A shift in Sweden’s national guidelines for late-term pregnancy management has significantly reduced perinatal and neonatal deaths, according to a recent population-based cohort study.
Researchers evaluated maternal and neonatal outcomes following the adoption of more active management offering induction at 41 weeks of gestation, replacing the previous approach of expectant management until 42 weeks. Their findings were published in PLOS Medicine.
The investigators analyzed 150,370 pregnancies lasting 41 weeks or more, excluding those with elective cesarean sections. Outcomes from January 2017 to December 2019 (before the policy change) were compared to outcomes from January 2020 to October 2023 (after the change).
Key findings showed a 48% reduction in perinatal mortality, with deaths decreasing from 1.7 per 1,000 live births in the pre-policy period to 0.9 per 1,000 live births post-policy (adjusted relative risk [RR] = 0.52; 95% confidence interval [CI] = 0.38–0.69; P < .001). These results align with previous clinical trials suggesting that earlier induction of labor may prevent perinatal mortality.
The study also reported improvements in composite neonatal outcomes, including reductions in perinatal death, low Apgar scores, and hypoxic-ischemic encephalopathy. Rates of adverse neonatal outcomes dropped from 53.9 per 1,000 live births before the policy change to 50.5 per 1,000 afterward (adjusted RR = 0.92; 95% CI = 0.88–0.96; P < .001). Excluding long-term neonatal intensive care unit (NICU) admissions further highlighted a significant decrease, from 22.5 per 1,000 live births to 18.5 per 1,000 (adjusted RR = 0.79; 95% CI = 0.74–0.85; P < .001).
However, the updated policy led to a slight increase in emergency cesarean sections, with rates rising from 10.5% to 11.9% (adjusted RR = 1.07; 95% CI = 1.04–1.10; P < .001). Induction rates also increased, from 33.7% to 52.4%, resulting in earlier average deliveries. The mean gestational age at birth decreased slightly, from 290.7 days to 289.6 days.
Karin Källén, PhD, the study’s first author, commented that she "consider[s] the decline in peri/neonatal mortality and adverse neonatal outcome in pregnancies lasting 41 weeks or more to be attributed with a more active management of late-term pregnancies."
The authors emphasized the importance of providing balanced information to women approaching 41 weeks of gestation about the benefits and risks of labor induction compared to expectant management until 42 weeks.
Senior author of the study Ulla-Britt Wennerholm, MD, PhD, of the University of Gothenburg, noted: "The absolute risk to an individual woman and her baby is very small, regardless of whether the delivery takes place after 41 or 42 weeks."
Although the study has some limitations, such as a lack of data on fetal monitoring during expectant management, it highlights real-world evidence supporting reduced neonatal mortality and morbidity through earlier intervention. Researchers recommend nuanced counseling for pregnant individuals, considering the slight increase in emergency cesarean rates.
No conflicts of interest were reported in the study.
