Prematurity is the leading cause of neonatal morbidity and mortality. Women identified as having a shortened cervix or women with a previous history of spontaneous premature birth face increased odds of pre-term birth (PTB). In these patients, the use of progesterone is shown to significantly reduce the risk of PTB.
The best predictor of SPTB is a previous history of PTB. From our previous research we know that women with at least one previous SPTB < 37 weeks gestation have a PTB recurrence risk as high as 30-40%. Women with multiple PTBs or very early PTBs are at the highest risk with as many as 50% of these women experiencing a recurrent PTB. Among 2009-2010 Utah Medicaid recipients, 15% of SPTBs occurred in women with a history of a previous PTB.
17 alpha-hydroxyprogesteronecaproate (17P), a synthetic form of progesterone,has been shown in randomized, controlled trials to reduce the rate of recurrent SPTB at gestational ages < 37 weeks, < 35 weeks and <32 weeks. 17P is administered through weekly injections beginning at 16-24 weeks until delivery. Studies show that administering 17P to an eligible woman reduces the chance of having another PTB by 33 percent.
Despite the fact that the beneficial effects of 17 P have been well documented, there is clear evidence that less than 50% of appropriate candidates for 17 P actually receive this intervention in the state of Utah. (PRAMS) The reasons for this failure include a lack of understanding on the part of both patients and physicians with respect to appropriate candidates for treatment, best timing and dosage and issues with acquisition of the medication.
Coordination of efforts to increase the appropriate use of 17P will provide a unique opportunity to reduce the incidence of PTB among the women of Utah. We will create a statewide program to improve identification of eligible women, increase availability of and access to 17P, and educate providers and patients on appropriate use of 17P.
Our goal will be to increase the use of 17 P so that 80% of eligible women receive appropriate treatment in Utah. We will accomplish this goal by:
• Creation of educational material and seminars for providers and patients. The statewide Prematurity Symposium will focus on optimal use of 17 P. Local seminars will be held at each participating hospital to educate providers on a local level.
• Creation of a Progesterone Protocol that will enhance optimal screening of patients at risk and make recommendations for best practice treatment for these women including 17 P timing and dosage. This protocol will be used in all participating hospitals and clinics.
• Creation of a data collection and reporting tool that will collect patient level, clinic level and hospital data about screening and implementation of the Progesterone Protocol. Additional efforts will be made using quality improvement techniques to identify other obstacles to optimal 17 P use in our state and design appropriate interventions targeted to these obstacles.