I’ve previously written about the 39-week rule and how it is affecting pregnancy after loss mothers, but new research has made this discussion even more important. At last week’s Annual Meeting of the Society for Maternal-Fetal Medicine, a paper was presented that claimed that stillbirths are increasing in the United States as a result of this rule. According to the researchers, an estimated 300 more babies died in 2013 (when the rule was implemented) than in 2007.

This is raising serious concerns from those in the loss community, and for good reason. And it is raising questions about practice guidelines and why they are useful, and why sometimes they are not. In theory, practice guidelines are an excellent idea. It takes a phenomenal amount of time to keep up with the latest research, and for the average doctor, even if they are a MFM specialist, it would be impossible. Practice guidelines are designed to have a collection of experts provide guidance to their colleagues on what to do in particular situations. The 39-week “rule” was initially intended as just that, a practice guideline. Doctors were not supposed to induce labor for their convenience, or the patient’s convenience. They needed to have criteria for when a labor induction was medically desirable. The problem arises when Medicaid, United Healthcare, Aetna and other insurers started to introduce financial incentives for reducing the number of inductions prior to 39-weeks gestation. This takes a practice guideline and turns it into a rule. Simply put, if your doctor induces your pregnancy outside their narrow criteria, the hospital, and your doctor, will not be paid. Ideally, doctors should always take three things into account: the best available research evidence (such as practice guidelines), the doctor’s knowledge and experience of local considerations and the values and wishes of the patient. This places the emphasis not on a balance between all three, but on the research evidence alone.

Here’s how it might work in practice. Imagine my own pregnancy, back in 2012. The practice guidelines say that for my otherwise healthy, singleton baby, there should be no labor induction and I should have to wait to go into labor naturally. My doctor, being aware of the guidelines, takes this fact into consideration. He also knows things about the local conditions, such as how close my workplace is to the hospital where I deliver:

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He’s pretty sure if I find myself in labor suddenly, I’m probably capable of waddling across the street and making it to the hospital on time.

He also knows that I had a previous stillbirth in 2007, my twins were stillborn at 36 weeks 5 days. Research done since 2007 suggests that may be late for twins, although we can’t say for certain that was the cause. My first rainbow was induced at 36 weeks 3 days, and she required sometime in the NICU (24 hours), as well as a hospital readmission, due to jaundice, but has mostly not had any problems related to prematurity. So, recognizing the difference between multiple pregnancies and singletons, but also taking my pregnancy into account, he wants me to wait a little longer than last time.

He also knows my values and wishes. We’ve spoken about my serious anxiety related to giving birth and about the last few weeks of pregnancy. He knows I’ve visited the emergency room for anxiety in the past. Waiting until 39 weeks before induction is likely to result in me being highly stressed. So instead, he talks over his thinking with me and we decide on an induction date together of 37 weeks and 1 day. I chose the date because it is my sister’s birthday. He also increases the number of prenatal visits I have until that day, to help keep my mind at ease. I have an ultrasound every Tuesday and see my doctor every Friday. I just have to pop across the road any time I’m feeling anxious too.

This is exactly how it evidence-based medicine is supposed to work.

2016-02-10_12-48-15A different decision might be arrived at for a different patient. For example, if you were exactly like me, except you lived in Sioux Lookout and the nearest high risk pregnancy center was in Thunder Bay, do you think you would want to have two doctor’s visits twice a week: one on Tuesdays, one on Fridays? Maybe you would prefer to see a local nurse practitioner or midwife? Or maybe have a consultation via Skype? Is it possible you might want to schedule an induction sooner than 39 weeks, because trying to drive 4 hours while in labor is impossible? Of course! Another reason why the 39 week rule just isn’t feasible. Even two very similar patients might have very different needs and wants.

Guidelines aren’t meant to be rigid rules. They are intended to summarize the available research literature in a way that helps guide the decision making of the professional (be they doctor, midwife, nurse or other professional). As loss moms, we need to make our doctors aware that we are not okay with rules. Instead, insist on patient-centered, evidence-based care. This should be our right.

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