The Australian Preterm Birth Prevention Alliance

Abstract

Preterm birth is the single greatest cause of death in the newborn period and early childhood.1 For those who survive there is an increased lifetime risk of disability including cerebral palsy, blindness, deafness and behavioural and learning problems at school age. Strategies that effectively reduce preterm birth would, therefore, have significant health, economic and social impact. Most recent data from 2017 demonstrate that in Australia 8.7% of babies were born preterm and this rate was higher than in 2010 when 8.4% of babies were preterm. Such an increase translates approximately to an extra 920 babies annually being born preterm. Of preterm births, 81% occur between 32 and 36 completed weeks.2 Across the nation there is variability in the rates of preterm births between states and territories. In New South Wales, the preterm birth rate is 7.4%, while in Northern Territory and Tasmania the rate is 11%. These variations are the result, in part, of the known associations of preterm birth with vulnerable populations. Many of the more significant risks of preterm birth are those that associate with socio-economic disadvantage, including history of preterm birth, young maternal age, low maternal education levels, current urogenital infection, alcohol consumption and smoking.3 In the Aboriginal population in the Northern Territory, the preterm birth rate is up to 14%. Aboriginal and Torres Strait Islander people comprise about 30% of the population of the Territory and more than 70% live in regional and remote communities.4 Such communities are more likely to face social disadvantage. In 2014, the Western Australian Preterm Birth Prevention Initiative was launched. It consisted of seven interventions. These included avoidance of elective delivery until at least 38+ weeks gestation; routine measurement of the length of the cervix at all mid-pregnancy ultrasound scans; prescription of natural vaginal progesterone for shortened cervix or past history of spontaneous preterm birth; promotion of smoking cessation; and the establishment of dedicated preterm birth prevention clinical service. To ensure maximal reach an intensive social media campaign known as ‘The Whole Nine Months’ was formulated as well as complementary print material that was widely distributed. Another important component was a state-wide outreach program that consisted of workshops for targeting healthcare practitioners in metropolitan, regional and rural Western Australia. The essence of the Initiative was to deliver learning programs to pregnant women and their families, in partnership with their healthcare providers. The Initiative was successful in reducing the preterm birth rate state-wide in the first full year of implementation. The preterm birth rate across Western Australia fell by 7.6% and in the tertiary-level centre by 20%.5 This was the world’s first instance of a population-wide intervention program that successfully reduced preterm birth. Leaning on the Western Australian experience, the Australian Preterm Birth Alliance was formed in 2018, led by Professor John Newnham as Chair, and Professor Jonathan Morris as Deputy Chair. Its vision is to safely lower the rate of early birth across the nation. The organisation sits within the Perinatal Society of Australia and New Zealand (PSANZ) as one of its sub-committees. Each of the six states and two territories has co-leaders, typically a senior obstetrician accompanied by a more junior clinician. Special expertise is provided by the members who represent the fields of neonatology, midwifery, biostatistics, health economics, health policy, consumer representation, media and marketing, and philanthropy. Together the 30 members sit on a Steering Committee with six members comprising an Executive. The Alliance initially is adopting, and adapting for local settings, the interventions that comprised the Initiative in Western Australia. It has set itself the mandate to play a central role in identifying those prevention strategies that are most effective and feasible in different areas of our healthcare system, assisting with implementation for our various communities, evaluating the benefits of their introduction, identifying appropriate research priorities, and mentoring the next generation of thought leaders. The Alliance also plans to participate in the development of preterm birth prevention strategies internationally through collaboration and knowledge sharing with the many potential agencies active in this important area of health care. The Alliance has been formally launched in five states and territories across our federation, each launch being characterised by the attendance of key government and health officials. In addition to the prevention of preterm birth, an important goal of the Alliance is to lengthen pregnancy and optimise the timing of birth when planned birth is deemed necessary for maternal and/or fetal indications. Gestational age at birth is strongly associated with an individual’s likelihood of surviving childhood. It also directly impacts one’s health and wellbeing throughout the life course. It is instructive to reflect on the following extrapolations from population data that demonstrate how powerful safe prolongation of pregnancy is for newborn and childhood outcomes. Within such a paradigm, gestational age can be, in some situations, considered a modifiable factor that can impact upon short, medium and long term outcomes. Such an approach has influenced care givers’ attitudes and decision making with respect to very preterm birth. It is, for instance, widely known that gestational age of birth affects survival at the lower limits of viability – such that the likelihood of death by two years of age is reduced by 8.5% if born at 27 weeks compared with 26 weeks.6 However, the powerful effect of prolongation of pregnancy is not as well incorporated into judicious decision making at more advanced gestational ages. Data from across Australia show that planned birth is becoming more common and the trends are for it to occur earlier in pregnancy.2, 7 Elective caesarean section performed at 34, 35 and 36 weeks gestation is associated with severe newborn morbidity rates of 54%, 32% and 19% respectively.7 These data suggest that, if possible, even a few days of temporisation in women who require planned birth will have clinically significant reductions in short term newborn health. It is also instructive to compare the effects of even a few days of maturation toward the end on fetal lung function. Extrapolating data from a double-blind randomised trial assessing the clinical effectiveness of corticosteroids before elective caesarean section for fetal lung maturation would suggest that at 38 weeks of gestation the therapeutic effect of steroids is the equivalent of the delivery occurring 4–5 days later8 when assessing the likelihood of the baby requiring admission to a special care setting for respiratory distress. These examples serve to demonstrate the benefits, if safe for mother and baby, of extending pregnancy up to 39 weeks. The recognition that 37 weeks is an arbitrary statistical construct and not a biological milestone that dichotomises fetuses into being mature or immature has seen a redefinition of ‘term’ pregnancy.9 It is recommended that births occurring between 37 weeks zero days and 38 weeks six days be considered ‘early term’ and those at 39 weeks zero days through 40 weeks six days are ‘full term’. There are common risk factors, including planned birth, that lead to late preterm and early term birth which suggest that common strategies will lead to their prevention.10 The association of shorter gestational duration even within the term range with poorer educational attainment11 and poorer socio-economic outcomes in adulthood11 underpin the importance of judicious decision making as to when planned birth should occur. Opportunities for the Alliance are therefore to deliver immediate and measurable benefit in the reduction of pregnancies that result in early planned preterm or early term birth. This will be complemented by effects of cervical screening and uniform management of the short cervix. Our well-established maternity data systems across the country are an opportunity for the Alliance to use routinely collected clinical data to measure uptake of interventions and their effectiveness. The Alliance also recognises that for vulnerable populations, such as remote Aboriginal and Torres Strait Islander communities, the task of reducing preterm birth will require a measured approach. This approach would encompass addressing the increased prevalence of risk factors, especially those related to social disadvantage, considering access to and appropriateness of care issues. This will be a long term commitment. In summary, The Australian Preterm Birth Alliance is well established across every state and territory of Australia. It aims to safely prevent early birth and, in so doing, ensure that planned birth occurs at the optimal time to ensure short and longer term health of the mother and child. Success will result in fewer early births, less resource utilisation and improved health of our children. It will be our nation as a whole that benefits. The authors wish to acknowledge the work of the Australian Preterm Birth Prevention Alliance Steering Committee: Catherine Arrese (Division of O&G, University of Western Australia, WA), Alicia Bauskis (WA Health, WA), Kiarna Brown (Royal Darwin Hospital, NT), Jeanie Cheong (Royal Women’s Hospital, VIC), Carina Cotaru (Royal Darwin Hospital, NT), Amanda Dennis (Launceston Obstetrics and Gynaecology, TAS), Dorota Doherty (Women and Infants Research Foundation, WA), Natasha Donnolley (National Perinatal Epidemiology and Statistics Unit, University of New South Wales, NSW), Lindsay Edwards (Fetal Maternal Unit, Royal Hobart Hospital, TAS), David Ellwood (Department of O&G, Griffith University, QLD), Tanya Farrell (Safer Care Victoria, VIC), Richie Hodgson (Women and Infants Research Foundation, WA), Stefan Kane (Royal Women’s Hospital, VIC), Chris Lehner (Royal Brisbane and Women’s Hospital, QLD), Boon Lim (Division of Women, Youth and Children, Canberra Hospital and Health Services, ACT), Paula Medway (SA Health, SA), Philippa Middleton (Paediatrics and Reproductive Health, University of Adelaide, SA), Jonathan Morris (Sydney Medical School – Northern, University of Sydney, NSW), John Newnham (Division of O&G, University of Western Australia, WA), Michael Nicholl (Division of Women’s, Children’s and Family Health, Royal North Shore Hospital, NSW), Tanya Nippita (Sydney Medical School – Northern, University of Sydney; Royal North Shore Hospital, NSW), Jeremy Oats (School of Population and Global Health, University of Melbourne, VIC), Roberto Orefice (Division of Women, Youth and Children, Canberra Hospital and Health Services, ACT), Deb Portughes (Women and Infants Research Foundation, WA), Monika Skubisz (Women's and Children's Hospital, SA), Euan Wallace (Safer Care Victoria, VIC), David Watson (Townsville Hospital, QLD), Scott White (King Edward Memorial Hospital, WA).

Topics & Concepts