Context: Preterm birth accounts for significant neonatal mortality and morbidity as well as substantial health costs. As our understanding of aetiology and risk factors for preterm birth increases, predictive tools and prophylactic interventions have been developed to improve maternal and fetal outcomes. These are effective, but require surveillance of asymptomatic high-risk women, as well as ultrasound and surgical expertise. This has led to the development of preterm birth surveillance clinics (PSCs), which pool these resources together and have changed the focus of care from reactive to predictive and preventative management. Methods: A literature review of the evidence surrounding the predictive tests (cervical length, fetal fibronectin, Actim Partus, Partosure) and prophylactic interventions (cerclage, progesterone, Arabin pessary, antibiotics, and steroids) for preterm birth to understand what preterm birth surveillance clinics do and how effective they are. Results: Measuring cervical length and fetal fibronectin levels are two of the most accurate predictive tests preterm birth, especially when used in combination. Other predictive tools like Actim Partus and Partosure are effective for symptomatic women, but their role in surveillance of asymptomatic women is unclear. Cervical cerclage is effective in reducing preterm birth in women with previous losses, but the role of progesterone and pessaries remains debated. Steroids remain one of the most effective antenatal intervention, but they need to be administered within a tight timeframe in order to confer maximal benefit. The role of PSCs in predicting the timing of birth and targeting women at highest risk to appropriate interventions is therefore crucial in optimizing care and improving outcomes. Conclusions: Nearly every step of management is still debated although many have a strong evidence-base and effective interventions do exist. The challenge is finding the optimal management pathway, and details of which populations benefit from which interventions need to be evaluated. While evidence continues to be collated, the poor outcomes of preterm birth and the multiple options available to reduce them justify preterm birth surveillance clinics being resourced.Keywords: Preterm Birth, Predictive, Fetal Fibronectin, Cervical Length, Cervical Cerclage ContextDefined as spontaneous or induced birth before 37+ 0 weeks' gestation, preterm birth (PTB) is responsible for significant perinatal morbidity and mortality. Preterm labour affects 11.1% of live births worldwide (1) and 7.6% of live births in England and Wales (2), but incidence is rising globally (3). PTB causes more than 3 million perinatal deaths a year (1) and causes increased risks of neurodevelopmental impairment, behavioural problems and respiratory diseases, which constitute significant health costs and decreased quality of life (4-6). MethodsThe primary research question our review is addressing is "what predictive tests and prophylactic interventions to preterm birth surveillance clini...

In this cohort, 14.5% of women (363/2505) delivered before 37 weeks. Pregnant women were stratified by fetal gender and were comparable for referral risk factors and demographic characteristics. There was no significant association between fetal gender and incidence of miscarriage less than 24 weeks (RR 1.17, 95% CI 0.65-2.10, p = 0.607), or preterm births 24 to 37 weeks RR 1.07 (95% CI 0.82-1.40, p = 0.383). Furthermore, analysis by gestational band [<28 RR 0.91 (95% CI 0.60-1.37, p = 0.647), <34 RR 1.18 (95% CI 0.89-1.57, p = 0.257 and <37 weeks RR 1.10 (95% CI 0.91-1.33, p = 0.309)] also showed no effect. This held true for both spontaneous and iatrogenic preterm delivery. In our high-risk cohort there was no gender difference for preeclampsia (RR 0.93, 95% CI 0.61 to 1.41, p = 0.725) or preterm premature rupture of membranes (PPROM) (RR 1.14, 95% CI 0.86 to 1.50, p = 0.384) CONCLUSIONS: In a high-risk cohort there was no significant increased risk of miscarriage, spontaneous or iatrogenic PTB, preeclampsia or PPROM for the male fetus. This is contradictory to low-risk populations and confirms that gender need not be integrated into high-risk management protocols for preterm birth.

Background The CRADLE (Community blood pressure monitoring in Rural Africa: Detection of underLying pre-Eclampsia) Vital Signs Alert device—designed specifically to improve maternity care in low resource settings—had varying impact when trialled in different countries. To better understand the contextual factors that may contribute to this variation, this study retrospectively evaluated the adoption of CRADLE, during scale-up in Sierra Leone. Methods This was a mixed methods study. A quantitative indicator of adoption (the proportion of facilities trained per district) was calculated from existing training records, then focus groups were held with ‘CRADLE Champions’ in each district (n = 32), to explore adoption qualitatively. Template Analysis was used to deductively interpret qualitative data, guided by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) Framework. Findings Substantial but non-significant variation was found in the proportion of facilities trained in each district (range 59–90%) [X2 (7, N = 8) = 10.419, p = 0.166]. Qualitative data identified complexity in two NASSS domains that may have contributed to this variation: ‘the technology’ (for example, charging issues, difficulty interpreting device output and concerns about ongoing procurement) and ‘the organisation’ (for example, logistical barriers to implementing training, infighting and high staff turnover). Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving). Conclusions Complexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation. These findings emphasise the importance of gaining an in-depth understanding of the specific system and context in which a new healthcare technology is being implemented. This study has implications for the ongoing scale-up of CRADLE, and for those implementing or evaluating other health technologies in similar contexts.

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