Strengths
The success of the initiative was multifactorial. Firstly, the study was
conducted in a well-resourced country, with a universal health care
system. This allowed for the key interventions to be implemented with
minimal issues around dissemination of information, access to care or
health care costs. Cost of progesterone pessaries were initially
subsidised by the Canberra Health Services to minimise barriers to use
as it was recognised that the higher cost of this medication could
results in unequal access to an effective
intervention.21 This medication is now available under
the Pharmaceutical Benefits Scheme, further removing the barriers to
accessibility of this treatment. The establishment of a dedicated
preterm birth prevention clinic was key to the initiative and provided a
consistent central point for information, education, referrals and
reviews. CHWC is the sole tertiary level referral centre for high risk
cases for the ACT and NSW surrounding areas and this assisted in
identifying and offering interventions for all women at risk of PTB. The
benefits of continuity of care especially for reducing preterm birth22 was recognised and all women were offered
continuity in pregnancy with a dedicated PTB prevention midwife and
obstetrician. Additional staff training was undertaken in nicotine
addiction and smoking cessation to support the implementation of a
structured smoking cessation program. Outreach education also played a
key role in the initiative’s success. A widespread education program
that included tertiary and regional hospitals in the ACT and NSW that
refer to the CHWC was conducted. Almost a quarter of women who gave
birth in the ACT are non-ACT residents and data from 2018 showed that
the proportion of PTB for ACT residents who gave birth in the ACT was
8.1% whereas 17.3% of non-ACT residents had PTBs in ACT
hospitals.8 Including NSW surrounding hospitals,
therefore, was crucial for the program’s success.
A before and after study was the best study design for our research
purpose. We wanted to evaluate an intervention by assessing trends over
time across a population. We did not identify any extraneous variables
that may have influenced the rates of early births across the ACT during
the study period. We included multiple measurement over many years to
strengthen the evidence of the effect of the initiative. The data for
the study was sourced from a highly reliable perinatal database meaning
our results are likely to be accurate which strengthens the study’s
results.