Duke Expands Its Prematurity Prevention Program

In 2016, the US preterm birth rate increased for the second year in a row after almost a decade of decline. According to the 2017 March of Dimes Premature Birth Report Card, racial disparities in preterm birth are also widening, with rates for black women and American Indian/Alaska Native women 49% and 18% higher, respectively, than those for white women.

In an effort to address these challenges, Duke Maternal Fetal Medicine (MFM) specialists Amy Murtha, MD, and Geeta Swamy, MD, launched the Duke Prematurity Prevention Program (DP3) in 2015. Now, 2 years later, the program has expanded, adding an advanced practice provider, who serves as patients' primary point of contact, and 2 new MFM specialists—Jennifer Gilner, MD, PhD, and Sarahn Wheeler, MD.

With more faculty whose primary research interest is in prematurity, Murtha says the program is even better positioned to offer patients the best quality care. The addition of an advanced practice provider has also been instrumental in ensuring that patients' needs are met, she says.

In addition to the MFM specialists and advanced practice provider, the clinic offers the expertise of a clinical social worker, a nutritionist, a nurse, and a certified nursing assistant. The presence of this core team of health care professionals interfacing with patients is essential to the team's ability to provide continuity of care, Wheeler says.

"The entire team works with each patient throughout the pregnancy to prevent preterm birth at every step," she explains. "We get to know the patients really well, and they get to know us. I think there's a real therapeutic aspect to the close relationship the patients have with the entire DP3 care team."

The clinic provides care and support for women who have a history of preterm birth or who are at high risk of preterm birth, offering the full range of nonsurgical and surgical options. This includes higher-level cerclages that are only offered at a handful of tertiary centers across the country. Ultimately, the DP3 team's goal is to develop a tailored, comprehensive prematurity prevention plan for each patient, whether she is thinking about getting pregnant, currently pregnant, or postpartum.

The center's ability to offer carefully tailored plans is facilitated by its team approach, Gilner says. "Preventing preterm birth is very complex, and there's a lot of disagreement in the field," she explains. "The nice thing about having multiple MFM specialists is that we make these decisions in a shared way, with careful attention to the literature, so patients leave their initial consultation with a responsible, evidence-based plan."

The program's clinicians have dedicated significant efforts to researching preterm birth. In 2015, Duke, in conjunction with University of Chicago and Northwestern University Feinberg School of Medicine, was announced as the fifth March of Dimes Prematurity Research Center. Murtha conducts prematurity research through the center, in addition to having several independent research projects.

Both Gilner and Wheeler also have independent research efforts as part of the DP3. Gilner's research focuses on understanding the underlying mechanisms of preterm birth, particularly the role of regulatory T cells in preterm births that have evidence of an immune rejection phenotype. Wheeler is studying the barriers to progesterone injection uptake among non-Hispanic black women at high risk of preterm birth, with the ultimate goal of identifying potential interventions to improve uptake and adherence.

The DP3 program focuses not only on patients' medical needs—making sure they have the right medicines and screening tests, for example—but also on providing psychosocial support, Murtha says: "We spend time with each patient, talking through what she can expect emotionally based on her pregnancy history and what we have available to help support her. I like to make sure our patients know that they're welcome to come see us or give us a call whenever they are worried or concerned. Worrying about preterm birth can be very stressful, and supporting the patient through that experience is a key component of what we do."