• Undertake multivariate modeling to refine the understanding of what drives the large variance of the economic burden, even by gestational age at birth;

• Be ongoing to provide the basis for ongoing assessments; and

• Establish the basis for refined economic assessment of policies and interventions that would reduce the economic burden.

1. Improve the Methods of Identifying and Treating Women at Risk for Preterm Labor

In the past 30 years, important strides in obstetric and neonatal tertiary care have been made to reduce the rates of infant morbidity and mortality as a result of preterm birth. However, the primary and secondary interventions implemented to date have not reduced the rate of preterm birth. Current prenatal care is focused on risks other than preterm birth. Birth defects, adequate fetal growth, preeclampsia, gestational diabetes, selected infections, and the complications of postdate pregnancy are emphasized in the prenatal record (see Chapter 9). Preterm birth has historically not been emphasized in prenatal care, in the belief that the majority of preterm births are due to social rather than medical or obstetrical causes (Main et al., 1985; Taylor, 1985) or are the appropriate result of pathological processes that would benefit the mother or infant.

African-American women deliver their infants before 37 weeks of gestation twice as often as women of other races and deliver their infants before 32 weeks of gestation three times as often as white women. The strongest risk factors in all ethnic groups are multiple gestations, a history of preterm birth, and vaginal bleeding.

The prevention of preterm birth by the use of interventions targeting a variety of risk factors has been attempted, but these interventions have largely been without success. The diagnosis and treatment of preterm labor are currently based on an inadequate literature and are compromised by an incomplete understanding of the sequence and timing of events that precede clinical evidence of preterm labor. The accurate diagnosis of early preterm labor is difficult because the symptoms (Iams et al., 1994) and signs (Moore et al., 1994) of preterm labor occur commonly in normal women who do not deliver preterm and because manual examination of the cervix in early labor is not highly reproducible (Berghella et al., 1997; Jackson et al., 1992). Treatment efforts are primarily focused on inhibiting contractions in women with preterm labor. This approach has not decreased the incidence of preterm birth but can delay delivery long enough to allow administration of antenatal steroids and to transfer the mother and fetus to the appropriate