Reduction in stillbirths at term after new birth induction paradigm: results of a national intervention

Abstract

ObjectiveThe risk of fetal death increases steeply after 42 gestational weeks. Since 2009, Denmark has had a more proactive policy including prevention of prolonged pregnancy, and early intervention in women with diabetes, preeclampsia, high body mass index and of a higher age group. The aim of this study was to describe the development in fetal deaths with this more proactive birth induction practice, and to identify and quantify contributing factors for this development.DesignNational cohort study.SettingDenmark.ParticipantsDelivering women in Denmark, 1 January 2000 to 31 December 2012.Outcome measuresStillbirths per 1000 women at risk (prospective risk of stillbirth) and per 1000 newborn from 37 and 40 gestational weeks, respectively, through the study period.ResultsDuring the study period, 829 165 children were live born and 3770 (0.45%) stillborn. Induction of labour increased from 12.4% in year 2000 to 25.1% in 2012 (p<0.001), and the percentage of children born at or after 42 weeks decreased from 8.0% to 1.5% (p<0.001). Through the same period, the prospective risk of stillbirth after 37 weeks fell from 0.70 to 0.41/1000 ongoing pregnancies (p<0.001), and from 2.4 to 1.4/1000 newborn (p<0.001). The regression analysis confirmed the inverse association between year of birth and risk of stillbirth. The lowest risk was observed in the years 2011–2012 as compared with years 2000–2002 with a fully adjusted HR of 0.69 (95% CI 0.57 to 0.83). The general earlier induction, the focused earlier induction of women with body mass index >30, twins, and of women above 40 years and a halving of smoking pregnant women were all independent contributing factors for the decrease.ConclusionsA gradually more proactive and differential earlier labour induction practice is likely to have mainly been responsible for the substantial reduction in stillbirths in Denmark.

Perinatal outcomes following an earlier post‐term labour induction policy: a historical cohort study

“…5 The present study demonstrates that the reduction in stillborn infants was followed by significant reductions in newborn asphyxia, neonatal mortality, newborn macrosomia and peripheral nerve injuries. The incidence rate of admission to neonatal intensive care units increased, but only in neonates born after planned vaginal delivery or elective caesarean section and not in neonates born after labour induction.…”

“…Awareness of the dangers related to smoking has grown, 35 explaining the significant reduction in pregnant smokers; this reduction contributed significantly to the decrease in stillbirths but only marginally to reductions in the perinatal outcomes described in this study. 5 The increased maternal age, greater nulliparity and higher body mass index indicated that more women were at risk according to time in our study population, suggesting that the crude results reported have underestimated the positive effect of labour induction. 36 However, adjusting for these factors only changed the results minimally.…”

“…The new guideline led to an increase in post-term labour induction, which was followed by a significant reduction in the number of stillborn infants at term. 5 It has also been suggested that maternal morbidity may be improved by a more proactive labour induction practice. 6 However, recent meta-analyses found only a few studies addressing the impact of different induction practices on neonatal mortality and morbidity; 4,7,8 and asked for further studies.…”

Decline in stillbirths and perinatal mortality after implementation of a more aggressive induction policy in post‐date pregnancies: a nationwide register study

“…Our results are supported by another Danish study, where the risk of stillbirth from 37 to 40 weeks were studied in 2000-2012. They found a generally decreasing risk of stillbirth in term pregnancies in Denmark throughout the years studied (14). Furthermore, an American study from 2011 using a cost effectiveness model based on the literature concluded that elective induction of labor at 41 weeks is cost-effective and improves outcomes (15).…”

Induction of labor with high‐ or low‐dosage oral misoprostol—A Danish descriptive retrospective cohort study 2015‐16

“…Induction of labor has increased significantly over the past decades . The rate of induced labor in Denmark has increased by 108% from 12.4% in 2000 to 25.1% in 2012, with labor induction occurring in one out of four deliveries . In 2011, the Danish Obstetrical Society changed the national guidelines regarding post‐term routine labor induction and intensified late‐pregnancy surveillance.…”