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discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/11552372

Frequency of Uterine Contractions and the Risk

of Spontaneous Preterm Delivery
ARTICLE in NEW ENGLAND JOURNAL OF MEDICINE FEBRUARY 2002
Impact Factor: 55.87 DOI: 10.1056/NEJMoa002868 Source: PubMed

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The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

FREQUENCY OF UTERINE CONTRACTIONS AND THE RISK OF SPONTANEOUS

PRETERM DELIVERY
JAY D. IAMS, M.D., ROGER B. NEWMAN, M.D., ELIZABETH A. THOM, PH.D., ROBERT L. GOLDENBERG, M.D.,
EBERHARD MUELLER-HEUBACH, M.D., ATEF MOAWAD, M.D., BAHA M. SIBAI, M.D., STEVE N. CARITIS, M.D.,
MENACHEM MIODOVNIK, M.D., RICHARD H. PAUL, M.D., MITCHELL P. DOMBROWSKI, M.D., AND DONALD MCNELLIS, M.D.,
FOR THE NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT NETWORK OF MATERNALFETAL MEDICINE UNITS*

ABSTRACT
Background The measurement of the frequency
of uterine contractions has not been useful for reducing the rate of preterm delivery in randomized trials. Nonetheless, ambulatory monitoring of contractions continues to be used in clinical practice.
Methods We assessed the frequency of uterine contractions as a predictor of the risk of spontaneous
preterm delivery before 35 weeks of gestation. We
enrolled women with singleton pregnancies between
22 and 24 weeks of gestation. The women used a
contraction monitor at home to record contraction
frequency twice daily on 2 or more days per week
from enrollment to delivery or 37 weeks of gestation.
Results We obtained 34,908 hours of successful
monitoring recordings from 306 women. Although
more contractions were recorded from women who
delivered before 35 weeks than from women who
delivered at 35 weeks or later, we could identify no
threshold frequency that effectively identified women
who delivered preterm infants. The sensitivity and
positive predictive value of a maximal hourly frequency of contractions of four or more between 4 p.m.
and 3:59 a.m. were 9 percent and 25 percent, respectively, at 22 to 24 weeks and 28 percent and 23 percent at 27 to 28 weeks. Other proposed screening
tests, such as digital and ultrasound evaluations of
the cervix and assays for fetal fibronectin in cervicovaginal secretions, also had low sensitivity and positive predictive value for preterm labor.
Conclusions Although the likelihood of preterm delivery increases with an increased frequency of uterine
contractions, measurement of this frequency is not
clinically useful for predicting preterm delivery.
(N Engl J Med 2002;346:250-5.)

preterm delivery, the clinical value of this measure has

been unclear. The clinical use of ambulatory monitoring of contractions continues, despite randomized
clinical trials that have indicated that measurement
of the frequency of contractions as a screening or diagnostic test has not been useful for reducing the
rate of preterm delivery.4-8
We therefore performed an observational study to
assess the frequency of uterine contractions as a predictor of spontaneous preterm delivery. We considered other variables that could affect the frequency of
contractions, including the duration of gestation,2,9
the time of day,9,10 and the womans history with respect to preterm delivery. We also compared contraction frequency with other proposed markers of the
risk of preterm delivery, including the results of digital
and ultrasound evaluations of the cervix and the presence or absence of fetal fibronectin in cervicovaginal
secretions.11-14
METHODS
Study Population
The study, which was initiated by the National Institute of Child
Health and Human Development Network of MaternalFetal
Medicine Units, was conducted at 11 network sites between 1994
and 1996 and was approved by the human-subjects review board
at each institution. All women provided written informed consent.
To enroll a population with an increased likelihood of preterm
delivery, we recruited women with singleton pregnancies who had
a history of spontaneous preterm delivery between 20 and 36
weeks of gestation or bleeding in the second trimester of the current pregnancy both risk factors for preterm delivery. We also
enrolled a limited number of women without any risk factors to

Copyright 2001 Massachusetts Medical Society.

SSESSMENT of the frequency of uterine

contractions has been suggested as a screening method to identify pregnant women
with an increased risk of preterm delivery
(i.e., delivery before 35 weeks of gestation)1,2 and as
a diagnostic test to detect preterm labor in its earliest stages.3 Although an increase in the frequency of
uterine contractions would be expected to precede

From the departments of obstetrics and gynecology at Ohio State University, Columbus (J.D.I.); the Medical University of South Carolina,
Charleston (R.B.N.); the University of Alabama, Birmingham (R.L.G.);
Wake Forest University, Winston-Salem, N.C. (E.M.-H.); the University of
Chicago, Chicago (A.M.); the University of Tennessee, Memphis (B.M.S.);
the University of PittsburghMagee Womens Hospital, Pittsburgh
(S.N.C.); the University of Cincinnati, Cincinnati (M.M.); the University
of Southern California, Los Angeles (R.H.P.); Wayne State University, Detroit (M.P.D.); the Biostatistics Center at George Washington University,
Washington, D.C. (E.A.T.); and the National Institute of Child Health and
Human Development, Bethesda, Md. (D.M.). Address reprint requests to
Dr. Iams at the Department of Obstetrics and Gynecology, Ohio State
University, 1654 Upham Dr., Columbus, OH 43210-1228.
Gary Thurnau, M.D., University of Oklahoma, Oklahoma City, was another author.
*Participants in the Network of MaternalFetal Medicine Units are listed in the Appendix.

250 N Engl J Med, Vol. 346, No. 4 January 24, 2002 www.nejm.org

F R EQ U E N CY O F U T E R I N E C O N T R AC T I O N S A N D T H E R I S K O F S P O N TA N EO U S P R ET E R M D E L I V E RY

allow comparison of the frequency of contractions in women with

and without risk factors for preterm delivery. The sample size was
based on a univariate comparison of the mean hourly contraction
rate at any given time between women delivering their infants before term and those delivering at term. We calculated that, for an
assumed preterm-delivery rate between 10 percent and 15 percent,
a sample of 300 would give the study approximately 80 percent
power to detect a difference of 0.5 standard deviation (e.g., a difference of one contraction per hour if the standard deviation was
no more than two contractions per hour 9). Because it contained patients at high risk, this sample of 300 was likely to include women
delivering before 35 weeks, when neonatal morbidity is increased.
The goal was to recruit 50 to 70 women at low risk and 230 to
250 women at high risk.
The women were screened for eligibility before 22 weeks of
gestation. All women underwent an ultrasound examination before enrollment to confirm or establish the duration of gestation.
Women who had received or were scheduled to receive an ambulatory monitor or tocolytic medication or to undergo cerclage were
not eligible, nor were women whose pregnancies were complicated by placenta previa or a major fetal anomaly detected by ultrasonography. Women who did not have telephones were not enrolled, because the transmission of data collected by the monitoring
system required a telephone.
Assessments
Once enrolled, women were evaluated every two to three weeks
at outpatient visits so investigators could reinforce compliance
with study protocols, perform examinations with a speculum to collect swabs of cervicovaginal fluid for the measurement of fibronectin, and perform digital and transvaginal ultrasound assessments
of the cervix. Fetal fibronectin is an extracellular-matrix protein
normally found at the interface between the fetal membranes and
the maternal decidua; its presence in cervicovaginal secretions has
been related to an increased risk of preterm delivery.11,13 The risk
of preterm delivery has also been related to cervical length as
measured by ultrasonography12 and to the Bishop score for digital
examination of the cervix.14 The Bishop score is a composite
measure of cervical length, dilatation, position, consistency, and
the degree of descent (station) of the presenting part of the fetus.
The results indicate the degree of readiness for labor; values from
0 to 4 indicate not ready for labor, and values from 9 to 13 indicate ready for labor. These procedures were performed by study
personnel according to previously established protocols.11-14
The visits were scheduled to collect data at 22 to 24 weeks (visit 1), 25 to 26 weeks (visit 2), 27 to 28 weeks (visit 3), 29 to 30
weeks (visit 4), 31 to 32 weeks (visit 5), and 33 weeks or later
(visit 6). Swabs of cervicovaginal fluid for detection of fibronectin
were collected at all six visits. Digital and ultrasound assessments
of the cervix were performed only at visits 1, 3, and 5.
Monitoring of Uterine Contractions
Research nurses at each center were trained in the use of a
home contraction monitor (Healthdyne System 37, Matria, Marietta, Ga.). Monitors and assistance with data collection were provided by the manufacturer under a contract chosen by competitive bidding in accordance with guidelines of the Department of
Health and Human Services.
A research nurse visited each woman at home to instruct her
in the use of the monitor and transmission of data. Women were
asked to record uterine activity for a minimum of one hour at
least twice daily in two sessions at least two hours apart, one between 4 a.m. and 3:59 p.m. and the other between 4 p.m. and 3:59
a.m., on 2 or more days per week from enrollment to 28 weeks.
After 28 weeks, two additional monitoring sessions per week were
required. Data were transmitted immediately after collection to a
dedicated computer system at the data-coordinating center at the

George Washington University Biostatistics Center. Compliance

with the protocol, including the time, date, and quality of the recordings for each woman, was monitored weekly. Data collected
from medical records, interviews, and ultrasound examinations were
transmitted weekly to the center.
The enrolled women were followed to delivery. The duration
of pregnancy and the reasons for preterm delivery, if it occurred,
were recorded. The health care providers, investigators, and patients
were blinded to the results of testing. None of the tests included
in the analysis were performed outside the study.
Analyses of Recordings
The recordings of uterine activity were analyzed according to
a standard protocol by four research nurses. Any session lasting
at least 30 minutes that produced a satisfactory tracing was reviewed. A research nurse first screened each recording to identify
those that showed no contractions. All recordings with one or
more contractions were read jointly by two nurses who were unaware of the outcome of the pregnancy. A contraction was defined as a deflection that occurred from a clear base line and that
had a rounded peak and lasted from 40 to 120 seconds. The guiding principle in formulating this definition was that it include all
deflections that any experienced obstetrician or obstetrical nurse
would easily agree to identify as a contraction. Inverted, doublepeak, and camel-back contractions were included. Possible
contractions that is, those that were subtle, had a variable base
line, had a flat peak, or were accompanied by an artifact that obscured the above criteria were not considered contractions. Regular audits, in which a sample of recordings with contractions was
reanalyzed, were conducted throughout the study to ensure consistent interpretation. Although discordant interpretation occurred
in 14 to 28 percent of recordings, the discrepancy was never greater
than one contraction per hour and was evenly distributed between
increased and decreased numbers of contractions. Ten percent of
recordings with no contractions were also reviewed again as a quality-control measure; the rate of discordance among observers was
1.4 percent for these recordings.
Statistical Analysis
Analyses of uterine activity were performed to identify relations
with the duration of gestation, the time of day (4 a.m. to 3:59
p.m. [designated as daytime] vs. 4 p.m. to 3:59 a.m. [designated
as nighttime]), risk status (high vs. low), and the timing of delivery
(term delivery vs. spontaneous preterm delivery at less than 35
weeks of gestation, after preterm labor or preterm rupture of the
membranes). Hourly contraction rates were calculated for each
woman and for each week of gestation and were analyzed by a repeated-measures, random-effects model. Because each woman could
contribute data only as long as her pregnancy continued, more
data were collected for women who did not deliver prematurely.
Contraction-frequency data from women who delivered their infants after 35 weeks were therefore compared with data collected
between 24 weeks 0 days and 28 weeks 6 days for women who delivered between 29 weeks 0 days and 32 weeks 6 days, and with data
collected between 24 weeks 0 days and 32 weeks 6 days for women
who delivered between 33 weeks 0 days and 34 weeks 6 days.
The maximal daytime and nighttime contraction rates per hour
for each interval of weeks (22 to 24, 25 to 26, 27 to 28, 29 to
30, 31 to 32, and 33 or more weeks) were evaluated as predictors
of preterm delivery by logistic regression.
To compare uterine activity with the results of other tests as
predictors of preterm delivery, we determined the sensitivity,
specificity, and predictive values of each test at each gestational
interval for spontaneous preterm delivery before 35 weeks of gestation. The results were dichotomized for the Bishop score (according to published criteria),14 cervical length (25 vs. >25
mm),12 and cervicovaginal fibronectin (<50 vs. 50 ng per mil-

N Engl J Med, Vol. 346, No. 4 January 24, 2002 www.nejm.org 251

The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

RESULTS

We screened 2205 women. Informed consent was

not obtained from 545, and 1206 were ineligible (400
who did not have a telephone, 252 who were beyond 24 weeks of gestation, 94 with twin gestations,
and 460 who had one or more of the other exclusion criteria listed above). There were 454 women
with singleton pregnancies who met the inclusion
criteria and consented to enroll. A total of 146 women (32 percent) did not comply with monitoring,
and 2 delivered within one week of enrollment. The
study group consisted of the remaining 306 women,
for all of whom complete information was available.
The mean (SD) age of the 306 women was 26.2
5.8 years, and the mean parity was 1.81.3. Seventyfour percent had 12 or more years of education, 60
percent were black, and 26 percent smoked cigarettes. Of 254 women who were at increased risk for
preterm delivery, 194 (76.4 percent) had one previous preterm delivery, 57 (22.4 percent) had two or
more prior preterm deliveries, and 8 (3.1 percent) had
second-trimester bleeding. Some women had more
than one risk factor for preterm delivery. One hundred six women (35 percent) delivered their infants before 37 completed weeks of gestation, 48 (16 percent)
before 35 weeks, and 18 (6 percent) before 32 weeks.
We obtained 34,908 hours of successful monitoring
recordings, of which 21 percent (7268 hours) contained recordings of contractions. Because the frequency of contractions was not related to the historical risk of preterm delivery (P=0.22), data from the
low-risk and high-risk women were combined in subsequent analyses. The mean frequency of contractions
increased significantly with the duration of gestation
and was higher during nighttime hours (4 p.m. to
3:59 a.m.), regardless of the week of gestation at delivery (Fig. 1). Analyses were performed separately
for daytime and nighttime contraction data. After
the week of gestation at the time of monitoring had
been controlled for, women who delivered their infants before 35 weeks of gestation had more contractions, as measured both during the daytime (P=

0.4

Contractions per Hour

liliter).13 Contraction frequency was dichotomized as less than four

or four or more contractions per hour, as previously described.3
We performed multivariate logistic-regression analyses that included maximal uterine-contraction frequency, presence or absence
of fetal fibronectin in cervicovaginal secretions, cervical length, and
Bishop score as dichotomous variables. Evaluation of collinearity,
including the standard errors and the correlation of the parameter
estimates, indicated that correlations between the results of the
screening tests did not cause a problem with the logistic-regression analyses.
Receiver-operating-characteristic curves were constructed for
each test for each two-week gestational interval. The curves were
compared by calculating the area under the curve with use of a
nonparametric approach based on the theory developed for generalized U statistics.15

Delivery before 35 weeks

Delivery at or after 35 weeks
4 p.m.3:59 a.m. (nighttime)
4 a.m.3:59 p.m. (daytime)

0.3
0.2
0.1
0.0
24

26

28

30

32

Week of Gestation
Figure 1. Relation of the Week of Gestation, Time of Day, and
Timing of Delivery (before 35 Weeks of Gestation or at 35
Weeks or More of Gestation) to the Frequency of Contractions
between 24 and 32 Weeks.
The mean hourly contraction rates for both daytime and nighttime recordings were calculated with use of a repeated-measures random-effects model.

0.09 for 24 weeks 0 days to 28 weeks 6 days and

P=0.03 for 24 weeks 0 days to 32 weeks 6 days) and
during the nighttime (P<0.001 for 24 weeks 0 days
to 28 weeks 6 days and P=0.02 for 24 weeks 0 days
to 32 weeks 6 days) than did women who delivered
at or after 35 weeks.
In univariate analyses, the maximal frequency of
contractions was inconsistently related to spontaneous delivery before 35 weeks of gestation (Table 1).
Because the logistic-regression models for maximal
morning and nighttime contraction frequency had
slightly better fit than that for mean contraction frequency, the maximal frequency was used in subsequent analyses.
The strength of the relation between the frequency
of contractions and preterm delivery relative to other
factors associated with preterm delivery is shown in
Table 2. These comparisons are limited to the three
study visits at which the Bishop score and the presence or absence of fetal fibronectin in cervicovaginal
secretions were determined and cervical ultrasonography was performed. In univariate analyses (data not
shown), cervicovaginal fibronectin levels of at least
50 ng per milliliter, a cervical length of 25 mm or less,
a Bishop score of 4 or more at all three visits, and a
maximal nighttime contraction frequency of 4 or more
per hour at 27 to 28 weeks were related to a greater
risk of preterm delivery. In multivariate analyses (Table
2), maximal nighttime contraction frequency at 27 to
28 weeks, cervical length at all three visits, Bishop

252 N Engl J Med, Vol. 346, No. 4 January 24, 2002 www.nejm.org

F R EQ U E N CY O F U T E R I N E C O N T R AC T I O N S A N D T H E R I S K O F S P O N TA N EO U S P R ET E R M D E L I V E RY

sons of areas under the curve. At 22 to 24 weeks

(data not shown), cervical length was a significantly
better predictor than the other measures. At 27 to
28 weeks (Fig. 2), cervical length had the greatest
area under the curve, but no test was superior to any
other. At 31 to 32 weeks (data not shown), cervical
length and Bishop score were both significantly better
than the frequency of contractions in predicting preterm delivery. The sensitivity, specificity, and predictive
values for maximal daytime and nighttime contraction
frequency, presence or absence of cervicovaginal fibronectin, cervical length, and Bishop score to predict delivery before 35 weeks are shown in Table 3.
No test had both good sensitivity and a high positive predictive value, but a contraction frequency of
four or more per hour was a particularly weak predictor of preterm delivery. At 22 to 24 weeks, the sensitivity of the frequency of contractions to predict preterm delivery was below 10 percent, as compared with
35 to 45 percent for digital or ultrasound assessment
of the cervix. Maximal nighttime contraction frequency had higher sensitivity at later weeks of gestation,
but it continued to have poor sensitivity and positive
predictive value.

TABLE 1. ODDS RATIO FOR SPONTANEOUS DELIVERY AT LESS

THAN 35 WEEKS, ACCORDING TO THE MAXIMAL DAYTIME
AND NIGHTTIME FREQUENCY OF CONTRACTIONS.
WEEK OF
GESTATION

2224
2526
2728
2930
3132
33

NO. OF
WOMEN

ODDS RATIO (95% CI)*

DAYTIME

NIGHTTIME

(4 a.m.3:59 p.m.)

(4 p.m.3:59 a.m.)

270
301
294
288
281
266

0.9
1.2
1.0
1.1
1.0
0.8

(0.61.3)
(1.01.5)
(0.81.2)
(0.91.2)
(0.81.3)
(0.61.2)

1.3
1.2
1.2
1.1
1.1
1.1

(1.01.6)
(1.01.4)
(1.11.4)
(1.01.2)
(0.91.3)
(0.91.4)

*CI denotes confidence interval.

P=0.02.
P=0.03.
P=0.003.

score at 22 to 24 weeks, and cervicovaginal fibronectin at 31 to 32 weeks were significantly related to

an increased likelihood of preterm delivery.
Receiver-operating-characteristic curves were used
to evaluate each measure as a predictor of spontaneous preterm delivery by means of pairwise compari-

DISCUSSION

Because increased uterine-contraction frequency

has been considered to lead to preterm labor and de-

TABLE 2. RELATION OF TEST RESULTS TO THE LIKELIHOOD OF SPONTANEOUS DELIVERY

AT LESS THAN 35 WEEKS, ACCORDING TO MULTIVARIATE LOGISTIC REGRESSION.
TEST*

WEEK
2224

Maximal nighttime contraction

frequency 4/hr
Odds ratio (95% CI)
P value
Maximal daytime contraction
frequency 4/hr
Odds ratio (95% CI)
P value
Cervicovaginal fibronectin
50 ng/ml
Odds ratio (95% CI)
P value
Cervical length 25 mm
Odds ratio (95% CI)
P value
Bishop score 4
Odds ratio (95% CI)
P value

OF

GESTATION

AT

TIME

2728

OF

TESTING
3132

3.0 (0.614.6)
0.18

3.0 (1.08.7)
0.04

1.3 (0.35.2)
0.74

3.2 (0.333.6)
0.34

1.6 (0.46.2)
0.54

0.5 (0.13.2)
0.49

2.3 (0.68.2)
0.22

2.0 (0.66.9)
0.25

3.8 (1.113.2)
0.04

5.9 (12.613.7)
<0.001

4.0 (1.610.2)
0.003

7.5 (1.929.7)
0.004

4.2 (1.710.6)
0.002

1.7 (0.74.2)
0.26

3.1 (0.812.7)
0.12

*CI denotes confidence interval.

The Bishop score is a composite measure of cervical length, dilatation, position, consistency, and
the degree of descent (station) of the presenting part of the fetus. The results indicate the degree of
readiness for labor; values from 0 to 4 indicate not ready for labor, and values from 9 to 13 indicate
ready for labor.

N Engl J Med, Vol. 346, No. 4 January 24, 2002 www.nejm.org 253

The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

1.0

Sensitivity

0.8

0.6

0.4
Cervical length
Bishop score
Contraction frequency, 4 p.m.3:59 a.m.
Cervicovaginal fibronectin

0.2

0.0
0.0

0.2

0.4

0.6

0.8

1.0

False Positive Rate

Figure 2. Receiver-Operating-Characteristic Curves for Cervical Length, Bishop Score, Frequency of
Contractions between 4 p.m. and 3:59 a.m., and Presence or Absence of Fetal Fibronectin in Cervicovaginal Secretions at 27 to 28 Weeks in the Prediction of Spontaneous Preterm Delivery (Less Than 35
Weeks).

livery, strategies for early detection and suppression

of contractions have been advocated to reduce the
incidence of premature delivery.3,4 However, the preponderance of evidence from randomized clinical
trials indicates that these strategies do not reduce
the rate of prematurity.4-8 Our results help to explain
these observations. We found that frequency of contractions is significantly related to preterm delivery,
but this measure has low sensitivity and low positive
predictive value as a screening test for impending preterm delivery in asymptomatic women. This was true
even in women at increased risk for preterm delivery.
We found a relatively small difference in the frequency of contractions between women who subsequently delivered a preterm infant and those who gave
birth at term. Not only was the difference small, but
its discriminative value was low, so that the frequency of contractions had a low positive predictive value
for preterm delivery. Because our data and those of
others9,16 show that the frequency of contractions is
increased in the afternoon and evening9 and with increased duration of gestation,9,16 increased frequency
of contractions in any individual woman is more likely

to reflect advancing gestation or diurnal variation than

occult preterm labor.
Our results also confirm previous reports11-14 of significant associations between prematurity and cervical length, Bishop score, and fibronectin in cervicovaginal secretions. However, our results indicate that
these tests are not useful as screening tests for preterm
delivery in asymptomatic women. Cervical length of
25 mm or less as measured by transvaginal ultrasonography was the most sensitive and consistent predictor of delivery before 35 weeks, but this test had a
positive predictive value below 40 percent, even
among women at increased risk for preterm delivery.
The measurement of fetal fibronectin had lower sensitivity in this study than has previously been
reported11,13; this low sensitivity may reflect the low
incidence of delivery before 28 weeks in our study
population, as compared with the incidence in prior
trials.11,13,17 Measurements of cervical length and fetal fibronectin in cervicovaginal secretions have been
reported to be clinically useful in ruling out preterm
labor among symptomatic women,17,18 a group we
did not study. Our data indicate that ambulatory

254 N Engl J Med, Vol. 346, No. 4 January 24, 2002 www.nejm.org

F R EQ U E N CY O F U T E R I N E C O N T R AC T I O N S A N D T H E R I S K O F S P O N TA N EO U S P R ET E R M D E L I V E RY

APPENDIX
TABLE 3. VALUE OF TESTS IN PREDICTING
SPONTANEOUS DELIVERY AT LESS THAN 35 WEEKS.

TEST

WEEK OF GESTATION
AT TIME OF TESTING
2224

2728

3132

percent

Maximal nighttime contraction

frequency 4/hr
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Maximal daytime contraction
frequency 4/hr
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Cervicovaginal fibronectin
50 ng/ml
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Cervical length 25 mm
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Bishop score 4*
Sensitivity
Specificity
Positive predictive value
Negative predictive value

8.6
96.4
25.0
88.3

28.1
88.7
23.1
91.1

27.3
82.0
11.3
93.0

0
98.4
0
87.0

12.9
93.9
20.0
90.2

13.6
84.9
7.1
92.1

18.9
95.1
35.0
89.4

21.4
94.5
30.0
91.6

41.2
92.5
30.4
95.2

47.2
89.2
37.0
92.6

53.6
82.2
25.0
94.1

82.4
74.9
20.9
98.1

35.1
91.0
35.1
91.0

46.4
77.9
18.8
92.9

82.4
61.8
14.7
97.8

*The Bishop score is a composite measure of cervical

length, dilatation, position, consistency, and the degree of
descent (station) of the presenting part of the fetus. The results indicate the degree of readiness for labor; values from
0 to 4 indicate not ready for labor, and values from 9 to 13
indicate ready for labor.

monitoring of uterine contractions does not identify

women destined to have preterm delivery, and they
thus explain the failure of this method to reduce the
risk of preterm delivery in clinical practice.
Supported by grants from the National Institute of Child Health and
Human Development (HD 19897, HD 21410, HD 21414, HD 21434,
HD 27860, HD 27861, HD 27869, HD 27883, HD 27889, HD 27905,
HD 27915, and HD 27917).

We are indebted to Anita Das, Ph.D., and Julia Zachary (George

Washington University Biostatistical Coordinating Center), Beth A.
Collins, Ph.D., R.N.C. (Medical University of South Carolina),
Molly Fischer, M.P.H., C.R.N.P. (National Institute of Child
Health and Human Development), Francee Johnson, R.N. (Ohio
State University), and Melissa Swain, R.N. (Wake Forest University), for their tireless efforts to collect, monitor, read, and analyze the
recordings from the uterine-contraction monitor.

Institutions and staff members participating in the National Institute of

Child Health and Human Development Network of MaternalFetal Medicine Units were as follows: National Institute of Child Health and Human
Development C. Catz, M. Klebanoff, and S. Yaffe; University of Alabama
at Birmingham J.C. Hauth and R. Copper; University of Chicago P.
Jones and M. Lindheimer; University of Cincinnati N. Elder and T. Siddiqi; George Washington University Biostatistics Center A. Das and J.
Zachary; Ohio State University M.B. Landon; University of Oklahoma
J.C. Carey and A. Meier; University of PittsburghMagee Womens Hospital
M. Cotroneo, J.H. Harger, and J.M. Roberts; University of Southern
California B. Kovacs and Y. Rabello; Medical University of South Carolina B.A. Collins and J.P. Van Dorsten; University of Tennessee B.
Mercer and R. Ramsey; Wake Forest University P. Meis and M. Swain;
Wayne State University G.S. Norman and Y. Sorokin.

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