An Individual Participant Data Meta-analysis of Maternal Going-to-Sleep Position, Interactions with Fetal Vulnerability, and the Risk of Late Stillbirth

Robin S Cronin, Minglan Li, John M D Thompson, Adrienne Gordon, Camille H Raynes-Greenow, Alexander E P Heazell, Tomasina Stacey, Vicki M Culling, Victoria Bowring, Ngaire H Anderson, Louise M O'Brien, Edwin A Mitchell, Lisa M Askie, Lesley M E McCowan, Robin S Cronin, Minglan Li, John M D Thompson, Adrienne Gordon, Camille H Raynes-Greenow, Alexander E P Heazell, Tomasina Stacey, Vicki M Culling, Victoria Bowring, Ngaire H Anderson, Louise M O'Brien, Edwin A Mitchell, Lisa M Askie, Lesley M E McCowan

Abstract

Background: Maternal supine going-to-sleep position has been associated with increased risk of late stillbirth (≥ 28 weeks), but it is unknown if the risk differs between right and left side, and if some pregnancies are more vulnerable.

Methods: Systematic searches were undertaken for an individual-level participant data (IPD) meta-analysis of case-control studies, prospective cohort studies and randomised trials undertaken up until 26 Jan, 2018, that reported data on maternal going-to-sleep position and stillbirth. Participant inclusion criteria included gestation ≥ 28 weeks', non-anomalous, singleton pregnancies. The primary outcome was stillbirth. A one-stage approach stratified by study and site was used for the meta-analysis. The interaction between supine going-to-sleep position and fetal vulnerability was assessed by bi-variable regression. The multivariable model was adjusted for a priori confounders. Registration number: PROSPERO, CRD42017047703.

Findings: Six case-control studies were identified, with data obtained from five (cases, n = 851; controls, n = 2257). No data was provided by a sixth study (cases, n = 100; controls, n = 200). Supine going-to-sleep position was associated with increased odds of late stillbirth (adjusted odds ratio [aOR] 2.63, 95% CI 1.72-4.04, p < 0.0001) compared with left side. Right side had similar odds to left (aOR 1.04, 95% CI 0.83-1.31, p = 0.75). There were no significant interactions between supine going-to-sleep position and assessed indicators of fetal vulnerability, including small-for-gestational-age infants (p = 0.32), maternal obesity (p = 0.08), and smoking (p = 0.86). The population attributable risk for supine going-to-sleep position was 5.8% (3.2-9.2).

Interpretation: This IPD meta-analysis confirms that supine going-to-sleep position is independently associated with late stillbirth. Going-to-sleep on left or right side appears equally safe. No significant interactions with our assessed indicators of fetal vulnerability were identified, therefore, supine going-to-sleep position can be considered a contributing factor for late stillbirth in all pregnancies. This finding could reduce late stillbirth by 5.8% if every pregnant woman ≥ 28 weeks' gestation settled to sleep on her side.

Keywords: Fetal death; Fetal vulnerability; Individual participant data; Interaction; Meta-analysis; Perinatal death; Pregnancy; Sleep; Sleep position; Stillbirth; Supine.

Figures

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Study selection.

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