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We were recently made aware of an Ontario, Canada-based OBGYN clinic (Credit Valley Obstetrics/Gynaecology Associates) that is recommending routine induction at 39 weeks for people born in Afghanistan, Bangladesh, India, Pakistan, and Sri Lanka.
It was shared by a birth doula seeking guidance regarding how to unpack the memo’s astonishing recommendation with her South Asian client. The clinic recommends routine induction at 39 weeks for people born in Afghanistan, Bangladesh, India, Pakistan, and Sri Lanka. The recommendation draws from 2017 and 2023 articles by the same Australian research team, finding that people born in these South Asian countries are at increased risk of stillbirth at term. The memorandum then shockingly claims that inductions “pose no major risks” and “do not hurt more than regular labour”.
This memorandum showcases in one fell swoop everything that is wrong with our current medical system. Some of the things birthing people are faced with every day:
The recommendation for induction at 39 weeks is based on the findings of two studies published by the same Australia-based research team. The studies show that women born in South Asia (SA) are at an elevated risk of stillbirth at 40 and 41 weeks as compared to their Australian/New Zealand-born counterparts (A/NZ). Conversely, Southeast and East Asian-born people were less likely to have stillbirths than their A/NZ-born counterparts.
The Ontario clinic recommendation notes that there is no way to know if these results apply to Canada, nor if they apply to people of South Asian backgrounds, or only those born in South Asia.
When assessing risk, it’s important to consider that the Australian data found that stillbirth among South Asian-born people was 5.1 per 1000 births compared with 3.3 per 1000 births in the general population. Thus while SA-born people were at statistically higher risk, the mean (average) risk of stillbirth is still low. The studies cited note that more research is needed to arrive at a more conclusive understanding of stillbirth risk by country of birth, causes, and prevention strategies.
The studies cited by the clinic do not recommend induction at 39 weeks for people from South Asian countries. Rather, the 2023 publication recommends increasing fetal surveillance at 39 weeks for people born in South Asia. The study found that this is an effective method of reducing the stillbirth rate and advocates for this as an alternative to routine induction at 39 weeks for South Asian-born people.
Given that we don’t know if the data is generalizable to Canada or Ontario, the evidence for recommending routine inductions at 39 weeks for South Asians is further weakened. In general Canada rarely collects race-based data, one of the main challenges we face with obtaining proper support for funded doula services. Contrarily the United States has significant amounts of this data and have been able to transform the Medicaid landscape around doula funding over the past few years.
The Canadian evidence we were able to find did not corroborate the A/NZ evidence. A 2015 study conducted a retrospective analysis of stillbirths in Ontario in relation to parental place of birth (Bartsch, 2015). When births are registered in Ontario, parents have the option to report their place of birth. Using this self-reported data, the study found that in general, stillbirths were higher among parents born outside of Canada than among Canadian-born parents. In this study, the odds of having a stillbirth were highest among Nigerian parents, followed by parents from Portugal, Jamaica, Guyana, India, and Sri Lanka. When both parents emigrated from a country with a high stillbirth rate, this increased risk was magnified. The study does not propose any preventative clinical interventions.
The clinic recommendation also does not cite any evidence that elective inductions at 39 weeks would reduce stillbirth rates. The Evidence-Based Birth article on inducing for due dates found that elective induction at 39 weeks made no difference to stillbirth or other adverse outcomes (Dekker, 2020).
In addition the study highlights that the A/NZ birthers were about 1.5 TIMES more likely to have a 1st trimester ultrasound than their South Asian counterparts (a sign of better prenatal care) the South Asian birthers were 3 TIMES more likely to have gestational diabetes. All in all it appears not all factors were given equal consideration to their impact on stillbirth rates.
The clinic memo states that there are no major risks associated with elective induction at 39 weeks. It also does not present any information on the risks and benefits of waiting for spontaneous labour. While it is accurate to say that inductions are generally safe, it is not accurate to say that they are risk-free. For example, a 2023 study found that induction at 39 weeks was associated with an increased risk of shoulder dystocia among first-time birthers and advised that patients be informed of benefits and risks (Hong, 2023).
“In 2018, the World Health Organization (WHO) released Intrapartum Care for a Positive Childbirth Experience. In 2018, Childbirth Connection and the National Partnership for Women and Children released The Blueprint for Advancing High Quality Maternity Care through Physiologic Childbearing. All three publications take a strong stand in support of the physiology of labor and birth and the importance of not interfering in that process without clear medical indication.” Source
It can be argued that the most powerful way that we can support the normal physiology of labor and birth is to let labor begin on its own. Virtually every definition and consensus statement on normal, physiologic birth includes “spontaneous onset of labor”. This Healthy Birth Practice paper summarizes the current evidence on the merits of letting labor begin on its own and the risks and benefits of labor induction.
Related to this, the Clinic article does not address the benefits of waiting for spontaneous labour. Childbirth satisfaction is rarely considered in clinical decision-making, but as doulas, we know it’s of the utmost importance. One study found that waiting for spontaneous labour was associated with higher childbirth satisfaction compared to elective induction (Adler, 2020). Another study conducted in Spain found that induction of labour far exceeded the WHO recommended rate of fewer than 10% of births and was associated with increased Cesarean sections and operative deliveries. Conversely, spontaneous labour was associated with earlier skin-to-skin and initiation of breastfeeding (Espada-Trespalacios, 2021). Lamaze International does a great job of summarizing some of the risks associated with the inappropriate use of interventions in this article.
We want to take a moment to remind our clients and anyone reading this that:
When considering any intervention, it’s important to consider the evidence regarding risks and benefits in relation to one’s individual situation. For example, the client should consider whether or not they are experiencing any risk factors for stillbirth apart from their place of birth.
Having an in-depth discussion with our medical team AND weighing our own knowledge, priorities and instincts are ALL important considerations before making a decision.
Race-based data has the potential to result in positive changes in the healthcare system. In the US, data showing racial disparities for Black birthers has been instrumental in securing public funding for doula care. However, recommendations like this one demonstrate that there are pitfalls if race-based data is not situated in a racial health equity lens. Well-applied race-based data can be used to elucidate and rectify the social determinants of health at a population level. It should not be used to give different care to individuals based on race. In the case of these data regarding South Asian-born birthers, constructive actions would be to:
Actions like these prioritize collecting adequate data and using it to address systemic disparities. It misses the mark when we use such data to generalize about an entire ethnic or racial group and make across-the-board recommendations that don’t centre the individual and support them to direct their care.
Celebrating 20 years serving the Greater Toronto Area, Discover Birth is the largest doula agency in Ontario. We help new and soon-to-be parents to increase health and confidence, while decreasing stress and anxiety. Our model is based on a 3-point system of assessment, education, and support. Our knowledgeable and experienced team provides a perfect blend of education classes and doula support during pregnancy, birth, and early parenthood.