Concerning Term Stillbirth and African-American Pregnancies: Can Higher-than-Standard Rates of Term Stillbirth Be Addressed Through a Modification of the 39-Week Rule?

his session will discuss the increased risk, in the USA, of term stillbirth in patients of African heritage, and will link that reality with available evidence that suggests that such patients may have a “due date” that is earlier than 40 weeks 0 days of gestation. This session will then discuss the theoretical benefit to modify, downward, the 39-week Rule for African-American patients, and will present previously reported evidence that supports the concept that use of “elective” labor induction in this population prior to 39 weeks 0 days of gestation is a beneficial and safe intervention. 

Dr. James A Nicholson obtained his undergraduate degree at Earlham College in 1977, his medical degree from the University of Pennsylvania in 1981 and completed his internship and residency with the Duke-Watts Family Medicine Residency Program in Durham NC in 1984.

Following his residency, Dr. Nicholson joined a private practice in North Governorsdale, Connecticut. In 1997 Dr. Nicholson returned to the University of Pennsylvania to join the Department of Family Practice and Community Medicine. While pursuing a Masters Degree in Clinical Epidemiology he published the AMOR-IPAT system of identifying pregnant women who would benefit from induction before 40 weeks of gestation. This publication was an editor’s choice paper in the American Journal of Obstetrics and Gynecology. The AMOR-IPAT concept was further developed and followed-up with a series of papers including a prospective randomized trial (RCT) of AMOR-IPAT. In 2012, Dr. Nicholson moved to the Hershey Medical Center of Penn State University in the Department of Family and Community Medicine. While there he became increasing concerned about the rising number of stillbirths in the US and has studied the correlation between strict implementation of the 39-week rule and the rising rate of term still birth. His 2016 paper on this topic was published in the American Journal of Obstetrics and Gynecology, and was the most highly cited paper from that journal in 2018.  

Since 2019 Dr. Nicholson works within the WellSpan Health System at the Good Samaritan Hospital in Lebanon PA. He continues to be concerned about the impact of both: 1) a reluctance to recommend “elective labor induction,” and 2) the strict application of the 39-week Rule in patients with known risk factors for early-term stillbirth.

Dr. Nicholson has disclosed that he does not have any real or perceived conflicts of interest in making this presentation.

Amanda Smyth: Dr. James A. Nicholson obtained his undergraduate degree at Earlham College in 1977, his medical degree from the University of Pennsylvania in 1981 and completed his internship and residency with the Duke-Watts Family Medicine Residency Program in Durham, North Carolina in 1984.

Following his residency, Dr. Nicholson joined a private practice in North Governorsdale, Connecticut. In 1997, he returned to the University of Pennsylvania to join the Department of Family Practice and Community Medicine. While pursuing a Masters Degree in Clinical Epidemiology, he published the AMOR-IPAT system of identifying pregnant women who would benefit from induction before 40 weeks of gestation. This publication was an editor’s choice paper in the American Journal of Obstetrics and Gynecology.

In 2012, Dr. Nicholson moved to the Hershey Medical Center of Penn State University in the Department of Family and Community Medicine. While there, he became increasingly concerned about the rising number of stillbirths in the US and has studied the correlation between strict implementation of the 39-week rule and the rising rate of term stillbirth. His 2016 paper on this topic was published in the American Journal of Obstetrics and Gynecology, and was the most highly cited paper from that journal in 2018.

Since 2019, Dr. Nicholson works within the WellSpan Health System at the Good Samaritan Hospital in Lebanon, Pennsylvania. He continues to be concerned about the impact of both a reluctance to recommend in elective labor induction, and the strict application of the 39-week rule in patients with known risk factors for early-term stillbirth.

Dr. Nicholson’s presentation is titled, Concerning Term Stillbirth and African-American Pregnancies: Can Higher-Than-Standard Rates of Term Stillbirth Be Addressed Through a Modification of the 39-Week Rule?

Dr. James A. Nicholson: Hi, my name is Dr. James Nicholson, speaking today about a topic close to my heart. Concerning Term Stillbirth and African-American Pregnancies: Can Higher-than-Standard Rates of Term Stillbirth Be Addressed Through a Modification of the 39-Week Rule? I’d like to thank Star Legacy for inviting me to talk today. Yes, let’s proceed.

The basic issue is, could more frequent use of planned delivery in the 38th week of gestation safely lower term stillbirth rates in women with an African heritage?

The basic concept of this talk is not very complicated, but the realization of the basic concept within this talk will probably be hard to accomplish. As a good way to start, I just want to basically say what I’m going to be talking about, which is that the cumulative risk of stillbirth progressively increases for all types of pregnant women after they pass 36 weeks of gestation. Women with African heritage have significantly higher rates of stillbirth at all gestational ages including during the term period of pregnancy at or after 37 weeks of gestation.

Also women with African heritage appear to have a due date that is earlier than Caucasian women. Their babies appear to be ready for birth earlier, and their babies develop problems related to post-maturity waiting too long, sooner than Caucasian babies. There is an increasing amount of evidence that planned labor induction at 39 weeks gestation as compared to waiting till later in all women reduces rates of adverse or bad birth outcomes including term stillbirth.

While planned labor induction prior to 39 weeks has not been possible in the USA since 2010 unless there’s an indication present due to what’s called the 39-week rule, I have personal experience prior to 2010 with providing that strategy, especially in women with African heritage. Accordingly, I believe that the regular use of planned labor induction in the 38th week of gestation in women with African heritage who want that intervention should lower rates of term stillbirth and rates of other adverse birth outcomes.

Prologue. I want to talk about two things. One is there’s the passage of time. I’ve been talking at Star Legacy since 2014 and many other colleagues have given talks as well. I want to point out that time passes, and I’m getting older, other lecturers are getting older. It’s one thing to talk about methods of prevention, but if those methods are not actively used and the passage of time happens, the lecturers will no longer be around to talk about things.

Secondly, why are we doing this? What’s the point of talking about stillbirth prevention? My brief story is that I had a patient at a previous institution from where I work now that suffered a fairly catastrophic change in fetal heart rate requiring an emergency section. The baby was born with AFCARS of zero at 1, 5 and 10 minutes of life.

Eventually, resuscitation was successful. Probably there was a fetal maternal hemorrhage that occurred and the baby’s blood volume was decimated. Make a long story short, the baby spent six weeks in the NICU. Thereafter had a fairly surprising recovery and I had the pleasure of visiting with that baby several weeks ago, now four years old, completely normal.

It was a great example of what happens when you actually prevent a catastrophic outcome like stillbirth. You have a normal functioning human being that otherwise would have been lost. That’s why we’re doing this talk about stillbirth prevention.

I have no conflicts of interest. I have no disclosures. However, I do have an agenda, a track record, and a major request. My agenda is I ask questions related to optimal timing of human delivery with reference to both major outcome stillbirth, and other birth outcomes. I promote the concept of individualized care theory when considering the optimal timing of human delivery. I vigorously challenged the strict use of the 39-week rule throughout the USA by describing the rule’s inadequate scientific and ethical foundation, pointing out that the strict application of the rule is unethical based on well-established medical concepts, and reporting that the rule has increased the rate of stillbirth in the USA.

Lastly, I push for the modification of the 39-week rule in response to both sincere requests by well-informed pregnant women, that’s the concept of autonomy, and known risk factors for term stillbirth like African heritage, and that’s what I’m going to be talking about today. Because pregnant Black women, women with African heritage are at increased risk of both maternal death during delivery and having their baby born still.

I want to say what is sometimes a controversial concept that Black lives matter. When we’re talking about stillbirth of women with African heritage, what we’re talking about is Black lives. I also believe that Caucasian lives matter, and that Brown lives matter, and that Blue lives matter. Asian lives matter, First People’s lives matter, and even Minnesotan lives matter. That’s kind of a joke. All lives matter equally. Therefore the lives of all babies matter equally and the lives of Black babies matter.

It comes from my core belief as a Quaker that there’s that of God in everyone. I’m not going to get into that too much, obviously, but there is also an issue of pragmatism related to that. We are all connected. Identification of new approaches to medical care that improve the health and wellbeing of one part of our society may identify new approaches that can be generalized and used to improve the health and wellbeing of others, perhaps many other parts of our societies. So, finding a way or ways to save the lives of Black babies may lead to finding a way or ways to save the lives of other types of babies. That’s my agenda.

I also have a track record. Multiple publications in prominent journals, several major talks at important conferences like this one that dealt with the probable causal link between strict application of the 39-week rule and increased incidence of term stillbirth, and nearly 30 years of clinical experience much of which is published that involved their regular and safe use of preventive labor induction prior to 39 weeks.

I’ve also had some major controversial predictions like that labor induction as compared to waiting till later lowers cesarean delivery rates. That turned out to be true. Second was that the strict adoption of the 39-week rule increases the incidence of term stillbirth. That turned out to be true. There are multiple studies documenting this increased risk and rate of term stillbirth following the adoption of the 39-week rule. This is at least for your studies.

I point out this one by Satti from Flint, Michigan. I called that hospital the other day. They have about a 60% African-American clientele that they take care of, and their term stillbirth rate is basically increased by a factor of four since the 39-week rule was imposed there. A track record, actively controversial, but tends to be on the right track.

I do have a request. That’s the third thing. To take very seriously my new controversial prediction that a downward modification of the 39-week rule for women with African heritage will reduce their rates of adverse outcomes, including their relatively high rates of term stillbirth. By take serious, I mean active support from this community to find a way to make possible a downward modification of the 39-week rule for women with African heritage if they so desire that and to make it known to these women, both at delivery prior to 39 weeks zero days may improve their birth outcomes, and that a downward modification of the 39-week rule is possible.

By active support from this community, I mean actions that will lead directly to the study of this prediction that the 39-week rule modification will improve outcomes including addressing high rates of term stillbirth.

I recently gave a talk at the Stillbirth Diagnosis and Prevention Symposium dealing with challenges of early delivery. Early delivery was defined as planned delivery either bisection or induction without an established indication prior to 39 weeks the gestation. The major challenges to early delivery that exist within most communities. Overcoming the belief that early delivery is bad. It’s not. Overcoming beliefs that mother nature knows best, and that pregnancy intervention called preventive or prophylactic induction is bad. It’s not and mother nature doesn’t always know best. Third is professional resistance to accepting new indications for planned delivery prior to 39 weeks, and fourthly professional refusal to balance official guidelines like the rule with the ethical principle of autonomy.

But the biggest challenge to early delivery is that currently it is just not allowed in the USA and is strongly vilified by multiple powerful institutions.

What is the 39-week rule? Basically, it says that planned delivery prior to 39 weeks of gestation may not occur unless there is an ACOG accepted indication or high-risk state. By the way, with an indication, if that is present, it is known that delivery now will provide better outcomes then delivery later. But if there’s not an indication, then the rule applies.

At that symposium, I clearly stated and will state again that there is questionable legitimacy to the strict imposition of this rule, at least on the juxtaposition of six important issues. One is an antiquated method of determining due date. I’m going to talk about that in a minute. Second, a body of research that strongly suggests that both due date and the length of gestation vary by race, ethnicity, and other factors.

Thirdly, the reliance on crude observational studies like ecological cohort studies to develop generalized beliefs concerning the optimal timing of delivery for all types of women. Fourth, unwillingness to apply individualized care theory in the estimation of the optimal timing of delivery. Fifth, reluctance by ACOG/SMFM to accept new indications like I just talked about, and then complete truncation of the ethical principle of autonomy.

I did give a lecture at Star Legacy’s conference in 2014 that basically outlines these issues. That can be referenced if you’re interested.

We’re basically talking about timing. Timing of delivery. It all currently centers around the due date and I want to talk briefly about Naegele’s rule that the expected duration of pregnancy is thought to be 40 weeks 0 days or 280 days after the first day of the last normal menstrual period. Naegele’s rule is based on a normal distribution of birth. Here’s the timing of birth on average in Minnesota in ’94 and 2004. Right in the center is 40 weeks gestation. It’s where Naegele started. This is the rule to determine the LMP, count back three months, add a week and add a year, and that’s the dude. Voila.

Naegele’s rule, if you really look at it, it was based on German Caucasian women living in the 18th century. I’m sorry, but that’s just not necessarily definitely going to be accurate for non-German women in the USA in the 21st century, and yet we don’t question it. Also, Naegele’s rule does not determine the optimal time of human delivery. It just identifies the most likely time. There is definitely a natural variability to gestational age based on things like maternal age, maternal weight, gravidity, prior gestational length.

If we use Naegele’s rule, we look at the continuum of pregnancy. The due date is there at 40 weeks 0 days. Last menstrual period first day is there, conception usually occurs at two weeks of timing. Then of course, there’s the term period. If we look more closely at the term period, there’s the due date, there’s full term, which is 39 to 41 weeks, and then there’s the early term period, which is 37 to 39. That’s the period we’re talking about?

The question is, how is the optimal time for human delivery determinant? I’m going to get to African-American pregnancy shortly, but bear with me. How is it determined? Well, the scientists have looked at live birth bad outcomes like cesarean delivery, neonatal respiratory distress, NICU admission, low infant developmental issues, and they do ecological cohort studies.

What the heck are ecological cohort studies? Well, you take all the babies from any given institution or any given body of data and put those babies into these boxes based on their week of gestational age at delivery. Then you rank and rate any particular bad outcome as a function of how many babies within that block of babies had the bad outcome.

Usually, you’ll get this kind of inverted curve with the lowest rate being in the 39th week, and then going up on either side. What the ecological cohort studies almost always do is throw out the 42nd week because we know that’s too late, but then they compare the first three weeks of this period in yellow with the second three weeks on green and determine that lo and behold, if you draw a line there at the 39th week, the green group does better than the yellow group. Therefore, we should have this thing called the 39-week rule and not allow none indicated deliveries prior to that time, because look what happens.

The problem is that these studies really are quite crude. They do not consider the day of birth, but rather a wide seven-day interval called week of birth, and the 39-week rule could have just as easily if you’d look by day than the 38 and 6 rule or the 39 and 2 rule, we just don’t know. Also quite crude because they do not consider risk factors that might’ve caused births to occur before 39 weeks, but also caused the bad outcomes like abruption, preeclampsia, all the indications that lead to early planned delivery. That’s a thing called “confounding”, which is not considered in most of these studies.

Also, the results of several investigations that studied these outcomes involved planned cesarean delivery, and the results were inappropriately used to make predictions about neonatal outcomes following planned induction of labor. Planned C-section versus planned induction have very different physiological impacts on the fetus. Specifically, C-sections does not prepare a baby to be born.

Also quite crude because they can only report trends present within a population, but cannot predict the optimal timing of delivery for any individual pregnancy. Worse than crude is ecological cohort studies ignored critical outcomes like term stillbirth, and we know that the risk of stillbirth increases with increasing gestational age starting at 36 weeks gestation, but that specific outcome is just not talked about in the ecological cohort studies.

Finally, it is well known in any area of medicine that ecological cohort studies should never, never be used by themselves to create strictly enforced clinical guidelines, and yet that’s what happens with the 39-week rule.

But if the issue of questionable scientific foundation is not bad enough, consider that the optimal time of delivery appears to be now 39 weeks 0 days for all patients. Low risk patients based on good recent research. And that the optimal time is definitely prior to 39 weeks 0 days for patients with an indication. Consider that the optimal time and delivery may be prior to to 39 weeks for some patients who do not have accepted indication, but who have an identifiable moderate risk state that is not an accepted indication.

These are all risk states that currently don’t qualify for planned delivery prior to 39 weeks. We know in many of these when we talk about stillbirth risk, but at the bottom there in red is African or South Asian heritage. It’s known to be a risk factor, but it doesn’t qualify one to be delivered before 39 weeks. Again, all of these factors increase the risk of term stillbirth and other bad outcomes. If the pregnancy is allowed to gestate until or after 39 weeks, there’s an increased risk of problems.

Finally, there’s autonomy, which is given a good understanding of risk and benefits of any given procedure, a patient should be able to request and obtain that procedure. This is a basic well understood ethical principle, but the principle is completely truncated in the USA today when delivery prior to 39 weeks is requested but there’s not an indication.

I claim that we have been collectively led to believe several incorrect things. One that 39 weeks 0 days represents a scientifically valid cut point for term pregnancy management and not the strict application of the 39-week rule is ethically justifiable. I just don’t agree. Rather, I believe that birth outcomes, including lower rates of term stillbirth might result from an easing of the 39-week rule. I would add that this isn’t an opinion, this is a point of view. Point of views are based on fact and opinions are not. This is a point of view based on evidence and I’m going to talk about that.

This easing of the 39-week rule might especially focus on early term planned labor induction for pregnant women with important risk factors, such as African American or south Asian heritage.

I closed my talk at the other conference asking when is on-time actually late? Well, that’s when a mother who had requested and been denied a planned early term delivery delivers a stillborn baby after passing into or beyond the 39th week. When is early actually on time? When a woman at increased risk of term stillbirth has a planned early term delivery that results in both a live born infant and no significant increase in risk of other more common bad birth outcomes. That’s key, and I’m going to talk about that safety issue in just a minute.

The challenge for us within this body of persons is find a way to make the option of early term birth possible for well-informed women, especially those who are at risk who desire that option.

Ahhhhhh!!!, so which women are at increased risk? Basically, we should all know by now that the risk of term stillbirth increases as a function of increasing gestational age. This is showing the rate going up from 37 weeks to 42 weeks. Secondly, women with African heritage are at increased risk of term stillbirth by at least a factor of two. This is a study by Willinger from 2009. In blue are African-American women stillbirth rates. In the lower black is Caucasian. Clearly, more stillbirth with African-Americans and this is the term period highlighted more. The upper line clearly above the lower line.

Looking at the data within that study, almost a twofold increase at 37 to 38 weeks, a little lower in 39 to 40, but then again, almost twofold stillbirth rate in the 41st week.

Well, why is that? There are a lot of people wondering why is that? Some people think maybe it’s educational issues, educational status, but actually here’s a paper that said the magnitude of gestational age-related discrepancies in birth outcomes actually increases with increasing educational status. High educational status is not protective in terms of discrepancies.

Adequacy of prenatal care? Studies show that racial disparities in prenatal mortality persist in contemporary obstetric practice despite early access to prenatal care. Is it bias implicit, or explicit? Is it racism? Not sure. This is a paper published in 2006. Said, “Racial disparities are multifactorial subject to ongoing research.” Is it that? Is it genetics? Again, same thing I said. We don’t know for sure. What we do know for sure is that stillbirth affects the women with African heritage significantly more commonly than Caucasian women.

Black women also have higher C-section rates. They have higher pregnancy-related maternal mortality rates. Again, getting back to term stillbirth, two specific factors I want to focus on, increasing gestational age and African heritage. Lastly, these are other risk factors for term stillbirth. I think we all know.

In terms of the main focus of this talk, I started with a fairly simple Google search targeting gestational age and African-American status, and it generated quickly a very interesting trail of research. As early as 1967, so a long time ago, this paper showed that there were differences in the duration of pregnancy that African Negro women have biologically shorter pregnancies than American white women. Wow, interesting.

1986, ethnic difference in duration of pregnancy. Again, this study documented that black women have shorter gestational theories than Caucasian women, and those differences persisted after adjustment for socioeconomic differences. 1990, this paper was able to quantify that difference. The average length of gestation, five to seven days shorter and Black populations than white populations. Suggesting that maybe the due date for Black patients should be 275 days after the LMP rather than the conventional 280.

Now the paper in 2004, finding a clear and consistent reduction in duration of gestation among Blacks and South Asians as compared to white Europeans. “Gestational age length is one week shorter,” this paper said.

Going back to 1996, going backwards in time, what about the safety issue? Maybe African-American women deliver earlier, but maybe that puts their babies at risk. Well, this study showed using something called a TDX Assay that Black fetuses mature faster with accelerated lung maturation compared with Caucasian fetuses. Another paper, 2008, suggested that gestation-specific patterns of neonatal respiratory distress syndrome RDS differ significantly by racial group.

Lower rates of RDS in Black babies in the weeks prior to the EDC, 37, 38 weeks. Those babies do better than Caucasian babies. That paper suggested that it might be more appropriate to have a separate policy of planned cesarean delivery or induction at 38 weeks of gestation for South Asian and Black women.

A paper in 2012, more about racial differences in pregnancy duration and its implications. This is built into it. Said, “For all delivery routes, the lowest adverse outcome rate for Black neonates was at 38 weeks.” That’s crazy. It’s saying that African American babies do better if they’re born at 38 weeks versus 39 weeks for white neonates. For both groups, the outcomes worsened for each week after those two intervals.

2013. The other piece is that ethnic disparities in prenatal mortality at 40 and 41 weeks. What does that mean? That means that with increasing gestational age beyond 39 weeks, perinatal mortality risk increases more strongly among African pregnancies compared to in European whites. Ethnic differences in post-maturity syndrome suggesting that, again, African-American babies are better if they’re born somewhat earlier, rather than later.

This is a graph that shows that. The red squares are African-American babies. Caucasian is in the green triangles. This is showing that clinical signs of post-maturity in newborns increases much quicker than for Caucasian babies.

This is my summary of what I just talked about. In the upper graph, there’s women with African heritage, the red is respiratory distress. Doesn’t happen as frequently at earlier gestational age. The brown is stillbirth. Happens sooner in African Americans than in Caucasians. Then lastly post-maturity is in the yellow. If you draw lines between the start of these things and when they occur and when the optimal time might be, you get these black boxes where there’s clearly a shift a week earlier for African-American babies. If you move that black box for African-American deliveries one week to the right, you get basically this interesting thing where those events all of a sudden become similar and the disparities go away. But this means that the women with African heritage are delivering at 38 to 39 weeks versus 39 to 40 weeks for Caucasian.

This was an idea in 2021. Perhaps women of African descent and heritage, the 39-week rule should be modified to become the 38-week rule.

Is this a theory? No, it’s actually my lived experience because I practiced at University of Pennsylvania from 1998 to 2012 working mostly with a clientele that was African-American. This arrow is pointing to the seventh floor of the hospital, University of Pennsylvania, that’s labor and delivery. I had three published studies when I was there looking at the outcomes of women when they were regularly induced in the 38th week.

This is just a slide showing that the percentage of women with African heritage was quite high in all three studies. This is a slide showing the induction activity occurring very early 38, 38 and a half weeks. That’s me on the left. That’s the standard there on the right. If you draw a line at 39 weeks, you can see that the red bars, which are the induced patients, clearly in the left-hand frame are fairly frequent prior to 39 weeks.

What about maternal and neonatal safety? You have all these inductions that are happening before 39 weeks. What the heck happens with those outcomes? Actually, I did a poster. Didn’t published as a written paper, but a poster, which ended in Berlin, Germany in 2010, and basically compared the pre-39-week preventive inductions 103 cases to 1,560 cases that delivered after 39 weeks within the standard of care. In the preventive IOLs pre-39 weeks, there was a lower section rate, a lower neonatal intensive care unit rate, and in the group that I’m talking about, the 103 cases, there were zero long NICU admissions. Apparently, it’s a safe issue.

This slide just shows that the crossover between term stillbirth and neonatal death in the first year of life crosses at about 37 weeks 5 days. That’s for all patients. Is probably earlier for African American babies. This counters what folks are saying that the 39-week rule prevents babies dying in the first year of life. I don’t think that’s true.

How might other providers get these same results in their patients? Well, provide planned induction of labor in the 38th week of gestation for patients who wish that intervention.

Then I want you to consider this pregnant patient who is 36 weeks today. We know that we could talk with her about fetal activity monitoring, sleeping position, we could do ultrasound for fetal weight and evaluate the placenta for abnormalities and ratios, but it’s not going to do us any good to talk with her about better prenatal care or better diet or smoking cessation or a reduction in psychosocial stress or systemic racism or any of that. She’s 36 weeks and she’s going to have her baby very soon.

I want to go back and remind everyone that the intrapartum complications were lower for African-Americans the 38th week than the 39th week with no increased risk of neonatal complications. While a 39-week goal is simple and benefits many patients and many Caucasian patients, perhaps a more personalized medicine approach may benefit mothers and babies with African heritage by encouraging delivering the 38th week either spontaneously, which would be great, or by a planned induction if labor hasn’t started. Perhaps delivery within the 38th week of gestation is the best plan.

Getting back to the 39-week rule, there have been modifications for special situations. As of February, 2021, an ACOG practice bulletin, we can now be doing 37-week, 38-week inductions for mild growth restriction, for hypertensive disorders, for cholestasis of pregnancy, and thankfully now for prior stillbirth with high levels of maternal anxiety, you can now do a planned induction in the 37th or 38th week.

But I would add that, sadly, even though Black fetuses have a gestational period that is shorter or ready to be delivered sooner, suffer the negative effects of post-maturity sooner and die in utero more frequently while waiting to deliver. African heritage is currently not considered worthy of a downward modification of the 39-week rule. Women with African heritage will continue to experience higher rates of term stillbirth within our current model of care unless there can be a downward modification for them of the 39-week rule.

I want to close. This is a slide of John Lewis. He said, “My philosophy is very simple. When you see something that is not right, not fair, not just, say something, do something, get in trouble, good trouble, necessary trouble.”

If we’re looking to prevent stillbirth and obtaining babies that are alive and live out a full life, what are we going to do? What kind of trouble are we going to cause? I think looking at the African-American situation is one way to challenge the 39-week rule, and if the African-American situation can be used to effectively challenge the 39-week rule, then my hope and prediction is that we can then move on and do similar actions with other risk factors that we know increase the risk of term stillbirth. Thank you, and if there are questions, I guess there’ll be a system for doing that. Take care.

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