Q&A on Preterm Birth

Maternal-Fetal Medicine specialists Jennifer Gilner, MD, PhD, and Sarahn Wheeler, MD, joined the Duke faculty in 2016. In addition to serving as clinicians, both physicians have a particular research interest in understanding the factors that drive preterm birth, with Gilner investigating the underlying cellular mechanisms and Wheeler focusing on identifying the barriers to treatment adherence that contribute to racial disparities.

What have we learned about preventing preterm birth?
Gilner: There are a number of interventions that are known to be effective in specific settings. These can include surgical options like cerclage or medical therapies such as progesterone (17-P) or aspirin. It’s also important to counsel women on weight, nutrition, and other lifestyle factors to help them achieve a healthy pregnancy. However, there isn’t a black and white protocol or clear standard of care for women at high risk of preterm pregnancy because each of these therapies only works in a subset of patients. Sometimes we know how to identify that subset, and sometimes we don’t.

How can we best help patients with a history of preterm birth, especially in the absence of a clear cause?
Wheeler: One of the keys is listening to the patient’s story—that’s really important for understanding what happened, developing a plan for future pregnancies, and knowing how to talk with the patient. Many of the interventions available require significant investment from the patient, ranging from surgical procedures with risks to painful weekly injections. If there’s a gray area where a woman may or may not benefit from a therapy, it can actually be incredibly liberating for them to hear, “You don’t have to feel like a horrible mother for not doing this.” Honestly, I think that’s one of the most powerful things we can do—give women the power to exercise that decision and make fully informed choices.

What are some of the gaps in our current understanding?
Gilner: We need to better understand the mechanisms that drive prematurity. Although we tend to view preterm birth as a single disease, in reality, there’s a lot of heterogeneity. Most preterm birth research has hinged on clinical presentation—water breaking early or preeclampsia, for example—but there’s almost certainly mechanistic overlap that’s not reflected by a woman’s ultimate clinical presentation. We may not be able to develop targeted therapies if we’re only focused on a common endpoint of what is actually multiple diseases.

Wheeler: This is also a population-level problem that needs to be addressed as such. The preterm birth rate in non-Hispanic black women is still significantly higher than the overall rate, and we don’t know why. We know that the uptake of 17-P in this population is relatively poor, but there haven’t been any studies outside of retrospective chart reviews seeking to understand the factors limiting uptake and adherence. We also don’t have any evidence-based interventions that are known to improve adherence.