In 2021, the National Program Area for Women’s Diseases and Childbirth published a national recommendation that women with »origin in Africa south of the Sahara« should have their labor started at week 41 + 0, regardless of other risk factors for the child dying in the womb [1]. For Swedish-born mothers without other risk factors, labor must start before week 42 + 0. The recommendation is based, among other things, on the doubled risk of stillbirth at full term that has been seen for women born in Africa south of the Sahara compared to Swedish-born mothers [2]. In another report from the National Board of Health and Welfare, it is noted that breech babies to mothers born in this region had a fivefold risk of dying compared to children born to mothers born in Sweden, possibly because the diagnosis of breech birth was not made and adequate birth planning was therefore lacking [3]. A recent study shows that the incidence of stillbirth among pregnant women born south of the Sahara increased from 8 percent in 2001-2005 to 10 percent in 2016-2020 [4]. The excess risk is also present before week 41, which is why induction at week 41 + 0–2 alone is considered an insufficient measure.
In the UK, a proposal to start for some ethnic minority groups in week 39 + 0 was abandoned after strong protests [5]. It was considered a blunt instrument that attacked the problem from the wrong end. In the USA, the American College of Obstetricians and Gynecologists writes that ethnicity (“race”) is not a biological risk factor for stillbirth, but that it is related to being exposed to racism and that racism itself is a risk factor for negative pregnancy outcomes [6]. The same organization calls for work against racism and own prejudices and to review how the health care system, including doctors themselves, contributes to the increased risks of stillbirth seen in people exposed to racism [6].
Similar discussions about racism within and outside healthcare are lacking in Sweden. It is difficult for Swedish registry researchers to analyze racism because data on self-identified ethnicity is missing. Different regions have therefore made different interpretations of the data reported by the National Board of Health and Welfare. While the national guidelines and Region Skåne [7] speaks of »origin«, Region Stockholm speaks of being »born in« Africa south of the Sahara as a risk factor [8]. The Västra Götaland region does not mention country of birth in its guidelines [9].
What it is that leads to an increased risk of stillbirth has not been sufficiently investigated in women of sub-Saharan African origin. Whether a white high-income earner born in South Africa has the same risk of stillbirth as a black refugee from the Horn of Africa is thus unclear, but unlikely. None of the above guidelines take this into account, even though an intersectional perspective that simultaneously considers several social dimensions is necessary to understand how patients are affected by the different social power structures that exist in society.
I cannot comment on whether it is right or wrong to offer induction of labor at 41 + 0 weeks of gestation to patients born in sub-Saharan Africa. To answer that question, more knowledge is needed, including about the patient group’s own view of the matter. Although it is racism rather than biological factors that explain the increased risk of stillbirth, it is possible that initiation at week 41 + 0 reduces the excess risk and is desired by the patients.
By responding to socially caused health problems with recommendations for medical interventions alone, healthcare risks contributing to making invisible the social oppression that creates inequalities in health. Authors of national guidelines that distinguish groups of different origins have a responsibility to deepen the discussion about the possible reasons behind the increased risk of perinatal death. Without such a discussion, the image of biological differences between women of different countries of birth is reinforced.
We who work with pregnant women have a responsibility to engage against racism and other structural injustices that create and maintain social differences in the risk of stillbirth.
Lakartidningen.se 2024-04-24
Tags: Recommendation pregnant women SubSaharan Africa nuance
