Summary

Preterm birth is a birth before 37 completed weeks of gestation. Worldwide, about 10% of all babies are born preterm. Preterm birth contributes to lifelong disability and ongoing health issues, such as respiratory problems, neurodevelopmental delay, hearing and visual loss, and learning and behavioural problems.

Preterm birth is also a significant contributor to perinatal and neonatal mortality. In Australia, spontaneous preterm labour or rupture of membranes alone was the cause of about 35% and 34%, respectively, of neonatal mortality in 2021 and 2022, and about 40% of neonatal mortality among babies born to First Nations women in 2020–2021.

Preterm birth rates in Australia have not changed much in 20 years. Among all babies born in Australia, the preterm birth rate was 8.1% in 2004, 8.3% in 2010, and 8.4% in 2023. Among babies born to First Nations mothers, the preterm birth rate fluctuated between 13.5% in 2010 and 13.8% in 2023.

This report presents evidence from 4 sources that preterm birth can be reduced. They are:

  • results from our modelling of the National Perinatal Data Collection
  • the declines in preterm birth observed in Europe and the United States after 2000
  • the decline in preterm births during the COVID-19 lockdowns in 2020
  • the results of evaluation of the First Nations-specific ‘Birthing in Our Country’ Service (BiOC) implemented at the Mater Mothers Hospital in Brisbane.

Disparities in preterm birth rates between developed and developing countries, as well as within countries, between high socioeconomic and low socioeconomic areas, provide some evidence of the role socioeconomic factors play in the occurrence of preterm birth.

Our analysis of the National Perinatal Data Collection shows that strategies to reduce preterm birth should include timely access to antenatal care, elimination of smoking before or during pregnancy, prevention and/or management of pre-existing and pregnancy-induced diabetes and hypertension, and improved nutrition to optimise body weight.

Improving First Nations women’s socioeconomic circumstances and involving First Nations women in the design and delivery of antenatal care services as shown by evidence from the Birthing in Our Country (BiOC) service would also contribute to reducing preterm births.

Public health campaigns such as Western Australia’s ‘thewholeninemonths’ and the ‘Healthy Babies Are Worth The Wait’ of the American College of Obstetricians and Gynecologists’ might also contribute to a reduction in non-medically indicated deliveries before term.

The reductions in preterm birth rates during the COVID-19 lockdowns in 2020 also provides some confidence that preterm birth rates can be reduced if the mechanisms that contributed to the reductions in COVID-19 during the lockdowns are identified and implemented.

Three groups of strategies (primary, secondary and tertiary) to reduce preterm birth have been identified. Primary strategies are directed at all women before they become pregnant. Primary strategies aim to create safe, connected and integrated communities where people have access to goods and services, including education, housing, employment, recreational and health services and health infrastructure. Safe, connected and integrated communities will contribute to the overall health of community members, and reduce concentrated poverty, malnutrition, crime and stress, which are known to be associated with preterm birth.

Smoking during pregnancy is a major risk factor for preterm birth. Primary strategies provide counselling and resources to encourage all women not to smoke at all, and to quit smoking immediately if they are already pregnant and are smoking.

Poor nutrition, including being underweight or overweight is a major risk factor for preterm birth. Primary strategies should incorporate public health educational campaigns and the provision of counselling and resources to encourage First Nations women, especially those intending to have a baby to maintain a healthy pre-pregnancy BMI.

A powerful component of primary strategies is to develop and carry out public educational campaigns to:

  • ensure greater public and professional awareness of the extent of preterm birth within the community; the short- to long-term health, economic, social and emotional impact of preterm birth; and the risk factors associated with preterm birth.
  • to discourage non-medically indicated medical interventions through induced labour or caesarean delivery before 39 weeks of gestation, as well as the use of artificial reproductive technology to create multiple gestations.

Post-conception primary strategies are directed broadly at all women who are already pregnant. They include antenatal care, screening of women to determine their risk of preterm birth, and the provision of social support, including stress reduction strategies. Screening covers risks such as pre-existing diabetes and hypertension, multiple gestation, various types of infections, and a history of recurrent preterm birth and stillbirth.

Many women who have a preterm birth do not have any obvious risk factors. Multiple levels of screening could therefore be used to identify women at risk of preterm birth. As part of postconception secondary strategies, First Nations women deemed to have risk factors for preterm birth from prior primary screening could be screened further to refine their risk of having a preterm birth by identifying additional key medical, obstetric or socioeconomic markers for preterm birth. Women deemed to have further risks could then be targeted for treatment and counselling, including referral to dedicated preterm prevention centres.

Tertiary strategies are mostly clinical and are directed at women at imminent risk of preterm birth. They include cervical cerclage, progesterone therapy, antenatal corticosteroids, tocolytic therapy and antibiotic prophylaxis. The role of these treatments is, variously, to prevent recurrent cervical insufficiency, to prevent spontaneous preterm birth in women with singleton pregnancies, to improve fetal lung maturation, to prolong gestation, reduce neonatal morbidity and increase survival in spontaneous preterm births, and protect against the adverse effects of inflammation in pregnancy.

First Nations women often have concerns about racism, receiving health care that is culturally appropriate, and being treated with dignity and respect. Evidence has shown that when First Nations people are involved in the design and implementation of health-care services or when they have leadership roles in the delivery of the service, the impact of the service is more positive than when a service is imposed, and when First Nations people have no role in how it is designed and delivered.

As shown by the ‘Birthing in our Community’ service located at the Mater Mothers’ Hospital in Brisbane, community and family relations are very important to First Nations people, and so is their ability to be able to participate in cultural activities within their communities. It is therefore important that service is delivered within the community or close to the community.

It is also important to design antenatal care and preterm birth prevention services so as to provide a comprehensive ‘wrap-around’ service which provides continuity of care by a known (caseload) midwife to women throughout pregnancy, birth, and up to 6 weeks postnatally.