Following declines between 2000 and 2006, the United States fetal mortality rate has been relatively unchanged since 2006 (MacDorman, 2015). Interpretation of these fetal mortality rates in the context of changing national healthcare strategies has spawned considerable debate. One example is the efort to prevent non-medically indicated deliveries before 39 weeks and its subsequent efect on term stillbirth rates. he value of this practice for neonatal outcome is described in Chapter 26 (p. 504). To analyze whether implementation of this "39week rule" has altered the term stillbirth rate, Nicholson and coworkers (2016) examined data from 45 states and the District of Columbia during a 7 -year period. The proportion of births before 39 weeks progressively declined from 2007 and 2013, but the term stillbirth rate rose. his suggested that the 39-week rule may cause unintended harm. MacDorman and associates (2015) also evaluated trends in stillbirth rates by gestational ages in the United States between 2006 and 2012. They used a "traditional stillbirth rate," which was calculated using a denominator composed of the live-birth number plus the stillbirth number at a given gestational age. They found increased rates at 24 to 27, 34 to 36, and 38 weeks' gestation. Alternatively, no diferences were found in "prospective stillbirth rates." These rates were calculated using a denominator composed of the number of women who are pregnant at a given gestational age for weeks 21 through 42. he discrepancies in stillbirth rates appear to be primarily due to the decline in the number of births in the preterm and early-term gestational ages.
To summarize, implementation of the 39-week rule has reduced the number of elective births before 39 weeks' gestation, although an unintended consequence may be an increase in term stillbirths-especially among women with medical complications. he importance of induction at less than 39 weeks in pregnant women with complications to prevent stillbirth is underscored by Little and colleagues (2015). These authors performed a retrospective multistate analysis of earlyterm deliveries (37°/7 to 386/7 weeks) from 2005 to 2011a. They noted a decline in the number of early-term deliveries during this time but not a signiicant change in the term stillbirth rates. There was, however, a 25-percent rise in the rate of term, singleton stillbirths among women with diabetes, and this was attributed to clinicians misapplying early-term delivery policies to high-risk women. Undoubtedly, continued surveillance of stillbirth rates is warranted for both high-and low-risk pregnancies at a state and national level.
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