Risk stratification and continuity of care in women at high risk of preterm birth
Seven per cent of births are premature
Babies born prematurely may need special care, are more likely to die and are more likely to have disabilities, or develop health problems in adult life than those born at full term(1)(2).
In 2012, seven per cent of live births in England and Wales were premature(3) – born before 37 weeks. 'In 40 per cent of cases, the cause of premature birth is not known,' says King's College London researcher Professor Jane Sandall who is leading the CLAHRC South London maternity and women's health research team. 'However, we do know that some women are at higher risk of giving birth prematurely. This includes women who have previously given birth prematurely, or women who have previously had a late miscarriage.'
The National Institute for Health and Care Excellence (NICE) is currently preparing a guideline about pre-term birth(4).
Piloting a dedicated team of midwives in Lewisham
Professor Sandall and her colleagues want to develop a better way of supporting women who have a higher risk of preterm birth. Working collaboratively with Lewisham Clinical Commissioning Group, they are going to trial a new-style service at Lewisham Hospital(4) in south-east London.
There are about 5,000 births a year registered in Lewisham: the Lewisham Maternity Pathway Profile 2011 (published by the former NHS London Health Programmes in March 2012) says two-thirds of the births that year were at Lewisham Hospital, and 191 of the total were pre-term.
The new service, which launched in May 2017, comprises a dedicated team of midwifes who will care for women at risk of premature birth during pregnancy, labour and thereafter at home, and a specialist obstetric preterm surveillance clinic at the hospital.
Professor Sandall's previous research(6) has shown the best care for pregnant women is given by the same individual midwife or team of midwives who offer support during pregnancy, birth and in the postnatal period. This enables women to get to know the person who will deliver their baby. Women who have this sort of continuity of care are more likely to give birth naturally and less likely to experience preterm birth.
A new clinic based on an award-winning model
The new clinic is modelled on the Preterm Surveillance Clinic (PSC) in the Maternal and Fetal Research Unit at St Thomas' Hospital, part of Guy's and St Thomas' NHS Foundation Trust, and set up and led by Professor Andrew Shennan, professor of obstetrics.
Staff at the PSC predict whether women will deliver prematurely by using a simple test to measure the exact level of the protein fetal fibronectin (fFN). This protein helps keep the baby in the womb.
The PSC at St Thomas' won an NHS Innovation Challenge Prize in 2013 for its success in reducing the number of premature births in south-east London. More than 90 per cent of high-risk women seen at the clinic have a healthy baby born at full-term.
Evaluating the success of the new service
The new service has been set up for research purposes only. It involves a reconfiguration of the existing midwifery service to support women who at risk of preterm birth in a different way.
Women who are identified as being at high risk of pre-term birth will be asked if they would like to take part in the research: some will be offered the new specialist service while others will be cared for in the usual manner.
Professor Sandall says: 'We will evaluate this pilot service over an 18 month to two-year period, if it is successful in Lewisham, we will apply for funding to run a multi-site trial of this new service model.'
Lewisham Clinical Commissioning Group has contributed £100,000 to help reconfigure the service from April 2015 to March 2017.
This pilot study of midwifery practice in preterm birth (POPPIE) launched in May 2017. Read the POPPIE newsletter.