Obstetrics
Metropolitan hospital

A high rate of preterm births prompted a team of obstetricians and midwives to investigate contributing factors. Read how the team put in place a preterm birth prevention initiative, based on a successful WA program. A new booking process for elective births also reduced variation in early planned births.

To view the summarised case study, you can skip to At a glance.

Last updated on 19 October 2022

Step 1. Select priority areas
Step 1. Select priority areas

Uncovering the problem – a high rate of preterm births

The Clinical Director of Obstetrics and Gynaecology in the ACT had been concerned by Australia’s rising rate of preterm births (before 37 weeks gestation), and early planned births (38-39 weeks gestation) without a medical indication, for many years. The recent success of the WA ‘Whole Nine Months’ initiative in reducing early births was the impetus for targeting this issue at the Centenary Hospital for Women and Children, Canberra, which is the sole tertiary referral hospital for high-risk pregnancies in the ACT and surrounding areas of NSW. Emerging evidence of the adverse long- and short-term effects of early term birth (37-38+6 weeks) was a further prompt to examine the hospital’s performance in this clinical area.

Step 2. Plan the project
Step 2. Plan the project

Finding the right tool for the job – one that allows comparisons

The team, made up of two obstetricians and a midwife, decided to use data from The Birth Outcome System electronic medical record of the Canberra Hospital and compare with rates from WA.

Step 3. Measure and review
Step 3. Measure and review

Assessing the findings – how do they compare?

The percentage of babies born preterm in the ACT pre-intervention was 9.7% (average 2014-2018), compared to 7.0% in WA over the same period.

The percentage of planned births with no medical indication between 37 to 38 weeks plus 6 days was 18.8% in the ACT (average 2014-2018).

Step 4. Explore reasons
Step 4. Explore reasons

Getting to the root of the problem – look for all the angles

The team identified contributing factors, including:

  • Inconsistent use of interventions to prevent preterm birth
  • A large proportion of high-risk pregnancies due to the hospital’s status as a tertiary referral service
  • High rates of smoking
  • Variable continuity of care for women with high-risk pregnancies
  • Lack of a consistent screening process for women at high risk of preterm births.
Step 5. Act to improve
Step 5. Act to improve

Putting the changes in place – a multi-faceted approach

The ACT preterm birth prevention initiative, based on the WA Whole Nine Months initiative, was introduced in 2019 with funding provided by the Canberra Hospital Foundation. The initiative included:

  • Developing a guideline for management of women with low-, medium- and high-risk pregnancies, followed by three months of outreach education for general practitioners, obstetricians, sonographers, and midwives
  • Establishing a dedicated multidisciplinary preterm birth prevention clinic
  • Appointment of a dedicated midwife for the service, supported by two obstetricians with an interest in preterm birth prevention
  • Universal screening of cervical length at the 18-20 week ultrasound scan
  • Progesterone pessaries for women with a shortened cervix or a history of preterm birth, and consideration of cervical cerclage (suture) in some cases
  • A structured smoking cessation program

Strategies to avoid planned birth before 39 weeks unless medically indicated were also introduced. These included a streamlined booking process for induction of labour and timing of elective caesarean sections for 39 weeks unless there was an obstetric indication for an earlier delivery.

Step 6. Monitor and report
Step 6. Monitor and report

Looking at the impact – celebrate success and build on it

After 16 months of the intervention, preterm births were reduced by 10% compared to the previous five years; planned early term births with no medical indication were reduced by 35% compared with the previous five years, with no increase in the stillbirth rate. Rates of preterm birth and early term birth continue to be monitored and reported to the department’s Quality and Safety Committee. The Unit is a member of the Australian Preterm Birth Prevention Alliance, and reports data to it also.

Education for obstetricians, midwives and ultrasonographers is ongoing. Further quality improvement activities are also continuing, including smoking cessation, and screening for infection projects.

At a glance

Issues
  • A high rate of preterm births
  • Planned births before 39 weeks with no medical indication
Barriers
  • Inconsistent use of interventions to prevent preterm birth
  • Variable continuity of care for women with high-risk pregnancies
  • Lack of consistent screening process for women at high risk of preterm birth
  • Smoking
Enablers
  • Success of the WA Whole Nine Months initiative, which could be emulated
  • Funding from Canberra Hospital Foundation
  • Reporting to and monitoring by the Quality and Safety Committee
Solutions
  • Development of a guideline for management of low-, medium- and high-risk pregnancies
  • Establishment of a dedicated multidisciplinary preterm birth prevention clinic
  • Universal screening of cervical length at the 18-20 week ultrasound scan
  • A structured smoking cessation program
  • Introduction of a streamlined booking process for elective induction or caesarean section at no earlier than 39 weeks