Sleeping on your back increases stillbirth risk

New University of Auckland research has found that women who go to sleep on their back in the last three months of pregnancy are almost four times more likely to experience a stillbirth.

The New Zealand Multi-Centre Stillbirth Study, led by Professor Lesley McCowan, Head of the University’s Department of Obstetrics and Gynaecology, found that going to sleep supine – lying on your back – is associated with a 3.7-fold increase in overall risk of late stillbirth (after 28 weeks of pregnancy), independent of other common stillbirth risk factors.

This research confirms the findings from an earlier University of Auckland study, which was the first study internationally to identify maternal sleep position in late pregnancy as a risk factor for stillbirth.

In addition, the current study found that the risk of a stillbirth associated with going to sleep on your back was higher in term pregnancies, after 37 weeks, compared to pregnancies between 28 and 36 weeks.

Professor McCowan says the findings are of particular importance as the risk of stillbirth associated with going to sleep on your back may be preventable with appropriate public health messaging for women in late pregnancy. At present approximately 160 babies are stillborn in the last three months of pregnancy in New Zealand each year.

“Now that we have confirmed our earlier findings, public health education encouraging women to go to sleep on their side in the last three months of pregnancy needs to be considered. This simple intervention has the potential to reduce late stillbirth by approximately 9 percent,” Professor McCowan says, and could prevent the deaths of approximately 15 unborn babies annually in New Zealand.

“Our findings make sense as lying on the back in late pregnancy is associated with physical effects that can compromise the baby’s wellbeing. These include a reduction in the mother’s cardiac output (the amount of blood pumped by the heart per minute), a reduced blood flow to the uterus, and lower oxygen levels in the baby”.

Sleeping on the back is also related to sleep disturbed breathing (snoring) and obstructive sleep apnea, which have each been associated with pregnancy complications.

“The good news is that the position women go to sleep in can be changed. Since our initial findings were published in 2009, our research shows that there has been a change in going to sleep position in New Zealand women who are now more likely to go to sleep on their side. This change in behaviour has been encouraged by maternity care providers aware of the 2009 study results. There has also been a reduction in late stillbirths in New Zealand during this period. The reasons for this are likely to be several but could include a change in going to sleep position.”

The recent Multi-Centre Stillbirth Study was conducted in seven New Zealand District Health Board areas comprising two-thirds of all New Zealand births (Waitemata, Auckland, Counties Manukau, Waikato, MidCentral, Capital & Coast, and Canterbury).

In this case-control study 164 women experienced a stillbirth at or beyond 28 weeks’ gestation in their current pregnancy, and 569 were pregnant with a live baby, allowing comparisons to be made between mothers with stillborn infants and those with ongoing pregnancies.

Participants were asked about a range of behaviours and sleep practices including what position they went to sleep in.

The study was funded through a partnership grant between Cure Kids and the Health Research Council of New Zealand. Cure Kids also funded the 2009 Auckland Stillbirth Study and is co-funding a similar study in the United Kingdom, which some of the New Zealand research team are contributing to.

Ady Priday, a self-employed community midwife in Counties Manukau, a region with a high stillbirth rate, is pleased to see this research. “I advise pregnant women in my care not to sleep on their backs and explain about the effect on blood flow to their baby. This advice is gratefully received.”

Sands New Zealand, a voluntary, parent-run organisation that supports bereaved parents, welcomes this research. Rebekah Gray, Board Member of Sands New Zealand, comments: “Stillbirth is one of the most traumatic experiences parents can go through. The shock and grief for families cannot be imagined. This news about the potential to reduce stillbirth rates due to a change in sleep position is exciting. If even one more family does not have to be affected by the devastation of a stillbirth, then Sands New Zealand is supportive of these initiatives.”

Professor Ed Mitchell, who had a leadership role in this study, says he hopes this new knowledge about pregnant women’s going to sleep position will have a similar impact on reducing stillbirth as the ‘Back to Sleep’ campaign did for reducing Sudden Infant Death Syndrome (SIDS), which started in the late 1980s following research led by Professor Mitchell.

Professor McCowan says that while some midwives, obstetricians and childbirth educators are already advising pregnant women not to go to sleep on their backs, a more formal campaign would be helpful so that all pregnant women and maternity providers receive consistent advice.

Going to sleep on your back increases the risk of stillbirth

Key messages and frequently asked questions about sleep position in the last three months of pregnancy

How you go to sleep in the last three months of pregnancy is important:

• While baby is inside settle to sleep on your side.

• Avoid going to sleep on your back. It’s best to settle to sleep on your side!

• If you wake up in the night on your back – don’t worry! This is common, just settle back to sleep on your side.

• If you take a day-time nap, settle to sleep on your side.

Frequently asked questions

1. Should I go to sleep on my back in late pregnancy?

Published results from three separate studies now show that going to sleep on your back in the last three months of pregnancy is associated with an increased risk of having a stillbirth.

2. What is the reason for the increased risk of stillbirth if I go to sleep on my back in late pregnancy?

We are not sure exactly but when women lie on their back in late pregnancy the large pregnant womb can put pressure on major blood vessels which reduces blood flow to the uterus and the baby. This can result in lower levels of oxygen in the baby. Lying on the back is also associated with sleep disturbed breathing (snoring) and sleep apnea, both of which can be associated with pregnancy complications.

3. Is it best to go to sleep lying on my left side rather than my right side?

Many pregnancy web sites suggest that sleeping on the left side is best. One study reported that the left side may be better for baby than the right but two further studies have shown no difference between left and right sides. Therefore we recommend that you can settle to sleep on either side.

4. What do I do if I wake up on my back in the night?

Don’t worry – this is normal. Just settle back to sleep on your side.

5. Why is it that going to sleep position is important rather than the position I wake up in?

The position that you fall asleep in is the one in which you have the longest and soundest sleep and may therefore have more impact on the baby.

6. What can I do to increase my chance of staying on my side during the night?

A pillow behind your back may be helpful.

7. What about having a sleep during the day?

A lot of pregnant women have a day time nap. If you nap during the day settle to sleep on your side.

Media: New Zealand Multicentre Stillbirth Study