All of the administrative respondents in our study were obstetricians, so they had a good understanding of the problems related to preterm births. They all worked in the field of pregnancy screening services concomitant with performing other jobs, such as teaching and conducting research. Consequently, their workloads negatively impacted on their personal ability to participate in a universal cervical length screening programme.
However, the primary responsibility of healthcare managers at tertiary hospitals in Thailand is setting hospital policies and managing their subordinates to ensure their compliance with those policies. At the same time, the experience of the healthcare managers can influence the instructions they issue to subordinates regarding the need to observe established policies as well as their specific screening recommendations(16). In particular, if the managers have personal experience with premature births, they are more likely to recommend screening.(16) Moreover, they are required to inform pregnant women about the risks of preterm delivery and its relationship with cervical length screening. Having more time available to describe the benefits of cervical length screening is necessary to properly assist patients to understand the importance of cervical length measurement.(17) Therefore, the healthcare managers’ workloads can affect the quality of screening as well as the educational processes within their hospital.
Performing cervical length measurements by vaginal ultrasound examination is useful and has been recommended to facilitate planning of patient management.(18) In terms of the accessibility and financial aspects of implementing cervical length measurement in Thailand, the Thai Ministry of Public Health has recognised the importance of cervical length screening to prevent premature births. The appropriate policies have been prescribed, and the necessary diagnostic tools are mostly sufficient. On the other hand, there are constraints related to the overall screening skill levels of the involved medical personnel at Thai public hospitals and the staff resources available there. Implementing universal cervical length screening to prevent preterm births is not just an issue for Thailand, but is a worldwide challenge.
From our study, almost all of the hospitals at the tertiary level (39/40 cases; 97.5%) still considered preterm births to be a major problem, and the respondents were well aware of the negative impacts of preterm deliveries. Most obstetricians in Thailand can perform cervical length measurements, even without certificate approval. However, 6 out of the 40 respondents (15%) stated they could not perform such measurements, and half (50%) were unsure of the correct method of performing cervical length measurements. Regular training programmes to improve and maintain skill levels should therefore be provided at tertiary centres.
The Thai public health system is committed to reducing preterm births. Many efforts have been made in this regard, including the establishment of a universal policy for cervical length measurement in Thailand to screen high-risk pregnant women for preterm delivery and to supply them with progesterone to prevent preterm births. Various forms of progesterone, including vaginal suppositories, oral medications and injections, have been prepared, but typically they are not free in Thailand. A previous study(19) that supported the use of natural progesterone in pregnancies stated that the administration of the hormone was not harmful to the nervous system; instead, it could actually prevent neurological complications. It has been reported that the use of 17-alpha-hydroxyprogesterone caproate, a synthetic progesterone, may have less benefit than natural progesterone(20) and may even have negative effects on the long-term functioning of a baby’s learning system.(21) Natural progesterone administered in a vaginal suppository form was found to reduce complications in newborns, with a reduced duration of hospital stay and reduction in preterm births, compared with 17-alpha-hydroxyprogesterone caproate.(20) However, further long-term studies are needed.
Our research suggests that the Maternal and Child Health Board has little active role in the execution of screening programmes at Thai public hospitals. However, if programmes were fully established at each hospital with appropriate Maternal and Child Health Board oversight of their effectiveness, the willingness of subordinates to support universal screening could be improved.
The experience of obstetricians after examinations also affects cervical length screening. For example, pregnant women with a short cervix may have been found to have a higher rate of full term delivery than those with a normal cervix. Patients with a short cervix and who receive regular treatment may have a greater risk of preterm delivery. Recent data indicates that a cervical length screening programme followed by progesterone for those with a short cervix will reduce preterm birth rates by less than 0.5%.(22) The authors in that study believed that the screening did not actually reduce the preterm birth rate and that it may not have been worth using progesterone in the indicated pregnant women. Therefore, universal cervical length measurement has not been implemented in some hospitals in Thailand and remains controversial.
From our study, cervical length measurement was opposed by about 24.1% of all respondents. This supports the previous study’s finding that healthcare managers’ experiences influence their policy decisions on the implementation of screening at their hospital.(16) Because of public healthcare funding constraints, some Thai hospitals do not have progesterone supplementation available for the treatment of patients with a short cervix. Hence, obstetricians at those centres may not be inclined to measure cervical lengths. Other reasons are heavy physician workloads, the length of time needed to perform the procedure and a reluctance of patients to undergo vaginal examinations. Patients may also find it inconvenient to use a vaginal drug and may prefer a weekly progesterone injection. Because of funding shortfalls, some tertiary hospitals in Thailand presently do not have both the vaginal and injected forms of progesterone available, which would make it impossible for them to provide progesterone prevention for pregnant women with a short cervix.
Cervical length measurement may not be available at all secondary hospitals. Therefore, relaxation or adjustment of the examination period should be considered to provide greater flexibility for cervical length measurement so that more people living in rural areas can have the opportunity to undergo screening. A previous sensitivity analysis suggested that universal transvaginal ultrasound cervical length screening is unlikely to be cost-effective when the prevalence of a transvaginal ultrasound cervical length of ≤ 20 mm falls below 0.31%.(23) Establishing the prevalence of short cervixes in a population and its contribution to preterm birth is therefore important before universal screening is introduced.
Multiple studies have shown that cervical length measurement and its implementation result in fewer preterm births and improved neonatal outcomes.(19, 24) Cervical length measurements should be considered along with foetal anatomy screening during 19–20 weeks gestation. Abdominal ultrasound examination on a regular basis during the 18- to 20-week gestation period does not incur additional costs. Transabdominal ultrasound screening can reduce the need for transvaginal ultrasound and the subsequent costs.(25) Although up to 60% of pregnant women may still need transvaginal ultrasound,(25) there is still the problem of who will bear the responsibility for the additional costs. However, some pregnant women clearly need serial screening for cervical length measurement. An additional cost-effectiveness analysis would therefore be required and is a worthy parameter to assess.
The Maternal and Child Health Board should inform healthcare managers in the obstetrics and gynaecology units of Thai hospitals about any screening and treatment programmes. This action recognises the roles of those personnel in managing their subordinates and instructing pregnant women in the intricacies of the screening programme. Deficiencies in the knowledge of those healthcare managers in any area relevant to preterm births, defensive strategies, screening options, treatments and related interventions will reduce the prevalence of cervical length screening.(26) Additionally, if a healthcare manager does not accept the value of screening or the performance of other preventive interventions, the likelihood that a patient will receive adequate counselling will also be hampered.(27)
The research found that 62.5% of secondary hospitals only screened high-risk women or those who had a previous preterm birth. This does not match the policies of the Ministry of Public Health. The main cause of preterm births was idiopathic in 60% of cases(28); only 7% of preterm births involved mothers with previous deliveries.(29) Therefore, universal cervical length screening is necessary, and adequate training of healthcare managers in obstetrics and gynaecology units should be pursued.
Nevertheless, our research found that most healthcare managers had a good level of awareness of the problem of preterm births and were willing to work to solve this serious problem in Thailand. The implementation of a universal cervical length screening programme accessible to all pregnant women should be possible.