Overview: new perspectives on the stubborn challenge of preterm birth Richard B. Johnston Jr a , Michelle A. Williams b , Carol J. R. Hogue c and Donald R. Mattison d a Department of Pediatrics, University of Colorado School of Medicine and National Jewish Medical and Research Center, Denver, CO, b Department of Epidemiology and MIRT Program Director, University of Washington, Seattle, WA, c Women's and Children's Center, Rollins School of Public Health of Emory University, Atlanta, GA and d March of Dimes Birth Defects Foundation, White Plains, NY, USA Introduction The rates of preterm birth and low birthweight have risen in the United States, despite unprecedented growth in the understanding of almost every dimen- sion of human biology at a cellular and genetic level. 1 No health problem affects more of our children more profoundly than this one, threatening all racial and ethnic groups, but particularly minority populations and the poor. 1,2 Improved medical knowledge and technical capacity allow many more premature babies to survive, but the costs to the baby, the baby's family and society can be tremendous. 3±6 The sequelae are particularly severe in the most premature babies with very low birthweight, who are more likely than full- term infants to die in their first year and to suffer significant health problems, hospitalisations, slow growth, and behavioural, attentional and learning disorders. 4,6 Thus, the challenge of this major problem derives not so much from an inability to save small babies once born but, rather, an inability to protect them from lifelong damage, and most importantly, to preserve their growth in utero until closer to term. We simply do not know how to prevent the problem in any effective way. 2,7 Researchers have been seeking effective prevention strategies for more than a quarter of a century. In 1985, Dr Emile Papiernik convened leading researchers in the field to examine progress to date, with particular emphasis on social causes and public health-based, randomised trials aimed at providing social and other supports to pregnant women. 8 Much of the research discussed was in progress at the time. Final results were presented at a subsequent conference, held in Chatham, Massachusetts, USA, convened in 1988 by Drs H. Berendes, S. Kessel and S. Yaffe. 8 The conference addressed risk-assessment activities that might identify those subgroups of pregnant women likely to benefit from educational materials aimed at increasing awareness of the signs and symptoms of preterm labour. This approach was motivated in large part by promising results from early clinical trials suggesting the efficacy of tocolytic agents, such as ritodrine, in treating spontaneous preterm labour. 9 Various risk prediction scoring systems had been developed 10,11 and tested in a wide variety of clinical obstetric situations. However, risk-scoring schemes tested both in large unselected and in high-risk obstetric populations 12 did not provide accurate and efficient means for classifying pregnant women according to their preterm delivery risk. During the decade following these conferences, major risk identification and reduction trials were completed. A third conference was convened in 1997 in Charleston, South Carolina, USA, to examine progress and propose future directions for research and interventions. 3 The news was generally disap- pointing. The previously reported significant impact of tocolytic therapy on halting preterm labour had not been confirmed in larger clinical trials. 13 Programmes aimed at preventing or ameliorating the impact of preterm labour through the monitoring of uterine activity and the provision of immediate access to health care had provided mixed results. 14 Preterm prevention programmes designed to provide nursing care with or without monitoring of uterine activity had failed to demonstrate meaningful improvements in pregnancy outcomes. These observations were particu- larly disappointing as considerable increases in clinical resources such as unscheduled visits or administration of prophylactic tocolytic agents were not associated with a reduction in preterm delivery rates. 15 Other programmes had placed considerable empha- sis on providing social support to those women determined to be at high risk of preterm delivery # Blackwell Science Ltd. Paediatric and Perinatal Epidemiology 2001, 15 (Suppl. 2), 3±6 Ahed Bhed Ched Dhed Ref marker Fig marker Table mar- ker Ref end Correspondence: Dr Carol Hogue, Women's and Children's Center, Rollins School of Public Health, Emory University, 1518 Clifton Road, N.E., Atlanta, GA 30322, USA. E-mail: chogue@sph.emory.edu 3 Paper 003 Disc