Preterm birth remains a major cause of neonatal morbidity and mortality, and in the UK, 7.8% of babies born were born before 37 weeks gestation in the year 2010 (World Health Organization, 2012). Some UK hospitals offer a specialist preterm birth service for women deemed to be at risk of a preterm birth or late miscarriage, including those with a history of preterm birth, late miscarriage or cervical surgery. However, practices in specialist preterm birth clinics vary in both surveillance methods and clinical management (Sharp and Alfirevic, 2014).
Various methods are used to identify those women who may benefit from interventions such as cerclage or progesterone treatment and closer monitoring (Min et al, 2016). Methods include transvaginal ultrasound, measurement of cervical length, and collection of vaginal fluid for evaluation using one of a range of predictive biomarker tests such as fetal fibronectin, PartoSure or Actim Partus.
Most biomarker tests require the use of a speculum, with the exception of PartoSure. The reduced need for examination with a speculum is thought to be more acceptable to some women. While there is evidence to support the use of quantitative fetal fibronectin in predicting preterm birth compared to PartoSure, fetal fibronectin does require the use of a speculum (Kurtzman et al, 2009; Abbott et al, 2013; 2015).
Although previous studies exploring transvaginal ultrasound scans in pregnancy have found them to be acceptable to women (Clement et al, 2003; Atalabi et al, 2012; Bello and Odeku, 2015), no studies that focused on women's experiences of speculum examinations in pregnancies at high risk of preterm birth were found.
This study sought to explore the experiences and views of pregnant women at high-risk of preterm birth who were undergoing tests requiring a speculum examination and at a preterm birth surveillance clinic.
Methods
Participants were a subset of women who were enrolled in the Evaluation of fetal fibronectin with a Quantitative Instrument for the Prediction of Preterm birth (EQUIPP) study. Women were enrolled through convenience sampling as they attended appointments at an antenatal preterm surveillance clinic at a large UK inner-city teaching hospital. Data were collected between February and August 2011. All women presenting to the clinic were provided with the study questionnaire and were asked to return their completed paperwork anonymously to the clinic receptionist after their appointment. This ensured that women did not feel pressured by the presence of the research staff working in the clinic.
Data collected consisted of demographic information, including parity and gestational age, and opinions on the use of speculum examinations. The survey asked women a total of eight questions about their experiences of the speculum examination and transvaginal ultrasound scan for cervical length measurement. These eight questions could be answered by selecting either ‘yes’, ‘no’ or ‘I don't know’. The data were then collected and analysed using a Microsoft Excel spreadsheet.
Results
Participant characteristics
The age of the participants at time of completing the questionnaire ranged from 17–44 years, with a mean and median age of 32 years. The demographics of the participants can be seen in Table 1.
| n | % | |
|---|---|---|
| Age range | ||
| >20 | 2 | 2 |
| 20–24 | 7 | 7 |
| 25–29 | 14 | 14 |
| 30–34 | 45 | 44 |
| 35–39 | 25 | 26 |
| 40–44 | 4 | 4 |
| No response | 5 | 5 |
| Ethnicity | ||
| White British | 29 | 28 |
| White Other | 16 | 16 |
| Black African | 27 | 26 |
| Black Caribbean | 8 | 8 |
| Asian | 6 | 6 |
| Mixed race | 3 | 3 |
| Other | 12 | 12 |
| No response | 1 | 1 |
| Parity | ||
| Nulliparous | 53 | 52 |
| Multiparous | 49 | 48 |
The gestational age of the participants at the time of completing the questionnaire ranged from 18–34 weeks, with a mean and median gestational age of 22 weeks. A total of five participants did not disclose their gestation. Results for the remainder of the survey are presented in Table 2.
| Yes | No | I don't know | No response | |||||
|---|---|---|---|---|---|---|---|---|
| Question | n | % | n | % | n | % | n | % |
| 1. Did you find the speculum examination acceptable? | 99 | 97 | 1 | 1 | 2 | 2 | 0 | 0 |
| 2.If ‘no’, would you accept the test if it did not involve a speculum? | 1 | 1 | - | - | - | - | - | - |
| 3. Did you understand why the test was done? | 100 | 98 | 1 | 1 | 0 | 0 | 1 | 1 |
| 4. Did you understand what the test result meant? | 89 | 86 | 0 | 0 | 5 | 5 | 8 | 8 |
| 5. Would you be happy to have the test again in this pregnancy? | 90 | 88 | 4 | 4 | 5 | 5 | 3 | 3 |
| 6. Would you be prepared to take the swab yourself without the speculum? | 48 | 47 | 35 | 34 | 15 | 15 | 4 | 4 |
| 7. Do you find the cervical length scan acceptable? | 97 | 95 | 2 | 2 | 2 | 2 | 1 | 1 |
| 8. Given the choice, would you come back to this clinic? | 97 | 95 | 2 | 2 | 2 | 2 | 1 | 1 |
There was a total of 102 participants who completed the questionnaire. Overall, 97% (n=99) of women found the speculum examination acceptable and 88% (n=90) stated they would be happy to have the examination again if required. This was comparable to 95% (n=97) of women who stated they found the transvaginal ultrasound examination acceptable.
Discussion
This is the first study exploring women's experience of speculum examination for preterm surveillance. Studies exploring women's experiences of a vaginal speculum examination suggest that they are associated with anxiety, embarrassment and discomfort (Hoyo et al, 2005; Yanikkerem et al, 2009). Anxiety in pregnancy is closely related to the woman's perception of her pregnancy being high-risk (Bayrampour et al, 2013). Women attending preterm birth surveillance clinics are aware that they are at high-risk, and therefore likely to be anxious and apprehensive even before any procedures or tests are carried out.
The majority of participants (n=99; 97%) found the speculum examination acceptable, with only one participant (1%) finding the speculum unacceptable. This one participant responded that they would have accepted the fetal fibronectin test if it had not involved a speculum. These results demonstrate that this cohort generally found the speculum examination acceptable.
This study found that 88% of participants who responded would be happy to have the test again in their pregnancy, while 4% said that they would not. These results are encouraging, as they suggest that this would not prevent the majority of women adhering to premature birth surveillance due to lack of acceptability with speculum use. Previous studies suggest that discomfort associated with speculum examinations may have led to some women not attending appointments for cervical cancer screening (Hoyo et al, 2005).
Of participants who responded, 47% of women would be prepared to take the swab themselves without a speculum, while 34% of women said that they would not. As previous studies have found women's experiences of specula to be anxiety-provoking, embarrassing and uncomfortable, this was surprising. For example, a pilot study on speculum ‘self-insertion’ (Wright et al, 2005) found that the majority of women were satisfied and would choose to self-insert a speculum again as it made the process less threatening. These differences may be explained by the fact the women in the present study were pregnant and in a ‘high-risk’ cohort, which may have meant that they had fears of harming the pregnancy or their baby. Nevertheless, as gestation increases, women may also find it physically difficult to take their own vaginal swabs.
Overall, 95% of women who responded found the transvaginal scan to measure their cervical length acceptable, while 2% of women did not. These results are similar to those in previous studies which found that transvaginal ultrasound scans were acceptable to pregnant women (Clement et al, 2003; Atalabi et al, 2012; Bello and Odeku, 2015).
Limitations of this study include a lack of formal power calculation or advanced statistical analysis performed on the data. In addition, as this was a convenience sample, there may be a possibility of selection bias. The women in this study were from an ethnically diverse background with a range of maternal ages and gestational ages. Caution must therefore be taken when applying these results to a different demographic of pregnant women.
Conclusions
The findings of this study suggest that women at risk of preterm birth find speculum examinations and transvaginal ultrasound scans for cervical length measurement acceptable. Any intimate examination should be approached with care, ensuring that the patient is treated with dignity and respect and that consent is given. While it is acknowledged that intimate medical examinations and procedures are not pleasant experiences, this study illustrates that the majority of pregnant women in a high-risk pregnancy are not opposed to them being performed.
More research is needed, however, to confirm this in a larger cohort using a formal power calculation and advanced statistical analysis. Further research could also focus on women's experience of speculum use in low-risk pregnancies (for example, for other swab tests), and if pregnant women would consider self-insertion of specula.