Background: Currently, noninvasive prenatal testing (NIPT) is only recommended in high-risk women following conventional Down syndrome (DS) screening, and it has not yet been included in the Australian DS screening program. Aims: To evaluate the cost-effectiveness of different strategies of NIPT for DS screening in comparison with current practice. Methods: A decision-analytic approach modelled a theoretical cohort of 300,000 singleton pregnancies. The strategies compared were the following: current practice, NIPT as a second-tier investigation, NIPT only in women >35 years, NIPT only in women >40 years and NIPT for all women. The direct costs (low and high estimates) were derived using both health system costs and patient out-of-pocket expenses. The number of DS cases detected and procedure-related losses (PRL) were compared between strategies. The incremental cost per case detected was the primary measure of costeffectiveness. Results: Universal NIPT costs an additional $134,636,832 compared with current practice, but detects 123 more DS cases (at an incremental cost of $1,094,608 per case) and avoids 90 PRL. NIPT for women >40 years was the most costeffective strategy, costing an incremental $81,199 per additional DS case detected and avoiding 95 PRL. Conclusions: The cost of NIPT needs to decrease significantly if it is to replace current practice on a purely costeffectiveness basis. However, it may be beneficial to use NIPT as first-line screening in selected high-risk patients. Further evaluation is needed to consider the longer-term costs and benefits of screening.

Background Perinatal depression and/or anxiety disorders are undertreated pregnancy complications. This is partly due to low rates of engagement by women. This study aimed to identify barriers and facilitators to women accessing perinatal mental health services in an outer metropolitan hospital in Queensland, Australia. Methods Data was collected from pregnant women through a cross-sectional survey. Women rated the extent certain factors influenced their engagement. Respondents were separated into three groups: women who were not offered a referral to perinatal mental health services, women who were offered a referral but did not engage, and women who engaged. Results A total of 218 women participated. A response rate of 71% was achieved. 38.1% of participants did not believe themselves knowledgeable about mental illness in the perinatal period, and 14.7% did not recall being asked about their mental health during their pregnancy. Of those participants who recalled being asked about their mental health, 37.1% were offered a referral. Of these, just over a third (36.2%) accepted, and out of this group, 40% attended an appointment. Regardless of referral and engagement status, the factors identified as influencing participant engagement were time restraints, lack of childcare support, and encouragement by family and health care professionals. Stigma was not identified as a barrier. Conclusions Perinatal mental health service engagement could be improved by health services: ensuring universal screening and actively engaging women in the process: assisting with childcare; improving appointment immediacy and accessibility; and educating health care professionals about their influence on women’s engagement. Electronic supplementary material The online version of this article (10.1186/s12884-019-2320-9) contains supplementary material, which is available to authorized users.

Noninvasive prenatal testing (NIPT) can analyze cell-free DNA of placental origin in maternal serum for trisomy 21. The detection rate is 99.5%, and the false-positive rate (FPR) is 0.2%. Noninvasive prenatal testing is recommended only for highrisk women after conventional screening. Noninvasive prenatal testing is deemed a screening modality, and invasive diagnostic testing is required for confirmation following a "positive" result. The present study was performed to evaluate NIPT by comparing 4 strategies examining cost-effectiveness and budget impacts for health care systems and parturients.A decision-analytic model was created to compare screening-related costs and consequences of NIPT implementation. The first strategy involved current practices using combined first-trimester screening (CFTS) is offered to all women at 11 to 13 weeks' gestation. Women at high risk for DS are offered invasive diagnostic testing, via amniocentesis with fluorescence in situ hybridization and karyotyping. For strategy 2, NIPT is a second investigation after high-risk CFTS stratification. It was assumed that only women with a positive NIPT undergo invasive diagnostic testing and further counseling. Strategies 3A and 3B categorize women as high or low risk. Women 35 years or older are considered high risk and are initially offered NIPT; all others are offered CFTS, and only those considered at high risk for DS undergo NIPT. All women who are NIPT positive are referred for invasive diagnostic testing. In strategy 4, universal NIPT replaces CFTS with NIPT as the primary screening modality. All women with a positive NIPT undergo invasive diagnostic testing and counseling. Estimated costs for each strategy were those directly related to screening and accruing to government agencies and out-of-pocket costs to the woman. Outcomes included the number of DS cases detected and the number of procedure-related losses (PRLs) avoided by not performing invasive diagnostic testing. Two cost estimates for each strategy were calculated. The low estimate included costs to the health system and patients based on the current Medicare Benefits Schedule cost and the lowest estimate of patient outof-pocket costs; the high estimate was based on both Medicare costs and the highest estimates of private health care prices.Universal NIPT was the most effective strategy and detected 657 DS cases, resulting in 11 PRLs. Strategies 3A and 3B (maternal ages >35 and >40 years, respectively) were more effective than current practices for detecting DS and avoiding PRLs. Strategy 2 was less effective for DS detection, but more effective in avoiding PRLs. Five to 11 PRLs occurred with the new strategies compared with 101 PRLs for the current practice. Strategy 2 was the least expensive option. Implementing universal NIPT would cost more than 4 times the current expenditures on DS screening. The higher cost estimates were double or triple those of the low cost, with higher out-of-pocket costs for patients. Based on DS detection, the most cost-effective new strategy wa...