COMMENTARY
The Case for Universal Cervical Length
Screening to Prevent Preterm Birth: Is it
Strong Enough to Change Practice in Canada?
Jennifer A. Hutcheon, PhD, M. Amanda Skoll, MD, FRCSC,
Genevieve D. Eastabrook, MD, PhD, FRCSC, Kenneth I. Lim, MD, FRCSC;
on behalf of the University of British Columbia Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
INTRODUCTION
T he search for a treatment to prevent preterm birth has
been described as “successions of enthusiasm and
disillusionment.”1 Such promising avenues for prevention
as antibiotics or antenatal support programs have yet to
yield effective treatments,2,3 prompting editorialists in 2001
to write that “the failure to prevent preterm deliveries has
been so disappointing that there is a risk that high rates of
preterm birth will be seen as unavoidable.”1
In the past year, however, several new studies have
demonstrated that among women with a short cervix
in the mid-trimester, daily use of vaginal progesterone
is able to decrease the risk of preterm delivery.4,5 With
this accumulation of evidence for a potentially effective
treatment to prevent preterm birth, Canadian obstetrical
care providers now have a responsibility to evaluate whether
the evidence is sufficient to warrant universal screening for
short cervix to identify women who might benefit from
this therapy. In this commentary, our goal is to facilitate the
process of deciding whether and how recent research on
vaginal progesterone for the prevention of preterm birth
should change routine antenatal care to ensure that care of
Canadian women reflects the best evidence available.
J Obstet Gynaecol Can 2012;34(12):1184–1187
Key Words: Preterm birth, cervical length measurement, prenatal
ultrasonography, progesterone, mass screening
Competing Interests: None declared.
Received on June 14, 2012
Accepted on July 9, 2012
1184 l DECEMBER JOGC DÉCEMBRE 2012
USE OF PROGESTERONE AMONG
WOMEN WITH A SHORT CERVIX
Clinical practice guidelines published in 2008 by the
Society of Obstetricians and Gynaecologists of Canada
give hesitant support for the use of progesterone among
women with a short cervix.6 Based on the evidence available
at the time from a single randomized trial,7 the guidelines
recommend only that women should be “informed”
of the randomized trial demonstrating a benefit from
progesterone in preventing preterm birth, and that a
cervical length < 15 mm at 22 to 26 weeks “could” be used
as an indication for progesterone treatment.
Since the publication of the guidelines, however, two new
pieces of evidence have considerably strengthened the case
for progesterone therapy. A randomized trial by Hassan
and colleagues of 458 asymptomatic women with a short
cervix reported a 45% reduction in preterm birth before 33
weeks among women treated with vaginal progesterone gel
(95% CI 8% to 67%).4 An individual patient-level meta-
analysis by Romero and colleagues of randomized trial
evidence from 775 women demonstrated a reduction in
preterm birth before 33 weeks of comparable magnitude,
as well as a 43% reduction (95% CI 19% to 60%) in
composite neonatal morbidity and mortality among
women treated with vaginal progesterone.5 Following
a critical appraisal of existing and recent literature, we
therefore believe that the evidence supports the following
changes to current antenatal care:
•• Progesterone therapy (90 mg vaginal gel daily from the
time of diagnosis until 36+6 weeks’ gestation, rupture
of membranes, or delivery) should be offered to all
 The Case for Universal Cervical Length Screening to Prevent Preterm Birth: Is it Strong Enough to Change Practice in Canada?
asymptomatic women found to have a cervical length
of 10.0 to 20.9 mm between 19+0 and 23+6 weeks.
These recommendations reflect the methodologies
demonstrated to be effective in the largest available
trial (by Hassan and colleagues4), but it is possible that
other progesterone formulations and cervical length
thresholds may be equally effective.
•• The situation is less clear for women with a cervical
length < 10 mm or between 21 and 30 mm. The care
of women with a cervical length < 10 mm must be
individualized, and the use of progesterone could
potentially be offered in these women as well depending
upon their full clinical picture. Women with a cervical
length of 21 to 24 mm should be rescanned after 10 to
14 days and offered progesterone if their cervical length
decreases to < 21 mm before 24+0 weeks.
As evidenced by the publication of similar conclusions
by the Society for Maternal-Fetal Medicine (based in the
United States),8 a consensus appears to be developing
regarding the benefits of progesterone therapy for women
with an identified short cervix in the prevention of preterm
birth.
UNIVERSAL SCREENING FOR
WOMEN WITH A SHORT CERVIX
The availability of a treatment for asymptomatic women
with a short cervix raises the question: should we actively
search for this population of women, or should we restrict
ourselves to offering progesterone to those women whose
short cervix has been detected incidentally? As outlined
in recent editorials,9,10 universal cervical-length screening
fulfils all of the general principles outlined by the World
Health Organization for a good screening tool. It screens
for an important adverse outcome (preterm birth); it uses
an acceptable and suitable screening test (transvaginal
ultrasonography); and there is an effective treatment
(vaginal progesterone therapy) available to offer those
identified by the screening. Economic analyses from the
United States showing that screening is not only cost-
effective, but likely also cost-saving, further strengthen the
argument.11,12 We replicated the economic analysis model
of Werner et al.,12 but replaced their United States-based
costs with crude estimates of costs reflective of the Canada
health care system (Appendix). Although their base-case
model may underestimate the true costs of screening (for
example, repeated scans may be performed on women with
a cervical length slightly above the 15 mm threshold, as
well as those with a cervical length below that), the exercise
supported the cost-effectiveness of universal screening in
Canada: for every 100 000 women screened, $4 023 552
would be saved under the base-case model. The costs of
preterm birth are so high that even small reductions in
preterm birth appear to produce significant cost savings.
Although it would seem that universal cervical length
screening has much to offer, it is important to recognize
that the evidence for universal screening is not as strong as
the evidence for progesterone use among women with an
identified short cervix,8 and there are several outstanding
questions and logistical barriers that we believe need to be
addressed prior to any implementation within the Canadian
health care system:
•• How common is a cervical length < 20 mm among Canadian
women? Cost-effectiveness analyses were based on
the assumption that 10% of women have a cervical
length of < 25 mm, with 1.7% of women having a
cervical length < 15 mm. In sensitivity analyses, these
rates varied to as low as 8.3% and 0.9%, respectively.
However, there is reason to believe that the prevalence
of short cervix may be much lower in general obstetrical
populations: a study of 203 healthy nulliparous women
in New Zealand reported that a cervical length of
25 mm corresponded to the first percentile, rather than
the tenth percentile, of their population,13 while an
ongoing trial by the Dutch obstetrical consortium on
the cost-effectiveness of screening low-risk women for
short cervix has reported than only 2.3% of women
(70/3000 screened) had a cervical length ≤ 30 mm,
over five times lower than expected.14 As the cost-
effectiveness analysis estimated that screening would no
longer be cost-effective if the prevalence of short cervix
(< 15 mm) was below 0.35%,12 a clear understanding of
the prevalence of short cervix among Canadian women
is critical.
•• What proportion of women with a short cervix would have
had a cervical length assessment performed under a risk-based
screening strategy? Further information is needed on the
proportion of women with a short cervix identified
through a universal screening strategy that would already
have been identified through a risk-based screening
strategy (e.g., based on a history of preterm birth).
•• What is the effectiveness of universal cervical length screening
outside the clinical trial setting? The acceptability of
endovaginal ultrasound screening to a general
obstetrical population remains to be established, as
does the extent to which women will adhere to daily
vaginal progesterone therapy in the real-world setting.
•• What are the resources required to perform universal cervical
length screening, and how should they be distributed to be available
DECEMBER JOGC DÉCEMBRE 2012 l 1185
COMMENTARY
to all pregnant women? The current capacity and availability
for performing obstetrical ultrasound varies from region
to region, so the cost implications and practicality of
implementation would have regional differences.
•• Can transabdominal ultrasound be used as a preliminary
screening tool? Results from one study suggest that a
two-stage screening approach, in which endovaginal
scanning is only performed when the cervical length
on a transabdominal scan measures < 28 mm, may be
an effective solution for reducing the burden and costs
associated with universal endovaginal screening,13 but
larger scale studies are needed to establish the extent to
which transabdominal screening can accurately rule out
short cervix in a preliminary screening.
CONCLUSIONS
Whether universal screening for short cervix is yet another
turn in the cycle of enthusiasm and disillusionment in
the research on preterm birth or a major advancement in
reducing the burden of morbidity and mortality associated
with preterm birth is not yet completely clear. While
promising, there are a number of logistical and scientific
questions that must be addressed prior to implementation
of universal cervical length screening. Nevertheless, the
economic and health consequences of preterm delivery are
so enormous that we have a responsibility to resolve these
outstanding questions in a timely manner and ensure that,
unlike the delay between the publication of randomized
trial evidence for antenatal corticosteroid administration
and uptake into practice, efforts to prevent preterm birth
in daily practice reflect current evidence.
REFERENCES
1. Buekens P, Klebanoff M. Preterm birth research: from disillusion to the
search for new mechanisms. Paediatr Perinat Epidemiol 2001;15:159–61.
2. Carey JC, Klebanoff MA, Hauth JC, Hillier SL, Thom EA, Ernest JM,
et al. Metronidazole to prevent preterm delivery in pregnant women with
asymptomatic bacterial vaginosis. National Institute of Child Health and
Human Development Network of Maternal-Fetal Medicine Units. N Engl
J Med 2000;342:534–40.
3. Hodnett ED, Fredericks S, Weston J. Support during pregnancy for
women at increased risk of low birthweight babies. Cochrane Database
Syst Rev 2010:CD000198.
4. Hassan SS, Romero R, Vidyadhari D, Fusey S, Baxter JK, Khandelwal M,
et al. Vaginal progesterone reduces the rate of preterm birth in women
with a sonographic short cervix: a multicenter, randomized, double-blind,
placebo-controlled trial. Ultrasound Obstet Gynecol 2011;38:18–31.
1186 l DECEMBER JOGC DÉCEMBRE 2012
5. Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, O’Brien JM,
Cetingoz E, et al. Vaginal progesterone in women with an asymptomatic
sonographic short cervix in the midtrimester decreases preterm delivery
and neonatal morbidity: a systematic review and metaanalysis of individual
patient data. Am J Obstet Gynecol 2012;206:124 e1–e19.
6. Farine D, Mundle WR, Dodd J, Basso M, Delisle MF, Grabowska K;
Maternal Fetal Medicine Committee of the Society of Obstetricians and
Gynaecologists of Canada. The use of progesterone for prevention of
preterm birth. SOGC technical update, No. 202, January, 2008. J Obstet
Gynaecol Can 2008;30:67–71.
7. Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Progesterone
and the risk of preterm birth among women with a short cervix. N Engl J
Med 2007;357:462–9.
8. Society of Maternal-Fetal Medicine Publications Committee. Progesterone
and preterm birth prevention: translating clinical trials data into clinical
practice. Am J Obstet Gynecol 2012:376–86.
9. Campbell S. Universal cervical-length screening and vaginal progesterone
prevents early preterm births, reduces neonatal morbidity and is cost
saving: doing nothing is no longer an option. Ultrasound Obstet Gynecol
2011;38:1–9.
10. Combs CA. Vaginal progesterone for asymptomatic cervical shortening
and the case for universal screening of cervical length. Am J Obstet
Gynecol 2012;206:101–3.
11. Cahill AG, Odibo AO, Caughey AB, Stamilio DM, Hassan SS,
Macones GA, et al. Universal cervical length screening and
treatment with vaginal progesterone to prevent preterm birth:
a decision and economic analysis. Am J Obstet Gynecol
2010;202:548 e1–8.
12. Werner EF, Han CS, Pettker CM, Buhimschi CS, Copel JA, Funai EF,
et al. Universal cervical-length screening to prevent preterm birth:
a cost-effectiveness analysis. Ultrasound Obstet Gynecol 2011;38:32–7.
13. Stone PR, Chan EH, McCowan LM, Taylor RS, Mitchell JM.
Transabdominal scanning of the cervix at the 20-week morphology
scan: comparison with transvaginal cervical measurements in a healthy
nulliparous population. Aust N Z J Obstet Gynaecol 2010;50:523–7.
14. van Os MA, van der Ven JA, Kleinrouweler CE, et al. Preventing preterm
birth with progesterone: costs and effects of screening low risk women
with a singleton pregnancy for short cervical length, the Triple P study.
BMC Pregnancy Childbirth 2011;11:77.
15. Canadian Institute for Health Information (CIHI). 2006. Giving
birth in Canada: the costs. Ottawa, ON. Costs of vaginal delivery
and Caesarean section were combined, assuming 26.8% Caesarean
section rate; costs < 34 weeks have average costs of admission for
threatened preterm labour added. Available at:
http://www.cihi.ca/CIHI-ext-portal/internet/en/Search/search/
search_main_en?q=giving%20birth%20in%20Canada&client=
all_results&start=0&num=10&filter=p. Accessed November 14, 2012.
16. CIHI Online Patient Cost Estimator. Case mix groups < 29 weeks
1000 to 1499 g; < 32 to 34 weeks 1500 to 1999 g; < 35 to 36 weeks
2000 to 2499 g; Normal Newborn Singleton Vaginal and Caesarean.
Available at: http://www.cihi.ca/cihi-ext-portal/internet/en/
applicationindex/applicationindex/applications_index_main#.
Accessed November 14, 2012.
17. Moutquin J, Lalonde A. The cost of prematurity in Canada. Background
paper prepared for the Preterm Birth Prevention Consensus Conference,
Ottawa ON, Canada 1998.
The Case for Universal Cervical Length Screening to Prevent Preterm Birth: Is it Strong Enough to Change Practice in Canada?

Appendix. Cost Estimates in Canadian Dollars

for the Base-Case Economic Analysis Model

We used the published probability estimates of preterm birth, death, disability, prevalence of short
cervix, adherence to progesterone therapy, and effectiveness of progesterone therapy to re-create
the economic analysis model of Werner et al.12 The model compared a strategy of universal screening
of low-risk, asymptomatic women with a strategy of no screening in a cohort of 100 000 women.
Simulations were performed using STATA SE version 11. Our results were comparable to those
published, with small differences likely explained by differences in random number generation used
to perform the simulations (e.g., for neurological deficit/deaths averted, n = 22 in Werner et al. model
and n = 21 in ours; total cost under a no-screening strategy is $1.31 million in Werner et al. model
and $1.32 million in ours; total cost under a screening strategy is $1.30 million in Werner et al. model
and $1.30 million in ours).
We then replaced the United States-based cost estimates in the model with publicly available
estimates from the Canadian health care system (Table). Costs presented are adjusted for inflation
to 2012 Canadian dollars. As it was not always possible to obtain exact costs for each variable,
we chose more conservative estimates that would err on the side of higher costs associated with
screening. For example, as a billing code for a cervical length scan is currently unavailable, we
used the cost of a stand-alone pelvic ultrasound examination using endovaginal probe; in practice,
however, the procedure would likely be a component of a mid-trimester ultrasound examination. As
a result, our findings should be interpreted as crude estimates only, and are intended to stimulate
further discussion and analyses rather than provide definitive values. Further details of our
calculations are available upon request.

Canadian cost estimates

Base case estimate,
Variable $
Cervical length ultrasound scan (cost per scan)* 104.79
Vaginal progesterone therapy, Crinone 8% vaginal gel with 1612
90 mg progesterone (total cost for gestation)†
Cost of maternal care if delivery at15
< 28 weeks 9680.70
≥ 28 weeks, < 34 weeks 9680.70
≥ 34 weeks, < 37 weeks 4031.25
≥ 37 weeks 4031.25
Cost of neonatal care if delivery at 16

< 28 weeks 105 459

≥ 28 weeks, < 34 weeks 24 773
≥ 34 weeks, < 37 weeks 5397
≥ 37 weeks 933
Lifetime cost of a disabled child resulting from a preterm birth in Canada 17
932 412.18
*British Columbia Medical Services plan billing code 08653 (Pelvic ultrasound scan with endovaginal probe).
†BC Children’s & Women’s Hospital Pharmacy

DECEMBER JOGC DÉCEMBRE 2012 l 1187