DOI: 10.1111/1471-0528.

14672 Systematic review

www.bjog.org

Physical activity and the risk of preterm birth: a

systematic review and meta-analysis of
epidemiological studies
D Aune,a,b,c S Schlesinger,b T Henriksen,d OD Saugstad,e S Tonstadf
a
Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim,
Norway b Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK c Bjørknes
University College, Oslo, Norway d Section of Obstetrics, Division of Obstetrics and Gynaecology, Rikshospitalet, Oslo University Hospital,
Oslo, Norway e Department of Pediatric Research, Rikshospitalet, Oslo University Hospital, University of Oslo, Oslo, Norway f Department of
Preventive Cardiology, Oslo University Hospital, University of Oslo, Oslo, Norway
Correspondence: D Aune, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St Mary’s Campus,
Norfolk Place, Paddington, London W2 1PG, UK. Email d.aune@imperial.ac.uk

Accepted 9 March 2017. Published Online 30 May 2017.

Background Physical activity has been inconsistently associated I2 = 0%, n = 30) for early pregnancy physical activity. The
with risk of preterm birth, and the strength of the association and summary RR for a 3 hours per week increment in leisure-time
the shape of the dose–response relationship needs clarification. activity was 0.90 (95% CI: 0.85–0.95, I2 = 0%, n = 5). There was
evidence of a nonlinear association between physical activity and
Objectives To conduct a systematic review and dose–response
preterm birth, Pnonlinearity < 0.0001, with the lowest risk observed
meta-analysis to clarify the association between physical activity
at 2–4 hours per week of activity.
and risk of preterm birth.
Conclusion This meta-analysis suggests that higher leisure-time
Search strategy PubMed, Embase and Ovid databases were
activity is associated with reduced risk of preterm birth. Further
searched for relevant studies up to 9 February 2017.
randomized controlled trials with sufficient frequency and
Selection criteria Studies with a prospective cohort, case-cohort, duration of activity to reduce the risk and with larger sample sizes
nested case-control or randomized study design were included. are needed to conclusively demonstrate an association.
Data collection and analysis Data were extracted by one reviewer Keywords Meta-analysis, physical activity, preterm birth.
and checked for accuracy by a second reviewer. Summary
Tweetable abstract Physically active compared with inactive
relative risks (RRs) were estimated using a random effects
women have an 10–14% reduction in the risk of preterm birth.
model.
Linked article This article is commented on by BA Armson, p. 1827
Main results Forty-one studies (43 publications) including 20
in this issue. To view this mini commentary visit https://doi.org/10.
randomized trials and 21 cohort studies were included. The
1111/1471-0528.14723. This article has journal club questions by
summary RR for high versus low activity was 0.87 [95%
Brett Einerson, p. 1828 in this issue. To view these visit https://doi.
confidence interval (CI): 0.70–1.06, I2 = 17%, n = 5] for physical
org/10.1111/1471-0528.14795.
activity before pregnancy, and it was 0.86 (95% CI: 0.78–0.95,

Please cite this paper as: Aune D, Schlesinger S, Henriksen T, Saugstad OD, Tonstad S. Physical activity and the risk of preterm birth: a systematic review
and meta-analysis of epidemiological studies. BJOG 2017;124:1816–1826.

cognitive and developmental disabilities, and chronic diseases

Introduction
In 2012 an estimated 15 million preterm births (defined as
birth before 37 completed weeks of gestation) occurred
worldwide.1 Preterm births account for approximately 29%
of the 3.6 million neonatal deaths worldwide,2 and is an
important risk factor for neonatal morbidity including
breathing problems, infections and jaundice.2 Babies born
preterm have also been found to have a greater risk of
in adulthood. Apart from tobacco smoking, which is an estab-
lished risk factor, maternal obesity has also been associated
with increased risk of preterm birth, particularly very preterm
births in several studies,3,4 and this was confirmed in a recent
meta-analysis that also found an increased risk of preterm
births among overweight and obese pregnant women.5
Physical activity is an important determinant of over-
weight and obesity,6 and reduces the risk of excess gestational

1816 ª 2017 Royal College of Obstetricians and Gynaecologists


weight gain,7–10 and has been associated with reduced risk of
other obesity-related pregnancy complications, including
gestational diabetes11 and preeclampsia.12 Several random-
ized trials,13–31 cohort studies32–54 and case-control stud-
ies55–63 have investigated the association between physical
activity and preterm births, but the results have been incon-
sistent, with some studies showing significant inverse associ-
ations,32–34,55,56,59 while other studies reported no significant
associations.13–19,21,23,24,26–31,35,37–39,41–43,45,57,58,63–65 Several
of the studies showed non-significant inverse associa-
tions,19,24,30,35,38,39,41,42 but may have been limited by low
statistical power. However, even among the studies that
reported inverse associations there was considerable variabil-
ity in the strength of the associations reported, with some
studies reporting a 15–20% reduction in risk with high phys-
ical activity,35,36,38,42 while other studies reported up to a 40–
80% reduction in risk.19,32–34,41,46,55,56,59 It is possible that
differences in the timing, amount, type and intensity of phys-
ical activity or different degrees of adjustments for con-
founders or other study characteristics could explain some of
this variation in the results. To clarify whether physical activ-
ity before or during pregnancy is associated with the risk of
preterm birth, we conducted a systematic review and meta-
analysis of epidemiological studies on the subject. We were
particularly interested in clarifying the dose–response rela-
tionship between physical activity, including total, leisure-
time and occupational physical activity, and preterm birth,
potential confounding, and other study characteristics that
could explain the observed heterogeneity in the results.
Methods
Search strategy
We searched the PubMed and Embase databases up to 15
December 2014 for cohort studies (including prospective
cohorts, case-cohorts and nested case-control studies within
cohort studies), and randomized trials of physical activity
(including total, leisure-time and occupational physical
activity) and risk of preterm birth (defined as birth before
37 completed weeks of gestation), and the searches were
later updated to 9 February 2017. We used the following
search terms: (‘physical activity’ OR ‘leisure activity’ OR
exercise OR sports OR walking OR biking OR running OR
fitness OR ‘exercise test’ OR inactivity OR sedentary) AND
(‘preterm birth’ OR preterm OR ‘premature birth’ OR pre-
maturity OR ‘preterm labor’ OR ‘premature labor’ OR
‘preterm delivery’ OR ‘premature delivery’ OR ‘premature
labor’ OR ‘birth outcomes’ OR ‘birth outcome’ OR ‘preg-
nancy outcomes’ OR ‘pregnancy outcome’) AND (‘case-
control’ OR retrospective OR cohort OR cohorts OR
prospective OR longitudinal OR ‘follow-up’ OR ‘cross-sec-
tional’ OR trial OR ‘relative risk’ OR ‘hazard ratio’ OR
‘odds ratio’ OR odds OR regression). We also searched the
ª 2017 Royal College of Obstetricians and Gynaecologists
Physical activity and preterm birth: a meta-analysis
reference lists of previous reviews of the subject and of the
studies included in the analysis for any further studies. DA
conducted the initial screening of all the records, and DA
and SS conducted the screening of the potentially relevant
records in duplicate. Any discrepancies between the review-
ers were resolved by discussion.
Study selection, and assessment of study quality
and risk of bias
To be included, the study had to have a prospective cohort,
case-cohort, nested case-control (within a cohort) or ran-
domized study design, and to investigate the association
between physical activity and risk of preterm birth and be
published in English language. Abstracts, grey literature
and unpublished studies were not included. Estimates of
the relative risk (RR; hazard ratio, risk ratio, odds ratio)
had to be available with the 95% confidence intervals
(CIs), and for the dose–response analysis, a quantitative
measure of activity level and the total number of cases and
person-years or participants had to be available in the pub-
lication or on request from the authors. For cohort studies
we included only studies that provided risk estimates that
were adjusted for at least one confounder, while we included
all randomized trials as they are considered adjusted due to
the randomization process. We calculated the RRs and 95%
CIs for the randomized trials based on the distribution of
cases and non-cases when risk estimates were not provided in
the paper using standard formula66 We included studies on
total and all subtypes of leisure-time physical activity, but for
occupational activity we only included studies of total occu-
pational activity and walking. Studies of physically demand-
ing work, such as prolonged standing, heavy lifting, physical
exertion, occupational fatigue and demanding posture, were
excluded as they have been summarized in a recent meta-ana-
lysis.67 A list of excluded studies and the reason for exclusion
is provided in Table S1.
Data extraction
The following data were extracted from each study in
duplicate by DA and SS: the first author’s last name, publi-
cation year, country where the study was conducted, the
study name, follow-up period, sample size, gender, age,
number of cases, exposure, physical activity level, RRs and
95% CIs for each physical activity level and variables
adjusted for in the analysis.
Risk of bias and study quality assessment
We used the Cochrane Collaboration’s tool to assess the
risk of bias of the randomized trials.68 The risk of bias
assessment was based on random sequence generation, allo-
cation concealment, blinding of participants and personnel,
blinding of outcome assessment, incomplete outcome data,
selective reporting and other biases. The quality of the
1817
 Aune et al.
cohort studies was assessed using the Newcastle-Ottawa
scale,69 which ranks studies based on the selection (repre-
sentativeness of the exposed cohort, selection of the non-
exposed cohort, ascertainment of exposure, demonstration
that the outcome was not present at the start of the study),
comparability (adjustment for confounding factors) and
the outcome (outcome assessment, long enough follow-up,
adequacy of follow-up of cohorts).
Statistical methods
We used random effects models70 to calculate summary RRs
and 95% CIs for the highest versus the lowest level of physi-
cal activity, and for the dose–response analysis. The average
of the natural logarithm of the RRs was estimated, and the
RR from each study was weighted by the inverse of its vari-
ance and was then unweighted by a variance component that
corresponds to the amount of heterogeneity in the analysis.
A two-tailed P < 0.05 was considered statistically significant.
We used the method described by Greenland and Long-
necker71 for the linear dose–response analysis, and computed
study-specific slopes (linear trends) and 95% CIs from the
natural logs of the RRs and CIs across categories of physical
activity. The method requires that the distribution of cases
and person-years or non-cases and the RRs with the variance
estimates for at least three quantitative exposure categories
are known. We estimated the distribution of cases or person-
years in studies that did not report these, but reported the
total number of cases/person-years.72 The median or mean
physical activity level in each category was assigned to the
corresponding RR for each study. For studies that reported
the physical activity by ranges of activity, we estimated the
midpoint for each category by calculating the average of the
lower and upper bound. When the highest or lowest category
was open-ended, we assumed the open-ended interval length
to be the same as the adjacent interval. We examined a
potential nonlinear dose–response relationship between
physical activity and preterm birth by using restricted cubic
splines with 3 knots at 10%, 50% and 90% percentiles of the
distribution, which was combined using multivariate meta-
analysis.73,74 A P-value for nonlinearity was obtained by test-
ing that the coefficient of the second spline term was equal to
zero.75
Heterogeneity between studies was assessed by the Q-test
and I2.76 A P-value for the Q-test < 0.05 indicated statisti-
cally significant heterogeneity. I2 is the amount of total vari-
ation that is explained by between-study variation. I2 values
of approximately 25%, 50% and 75% are considered to
indicate low, moderate and high heterogeneity, respectively.
Sources of heterogeneity were explored in subgroup analyses
stratified by study design, geographic location, study quality
(cohorts), risk of bias (randomized trials), number of cases
as an indicator of study size, and adjustment for confound-
ing factors [including age, education, income, drug use,
1818
smoking, alcohol, parity, hypertension, diabetes and body
mass index (BMI)], and meta-regression analyses were used
to test for heterogeneity between subgroups.
Publication bias was assessed with Egger’s test,77 and the
results were considered to indicate publication bias when
P < 0.10. We conducted sensitivity analyses excluding one
study at a time to ensure that the results were not simply
due to one large study or a study with an extreme result.
The statistical analyses were conducted using Stata, version
13.0 software (StataCorp, College Station, TX, USA).
Results
Out of a total of 2053 records identified by the search, 41
studies (43 publications) were included in the meta-analysis
of physical activity and preterm birth, including 20 ran-
domized trials,13–21,23–31,64,65 and 21 cohort studies (23
publications; Figure 1; Tables S2 and S3).32–54 Thirteen
studies were from Europe, 15 studies were from North
America, five from South America, four from Asia, and
four from Australia and New Zealand (Tables S2 and S3).
The definition of preterm birth was consistent across stud-
ies (<37 weeks; Tables S2 and S3).
2053 records identified in total:
715 records identified in the PubMed database
889 records identified in the Embase database
447 records identified in the Ovid database
2 records identified from other searches
1870 excluded based on
information in title or abstract
183 given detailed assessment
142 studies excluded
48 not relevant data,
outcome or exposure
15 abstracts
14 case-control studies
10 reviews
9 protocols
9 combined diet and
activity interventions
7 no risk estimates
7 not relevant activity
6 meta-analyses
4 duplicates
4 cross-sectional studies
3 yoga/stretching
3 unadjusted risk estimates
3 comment
41 studies included (43 publications)
20 randomized trials (20 publications)
21 cohort studies (23 publications)
Figure 1. Flow-chart of study selection.
ª 2017 Royal College of Obstetricians and Gynaecologists

Leisure-time physical activity before pregnancy
Five cohort studies 36,41,46,47,78
were included in the analysis
of pre-pregnancy leisure-time physical activity and the risk
of preterm birth including 633 cases and 12 723 partici-
pants. The summary RR for high versus low pre-pregnancy
physical activity was 0.87 (95% CI: 0.70–1.06, I2 = 16.5%,
Pheterogeneity = 0.31, n = 5; Figure 2A). Because of differ-
ences in the way the data were reported, it was not possible
to conduct dose–response analyses.
Leisure-time physical activity during pregnancy
Twenty randomized trials13–20,23–31,64,65,79 and 10 cohort
studies33,34,37–39,41,42,44,45,47 were included in the analysis of
leisure-time physical activity during pregnancy and the risk
of preterm birth, and included >8621 cases among 171 595
participants. The summary RR for high versus low physical
activity in early pregnancy was 0.86 (95% CI: 0.78–0.95,
I2 = 28%, Pheterogeneity = 0.12; Figure 3). The summary RR
was significant for cohort studies (summary RR = 0.84,
95% CI: 0.73–0.96, I2 = 21.7%, Pheterogeneity = 0.24), but
not for randomized clinical trials (summary RR = 0.91,
95% CI: 0.72–1.15, I2 = 0%, Pheterogeneity = 0.76); however,
there was no between-subgroup heterogeneity, P = 0.61.
There was no evidence of publication bias with Egger’s test,
P = 0.89 and Begg’s test, P = 0.63 (Figure S1). The sum-
mary RR ranged from 0.84 (95% CI: 0.75–0.94) when the
study by Bird et al.47 was excluded to 0.87 (95% CI:
0.79–0.97) when the study by Mishra et al.80 was excluded
(Figure S2). Five studies38,41,42,45,81 were included in the
dose–response analysis, and the summary RR was 0.90
(95% CI: 0.85–0.95, I2 = 0%, Pheterogeneity = 0.67) per
3 hours per week increase in leisure-time activity
(Figure 2B), and 0.84 (95% CI: 0.76–0.91, I2 = 0%,
Pheterogeneity = 0.67) for a 5 hours per week increase in lei-
sure-time activity during pregnancy. There was evidence of
a nonlinear association between physical activity during
pregnancy and preterm birth, Pnonlinearity < 0.0001, with a
reduction in risk up to 2–4 hours per week of activity, but
no further reductions in risk with higher levels of activity
(Figure 2C; Table S4).
Moderate physical activity during pregnancy
Two cohort studies39,44 were included in the analysis of
moderate physical activity during pregnancy and preterm
birth, and included 349 cases and 6581 participants. The
summary RR for high versus low moderate intensity physi-
cal activity was 0.64 (95% CI: 0.22–1.83, I2 = 79.4%,
Pheterogeneity = 0.03; Figure 4A).
Vigorous physical activity during pregnancy
Two cohort studies35,41 were included in the analysis of vigor-
ous physical activity during pregnancy and preterm birth, and
included 301 cases and 3346 participants. The summary RR
ª 2017 Royal College of Obstetricians and Gynaecologists
Physical activity and preterm birth: a meta-analysis
for high versus low vigorous intensity activity was 0.36 (95%
CI: 0.04–3.09, I2 = 66.6%, Pheterogeneity = 0.08; Figure 4B).
Total physical activity during pregnancy
Four cohort studies32,41,54,82 were included in the analysis
of total physical activity (including leisure-time and occu-
pational physical activity) during pregnancy and preterm
birth, and included >466 cases and 7519 participants. The
summary RR for high versus low total physical activity was
0.95 (95% CI: 0.63–1.42, I2 = 56.8%, Pheterogeneity = 0.07;
Figure 4C).
Occupational physical activity during pregnancy
Two cohort studies41,48 were included in the analysis of
occupational physical activity and preterm birth, and
included 349 cases and 6581 participants. The summary RR
for high versus low occupational activity was RR = 0.67
(95% CI: 0.33–1.34, I2 = 0%, Pheterogeneity = 0.82; Fig-
ure 4D).
Walking during pregnancy
Five cohort studies34,39,44,49,51 and two randomized tri-
als64,65 were included in the analysis of walking during
pregnancy and preterm birth, and included 1065 cases and
26 903 participants. The summary RR for high versus
low walking was 1.09 (95% CI: 0.68–1.75, I2 = 72.3%,
Pheterogeneity < 0.0001; Figure 4E).
Bicycling during pregnancy
Five randomized trials19,23,26,28,31 and one cohort study40
investigated the association between bicycling during preg-
nancy and the risk of preterm birth, and included 3706
cases and 74 682 participants. The summary RR for high
versus low bicycling was 0.84 (95% CI: 0.69–1.04, I2 = 0%,
Pheterogeneity = 0.44; Figure 4F).
Subgroup, sensitivity and meta-regression analyses
In subgroup and meta-regression analyses, we found no
significant heterogeneity between subgroups when studies
were stratified by study type, geographic location, number
of cases, physical activity assessment, risk of bias (random-
ized controlled trials), study quality (cohorts) or adjust-
ment for confounding factors, including age, education,
income, drug use, smoking, alcohol, parity, hypertension,
diabetes or BMI (Table S5). In general, there was low or
moderate heterogeneity in most of the subgroup analyses.
The inverse association between physical activity and pre-
term birth was significant only among the cohort studies
with a high study quality, although there was no between-
subgroup heterogeneity (Table S5). The risk of bias assess-
ment showed that eight studies had low, eight studies had
unclear and four studies had high risk of bias (Table S6).
The mean (median) study quality score for the modified
1819
 Aune et al.

A
Leisure-time physical activity before pregnancy and preterm birth,
high vs. low analysis
Relative Risk
Study (95% CI)

Bird, 2016 0.99 ( 0.79, 1.24)

Vamos, 2015 0.55 ( 0.33, 0.91)

Jukic, 2012 0.60 ( 0.10, 2.80)

Orr, 2006 0.95 ( 0.62, 1.46)

Haas, 2005 0.81 ( 0.52, 1.27)

Overall 0.87 ( 0.70, 1.06)

.2 .5 .75 1 1.5 2 3
Relative Risk

B
Leisure-time physical activity during pregnancy and preterm birth,
per 3 hours per weekt
Relative Risk
Study (95% CI)

Tinloy, 2014 1.11 ( 0.69, 1.77)

Jukic, 2012 0.97 ( 0.76, 1.24)

Owe, 2012 0.90 ( 0.84, 0.98)

Hegaard, 2008 0.71 ( 0.45, 1.13)

Juhl, 2008 0.88 ( 0.81, 0.96)

Overall 0.90 ( 0.85, 0.95)

.2 .5 .75 1 1.5 2 3
Relative Risk

C
Leisure- time physical activity during pregnancy and preterm birth,
nonlinear dose-response analysis

1.0

0.8
RR

0.6
0 1 2 3 4 5 6 7
Physical activity during pregnancy (hours/wk)
Best fitting cubic spline
95% confidence interval

Figure 2. Leisure-time physical activity before and during pregnancy and preterm birth.

1820 ª 2017 Royal College of Obstetricians and Gynaecologists

 Physical activity and preterm birth: a meta-analysis

Relative Risk
Study (95% CI)
Randomized controlled trials
Wang, 2017 0.60 ( 0.14, 2.57)
Barakat, 2016 0.76 ( 0.46, 1.28)
Garnæs, 2016 0.98 ( 0.14, 6.80)
Seneviratne, 2016 2.30 ( 0.20, 29.60)
Taniguchi, 2016 0.19 ( 0.02, 2.10)
Halse, 2015 1.50 ( 0.33, 7.00)
Nobles, 2015 1.03 ( 0.47, 2.25)
Barakat, 2014 0.55 ( 0.21, 1.39)
Barakat, 2014 0.87 ( 0.24, 3.10)
Ghodsi, 2014 3.00 ( 0.45, 20.51)
Kong, 2014 0.35 ( 0.03, 4.03)
Renault, 2014 1.32 ( 0.49, 3.57)
Salvesen, 2014 1.05 ( 0.57, 1.92)
Kasawara, 2013 0.53 ( 0.26, 1.06)
Tomic, 2013 1.57 ( 0.72, 3.47)
Price, 2012 3.34 ( 0.28, 40.27)
Haakstad, 2011 2.04 ( 0.38, 10.89)
Cavalcante, 2009 0.84 ( 0.28, 2.53)
Barakat, 2008 0.65 ( 0.13, 3.16)
Santos, 2005 1.89 ( 0.26, 14.12)
Subtotal 0.91 ( 0.72, 1.15)

Cohort studies
Bird, 2016 0.98 ( 0.76, 1.24)
Sealy-Jefferson, 2014 0.77 ( 0.44, 1.36)
Tinloy, 2014 1.12 ( 0.67, 1.86)
Jukic, 2012 0.60 ( 0.30, 1.20)
Owe, 2012 0.86 ( 0.73, 1.07)
Hegaard, 2008 0.70 ( 0.38, 1.28)
Juhl, 2008 0.81 ( 0.64, 1.04)
Orr, 2006 0.93 ( 0.63, 1.38)
Hatch, 1998 0.11 ( 0.02, 0.81)
Misra, 1998 0.51 ( 0.27, 0.95)
Subtotal 0.84 ( 0.73, 0.96)

Overall 0.86 ( 0.78, 0.95)

.01 .1 .25 .5 .75 1 1.5 2 3 5

Relative Risk

Figure 3. Leisure-time physical activity during pregnancy and preterm birth.

Newcastle-Ottawa score was 6.7 (7.0) out of eight possible
points (Table S7).
Because few studies could be included in the dose–re-
sponse analysis of leisure-time physical activity during
pregnancy and the risk of preterm birth, we conducted a
sensitivity analysis restricting the high versus low analysis
to the five studies included in the dose–response analysis to
see if these studies differed greatly from the overall result
among cohort studies. The summary RR was 0.84 (95% CI:
0.73–0.96) for these five cohort studies, which was similar
to the summary estimate 0.86 (95% CI: 0.78–0.95) for all
the cohort studies.
Discussion
Main findings
This is to our knowledge the first dose–response meta-ana-
lysis of physical activity and risk of preterm birth, and we
found that higher leisure-time physical activity during
pregnancy was associated with a statistically significant 14%
decrease in the RR of preterm birth, and for each 3 hours
per week increase in leisure-time physical activity during
pregnancy there was a 10% reduction in the RR of preterm
birth. There was evidence of a nonlinear association
between physical activity during pregnancy and preterm
birth, with the lowest risk (15–16% reduction in RR)
observed at a physical activity level of approximately 2–
4 hours per week; however, some caution is needed in the
interpretation of the nonlinear analysis as the number of
data points at higher physical activity levels was limited.
The inverse association was significant in cohort studies,
but not in the randomized controlled trials; however, there
was no heterogeneity by study design, and the small study
sizes and low number of cases may have contributed to the
lack of a significant association among the randomized tri-
als. Other measures of physical activity including leisure-

ª 2017 Royal College of Obstetricians and Gynaecologists 1821

 Aune et al.

A C E
Moderate physical activity during pregnancy and preterm birth, high vs. low analysis Total physical activity during pregnancy and preterm birth, high vs. low analysis Walking during pregnancy and preterm birth, high vs. low analysis

Relative Risk
Relative Risk Relative Risk Study (95% CI)

Study (95% CI) Randomized controlled trials

Study (95% CI) Taniguchi, 2016 0.19 ( 0.02, 2.10)
Kong, 2014 0.35 ( 0.03, 4.03)
Rego, 2016 1.35 ( 0.74, 2.49) Subtotal 0.25 ( 0.05, 1.37)

Sealy-Jefferson, 2014 1.01 ( 0.71, 1.44) Currie, 2014 1.06 ( 0.67, 1.69) Cohort studies
Sealy-Jefferson, 2014 0.64 ( 0.43, 0.94)
Hegaard, 2008 1.01 ( 0.51, 2.01)
Jukic, 2012 1.20 ( 0.50, 3.10)
Hegaard, 2008 0.34 ( 0.14, 0.85) Misra, 1998 2.18 ( 1.38, 3.20)
Henriksen, 1995 1.40 ( 0.70, 2.50)
Magann, 1996 0.62 ( 0.44, 0.87) Launer, 1990 1.33 ( 0.85, 2.08)
Overall 0.64 ( 0.22, 1.83) Subtotal 1.21 ( 0.75, 1.95)
Overall 0.95 ( 0.63, 1.42)
Overall 1.09 ( 0.68, 1.75)

.01 .1 .25 .5 .751 1.5 2 3 5 .01 .1 .25 .5 .751 1.5 2 3 5 .01 .1 .25 .5 .75 1 1.5 2 3 5
Relative Risk Relative Risk Relative Risk

B D F
Vigorous physical activity during pregnancy and preterm birth, high vs. low analysis Occupational physical activity during pregnancy and preterm birth, high vs. low analysis Bicycling during pregnancy and preterm birth, high vs. low analysis

Relative Risk
Relative Risk Relative Risk Study (95% CI)
Randomized controlled trials
Study (95% CI) Study (95% CI) Ghodzi, 2014 3.00 ( 0.45, 20.51)
Kasawara, 2013 0.53 ( 0.26, 1.06)
Wang, 2017 0.60 ( 0.14, 2.57)
Seneviratne, 2016 2.30 ( 0.20, 29.60)
Jukic, 2012 0.08 ( 0.01, 1.00) Jukic, 2012 0.60 ( 0.20, 2.00)
Halse, 2015 1.50 ( 0.33, 7.00)
Subtotal 0.83 ( 0.44, 1.58)

Evenson, 2002 0.80 ( 0.48, 1.35) Teitelman, 1990 0.71 ( 0.35, 2.04)
Cohort study
Juhl, 2010 0.86 ( 0.69, 1.08)
Subtotal 0.86 ( 0.69, 1.08)
Overall 0.36 ( 0.04, 3.09) Overall 0.67 ( 0.33, 1.34)

Overall 0.84 ( 0.69, 1.04)

.01 .1 .25 .5 .751 1.5 2 3 5 .01 .1 .25 .5 .751 1.5 2 3 5 .01 .1 .25 .5 .75 1 1.5 2 3 5

Relative Risk Relative Risk Relative Risk

Figure 4. Moderate, vigorous, total and occupational physical activity, and walking and bicycling during pregnancy and preterm birth.

time physical activity before pregnancy, and total, moderate of physical activity (up to 5–7 hours per week) in relation to
or vigorous physical activity, bicycling, walking and occu- preeclampsia,12 gestational diabetes11 and type 2 diabetes,83
pational physical activity during pregnancy showed non- and any recommendations regarding physical activity need
significant associations in the direction of reduced risk, to take into consideration overall health, not just the risk of
most likely also due to low statistical power. preterm birth.

Strengths Limitations
Our meta-analysis also has several strengths. Because we only Our meta-analysis may have some limitations that could
included cohort studies and randomized trials, the possibility have affected the results. Unmeasured or residual con-
that recall bias and selection bias explains the results is founding could have influenced the results. Higher physical
reduced. The study quality of the cohort studies was high, activity is associated with other healthy behaviours and risk
and approximately half of the randomized trials were at low factors, including lower prevalence of smoking and over-
risk of bias. Among the cohort studies the inverse association weight/obesity. However, many of the studies included in
was only significant among studies with a high study quality, this meta-analysis adjusted for known confounding factors
although there was no between-subgroup heterogeneity. We such as age, BMI, smoking, and the associations persisted
conducted dose–response analyses and found evidence of a in subgroup analyses with adjustment for these variables
dose–response relationship up to 2–4 hours per week, but and there was no evidence of between-subgroup hetero-
no further reductions in risk with higher levels of activity; geneity with meta-regression analyses. The possibility of
however, because of few data points at higher levels of physi- confounding by less established risk factors including diet
cal activity further studies are needed to clarify the dose–re- cannot be ruled out, but needs clarification in future stud-
sponse relationship at higher levels of activity. In contrast, ies. We found no evidence of publication bias with the sta-
we have previously reported further benefits of higher levels tistical tests or by inspection of the funnel plot.

1822 ª 2017 Royal College of Obstetricians and Gynaecologists


Although the result from the 20 randomized clinical trials
was not statistically significant, most of the trials were very
small (14 of the trials had <10 cases, five trials had between
17 and 39 cases, and the largest trial had 66 cases), and had
therefore too low statistical power to detect an association.
Some of them may have had a physical activity level that may
have been too low to reduce risk, and there may also be
issues with low compliance and contamination of the control
groups, which could have biased the estimates toward the
null. The percentage of withdrawals was similar in the inter-
vention and control groups in most of the clinical trials, thus
attrition bias is less likely to have affected the results.
Another limitation was that few of the studies reported
results in such a way that they could be included in dose–
response analyses (for example in three-four or more cate-
gories by hours or MET-hours per month or week), and
therefore the dose–response analyses may not have been
representative for all the studies. This problem has also
been observed in our previous meta-analyses of physical
activity and preeclampsia,12 gestational diabetes11 and type
2 diabetes,83 and point to a need for more standardized
reporting of physical activity data in epidemiological stud-
ies. Based on the nonlinear dose–response analysis, the data
suggest that 2–4 hours per week of physical activity will be
needed to reduce the risk of preterm birth by 15–16%,
although for other pregnancy complications further benefits
are observed for higher levels of activity.11,12
Because most of the morbidity and mortality associated
with preterm births occurs in infants born very premature,
a further limitation of the present study is that most of the
studies included in this meta-analysis reported results for
preterm birth overall, and did not present results according
to clinical subtype or severity. One study reported similar
inverse associations for very premature births (<33 weeks)
as for premature births (33–35 weeks),62 while another
study that found no association found no differences by
subtypes of severity.84 Any further studies could try to clar-
ify if the association differs by clinical subtypes or severity.
Interpretation
Several potential mechanisms may explain the inverse associ-
ation we observed between physical activity and preterm
birth. Physical activity is essential for weight control, and
reduces the risk of adiposity and excess gestational weight
gain,7–9 which has been associated with increased risk of pre-
term birth.5 Although the association was slightly stronger
among studies that did not adjust for BMI and reduced adi-
posity partly may explain the association, there was still a sig-
nificant 21% reduction in the RR among studies that adjusted
for BMI, suggesting a clinically relevant reduction in risk inde-
pendent of BMI. Physical activity also reduces the risk of type
2 diabetes,83 gestational diabetes11 and preeclampsia,12 obe-
sity-related conditions that have been associated with
ª 2017 Royal College of Obstetricians and Gynaecologists
Physical activity and preterm birth: a meta-analysis
increased risk of preterm birth in several studies.85–89 Physical
activity improves insulin sensitivity,90–92 and may decrease
the inflammatory response that is suggested as a risk factor
for preterm birth.93 Higher levels of tumour necrosis factor-
a (TNF-a) have been related to the onset of labour and
preterm birth,94,95 and physically active women have lower
levels of TNF-a than inactive women.96,97
Conclusion
In conclusion, these results suggest that higher physical
activity is associated with reduced risk of preterm birth.
Any additional studies should try to further clarify the
dose–response relationship, joint effects between physical
activity before and during pregnancy and risk of preterm
births, and associations between specific subtypes and
intensities of physical activity and risk of preterm birth, as
well as clinical subtypes and severity of preterm births. Fur-
ther well-designed large randomized controlled trials with a
sufficient level of activity to reduce the risk are also needed
to conclusively demonstrate an association. However, con-
sidering benefits of physical activity for the prevention of
obesity and other pregnancy outcomes, our results support
previous recommendations for pregnant women to be
active on most if not all days of the week.
Acknowledgement
The authors thank Dr Darren C. Greenwood (Biostatistics
Unit, Centre for Epidemiology and Biostatistics, University
of Leeds, Leeds, UK) for providing the Stata code for the
nonlinear dose–response analyses.
Disclosure of interest
None declared. Completed disclosure of interests form
available to view online as supporting Information.
Contribution to authorship
DA designed the project, conducted the literature search
and analyses, and wrote the first draft of the paper. SS con-
tributed to the study screening and data extraction. DA,
SS, TH, ODS, ST interpreted the data, revised the subse-
quent drafts for important intellectual content and
approved the final version of the paper to be published.
Details of ethics approval
Ethical approval was not needed as the study uses already
published data.
Funding
This project has been funded by Liaison Committee
between the Central Norway Regional Health Authority
(RHA) and the Norwegian University of Science and Tech-
nology (NTNU) and the Imperial College National Institute
1823
 Aune et al.
of Health Research (NIHR) Biomedical Research Centre
(BRC).
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Figure S1. Funnel plot of leisure-time physical activity
during pregnancy and preterm birth.
Figure S2. Influence analysis of leisure-time physical
activity during pregnancy and preterm birth.
Table S1. List of excluded studies and exclusion reason.
Table S2. Randomized controlled trials of physical activ-
ity and preterm birth risk.
Table S3. Prospective cohort studies of physical activity
and preterm birth risk.
Table S4. Leisure-time physical activity during pregnancy
and preterm birth, risk estimates from the nonlinear dose-
response analysis.
Table S5. Subgroup analyses of leisure-time physical
activity and preterm birth risk, dose-response analysis.
Table S6. Risk of bias assessments for the included ran-
domised control trials.
Table S7. Study quality (Newcastle-Ottawa scale) for
cohort studies of leisure-time physical activity during preg-
nancy and preterm birth. &
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