Specialist antenatal clinics for women at high risk of preterm birth: a systematic review of qualitative and quantitative research

Abstract

BackgroundPreterm birth (PTB) is the leading cause of perinatal morbidity and mortality. Women with previous prenatal loss are at higher risk of preterm birth. A specialist antenatal clinic is considered as one approach to improve maternity and pregnancy outcomes.MethodsA systematic review of quantitative, qualitative and mixed method studies conducted on women at high risk of preterm birth (PTB). The review primary outcomes were to report on the specialist antenatal clinics effect in preventing or reducing preterm birth, perinatal mortality and morbidity and women’s perceptions and experiences of a specialist clinic whether compared or not compared with standard antenatal care. Other secondary maternal, infant and economic outcomes were also determined. A comprehensive search strategy was carried out in English within electronic databases as far back as 1980. The reviewers selected studies, assessed the quality, and extracted data independently. Results were summarized and tabulated.ResultsEleven studies fully met the review inclusion criteria, ten were quantitative design studies and only one was a qualitative design study. No mixed method design study was included in the review. All were published after 1989, seven were conducted in the USA and four in the UK. Results from five good to low quality randomised controlled trials (RCTs), all conducted before 1990, did not illustrate the efficacy of the clinic in reducing preterm birth. Whereas results from more recent low quality cohort studies showed some positive neonatal outcomes. Themes from one good quality qualitative study reflected on the emotional and psychological need to reduce anxiety and stress of women referred to such a clinic. Women expressed their negative emotional responses at being labelled as high risk and positive responses to being assessed and treated in the clinic. Women also reported that their partners were struggling to cope emotionally.ConclusionsFindings from this review were mixed. Evidence from cohort studies indicated a specialist clinic may be a means of predicting or preventing preterm birth. Testing this in a randomised controlled trial is desirable, though may be hard to achieve due to the growing focus of such clinics on managing women at high risk of preterm birth. Ongoing research has to recognize women’s experiences and perceptions of such a clinic. Further clarification of the optimal referral route and a clear and standardized management and cost economic evaluation plan are also required. Fathers support and experience of PTB clinics should also be included in further research.

The Role of PTB Clinics: A Review of the Screening Methods, Interventions and Evidence for Preterm Birth Surveillance Clinics for High-Risk Asymptomatic Women

“…However, the trials were from 1985 -1990, before interventions like fFN and CL were developed. The authors conclude that PSCs reduce PTB, adverse neonatal outcomes and increase net savings in cost of care, but that there was insufficient evidence to strongly refute or support their use (82). It could argued that very few clinics in other settings have been formally evaluated, and sufficient predictive tools and interventions exist to justify PSCs.…”

“…The conflicting conclusions on PSC efficacy stem from the fact that it is difficult to run RCTs in this setting, which are traditionally the highest level of evidence (82). However, it is nearly impossible to run RCTs looking at multiple interventions simultaneously, and defining which outcomes to equate to success is complex.…”

“…Given their clustering of specialist skill and resources, PSCs foster an environment conducive to research, and further sharing of data will encourage innovation and self-improvement. These results will enable the medical community to clarify the true effectiveness of many treatments, as well as develop a standardized approach to goldstandard management (26,82). The challenge is finding the optimal management pathway, and details of which populations benefit most from which interventions need to be evaluated.…”

The use of specialised preterm birth clinics for women at high risk of spontaneous preterm birth: a systematic review

“…Although there is good evidence to support many of the practices that occur in preterm birth clinics, specific evidence to support the utility of preterm birth clinics as a whole is still evolving [5]. Two previous systematic reviews have attempted to assess the efficacy of preterm birth clinics in reducing spontaneous preterm birth and improving neonatal outcomes [11,12]. Neither found conclusive evidence to either support or refute the efficacy of specialised preterm birth clinics compared to standard antenatal care [11,12].…”

“…Two previous systematic reviews have attempted to assess the efficacy of preterm birth clinics in reducing spontaneous preterm birth and improving neonatal outcomes [11,12]. Neither found conclusive evidence to either support or refute the efficacy of specialised preterm birth clinics compared to standard antenatal care [11,12]. However, both acknowledged the limited number of studies in this field; only five were randomised controlled trials, all of which were conducted prior to 1990 and no longer reflect practice in modern-day preterm birth clinics.…”