“Improving our understanding of preterm birth through research” – with Dr. Helen Feltovich

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I am your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist, practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

Dr. Helen Feltovich, professor of obstetrics and gynecology, how you doing? Welcome to the podcast.

Dr. Feltovich: I am so excited to be here with you.

Dr. Fox: I’m pumped. We’ve been talking about this for a while, ever since you came to New York City.

Dr. Feltovich: Yoikes.

Dr. Fox: And here we are, sitting together, a couple of Midwesterners, just transplanted out East. Just me a little earlier than you.

Dr. Feltovich: Yeah, you know, it took me a while to warm up to it.

Dr. Fox: Okay. Good stuff.

Dr. Feltovich: But here I am, and glad to be here.

Dr. Fox: So this is wonderful. So our listeners, I’m sure I said something nice in the intro about how wonderful, and academic and accomplished you are, but I want to go through a little bit of how you got to this room today from…let’s start at birth. So tell me, let’s go over your labor. No, when were you…where are you from? What’s your story? How did you get into all of this? Open question.

Dr. Feltovich: Oh… That’s a long one, Natey.

Dr. Fox: We’ve got time.

Dr. Feltovich: You sure you want to know that?

Dr. Fox: Yeah, hit me.

Dr. Feltovich: All right. So I was born in Brunswick, Georgia. I was a Navy brat for the first part of my life, and then we settled after my dad got out of the Navy. I had 13 different elementary schools, and junior highs and things like that. And after my dad got out of the Navy, we settled in Owatonna, Minnesota, and that’s where I finished my growing up.

My highest ambition was to be a legal secretary.

Dr. Fox: Cool.

Dr. Feltovich: Mm-hmm. I was really excited about it because I thought I’d learn something about law, and that would be really interesting. And so to work up to that, I was a policy typist for an insurance company for about a year. But that didn’t go that well because all of these trainees that would come in, it was Federated Insurance in Owatonna, Minnesota, and all these trainees… I can’t believe we’re talking about this, but it’s kind of fun. All these trainees would come in, and my desk was by… This was like, there was a typewriter, like clickety-click.

Dr. Fox: Yeah. It was old school, yeah.

Dr. Feltovich: It’s old school. And my desk was by the water station, and the guys would always come, they were like, right out of college, and they’d sort of hang over my, you know, little cubicle and say, you know, chitty chat or whatever, and I had lots of dates. It was great. And so a sign went up in the break room one day that said, “We need to keep Helen working,” like, quit talking to her. Which completely cheesed me off because I am a really fast typist. I still am, fun fact.

Dr. Fox: Oh, really?

Dr. Feltovich: Uh-huh. 100…

Dr. Fox: What… It’s words per minute, WPMs?

Dr. Feltovich: WPMs, 120 to 140, like, no joke.

Dr. Fox: Wow. That’s like Clark Kent.

Dr. Feltovich: Mm-hmm.

Dr. Fox: Unbelievable.

Dr. Feltovich: Superstar typist.

Dr. Fox: Okay.

Dr. Feltovich: I could have been a policy typist forever, I was so good at it. So I proved that despite the chitty chatting, I got more done than anyone in the department, and that kind of made people mad because I was like a sassy 18-year-old.

Dr. Fox: Okay.

Dr. Feltovich: So then I had to go across the street to work at the bank.

Dr. Fox: Right.

Dr. Feltovich: And while I was at the bank, the high school counselor came in and said, Helen Donbrock, what are you doing here? And I said, I’m taking your deposit. Maybe someday I’ll be a legal secretary, and he was like, no, no, no, no, no, no, no.

And so fast forward, I’m in college, and I took an art degree because, you know, mostly because my mom never got to go to college when she was young. She went in her late 50s, actually, and got…

Dr. Fox: Oh, cool.

Dr. Feltovich: Yeah. To Mankato State University, and got a degree in history. But my dad never went to college because he…

Dr. Fox: Mm-hmm, went in the military.

Dr. Feltovich: Well, and he was badly dyslexic, so he sort of flunked out of…

Dr. Fox: Oh, okay.

Dr. Feltovich: Yeah.

Dr. Fox: Okay.

Dr. Feltovich: So college just wasn’t, you know, sort of a thing. But my mom would have always liked to take a degree in art, and I thought, okay, that’s fine. So I majored in art and philosophy, and then, when I got done with college, I thought, what do you do with a philosophy degree? So I was working as a window trimmer. Do you know what that is?

Dr. Fox: I assume it’s not, like, cutting wood off windows.

Dr. Feltovich: It is not.

Dr. Fox: All right.

Dr. Feltovich: Natey Fox, you’re the smartest. You always know the thing.

Dr. Fox: I mean, because that’s a trick question. That’s like, that’s what I would have thought it is. Like, why would someone need their window trimmed back? It’s too big… All right. But it’s something that…this is something to do with, like, decorations or something?

Dr. Feltovich: Decorations.

Dr. Fox: Okay.

Dr. Feltovich: So I worked for this…

Dr. Fox: Like drapes and curtains and stuff?

Dr. Feltovich: No.

Dr. Fox: No.

Dr. Feltovich: Even better. I had this job for two years, I walked around with…you know, like in overalls, with a belt like the, you know, like electricians wear, and I had a glue gun on it, and moss…

Dr. Fox: Right. Right.

Dr. Feltovich: This was like in the ’80s, when moss was a big thing, early ’90s.

Dr. Fox: Okay.

Dr. Feltovich: And I got to, like, make displays out of towels and dishes and things like this for a new department store that was opening up, a super fancy department store in Minneapolis.

Dr. Fox: Oh, wow.

Dr. Feltovich: So…yeah, super, super fun. But in the middle of that, I met this guy, who is now my husband, but this was like, 30-odd years ago. So I met him, I fell in love with him, I moved down the next weekend to… Like, literally two weeks after I met him, I moved down to Iowa City. He was in this thing called the Iowa Writers Workshop down there. And I thought I was going to, like, live with him or something.

Dr. Fox: Right.

Dr. Feltovich: And he was all, no, no, no, no, no, no, no. Like, what are you doing here?

Dr. Fox: Right.

Dr. Feltovich: So I had to take an apartment, which meant I had to find a job. So I looked in the paper, this was back when they were listed in that newspaper. I circled some things…

Dr. Fox: Like the “Iowa Gazette?”

Dr. Feltovich: Yes.

Dr. Fox: Oh. Seriously?

Dr. Feltovich: Yeah.

Dr. Fox: Oh, all right. That was a guess. All right.

Dr. Feltovich: Exactly like that. I can’t remember it was called the Gazette, but that’s very close, and very Midwestern.

Dr. Fox: Okay. Probably.

Dr. Feltovich: Yes. So I interviewed with these lawyers, and they were these, like, awesome super liberal, you know, women, and they were all like, you’d be great. You can be our legal assistant. Like, never mind, you know, legal secretary, that’s in the past. We’ll help you go to law school… Philosophy, law, I mean, it all made sense, right?

Dr. Fox: Right.

Dr. Feltovich: So they’re like, this was a Tuesday, they’re like, well, we’ll…our assistant will call you by Friday, we have to do the proper things for whatever the work rules are, and interview some other people, but this job is yours. So you’ll hear from us Friday, or at latest Monday. Friday comes and goes, nothing. Monday comes and goes, nothing. Tuesday morning I get the paper out again, like I need to pay my rent.

Dr. Fox: Right.

Dr. Feltovich: So I circle this thing, and it’s for a secretary position for some doctors up at the University of Iowa.

Dr. Fox: Ah, here we go.

Dr. Feltovich: And I went up there, and the woman said, well, you know, you’re overqualified, but if you can promise me a year, I will…you know, you can have this job.

Dr. Fox: Yeah.

Dr. Feltovich: And everybody in Iowa…like, PhDs are driving buses in Iowa City.

Dr. Fox: Right. Okay.

Dr. Feltovich: It’s that kind of a town, right? A college town. So I’m like, this is awesome. This guy that I have the hots for his, his program lasts another year, so I said, I will do it, so I signed the little thing. And then that afternoon, one of the lawyers calls me and she says, Helen, our assistant called the wrong woman, and we just learned about this. Like, the job is yours. I said, but I just promised a year… And she’s all, that was three hours ago. Like, you can unpromise that. It’s easy to find… I’m like, no, but I promised.

See, you understand this, being a Midwesterner yourself.

Dr. Fox: Sure. That’s it, done.

Dr. Feltovich: Yep, done.

Dr. Fox: You gave your word, your bond. Yeah.

Dr. Feltovich: I gave my word, my bond.

Dr. Fox: Yeah.

Dr. Feltovich: And I worked for these four doctors, HIV doctors, in the early ’90s, so there was all kinds of stuff happening that was fascinating.

Dr. Fox: Right.

Dr. Feltovich: And one thing led to another, and bottom line, they talked me into…you know, they said that deep down, I really wanted to be a doctor. Actually, there were three guys and one woman, and the guys would just, like, they’d go to their medical meetings, and bring me back the bath salts from the hotel sitting on top of the receipts that I had to type up and file.

Dr. Fox: Right.

Dr. Feltovich: But the woman was like, I think you really want to be a doctor. I’m like, no. My only science class in college was quantum theory leads up the evolutionary tree. I do not want to…you know? But she said, I’m going to send you to Brazil to do some research on Leishmaniasis, it’s a childhood parasitic illness, and you see what you think about that, you know? I think you really… So I did that, and the maternidade hospital was the same as the Children’s Hospital I was in. Like, Northeast Brazil nobody had any English, like on this…

Dr. Fox: Right.

Dr. Feltovich: And so this one day, and like, I’m seriously not making this up, Natey, like, truth is stranger than fiction, this one day I’m walking in the hospital, which is basically like cinder blocks with air flowing through, you know?

Dr. Fox: Okay. Yeah.

Dr. Feltovich: They had soap and water. That was pretty good. And the bottom floor was the maternidade part, and there would just be people on carts, like moaning and stuff, and every now and then someone would go around and do one of those listeners, those old fashioned listeners to the fetal heartbeat. Or they would check them, just sitting there in this hallway, and if things were getting…like, if they progressed enough, they’d take them into a room to deliver. I would have to go through there, and upstairs to see the children.

So I was walking in this one day, and because I had a white coat on, and because of the color of my skin, I was, like, dragged into the operating room. And I couldn’t speak Portuguese fast enough to say, no, no, no, I’m not… Like, you don’t get it, right?

Dr. Fox: Right. Right.

Dr. Feltovich: All of a sudden, like, these… We were washing hands, and putting on gloves, and you know, I went into this operating room, and I was given, like, retraction equipment on this C-section.

Dr. Fox: Nice.

Dr. Feltovich: Right? And I was like, this is not so hard. A monkey could do this work. It’s just intuitive.

Dr. Fox: Right.

Dr. Feltovich: Like, let the person see where they’re going. And then, that little head came out of that uterus, and that was magical for me, and I said I’m going to be an obstetrician.

Dr. Fox: So you knww going into medical school that you wanted to do OB.

Dr. Feltovich: Mm-hmm.

Dr. Fox: And then, so you’re doing OB, how did you decide…

Dr. Feltovich: Actually, that was the year between…

Dr. Fox: Right, before medical school.

Dr. Feltovich: …the year before I started. But I was already accepted in medical school.

Dr. Fox: Right. Got it. When did you decide, when you were doing OB, that you wanted to do maternal-fetal medicine?

Dr. Feltovich: You know what? Honestly, pretty much right away.

Dr. Fox: Really?

Dr. Feltovich: I love operating, I love, you know, all the little details of it, and so I thought op was really fun, too. And it’s nice to do stuff that… I mean, I have those fingers, right? My typist fingers, yeah.

Dr. Fox: Right, typing. Yeah. Right.

Dr. Feltovich: So I actually had pretty good surgery fingers, too. But I just really fell in love with it.

Dr. Fox: And where were you, geographically, for your residency, and then your fellowship?

Dr. Feltovich: So I went to medical school in Iowa City, and then I went out and Brian finished his degree there and stuff, and as we saved… And then, after that… Do you want to hear this other funny story, or do you not have time?

Dr. Fox: Always.

Dr. Feltovich: Always?

Dr. Fox: Yeah. If we don’t have time, we just cut it out. Who cares? It’s all good.

Dr. Feltovich: Okay, cool. All right. Perfect.

Okay. So this one day, I had, I was… I applied to medical school at a time when it was pretty hot to be, like, what they used to call, like, a “quota,” filling a quota.

Dr. Fox: Okay. Right.

Dr. Feltovich: Because that’s when fewer than half of the people applying were female, and nobody had, like, degrees in art and philosophy. So that was a big thing, right?

Dr. Fox: Right. Right.

Dr. Feltovich: So I got in, like, crazy places. And so this one day, I had this migraine, because I was trying to figure out, like, do we want to go to San Francisco? Do we want to go to Cambridge…well, Boston? Do we want, you know, do we want to stay in Iowa City, where they’ll pay for my…like, I have a scholarship and stuff to there, back in the day? And I really wanted to stay in Iowa City, and for all kinds of reasons. Don’t put this on the air, but it’s because this guy…really don’t put this on the air because it sounds like flexing. But this guy at Harvard, he told me… I called him, and I’m like, what should I do? Because I was waitlisted.

Dr. Fox: Right.

Dr. Feltovich: And then he goes, this means you’re in, you know, so you need to line up. He goes, honestly, Helen, I don’t think you have the chutzpah to be out here. I think you’ll get, like, chewed up and spit out. You’ll do fine academically, you’ll get your degree, but people that come here really think they’re the cat’s pajamas.

Dr. Fox: Okay.

Dr. Feltovich: And I’m like, was he right?

Dr. Fox: Wait, so why can’t we put that on the air?

Dr. Feltovich: That people think they’re the cat’s pajamas?

Dr. Fox: Oh, no, that’s fine. We can keep this.

Dr. Feltovich: Oh, okay.

Dr. Fox: You haven’t said anything incriminating yet.

Dr. Feltovich: Well, it’s not incriminating, it just sounds like flexing, to drop the name Harvard. That’s all.

Dr. Fox: Oh… No, it’s fine.

Dr. Feltovich: And I just think that’s yucky.

But anyway, so he said I think you’ll get chewed up and spit out, whereas if you stay at your home school, you’re going to get out with very little debt, and I predict you’re going to be like, you know, AOA, you’re going to graduate in the top 5% of your class, you’re going to have your residency of choice. So that’s what I wanted to do.

Dr. Fox: Right. Okay.

Dr. Feltovich: And in fact, that is what happened.

Dr. Fox: Okay. So where was your residency of choice?

Dr. Feltovich: Well, that’s the story. So my husband comes home that night, I have a migraine, and…well, he wasn’t my husband yet. But he comes home, and I’m like, I want to stay in Iowa City, and the next morning I wake up, and he’s gone. This is before cell phones, right?

Dr. Fox: Right.

Dr. Feltovich: I’m like, where is the dude? And all day long he’s gone. He gets home, like, about midnight. He’d driven to Chicago, because he needed to be in a big city to think, and he was like, okay, fine. We’ll stay in Iowa City for four years. But I was just up at the library, the public library in Chicago all day, and I learned that Iowa is famous for pheasant hunting. So I’m going to get a dog, I’m going to train it, I’m going to do pheasant hunting, I’m going to learn how to be like a wild man cook, and at the end of four years, I choose where we go.

Dr. Fox: Okay.

Dr. Feltovich: So that’s what we did. So then we went to Portland, Oregon for residency, which was great. And then we went to, again, more mountains and ocean, Vermont for fellowship.

Dr. Fox: Right. Right.

Dr. Feltovich: We went out there, and…never mind that story [crosstalk 00:14:07.011]

Dr. Fox: And then you ended up in Utah for a very long time.

Dr. Feltovich: I was in Utah for a very long time.

Dr. Fox: How did that happen? How did you end up in Utah? Because that’s sort of like, you know, somewhere between Portland and Vermont.

Dr. Feltovich: Yeah. Well, so…

Dr. Fox: It’s like the average.

Dr. Feltovich: …that story starts right here in New York City. So you know that Big Apple conference that you and I get to talk at together this year? Yay!

Dr. Fox: Yeah.

Dr. Feltovich: I went to that my very first year out as a person, and you know, as an attending doctor.

Dr. Fox: Yeah.

Dr. Feltovich: I joined a group in Minneapolis. Because I was looking around for research stuff, because I’m really interested in the problem of preterm birth, and that’s what my fellowship research had to do with, but I couldn’t find someone who told me that I wouldn’t need to take a PhD in physics.

Dr. Fox: Right.

Dr. Feltovich: This was before translational research was huge at NIH.

Dr. Fox: Right.

Dr. Feltovich: So I’m like, fine, then I’m going home, because I’m not going to take a PhD in physics. Not smart enough, among other things. So I went home because my family or origin…you know, help with the kids. We had little kids.

Dr. Fox: Right. Mm-hmm.

Dr. Feltovich: So I went to this Big Apple conference, and I asked a question. I can’t even remember what it was about. But I remember being so terrified because Mike Belfort was speaking, and he pointed at me and he goes, stand up, what is your name? And I was like…

Dr. Fox: With this beautiful accent. Yeah.

Dr. Feltovich: With his beautiful accent, his salt-and-pepper hair, and I thought, did I drop the F-bomb?

Dr. Fox: Yeah.

Dr. Feltovich: Like, I am really in trouble, right? So I stood up, and I’m like, hello? And he goes, come talk to me afterwards. So to make a really, really long story short, there ensued this whole thing where he’s like, you kind of have a research brain, I think you need to go have the job that I used to have with Intermountain Healthcare. I have a really good friend there, Glenn Schemmer, he’s been my partner forever, and Glenn and I are still friends, too. And so one thing led to another, and not only did I go to Utah and take Mike’s previous job, I also lived in their house. My family lived in his house in Park City after he…

Dr. Fox: I didn’t know that.

Dr. Feltovich: Yeah. Well, he went to Baylor, but they kept their Park City house.

Dr. Fox: Right.

Dr. Feltovich: We lived there for a year while our house was being remodeled, almost a year.

Dr. Fox: Right.

Dr. Feltovich: Yeah. The hospital where I worked, in Provo, was in the MFM Units Network.

Dr. Fox: Right.

Dr. Feltovich: And like, Mike Varner said, you know, it was…back then, it was the highest enrolling hospital, I guess. And Mike Varner said, you know, these nice Mormon ladies just want to help so much, and they will line up around the block, in the rain, for no compensation, to participate in a study that will help other women.

Dr. Fox: That’s amazing.

Dr. Feltovich: Mm-hmm.

Dr. Fox: So tell me about you got involved both in private practice, taking care of patients, and like, legitimate research, right? Not like as the smoke and mirrors that I do, but like, legitimate serious research, like and for the next… How did that…how did you do that at that time? That’s pretty unusual.

Dr. Feltovich: Yeah. I mean, I think how I did it is called Brian. Because I had such a… That’s the name of my husband. I had such a passion that I couldn’t put down because, you know, during those years that…those couple of years that I was in Minneapolis, you know, I would tell patients, I’m really sorry about your little tiny baby, you know, when I had to…when they’d lose a baby or something, I’d be like, I’m really sorry. And when they’d say, why does this happen? I would say, we don’t know. We have no idea, and I just…I couldn’t sleep at night. Like, the problem literally wrastled, wrastled me awake in the night. And so when I decided I wanted to do two jobs, Brian decided that he would stop working, and stay home and be house dad.

But if you mean how did it actually happen, so I went to Intermountain, and I was working in Provo, and it’s really true that people sign up. So even though I had a 1.0 FTE clinically, I was able…they had a really good infrastructure. And we were able to do just a couple of little, like, proof of concept things.

Dr. Fox: Right.

Dr. Feltovich: Like, not big research, but enough to get preliminary data together to get initial funding, just a couple of little R21s.

Dr. Fox: Right.

Dr. Feltovich: And then… And full time in private practice is four days a week, not five days a week. So the fifth day, you know…

Dr. Fox: Well, for you, maybe.

Dr. Feltovich: Well, for me. At Intermountain, back then… Actually…

Dr. Fox: I feel like I’m six-and-a-half days a week.

Dr. Feltovich: Well, yeah. I mean, frankly, I worked eight-and-a-half days a week while I was there, for both.

Dr. Fox: Yeah, yeah, that’s…

Dr. Feltovich: No, but back then, full-time was considered, like, four full clinical days a week, you know, then plus call…

Dr. Fox: Right. So you had a day built into your schedule, basically.

Dr. Feltovich: A day, like, of admin.

Dr. Fox: Yeah.

Dr. Feltovich: But that was back in the day when they also bought us, like, briefcases. They bought me this gorgeous…

Dr. Fox: Sure, swag. The doctor swag.

Dr. Feltovich: Oh, I loved it.

Dr. Fox: Yeah.

Dr. Feltovich: I got this gorgeous Coach bag. I still have it.

Dr. Fox: Yeah, those days are over.

Dr. Feltovich: Those days are so gone.

Dr. Fox: Yeah, now if you do that you’re a criminal.

Dr. Feltovich: Right?

Dr. Fox: If you take a bag, you’re a criminal. You’re a horrible doctor, for accepting a gift.

Dr. Feltovich: I know. I know. Yeah, it’s terrible.

Dr. Fox: Yeah, got it. So, why preterm birth? What is so perplexing about preterm birth, that led you to do so much research? Obviously it’s a problem, right? But there’s a lot of things that are problems, right? So why preterm birth specifically, that really, I don’t know, intrigued you?

Dr. Feltovich: Well, that is a very interesting question that I could flip on you, Cerclage King. But… Oh, and by the way, I want to bring up that you just said something about smoke and mirrors research that you do. You do serious badass research, Natey Fox, and you know it. So knock off the humility.

Dr. Fox: So you either said I did bad research, or I’m an ass who does research. So I like that. Okay.

Dr. Feltovich: Nope. Nope, I didn’t.

Dr. Fox: Good. All right. Well, that’s very kind.

Dr. Feltovich: Badass research means you do great research. But…yeah.

Dr. Fox: That’s very kind of you. All right, so going back to why preterm birth? Which is essentially, this is the topic of our podcast today. So you know, here we are, we’re at preterm birth.

Dr. Feltovich: We finally got to it, finally. Yeah.

So here’s the thing about preterm birth that sort of extends for me into all of birth, which is that I, the feminist part of my soul is sort of deeply insulted/puzzled/maybe even on the edge of hurt that we know nothing about one of the oldest questions in the world, like, when will I deliver? Like, have you ever had a patient who’s not asked you when do you think I’ll deliver?

Dr. Fox: Yeah. And I always tell them if I could answer that question, I would be a billionaire, retired, you know? That’s it. Because I mean, I would just sell that formula, and be done. Because everyone wants to know.

Dr. Feltovich: Everyone wants to know.

Dr. Fox: And we have no freaking clue.

Dr. Feltovich: We have no freaking clue. And that, to me, just feels like such a travesty. We don’t have hardly anything more at our disposal for predicting timing of delivery than Hippocrates. Soranus, the original gynecologist… And by the way, truth is stranger than fiction, you can not…that really is his name.

Dr. Fox: Soranus. Yeah.

Dr. Feltovich: Soranus, the original gynecologist, he taught his midwives that when a cervix was readying, you know, when the pregnant cervix was readying for delivery, it felt soft like an egg. And today we teach, you know, soft like your cheek, versus your nose, versus firm like… I mean, it’s what, three millennia, and is that any different?

Dr. Fox: Right. An egg is probably better, actually. An egg is…yeah, a better description.

Dr. Feltovich: Yeah. It probably is. But it just strikes me that that’s really pathetic. Because what is the one experience that every single human being that ever was and ever will be goes through? It’s birth. We all get born.

Dr. Fox: Right. Right.

Dr. Feltovich: We all also die. Some of us die in utero, so, you know, the birthing is the main event to usher us into the world. But the point is that we don’t know anything about this event. It feels to me like the Holy Grail, answering the question finally, or even getting anywhere close to this question of when will I deliver, that has plagued pregnant people and birthing attendants for, like, you know, ever. That just seems like something that needs to be answered.

And when you think about that in the face of what’s going on in other parts of medicine, it’s just…it’s really sad and pathetic, and it just offends the feminist part of my soul.

Dr. Fox: Right. The feminist part of my soul feel similarly. I mean, I tell patients all the time, when we’re talking about, let’s say preterm birth, and I say, you know, we have a very hard time understanding why someone delivers preterm, and then I always say just so you know, we have a very hard time understanding why someone delivers at term.

Dr. Feltovich: Exactly.

Dr. Fox: I say we know what happens when someone goes into labor, and we can map out a bajillion pathways and chemicals and hormones, and all these things, we can write all these fancy arrows on it, but we don’t know why that day, and not the day before, or the day after, like what flips that switch. And since we don’t know it for anybody, all the more so we don’t know it when it’s sort of like, different from average, and so it’s preterm. And so we’re, like…yeah.

Dr. Feltovich: Exactly. Or post-dates.

Dr. Fox: Yeah, afterwards, why does someone not going to labor? It’s really…yeah. I agree, the feminist part of me is offended by that, that we don’t know it yet. Well, that, you…

Dr. Feltovich: Natey…I know our souls are tied up in this together, yours and mine, and so many…

Dr. Fox: Andre always says, he’s in touch with his inner uterus. That’s what he always tells people. That’s one of his lines.

But yeah, so okay, so we have a very hard time knowing this. So what do you tell people about preterm birth? You know, when they ask, like, either they feel like they’re at risk for it, or they have a history of it, how do you go through that with somebody, given our lack of understanding?

Dr. Feltovich: Yeah, that’s a tough one, and that is… I mean, what I do is I just speak the truth. I say, you know, if I knew the answer to the question, when will I deliver, I don’t say I’d be a billionaire and retired, but I do say I’d be living on the island I bought with the money I received from my Nobel Prize, you know, reading remotely.

Dr. Fox: Right.

Dr. Feltovich: So I just, I tell the truth. And I often will say things like, I’m just so sorry to tell you this, but women’s medicine is understudied because it’s been underfunded, and fortunately, now there’s awareness of that, so there’s hope. I always like to leave people with hope on the horizon. But I’m very honest about even, you know, measuring the length of the cervix. This predictive value is about equal to flipping a coin.

Dr. Fox: Right.

Dr. Feltovich: And it’s really sad that we have exactly one imaging biomarker to predict timing of delivery. Whereas let’s compare this to cancer medicine. Let’s talk about, you know, things that take people out. We know nothing about what brings people into the world, right?

Dr. Fox: Right.

Dr. Feltovich: What about what takes people out? We know a ton about that stuff, right?

Dr. Fox: Right.

Dr. Feltovich: So just look at what’s happened in cancer medicine over the last hundred years, since 1924, right?

Dr. Fox: Right.

Dr. Feltovich: So back then, cancer was basically cancer, it just happened in different places. And you did three things with it, you gave it surgery, radiation, and chemotherapy. Over the last hundred years, and especially accelerating in, like, the ’70s, ’80s, ’90s, and on into now, because people have figured out how to use advanced imaging technologies to learn what is going on, like, right then, right there in the tissue, with proven biopsies and etc., that has led people to understanding the molecular basis of this, and now we have very targeted medications that can go to a specific receptor on a specific cell, at a specific time, in a specific woman’s…in a specific person’s body.

Dr. Fox: Mm-hmm.

Dr. Feltovich: What’s the result of that? Some cancers are flat-out curable, and many others are managed as chronic diseases. Like, the unthinkable has happened. Meanwhile… And they have textbooks full of imaging biomarkers for all kinds of different cancers, right? They have textbooks full of all sorts of bodily fluid biomarkers for different cancers, and other textbooks full of how you combine these things to arrive at a solution. What do we have…

Dr. Fox: Right. And genetic biomarkers now. I mean, all the..you know.

Dr. Feltovich: All of it.

Dr. Fox: Crazy, mutations on the tumor, mutations in the people, I mean, it’s just, it’s… You can really focus on… For the same cancer in two different people, you could have wildly different treatments, saying this one’s genetically going to be A, and this one’s genetically B, and they do that. This is like, routine medicine now for treatment of cancer.

Dr. Feltovich: Routine medicine now, 100%.

Dr. Fox: Yeah.

Dr. Feltovich: And you know, it’s kind of like in our field, diagnoses of skeletal dysplasias and dysthoses.

Dr. Fox: Right.

Dr. Feltovich: Because, you know, the more we understand about the molecular underpinnings, the more we understand that if things look the same, they might not necessarily stay the same genetics.

Dr. Fox: Right.

Dr. Feltovich: And so, you know, you know, this definitions are scrambled up about every 10 years, we call things different things as we learn.

Dr. Fox: Right.

Dr. Feltovich: In the preterm birth space, we have none of that. We have one imaging marker, we have no super reliable bodily fluid biomarkers, you know? There are papers that have looked at meta-analyses, trying to combine them, and you know this as well as I do, nothing works.

Dr. Fox: Yeah.

Dr. Feltovich: So what’s the answer to that? We have to do what the oncology specialists have done. We have to go, okay, look at the tissue, what’s going on in here? What does it mean? How is it changing? Where is it going? And then figure out from there, okay, what’s happening in the molecular space right here, right now, that’s related to that? And then back up from that and say, what’s happening in the genomic space to inform this?

Dr. Fox: Right. I mean, it’s really the difference between, let’s say eyeballing something from across the room, and looking at it with an electron microscope. I mean that’s…you know? Because we…

Dr. Feltovich: That’s a great analogy. That’s exactly what it is.

Dr. Fox: Yeah, I mean… Well, thank you. I mean, the rate of preterm birth is about 10%. It’s about 10%.

Dr. Feltovich: And increasing, by the way.

Dr. Fox: Yeah. But it’s been about 10% for a very, very long time. When it increases, it goes to 11% or 12%. When it decreases, it goes to 9.4%. I mean, this is what we do, look at the papers. But it’s basically been like that forever, right?

Dr. Feltovich: Since it’s been recorded. Yep.

Dr. Fox: Yeah. Yeah, pretty much forever. And all we know, we know sort of what happens at the very end, right? So we can say, oh, you know, this person, you know, had preterm labor because their uterus was distended, or this person had preterm labor…

Dr. Feltovich: Yeah. And it’s only retrospective of preterm labor.

Dr. Fox: Yeah, yeah, right? Yeah.

Dr. Feltovich: Because if someone contracts, but the baby doesn’t come out until after 37 weeks and 0 days…

Dr. Fox: Right, it’s not preterm labor. Right.

Dr. Feltovich: …it wasn’t preterm labor, even though she might have been on bed rest for four months. Yeah.

Dr. Fox: Yeah, right. Or it’s something like, we could say it’s this activation of this hypothalamic pituitary axis, which we talk about, and again we sort of have mapped out, but don’t understand why it’s activated early.

Dr. Feltovich: Yeah.

Dr. Fox: This idea of the cervix, that you were talking about, and like, inflammation or infections. We sort of understand, like, sort of what road they may be in, but we don’t know, again, when someone’s going to go on that road, or when they show up, frequently they’re already way too down the road to do anything about it.

Dr. Feltovich: Yeah.

Dr. Fox: So our treatments for preterm labor have never worked, right? Or…

Dr. Feltovich: Yep. And by the way, all of them are ancient.

Dr. Fox: Yeah.

Dr. Feltovich: Oh, here’s a fun fact that I bet you know.

Dr. Fox: Don’t be surprised if I don’t.

Dr. Feltovich: Natey Fox, you know…

Dr. Fox: Unless it’s about baseball, or movies.

Dr. Feltovich: You know everything.

Dr. Fox: All right, baseball or movies?

Dr. Feltovich: No, it’s about cerclages.

Dr. Fox: Mm, maybe.

Dr. Feltovich: I don’t know anything about baseball.

Dr. Fox: All right. Okay.

Dr. Feltovich: Okay, so do you know when the first cerclage was placed?

Dr. Fox: Oh, in ever? I don’t know. I mean, Shirodkar was in the ’50s, but presumably a thousand years ago, someone put, like, a bear claw on a cerclage.

Dr. Feltovich: 1902.

Dr. Fox: Yeah, that makes sense.

Dr. Feltovich: It was called Emmet’s Procedure, and it was developed in the late 1800s as a way to…well, to fix cervical lacerations, actually.

Dr. Fox: Okay.

Dr. Feltovich: And then somebody in the U.S., it was a big deal with, like, you know, physicians fighting each other, and going that’s unethical, and all the same stuff we do now, you know? We’re still arguing about cerclage.

Dr. Fox: Right.

Dr. Feltovich: But somebody used it in…and I’m forgetting their name, but they used it in a patient who had had recurrent second trimester losses. And then, after that, you know, there was like a small series, and a bunch of discussion, and after that, it kind of went quiet until the ’50s, when Shirodkar and McDonald both introduced their techniques.

Dr. Fox: Right.

Dr. Feltovich: And by the way, we still today just sort of…we’re still arguing. It’s been decades and decades, and we’re still arguing about, like, which one should we use, and does it matter, and where should you place it? And like…

Dr. Fox: Right. And in whom should you place it?

Dr. Feltovich: And in whom should you place it? And like, my gosh, give us the targeted… You know, we need nanomedicine for this. We need to, you know, get out of our thinking box, and address nanomedicine.

I do want to say that there has been tons, there’s been tons of progress in what you just mentioned, understanding the hypothalamic pituitary access, understanding the role that infection and inflammation play in abnormal timing of delivery, in the microbiome, you know? There’s been really valuable, amazing research that preterm birth is now…it used to be understood as a single entity, just like cancer, you know, more than a hundred years ago or whatever.

Dr. Fox: Right.

Dr. Feltovich: But now it’s understood as, you know, it’s sort of a syndrome, you know? And so we’ll get there. It probably has hundreds, and perhaps thousands of, you know, different mechanisms to cause it, just like various cancers do, but you know, we are well started along that pathway, and there are some really, really, really great people in this space who I think are looking at, you know, sort of the mechanics of it, and the imaging part. Like, doing what the oncologists did at first, which was look at the tissue. Because tissue doesn’t lie. The truth is always in there, you’ve just got to find it, right?

Dr. Fox: And so what would you mean by that? Do you mean doing some sort of, like, functional imaging, or do you mean, like, biopsies? What is your… What do you propose?

Dr. Feltovich: So our lab collaborative, and I just want to say that…and I’m not saying this with, like, false humility or anything like that, I just feel very, very grateful to people people who I have been able to, like, you know, strong-arm into caring about this problem. My colleagues at University of Wisconsin Medical Physics, Drs. Tim Hall and Ivan Rosado-Mendez, and my colleagues here at Columbia University, in the lab run by Dr. Kristin Myers, and Dr. Joy Vink used to be there, and now is in Hawaii, but is still in our, you know, research fold.

So these really smart people who know about things like, in the case of Wisconsin, how to do quantitative imaging, so non-invasive imaging that gives you information about what a tissue is doing, right? And ultimately, even molecular processes within that tissue, with nano-imaging technologies and things like that. They know a lot about that. And Kristin Myers, here at Columbia, knows a ton about computational modeling, so taking… You know, one of the things we’ve done is taken just straight up B-mode imaging, and you know, a lot of us sat down and made little measurements on it and things, and then the brilliant kids in her lab are able to develop computational models from this.

We’re ultimately integrating quantitative, so not just the B-mode macrostructural features of maternal anatomy that you can see, but also the quantitative features. Like how do we talk about… Instead of saying, you know, a tissue is soft, if it feels like a soft egg or your cheek, how do you put a number on that so that we can meaningfully communicate with each other, and quantitate it?

Dr. Fox: Right. Right.

Dr. Feltovich: So folding all of those things in, our goal, the goal of our collaborative is to combine all kinds of different imaging biomarkers into computational modeling, and effectively make what… Do you know what a digital twin is?

Dr. Fox: No.

Dr. Feltovich: So I mean, it’s kind of exactly what you would think. Like if I wanted to make a digital twin of the chair that you’re sitting in, with your happy face sitting there, we could do that on the computer, and then we could play with it, like tweak different elements, and see what happens.

Dr. Fox: Okay.

Dr. Feltovich: So the idea is to have enough information about how these pregnancy tissues change both in terms of their tissue properties, you know, their physics properties, and how that informs their biomechanical performance.

Dr. Fox: Right.

Dr. Feltovich: Right? Like, you can think of the cervix as… Well, we often use these terms, like why do some people have recurrent deliveries at 22 weeks, you know? Sometimes they’ll be thought of as having a weak cervix, right? Like, you can think of it in terms of engineering and physics very easily.

Dr. Fox: Right.

Dr. Feltovich: So the idea is to understand that, with enough information from ultrasound, non-invasive techniques, and then create digital twins both of normal pregnancy versus abnormal pregnancy, and even of an individual’s own personal pregnancy, that you can actually manipulate and figure out what’s going on.

So for instance, what if we learn that… we have many, many different metrics, and they’re called like UTD1, UTD2, like all this stuff. Some of the students in our lab have done, the students in Kristin’s lab, and in [inaudible 00:36:31] lab have done some really brilliant work in this space.

And I got off track because I always get so worried that people are going to think that, like, I think I’m doing this all, when really, I’m just the organizer, and the bringer together, and the…

Dr. Fox: No worries.

Dr. Feltovich: I just never want to sound… Like, I’m not… I just never want to sound like I’m arrogant. Okay, you have to cut all that out.

Dr. Fox: No, no…I didn’t do anything.

Dr. Feltovich: Well, and also I’m like, I’m big on giving credit where credit’s due, and these…

Dr. Fox: Yeah. No, you’re doing a good job. You figure… So let’s say this works, right?

Dr. Feltovich: Yeah.

Dr. Fox: Is the thought that you’re going to better predict when, let’s say, a short cervix is going to lead to preterm birth versus not? Or is the thought that based on the changes that we see, we can develop targeted therapies, whether pharmacologic or surgical or other, that will stop that process, and prevent the birth? Or both?

Dr. Feltovich: Both.

Dr. Fox: Okay.

Dr. Feltovich: As well as, and this is what’s really exciting to me, and Natey, you know, five years ago, I would have never thought this is possible. But today, with the massive advance we’ve had in just data science, basically, and our understanding of true multidisciplinary effort, you know, not just like, one specialty of doctor working with another specialty of doctor, but you know, clinicians working with engineers and physicists and data scientists and epidemiologists, you know, true, true, true multidisciplinary research, I think this is possible.

So the most exciting thing is, I really do think in our lifetimes, we could see a situation where we say the prediction is that you will deliver on December 12, 2025, you know?

Dr. Fox: Mm-hmm. Yeah.

Dr. Feltovich: Well, it’s not going to be that soon.

So the idea is that exactly as the oncologists did, if we can figure out what are the structural changes, you know, the microscope, the quantitative, the microstructural changes in tissue that lead to whichever of the hundred different, you know, pathways, then we can say when that’s happening in a person, look right here, right now, like what is going on in the molecular space at this moment? Not the whole, you know, hypothalamic…HPA, not the whole HPA access that is all of it swimming around in there, but like, what four things are happening in this exact space?

Dr. Fox: Right.

Dr. Feltovich: Because if we can see it, right, through exploration of quantitative ultrasound techniques, and computational modeling, if we can see it enough to predict what sort of shapes, it’s this thing called shape statistics is involved, artificial intelligence strategies are involved, like, our lab collaborative is throwing all that at this problem, if we can see it, then we can say, okay, this is the moment. So what is going on here, and really narrow it down, instead of this great big general, like…

Dr. Fox: Yeah. Right. And we’re very blunt now. I mean, basically, now it’s progesterone or not, cerclage or not, bed rest or not, and that’s not shown to work on anybody, right?

Dr. Feltovich: No. Not.

Dr. Fox: And tocolytics or not, which basically don’t work.

Dr. Feltovich: Not.

Dr. Fox: And so it really comes down to progesterone or not, cerclage or not, and then things like if someone’s about to deliver, steroids or magnesium, like, prediction, and that’s it. It’s like we’re using a sledgehammer when you need to be using, you know, like a 28-gauge needle.

Dr. Feltovich: Amen.

Dr. Fox: Yeah.

Dr. Feltovich: That is exactly the analogy I use. It’s like taking a great big hammer, and smacking on it… Just like they used to do with cancer, and it didn’t work, and now look at where they are. And we get to stand on the shoulders of giants, because all of the technologies, the proteomics and genomics and transcriptomics, you know, all the technologies are so well developed now.

Dr. Fox: Yeah.

Dr. Feltovich: And the ability to gather data is progressing so much right now that we can go so much faster. It shouldn’t take us decades and decades, like it did.

Dr. Fox: So for our listeners who, again, a lot of this is pretty high-level kind of research stuff and concepts, but obviously our listeners understand that preterm birth is a problem, and they don’t have great solutions, and they understand that…certainly today they understand our knowledge about all of this is pretty limited, and it’s a little bit depressing. But I’m going to ask you this, Helen Feltovich, are you optimistic or pessimistic?

Dr. Feltovich: You know what? I am optimistic. I…

Dr. Fox: Okay. Why are you optimistic? I was going to guess that, but why are you optimistic?

Dr. Feltovich: Why were you going to guess it?

Dr. Fox: Well, you’re an optimistic person.

Dr. Feltovich: I knew you were going to say that. It’s true that I am an optimistic person, but I did have…I did have moments of pessimism during the pandemic, for two reasons. One is that we all were depressed during the pandemic, because it was just a terrible time. But also, I seriously thought, humans against the virus. This is going to unite us, finally. So, and when I learned… I know, it’s funny. But when I learned…

Dr. Fox: It’s like “War of the Worlds.”

Dr. Feltovich: Right?

Dr. Fox: You know, we beat the virus, you know, ultimately, right?

Dr. Feltovich: I know. And I thought…

Dr. Fox: Or the virus helped us beat the aliens, something like that. Yeah.

Dr. Feltovich: Something like that. I seriously thought that… Like, that’s the kind of optimism I used to have. I do not have that kind of optimism anymore. But I’ll tell you what, since… You know, over my career, I finally think that in the period of time before, you know, you and I retire within a couple of decades, I think that we’ll be able to see change, because of what we were just talking about. We get to… There’s all these technologies, we just have to apply them. We have to figure out our imaging biomarkers. We have to figure out our bodily fluid biomarkers. We have to put them together, and there are roadmaps for this. In oncology, cardiology, orthopedics, there are roadmaps for this kind of thing. We have more data storage power and computing power than we’ve ever had, and all we need to do is throw money to get those things at the problem, and we will solve it.

And there’s a growing awareness of… I mean, you know this, of course. There’s such a massive awareness these days of how understudied women’s medicine is in general, including pregnancy medicine, because it’s underfunded, and I think that that’s starting to turn people’s heads. There’s a foundation right here in New York City called the Iris Fund, that’s founded by a woman named Brittney Crystal who’s the, she started off being, you know, a grateful patient, because obviously she had a preterm birth, and you know, that’s what stimulated her to start up this fund.

But you know, there are efforts like that, and other small foundations around the city and elsewhere, around the world, that are really pushing the forefront, and bringing real awareness to this problem. And I think that is going to turn into funding, just these, you know, like, smaller grassroots organizations like these small foundations, as well as, you know, Jill Biden saying we need to dump a bunch of money into women’s medicine. All of that is just building the kind of awareness that will get researchers, and there are good researchers, on this problem all over the world. To my knowledge, we are the only ones who are taking this sort of ultrasound, quantitative ultrasound, you know, imaging, biomarker, feeding into computational modeling approach, but we are open sourcing all the things that we come up with, and when that happens, it’s just a matter of time before others take it up. And with our ability, with the growing awareness, and with our ability to look at data, and process data in a way like we never have before, yeah, I think there’s a lot of room for optimism.

Dr. Fox: Awesome.

Dr. Feltovich: Do you?

Dr. Fox: Yeah, I’m always optimistic.

Dr. Feltovich: Yeah, I know you are, too.

Dr. Fox: As long as there’s, you know, a couple of old, and many smart young people working on this, I think we’ll do great.

Dr. Feltovich: Yeah.

Dr. Fox: Helen, thank you for coming on the podcast. This was terrific.

Dr. Feltovich: Thank you, Natey.

Dr. Fox: I really did… We’re going to have you back in, like, four minutes.

Dr. Feltovich: We are?

Dr. Fox: Yeah, we’re doing another podcast. I just dropped that on you.

Dr. Feltovich: I can’t wait. This was so fun

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast, or any other topic you would like us to address, please feel free to email us at HW@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only, and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health, and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.

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