Introduction
It is widely acknowledged that the rates of stillbirth are higher among
women of South Asian background (e.g. India, Sri Lanka, Pakistan and
Bangladesh) compared to other women in high income countries around the
world1-10. The drivers of this are likely
multifactorial, but one potential contributing mechanism is earlier
feto-placental maturation. Evidence in support of this hypothesis
includes south Asian women having a shorter duration of
pregnancy8, 9, higher rates of fetal compromise in
late pregnancy11 and during labour12, more functionally mature babies at preterm
gestations13 and an earlier and more rapid increase in
the risk of stillbirth at the end of pregnancy than in other
women8. We have previously shown that south Asian
women at 39 weeks’ gestation have similar rate of stillbirth to
Australian born women at 41 weeks8.
Leading maternity guidelines (NICE guidelines, Royal Australia and New
Zealand College of Obstetricians and, Gynaecologists Guidelines
(RANZCOG)) recommend routine ultrasound assessment and/or induction of
labour at 41 weeks to reduce the rates of stillbirth. However, by the
time south Asian born women are offered these tests to assess fetal
wellbeing they are already at between 2 and up to five times the risk of
stillbirth compared to the Australian-born population1,
14, 15. The most recent NICE guidelines have recommended earlier
induction of labour from 39 weeks for all women of South Asian
background. However, widespread criticism and concern around this
recommendation16 have been highlighted and there is
currently no evidence to suggest that earlier induction for south Asian
women would reduce their rates of stillbirth.
In July 2017, informed by our observations of biological variation in
gestation length and gestation specific stillbirth rates in South Asian
women, Monash Health, Victoria’s largest maternity service implemented a
new clinical guideline. The new guideline recommended twice weekly
“post-term” monitoring to assess fetal wellbeing (cardiotocography
(CTG) and measurement of amniotic fluid) from 39 weeks for south Asian
women rather than the 41 weeks it had previously been and remains for
all other women. Here we present the evaluation of the impact of the
change in clinical care for south Asian women on rates of stillbirth,
neonatal and obstetric interventions.