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Original Investigation |

Maternal Body Mass Index and the Risk of Fetal Death, Stillbirth, and Infant Death:  A Systematic Review and Meta-analysis

Dagfinn Aune, MS1,2,3; Ola Didrik Saugstad, MD, PhD4; Tore Henriksen, MD, PhD5; Serena Tonstad, MD, PhD2,6
[+] Author Affiliations
1Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, United Kingdom
2Department of Preventive Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
3Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
4Department of Pediatric Research, Rikshospitalet, Oslo University Hospital, University of Oslo, Oslo, Norway
5Section for Obstetrics, Women and Children’s Division, Rikshospitalet, Oslo University Hospital, Oslo, Norway
6Department of Health Promotion and Education, Loma Linda University, Loma Linda, California
JAMA. 2014;311(15):1536-1546. doi:10.1001/jama.2014.2269.
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Importance  Evidence suggests that maternal obesity increases the risk of fetal death, stillbirth, and infant death; however, the optimal body mass index (BMI) for prevention is not known.

Objective  To conduct a systematic review and meta-analysis of cohort studies of maternal BMI and risk of fetal death, stillbirth, and infant death.

Data Sources  The PubMed and Embase databases were searched from inception to January 23, 2014.

Study Selection  Cohort studies reporting adjusted relative risk (RR) estimates for fetal death, stillbirth, or infant death by at least 3 categories of maternal BMI were included.

Data Extraction  Data were extracted by 1 reviewer and checked by the remaining reviewers for accuracy. Summary RRs were estimated using a random-effects model.

Main Outcomes and Measures  Fetal death, stillbirth, and neonatal, perinatal, and infant death.

Results  Thirty eight studies (44 publications) with more than 10 147 fetal deaths, more than 16 274 stillbirths, more than 4311 perinatal deaths, 11 294 neonatal deaths, and 4983 infant deaths were included. The summary RR per 5-unit increase in maternal BMI for fetal death was 1.21 (95% CI, 1.09-1.35; I2 = 77.6%; n = 7 studies); for stillbirth, 1.24 (95% CI, 1.18-1.30; I2 = 80%; n = 18 studies); for perinatal death, 1.16 (95% CI, 1.00-1.35; I2 = 93.7%; n = 11 studies); for neonatal death, 1.15 (95% CI, 1.07-1.23; I2 = 78.5%; n = 12 studies); and for infant death, 1.18 (95% CI, 1.09-1.28; I2 = 79%; n = 4 studies). The test for nonlinearity was significant in all analyses but was most pronounced for fetal death. For women with a BMI of 20 (reference standard for all outcomes), 25, and 30, absolute risks per 10 000 pregnancies for fetal death were 76, 82 (95% CI, 76-88), and 102 (95% CI, 93-112); for stillbirth, 40, 48 (95% CI, 46-51), and 59 (95% CI, 55-63); for perinatal death, 66, 73 (95% CI, 67-81), and 86 (95% CI, 76-98); for neonatal death, 20, 21 (95% CI, 19-23), and 24 (95% CI, 22-27); and for infant death, 33, 37 (95% CI, 34-39), and 43 (95% CI, 40-47), respectively.

Conclusions and Relevance  Even modest increases in maternal BMI were associated with increased risk of fetal death, stillbirth, and neonatal, perinatal, and infant death. Weight management guidelines for women who plan pregnancies should take these findings into consideration to reduce the burden of fetal death, stillbirth, and infant death.

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Figure 1.
Study Selection for Maternal BMI and the Risk of Fetal Death, Stillbirth, and Infant Death

BMI indicates body mass index; ICSI, intracytoplasmic sperm injection; IVF, in vitro fertilization; SIDS, sudden infant death syndrome.aExact reasons for exclusions were not documented.

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Figure 2.
Association Between Maternal BMI and Risk of Fetal Death

Linear (panel A) and nonlinear (panel B) dose-response analyses for fetal death using a random-effects model. BMI indicates body mass index.A, The relative risks (RRs) are represented by squares and the 95% CIs are represented by lines through the squares. Larger studies have greater weight, indicated by larger-sized squares. The summary RR is represented by the diamond and risk estimate at the bottom of the plot.

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Figure 3.
Association Between Maternal BMI and Risk of Stillbirth

Linear (panel A) and nonlinear (panel B) dose-response analyses for stillbirth using a random effects model. BMI indicates body mass index.A, The relative risks (RRs) are represented by squares and the 95% CIs are represented by lines through the squares. Larger studies have greater weight, indicated by larger-sized squares. The summary RR is represented by the diamond and risk estimate at the bottom of the plot.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
Association Between Maternal BMI and Risk of Perinatal Death

Linear (panel A) and nonlinear (panel B) dose-response analyses for perinatal death using a random effects model. BMI indicates body mass index.A, The relative risks (RRs) are represented by squares and the 95% CIs are represented by lines through the squares. Larger studies have greater weight, indicated by larger-sized squares. The summary RR is represented by the diamond and risk estimate at the bottom of the plot.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.
Association Between Maternal BMI and Risk of Neonatal Death

Linear (panel A) and nonlinear (panel B) dose-response analyses for neonatal death using a random effects model. BMI indicates body mass index.A, The relative risks (RRs) are represented by squares and the 95% CIs are represented by lines through the squares. Larger studies have greater weight, indicated by larger-sized squares. The summary RR is represented by the diamond and risk estimate at the bottom of the plot.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.
Association Between Maternal BMI and Risk of Infant Death

Linear (panel A) and nonlinear (panel B) dose-response analyses for infant death using a random effects model. BMI indicates body mass index.A, The relative risks (RRs) are represented by squares and the 95% CIs are represented by lines through the squares. Larger studies have greater weight, indicated by larger-sized squares. The summary RR is represented by the diamond and risk estimate at the bottom of the plot.

Graphic Jump Location

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