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Hello! I've had a small but much-needed break from writing. My family has been on a two-week vacation in Southern France. We've basically been living in swimsuits/shorts the whole time. Sooo nice! Now we're back home, and I'm starting fresh.
Do you remember my last post? Where I was pondering the Swepis study that was conducted in Sweden a couple of years ago. I described how it has changed our thinking regarding "going overdue" and inducing labor.
Many of the results from that study have undoubtedly been beneficial, although the quality of the study itself has been discussed. Unfortunately, it has also scared many of our pregnant women.
For some, making the decision to wait for a spontaneous and natural start of their labor has been difficult. This is because the study also mentions how many babies die as a result of waiting.
So what is the difference between the Swedish view and the international view of a longer pregnancy?
International Perspectives on a Longer Pregnancy
I am actively involved in research and have many international contacts. Many of my studies have been conducted at various clinics within and outside of Europe. In recent years, there hasn't been much traveling, of course, due to natural reasons. The pandemic put a stop to most of the research, conferences, and exchanges, but now the research world is starting to awaken again.
At several international conferences I have attended, the induction of labor has been discussed. The question is, how long should a woman actually be pregnant? What is best?
The main question in these discussions is: how many babies do we accept to die in the mother's womb at the end of pregnancy?
In Sweden (which I often perceive as a small isolated pond), we talk about going one or two or maybe three weeks overdue. We conduct large-scale studies (Swepis) and have our own discussions within the profession as well as in the media. What is best?
Listening to the results from other countries is not particularly relevant for us.
The Swedish Opinion
The argument for why we cannot be compared to others in Sweden (and therefore must conduct our own studies) is that we have such low cesarean section rates in the country overall. In Sweden, we perform cesarean sections on around 20% of our pregnant women. Many other countries have rates of 30-40% and sometimes even up to 60-70%.
This, they say, means that we cannot compare ourselves to other countries with higher rates. One of the most well-known risks of inducing early (after 37 weeks) is that the induction may not work, and a cesarean section will be necessary. One might argue that it is unnecessary.
Inducing earlier would likely significantly increase our cesarean section rates in the country, while it would not affect the rates in other countries as much. They already have such high rates initially.
Internationally, however, there is quite a conviction that being pregnant for 39 weeks, sometimes even as little as 37 weeks, is sufficient. This means that labor can actually be initiated before the due date, and it could have a protective effect on the babies. They are convinced that the percentage of babies dying in the mother's womb would decrease significantly.
I also want to remind you that in terms of IUFD (intrauterine fetal demise), we are not doing well in Sweden. Despite our well-developed healthcare, we rank 12th (see my previous post). Clearly behind our neighboring countries.
Cochrane Analysis from 2020
Below, I summarize the Cochrane meta-analysis conducted as recently as 2020. You know that Cochrane is the organization that reviews various publications and tries to compile an overall result.
The publication is titled "Induction of Labor at or beyond 37 weeks' Gestation." The aim was to study the differences between inducing labor after 37 weeks compared to waiting.
The result is quite clear according to the authors:
A significant reduction in the number of babies dying in the mother's womb is demonstrated in places around the world where there is a policy to induce after 37 weeks, compared to places where they wait.
Surprisingly, the compilation showed a LOWER frequency of cesarean sections and transferring the fetus to neonatal care in the induced group. The opposite of what we assume here in Sweden.
How does this fit into our discussions? However, there is currently no further discussion on this in Sweden. We continue to recommend, according to Swepis, not to go beyond 41 weeks.
Right or wrong? I don't have the answer at the moment. What is clear, though, is that if we are to allow women to go overdue, there must be a developed monitoring system available. Otherwise, in my opinion, it is life-threatening.
Should large babies be delivered earlier?
Another similar publication, published in The Lancet (one of the "prestigious" journals) in 2018, also discusses this topic but in a slightly different way. It addresses the scenario where it is discovered that the baby a woman is carrying is large.
Previously in Sweden, we turned a blind eye to it. We didn't take action and hoped that everything would be fine. The risks of delivering a very large baby include injuries and severe tears for the mother, as well as injuries to the baby.
The Lancet publication recommends that if a woman is carrying an LGA (large for gestational age) baby, she should not go beyond 39 weeks in her pregnancy. Maximum. In Sweden, at least at my clinic (Södersjukhuset), we have adopted this recommendation and now advise initiating labor after 39 weeks if the fetus is suspected to be largely based on ultrasound.
However, we know that measuring large babies with ultrasound is challenging. It is not an exact science, and the baby can be smaller or larger than the measurements we obtain during the examination.
As you can understand, there is no clear-cut answer to these questions. What we can conclude, though, is that every baby that dies in the mother's womb is a tragedy. Not only for the woman and her family but also for society as a whole. If we can prevent this, it is of the utmost priority.
Delivering (large) babies that suffer during labor is also not ideal. Should we initiate these deliveries earlier? So that the baby is smaller? Should we opt for a primary cesarean section (and possibly increase our cesarean section rate)?
Nothing is simple and straightforward. That, we can safely say.
Best regards,
Dr. Eva