In the era of blue growth, ocean multi-use is gaining popularity for its potential environmental, economic and societal synergies. Expectations are high for multi-use applications to alleviate marine spatial allocation conflicts amongst users of the sea, and to stimulate innovative ways of sustainably exploiting marine resources. However, a potential barrier to implementing multi-use and co-location is the lack of a well-defined framework to evaluate the impacts of ocean multi-use projects. This paper introduces the Ocean Multi-Use Assessment Framework (OMAF), which builds upon traditional environmental impact assessments but expands to include societal and economic dimensions. In addition to these three pillars of sustainable development, the framework incorporates two critical conditions: technological feasibility and regulatory appropriateness (legal, policy, and governance). The framework promotes the use of scenarios to compare single-use and multi-use approaches in an integrated manner. This approach allows for a comprehensive, holistic evaluation of multi-use projects compared to single-use alternatives, supporting decision-making. Strong stakeholder engagement throughout the process is emphasized. The OMAF has been developed and tested under the EU-funded Horizon 2020 UNITED project, where it was applied to five multi-use pilot projects. Despite challenges related to data availability for emerging marine activities, the framework has proven applicable and effective for most projects.

OBJECTIVE: To assess and compare the rate of procedure-related complications after intrauterine treatment of spina bifida by endoscopic surgery and by open fetal surgery.

METHODS: Systematic literature searches in PubMed and SCOPUS databases were performed on 20 September 2015 to identify randomized controlled trials and observational studies on treatment of human spina bifida by endoscopic or open fetal surgery techniques. Only studies with ≥ 10 cases that were published in or after 2000 were included in the meta-analysis in order to reduce the risk of bias. Primary outcomes (complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar; preterm delivery < 34 weeks; mean gestational age at delivery) and secondary outcomes (oligohydramnios, prelabor rupture of membranes, placental abruption, chorioamnionitis and perinatal death) were assessed for both techniques. Precision of the estimated proportions was evaluated with 95% CIs. Inconsistency was assessed using the I(2) statistic.

RESULTS: The search identified 1080 records that were examined based on title and abstract, of which 28 full-text articles were examined completely for eligibility. Nine records were excluded because cases were also described in other studies, leaving 19 records for analysis. When comparing endoscopic vs open fetal surgery, the rate of complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar was, respectively, 1% (95% CI, 0-4%) vs 26% (95% CI, 12-42%); preterm delivery < 34 weeks was 80% (95% CI, 41-100%) vs 45% (95% CI, 38-53%); oligohydramnios was 39% (95% CI, 9-75%) vs 14% (95% CI, 7-24%); prelabor rupture of membranes was 67% (95% CI, 12-100%) vs 38% (95% CI, 26-50%); and perinatal death was 14% (95% CI, 1-38%) vs 5% (95% CI, 3-8%).

CONCLUSION: Open fetal surgery for spina bifida seems to show lower rates of procedure-related complications than does endoscopic surgery, but the rate of hysterotomy scar complications is high after open surgery. Because of the low quality of evidence, the conclusions should be interpreted with caution.