Background
Methods
Search strategy
Study selection and outcome definition
Statistical analysis
Results
Reference | Author year | Study type | Population | Location | Exposure: smoking during pregnancy and validity | Definition of stillbirth (outcome) and gestational period | Estimates | Factors adjusted for in individual studies if available |
---|---|---|---|---|---|---|---|---|
Studies included in meta-analysis
| ||||||||
12 | Wood et al (2009) | Cohort | 158,502 | Alberta Perinatal Health Program, 1991-2004 Canada | Smokers: Yes | Fetal death after at least 24 completed weeks of gestation. | Adjusted OR 1.04 (0.74-1.47) | Maternal age, diabetes, hypertension, previous caesarean section. |
Not validated | ||||||||
13 | Smith et al (2007) | Cohort | 84,769 | Scotland morbidity records 1991-2001, UK | Smokers: Yes | Fetal death after at least 24 completed weeks of gestation. | OR for smoking was calculated 2.15 (95% CI 1.74-2.65) | Age, deprivation, height, BMI, Marital Status. |
Not validated | ||||||||
14 | Hogberg and Cnattingius (2007) | Cohort | 526,691 | Sweden – Swedish National study 1983-2001- Participants with two consecutive pregnancies. | Smokers: Yes | Fetal death after at least 28 completed weeks of gestation. | OR for smoking in both Pregnancies 1.35 (1.15-1.58). 1-9cig/day OR 1.16 (0.92-1.46) ≥10 cig/day 0R 1.55 (1.17-2.04). OR for smoking in the 1st pregnancy only OR 1.02 (0.79-1.30), 1-9 cig/day OR 1.13 (0.9-1.39), ≥10 cig/day OR 1.14 (0.87-1.51). OR for smoking in 2nd pregnancy only 0.84 (0.55-1.26), 1-9cig/day OR 1.10 (0.89-1.35), ≥ 10 cig/day OR 1.45 (1.16-1.81). | Maternal age, education, cohabiting with infant’s father, mother’s country of birth, year of second delivery, inter-pregnancy interval and stillbirth in first pregnancy. |
1-9 cig/day, ≥10 cig/day. | ||||||||
Not validated | ||||||||
26 | Salihu et al (2008) | Case control | 1,444,378 | USA – Missouri 1978-1997. | Smokers: Yes | In-utero fetal death at least 20 week into gestation. | a) Bidirectional case cross-over OR 1.20 (1.03-1.39) 1-9 cig/day OR 1.16 (0.88-1.53) 10-19 cig/day OR 1.10 (0.90-1.24) ≥ 20 cig/day OR 1.21 (1.01-1.50), | Maternal race and age. |
1-9 cig/day, | ||||||||
10-19 cig/day, | b) Case Control OR 1.34 (1.26-1.43) 1-9 cig/day OR 0.94 (0.76-1.70) 10-19 cig/day OR 1.31(1.22-1.41) ≥20 cig/day OR 1.43 (1.31-1.54). | |||||||
≥20 cig/day. | ||||||||
Not validated | ||||||||
34*** | Ahlenius and Thomassen (1999) | Cohort | 94,270 in 1984 and 124,201 in 1991. | Sweden - Using the Swedish medical birth register in 1984 and 1991 | Smokers: Yes. | Death of a fetus before or during delivery with a gestational duration of at least 28 weeks. | Combined (1984 and 1991) OR 1.37 (1.17 to 1.61) | Maternal age and parity. |
1-9 cig/day, ≥10 cig/day. | 1-9 Cig/day OR 1.22 | |||||||
(1.00-1.48) | ||||||||
Not validated | ≥10 Cig/day OR 1.62 (1.31-2.00) | |||||||
1991 OR | ||||||||
1.47 (1.19 to 1.82) | ||||||||
>10 Cig/day OR 1.97 (1.51-2.59) | ||||||||
36*** | Aliyu et al (2007) | Cohort | 1,436, 725 | USA Missouri – Using Missouri maternally linked cohort data 1978 – 1997 | Smokers: Yes | In utero fetal death at < = 20 weeks gestation | OR(originally presented as HRs) 1.43 (1.36-1.51) | N/A* |
1-9 cig/day, 10-19 cig/day, ≥ 20 cig/day. | ||||||||
Not validated | ||||||||
37 | Gray et al (2009) | Cohort | 532,016 | UK- Scotland, National study 1994-2003. | Smokers: Yes. | 24-44 weeks’ gestation | OR 1.75 (1.61-1.91) | N/A* |
Not validated | ||||||||
38 | McCowan et al (2007) | Cohort | 69,173 | New Zealand - National Women’s | Smokers: Yes | Birth of a baby with no signs of life delivered at ≥ | OR 1.33 (0.99-1.79) | Infant sex, maternal ethnicity, parity, marital status, maternal age at delivery, history of previous miscarriage, history of previous abortion, previous low-birth weight infant, previous C-section. |
Hospital, Auckland, New Zealand from 1993 to 2000 | Not validated | 20 weeks or with a birth weight of > 400 g if gestation was not known. | ||||||
39 | Miller et al (2010) | Cohort | 359,747 | Canada – Ontario state 2004-2006 | Smokers: Yes | Death of fetus at 20 weeks of gestation | Overall OR 1.58 (1.38-1.81) | Age, parity, multiple gestation |
Not validated | ||||||||
40 | Moshin et al (2005) | Cohort | 433,227 | Australia – New South Wales 1998-2002 | Smokers: Yes | Fetal death at ≥ 20 weeks gestation or of 400 g or more birth weight. | Overall adjusted OR 1.17 (1.05–1.31) Unadjusted OR 1.05 (0.94–1.17). | Maternal age, maternal country of birth, socioeconomic status, maternal diabetes mellitus, and first antenatal care visit. |
Not validated | ||||||||
17*** | Raymond et al (1994) | Cohort | 638,242 | Sweden National study 1983-1989 | Smokers: Yes | Fetus death at 28 weeks of gestation or more. | OR 1.4 (1.2-1.4) | Age, parity, pregnancy complications, hypertensive diseases, diabetes, placental complications and intrauterine growth retardation (IUGR). |
Not validated | ||||||||
42 | Reddy et al (2006) | Cohort | 174,809 | USA – 12 clinic centres and 19 hospital sites. 2002-2008. | Smokers: Yes | Fetal death at 23 weeks gestation and beyond. | OR (originally presented as HRs) 1.57 (1.21-2.02) | N/A* |
Not validated | ||||||||
43 | Sutan et al (2010) | Cohort | 541,811 | UK- Scotland, National study (NHS Hospital) | Smokers: Yes | Late fetal death from 20 weeks gestation. | OR 1.64 (1.46-1.84) | Non stated |
Not validated | ||||||||
44 | Tuthill et al (1999) | Cohort | 16,047 | Wales – All Wales Perinatal Survey 1993-1995 | Smokers: Yes | Mortality from 20 completed weeks of gestation | OR 1.72(1.38-2.13) | Social class, infection, placental abruption, sudden infant death syndrome. |
Not validated | ||||||||
45 | Wisborg et al (2001) | Cohort | 25,102 | Denmark – Aarhust University Hospital 1989-1996. | Smokers: Yes | Delivery of a dead fetus occurring at 28 weeks or more gestation. | OR 1.9 (1.3-2.9), | Sex of child, parity, maternal age, education, alcohol, caffeine intake. |
1-9 cig/day, ≥10 cig/day. | 1-9 cig/day OR 1.5 (0.9-2.4) ≥10 cig/day 1.8 (1.2-2.8) | |||||||
Not validated | ||||||||
46 | Winbo et al (2001) | Cohort | 1,412,747 | Sweden – National study 1983 - 1995 | Smokers: Yes | Death of fetus after competing 28 weeks of gestation. | OR stillbirths ≥37 weeks compared with live births 1.08 (0.96-1.22) | Non stated |
Not validated | ||||||||
27 | Ferraz and Gray (1991) | Case control | 11,483 | Brazil – Natal city and state of Rio Grande do Norte 1984-1986 | Smokers: Yes | Stillborn cases weighing 500 g or more | OR 1.4 (1.0-2.0) | Non stated |
Not validated | ||||||||
29 | Dodds et al (2006) | Case control | 494 | Canada – Nova Scotia and Eastern Ontario 1999-2001 | Smokers: Yes | Not specified - Death before delivery of a fetus weighing 500 g or more | OR (originally presented in HRs) Smoking during 1st trimester 2.13 (1.23-3.64) | N/A* |
Not validated | ||||||||
30 | Efkarpidis et al (2004) | Case control | 599 | UK – Nottingham City Hospital 1991-1997. | Smokers: Yes | Definition of stillbirth not stated- pregnancies considered from ≥ 24 weeks | OR 1.2 (0.64-1.6) | Non stated |
Not validated | ||||||||
31 | Froen et al (2002) | Case control | 598 | Norway – Oslo 1986-1995. | Smokers: Yes | Intrauterine death before onset of labour of a fetus > =22 weeks gestation or > = 500 g body mass | OR calculated Using Stats 1.81 (1.02-3.15) 1-9 cig/day OR 1.0 (0.43-2.12), ≥10 cig/day 0R 3.04 (1.13-8.19) | N/A* |
1-9 cig/day, ≥10 cig/day. | ||||||||
Not validated | ||||||||
32 | Goy et al (2008) | Case control | 510 | Canada – Nova Scotia and Eastern Ontario 1999-2001. | Smokers: Yes | Not specified - Death before delivery of a fetus weighing 500 g or more | OR 2.06 (1.22-3.47) | Province of origin, age, inactivity during pregnancy, stillbirth in previous pregnancy, used fertility treatment |
Not validated | ||||||||
33 | Little and Weiberg (1993) | Case control | 4667 | USA | Smokers: Yes | Fetal death at 28 weeks or more gestation | OR calculated using Stata 1.29 (1.09-1.53) | N/A* |
1-19 cig/day, | OR 1-19 cig/day 1.3 (1.09-1.57), 20-29 cig/day OR 1.39 (1.06-1.82), ≥30 cig/day OR 0.67 (0.41-1.12). | |||||||
20-29 cig/day, | ||||||||
≥ 30 cig/day. | ||||||||
Not validated | ||||||||
47 | Mishra et al (2005) | Cross-sectional | 16,802 | India - Survey conducted 98-99 | Smokers: Yes | Delivery of a dead baby at > 28 weeks of pregnancy | OR 1.23 (0.92-1.64) | Cooking smoke, anaemia, BMI, education, standard of living, house type. |
Not validated | Unadjusted OR 1.60 (1.23-2.08). | |||||||
48 | Robson et al (2006) | Cross-sectional | 21, 880 | Australia – New South Wales 1998-2003. | Smokers: Yes | Not stated | OR 1.65 (1.15-2.38) | Age, parity, medical/obstetric complications |
1-10 cig/day >10 cig/day. | 20 weeks | 1- 10 cig/day OR 1.16 (0.80-1.69) >10 cig/day OR 1.68 (1.17-2.41). | ||||||
Not validated | ||||||||
Studies included in narrative synthesis
| ||||||||
16*** | Cnattingius et al (1988) | Cross-sectional | 262,582 | Sweden National Study – Using Swedish medical birth registry covering more than 99% of all births in Sweden. 1983-1985 | Smokers: Yes | Late fetal death – still birth occurring at 28 weeks of gestation or later | OR (originally presented as RR) 1.37 (1.20-1.57) | N/A* |
1-9 cig/day, | 1-9 cig/day 1.32 (1.12-1.55) | |||||||
≥10 cig/day. | ≥10 cig/day 1.45 (1.21-1.75) | |||||||
Not validated | ||||||||
28*** | Walles (1994) | Case control | 202 | Sweden – 5 centres (Boras, Helsingborg, Karlskrona, Kristianstastad and Lund) 1983-1989. | Smokers: Yes | Definition of stillbirth not stated, pregnancies considered | OR calculated using Stata. OR 1.18 (0.62-2.26) | N/A* |
1-10 cig/day, | 1-10 cig/day OR 1.33 (0.58-3.09) >10 cig/day 1. 04 (0.43-2.50) | |||||||
≥10 cig/day. | ≥ 28 weeks | |||||||
Not validated | ||||||||
35*** | Aliyu et al (2008) | Cohort | 1,436,628 | USA Missouri – Using Missouri maternally linked cohort data 1978 – 1997. | Smokers: Yes. | In utero fetal death at < = 20 weeks gestation. | OR (originally presented as HRs) 1.48 (1.40-1.56) | N/A** |
< 35 years old, ≥ 35yers old. Not validated | < 35 years smokers1.43 (1.35-1.51) | |||||||
≥35 years Smokers OR 2.4 (2.06-2.80) | ||||||||
49 | Kleinman et al (1988) | Cohort | 362,261 | USA Missouri 1978-1983 | Smokers: Yes | (Fetal mortality) Fetal death at 20 weeks or more. | OR Primiparas | N/A** |
< 1 pack/day ≥1 pack/day. | <1 pack/day 1.36(1.16-1.59) ≥1 pack/day 1.62 (1.34-1.97) | |||||||
Not validated | Multiparas | |||||||
<1 pack/day 1.21 (1.06-1.38) ≥1pack/day 1.15(0.99-1.34) | ||||||||
50 | Raatikainen et al (2006) | Cohort | 25,591 | Finland-Kuopio University Hospital 1989-2001. | Smokers: Yes. | Fetal death was defined as intrauterine death before | No estimates | N/A** |
Not validated | ||||||||
22 weeks of pregnancy or 500 g fetal weight. | ||||||||
51 | Aliyu et al (2010) | Cohort | 633,849 | US Missouri – Using Missouri maternally-linked cohort data files 1978 – 1997. | Smokers: Yes | In utero fetal death at > = 20 weeks gestation. | Results HRs, | N/A** |
Not validated | <15 years 3.3 (1.4-7.8), 15-19 years 1.7 (1.5-1.9), 20-24 years 1.5 (1.4-1.6) | |||||||
No sufficient data to calculate Odds ratios. | ||||||||
52 | Bai et al (2000) | Cohort | 7138 | Australia- Liverpool hospital Sydney March 1996 to June 1998 | Smokers: Yes | Not Clear (births occurring at less than 20 weeks gestation age exclusion criteria). | Results presented in Percentages. No odds ratios and no sufficient data to calculate OR. | N/A** |
Not validated | ||||||||
53 | Huang et al (2000) | Cohort | 84,294 | Canada – The Royal Victoria Hospital in Montreal 1961-1974 and 1978-1996. | Smokers: Yes | Fetal deaths occurring before labour without evidence of significant fetal, maternal or placental pathology weighing 500 g or more. | No estimates | N/A** |
Not validated | ||||||||
18 | Schramm (1997) | Cross-sectional | 176,843 | USA – Missouri 1978-1990 | Smokers: Yes Not validated | Fetal death greater or equal to 20 weeks gestation. | Results in RR no sufficient data to calculate OR | N/A** |
Smoking in 1st and not in 2nd pregnancy RR 1.11, Not smoking in 1st but in 2nd pregnancy RR 1.6.smoking in both pregnancies RR 1.19. | ||||||||
54 | Salihu et al (2004) | Cross-sectional | 7,792,990 | USA – 1995-1997. | Smokers: Yes | Intrauterine fetal demise after 20 weeks of gestation. | Estimates in Hazard ratios not enough data to calculate OR. | N/A** |
Not validated | ≥ 40 years 2.71 (1.88-3.91), 30-39 years 1.58 (0.96-2.60), 20-29 years 1.41 (1.16-1.71) |
The type of exposure
Data collection on outcome
Meta-analysis of maternal smoking and risk of stillbirth
Subgroup analysis by study quality
Subgroup analysis by categories of cigarette consumption
Subgroup analysis by gestation of stillbirth
Subgroup analysis by study location
Narrative synthesis
Discussion
Assessment criteria | Odds ratio | 95% CI |
---|---|---|
i) Overall pooled Results from main meta-analysis (25 studies)
| 1.47 | 1.37-1.57 |
ii) Subgroup analysis by daily amount of cigarettes consumption
| ||
1-9 cig/day (6 studies) | 1.09 | 0.97-1.24 |
≥ 10 cig/day (7 studies) | 1.52 | 1.30-1.78 |
iii) Subgroup analysis by gestation period at which stillbirth occurred
| ||
Stillbirth ≥ 20 weeks (11 studies) | 1.43 | 1.32-1.54 |
Stillbirth ≥ 24 week (4 studies) | 1.58 | 1.21-2.06 |
Stillbirth ≥ 28 weeks (7 studies) | 1.33 | 1.18-1.49 |
iv) Subgroup analysis by geographic location
| ||
North America (9 studies) | 1.39 | 1.29-1.50 |
Europe (11 studies) | 1.55 | 1.36-1.78 |
Asia (1 study) | 1.23 | 0.92-1.64 |
South America (1 study) | 1.40 | 1.00-1.96 |
Australia (3 studies) | 1.29 | 1.07-1.55 |
v) Subgroup analysis by quality
| ||
High score (14 studies) | 1.41 | 1.28-1.55 |
Low score (11 studies) | 1.49 | 1.33-1.67 |