Pregnancy care to predict and prevent preterm birth – a survey of clinical practice predominantly from high-income settings

Preterm birth (PTB) before 37 weeks’ gestation is a global public health concern. PTB is major contributor to neonatal deaths and long-term morbidity. Rates of preterm birth globally are static and the burden of PTB disproportionately affects low-and-middle income countries. By contrast, the majority of clinical practice guidance to predict and prevent PTB has been developed in high-income countries. This survey was performed to describe clinician practice to predict and prevent PTB and identify barriers to implementation of current recommendations in a sample predominantly drawn from high-income settings. The survey was designed using the International Federation of Gynecology and Obstetrics (FIGO) good practice recommendations to prevent PTB which were published in 2021. Feedback was received during the design process from clinicians working in high- and low-income settings, and consumer feedback from the Miracle Babies Foundation. Ethical approval was granted by the University of Sydney Human Research Ethics Committee (protocol 2023/409). The survey was implemented electronically at the Fetal Medicine Foundation World Congress in June 2023 and through the Perinatal Society of Australia and New Zealand in August 2023. The survey was administered in English only. Statistical analysis was conducted using R: A language and environment for statistical computing (R Foundation for Statistical Computing, Vienna, Austria). One hundred twenty-four clinicians responded to the survey including 23 participants (18.5%) from low-and-middle-income countries and 101 participants (81.5%) from high-income countries. Most clinicians (96.0%) performed history-based screening for PTB, 59.7% measured the cervical length in all pregnancies, and 33.1% only measured cervical length in pregnancies at increased risk for PTB. Most clinicians offered progesterone (94.4%) or cervical cerclage (93.5%) for prevention of PTB. The main barriers identified were late presentation for antenatal care and referral pathways to PTB clinics. Additional barriers reported more commonly by clinicians in low-and-middle income countries were lack of support or tools for risk assessment, cost of progesterone, and reduced access to progesterone and cerclage. This study shows that there are barriers to implementation of current recommendations for prediction and prevention of PTB among surveyed clinicians, predominantly from high- income settings, with limited representation from low-and-middle income countries. Future prevention initiatives for PTB should consider implementation in a variety of clinical settings, include strategies to overcome barriers to care and should evaluate uptake of recommendations.