The document summarizes a program in Western Australia called the Western Australian Preterm Birth Prevention Initiative. The initiative aims to lower the preterm birth rate in WA through new clinical guidelines, an outreach program to healthcare providers, an online public health campaign, and a dedicated preterm birth prevention clinic. The initiative is showing early signs of success in changing practices and hopes to improve outcomes for WA families by helping babies complete a full 9 months of development before birth.

1. McCusker
Charitable
Foundation
Discover the research findings that have made the Western Australian Preterm Birth Prevention Initiative possible and
the clinical strategies aiming to lower the preterm birth rate and make pregnancies safer for women and their babies.
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Published March 23, 2016
LASTS A LIFETIME HOW WE CAN REDUCE THE RISK OF
PRETERM BIRTH IN WESTERN AUSTRALIA

2. 2
In Western Australia, one in 12 pregnancies ends
too early, often causing significant problems for
the child. In many cases the problems may be
lifelong.
After several decades of targeted research
conducted by ourselves here in Perth and
our colleagues elsewhere, we now have the
knowledge to prevent a meaningful proportion
of these births ending too early.
The challenge, however, is working out how to
apply our new discoveries into health care at a
population level.
WA has 33,000 births each year, spread across a
wide geographical area and with many different
models of health care.
But we have some great strengths enabling us
to be world leaders in this field. The isolation of
our State presents many challenges but can also
be used to great advantage in some areas of
medicine and this is one of them.
Striving to safely lower early birth rates
For most women and
their families, pregnancy
is one of life’s most
exciting and rewarding
moments. Nine months
is followed by the birth
of a healthy child full of
potential. But not all are
so fortunate.
Professor John Newnham
The pre-pregnancy checklist
Page 5
Treatment of a shortened
cervix in mid-pregnancy
Page 6
Infertility treatment and
advice
Page 9
HPV vaccination
Page 9
Speeding up maturation of
the baby before preterm
birth
Page 10
Reducing tobacco exposure
Page 13
Reducing the mother’s
stress
Page 14
The seven key
interventions
to prevent
preterm birth
As a medical community we are functionally
an island, empowered by our relatively well-
educated and well-resourced community, with
excellent computerisation of data describing
health outcomes.
This combination of attributes gives us a natural
competitive advantage in translating research
discoveries into clinical practice.
In November 2014 we launched the Western
Australian Preterm Birth Prevention Initiative.
This unique statewide program aims to safely
lower the rate of early birth, saving lives and
preventing lifelong disability.
The world is watching the progress of this
unique program. The Initiative has been built on
the development of new clinical guidelines to
be available for all health care professionals and
pregnant women in our State.
There are three major components. First is a
statewide outreach program ensuring that all
health care providers who care for pregnant
women are up-to-date with the new clinical
strategies. Second is an online public health
program.
Third is a dedicated preterm birth prevention
clinic based at King Edward Memorial Hospital
providing management plans for those
pregnant women at highest risk.
In this magazine you will find short articles
written by some of our key health care
professionals who contribute to this field.
For pregnant women and their families, we
hope you find this information to be of value
and help you enjoy your pregnancy.
Editor: Louise Allan | Writer: Laura Galic
Subeditor: Brad Davis | Design: Kara Smith
Advertising: Eithne Healy, 9482 3559
Further information can be found at
www.thewholeninemonths.com.au.
Many individuals and organisations are
contributing to the success of this Initiative.
I would like to acknowledge and thank each and
every health care practitioner and researcher
who is involved, together with the organisations
that are contributing financially. Details of these
organisations can be seen later in the magazine.
Preventing preterm birth whenever possible is
now a major priority. The new clinical guidelines
and education programs are clearly changing
clinical practice and the early signs suggest the
Initiative is proving to be successful.
But we cannot do this alone. Improving the lives
of the next generation of Western Australians
by ensuring they can benefit from the full nine
months of development before birth requires a
combined effort from the women and families
of our State, in partnership with our health care
workforce.
This magazine contains some of the information
that will help this partnership to be successful.
Professor John Newnham AM
Chair and Founder, The Western Australian
Preterm Birth Prevention Initiative
Executive Director, The Women and Infants
Research Foundation

3. 33
Key terms to know
Up to 10 per cent of births in Western Australia
and Australia are preterm. And while European
countries such as Italy, France and Spain have
recorded even lower figures than Australia, US and
African countries such as Malawi, Mozambique and
Congo have a high percentage of preterm births.
Born too soon -
estimated rates
of preterm birth,
2010 (%)
Malawi
18.1
Congo
16.7
Mauritania
15.4
Equatorial Guinea
16.7
Gabon
16.3
Botswana
15.1
France
6.7
The Netherlands
8.0
Spain
7.4
Canada
7.8
USA
12.0
Pakistan
15.8
United Kingdom
7.8
Italy
6.5
Zimbabwe
15.1
Mozambique
16.7
Western Australia
8-9
Australia
7.9
Indonesia
15.5
Comoros
16.7
Preterm births
per 100 live births
Less than 10
10 to 15
More than 15
Developmental delay: When a child is behind or less
developed mentally or physically than what is normal for
their age.
Gestation: The period of development in the uterus from
conception until birth.
Neonatal intensive care unit (NICU): A specialised
intensive care unit to care for preterm and seriously ill
newborns.
Neonatology: The subspecialty of paediatrics that consists
of the medical care of newborn infants; especially ill or preterm
newborns.
Obstetrics: The branch of medicine that deals with the care
of women during pregnancy, childbirth and the recuperative
period following delivery.
Preterm birth: Defined as birth before 37 and after 20
completed weeks of pregnancy.
Cervix: A cylinder-shaped neck of tissue that connects the
vagina and uterus. A shortened cervix is strongly associated
with preterm birth.
Progesterone: A female hormone that is produced in the
ovaries and prepares the lining of the uterus for pregnancy. A
key intervention for preventing preterm birth.
Steroids: Medication given to women in preterm labour and
babies who have difficulty breathing to help with lung function.
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4. 4
This program is built on new clinical guidelines
that have resulted from research conducted
in Perth and elsewhere, an outreach program
reaching out to all health care practitioners in our
State who are involved in caring for pregnant
New initiative saving lives across WA
women, an online public health campaign for
women and their families and a dedicated new
clinic at King Edward Memorial Hospital.
During 2015, the Initiative’s Outreach Team
ran workshops in hospitals across WA, from
Kununurra in the north to Albany in the south.
Travelling 13,000 km over the year, more
than 500 health care practitioners attended
workshops and lectures.
The Outreach Team consists of two
obstetricians, a senior ultrasonographer and
midwives with special expertise in this field.
Support for this program has been provided by
The Women and Infants Research Foundation
(WIRF), Channel 7 Trust and the McCusker
Charitable Foundation.
The Western Australian
Preterm Birth Prevention
Initiative is a world-
unique program with
the single goal of safely
lowering the rate of
preterm birth in the state.
The online public health program for women
and their families can be found at
www.thewholeninemonths.com.au.
In both 2013 and 2015, the Initiative was a
finalist in the Orange Seed Competition, which
is a joint collaboration between West Australian
Newspapers and Jack-In-The-Box advertising
company based in Busselton.
As a result the public health campaign will now
receive additional support and you can expect
to see special health messages on preterm birth
prevention in The West Australian during this
year.
A new dedicated Preterm Birth Prevention Clinic
was launched at King Edward Memorial Hospital
in November 2014 and was funded by the
Minister for Health, Director General of Health
and Chief Medical Officer through a block grant
to the Hospital.
This clinic provides management plans for
women at very high-risk of preterm birth and
typically refers women back to their usual health
care provider once the high-risk period is over.
Multidisciplinary team members include
obstetricians, ultrasonographers, a psychologist
and midwives.
Progress of the Initiative across the state is being
closely monitored through the many existing
computer-based systems.
This ongoing assessment will enable the team
to confirm the effectiveness of the various
clinical strategies and to adjust guidelines to
ensure the program can be as successful as
possible.
The Western Australian Preterm Birth
Prevention Initiative Chair and Founder
Professor John Newnham said the Initiative
had been made possible by medical research
but there was still much to learn.
“Our state is known worldwide for being
a leader in scientific discovery in this field,
led by The University of Western Australia’s
School of Women’s and Infants’ Health
and the Women and Infants Research
Foundation,” he said.
“There are many pathways to preterm birth
and our research programs are diversified to
help us discover new strategies for as many
of these pathways as possible.
“The Western Australian Preterm Birth
Prevention Initiative is now a unique feature
of our state’s medical practice and research.
“We are all part of the team – whether we are
health care practitioners, pregnant women or
members of their families.
“Together, we have a major opportunity
to save young lives and prevent lifelong
disability for many of our future children.”
The survival chances for preterm babies have
been increasing, especially for those born
extremely early.
About 80 out of 100 babies born at 24 weeks at
King Edward Memorial Hospital (16 weeks early)
and admitted to the neonatal intensive care unit
(NICU) survive.
For babies born at 30 weeks gestation (10
weeks early) about 98 out of 100 babies
survive.
A baby born prematurely will need extra care.
Most preterm babies will need to be cared for
away from their mother’s bedside in either a
special care nursery or, if the baby is more sick,
in the NICU.
Four years ago, Christine Botha was
undergoing a routine pregnancy anomaly
scan when the doctor broke the devastating
news that they couldn’t find a heartbeat.
Her baby boy Samson Gregory Botha was
born at 21 weeks and despite all of the tests
no cause of death was found.
“They couldn’t find anything wrong
medically, which is good in a way, but scary
for the next pregnancy,” she said.
“Therefore my second pregnancy was
monitored so carefully and my GP referred
me to the Preterm Birth Prevention Clinic.
“Because I was induced so early with the
first pregnancy, you have a one in three
chance of delivering early again, even if
nothing is wrong.”
Naturally, both Christine and her husband
were extremely anxious going into the
second pregnancy.
“The clinic understood our history and took
it seriously,” she said.
“They truly cared and went above and
Preterm birth outcomes in WA Forever grateful
Common problems include the baby becoming
cold more easily, having breathing problems,
being unable to suck their feeds as would a
full-term baby and being more vulnerable to
infections.
Preterm babies can go home once they can
suck their feeds well, are gaining weight and
have recovered from any problems they may
have had. For most babies this happens around
the time when they should have been born (the
mother’s expected due date).
Breastfeeding is the best feed for premature
babies. In the beginning most premature babies
are not strong enough to suck directly from
their mother’s breast. As a result, the mother
will express milk regularly and this milk will be
given to their baby through a feeding tube.
Most mothers who intend to breastfeed their
baby are able to do so as their baby becomes
stronger.
Long-term outcomes for babies born early
depend on many factors, one of which is how
early the baby is born and their birth weight.
Most babies born preterm go on to lead normal,
healthy lives.
Dr Mary Sharp
A baby born before 37 weeks
has not had enough time
to fully develop. The baby’s
survival chances depend on
how early the baby is born
and how much they weigh.
Some babies, however, face challenges ranging
from speech delay or learning difficulties in
school through to more complex issues.
The risk of challenges increases the earlier the
age at which the baby is born.
At King Edward Memorial Hospital there is a
follow-up program throughout the early years
for those born very early to monitor their
progress.
Dr Mary Sharp
Consultant Neonatologist,
Head Neonatology Clinical Care Unit,
King Edward Memorial Hospital

5. 55
A woman’s health and lifestyle prior to falling
pregnant is critical to the outcome of the
pregnancy and may have a lifelong impact on
your baby’s health.
Although a significant number of pregnancies
are unintended, it is strongly recommended that
women seek appropriate pre-conception care
and advice from their family doctor, two to three
months before falling pregnant.
Many risk factors for preterm birth have been
identified over the years.
These factors include any personal or family
history of preterm birth, previous surgeries to
the cervix, medical conditions, chronic stress
and anxiety and smoking.
Identification of these risk factors before
pregnancy can help your doctor start
preventative measures.
Preconception counselling includes: strategies
to achieve an ideal body weight, screening for
diabetes, minimising exposure to cigarette
smoking, avoidance of alcohol and other
recreational drugs, screening and treatment
of sexually transmitted diseases, ensuring all
vaccinations are up to date, and ensuring folate
The pre-pregnancy checklist
supplementation
has started three
months before
conception.
Women with pre-
existing medical and
psychological conditions
that can potentially affect the
outcome of their pregnancy should seek pre-
pregnancy advice from their relevant specialists
to discuss the potential risks and impact their
disease might have on their future pregnancy.
It is also important to consider any impact the
pregnancy may have on the medical condition.
Management should include stabilisation of the
medical condition with the fewest medications
at the lowest dose and to only include those
medications that are safe for use in pregnancy.
Taking a proactive approach before pregnancy
will help to achieve a good pregnancy outcome
and consequently, a healthy mum and baby.
Dr Shin Lee
Maternal Fetal Medicine Fellow
King Edward Memorial Hospital
Dr Shin Lee
beyond to ensure our little one was healthy,
growing well and wouldn’t come early again.”
“With regular scans and appointments, as well
as access to incredible midwives and even
a psychologist, it was exactly the care we
needed to help get us through.”
Christine and her husband are now proud
parents to a gorgeous little boy, Joel Russell
Botha, who was born on Australia Day earlier
this year.
“The more research that goes into this,
the more we can prevent preterm birth
happening to other mums,” she said.
“It’s something that you’ll never ever want to
go through. We were so happy to help and be
part of any research they needed at the clinic.
“When Joel was finally placed on my
chest almost four years later, his cry made
everything worth it. It was literally the
sweetest sound.
“This clinic and the support I received made it
possible for me to hear that sound and I will be
forever grateful.”
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6. 6
Between 16 and 26 weeks of pregnancy, a
shortened cervix is strongly associated with
preterm birth and a long cervix is associated
with a term birth.
When measured earlier than 16 weeks and later
than 26 weeks, length of the cervix is much less
predictive.
In November 2014, the Western Australian
Preterm Birth Prevention Initiative
recommended that the length of the cervix be
included as a standard measurement at all mid-
pregnancy scans.
All pregnant women in WA are offered a
standard mid-trimester fetal anatomy scan,
typically at 18-20 weeks of pregnancy, and it is
at this scan that the measurement should be
done.
This recommendation applies to all pregnancies,
regardless of whether the pregnant woman is
at low or high risk of preterm birth.
There are two ways to measure the length of
the cervix using ultrasound: either as part of the
usual trans-abdominal scan or by the additional
use of a special trans-vaginal (internal)
approach.
When using the standard trans-abdominal
approach, measuring the cervix is relatively
quick and straightforward.
However, imaging through the abdomen is
best done with a full bladder and the stretching
effect of the full bladder may provide a
misleading elongation of the length of the
cervix.
The full bladder, however, cannot stretch the
cervix more than 10mm.
Trans-vaginal scanning is performed with an
empty bladder and provides a measure of the
true length of the cervix.
A length of more than 25mm is considered
normal and any length less than 25mm
warrants further investigation or treatment.
Not all women need to have an internal (trans-
vaginal) scan performed at the time of their
routine mid-pregnancy scan.
Women at low-risk of preterm birth and women
with a suitably long cervix on trans-abdominal
scan need no further testing.
Ultrasound measurement of the
length of the cervix
Measurement of the
length of the cervix in
mid-pregnancy is one of
the best predictors for
preterm delivery.
The trans-vaginal approach is usually
required for women at increased risk of
preterm birth (typically those women with a
previous history of a preterm baby, surgery
on the cervix, or pregnancy loss).
An internal scan is also required for those
cases in which the cervix cannot be imaged
clearly on trans-abdominal scanning, even in
low-risk women.
Other features of the cervix are important
as well.
These features include the shape of
the cervix and the rate at which it
shortens in high-risk cases in which serial
measurements are taken over a period of
weeks.
It is important to note that shortening of
the cervix does not generally cause any
symptoms, leaving ultrasound examination
as the only means by which it can be
measured with any degree of accuracy.
Appropriate measurement of the length of
the cervix requires adherence to rigorous
standards.
The Western Australian Preterm Prevention
Initiative is encouraging all sonographers in
the state to undertake appropriate training
and credentialing procedures and provides
support for practitioners if required.
It is the right of all women to know the
length of their cervix at the time of their
mid-pregnancy scan.
The length of the cervix below which action
is required is 35mm when measured by
a trans-abdominal scan and 25mm when
measured by a trans-vaginal scan.
When the cervix is less than 35mm on a
trans-abdominal scan, the next step is a
trans-vaginal measurement.
If the cervix is less than 25mm on a trans-
vaginal scan then your doctor needs to
become involved, and in most cases, natural
vaginal progesterone treatment will then be
prescribed.
Treatment of a shortened cervix in mid-pregnancy
We now have an effective treatment for
women with a shortened cervix in mid-
pregnancy.
When given for this indication, natural
vaginal progesterone halves the risk of
subsequent preterm birth.
This treatment is simple and believed to be
entirely safe.
It requires insertion of a small pessary into
the vagina each evening as the woman goes
to bed.
Most women have no symptoms, although
a small number will have itching, usually due
to thrush, which can be easily treated.
Progesterone treatment is commenced
immediately if the cervix is found to
be shortened in mid-pregnancy and is
continued until 36 weeks of pregnancy.
Progesterone treatment is also used in
some cases of previous preterm birth,
regardless of the length of the cervix.
In cases in which the cervix continues to
shorten despite treatment, or if the cervix is
found to be very short, a surgical procedure
called cerclage is sometimes performed.
This procedure effectively closes the cervix
but the decision to perform this procedure
can be complex and requires specialist
input.
Michelle Pedretti
Chief Sonographer
Ultrasound Department, King Edward
Memorial Hospital
Dr Scott White
Consultant Obstetrician and Maternal
Fetal Medicine Specialist
King Edward Memorial Hospital
Dr Craig Pennell
Consultant Obstetrician and Maternal
Fetal Medicine Specialist
King Edward Memorial Hospital

7. ®

8. 8
In Australia, twins make up 1.5 per cent of all
births (about 4300 sets each year).
Many parents are excited at the news of a
multiple pregnancy, but often the increased
risk of problems that may occur with a twin
pregnancy is not understood.
Twin pregnancies are more likely to be
complicated by preterm birth than single ones.
One in every 10 twin pregnancies is born at less
than 32 weeks gestation and more than half
deliver preterm (less than 37 weeks gestation).
Being born preterm places the twins at
increased risk of lung problems, infection, brain
development problems and death.
Most pregnancy complications are increased in
twins compared with a single.
Twins are at a higher risk of preterm birth
If the twins share one placenta (monochorionic)
the risks are extremely high compared with
those twins with two placentas (dichorionic).
Fortunately, early ultrasound is very good
at sorting out the placental types and the
obstetrician then can create a pregnancy care
plan specific to the form of twinning.
While there has been progress in the
prevention of preterm birth in single
pregnancies, most of the discoveries that have
enabled this progress do not apply to multiple
pregnancies.
For many years it had been thought that bed
rest may be of great use.
Recent research, however, has shown that
placing the mother on bed rest does not
decrease preterm birth rates in twins – in
fact there is evidence it may actually lead to
psychological harm in some women.
At present vaginal progesterone treatment,
which is of such great use in single pregnancies,
has not been shown to be effective in
preventing preterm birth in most women with
twins and neither has the routine use of cervical
cerclage (stitch). Recent studies investigating
the use of a cervical pessary in women with
twins have led to inconsistent results, with some
studies showing a benefit in reducing preterm
birth and others reporting no benefit.
At this point the routine use of vaginal
progesterone, cervical cerclage or the
cervical pessary is not recommended in twin
pregnancies. .
Twins are also at increased risk of other
pregnancy complications that may require a
preterm delivery, such as poor fetal growth of
one or both babies.
Therefore, both medically-indicated and
spontaneous preterm deliveries are very
common. Indeed, 25 per cent of all preterm
Professor Jan Dickinson
Ultrasound of a twin placenta with arrow indicating
the ‘twin peak’ appearance characteristic of a
dichorionic placenta.
Ultrasound of a twin placenta with arrows showing
thin dividing membrane of a monochorionic placenta.
Over the past 30 years twin
births have increased, due
mainly to two factors: fertility
treatments and the increasing
age of women having babies.
births occur in multiple pregnancies.
Some complications specific to twins have been
improved by specialised treatments such as
intrauterine surgery with placental laser therapy
for severe Twin-Twin Transfusion Syndrome.
However, at this time there is no pre-birth
treatment for fetal growth restriction apart from
the timely administration of corticosteroids to
the mother to reduce neonatal complications
and magnesium sulphate to reduce the risk of
cerebral palsy in extremely preterm babies.
Professor Jan Dickinson
Head, Maternal Fetal Medicine Service,
King Edward Memorial Hospital
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9. 99
This reduction is saving many young women
from needing surgical treatment of the cervix.
The national HPV vaccination program for girls
and boys was introduced to prevent cancer, in
particular of the cervix.
It looks likely that a secondary, and very
beneficial effect, may be to help specialists
prevent preterm birth.
Professor Yee Leung
Head of Gynaecological Oncology,
King Edward Memorial Hospital
HPV vaccination
helping prevent
preterm births
This may involve simply taking some tablets to
assist with ovulation, or whether she embarks
on IVF treatment.
It is not quite clear what is the cause of this
increased risk; however, if she conceives a
twin pregnancy or even triplets, the risks are
increased even more.
Therefore it is essential that a couple that is
having difficulty in conceiving is offered top
quality care. Australian fertility clinics lead
the world in minimising the number of twin
pregnancies.
Despite this, there are still many women
undergoing fertility treatment who will
ultimately have a preterm birth.
The reason for this outcome is often entirely
outside the woman’s, and her treating
doctor’s, control.
For instance, women with Polycystic
Ovary Syndrome are at an increased risk of
developing diabetes and high blood pressure
in pregnancy and are at an increased risk of
preterm delivery.
A way that this risk can be reduced is by
excellent preconception care and top quality
fertility treatment.
Good quality infertility treatment and
advice will prevent preterm births
Professor Yee Leung
Professor Roger Hart
It has been known for
many years that a woman
who undergoes fertility
treatment is at a greater
risk of complications in
pregnancy, which may
result in a preterm birth.
What does the HPV vaccination program have
to do with cervical length?
Persistent HPV infection may cause
precancerous changes to the cervix and it is the
treatment of these changes that can affect the
cervix and its subsequent function.
Precancerous changes to the cervix are generally
treated by having part of the cervix removed by
a loop excision procedure (LLETZ or LEEP) or by
cone biopsy using a regular scalpel.
These procedures can reduce the length of the
cervix.
Women who have a loop excision or cone biopsy
are 1.7 to 2.6 times more likely to have a preterm
birth and 1.8 to 2.5 times more likely to have a
low birth weight baby.
The news, however, is not all bad.
First, your medical practitioner will be well aware
of the potential changes to your cervix that may
have resulted from such a treatment and the
WA Preterm Birth Prevention Initiative has solid
clinical guidelines as to how the risk of early birth
may be reduced.
Second, the national HPV vaccination program for
school-aged girls and boys that began in 2007 has
already nearly halved the incidence of significant
precancerous changes in young women.
One of the most
important factors of
preterm birth is the
length of the cervix
measured by ultrasound
in mid-pregnancy.
All women and their partners should try
to get themselves as healthy as possible
before they try to conceive.
This not only reduces the time to become
pregnant, but also improves their chances
of a successful pregnancy and delivering a
healthy child.
Therefore couples should work towards
getting their bodies into the healthy
weight range, stop smoking and moderate
or stop drinking, and taking their
multivitamins.
The woman should perform some
gentle exercise that she would be happy
to continue into pregnancy and she
should visit her general practitioner for a
preconception check-up.
This visit is very important as it will
enable the doctor to stabilise any medical
conditions, and the medication the woman
is taking; such as antidepressants, thyroid,
diabetes and asthma medication and also
ensure her PAP smears are up to date.
Professor Roger Hart
Head, Fertility Services,
King Edward Memorial Hospital
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10. 10
Non-medically indicated late preterm birth a serious issue
Specialists have known
for four decades
that simple steroid
injections, called
betamethasone, if
given to the mother
before preterm birth
will rapidly mature the
lungs and other organs.
This treatment is given routinely to women
in whom preterm birth appears to be
inevitable and halves the chance of death in
the immediate newborn period.
This treatment, however, is not effective
in all cases and why some babies respond,
while others do not, remains a mystery.
A team of researchers at The University of
Western Australia’s School of Women’s and
Infants’ Health led by Associate Professor
Matthew Kemp is trying to work out why the
treatment is not effective in all and if they
are using the right dose and at the right time
before birth.
Researchers’ interest in this field has been
increased recently by the discovery that the
treatment does not work as well in low-
resource communities as it does in countries
like Australia.
Refining the treatment to improve its
effectiveness in developing countries has
the potential to save thousands of lives each
year.
The use of steroid injections to rapidly
mature the baby before preterm birth is
just one of many new treatments being
explored to enable specialists to improve the
prospects of babies who will be born early.
But the ultimate goal, of course, is to work
out how all babies can stay safely in the
womb until their full nine months has been
reached.
Associate Professor Matthew Kemp
Head, Perinatal Research Laboratories
Women and Infants Research Foundation
and The University of Western Australia
According to the Western
Australian Preterm Birth
Prevention Initiative
Founder Professor John
Newnham, doctors
have inherited from
their medical ancestors
a definition of term
pregnancy that says a
pregnancy has reached
term at 37 completed
weeks. Thus 36 weeks
and six days is preterm
and 37 weeks is term.
Speeding up
maturation of
the baby before
preterm birth
Professor Matthew Kemp
“We now know this arbitrary cut-off can be
misleading and potentially dangerous,” Professor
Newnham said.
“Recent research conducted by ourselves here
in Perth and in many other cities and countries,
has taught us that babies born this early can still
be at risk of complications of prematurity, both in
the newborn period and at school age.”
Immediately after birth, babies born in the
late preterm or early term age periods have
increased risks of many problems which might
require admission to the special care nursery.
At school age, there are increased risks of
attention and learning difficulties.
For these reasons, it is now strongly
recommended that all pregnancies should be
left undelivered until at least 38 and a half weeks,
or preferably 39 weeks, unless there is a medical
reason justifying earlier intervention.
Reasons to deliver pregnancies early in the
mother include: high blood pressure, diabetes
and bleeding, and in the baby include problems
with growth or concern for wellbeing.
“Going ‘the whole nine months’ can have
important and long-lasting benefits for your
baby,” Professor Newnham said.
“Unless there is a reason warranting early
delivery, it is strongly recommended that
pregnancies continue until at least 38 weeks or
longer.”
The Western Australian Preterm Birth
Prevention Initiative is closely monitoring the age
at birth across the state.
It is hoped that education of the healthcare
workforce, together with the women for whom
they provide care, will reduce the number of
babies delivered early without a valid medical
reason.
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11. 1111
“Leading up, I had a healthy pregnancy, I was fit
and continued to exercise. At that time I was
very full of life and never had any problems,” she
said.
“At 23 weeks I didn’t realise that I was
experiencing my waters leaking, I had no idea
that’s what it was.
“I was rushed to the hospital, did all the tests and
they told me I could have the baby at any time.
“My husband and I hadn’t bought any baby
equipment – no cot, no pram – we thought we
would slowly go along with the journey and
collect bit by bit.
“All of sudden we were told overnight that we
could be expecting a child and that our child
Tye Sellers’ rollercoaster pregnancy
could be at very high risk. It just turned my whole
world upside down.”
Over the next month, Mrs Sellers was put on bed
rest and monitored very closely by the staff at
King Edward Memorial Hospital.
“It was a stressful and challenging time for my
husband and I. I felt like I lost control of what
could happen,” Mrs Sellers said.
“The weirdest part about it was I’ve never been
sick in my whole life and I’ve never been to the
hospital.
“One of the reasons I did have a lot of
complications was because of the shape of my
uterus, it was quite rare. It’s the shape of a heart
and could be part of the reason why the baby
couldn’t develop.”
Matthew Sellers was born at 33 weeks with a
collapsed lung on the right hand side, which
stopped him from breathing but the doctors
were able to keep him alive.
“It felt surreal knowing that this happens to many
mothers out there and the pain they go through,”
Mrs Sellers said.
“I just remember thinking to myself how blessed
we are to have wonderful surgeons, nurses,
doctors and the technology to create miracles
for families like myself.”
Matthew bounced back really quickly and was
able to come home three weeks later. This year
he turns three and like many young boys his age,
he’s full of life (a little cheeky) and developing
normally without any complications – a true
fighter.
With Mrs Sellers’ second pregnancy, her doctor
prescribed a progesterone treatment to help
prevent another early birth.
“The daily pill made such a massive impact, it
was really reassuring and felt like I was having a
normal pregnancy,” she said.
Her daughter Coral-Eve was delivered at 39
weeks with no complications and a much
smoother birth.
“I’m just grateful for the technology and research
that’s there to help people in need in different
circumstances. I don’t think I could have done
without that,” Mrs Sellers said.
As a mum-to-be for the
first time, Tye Sellers was
told to expect anything
that comes under the sun
with the first pregnancy.

12. 12
Predict 1000
Researchers at The University
of Western Australia’s (UWA)
School of Women’s and
Infants’ Health have had a
long-standing interest in
understanding the causes of
preterm birth, in particular
the role of bacterial infection.
Over the past three decades it has become clear
that about one quarter of all preterm deliveries
are caused by bacterial infections in the womb.
The amniotic cavity – the inside of the womb
containing the amniotic fluid and growing fetus –
is usually free of harmful bacteria.
A few bacteria may be present in the fluid and
placenta, but these appear to be ‘harmless
passengers’.
In some cases, however, bacteria manage
to colonise the amniotic fluid and proliferate
dramatically, triggering the mother’s and baby’s
immune systems to produce chemicals to try
and kill the infection. Ironically, it is this very
reaction (called an inflammatory response)
that triggers preterm labour and birth.
The problem is particularly common in
extremely preterm deliveries – those more
than two months premature.
Exposure of the fetus to the bacteria and the
inflammatory response in the womb is known
to be linked to organ damage and a number
of serious illnesses that can have lifelong
consequences.
It is very hard for doctors to detect this until
after birth, by which time the damage is done.
Many different types of bacteria have been
found in the amniotic cavity of preterm
deliveries, although the most common by far
is a tiny bacteria called Ureaplasma.
This bacteria is present in about half of all
Australian women in pregnancy, usually
without causing any symptoms or problems.
It uses urea, a chemical found in urine, as a
source of energy, which is probably why it
seeks out and colonises the amniotic fluid
(which is mostly composed of fetal urine).
So, why do some women deliver preterm with
a severe inflammatory reaction to amniotic
Ureaplasma infection, while most do not?
Can they be identified early in pregnancy
and receive antibiotic treatment to prevent
preterm birth?
These and related questions are being
investigated by a team of researchers led by
Professors Jeff Keelan and John Newnham
of the UWA School of Women’s and Infants’
Health at King Edward Memorial Hospital in
Subiaco.
One of the researchers in the team, Dr
Demelza Ireland, is attempting to develop
a blood test that will identify women with
Ureaplasma colonisation who are at risk of
developing a harmful inflammatory reaction.
She is working on the theory that women
who deliver preterm have a distinct immune
response to Ureaplasma and that this can be
picked up by measuring levels of antibodies
and white blood cells in the blood.
The advantage of a blood test is that it
would be cheap and simple to perform, plus
the treatment would be a short course of
antibiotics – again, simple and inexpensive.
Her preliminary results are encouraging,
although the final results are still some way off.
Another team member, Dr Matt Payne, is
exploring a different approach.
He is analysing the bacterial signature of
1000 women in mid-pregnancy to attempt to
identify a microbial profile that predicts high
risk of delivering preterm.
Researchers now know that microbes that
live in the body exist as communities, often
consisting of hundreds of different species,
each occupying a niche and performing a
distinct role in that particular body site.
Dr Payne’s research will analyse the various
bacterial communities that live in the vagina
during pregnancy to identify a community type,
or a specific set of bacteria, that are likely to lead
Important research underway
BACTERIA
(e.g. genital mycoplasmas)
PLACENTA
ANTIBIOTICS
(Solithromycin)
ANTI-INFLAMMATORIES
Professor Jeffrey Keelan
to infection of the womb and preterm birth.
Recruitment for the study (called ‘Predict
1000’) started in 2015 and is due to be
completed at the end of this year.
Professor Keelan and his team are also
working on a new antibiotic, called
solithromycin, for use in pregnancy for the
prevention of preterm birth. Solithromycin
belongs to a class of antibiotics called
macrolides.
Macrolides have been used for decades
in pregnancy and are safe and effective
antibiotics.
However, most macrolides have difficulty
crossing the placenta, so when given to
the mother they may not be able to treat
an infection in the fetus or the amniotic
cavity. Professor Keelan recently found that
solithromycin is the first macrolide antibiotic
capable of efficiently crossing the placenta,
reaching high levels in fetal blood and
amniotic fluid after a single maternal dose.
This breakthrough discovery could lead to
new and effective treatments for bacterial
infections in pregnancy.
Solithromycin is particularly good at killing
Ureaplasma and related bacteria, which are
often insensitive to many other antibiotics.
It also kills many antibiotic-resistant bacteria,
plus it may also have anti-inflammatory
properties.
Trials of solithromycin in pregnancy are
planned for later this year.
The team hopes that within five years to
have developed a comprehensive program
of risk identification and treatment that
could dramatically reduce the numbers of
infection-driven preterm births in WA and
around the world.
Professor Jeffrey Keelan
Head of Research,
Women and Newborns Health Service
Caring for your baby should begin
before you know it’s there
Available in Pharmacy
Always read the label. Use only as directed. See the label for full list of ingredients. If you
have had a baby with a neural tube defect / Spina bifida, seek specific medical advice.
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at least a month prior to and during pregnancy. 1. De-Regil LM, Fernandez-Gaxiola AC,
Dowswell T, Pena- Rosas JP. Cochrane Database of Systematic Reviews 2010, Issue 10. Art
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The first 6-8 weeks after conception are critical for a baby’s development
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It can take time to build the higher level of nutrients your body will need
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Elevit contains essential nutrients for baby’s healthy development including folic acid,
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Iron helps prevent dietary iron deficiency and
iodine is important for your baby’s brain development.
Visit www.elevit.com.au for lots of helpful information
and online tools designed to help you all the way
through pregnancy.

13. 1313
Reducing tobacco exposure
This figure is even greater in Aboriginal and
socially disadvantaged women, among whom
the rate may be as high as 50 per cent.
This can lead to an increase in a range of
pregnancy complications, in particular a
reduction in birth weight and an increase in
preterm birth.
Chemicals within cigarette smoke may be
concentrated in the placenta and in the fetus,
which is exposed to even greater doses of
harmful substances than is the mother.
Abnormalities of fetal growth are clearly
associated with changes to long-term health
with babies of low birth weight subject to a
greater risk of obesity, high blood pressure,
diabetes and heart disease as adults.
About one in eight pregnant
women in Western Australia
continues to smoke during
pregnancy.
In addition, children exposed to cigarette
smoking in early life are at increased risk of
respiratory complications such as asthma,
allergies and lower respiratory tract infections.
Also of concern are the greater frequencies of
miscarriage, stillbirth and sudden infant death
syndrome in the children of smoking parents.
Avoiding cigarette smoking in pregnancy has a
wealth of benefits for the fetus and mother.
It promotes the development of a healthy
placenta, which sets the foundation for
a healthy pregnancy and early life for the
developing child and into adulthood, as well as
reducing complications of pregnancy for the
mother.
For women at risk of preterm birth, smoking is
one factor which can be modified in order to
reduce that risk.
Healthcare professionals can provide advice
and assistance to help women quit smoking
either before or during pregnancy.
Other resources include Quitline WA on 13 78
48 and www.quitnow.gov.au.
Dr Suzanne Meharry
Consultant Obstetrician,
Preterm Birth Prevention Clinic,
King Edward Memorial Hospital
When a baby’s on the way, it’s twice as important to get the support you need to quit smoking. Phone Quitline (13 7848)
and ask about Quit for you Quit for two. They can help you beat the cravings, with tips like the 4Ds listed here.
• Delay: Delay for a few minutes – the urge will pass
• Deep breathe: Breathe slowly and deeply
• Do something else: Ring a friend or practise your prenatal exercises
• Drink water: Take ‘time out’ and sip slowly
When you choose to quit, you lower the risk of:
• miscarriage
• premature labour
• ectopic pregnancy
• SIDS
Download the free app
Go to the App Store or Android Market now to download Quit for you Quit for two
for free, and get your pregnancy off to a healthy start. makesmokinghistory.org.au

14. 14
As with many life-changing events, parents
often also experience a range of emotions in
addition to joy, such as fear, apprehension and
frustration.
These are very normal feelings when big
changes occur, because while we are adjusting
to our new circumstances, we are being
stretched to cope in ways we have never had
to cope before.
Emotional health in
pregnancy
Just like the benefits of remaining active and
looking after our physical health, emotional
health and wellbeing is particularly important
during pregnancy for mothers and their babies.
Reducing the mother’s stress
Emotional wellbeing of our expectant and new
mothers is important because it prepares them
to better cope with the major life transition into
parenthood.
Strengthening relationships with family and
friends and developing local community
connections supports an experience of social
belonging and helps promote emotional health.
Babies in-utero are exposed to all the things that
their mothers experience – the sounds of their
environment, the air she breathes, the food she
eats, as well as the feelings she experiences.
When a mother is happy and calm, this
allows her baby to grow in a happy and calm
environment.
On the other hand, stress releases hormones
into the body that can impact the baby’s body
and brain.
Complex pregnancies and
preterm birth
For parents who are at risk of complications in
their pregnancy, the accent of stress and worry
is different from normal worry because their
situation is quite extraordinary.
In addition to experiencing worry about the
safety of their pregnancy and unborn baby,
women may carry memories of previous trauma
or loss associated with delivering a preterm or
sick baby.
Feelings of worry, sadness and loss can be
difficult to manage alongside the development
of a woman’s very special relationship with her
unborn baby and many women describe a fear
of bonding with their baby too soon or until
important anniversary dates pass.
It is important women in this situation
understand this sort of stress and worry is
common.
Giving birth to a preterm or sick baby is a crisis
for most parents and it’s a crisis for their baby
too. There are many stressful complications that
require rapid decision-making in the context of
fear and fatigue.
Partners may feel torn between staying to
support their partner and travelling with the
baby to the intensive care unit and mothers’
first memories of their baby may become
characterised by separation.
Feelings of displacement, helplessness and loss
of control are very common as parents adjust
to their new situation in the intensive care
environment.
Parents are required to quickly come to terms
with and adjust their expectations for their child
in the face of threat and uncertainty and learn to
co-parent with hospital teams.
Often women describe mourning the loss of
their pregnancy and some women can find it
difficult to embrace their child in the incubator
for a short while.
For parents from different cultures, the impact
of various medical treatments can be traumatic,
particularly if they are confronted with options
that compromise other firmly held beliefs.
A number of factors can increase a woman’s risk
of finding this extraordinary experience very
stressful.
These include having current or previous
mental health difficulties, other complicated
pregnancies, loss and grief, a tendency to worry,
conflict in important relationships or other social
hardship.
For many women and
their partners, becoming
parents is an exciting
time and is a life-changing
event.
Feeling overwhelmed with emotions is not
uncommon and very understandable at
some stage during pregnancy, or the post-
birth period, particularly when there are
complications.
Unfortunately, it is still the case that many
people feel they have to struggle on, because
they feel that admitting that they are not
coping is shameful.
Nevertheless, talking about one’s feelings
to one’s partner or trusted friend or family
member and accepting support can be helpful.
In addition, many women benefit from simple
things, like being kind to themselves, resting
when possible, eating well and doing some
gentle exercise.
Psychological support for women who
encounter these stressful circumstances often
involves simply naming and validating the
complex array of emotions that make up their
Dr Catherine Campbell
Clinical Psychologist,
Western Australian Preterm Birth
Prevention Initiative
Dr Felice Watt
Consultant Psychiatrist, Director of Psychiatry,
Womens Health Clinical Care Unit,
Women and Newborn Health Service
What can help?
grief and traumatic stress, as they find ways to
reconnect with their ‘invisible’ rules for coping
that have carried them through their ‘pre-
existing’ lives.
Access to the family’s support networks and
accurate information is important.
Women and their families experiencing
significant stress or emotional difficulties
can receive help from health professionals
including their general practitioner,
child health nurse, community midwife,
obstetrician, private psychologist, psychiatrist
or counsellor.
For more information about mental health in
pregnancy go to www.beyondblue.org.au or
www.cope.org.au.
If you or someone you care about is in crisis
call the mental health emergency response
line 1300 555 788 (metro) 1800 552 002
(rural) or lifeline 131 114.
1. Rapid fFN 10Q Cassette Package Insert, AW-09189-001-002-02, Marlborough MA, Hologic Inc. 2015.
Hologic cannot provide clinical advice. Please consult your doctor if you experience any signs or symptoms of preterm labour.
Your doctor will advise if the Rapid fFN test is suitable for you. The Rapid fFN test can only be performed by a medical professional.
ADS- -AUS-EN ©2016 Hologic, Inc. 02/16. All rights reserved. Hologic, The Science of Sure, Rapid fFN and associated logos
are trademarks or registered trademarks of Hologic, Inc., and/or its subsidiaries in the United States and/or other countries.
Hologic (Australia) Pty Ltd, Level 4, 2-4 Lyon Park Rd, Macquarie Park NSW 2113. Tel. +61 2 9888 8000. ABN 95 079 821 275.
Testing your risk
of preterm birth.
The quantitative Fetal Fibronectin
test helps your doctor assess
your risk of preterm birth if you
have symptoms or have risk factors
such as a previous preterm birth.1
Ask your doctor if the test
is right for you.
Doctor enquiries: australia@hologic.com

15. 1515
Members of the Western Australian
Preterm Birth Prevention Initiative
The Outreach and Public Health Programs:
• Women and Infants Research Foundation
• Channel 7 Telethon Trust
• The McCusker Charitable Foundation
The Preterm Birth Prevention Clinic at KEMH:
• The Health Department of Western Australia
• The Women and Newborns Health Service of
Western Australia
Research:
• National Health and Medical Research Council
of Australia
• National Institutes of Health (USA)
• Women and Infants Research Foundation
• Channel 7 Telethon Trust
Chair and Founder:
• Professor John Newnham AM
Obstetricians
• Professor Jan Dickinson
• Dr Shin Lee
• Dr Suzanne Meharry
• Professor John Newnham
• Dr Craig Pennell
• Dr Scott White
Midwives
• Suzie Allen
• Cate Belcher
• Teresa Warner
Ultrasonographers
• Michelle Pedretti
• Adrienne Gee
Pyschologist
• Dr Catherine Campbell
Neonatologist
• Dr Mary Sharp
Biostatistician
• Professor Dorota Doherty
Other Research Members
• Dr Catherine Arrese
• Dr Demelza Ireland
• Professor Jeffrey Keelan
• Associate Professor Matthew
Kemp
• Jennifer Leverington
• Dr Shaofu Li
• Dr Matthew Payne
• Narisha Pendal
• Hannah Smith
Advisory Panel
• Graeme Boardley
(Head of Midwifery, Womens
and Newborns Health Service)
• Dr Janet Hornbuckle
(Head, Department of
Obstetrics, KEMH)
• Dr Anne Karczub
(Director, Department of
Obstetrics, KEMH and
Co-Director, State-wide
Obstetric Support Unit)
• Dr Dianne Mohen
(Co-Director, State-wide
Obstetric Support Unit)
• Dr Felice Watts
(Director of Psychiatry, Womens
Health Clinical Care Unit, Women
and Newborn Health Service)
• Dr Tarun Weeramanthi
(Director, Department of Public
Health, Health Department of
Western Australia)
Marketing and Media
• Richie Hodgson
• Tina Williams
Principal financial supporters
The Western Australian Preterm Birth Prevention
Initiative is supported as follows: