia (July 2013 to June 2018). Using a population-based historical cohort study design, we analyzed dispensing volume, prevalence, and government expenditure across socioeconomic quintiles, with socioeconomic disadvantage defined using the Australian Bureau of Statistics' Index of Relative Socioeconomic Disadvantage. Inequalities in medication access and public expenditure were assessed using concentration indices (C) and concentration curves. RESULTS:Off-label ondansetron dispensings for nausea and vomiting in pregnancy (i.e., use outside Therapeutic Goods Administration-approved indications and not subsidized under the Pharmaceutical Benefits Scheme) accounted for the largest share of public expenditure (53.5%), followed by metoclopramide (45.2%) and prochlorperazine (1.3%). Across all three antiemetics, prevalence was highest among women in the most socioeconomically disadvantaged quintiles and declined progressively across the two least disadvantaged groups. Small pro-poor inequalities in access (C < -0.10) and moderate pro-poor inequalities in public expenditure (C > -0.25) were observed across all antiemetics. (Medication access: Cmetoclopramide = -0.07, 95% CI (-0.080 to -0.068); Condansetron = -0.09, 95% CI (-0.114 to -0.075); Cprochlorperazine = -0.08, 95% CI (-0.109 to -0.045). Government expenditure: Cmetoclopramide = -0.30, 95% CI (-0.316 to -0.285); Condansetron = -0.25, 95% CI (-0.297 to -0.198); Cprochlorperazine = -0.28, 95% CI (-0.350 to -0.205)). CONCLUSIONS:Off-label ondansetron access accounted for the majority of public expenditure on antiemetics dispensed during pregnancy, revealing a disconnect between health policy, clinical practice, public expenditure, and pregnant women's needs. While pro-poor access and public subsidies for antiemetics align with the equity elements embedded in the design of the Pharmaceutical Benefits Scheme, they may also be reflective of inequitable access to other unsubsidized, guideline-recommended pharmacotherapies for nausea and vomiting in pregnancy.

While existing literature has compared the methodological strengths and limitations of randomized controlled trials (RCTs) and real-world data (RWD) in general medical research, two critical gaps remain unaddressed: (1) no prior communication papers have specifically examined this comparison in the context of maternity care where unique ethical and practical considerations exist, and (2) no studies have systematically compared cost-effectiveness analyses derived from RCTs versus RWD approaches—a crucial dimension for value-based maternity care decisions. This article examines how both approaches can strengthen the evidence base and support the delivery of value-based maternity care. We argue that neither RCTs nor RWD should be regarded as inherently superior in guiding decision-making. Each study design offers valuable insights, and their findings must be critically appraised in light of methodological rigor, context, and relevance, particularly when their results diverge.

Uterine contractions during labor reduce placental perfusion, which limits fetal oxygenation. Intrapartum fetal hypoxia and acidemia occur when there is insufficient reperfusion time between contractions or when placental dysfunction restricts oxygen transfer. The risks of hypoxic-ischemic injury during labor include intrapartum stillbirth, neonatal death, and neonatal encephalopathy. Emergency cesarean or instrumental deliveries are often required when fetal acidemia is suspected, though these interventions carry increased maternal and neonatal risk. Despite widespread use of electronic fetal heart rate monitoring to detect fetal compromise, rates of cerebral palsy, perinatal mortality, and other neonatal well-being measures have not improved. This highlights the need for more effective strategies to prevent adverse perinatal outcomes related to hypoxic injury. Phosphodiesterase type 5 inhibitors may be used to improve uteroplacental perfusion and enhance vasoconstriction in uterine and spinal arteries. Sildenafil citrate, a PDE5 inhibitor, has been used for indications related to placental dysfunction, to treat maternal hypertension, or both. A previous phase II randomized clinical trial (RCT) found that oral sildenafil reduced operative birth for fetal distress by 51% compared with placebo, but was underpowered to assess perinatal outcomes. The aim of this study was to assess whether oral sildenafil citrate during labor improves perinatal outcomes related to intrapartum hypoxia.The iSEARCH trial was a placebo-controlled, double-blind RCT conducted at 14 Australian hospitals from September 2021 to June 2024. Included were adult women with singleton or dichorionic twin pregnancies attempting vaginal birth at term, either by spontaneous labor or induction of labor. Excluded were those with monochorionic twins, triplets, higher-order multifetal gestation, or severe hepatic or kidney impairment. Also excluded were those taking nitrate-containing medications or other PDE inhibitors. Study participants were randomized 1:1 to receive 50 mg sildenafil citrate or a placebo every 8 hours for a maximum of 3 doses. The primary outcome was a composite of 10 intrapartum or neonatal events, including intrapartum stillbirth, 28-day neonatal death, Apgar score <4 at 5 minutes, acidosis at birth, hypoxic ischemic encephalopathy, neonatal seizure, neonatal respiratory support, admission to the neonatal unit, persistent pulmonary hypertension of the newborn, or meconium aspiration syndrome. Secondary outcomes included the 10 individual primary outcomes and emergency cesarean delivery or instrumental vaginal birth for fetal distress.A total of 3257 women were included in the analysis, with 1626 in the sildenafil citrate group and 1631 receiving placebos. The primary composite outcome occurred in 5.1% of women in the intervention group and 5.2% in the placebo group [relative risk (RR), 1.02; 95% CI, 0.75-1.37]. No cases of infant death occurred. The sildenafil group had no effect on the individual secondary outcomes. There was also no effect on emergency operative birth for fetal distress (RR, 1.12; 95% CI, 0.98-1.29). In conclusion, no differences were observed in the incidence of adverse perinatal outcomes or emergency operative birth between women who received sildenafil citrate or placebo during labor.

Service context: Promoting value-based maternity care requires maternity services to actively monitor costs and outcomes, where value is defined as patient outcomes achieved relative to the costs of care, rather than focusing solely on cost minimisation. Aim: This study aimed to present an applied, real-world example of how linked health administrative and clinical cost data can be accessed, managed, and analysed, and to demonstrate their use in evaluating health service value within a value-based care framework. Practice innovation: To facilitate broader adoption, we provide fully annotated open-source code and detailed documentation to guide researchers in applying this approach to their own administrative perinatal data. Lessons learned: Reporting and analysing costs should be an ongoing part of service delivery and are enabled by the vast amounts of data that are routinely collected. Conclusion: This study demonstrates how to measure costs of the entire pregnancy journey using existing administrative data and to implement this as a system-wide, routine monitoring metric at the health system level or even whole of state/country level to support benchmarking. Implications for health information management practice: Better utilising existing routinely collected health data can support maternity services to implement cost measurement as a part of performance monitoring, identifying areas of service delivery that are high and low value, and evaluating any changes in service delivery into routine practice.

Objectives Antenatal lifestyle interventions are effective in reducing negative outcomes associated with excess gestational weight gain. While strong cost-effectiveness has also been demonstrated, the cost of implementation is potentially a barrier to uptake. We aimed to estimate whether targeted implementation in high risk clinical groups (categorized by age, body mass index (BMI) and gravidity) returns greater health cost savings through a reduction in aggregate incidence of adverse pregnancy and birth outcomes. Study design Distributional budget impact analysis utilising population level linked data collections. Methods Total budget expenditure (cost of intervention minus cost savings from the associated reduction in adverse pregnancy outcomes) of implementing the lifestyle intervention in risk targeted population sub-groups was estimated, stratified by health system (public vs. private funding). Results Total annual budget expenditure if the intervention is routinely provided to 80 % of pregnant women in New South Wales and Queensland, Australia, is projected to be AU$11,654,857 for n = 94,539 public patients, and AU$6,527,434 for n = 33,516 private patients. If implemented in the BMI ≥30 kg/m2 group only, expenditure is reduced to AU$643,339 for n = 10,298 public patients, and AU$579,003 for n = 5018 private patients, while for implementation in the Age ≥35 years group, it was AU$1,290,965 (n = 21,071 public) and AU$2,169,851 (n = 12,776 private). The number of adverse pregnancy outcomes averted per women was greatest in the BMI ≥30 kg/m2 group. Conclusions Women in the highest BMI category should be prioritised for implementation of effective and cost-effective antenatal lifestyle intervention to reduce the aggregate budgetary impact of adverse pregnancy outcomes.

To determine the quality-of-life scores of women during pregnancy and postpartum and compare the differences by mode of birth. A secondary analysis of a prospective, observational cohort study comprising 2866 pregnant women in Queensland, Australia. Women’s quality-of-life scores were collected at 36 weeks of gestation and 6- and 12-week postpartum and converted into utility values. On average, quality-of-life utility scores increased from 36 weeks of gestation to 12 weeks postpartum, regardless of birth type. After adjusting for socioeconomic characteristics, women who went on to have a planned caesarean section had a significantly lower utility score at 36 weeks of gestation compared to women who went on to have a spontaneous vaginal birth (adjusted mean difference = − 0.07; 95

Importance Sildenafil citrate may increase uteroplacental blood flow. Its ability to reduce perinatal complications related to fetal hypoxia during labor is uncertain. Objective To compare the effectiveness of intrapartum maternal oral sildenafil citrate vs placebo in improving perinatal outcomes potentially related to intrapartum hypoxia in term pregnancies. Design, Setting, and Participants This pragmatic, multicenter, investigator-initiated, placebo-controlled randomized clinical trial including 3257 women was conducted in 13 Australian hospitals from September 6, 2021, to June 28, 2024. The last date of follow-up (28-day neonatal mortality) was July 26, 2024. Women aged 18 years or older with singleton or dichorionic twin pregnancies, planning vaginal birth at term by either spontaneous labor or induction of labor, were recruited. Interventions Women were assigned to 50 mg oral sildenafil citrate every 8 hours up to 150 mg or equivalent placebo. Main Outcome and Measures The primary composite outcome was intrapartum stillbirth, neonatal death, Apgar score less than 4 at 5 minutes (a score of <4 at 5 minutes is indicative of severe neonatal depression at birth, with scores ranging from 0 to 10), acidosis at birth (umbilical cord artery pH <7.0), hypoxic ischemic encephalopathy, neonatal seizures, neonatal respiratory support for greater than 4 hours, neonatal unit admission for greater than 48 hours, persistent pulmonary hypertension of the newborn, or meconium aspiration syndrome. Secondary outcomes were the individual components of the primary composite and emergency cesarean delivery or instrumental birth for intrapartum fetal distress. Results A total of 3257 women were randomized to sildenafil citrate (n = 1626 women and 1634 infants) or placebo (n = 1631 women and 1641 infants). Mean (SD) maternal age and gestation at randomization were similar in both groups (31.7 [5.1] vs 31.5 [5.0] years and 39.5 [1.2] vs 39.5 [1.1] weeks, respectively). A total of 868 participants (53.4%) vs 874 participants (53.6%) were of Australia/New Zealand ethnicity and 315 participants (19.4%) vs 311 participants (19.1%) were of European ethnicity. Most participants were nulliparous (944 of 1624 [58.1%; 2 missing values] vs 966 of 1630 [59.3%; 1 missing value]). Induction of labor occurred in 1353 of 1621 women (83.5%) in the sildenafil citrate group and 1348 of 1627 women (82.9%) in the placebo group. The primary outcome occurred in 83 of 1625 women (5.1%) in the sildenafil citrate group and 84 of 1625 (5.2%) in the placebo group (relative risk, 1.02; 95% CI, 0.75-1.37). Sildenafil citrate had no significant effect on emergency cesarean delivery or instrumental vaginal birth for fetal distress (relative risk, 1.12; 95% CI, 0.98-1.29) or on any of the individual components of the primary outcome. Subgroup analyses showed no evidence of heterogeneity of treatment effect. Conclusions and Relevance Sildenafil citrate did not result in a lower incidence of adverse perinatal outcomes potentially related to intrapartum hypoxia. Trial Registration anzctr.org.au Identifier: ACTRN12621000231842

BACKGROUND:Delivering timely, accessible, and cost-effective perinatal bereavement support to parents is essential to support their emotional and mental wellbeing. However, there is limited evidence on the economic impact of online-based support programs. OBJECTIVE:This study conducted a cost-utility analysis of parents who participated in a randomised controlled trial - comparing the Living with Loss program (LWL; eight-week online program for parents following perinatal death) with care-as-usual (CAU), from the perspective of the healthcare system. METHODS:A health service utilisation survey was designed to collect the hospital and out-of-hospital health services, and prescription medications accessed by participants during the study period. Total costs included costs to the governments and individuals (AUD 2023/24) over time. Utility was measured using quality-adjusted life years (QALYs) calculated based on the Assessment of Quality of Life (AQoL)-8D. FINDINGS:Among the 95 randomised parents, 52 (20 LWL, 32 CAU) completed economic assessments at baseline (week 0) and post-program (week 9). Of these 52 participants, 39 (16 LWL, 23 CAU) further completed the three-month follow up assessment (week 21). Compared with CAU, the LWL program showed trends towards costs savings in primary care and maintained similar health outcomes at post-program (-$264.59 per participant, p = 0.47; QALY gained=-0.001, p = 0.9) and three-month follow up (-$531.52 per participant, p = 0.3; QALY gained=-0.002, p = 0.94). CONCLUSION:This study provides preliminary evidence of potential economic benefits of the LWL Program. Future studies with larger sample sizes and adequate power are needed to fully assess the cost-effectiveness of online perinatal bereavement support services.

AIMS:To examine self-perceived need for mental health care in the Australian adult population between 2007 and 2021. METHODS:The Perceived Need for Care Questionnaire in the 2007 and 2021 National Study of Mental Health and Wellbeing captures types of help needed in five mental health care categories: medication, information, counselling, social interventions and skills training. Needs are rated as unmet, partially met, or fully met. Twelve-month affective, anxiety and substance use disorders are assessed using WHO's Composite International Diagnostic Interview. RESULTS:Demand for mental health care (composite of need categories) among adult Australians increased from 14% (2007) to 20% (2021). It also increased in those with common disorders (43.3-58.9%) and without (6.5-9.9%). Highest 2021 demand was in those with affective (76%), followed by anxiety (61%) and substance use (43%) disorders. Rates of demands being fully met remained stable (45% in 2007; 48% in 2021), with rates among those with substance use (24% in 2021), affective or anxiety (38%) disorders, and those without a common disorder (63%). In 2021, needed supports were counselling (16%), information (11%), medication (10%), skills training (6%) and social interventions (5%). Fully met needs were highest for medication (81%), then counselling (57%), information (54%), skills training (41%) and social interventions (15%). CONCLUSIONS:Despite service expansion, less than half of people with demand had fully met needs. Attention is needed on the causes, population-level prevention as well as treatment strategies to address this burgeoning mental health crisis.

The rapid uptake of supervised machine learning (ML) in clinical prediction modelling, particularly for binary outcomes based on tabular data, has sparked debate about its comparative advantage over traditional statistical logistic regression. Although ML has demonstrated superiority in unstructured data domains, its performance gains in structured, tabular clinical datasets remain inconsistent and context dependent. This viewpoint synthesizes recent comparative studies and simulation findings to argue that there is no universal best modelling approach. Model performance depends heavily on dataset characteristics (eg, linearity, sample size, number of candidate predictors, minority class proportion) and data quality (eg, completeness, accuracy). Consequently, we argue that efforts to improve data quality, not model complexity, are more likely to enhance the reliability and real-world utility of clinical prediction models.

Induction of labor (IOL) is a common yet complex clinical procedure associated with varying risks, including cesarean section (CS). Accurate prediction models may help support more informed, personalized decision-making. This study aimed to develop and validate an explainable machine learning prediction model for CS following IOL. We used population-based administrative perinatal datasets from two Australian states (New South Wales (NSW) and Queensland) covering all births between 2016 and 2019 for model development. Temporal validation was conducted using 2020 births from NSW, and geographical validation using 2016–2018 births from Victoria. We included women with singleton, cephalic, term, live births who attempted IOL and had no prior CS. Seven models (logistic regression, random forest, gradient boosting, LightGBM, XGBoost, CatBoost, and AdaBoost) were developed with hyperparameter tuning and feature selection. Performance was assessed using the area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve, calibration plot (overall and across sociodemographic subgroups), decision curve analysis, Brier Score, and model parsimony. SHAP (SHapley Additive exPlanations) values were used to explain predictor contributions. A total of 180,700 women were included in model development (mean age 31 ± 5 years; CS = 20.8%). The optimal model, developed using XGBoost with ten predictors, achieved AUROCs of 0.76 (95% CI: 0.75–0.77) and 0.75 (95% CI: 0.74–0.76) in temporal (n = 14,527; CS = 22.5%) and geographical (n = 14,755; CS = 19.0%) validations, respectively. The most influential predictors were nulliparity, pre-pregnancy body mass index, and maternal age, while diabetes and hypertension (pre-existing or pregnancy-related) contributed least. Women with higher predicted CS probabilities had increased inpatient costs and maternal morbidity, regardless of actual mode of birth. The final model is accessible via an interactive web application ( https://csai-8ccf2690242c.herokuapp.com/ ). This model demonstrates strong predictive performance using routinely collected maternal factors. Further co-design and implementation research is needed before potential clinical adoption.

OBJECTIVE:To critically appraise the literature on the cost-effectiveness of guideline-recommended treatments for osteoarthritis (OA). DESIGN:Electronic databases were searched for studies that provided incremental cost-effectiveness ratios (ICER) for treatments recommended by key international guidelines to manage OA in adults. Treatments were grouped as lifestyle and rehabilitative therapies, pharmacological, injection, or surgical. Primary outcome was ICERs, converted to 2023 US dollars for comparability across studies. Risk of bias was assessed using the Consensus on Health Economic Criteria checklist for trials and the Drummond checklist for modelling studies. Studies were deemed cost-effective based on established country-specific thresholds per quality-adjusted life-year. RESULTS:There were 110 studies that included 33 lifestyle and rehabilitative therapies, 25 pharmacological, 11 injection and 42 surgical studies. Most studies (95%) were conducted in high-income countries. Time horizons varied from 8 weeks to a lifetime. Risk of bias domains were frequently scored poorly related to cost methods. Overall, the cost-effectiveness of lifestyle and rehabilitative therapies and non-steroidal anti-inflammatory drugs (NSAIDs) was mixed. Hyaluronic acid injection was cost-effective in knee OA compared to placebo, usual care and paracetamol but not to corticosteroid injections and NSAIDs. Total hip or knee replacement was cost-effective compared to usual care or no surgery, with early access to replacement cost-effective compared to delaying surgery. CONCLUSIONS:There was a diversity of analytical perspectives and clinical heterogeneity of interventions. Policymakers should consider their local context when deciding clinical care and resource allocation.

Objectives:Pre-eclampsia (PE) affects approximately 2%-4% of pregnancies. Diagnosis involves repeated assessment of pregnant patients with risk factors. The sFlt-1/PlGF ratio test is shown to have clinical utility in ruling in and out PE among at-risk patients. By excluding the probability of PE, the addition of the sFlt-1/PlGF ratio test to antenatal care may prevent unnecessary hospital admissions, intensive management, and premature delivery, thus reducing costs. The objective of this systematic review is to determine the cost-effectiveness of the sFlt-1/PlGF ratio test globally for pregnant patients at-risk of developing PE. Data sources:PubMed, Medline (OVID), National Health Service Economic Evaluation Database, Web of Science, Econlit, and Cost Effectiveness Analysis Registry was systematically searched between 2013-April 2023. Study eligibility criteria:Empirical studies quantifying costs of the sFlt-1/PlGF ratio test compared to other diagnostic options for pregnant patients with suspected PE. Study appraisal and synthesis methods:Eleven studies were included in the systematic review; all were cost analyses and modelled economic evaluations, and most used a health system perspective. Cost data were extracted into tables and indexed to 2022 United States Dollars (USD). An assessment of risk of bias for each study was performed using the Drummond critical appraisal checklist. Results:All studies reported "cost-savings" of the test in antenatal care. Studies varied with costs and assumptions included, therefore a large range of incremental cost savings per patient was reported ($15-$1,881, 2022USD). No Incremental Cost-Effectiveness Ratios or health outcomes including Quality Adjusted Life Years were reported. Conclusions:The included studies demonstrated "cost-savings" of the sFlt-1/PlGF ratio test in antenatal care for at-risk pregnant patients. However, this does not account for health outcome differences and long-term health care utilisation and expenditure.

( Acta Obstet Gynecol Scand . 2024;103:946–954. doi:10.1111/aogs.14785) In high-income countries, there has been a clear trend toward earlier deliveries and a rise in the use of labor induction (IOL) and cesarean deliveries (CD) for women with term pregnancies. From 1990 to 2018, the average CD rate in high-income settings increased from 12% to 27% and is expected to reach 37% by 2030. Likewise, the rate of IOL rose from 20% in 1990 to 30% in 2019. Subsequently, the average length of pregnancy at delivery has dropped in the United States and Australia from 40 to 39 weeks. Australia has seen greater IOL and CD rates than other affluent nations. From 2010 to 2020, there was a rise in IOL rates from 25% to 37%, and CD rates increased from 31% to 36% for pregnancies at full term. There is concern that Australia’s CD rate may hit 45% by 2030. Cesarean delivery imparts increased risk for maternal and neonatal morbidity as well as substantial financial challenges for individuals and health care systems. This study investigated the probability of needing a CD after IOL in women with single, head-first pregnancies at 37 to 40 weeks, compared to women with spontaneous labor.