Investigating implementation of the preterm birth surveillance pathway

Currently some women at risk of preterm birth are referred to a specialist Preterm Birth Prevention Clinic alongside standard care, while the majority are offered standard care only. Only 33 consultant-led hospitals have a specialist preterm clinic out of 187 hospitals offering UK obstetric care (Care et al., 2018). 

Guidance recommends a new ‘Preterm Birth Surveillance Pathway’ (NHS England, 2019a) to standardise care and to reduce the preterm birth rate. This involves midwives assessing all women for their risk of preterm birth. Women at high or intermediate risk should be referred to a Preterm Birth Prevention (PBP) Clinic alongside normal care, where they can be offered further screening tests and interventions.

This pathway is in the NHS standard contract, meaning maternity providers should implement this by April 2020 (NHS England, 2019b). This study known as IMPART (Implementation of the Preterm Birth Surveillance Pathway), aims to research how, why, for whom, to what extent and in what contexts the Preterm Birth Surveillance Pathway is  or isn’t being implemented through a realist evaluation.

Study aims

• To identify contexts and mechanisms leading to both positive and negative outcomes in terms of implementation of the PBP
• To understand the relationship between the contexts, mechanisms and outcomes in implementing the PBP
• To identify and assess a range of implementation outcomes in implementing the PBP, and any unintended consequences
•  To determine optimal implementation theories for effective national uptake of PBP, to produce a set of recommendations to implement the pathway in a range of hospitals

Secondary clinical objective

•  Determine whether implementation of the pathway will reduce the incidence of women having a preterm birth (liveborn and stillborn).

How the study will be carried out

The research will be carried out through a realist evaluation, approach that is based on an assumption that projects and programmes work under certain conditions and are influenced by the way that different stakeholders respond to them. Instead of just asking ‘what works?’, realist evaluation asks ‘what works, for whom, in what circumstances?’ (Pawson and Tilley, 1997). The mixed methods data collection includes: women and staff interviews, observing staff, analysing hospital documentation, and analysing routinely collected hospital and administrative data across three demographically different case sites situated in different local maternity systems. 

Collaborators

The research will involve collaboration with a range of networks and experts in the fields of preterm birth, realist evaluation, implementation science and midwifery – all of which are crucial for this project. These include supervisors Prof Sandall from King's College London, Dr Dalkin at Northumbria University, and Prof Shennan from King's College London. Mary Newburn, (a health researcher and consultant in patient and public involvement in maternity services) is also involved, alongside Tommy’s and Bliss charities (who have written letters of support for this project).  The research lead is also a member of the London Maternity Clinical Network Perinatal Morbidity and Mortality Working Group, and the UK Preterm Birth Network.

How this research is meeting the needs of local people

While the current preterm rate is 8% in the UK, we know that particular groups of women are more likely to have a preterm birth. These include women living in deprived neighbourhoods, and women who are from Black, Asian and/or minority ethnic backgrounds. Areas in south London include some of the most deprived parts of the city and south London is one of the most ethnically diverse areas in England.

Babies that are born preterm have high rates of neonatal mortality. Those that do survive often have short and long term health problems, which can affect their whole adult life.

Benefits of the research

This research will produce a set of recommendations for implementing the pathway in a range of hospitals. This will ensure the Preterm Birth Pathway is implemented effectively, helping to decrease the preterm birth rate from 8% to 6% by 2025 (Department of Health, 2017), and reduce the annual NHS preterm birth cost of over one billion pounds (Mangham et al., 2009).    

How service users are involved in the research

A patient and public involvement (PPI) meeting will be held (inviting up to five women who have recently given birth) to explain the project, discuss mutual expectations, develop and review study documents. As busy new mothers, their expectations regarding involvement will be discussed and all meetings will have teleconference facilities to simplify attendance. Effort will be made to recruit PPI women from groups at higher risk of preterm birth (e.g.  women who identify as Black or Black British). 

Throughout the study, the research team will meet the project advisory group (invited members to include the four women from the initial PPI meeting above). As realist evaluation is an iterative, non-linear process, regular PPI input throughout the study will be crucial to honing the research at each stage. At the end of the study, a dissemination plan will be co-developed with the project advisory group.

The study is funded by an NIHR Clinical Research Doctoral Fellowship. It was adopted by ARC South London in November 2020 and will be completed by September 2023.