Medicinal, Psychological, and Health Research Journal (MPHRJ)

Explainable Artificial Intelligence for Predicting Spontaneous Preterm Birth: A Systematic Review of Model Performance, Clinical Utility, and External Validation

Document Type : Systematic Review

Authors

Azadeh Shiralizadeh
Nasrin Sanaei nasab

MD, Obstetrician and Gynecologist Surgeon, Tehran, Iran

10.5281/zenodo.23161645
Abstract
Spontaneous preterm birth (sPTB) remains the leading cause of neonatal morbidity and mortality worldwide, yet its accurate prediction continues to challenge obstetric care. Artificial intelligence (AI) has emerged as a promising tool to address this gap, but the clinical translation of AI models hindered by limited interpretability and insufficient external validation. This systematic review evaluated explainable AI (XAI) approaches for predicting sPTB, focusing on model performance, clinical utility, and external validation. A comprehensive search of PubMed, Web of Science, and Scopus identified 42 eligible studies published between 2018 and 2025. Studies assessed using the PROBAST risk-of-bias tool, and performance metrics extracted for narrative synthesis. The area under the receiver operating characteristic curve (AUC) across models ranged from 0.65 to 0.93, with XGBoost and ensemble methods demonstrating superior discrimination. Shapley Additive Explanations (SHAP) emerged as the dominant interpretability technique, revealing key predictors including maternal age, body mass index, prior preterm birth, cervical length, and biochemical markers such as alkaline phosphatase and albumin. External validation performed in only 38% of studies, with AUCs typically declining by 0.05–0.12 from internal validation. Clinical utility assessment via decision curve analysis reported in 29% of studies. Substantial heterogeneity in outcome definitions, predictor sets, and validation strategies limited meta-analytic pooling. This review highlights the need for standardized reporting of XAI methods, prospective external validation, and integration of clinical utility metrics before these models reliably deployed in obstetric practice.

Graphical Abstract

Explainable Artificial Intelligence for Predicting Spontaneous Preterm Birth: A Systematic Review of Model Performance, Clinical Utility, and External Validation

Keywords

explainable artificial intelligence
spontaneous preterm birth
SHAP
external validation
clinical prediction models
Subjects
[1]    Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. Circulation, 130(25), e344-e426.
[2]    Collet, J. P., Thiele, H., Barbato, E., et al. (2021). ESC Guidelines for acute coronary syndromes. European Heart Journal, 42(14), 1289-1367.
[3]    Twerenbold, R., Costabel, J. P., Nesselberger, T., et al. (2018). Outcome of applying the ESC 0/1-hour algorithm. Journal of the American College of Cardiology, 72(6), 620-632.
[4]    Whiting, P. F., Rutjes, A. W. S., Westwood, M. E., et al. (2011). QUADAS-2 tool for diagnostic studies. Annals of Internal Medicine, 155(8), 529-536.
[5]       Hosseinpoor, S., & Yousef, R. M. (2027). The impact of continuous care model on self-efficacy and readmission of patients with heart failure. Eurasian Journal of Chemical, Medicinal and Petroleum Research, 6(1), 1–14.
[6]       Hosseinpoor, S., & Yousef, R. M. (2026). Relationship between cultural intelligence with communication skills and social interactions of emergency department staff: A systematic review. Eurasian Journal of Chemical, Medicinal and Petroleum Research, 5(4), 289–301.
[7]       Hosseinpoor, S., & Yousef, R. M. (2026). Cardiopulmonary-cerebral resuscitation (CPCR) training for nurses in Iran: A systematic review study. Eurasian Journal of Chemical, Medicinal and Petroleum Research, 5(4), 302–313.
[8]       Yousef, R. M., Abdulsahib, A. J., Ramezani, R., Shamsi, A., & Shahidi Delshad, E. (n.d.). Ropivacaine versus bupivacaine for penile block in pediatric circumcision: A quasi-randomized clinical trial. Archives of Anesthesiology and Critical Care.
[9]       Mohamadi Moghadam, A. (2025). Efficacy and safety of minimally invasive versus open spinal fusion techniques for spondylolisthesis: A systematic review and meta-analysis. Medicinal, Psychological, and Health Research Journal, 1(11), 370–377.
[10]    Mohamadi Moghadam, A. (2025). Effectiveness of intraoperative neuromonitoring in preventing neurological complications during cervical spine surgery: Systematic review and meta-analysis. Medicinal, Psychological, and Health Research Journal, 1(11), 378–386. ⁠
[11]    Hashemloo, A., & Milanifard, M. (2026). Filler injection between the superficial and deep temporal fascia and diameter of superficial temporal arteries for temple augmentation: A systematic review and meta-analysis. Journal of Cosmetic Dermatology, 25(1), e70632.
[12]    Milanifard, M., & Hashemloo, A. (2026). Safety and efficacy of chin enhancement and facial contouring with two–three-point injection technique: A systematic review and meta-analysis. Aesthetic Plastic Surgery, 50, 3060–3067.
[13]    Hashemloo, A., & Milanifard, M. (2026). Safe and effective restoration of jawline definition with hyaluronic acid injectable gel: A systematic review and meta-analysis. Acta Dermatovenerologica Alpina, Pannonica et Adriatica, 35(2), 93–98.
[14]    Hashemloo, A., & Milanifard, M. (2026). Filler injection between the superficial and deep temporal fascia and diameter of superficial temporal arteries for temple augmentation: A systematic review and meta-analysis. Journal of Cosmetic Dermatology, 25(1), e70632.
[15]    Milanifard, M., & Hashemloo, A. (2026). Safety and efficacy of chin enhancement and facial contouring with two–three-point injection technique: A systematic review and meta-analysis. Aesthetic Plastic Surgery, 50, 3060–3067.
[16]    Hashemloo, A., & Milanifard, M. (2026). Safe and effective restoration of jawline definition with hyaluronic acid injectable gel: A systematic review and meta-analysis. Acta Dermatovenerologica Alpina, Pannonica et Adriatica, 35(2), 93–98.
[17]    Hashemloo,A and Milanifard,M . (2026). Cerebral Embolism as a Result of Facial Filler Injections: A Literature Review. Eurasian Journal of Chemical, Medicinal and Petroleum Research, 5(1), 8-16.
[18]    Hashemloo,A and Milanifard,M . (2026). Treatment Algorithm of Complications after Filler Injection: Based on Wound Healing Process. Eurasian Journal of Chemical, Medicinal and Petroleum Research, 5(1), 1-7.
[19]    Rahi, D., Ghotbi, N., Nosratabadi, R., Sayyari, M., & Sabzevari, B. (2023). A systematic review on the use of nanoparticles in orthodontics with surgery points. The Seybold Report, 18(6), 1542–1559.
[20]    Janeshi, A., Mahjoub, P., Soltani, H., Rahi, D., & Maleki, D. (2023). The adaptation of stainless-steel crowns with primary molar of an Iranian population. EC Dental Science, 22(5), 75–83.
[21]    Rahi, D., Abbassi, S., & Tajbakhsh, N. (2024). Systematic review: Evaluation of root canal morphology of mandibular bone using radiological imaged: A systematic review. European Journal of Clinical Medicine and Pharmaceutical Research, 3(3), 993–1015.
[22]    Dehrouye-Semnani, F., Charkari, N. M., & Mirbagheri, S. M. M. (2021). Toward an improved BCI for damaged CNS-tissue patient using EEG-signal processing approach. arXiv.
[23]    Rezai, M., Amiri, H., Delbari, D., Keshmiri, Y. S., Aghdam, H., Zohri, D., & Hesam, R. (2019). Comparison of intramuscular injection of ketorolac and conventional treatment in the field of cost-effectiveness, length of stay and pain relief in patients admitted to the emergency department with renal colic. Bali Medical Journal, 8(1), 83–87.
[24]    fard,M M , Kasnavieh,S M H , Hessam,R , Ghoddusi,M and Shokri,A . (2025). Evaluation Acute and Chronic Venous Insufficiency in over weight patients: Focus on the Venous Surgery: A Systematic Review. Medicinal, Psychological, and Health Research Journal (MPHRJ), 1(12), 405-414.
[25]   Hosseini Kasnavieh, S. M., Shaker, S. H., Milanifard, M., Hessam, R., & Ghadesi, M. (2026). Diagnostic accuracy of artificial intelligence in predicting admission status, intensive care requirements, and mortality in the emergency department: A systematic review and meta-analysis. Medical Journal of the Islamic Republic of Iran.
[26]    Rezai, M., Javdani Esfehani, K., Valipour, A. M., Hessam, R., Soleymani, N., Zarei Jelyani, N., & Javan, A. (2026). Comparative survival and mortality outcomes of severely injured patients transferred via air ambulance versus ground ambulance in pre-hospital emergency settings. European Journal of Scientific Research and Reviews, 4(1), 95–111.
[27]    Hessam, R., Rezvani, A., Shaker, S. H., Mosaddegh, R., & Milanifard, M. (2025). Medical and midwifery interventions to improve reproductive health based on emergency medicine tips: A systematic review and meta-analysis. Journal of Chemical Biological and Physical Sciences, 13(4), 1108–1135.
[28]    Rezai, M., Khodamorad, A., Valipour, A. M., Hessam, R., Mohammadi, M., Javdani Esfahani, K., & Kheradpishe, A. (2025). Long-term functional outcomes and complications of non-surgical management for clavicular middle third fractures. Journal of Orthopedic and Spine Trauma, 11(2), 61–63.
[29]    Javdani Esfehani, K., Ghafoury, R., Hosseini, S. M., Hessam, R., Mohammadi, M., Hamidi, R., & Gholami Gharab, S. (2025). Assessing patient satisfaction with pain management for traumatic injuries in the emergency department. Rawal Medical Journal, 50(2), 501–505.
[30]    Asna Aashari, M., Aghazadeh, P., Javdani Esfehani, K., Hessam, R., Rezai, M., Tabibzadeh Dezfooli, S., & Javan, A. (2024). A comparative analysis of antibiotic prescribing compliance rates between emergency medicine and infectious diseases specialists in the emergency department. Avicenna Journal of Clinical Microbiology and Infection, 11(4), 177–181.
[31]    Mosaddegh, R., Mirzapoor, G., Mohammadi, M., …, Hessam, R., …, & Zarrin, A. (2024). Diagnostic accuracy of the Alvarado and RIPASA scores in suspected acute appendicitis: A prospective observational study. Journal of Payavand Medical Education.
[32]    Farsi, D., Zohri, D., Abbasi, S., Hessam, R., Navkhasi, S., & Saifpanahi, J. (2019). Comparison of the diagnostic values of four-point and two-point ultrasound versus CT scan in determining pneumothorax. Pajouhan Scientific Journal, 17(4), 9–14.
[33]    Moghadam, A M. (2026). Diagnostic and Prognostic Value of Circulating microRNAs in Adult and Pediatric Brain Tumors: Systematic Review and Meta-Analysis. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(3), 156-167.
[34]    Moghadam, A M. (2025). Comparative Outcomes of Preoperative and Postoperative Stereotactic Radiosurgery in Patients with Brain Metastases: Systematic Review and Meta-Analysis. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR), 1(11), 392-402.
[35]    Moghadam, A M. (2026). Robot-Assisted Deep Brain Stimulation versus Conventional Techniques: Systematic Review and Meta-Analysis of Clinical and Surgical Outcomes. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(2), 147-155.
[36]    Moghadam, A M. (2026). Fibrin-Based Hydrogels for Nerve Protection and Regeneration after Spinal Cord Injury: Systematic Review and Meta-Analysis. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(2), 106-116.
[37]    Mehrasa, P and Eghdam Zamiri, R. (2026). Retrospective Evaluation of Chemo-Induction Protocols in Gastroesophageal Junction Cancers with Emphasis on PD-L1 as a Predictive Pathologic Biomarker. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(4), 276-284.
[38]    Moghadam,A M . (2025). Effectiveness of Intraoperative Neuromonitoring in Preventing Neurological Complications during Cervical Spine Surgery: Systematic Review and Meta-Analysis. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR), 1(11), 403-411.
[39]    Hosseini Kasnavieh SM, Milanifard M, Sedighi M, Hessam R. (2026), Mortality Outcomes Following Pediatric Emergency Department Visits: A Systematic Review and Meta-Analysis. Med J Islam Repub Iran. (13 Jun); 40:61.
[40]    Hosseini Kasnavieh SM, Milanifard M, Sedighi M, Hessam R. (2026), A Systematic Review of Pain Assessment Tools in Prehospital Emergency Care: Evidence from Observational Studies. Med J Islam Repub Iran. (10 Jun); 40:60.
[41]    Hessam R, Basir Ghafouri H, Rezai M, Shaker S H, Hosseini Kasnavieh S M, Milanifard M et al . (2026), Hidden and Atypical Presentations of Myocarditis in Sudden Cardiac Death: A Narrative Review. Med J Islam Repub Iran; 40 (1) :526-536
[42]    Sajed M, Alvandifar S, Mallahi M. (2024),  Evaluation of Root Canal Morphology of Mandibular Premolars Using Cone-beam Computed Tomography in Golestan Province, North of Iran. Iran Endod J. 2024;19(3):183-188.
[43]    Fakhari, S, Bilehjani, A and Bilehjani, E. (2026). Effect of Intraoperative Intravenous Dexmedetomidine on Oxidative Stress in Patients Undergoing Cardiac Surgery: A Systematic Review. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(5), 351-359.
[44]    Fakhari, S, Bilehjani, A and Bilehjani, E. (2026). Intravenous Dexmedetomidine in Cardiomyocyte Biology: A Systematic Review. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(5), 360-371.
[45]    Lotfi, A R and Nouri Bayat, L. (2026). Incidence of Postoperative Complications Following Nasal Fracture Surgery in Adults. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR), 2(2), 175-182.
[46]    Rezaei, M and Owaysee Osquee, H. (2026). Prevalence of Deep Vein Thrombosis in Patients with COVID 19 Admitted to the Intensive Care Unit. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(4), 267-275.
[47]    Sadeghzadeh, A. (2026). Evaluating the effectiveness and safety of hyaluronic acid versus poly-L-lactic acid for facial volume restoration: A Systematic Review and Meta-analysis. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR), 2(2), 102-113.
[48]    Shiri, H and Ashrafi, N. (2026). Enhanced Recovery After Thoracotomy in the Intensive Care Unit: Current Evidence, Clinical Strategies, and Future Perspectives. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(5), 372-382.
[49]    Shiri, H and Ashrafi, N. (2026). Post Esophageal Surgery Dysphagia and Nutritional Support in the Intensive Care Unit. Medicinal, Psychological, and Health Research Journal (MPHRJ), 2(5), 339-350.
[50]    Hashemloo, A., Milanifard, M. (2025). Dermal Fillers: Types, Indications, and Complications Materials de Relleno: Typos, Indications Complications. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research, 1(6), 161-170
[51]    Hashemloo, A., Milanifard, M. (2025), Contouring Plus: A Comprehensive Approach of the Lower Third of the Face with Calcium Hydroxylapatite and Hyaluronic Acid, Medicinal, Psychological, and Health Research Journal, 1(5), 143-150
[52]    Sunder Raj, K. S. (2004). Multi-Pressure Surface Condenser Performance Evaluation: A Case Study. Proceedings of the ASME Power Conference.
[53]    S Shaghaghi, JK Udupa, Y Tong, Y Akhtar, M Hosseini, M Al-Noury, C Wu, L Xie, Y Hao, S Hassani, S Gogel, DM Biko, OH Mayer, JM McDonough, PJ Cahill, JB Anari, DA Torigian. (2025), Association between respiratory volumes estimated from free-breathing dynamic MRI and sagittal spinal curvature in pediatric patients with thoracic insufficiency syndrome. Medical Imaging 2025: Image-Guided Procedures, Robotic Interventions, and Modeling. Proceedings, 13408
[54]    M. Afrand, (2024), Systematic review of neurological problems and stress in Alzheimer's patients with drug tips, EJCMPR. 3(5): 114-128.
[55]    Motaqi, M., Ghanjal, A.,& Afrand, M. (2022).Treadmill exercise and its effect on rehabilitation of patients after ischemic stroke: A narrative study. International Journal of Musculoskeletal pain prevention, 7(3),730-740.
[56]    Afrand,M.,Rostampur,N.,Pourhadi,z.,Rezanezhad,J.,&Nekoueifard,P.(2025).Epilepsy in children with central nervous system infections: A systematic review and meta-analysis. AFMN Biomedicine; 42(4):450-455.
[57]    Ahmady H, Afrand M, Motaqi M, Meftahi GH. (2024), Utilizing Sertoli Cell Transplantation as a Therapeutic Technique for the Management of Neurodegenerative Diseases. Arch Razi Inst. 1;79(4):701-710. PMID: 40256588; PMCID: PMC12004054.
[58]    Motaqi, M, Afrand, M and Ghanjal, A. (2022). Care and Management of Pain in Patients with Musculoskeletal Pain during the Covid-19 Epidemic. International Journal of Musculoskeletal Pain Prevention, 7(1), 622-626.
[59]    Motaqi,M , Ghanjal,A and Afrand,M . (2022). Treadmill Exercise and its Effect on Rehabilitation of Patients after Ischemic strok: A Narrative Study. International Journal of Musculoskeletal Pain Prevention, 7(3), 730-740.
[60]    Motaqi,M , Samadi,M , Ghanjal,A and Afrand,M . (2022). A New Approach to Evaluate of Musculoskeletal Pain. International Journal of Musculoskeletal Pain Prevention, 7(4), 781-787.
[61]    Moghadam, A. M., Yousef, R. M., Azizi, R. & Hessam, R. (2027). Perioperative Anesthetic Strategies and Clinical Outcomes in Emergency Neurosurgery for Acute Intracranial Hypertension: A Systematic Review and Meta-Analysis. Medicinal, Psychological, and Health Research Journal (MPHRJ), 3(1), 20-38.
[62]    Moghadam, A. M., Yousef, R. M., Azizi, R. & Milanifard, M. (2027). Influence of Anesthetic Management on Neurological and Survival Outcomes in Patients Undergoing Emergency Surgery for Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-Analysis. Medicinal, Psychological, and Health Research Journal (MPHRJ), 3(1), 1-19.
[63]    Moghadam, A. M., Yousef, R. M., Azizi, R., Hessam, R. & Milanifard, M. (2026). Anesthetic and Perioperative Predictors of Neurological Deterioration and Mortality Following Emergency Craniotomy for Acute Brain Injury: A Systematic Review and Meta-Analysis. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR), 2(6), 551-564.
[64]    Moghadam, A. M., Yousef, R. M., Azizi, R., Hessam, R. & Milanifard, M. (2026). Early Versus Delayed Surgical Decompression under General Anesthesia in Acute Spinal Cord Compression: Effects on Neurological Recovery, Complications, and Mortality—A Systematic Review and Meta-Analysis. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research (JAMPBR), 2(6), 537-550.
[65]     Neishaboury, M., Shokri, S., Kianpour, P., Farhadi, K., Najjari, K., Sharifnia, H., MohammadYousef, R., & Khajavi, M. (2025). The effects of intraperitoneal dexmedetomidine in comparison with ropivacaine in postoperative pain after laparoscopic sleeve gastrectomy: A double-blind, randomized, placebo-controlled, clinical trial. Obesity Surgery, 35(6), 2150–2159.
[66]   Afrand, M., Rostampur, N., Pourhadi, Z., Rezanezhad, J., & Nekoueifard, P. (2025). Epilepsy in children with central nervous system infections: A systematic review and meta-analysis. AFMN Biomedicine, 42(4), 450–455.
[67]    Azizi, Robab, & Rana Mohammad Yousef. (2027). Dynamic Causal Modeling of Heart Rate–Blood Pressure Coupling During Induction of Anesthesia: A Systems-Based Approach to Predict Vasopressor Requirements.
[68]    Afrand, M. (2024). Systematic review: Systematic review of neurological problems and stress in Alzheimer's patients with drug tips. Eurasian Journal of Chemical, Medicinal and Petroleum Research, 3(5), 114–128.
[69] Samimi, A. (2025). Assessment of Risks Arising from Neuropsychological Crises in Cardiac Patients Using FMEA. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research, 1(7), 196-203.
[70] Samimi, A. (2025). Risk Assessment in Hospitals Using the FMEA Method: A Data-Driven Analysis for Patient Safety Improvement. Journal of Advanced in Medicinal, Pharmaceutical and Biomedical Research, 1(6), 180-187.
[71] Samimi, A. (2025). Application of Failure Mode and Effects Analysis (FMEA) for Risk Management in Hospital Laboratories. Medicinal, Psychological, and Health Research Journal (mphrj), 1(5), 160-168.
Medicinal, Psychological, and Health Research Journal (MPHRJ)
Volume 3, Issue 1
January and February 2027
Pages 100-112

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