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.