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.