Back sleeping and stillbirth revisited: A reason for caution, or a few extra pillows

As longtime readers of my blog know, in 2011, carrying my first child, I became obsessed with the question of whether pregnant women could lie on their backs–either for short periods of time, such as during a yoga class, or while asleep at night.

Several OBs told me to avoid lying on my back. But their justifications were murky, and their advice conflicting. Not a one could point to a single published study backing this advice up. And when asked at what point in pregnancy I needed to start avoiding back sleeping, their answers were all over the place. One told me it was verboten from 4 months on, another from 5 months on, and the third claimed I should worry only in the last month or so.

Sleeping with a bowling ball-sized stomach is challenging, to say the least. At the same time, groundless sleep prohibitions with vague but terrifying warnings that you might harm your baby are immensely frustrating, and yet almost impossible to disregard.

But while in 2011, these dire warnings sounded like a yet another pregnancy prohibition in search of a reason (no Brie, not a drop of alcohol, keep your heart rate below 140 while exercising, etc., etc.), several studies (one from Australia, two from New Zealand, one from Ghana, and the latest, from the UK) have since found that back sleep may indeed be linked to what is termed late stillbirth, or pregnancy loss after 28 weeks.

The science of back sleeping and stillbirth

The latest and largest of these studies, involving over 700 stillbirths, came out earlier this year. Like its smaller predecessors, this UK-based study compared the sleep practices of women with a late stillbirth with those of women with ongoing pregnancies.

(Why did researchers use a retrospective study design? Because late stillbirth is fairly rare, affecting only around 3 pregnancies in 1,000. Prospective studies on late stillbirth–that is, following a large number of pregnant women before their pregnancy outcomes are known– while scientifically superior, are prohibitively large and expensive.)

As in the earlier studies,  women who slept on their backs had about twice the chances of late stillbirth than women who slept on their left sides. Because it was the larger than earlier studies, the researchers were able to look at whether back sleeping was only risk factor for some women, such as those who were obese or who had a baby that was small for its gestational age (SGA). This was not true–back sleeping appeared to increase the risk of stillbirth for all women.

Why would back sleeping cause stillbirth?

A large vein, the vena cava, runs under the right side of the uterus. Late in pregnancy, when a woman lies on her back or her right side, the unusually heavy weight of uterus can compress this vein, reducing blood flow to the fetus.

lateral versus supine

Researchers believe the reduction of blood flow to the fetus, if sufficiently severe and prolonged, may lead to fetal death.

What does this mean in practice?

First off, if you have been lying on your back to sleep, do not panic! Your baby is fine.

But should you continue to sleep on your back? What if you accidentally roll onto your back while sleeping? What if you cannot comfortably sleep in any other position?

Well, here’s where it gets complicated. With four studies all showing the same thing, it seems likely that back sleeping really does raise the chances of a late stillbirth. But whether it meaningfully raises the chances of a late stillbirth is a more complicated question.

First, let’s recall that late stillbirth is rare–affecting only 3 pregnancies in 1,000. About a third of these late stillbirths are caused by birth defects, placental abruption (the placenta breaks away from the uterine wall), and infections. Back sleeping is unrelated to these explained stillbirths.

For the remainder, known as unexplained late stillbirths, the causes remain incompletely understood, but primarily appear related to a failing placenta. Back sleeping may exacerbate placental failure by further restricting the fetus’s already compromised blood flow.

However, back sleeping is far from the most important risk factor linked to unexplained late stillbirths. Being obese, being over 40, and smoking during pregnancy are far more important. The Centers for Disease Control estimates that in high income countries like the U.S., being obese or overweight during pregnancy contributes to about 8,000 stillbirths each year, pregnancy among women aged 35 and up contributes to about 4,200 stillbirths each year, and smoking during pregnancy contributes to about 2,800 stillbirths each year.

About 45% of pregnancies that end in late stillbirth involve fetuses with intrauterine growth restriction. Mom having diabetes or high blood pressure also ups the risk. And African-American women have a higher risk than Asian and White women.

In short, back sleeping appears to contribute to a fraction of a fraction of an absolutely tragic, but thankfully rare event.

And here’s what does not make it into the standard media write-ups about this research: Regular daytime napping also raises the risk of late stillbirth about two-fold, according to these studies. No one knows why. I have yet to see a researcher even hazard an explanation.

Oh, and so does getting up to go to the bathroom once or less in the middle of the night. (Yep, you can’t even consider not having to pee multiple times per night in your third trimester as a win! There is no winning with these data.)

Pregnant woman unable to sleep

As yet, not a single researcher or public health official has proposed that  pregnant women abstain from napping or that they set alarms to ensure they get up to pee at least twice per night. Perhaps they recognize the futility of such efforts. Women in their third trimester are tired. Then again, they are pondering widespread public health messages again back sleeping.

Counting on these people to consider the practical effects of their pregnancy recommendations is like counting on a newborn to sleep through the night. In short, don’t.

The Bottom Line

AdobeStock_99826164_Preview

Fortunately, whether this research has you running to Amazon for a new pregnancy pillow, vowing to sleep only on your left side, or calling BS while you reach for a second helping of Brie and a half glass of wine, a very simple fix exists: Put a pillow under your right side if you sleep on your back. Propping your right buttock up as little as 10-15 degrees prevents compression of the vena cava. Women who sleep on their backs but propped up have no higher risk of stillbirth than women who sleep on their left sides, according to the one study of the these four that inquired about propped sleeping.

References

1. Flenady V, Koopmans L, Middleton P, Froen JF, Smith GC, Gibbons K, et al. Major risk factors for stillbirth in high‐income countries: a systematic review and meta‐analysisLancet2011;377:1331–40. 
2. Heazell AE, Whitworth MK, Whitcombe J, Glover SW, Bevan C, Brewin J, et al. Research priorities for stillbirth: process overview and results from UK Stillbirth Priority Setting PartnershipUltrasound Obstet Gynecol 2015;46:641–7. 
3. Stacey T, Thompson JM, Mitchell EA, Ekeroma AJ, Zuccollo JM, McCowan LM. Association between maternal sleep practices and risk of late stillbirth: a case‐control studyBMJ 2011;342:d3403. 
4. Gordon A, Raynes‐Greenow C, Bond D, Morris J, Rawlinson W, Jeffery H. Sleep position, fetal growth restriction, and late‐pregnancy stillbirth: the Sydney stillbirth studyObstet Gynecol2015;125:347–55.
5. McCowan LME, Thompson JMD, Cronin RS, Li M, Stacey T, Stone PR, et al. Going to sleep in the supine position is a modifiable risk factor for late pregnancy stillbirth; Findings from the New Zealand multicentre stillbirth case‐control studyPLoS ONE 2017;12:e0179396. 
6. Platts J, Mitchell EA, Stacey T, Martin BL, Roberts D, McCowan L, et al. The Midland and North of England Stillbirth Study (MiNESS)BMC Pregnancy Childbirth 2014;14:171.
7. Gardosi J, Kady SM, McGeown P, Francis A, Tonks A. Classification of stillbirth by relevant condition at death (ReCoDe): population based cohort studyBMJ 2005;331:1113
8. McIntyre JP, Ingham CM, Hutchinson BL, Thompson JM, McCowan LM, Stone PR, et al. A description of sleep behaviour in healthy late pregnancy, and the accuracy of self‐reportsBMC Pregnancy Childbirth 2016;16:115. [PubMed]

 

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9 thoughts on “Back sleeping and stillbirth revisited: A reason for caution, or a few extra pillows”

  1. Hm, timely advice as I head into the 2nd trimester! I propped in my last pregnancy — I remember seeing at least the Australian study back then, but the others are news to me, so even more reason to break out the pregnancy pillow sooner rather than later. I appreciate the emphasis on absolute vs. relative risk. Still, as someone who has experienced second-trimester loss, my risk tolerance is pretty low and this is a simple thing to do!

    1. Yes, I can understand how even small risks can seem like too much to bear! Congratulations on your pregnancy! I hope it’s smooth sailing from here on out.

  2. Hi Amy, do the studies provide advice on when to start propping? I recall seeing something about the risk being greater after 32 or 34 weeks as opposed to 28?

    1. Hi Jessica—the studies are a bit conflicting on this point and really too small to give a definitive answer. The latest and largest study out of the UK found no difference in risk from 28 weeks on. They did not look at earlier in pregnancy. One of the New Zealand studies found a much greater risk at term than preterm, so around 37 weeks.

  3. I’d love some clarification on whether sleeping on your right side increases the risk as much as sleeping on your back. It is grouped together above but are they equally risky?

    1. Sleeping on your right is higher risk than sleeping on your left but lower risk than sleeping on your back in most of these studies.

  4. Thanks for your work putting together this article. Can you clarify this statement “Women who sleep on their backs but propped up have no higher risk of stillbirth than women who sleep on their left sides” Does it have to be a pillow under the right butt cheek to tilt you, or does propped up also mean just making sure your back is elevated? About the only comfortable way for me to sleep right now is on my back propped up with a bunch of pillows so my top half is elevated. I thought that eliminated the problem but now I’m not sure.

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