Search

Information provision for women about the risk for preterm birth (PTB)

Authors

Schlembach D, Simeoni U, Nagy Bonnard L, Bernloehr A, Cetin I, Gente M, Grosek S, Johnston L, Jourdain G, Kainer, Ratnavel N, Rossi R, Roth-Kleiner M, Visser G

© Christian Klant Photography

User group

Healthcare professionals caring for women, perinatal units, hospitals, and health services

Statement of standard

All (pregnant) women receive timely information and counselling about potential risk factors for and signs and symptoms of preterm birth and how to find appropriate healthcare advice. (see TEG Follow-up & continuing care)

Rationale

Risk identification and education regarding the signs and symptoms of preterm birth are essential components of obstetric care. They should be a routine part of obstetric care, since counselling of women and their partners and early intervention may be effective in reducing the risk of preterm birth. Healthcare providers (be it a midwife, general practitioner or an obstetrician/gynaecologist) should be able to advise and appropriately triage patients at risk for preterm birth. (1–10)

Differentiation between low risk and high risk pregnancies is important to assess the best strategy of preventing preterm birth or managing women at risk. Specific standards of care should be applied to women with known risk factors for preterm birth. Early detection and provision of specialist care may reduce the incidence of preterm birth and the associated fetal/neonatal and maternal complications. (1–10). Although for the majority of preterm births the cause may be uncertain, there are specific risk constellations that women and healthcare professionals should be aware of.

Criteria/risk factors for preterm birth include pregnancy related factors, demographic and behavioural factors, underlying medical conditions of the mother and fetal conditions (detailed information see table at “description”). (1–10)

Benefits

Short-term benefits

  • Better informed women and partners (6,11–14,17,20–24)
  • Improved pregnancy follow-up (4,11,15,17,20,21)
  • Earlier recognition of impending complications (4,11,15,19–21)
  • Earlier transfer/referral to a specialist (4,11,15,17,19–21)
  • Better and earlier initiation of prophylactic or therapeutic regimens (4,11,15,17–21)
  • Reduced perinatal mortality and morbidity (12,15–21,24)
  • Reduced maternal mortality and morbidity (12,17–19,23,24)
  • Reduced healthcare costs (12,17)

Long-term benefits

  • Improved short- and long-term outcomes (mother and infant/child) (consensus)
  • Reduced healthcare costs (consensus)
  • Increased population awareness about pregnancy complications (consensus)

 

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. (Pregnant) women are informed by healthcare professionals about risk factors and also symptoms and/or signs for impending pregnancy complications. (13,14,20–24) A (High quality)
B (High quality)
Patient information sheet
       
2. Accurate communication (all essential information) is provided. (13,14) A (High quality)
B (High quality)
Parent feedback
       
For healthcare professionals    
3. Training on the risks and signs of preterm birth and tools for assessment of risk for impending preterm birth is attended by all responsible healthcare professionals. (25–30) A (High quality)
B (High quality)
Training documentation
       
4. Professional and empathic communication is provided. (13,14) A (High quality)
B (High quality)
Healthcare professional feedback, parent feedback
       
5. Women at risk for very preterm birth are cared for exclusively in specialist centres. (31–33) A (High quality)
B (High quality)
Audit report
       
For perinatal unit    
6. A unit guideline on procedures and algorithms for the management of threatened preterm birth and underlying conditions is available and regularly updated. (34) A (High quality)
B (High quality)
Guideline
       
7. Women at risk for very preterm birth are referred and transferred to appropriate delivery clinic in a timely fashion. (31–33) A (High quality)
B (High quality)
Audit report
       
For hospital    
8. Training on the risks and signs of preterm birth and tools for assessment of risk for impending preterm birth is ensured. B (High quality) Training documentation
       
9. Continuous quality improvement programme is in place. (35) A (High quality)
B (Moderate quality)
Audit report
       
For health service    
10. A national guideline on procedures and algorithms for the management of threatened preterm birth and underlying conditions is available and regularly updated. B (High quality) Guideline
       
11. Regional networks for perinatal care are established. (36) A (High quality) Regional network
       
12. Risk reduction programmes are in place. B (Moderate quality) Audit report
       
13. An appropriate working environment for pregnant women is provided by employers. (37) C (High quality) Workplace legislation
       

Where to go

Further development Grading of evidence
For parents and family  
  • Advocate for enhanced maternity and paternity leave benefits.
B (High quality)
For healthcare professionals  
N/A  
For perinatal unit  
N/A  
For hospital  
N/A  
For health service  
  • Encourage or promote increase in funding of research on the causes and prevention of preterm birth.
B (Moderate quality)
   

Getting started

Initial steps
For parents and family
  • Parents are verbally informed in a timely manner on healthy pregnancy and pregnancy complications by healthcare professionals.
For healthcare professionals
  • Attend training on the risks and signs of preterm birth and tools for assessment of risk for impending preterm birth and pregnancy complications.
  • Counsel women/couples (e.g. by midwives, general practitioners, obstetricians/gynaecologists).
For perinatal unit
  • Develop and implement a unit guideline on procedures and algorithms for the management of threatened preterm birth and underlying conditions.
  • Distribute information material on healthy pregnancy and pregnancy complications for parents.
For hospital
  • Support healthcare professionals to participate in training on the risks and signs of preterm birth and tools for assessment of risk for impending preterm birth.
For health service
  • Develop and implement a national guideline on procedures and algorithms for the management of threatened preterm birth and underlying conditions.
  • Develop information material on healthy pregnancy and pregnancy complications for parents.
 

Description

Risk factors for preterm birth (3–10)

Pregnancy related conditions

  • Reproductive history: history of (spontaneous) preterm birth or abortion
  • Preterm labour: may be caused by several conditions: multiples, hydramnios, infection, …
  • Multiple pregnancy
  • Pregnancy complications: Gestational diabetes, hypertensive disorders (preeclampsia), intrauterine growth restriction, vaginal bleeding in early pregnancy, cervical insufficiency
  • Assisted reproduction techniques: higher number of multiples and increased risk of pregnancy complications
  • Uterine/cervical infections

Fetal conditions

  • Fetal malformations
  • Intrauterine growth restriction

Underlying medical conditions

  • Uterine or cervical abnormalities
  • Chronical medical disorders: hypertension, renal insufficiency, diabetes mellitus, autoimmune diseases, anemia

Demographic factors

  • Age: particularly young (<17 years) or older women (>35 years)
  • Ethnicity: higher risk for preterm birth in black women
  • Socioeconomic background: low education level, low income, little social support does play a role for preterm birth
  • Genetic influence: Specific fetal and maternal genotypes

Modifiable lifestyle risk factors

  • Short inter-pregnancy interval
  • Smoking or substance abuse
  • Exposure to environmental pollutants
  • Under- and overweight (obesity)
  • Unbalanced diet
  • High stress level
  • Suboptimal prenatal care

Sources

  1. Rubens CE, Sadovsky Y, Muglia L, Gravett MG, Lackritz E, Gravett C. Prevention of preterm birth: harnessing science to address the global epidemic. Sci Transl Med. 2014 Nov 12;6(262):262sr5.
  2. Delnord M, Blondel B, Zeitlin J. What contributes to disparities in the preterm birth rate in European countries? Curr Opin Obstet Gynecol. 2015 Apr;27(2):133–42.
  3. Frey HA, Klebanoff MA. The epidemiology, etiology, and costs of preterm birth. Semin Fetal Neonatal Med. 2016 Apr;21(2):68–73.
  4. Koullali B, Oudijk MA, Nijman T a. J, Mol BWJ, Pajkrt E. Risk assessment and management to prevent preterm birth. Semin Fetal Neonatal Med. 2016 Apr;21(2):80–8.
  5. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet Lond Engl. 2016 Feb 6;387(10018):587–603.
  6. Mehta-Lee SS, Palma A, Bernstein PS, Lounsbury D, Schlecht NF. A Preconception Nomogram to Predict Preterm Delivery. Matern Child Health J. 2017 Jan;21(1):118–27.
  7. Robinson J, Norwitz E. Risk factors for preterm labor and delivery [Internet]. 2016. Available from: www.uptodate.com
  8. Sørbye IK, Wanigaratne S, Urquia ML. Variations in gestational length and preterm delivery by race, ethnicity and migration. Best Pract Res Clin Obstet Gynaecol. 2016 Apr;32:60–8.
  9. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet Lond Engl. 2008 Jan 5;371(9606):75–84.
  10. Keller M, Saugstad OD, van Steenbrugge G, Mader S, Thiele N. Caring for Tomorrow. EFCNI White Paper on Maternal and Newborn Health and Aftercare Services [Internet]. European Foundation for the Care of Newborn Infants (EFCNI); 2011. Available from: http://www.efcni.org/fileadmin/Daten/Web/Brochures_Reports_Factsheets_Position_Papers/EFCNI_White_Paper/EFCNI_WP_01-26-12FIN.pdf
  11. Chandiramani M, Shennan A. Preterm labour: update on prediction and prevention strategies. Curr Opin Obstet Gynecol. 2006 Dec;18(6):618–24.
  12. Kiss H, Pichler E, Petricevic L, Husslein P. Cost effectiveness of a screen-and-treat program for asymptomatic vaginal infections in pregnancy: towards a significant reduction in the costs of prematurity. Eur J Obstet Gynecol Reprod Biol. 2006 Aug;127(2):198–203.
  13. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ. 2007 Jul 7;335(7609):24–7.
  14. Johnson B, Abraham M, Conway J, Simmons L, Edgman-Levitan S, Sodomka P, et al. Institute for Healthcare Improvement: Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices [Internet]. [cited 2017 Nov 3]. Available from: http://www.ihi.org/resources/Pages/Publications/PartneringwithPatientsandFamiliesRecommendationsPromisingPractices.aspx
  15. Lim K, Butt K, Crane JM, DIAGNOSTIC IMAGING COMMITTEE, FAMILY PHYSICIANS ADVISORY COMMITTEE, MATERNAL FETAL MEDICINE COMMITTEE. SOGC Clinical Practice Guideline. Ultrasonographic cervical length assessment in predicting preterm birth in singleton pregnancies. J Obstet Gynaecol Can JOGC J Obstet Gynecol Can JOGC. 2011 May;33(5):486–99.
  16. Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, O’Brien JM, Cetingoz E, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol. 2012 Feb;206(2):124.e1-19.
  17. Heller HM, van Straten A, de Groot CJM, Honig A. The (cost) effectiveness of an online intervention for pregnant women with affective symptoms: protocol of a randomised controlled trial. BMC Pregnancy Childbirth. 2014 Aug 14;14:273.
  18. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD007754.
  19. Conde-Agudelo A, Romero R. Vaginal progesterone to prevent preterm birth in pregnant women with a sonographic short cervix: clinical and public health implications. Am J Obstet Gynecol. 2016 Feb;214(2):235–42.
  20. Ellings JM, Newman RB, Hulsey TC, Bivins HA, Keenan A. Reduction in very low birth weight deliveries and perinatal mortality in a specialized, multidisciplinary twin clinic. Obstet Gynecol. 1993 Mar;81(3):387–91.
  21. Hobel CJ, Ross MG, Bemis RL, Bragonier JR, Nessim S, Sandhu M, et al. The West Los Angeles Preterm Birth Prevention Project. I. Program impact on high-risk women. Am J Obstet Gynecol. 1994 Jan;170(1 Pt 1):54–62.
  22. Hofmanova I. Pre-conception care and support for women with diabetes. Br J Nurs Mark Allen Publ. 2006 Feb 26;15(2):90–4.
  23. Ota E, Hori H, Mori R, Tobe-Gai R, Farrar D. Antenatal dietary education and supplementation to increase energy and protein intake. Cochrane Database Syst Rev. 2015 Jun 2;(6):CD000032.
  24. Chamberlain C, O’Mara-Eves A, Porter J, Coleman T, Perlen SM, Thomas J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017 14;2:CD001055.
  25. Chang E. The role of simulation training in obstetrics: a healthcare training strategy dedicated to performance improvement. Curr Opin Obstet Gynecol. 2013 Dec;25(6):482–6.
  26. Daniels K, Auguste T. Moving forward in patient safety: multidisciplinary team training. Semin Perinatol. 2013 Jun;37(3):146–50.
  27. Bogne V, Kirkpatrick C, Englert Y. [Simulation training in the management of obstetric emergencies. A review of the literature]. Rev Med Brux. 2014 Dec;35(6):491–8.
  28. Ameh CA, van den Broek N. Making It Happen: Training health-care providers in emergency obstetric and newborn care. Best Pract Res Clin Obstet Gynaecol. 2015 Nov;29(8):1077–91.
  29. Moran NF, Naidoo M, Moodley J. Reducing maternal mortality on a countrywide scale: The role of emergency obstetric training. Best Pract Res Clin Obstet Gynaecol. 2015 Nov;29(8):1102–18.
  30. American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality Improvement, American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 657 Summary: The Obstetric and Gynecologic Hospitalist. Obstet Gynecol. 2016 Feb;127(2):419.
  31. Viisainen K, Gissler M, Hartikainen AL, Hemminki E. Accidental out-of-hospital births in Finland: incidence and geographical distribution 1963-1995. Acta Obstet Gynecol Scand. 1999 May;78(5):372–8.
  32. Lui K, Abdel-Latif ME, Allgood CL, Bajuk B, Oei J, Berry A, et al. Improved outcomes of extremely premature outborn infants: effects of strategic changes in perinatal and retrieval services. Pediatrics. 2006 Nov;118(5):2076–83.
  33. Sudo A, Kuroda Y. The impact of centralization of obstetric care resources in Japan on the perinatal mortality rate. ISRN Obstet Gynecol. 2013;2013:709616.
  34. Imamura M, Kanguru L, Penfold S, Stokes T, Camosso-Stefinovic J, Shaw B, et al. A systematic review of implementation strategies to deliver guidelines on obstetric care practice in low- and middle-income countries. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2017 Jan;136(1):19–28.
  35. Bennett IM, Coco A, Anderson J, Horst M, Gambler AS, Barr WB, et al. Improving maternal care with a continuous quality improvement strategy: a report from the Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network. J Am Board Fam Med JABFM. 2009 Aug;22(4):380–6.
  36. American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine, Menard MK, Kilpatrick S, Saade G, Hollier LM, Joseph GF, et al. Levels of maternal care. Am J Obstet Gynecol. 2015 Mar;212(3):259–71.
  37. European Agency for Safety and Health at Work. EUR-Lex – 01992L0085-20140325 – EN – EUR-Lex [Internet]. [cited 2017 Nov 3]. Available from: http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A01992L0085-20140325

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Schlembach D, Simeoni U et al. European Standards of Care for Newborn Health: Information provision for women about the risk for preterm birth. 2018.

For the purpose of evaluation, we would be grateful if you could send us details on your profession and country. This information is optional, anonymous and the data processed will exclusively be used for the aforementioned purpose, in line with Article 6, Para. 1 lit. a GDPR (General Data Protection Regulation).

Thank you for your support!