Temperature exposure during pregnancy and birth outcomes: An updated systematic review of epidemiological evidence

Seasonal patterns of birth outcomes have been observed worldwide, and there was increasing evidence that ambient temperature played as a trigger of adverse birth outcomes, such as preterm birth (PTB), low birth weight (LBW), and stillbirth. To systematically review updated epidemiological evidence about the relationship between temperature exposure during pregnancy and PTB, LBW, and stillbirth, we searched for related studies published in English from electronic databases and references of identified papers. We only included original articles that directly reported the effects of prenatal temperature exposure on birth outcomes. The characteristics and main findings of included studies were examined. A total of 36 epidemiological studies were finally included in this review. Most of these studies focused on PTB and LBW, while less attention has been paid to stillbirth that was relatively rare in the occurrence. Several designs including ecological (e.g., descriptive and time-series) and retrospective cohort studies (e.g., case-crossover and time-to-event) were applied to assess temperature effects on birth outcomes. Temperature metrics and exposure windows varied greatly in these investigations. Exposure to high temperature was generally found to be associated with PTB, LBW, and stillbirth, while several studies also reported the adverse impact of low temperature on birth outcomes of PTB and LBW. Despite no conclusive causality demonstrated, the current evidence for adverse effect on birth outcomes was stronger for heat than for cold. In summary, the evidence linking birth outcomes with ambient temperature was still very limited. Consequently, more related studies are needed worldwide and should be conducted in diversified climate zones, so as to further ascertain the association between temperature and birth outcomes. Future studies should focus on more sophisticated study designs, more accurate estimation of temperature exposure during pregnancy, and more efficient methods to find out the exposure windows, as well as cold-related effects on birth outcomes.