Public Health Commons^™

A Qualitative Endline Evaluation Study Of Male Engagement In Promoting Reproductive, Maternal, Newborn, And Child Health Services In Rural Kenya, Adelaide Lusambili, Stefania Wisofschi, Constance Shumba, Peter Muriuki, Jerim Obure, Michaela Mantel, Lindsay Mossman, Rachel Pell, Lucy Nyaga, Anthony Ngugi, James Orwa, Stanley Luchters, Kennedy Mulama, Terrance J. Wade, Marleen Temmerman

Population Health, East Africa

Background: Globally, male involvement in reproductive, maternal, newborn, and child health (RMNCH) is associated with increased benefits for women, their children, and their communities. Between 2016 and 2020, the Aga Khan University implemented the Access to Quality of Care through Extending and Strengthening Health Systems (AQCESS), project funded by the Government of Canada and Aga Khan Foundation Canada (AKFC). A key component of the project was to encourage greater male engagement in RMNCH in rural Kisii and Kilifi, two predominantly patriarchal communities in Kenya, through a wide range of interventions. Toward the end of the project, we conducted a …

Translation And Validation Of Training Needs Analysis Questionnaire Among Reproductive, Maternal And Newborn Health Workers In Tanzania, Tumbwene Mwansisya, Columba Mbekenga, Kahabi Isangula, Loveluck Mwasha, Eunice Pallangyo, Grace Edwards, James Orwa, Michaela Mantel, Micheal Mugerwa, Leonard Subi, Secilia Mrema, David Siso, Edna Selestine, Marleen Temmerman

School of Nursing & Midwifery, East Africa

Background: Continuous professional development (CPD) has been reported to enhance healthcare workers’ knowledge and skills, improve retention and recruitment, improve the quality of patient care, and reduce patient mortality. Therefore, validated training needs assessment tools are important to facilitate the design of effective CPD programs.

Methods: A cross-sectional survey was conducted using self-administered questionnaires. Participants were healthcare workers in reproductive, maternal, and neonatal health (RMNH) from seven hospitals, 12 health centers, and 17 dispensaries in eight districts of Mwanza Region, Tanzania. The training needs analysis (TNA) tool that was used for data collection was adapted and translated into …

Contextual Challenges In The Implementation Of The Alliance For Maternal And Newborn Health Improvement, Prospective Cohort Study, An Experience From Rural Pakistan, Yaqub Wasan, Shabina Ariff, Amjad Hussain, Sheraz Ahmed, Mansoor A. Abro, Imran Ahmed, Atif Habib, Sajid Bashir Soofi

Centre of Excellence in Women and Child Health

Introduction: Improving maternal and newborn survival needs robust data on patterns of morbidity and mortality from well-characterized cohorts. It is equally important for researchers to document and understand the contextual challenges of data collection and how they are addressed.
Methods: This was a prospective cohort study implemented from December 2012 to August 2014 in Matiari, Pakistan. A total of 11,315 pregnancies were enrolled. Participants were approached at home for sequential data collection through the standard pretested structured questionnaires. Some indicators were sourced through health facility records. Information on field challenges gathered through field diaries and minutes of meetings with field …

The Relationship Between Regulation And Care Access In The Doula Industry, Charissa Billings

University Honors Theses

Birth doulas are unregulated service providers in the United States, who provide informational, emotional, and physical support before, during, and after birth. Currently, the United States has the highest maternal mortality rate amongst the most developed nations, as well as a serious racial gap, with Black women being twice as likely to die due to pregnancy-related complications when compared to White women. Birth doulas can help close the gaps with trained support and advocacy. Since over 40% of the births in the US are covered by Medicaid, providing birth doula services to Medicaid recipients could result in improved birth outcomes. …

Pregnancy And Substance Use, Elise Withers, Krista Thompson, Emily Hamilton, Maren Wright Voss

All Current Publications

The use of alcohol and other harmful substances, such as cocaine, opioids, and marijuana during pregnancy has increased over the last decades (Sebastiani et al., 2018). Using these substances can be very harmful to the unborn baby and mother (Viteri et al., 2015). This fact sheet covers (1) the consequences of substance use and (2) the current recommendations for substance use during pregnancy.

Direct Maternal Morbidity And The Risk Of Pregnancy-Related Deaths, Stillbirths, And Neonatal Deaths In South Asia And Sub-Saharan Africa: A Population-Based Prospective Cohort Study In 8 Countries, Imran Ahmed, Shabina Ariff, Zulfiqar Ahmed Bhutta, Muhammad Ilyas, Fyezah Jehan, Usma Mehmood, Karim Muhammad, Muhammad Imran Nisar, Sajid Bashir Soofi, Yaqub Wasan, Anita K. M. Zaidi

Woman and Child Health

Background: Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa.
Methods and findings: This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive …

Evaluation Of The Feasibility Of The Fast-M Maternal Sepsis Intervention In Pakistan: A Protocol, Sheikh Irfan Ahmed, Raheel Sikandar, Rubina Barolia, Bakhtawar M H. Khowaja, Kashif Ali Memon, James Cheshire, Catherine Dunlop, Arri Coomarasamy, Lumaan Sheikh, David Lissauer

Department of Obstetrics & Gynaecology

Background: Maternal sepsis is a life-threatening condition, defined by organ dysfunction caused by infection during pregnancy, childbirth, and the postpartum period. It is estimated to account for between one-tenth and half (4.7% to 13.7%) of all maternal deaths globally. An international stakeholder group, including the World Health Organization, developed a maternal sepsis management bundle called "FAST-M" for resource-limited settings through a synthesis of evidence and international consensus. The FAST-M treatment bundle consists of five components: Fluids, Antibiotics, Source identification and control, assessment of the need to Transport or Transfer to a higher level of care and ongoing Monitoring (of the …

Evidence On Child Nutrition Recommendations And Challenges In Crisis Settings: A Scoping Review, Aniqa Islam Marshall, Gideon Lasco, Mathudara Phaiyarom, Nattanicha Pangkariya, Phetdavanh Leuangvilay, Pigunkaew Sinam, Rapeepong Suphanchaimat, Sataporn Julchoo, Watinee Kunpeuk, Yunting Zhang

Development Studies Faculty Publications

Adequate child nutrition is critical to child development, yet child malnutrition is prevalent in crisis settings. However, the intersection of malnutrition and disasters is sparse. This study reviews existing evidence on nutrition responses and outcomes for infants and young children during times of crisis. The scoping review was conducted via two approaches: a systematic search and a purposive search. For the systematic search, two key online databases, PubMed and Science Direct, were utilized. In total, data from 32 studies were extracted and included in the data extraction form. Additionally, seven guidelines and policy documents were included, based on relevance to …

A Hidden Crisis During Covid-19: How Have Intimate Partner Violence Screening Guidelines For Pregnant Patients Changed Since The Start Of The Global Covid-19 Pandemic?, Zayba Afshar

University Honors Theses

Introduction: Due to the risks of pregnancy outcomes in relation to IPV and the increased rates of IPV as a result of COVID-19 precautions, health care screening for IPV in the prenatal process is even more imperative for preventing negative healthcare outcomes for both the pregnant patient and children.

Background: Intimate partner violence (IPV) is a significant public health issue that puts both baby and pregnant patients at risk for severe negative healthcare outcomes. Healthcare screening is a tool to find a condition or to learn more about a patient before symptoms become severe.

Methods: Screening for …

Comparative Analysis Of Pediatric Covid-19 Infection In Southeast Asia, South Asia, Japan, And China, Judith Ju Ming Wong, Qalab Abbas, Soo Lin Chua, Ririe Fachrina Malisie, Kah Min Pon, Tomohiro Katsuta, Hongxing Dang, Pei Chuen Lee, Muralidharan Jayashree, Quratulain Maha

Department of Paediatrics and Child Health

There is a scarcity of data regarding coronavirus disease 2019 (COVID-19) infection in children from southeast and south Asia. This study aims to identify risk factors for severe COVID-19 disease among children in the region. This is an observational study of children with COVID-19 infection in hospitals contributing data to the Pediatric Acute and Critical Care COVID-19 Registry of Asia. Laboratory-confirmed COVID-19 cases were included in this registry. The primary outcome was severity of COVID-19 infection as defined by the World Health Organization (WHO) (mild, moderate, severe, or critical). Epidemiology, clinical and laboratory features, and outcomes of children with COVID-19 …

Uterine Artery Embolization Combined With Methotrexate For Broad Ligament Ectopic Pregnancy In A 30-Year Old Primigravida, Khurram Khaliq Bhinder, Azza Sarfraz, Zouina Sarfraz, Shaista Riaz, Samreen Aslam, Zouina Ameena

Department of Paediatrics and Child Health

We present the case of 30-year old primigravida female at 11 weeks' gestation who was diagnosed to have ectopic pregnancy on obstetric ultrasound. An MRI pelvis was ordered to assess invasion into the posterior myometrium which confirmed a single right-sided broad ligament-extra uterine pelvic ectopic pregnancy with extrinsic mass effect on the right lower uterine segment without frank myometrial invasion. On an urgent basis, a uterine artery embolization (UAE) was performed by targeting the right femoral artery. Selective catheterization was performed of both uterine arteries and the right side showed a major feeder of the gestational sac. Supplied dose of …

Influence Of The Request And Purchase Of Television Advertised Foods On Dietary Intake And Obesity Among Children In China, Jinli Xian, Mao Zeng, Zhengjie Cai, Changxiao Xie, Yuqian Xie, Manoj Sharma, Yong Zhao, Zumin Shi

Environmental & Global Health Faculty Research

Background: This study aims to examine the effects of the request and purchase of Television (TV) advertised foods on children’s dietary intake, overweight and obesity in China. Methods: Data from 1417 children (aged 6–17 years) in the 2011 China Health and Nutrition Survey were analysed. The request and purchase of TV advertised foods were assessed through the frequency of children’s requests to purchase TV advertised foods and the frequency of parents’ purchases of these advertised foods, as well as the frequency of children’s purchases of TV advertised foods. The height and weight of children were measured. Logistic regression models were …

Development Of The Infant Gut Microbiome Predicts Temperament Across The First Year Of Life, Molly Fox, S. Melanie Lee, Kyle S. Wiley, Venu Lagishetty, Curt A. Sandman, Jonathan P. Jacobs, Laura M. Glynn

Psychology Faculty Articles and Research

Perturbations to the gut microbiome are implicated in altered neurodevelopmental trajectories that may shape life span risk for emotion dysregulation and affective disorders. However, the sensitive periods during which the microbiome may influence neurodevelopment remain understudied. We investigated relationships between gut microbiome composition across infancy and temperament at 12 months of age. In 67 infants, we examined if gut microbiome composition assessed at 1–3 weeks, 2, 6, and 12 months of age was associated with temperament at age 12 months. Stool samples were sequenced using the 16S Illumina MiSeq platform. Temperament was assessed using the Infant Behavior Questionnaire-Revised (IBQ-R). Beta …

The Ways In Which Women’S Suffrage Affected Healthcare, Madison M. Weber

The Review: A Journal of Undergraduate Student Research

The 19th Amendment had and continues to have a major impact on women’s healthcare in the United States. Prior to suffrage, women had little to no ability to voice their thoughts on and change policies that regarded their own health. This essay addresses the way in which the vote both directly and indirectly impacted healthcare; including workplace conditions, maternal and reproductive rights, racial disparities, political advocacy and healthcare, the different waves of feminism, and how this has all affected modern healthcare for women. From progressive articles being published in women's magazines, to the establishment of marital rape, to the availability …

Mapping Inequalities In Exclusive Breastfeeding In Low- And Middle-Income Countries, 2000–2018, Natalia V. Bhattacharjee, Laauren E. Schaeffer, Simon I. Hay, Arianna Maever L. Amit, Veincent Christian F. Pepito, Local Burden Of Disease Exclusive Breastfeeding Collaborators, 477 Co-Authors

Ateneo School of Medicine and Public Health Publications

Exclusive breastfeeding (EBF)—giving infants only breast-milk for the first 6 months of life—is a component of optimal breastfeeding practices effective in preventing child morbidity and mortality. EBF practices are known to vary by population and comparable subnational estimates of prevalence and progress across low- and middle-income countries (LMICs) are required for planning policy and interventions. Here we present a geospatial analysis of EBF prevalence estimates from 2000 to 2018 across 94 LMICs mapped to policy-relevant administrative units (for example, districts), quantify subnational inequalities and their changes over time, and estimate probabilities of meeting the World Health Organization’s Global Nutrition Target …

Can Racial Disparities In Poor Birth Outcomes Be Partially Attributed To Stress: A Mendellian Randomization Study, Madeline Travers

Dissertations and Theses

In the United States, low birth weight (LBW) is a leading cause of infant death overall, and the leading cause of death for Black infants. Understanding and preventing adverse birth outcomes is a major public health priority. Observationally, there is some evidence to support the hypothesis that maternal stress may be associated with LBW. To clarify the effect of maternal stress exposure on LBW, I conducted three separate-sample instrumental variable analyses with genetic instruments (Mendelian randomization) based on single nucleotide polymorphisms (SNP), from genome wide association studies, strongly (p-value < 5 × 10⁻⁶) and independently associated with neuroendocrine, vascular, and immune measures …

Developmental Ethanol Exposure Causes Central Nervous System Dysfunction And May Slow The Aging Process In A Drosophila Model Of Fetal Alcohol Spectrum Disorder, Khaoula Belhorma, Nahed Darwish, Elizabeth Benn-Hirsch, Annalisa Duenas, Hillary Gates, Navneet Sanghera, Jodie Wu, Rachael L. French

Faculty Research, Scholarly, and Creative Activity

Alcohol is a known teratogen, and developmental exposure to ethanol results in fetal alcohol spectrum disorder (FASD). Children born with FASD can exhibit a range of symptoms including low birth weight, microcephaly, and neurobehavioral problems. Treatment of patients with FASD is estimated to cost 4 billion dollars per year in the United States alone, and 2 million dollars per affected individual's lifetime. We have established Drosophila melanogaster as a model organism for the study of FASD. Here we report that mutations in Dementin (Dmtn), the Drosophila ortholog of the Alzheimer's disease-associated protein TMCC2, convey sensitivity to developmental ethanol exposure, …

Maternal Sociodemographic Factors And Antenatal Stress, Maheshwari Andhavarapu, James Orwa, Marleen Temmerman, Wangira Musana

Obstetrics and Gynaecology, East Africa

Antenatal stress has been associated with adverse birth outcomes such as fetal growth restriction, low birth weight, and preterm birth. Understanding key determinants of stress in a vulnerable pregnant population has the potential of informing development of targeted cost-effective interventions to mitigate against these adverse birth outcomes. We conducted a secondary analysis of data from 150 pregnant women attending antenatal care services at a rural referral hospital in Kenya. The participants completed a sociodemographic and clinical questionnaire, the Cohen’s Perceived Stress Scale (PSS) and gave a hair sample for cortisol and cortisone analysis. The association between selected sociodemographic predictors (age, …

Evaluating Motor Performance With The Bruininks-Oseretsky Test Of Motor Proficiency In Impoverished Pakistani Children, Zehra Habib Hasan, Fariha Shaheen, Arjumand Rizvi, Jelena Obradovic, Aisha Khan Yousafzai

Department of Paediatrics and Child Health

Objective: To evaluate the sensitivity of the modified Brief Form of Bruininks Oseretsky Test in identifying motor differences secondary to malnutrition and poverty.
Methods: This longitudinal cohort study was conducted at Nowshero Feroze, Sindh from 2013 to 2014 and comprised data drawn from children who participated in a randomised controlled trial, that assessed responsive stimulation and nutrition interventions in the first two years of life. Outcome measures included motor development assessed using Brief Form of Bruininks Oseretsky Test, child anthropometry and household economic and demographic information. Data was analysed using SPSS 15 and STATA 12.
Results: Of the 1058 children, …

Impact Of Local Terminology On The Design Of A Community-Based Diagnostic And Management Algorithm For Postpartum Sepsis: Findings Of Formative Research, Shabina Ariff, Fatima Mir, Wafa Aftab, Farrukh Raza, Shujaat Zaidi, Sheraz Memon, Amnesty Lefevre, Linda A. Bartlett, Peter Winch, Sajid Bashir Soofi, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Postpartum sepsis is one of the leading causes of maternal mortality and morbidity in developing countries. This formative research elicits local terms used for postpartum illnesses and symptoms of postpartum sepsis with the aim of improving postpartum diagnosis and management in Pakistan.
Methods: We conducted 34 in-depth interviews with recently delivered women (RDW), traditional birth attendants (TBAs), healthcare providers and family members of RDW from rural Sindh to explore local Sindhi terms used to describe postpartum sepsis and related symptoms. During interviews, all participants were asked to orally free list common symptoms of postpartum illnesses; those who were aware …

Improved First Trimester Maternal Iodine Status With Preconception Supplementation: The Women First Trial, Amy E. Young, Jennifer F. Kemp, Charis Uhlson, Jamie L. Westcott, Sumera Aziz Ali, Sarah Saleem, Ana Garcès, Lester Figueroa, Manjunath S. Somannavar, Shivaprasad S. Goudar

Community Health Sciences

Maternal iodine (I) status is critical in embryonic and foetal development. We examined the effect of preconception iodine supplementation on maternal iodine status and on birth outcomes. Non-pregnant women in Guatemala, India and Pakistan (n ~ 100 per arm per site) were randomized ≥ 3 months prior to conception to one of three intervention arms: a multimicronutrient-fortified lipid-based nutrient supplement containing 250-μg I per day started immediately after randomization (Arm 1), the same supplement started at ~12 weeks gestation (Arm 2) and no intervention supplement (Arm 3). Urinary I (μg/L) to creatinine (mg/dl) ratios (I/Cr) were determined at 12 weeks …

Review Of Fetal Alcohol Spectrum Disorder (Fasd) Among Aboriginal And Torres Strait Islander People, Sharynne Hamilton, Michael Doyle, Carol Bower

Australian Indigenous HealthBulletin

Fetal Alcohol Spectrum Disorder (FASD) is a preventable, lifelong disability that disproportionately affects Aboriginal and Torres Strait Islander people. This review provides a comprehensive synthesis of the available information on FASD among Aboriginal and Torres Strait Islander people, with reference to the limitations on population-based data and evaluated programs. The review outlines; the harms of alcohol use in the context of colonisation, cultural perspectives on assessment and diagnosis, effective prevention programs and a summary of state and national policies. Health impacts, educational outcomes and the effects of FASD on vulnerable populations such as children in protection and young people in …

Mindfulness-Based Interventions For Prenatal Stress, Anxiety, And Depression, Fiona Kate Rice

Expressive Therapies Capstone Theses

Pregnant people in the United States (US) face myriad barriers to resource accessibility when seeking support, including financial gatekeeping, discrimination, and cis-gendering of the process. Commodification of prenatal support is exhaustive and contributes to a growing exclusivity of traditionally accessible interventions designed to reduce stress, anxiety, and depression, and to promote positive fetal outcomes and parent-child bond. Mindfulness-based interventions are particularly appropriate for reducing stress, anxiety, and depression in pregnancy. Mindfulness-based interventions are intersectional, accessible means of pregnancy and childbirth support with evidence-based outcomes of positive birth experiences and results. Mindfulness is defined as nonjudgmental awareness of the present moment. …

Cost Estimation Alongside A Multi-Regional, Multi-Country Randomized Trial Of Antenatal Ultrasound In Five Low-And-Middle-Income Countries, B W. Bresnahan, E Vodicka, J B. Babigumira, Ashar Muhammad Malik, F Yego, A Lokangaka, B M. Chitah, Z Bauer, H Chavez, Sarah Saleem

Community Health Sciences

Background: Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency.
Methods: We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and …

Stress, Alcohol Use, And Punitive Parenting During The Covid-19 Pandemic, Jennifer Price Wolf, Bridget Freisthler, Caileigh Chadwick

Faculty Research, Scholarly, and Creative Activity

Background
Emerging research suggests that parents are experiencing heightened stress during the COVID-19 pandemic. Parental stress is a risk factor for harsh or punitive parenting, and this association may be exacerbated by the use of alcohol.
Objective
We examine whether parental stress is associated with use of punitive parenting, as well as whether this association is modified by drinking pattern.
Participants & setting
We used advertisements and word-of-mouth to recruit 342 parents living in Central Ohio during the initial stay-at-home order for COVID-19.
Methods
We used geographic ecological momentary assessment (gEMA) to measure parental stress and punitive parenting during three …

The Prevalence Of Postpartum Depression In Black And Hispanic Women In New Jersey, Courtney Chineme, Rachel Shmuts, Chris Canlas

Rowan-Virtua Research Day

Postpartum depression (PPD) is defined as symptoms of major depressive disorder (MDD) within one month of giving birth with the prevalence in the United States being 10-15%. There are well documented instances of racial differences and their effects on maternal outcomes including infant, maternal mortality and postpartum mood disorders. In New Jersey, there are monitoring systems that explore the relationships between maternal characteristics such as race, age, education level, insurance status, and racial bias and how they may correlate with higher incidences of Postpartum Depression (PPD) in these communities of women. The purpose of this comparative study is to analyze …

The Role Of Primary Care Physicians In Post-Partum Depression (Ppd), Elizabeth Bowman

Rowan-Virtua Research Day

Background

• Symptoms of depression lasting longer than 2 weeks following birth
• 10-15% of new mothers affected yet 50% of cases go undiagnosed
• Long-lasting consequences for the mother, baby, and father
• Multi-factorial condition

Conclusion

• Primary care providers are the first-line defense against PPD
• Many providers are resistant to PPD screenings
• Interventions from primary care providers are effective

The Impact Of Exercise On Pregnant Women Aged 18-40 And Fetal Development, Jinisha Patwa

Rowan-Virtua Research Day

68% of those who performed minimum level exercise prior to pregnancy stopped completely during early pregnancy.

Women stop exercising during pregnancy due to worries about the impact it may have on the development of the fetus.

Starting moderate-intensity, weight-bearing exercise early in pregnancy increases placental growth rate and volume.

Exercise reduces the risks of excess gestational weight gain and high maternal body weight before pregnancy.

Physical exercise reduces the risk of gestational diabetes mellitus.

Breastfeeding Education Support Tool For Baby (Best4baby): Feasibility, Acceptability, And Preliminary Impact Of An Mhealth Supported Breastfeeding Peer Counselor Intervention In Rural India, Parth D. Lalakia, Vanessa L. Short, Roopa M. Bellad, Patricia J. Kelly, Yukiko Washio, Tony Ma, Katie Chang, Niranjana Majantashetti, Umesh S. Charantimath, Frances J. Jaeger, Shivaprasad S. Goudar, Richard J. Derman

Rowan-Virtua Research Day

Objective: To evaluate the feasibility of an mHealth-supported breastfeeding peer counselor intervention implemented in rural India and the preliminary impact of the intervention on maternal breastfeeding behaviors, including exclusive breastfeeding (EBF).

Methods: In this quasi-experimental pilot study, participants received either the intervention plus usual care (n = 110) or usual care alone (n = 112). The intervention group received nine in-home visits during and after pregnancy from peer counselors who provided education about and support for EBF and other optimal infant feeding practices and were aided with an mHealth tool. The control group received routine prenatal and postnatal health education. …

Ethnic Differences In Maternal Cytokines And Adipokines And Their Association With Spontaneous Preterm Delivery, Yelizavet D. Lomakova, Xinhua Chen

Rowan-Virtua Research Day

Spontaneous preterm delivery (SPTD, birth at <37 weeks’ gestation) is a leading cause of infant mortality in the United States [1]. Infants born prematurely are more likely to suffer from both short and long-term complications including neurodevelopmental delay, visual and hearing impairment, and chronic diseases such as heart disease, hypertension and diabetes in later life [2-4]. African American women have a 2-fold increased risk of preterm delivery compared to Caucasian women [5].The reasons for this disparity are poorly understood. This limits the ability to predict and prevent preterm delivery in the most high-risk populations.