Current Approaches to Reducing Premature Births and Implications for Disparity Elimination

Abstract

In this chapter we review two interventions for the reduction of preterm birth, antibiotic treatment for bacteria vaginosis (BV) and progesterone, 17 alpha hydroxyprogesterone caproate (17p). While there has been recent attention to the evidence base for both interventions, the back story underlying the generation and promulgation of the evidence base for each intervention has been quite different. Although the strength of evidence for a role of BV in preterm birth and the related observed disparity has been amply demonstrated through numerous observational studies, a consistently effective treatment modality has yet to be discovered resulting in ambiguous, at best, recommendations for treatment during pregnancy. On the other hand, despite few studies in a recently developed evidence base, and an unknown biologic effect, the recommendations and practice patterns for use of progesterone to prevent preterm birth (PTB) and address disparities are more prominent. We note flaws in the development of the clinical evidence for PTB, an inconsistent interpretation and application of the clinical evidence, and a tendency toward over- reliance on a clinical cure to reduce preterm birth and eliminate disparities. It is widely assumed that the existence of an effective intervention will result in declines in preterm delivery rates and consequently a reduction in the disparity; however, we argue that the process of development and interpretation of the recent evidence base may actually have somewhat hindered scientific progress toward identifying an effective intervention for PTB. In addition, we believe that the process of eliminating disparities may require action above and beyond the identification of an effective clinical intervention. The roadmap toward sustained reductions in the disparity in preterm birth is clearly more complex than the unearthing of a magic clinical bullet.