This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Some hospitals have established a preterm birth pathway to predict, prevent, and prepare for early births. This study reviewed and made suggestions on how best to implement the pathway. These included:
- better staff training on early birth and the pathway
- multidisciplinary preterm teams
- women-centered care.
Obstetricians, midwives, hospital managers, and professional bodies for maternity care could use the findings to improve care.
More information on premature birth can be found on the NHS website.
The issue: Can we improve the health of babies born early?
In the UK, 1 in 6 babies (8%) are born early (or prematurely) before 37 weeks. Babies born early are at higher risk of dying as newborns and of long-term health issues.
The NHS’ Saving Babies Lives Care Bundle recommends creating a pathway to predict, prevent, and prepare for early births. The guidance suggests that midwives assess all women for their risk of an early birth, with those at intermediate or high risk referred for further screening and possible interventions (a procedure to prevent the cervix opening too early, for instance). Since this guidance was published, the number of preterm birth clinics in England has risen from 30 (in 2017) to 78 (in 2021).
As more preterm birth clinics are being set up, this analysis evaluated the early birth pathway; it provides evidence-based advice on how to improve implementation.
What’s new?
The analysis included 29 research papers. The team interviewed 5 people who developed guidance for the pathway, and conducted a national survey of practice (96 hospitals in England responded). In-depth analysis at 3 hospitals with a pathway included interviews with 11 women and 13 staff, observation of practice in appointments with 87 women, and a review of local guidelines.
1. Risk assessments and referrals
Staff sometimes lacked knowledge about risk assessments and how women could reduce their risk, the research found. Referrals were often double checked by senior staff, wasting time and effort, and undermining the junior members of staff. Practical issues (outdated computer systems, for instance) prevented or slowed down risk assessments and referrals.
The researchers suggested:
- improved education and training on early birth; removal of barriers to assessment including adding checklists to computer systems, for example
- prompts for staff (via posters and email reminders) to promote risk assessments and referrals
- a culture of learning created by senior staff, encouraging staff to ask for help.
2. Preterm birth clinic
Units with a named preterm consultant and midwife, with specialist skills, delivered effective care. In these units, staff trusted each other, skills were passed on, and variation in care was reduced. Where a single staff member had specialist training (such as using ultrasound to measure the cervix), units struggled when that person was absent.
Specialist multidisciplinary teams could improve care, the researchers say. They suggest that individual units:
- audit their practice, and hold regular team meetings to discuss the care of women with complex needs
- are supported by local networks, which ensure sharing of resources (such as guidelines)
- all hold clinics on the same day so staff from different units can support each other.
The research team called for:
- clinical staff to flag issues to managers to speed up resolution
- hospital managers to improve hospital and clinic environments and ensure that necessary equipment is on hand, so that women and staff do not have to walk long distances through the hospital for tests
- managers to ensure that necessary training on specific scanning techniques is provided and that staff have protected time to attend; the Royal College of Obstetricians and Gynaecologists could extend its curriculum to include them.
3. Women-centred care
Women were reassured by continuity of care and seeing professionals who were aware of their medical history. Attending to routine aspects of pregnancy (such as birth plans and antenatal classes) helped women not to feel defined by their high-risk status. Focusing on what women can do, instead of what they cannot, and asking about preferences for birth, helped women feel in control.
The researchers suggested:
- greater continuity of care; women could have the contact details of their lead member of staff
- clinicians to signpost support, including relevant charities, such as Tommy’s
- hospital managers to ask women and staff for feedback on the pathway and be ready to adapt services.
Why is this important?
The researchers hope their suggestions will improve the implementation of the pathway for early birth risk assessment. They recognised that clinics work with tight budgets and have staffing shortages. Several of their suggestions do not require additional money or staff.
What’s next?
The study was carried out before the updated version 3 of the Saving Babies Lives Care Bundle was published. The researchers’ suggestions are in line with version 3 of the care bundle, and extend its recommendations. For example, the bundle recommends that clinics have access to transvaginal scans; the researchers suggest that scans would best be provided by the clinic itself.
Since the research was published, a screening test (Fetal Fibronectin biomarker swab) has been taken off the market. The NHS now advises use of alternatives (Actim Partus and/or PartoSure).
The team is carrying out 2 further studies; one on the newly developed role of preterm birth midwives, another is a national questionnaire on early birth practice.
You may be interested to read
This is a summary of: Carlisle N, and others. IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation (The IMPART Study). Implementation Science Communication 2024; 5: 1 – 15.
Information on preterm birth prevention clinics.
A book on early birth for midwives written by the study authors.
Information and support from the charity Tommy’s.
Information on taking part in NIHR research on pregnancy.
Funding: This study was supported by the NIHR Applied Research Collaboration South London and the NIHR Clinical Doctoral Research Fellowship Programme.
Conflicts of Interest: None relevant. Full disclosures are provided in the original paper.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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