Comment on “Timing of Term Births and Associated Mortality Risks: Ecological Analysis Across 28 European Countries”

Stillbirth often occurs without warning. Although pregnancy complications, such as preeclampsia, fetal growth restriction, and pregestational diabetes, are strongly associated with stillbirth, there is limited reliable screening to detect its risk. Induction of labor (IOL) is offered to women with moderate risk, including late-term and full-term pregnancies, and women over 39 years of age. Recently, early-term induction has been used with conditions that have weaker associations with stillbirth, such as mild cholestasis and gestational diabetes. However, most guidelines discourage elective IOL or cesarean delivery before 39 weeks due to the association between early-term birth and higher neonatal morbidity and mortality. Despite this, planned early-term births and wide variation in practice persist. The aim of this study was to examine the rates of stillbirth, neonatal, and perinatal mortality and their association with early-term birth rates as a proxy for elective delivery practices. This was an ecological design study using aggregated national birth data from 2015 to 2020 in 28 European countries. Included were all term births (≥37 wk of gestation). Excluded were pregnancy terminations. The main outcomes were national-level stillbirth, perinatal death, and neonatal death in term pregnancies. The exposure was gestational age distribution at term: early term (37 to 38+6 wk), full term (39 to 40+6), late term (41 to 41+6), and post term (≥42). Countries were then divided into 3 groups based on the rate of early-term birth—high, medium, and low—using terciles of the distribution to define cutoffs. The early-term birth rate was lowest in Iceland (17.8%) and highest in Cyprus (49.1%), with tercile thresholds at 21%, 21% to 27%, and >27%. The postterm birth rate was lowest in Malta, Luxembourg, Portugal, and Cyprus (0.1%) and highest in Sweden (6.6%). The stillbirth rate per 1000 total births was lowest in Cyprus (0.69) and highest in Sweden (1.52). For stillbirths, the pooled estimates were highest in the lower early-term birth rate tertile at 1.28 per 1000 total births, compared with 1.16 in the middle tercile and 1.05 in the highest tercile. For perinatal mortality, the pooled estimates were 1.64 per 1000 total births in the lowest tercile, 1.51 in the middle tercile, and 1.54 in the highest tercile. For neonatal mortality, the pooled estimates were 0.53 in the lowest tercile, 0.50 in the middle tercile, and 0.74 in the highest tercile. In conclusion, the stillbirth rate was lowest in countries where early-term birth rates were highest. There were no statistically significant differences observed in the rates of perinatal and neonatal mortality. Given the variation in gestational age distribution and early-term birth rates in this study, these findings should be viewed with caution. (Summarized from Gunnarsdóttir J, Philibert M, Gissler M, et al. Timing of term births and associated mortality risks: ecological analysis across 28 European countries. BJOG 2025;132:1655-1663. doi: 10.1111/1471-0528.18292).