Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls

Interventions for congenital talipes equinovarus (clubfoot)

BACKGROUND

Congenital talipes equinovarus (CTEV), also known as clubfoot, is a common congenital orthopaedic condition characterised by an excessively turned-in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical. Different treatments might be effective at different stages: at birth (initial presentation); when initial treatment does not work (resistant presentation); when the initial treatment works but the clubfoot returns (relapse/recurrent presentation); and when there has been no early treatment (neglected presentation). This is an update of a review first published in 2010 and last updated in 2014.

OBJECTIVES

To assess the effects of any intervention for any type of CTEV in people of any age.

SEARCH METHODS

On 28 May 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, AMED and Physiotherapy Evidence Database. We also searched for ongoing trials in the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (to May 2019). We checked the references of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating interventions for CTEV, including interventions compared to other interventions, sham intervention or no intervention. Participants were people of all ages with CTEV of either one or both feet.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risks of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available. When required we attempted to obtain individual patient data (IPD) from trial authors for re-analysis. If unit-of-analysis issues were present and IPD unavailable we did not report summary data, MAIN RESULTS: We identified 21 trials with 905 participants; seven trials were newly included for this update. Fourteen trials assessed initial cases of CTEV (560 participants), four trials assessed resistant cases (181 participants) and three trials assessed cases of unknown timing (153 participants). The use of different outcome measures prevented pooling of data for meta-analysis, even when interventions and participants were comparable. All trials displayed high or unclear risks of bias in three or more domains. Twenty trials provided data. Two trials reported on the primary outcome of function using a validated scale, but the data were not suitable for inclusion because of unit-of-analysis issues, as raw data were not available for re-analysis. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials in participants at initial presentation. The Pirani score is a scale ranging from zero to six, where a higher score indicates a more severe foot. At initial presentation, one trial reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 points lower than that of the Kite group (mean difference (MD) -1.15, 95% confidence interval (CI) -1.32 to -0.98; 60 feet; low-certainty evidence). A second trial found the Ponseti technique to be superior to a traditional technique, with mean total Pirani scores of the Ponseti participants 1.50 points lower than after serial casting and Achilles tenotomy (MD -1.50, 95% CI -2.28 to -0.72; 28 participants; very low-certainty evidence). One trial found evidence that there may be no difference between casting materials in the Ponseti technique, with semi-rigid fibreglass producing average total Pirani scores 0.46 points higher than plaster of Paris at the end of serial casting (95% CI -0.07 to 0.99; 30 participants; low-certainty evidence). We found no trials in relapsed or neglected cases of CTEV. A trial in which the type of presentation was not reported showed no evidence of a difference between an accelerated Ponseti and a standard Ponseti treatment in foot alignment. At the end of serial casting, the average total Pirani score in the accelerated group was 0.31 points higher than the standard group (95% CI -0.40 to 1.02; 40 participants; low-certainty evidence). No trial assessed gait using a validated assessment. Health-related quality of life was reported in some trials but data were not available for re-analysis. There is a lack of evidence for the addition of botulinum toxin A during the Ponseti technique, different types of major foot surgery or continuous passive motion treatment following major foot surgery. Most trials did not report on adverse events. Two trials found that further serial casting was more likely to correct relapse after Ponseti treatment than after the Kite technique, which more often required major surgery (risk differences 25% and 50%). In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas), and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting.

AUTHORS' CONCLUSIONS

From the evidence available, the Ponseti technique may produce significantly better short-term foot alignment compared to the Kite technique. The certainty of evidence is too low for us to draw conclusions about the Ponseti technique compared to a traditional technique. An accelerated Ponseti technique may be as effective as a standard technique, but results are based on a single small comparative trial. When using the Ponseti technique semi-rigid fibreglass casting may be as effective as plaster of Paris. Relapse following the Kite technique more often led to major surgery compared to relapse following the Ponseti technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and the unavailability of raw data. Future RCTs should address these issues.

Maternal smoking as an independent risk factor for the development of severe retinopathy of prematurity in very preterm infants

BACKGROUND/OBJECTIVES

Retinopathy of prematurity (ROP) is a severe neonatal complication potentially leading to visual impairment and blindness. Known risk factors include preterm birth, low birth weight and respiratory support. Limited and contradictory data exist on the risk of maternal smoking during pregnancy on the development of ROP. This study aims to investigate smoking as an independent risk factor for the development of severe ROP (≥stage 3).

SUBJECTS/METHODS

This is a single centre retrospective case-control study of prospectively collected clinical data of infants born before 32 weeks of gestation between 2001 and 2012 at a tertiary care university hospital. The association between maternal smoking during pregnancy and the development of severe ROP was analyzed by multivariate logistic regression.

RESULTS

In total, n = 751 infants born < 32 weeks of gestation were included in this study. In total, 52.9% (n = 397) were diagnosed with ROP and 10.8% (n = 81) developed ROP ≥ stage 3. In total, 8.4% (n = 63) mothers presented with a history of smoking during pregnancy, which was associated to a higher rate of ROP (OR 2.59, 95% CI 1.10-6.12). Low gestational age, low birth weight and prolonged respiratory support were confirmed as independent risk factors for the development of severe ROP.

CONCLUSIONS

To date, this is the largest study evaluating the effect of maternal smoking on the development of ROP. Maternal smoking during pregnancy is identified as an independent risk factor for the development of severe ROP in preterm infants born < 32 weeks of gestation.

Influence of Second-Hand Smoke and Prenatal Tobacco Smoke Exposure on Biomarkers, Genetics and Physiological Processes in Children-An Overview in Research Insights of the Last Few Years

Children are commonly exposed to second-hand smoke (SHS) in the domestic environment or inside vehicles of smokers. Unfortunately, prenatal tobacco smoke (PTS) exposure is still common, too. SHS is hazardous to the health of smokers and non-smokers, but especially to that of children. SHS and PTS increase the risk for children to develop cancers and can trigger or worsen asthma and allergies, modulate the immune status, and is harmful to lung, heart and blood vessels. Smoking during pregnancy can cause pregnancy complications and poor birth outcomes as well as changes in the development of the foetus. Lately, some of the molecular and genetic mechanisms that cause adverse health effects in children have been identified. In this review, some of the current insights are discussed. In this regard, it has been found in children that SHS and PTS exposure is associated with changes in levels of enzymes, hormones, and expression of genes, micro RNAs, and proteins. PTS and SHS exposure are major elicitors of mechanisms of oxidative stress. Genetic predisposition can compound the health effects of PTS and SHS exposure. Epigenetic effects might influence in utero gene expression and disease susceptibility. Hence, the limitation of domestic and public exposure to SHS as well as PTS exposure has to be in the focus of policymakers and the public in order to save the health of children at an early age. Global substantial smoke-free policies, health communication campaigns, and behavioural interventions are useful and should be mandatory.

Association between generational status and smoking behaviors before and during pregnancy among Hispanic women

BACKGROUND

Evidence is limited on the risk of maternal smoking before and during pregnancy across generations of Hispanic immigrants.

PURPOSE

The aim of this study was to determine whether immigration generational status predicts maternal smoking behaviors before and during pregnancy among Hispanic women.

METHODS

Data on pregnancies in National Longitudinal Survey of Youth 1979 were used. Current study sample consists of Hispanic women (15-24 years) reporting pregnancy between 1979 and 2014 (n = 616). Data on birthplaces of the respondent and their parents were used to determine generation status. Maternal smoking behaviors before and during pregnancy were self-reported. Data were analyzed using weighted covariate-adjusted logistic regression models.

RESULTS

There were 24% first-generation, 20% second-generation, and 56% third or higher generation Hispanic women in the sample. Majority of participants were married (72%), with a high school degree or more (69%), and of Mexican origin (56%). After controlling for covariates, first generation Hispanic women had lower likelihood of smoking prior to (OR = 0.40, p = 0.009) and during pregnancy (OR = 0.35, p = 0.007) compared to third or higher generation women. The second-generation women had lower likelihood of smoking during pregnancy (OR = 0.46, p = 0.038) compared to third or higher generation women.

CONCLUSIONS

First generation Hispanic women are at lower risk of smoking both prior to and during pregnancy. Identification of cultural factors discouraging smoking during pregnancy among first/second generation Hispanic women and incorporating in smoking prevention interventions targeting Hispanic women could benefits the later generations of Hispanic immigrants.

Risk factors for gastroschisis: A case-control study in a Brazilian population

OBJECTIVE

To evaluate risk factors associated with fetal gastroschisis.

METHODS

As a secondary aim of a larger case-control study, pregnant women attending the Fetal Medicine Unit at the Department of Obstetrics and Gynecology at Hospital das Clinicas, Sao Paulo University Medical School between July 1, 2013, and July 31, 2015, were allocated into either the gastroschisis group, where the woman was carrying a fetus with gastroschisis, or the control group, where the fetus was normal. Patients in the control group were matched at study entry for maternal age, preconception body mass index and weeks of gestation. In-person interviews were conducted during pregnancy to obtain data on demographic, medical, and social characteristics; exposure to substances; pregnancy history; the presence of chronic disease, urinary tract infections (UTIs), influenza, and fever; and the occurrence of stress events between the month before the last menstrual period and the first trimester of pregnancy.

RESULTS

Of 171 women included in the study, 57 were allocated to the gastroschisis group and 114 to the control group. There were significant associations between gastroschisis and maternal UTI (P=0.011), tobacco use (P=0.001), alcohol consumption (P≤0.001), and illicit drug use (P=0.012). After analysis by standard logistic regression, the remaining significant factors were UTI, tobacco use, and alcohol consumption.

CONCLUSION

UTI and exposure to tobacco or alcohol just before conception and during early pregnancy were associated with an increase in the likelihood of fetal gastroschisis.

Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting

The aim of this review of reviews was to collate the latest evidence from systematic reviews about the maternal and child health outcomes of being exposed to tobacco and nicotine during pregnancy; the effectiveness of interventions designed to reduce these exposures, and barriers to and facilitators of smoking cessation during pregnancy. Two databases were searched to obtain systematic reviews published from 2010 to 2019. Pertinent data from 76 articles were summarized using a narrative synthesis (PROSPERO reference: CRD42018085896). Exposure to smoke or tobacco in other forms during pregnancy is associated with an increased risk of obstetric complications and adverse health outcomes for children exposed in-utero. Counselling interventions are modestly effective, while incentive-based interventions appear to substantially increase smoking cessation. Nicotine replacement therapy is effective during pregnancy but the evidence is not conclusive. Predictors and barriers to smoking cessation in pregnancy are also discussed. Smoking during pregnancy poses substantial risk to mother's and child's health. Psychosocial interventions and nicotine replacement therapy (NRT) appear to be effective in helping pregnant women quit smoking. Barriers to smoking cessation must be identified and steps taken to eradicate them in order to reduce smoking among pregnant women. More research is needed on smoking cessation medications and e-cigarettes.

Risk factors for congenital heart disease: The Baby Hearts Study, a population-based case-control study

We investigated the role of maternal environmental factors in the aetiology of congenital heart disease (CHD). A population-based case-control study (242 CHD cases, 966 controls) was conducted using an iPad questionnaire for mother with linkage to maternity and first trimester prescription records. Risk of CHD was associated with low maternal education (OR adjusted for confounders 1.59; 95% confidence interval [CI], 1.02-2.49), pregestational diabetes (OR 4.04; 95% CI 1.00-16.28), self-reported maternal clotting disorders (adjOR 8.55, 95%CI 1.51-48.44), prescriptions for the anticlotting medication enoxaparin (adjOR 3.22, 95%CI 1.01-10.22) and self-reported vaginal infections (adjOR 1.69, 95%CI 1.01-2.80). There was no strong support for the hypothesis that periconceptional folic acid supplements have a protective effect, but there was a protective effect of frequent consumption of folate rich fruits (adjOR 0.64, 95%CI 0.47-0.89). Compared to the most common pre-pregnancy dietary pattern, CHD risk was associated with a poor diet low in fruit and vegetables (adjOR 1.56, 95%CI 1.05-2.34). Mothers of cases reported more pregnancy related stress (adjOR 1.69; 95% CI 1.22-2.34) and multiple stressors (adjOR 1.94, 95%CI 0.83-4.53). We found no supportive evidence for CHD risk being associated with obesity, smoking, depression or antidepressant use in this population. Our findings add to the previous evidence base to show potential for public health approaches to help prevent CHD in future by modifying environmental factors. Independent confirmation should be sought regarding elevated CHD risk associated with maternal blood clotting disorders and their treatment, since we are the first to report this.

A Population-Based Study of Diabetes During Pregnancy in Spain (2009-2015): Trends in Incidence, Obstetric Interventions, and Pregnancy Outcomes

(1) Background: We examined trends in incidence and outcomes in women with existing type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) compared with a control group without diabetes. (2) Methods: This was an observational, retrospective epidemiological study using the National Hospital Discharge Database. (3) Results: There were 2,481,479 deliveries in Spain between 2009 and 2015 (5561 mothers with T1DM, 4391 with T2DM, and 130,980 with GDM). Incidence and maternal age of existing diabetes and GDM increased over time. Women with T2DM were more likely to have obstetric comorbidity (70.12%) than those with GDM (60.28%), T1DM (59.45%), and no diabetes (41.82%). Previous cesarean delivery, preeclampsia, smoking, hypertension, and obesity were the most prevalent risk factors in all types of diabetes. Women with T1DM had the highest rate of cesarean delivery (Risk Ratio (RR) 2.34; 95% Confidence Interval (CI) 2.26-2.43) and prolonged maternal length of stay. Labor induction was higher in T2DM (RR 1.99; 95% CI 1.89-2.10). Women with T1DM had more severe maternal morbidity (RR 1.97; 95% CI 1.70-2.29) and neonatal morbidity (preterm birth, RR 3.32; 95% CI 3.14-3.51, and fetal overgrowth, RR 8.05; 95% CI 7.41-8.75). (4) Conclusions: existing and GDM incidence has increased over time. We found differences in the prevalence of comorbidities, obstetric risk factors, and the rate of adverse obstetric outcomes among women with different types of diabetes. Pregnant women with diabetes have the highest risk of adverse pregnancy outcomes.

Disinfection By-Product Exposures and the Risk of Musculoskeletal Birth Defects

Supplemental Digital Content is available in the text.

Epidemiologic studies suggest that exposure to water disinfection by-products (DBPs) may increase the risk of certain birth defects. However, evidence for musculoskeletal defects (MSDs) is limited. Previous MSD studies have not examined DBPs beyond trihalomethanes (THMs) and have not separately examined limb or diaphragm defects which may have distinct developmental etiologies.

Association between maternal occupational exposure to polycyclic aromatic hydrocarbons and rare birth defects of the face and central nervous system

BACKGROUND

Previous studies suggested associations between maternal smoking, a source of exposure to polycyclic aromatic hydrocarbons (PAHs) and other chemicals, and central nervous system and face birth defects; however, no previous studies have evaluated maternal occupational PAH exposure itself.

METHODS

Jobs held in the periconceptional period were retrospectively assigned for occupational PAH exposures. Associations between maternal occupational PAH exposure and selected rare defects of the face (cataracts, microphthalmia, glaucoma, microtia, and choanal atresia) and central nervous system (holoprosencephaly, hydrocephaly, cerebellar hypoplasia, and Dandy-Walker malformation) were evaluated using data from the National Birth Defects Prevention Study, a population-based case-control study in the United States. Crude and adjusted odds ratios (ORs) with 95% confidence intervals were calculated to estimate associations between each evaluated defect and PAH exposure using multivariable logistic regression.

RESULTS

Food and beverage serving, as well as cooks and food preparation occupations, were among the most frequent jobs held by exposed mothers. Cataracts, microtia, microphthalmia, and holoprosencephaly were significantly associated with PAH exposure with evidence of dose-response (P-values for trend ≤.05). Hydrocephaly was associated with any PAH exposure, but not significant for trend. Sensitivity analyses that reduced possible sources of exposure misclassification tended to strengthen associations.

CONCLUSIONS

This is the first population-based case-control study to evaluate associations between maternal occupational PAH exposures and these rare birth defects of the central nervous system and face.

Sustained maternal smoking-associated changes in the physico-chemical properties of fetal RBC membranes might serve as early markers for vascular comorbidities

Maternal smoking-induced congenital heart and microvascular defects are closely associated with the impaired functioning of the in-utero feto-placental circulation system. Current groundbreaking facts revealed intimate crosstalk between circulating red blood cells (RBCs) and the vascular endothelium. Thus, RBCs have become the protagonists under varied pathological and adverse pro-oxidative cellular stress conditions. We isolated and screened fetal RBCs from the arterial cord blood of neonates, born to non-smoking (RBC-NS) and smoking mothers (RBC-S), assuming that parameters of fetal RBCs are blueprints of conditions experienced in-utero. Using atomic force microscopy and mass spectrometry-based shotgun lipidomics in the RBC-S population we revealed induced membrane stiffness, loss in intrinsic plastic activities and several abnormalities in their membrane-lipid composition, that could consequently result in perturbed hemodynamic flow movements. Altogether, these features are indicative of the outcome of neonatal microvascular complications and suggest unavailability for the potential rescue mechanism in cases of vascular endothelium impairment due to altered membrane integrity and rheological properties.

Maternal Smoking Highly Affects the Function, Membrane Integrity, and Rheological Properties in Fetal Red Blood Cells

An understanding of the basic pathophysiological mechanisms of neonatal diseases necessitates detailed knowledge about the wide range of complications in the circulating fetal RBCs. Recent publications on adult red blood cells (RBCs) provide evidence that RBCs carry an active nitric oxide synthase (NOS3) enzyme and contribute to vascular functioning and integrity via their active nitric oxide synthesis. The aim of this study was to determine the effect of maternal smoking on the phenotypical appearance and functionality of fetal RBCs, based on morphological and molecular studies. We looked for possible links between vascular dysfunction and NOS3 expression and activation and its regulation by arginase (ARG1). Significant morphological and functional differences were found between fetal RBCs isolated from the arterial cord blood of neonates born to nonsmoking (RBC-NS, n = 62) and heavy-smoking (RBC-S, n = 51) mothers. Morphological variations were quantified by Advanced Cell Classifier, microscopy-based intelligent analysis software. To investigate the relevance of the newly suggested “erythrocrine” function in fetal RBCs, we measured the levels of NOS3 and its phosphorylation in parallel with the level of ARG1, as one of the major influencers of NOS3 dimerization, by fluorescence-activated cell sorting. Fetal RBCs, even the “healthy-looking” biconcave-shaped type, exhibited impaired NOS3 activation in the RBC-S population, which was paralleled with elevated ARG1 level, thus suggesting an increased redox burden. Our molecular data indicate that maternal smoking can exert marked effects on the circulating fetal RBCs, which could have a consequence on the outcome of in utero development. We hypothesize that any endothelial dysfunction altering NO production/bioavailability can be sensed by circulating fetal RBCs. Hence, we are putting forward the idea that neonatal RBC could serve as a real-time sensor for not only monitoring RBC-linked anomalies but also predicting the overall status of the vascular microenvironment.

Parental Smoking and Under-Five Child Mortality in Southeast Asia: Evidence from Demographic and Health Surveys

Smoking remains the main cause of preventable early death. However, little is known about the association between parental smoking and child mortality in under-fives in developing countries. This study assesses the association between parental smoking status, smoking amount and smoking frequency with child mortality in under-fives in four Southeast Asian countries (Cambodia, Indonesia, Lao People’s Democratic Republic and Timor Leste). We used the Demographic and Health Survey dataset. The information from couples consisting of fathers and mothers (n = 19,301 couples) in the same household were collected. Under-five child mortality was significantly associated with paternal smoking only (odds ratio (OR) = 1.25, 95% confidence interval (CI): 1.14–1.38), maternal smoking only (OR = 2.40, 95% CI: 1.61–3.59) and both parents smoking (OR = 2.60, 2.08–3.26). Paternal, maternal, both parents’ smoking amount and frequency were also assessed. The estimated association decreased after adjusting for covariates but remained highly significant for smoking in both parents, mothers who smoked 1–10 cigarettes/day, when both parents smoked > 20 cigarettes/day, and in mothers who smoked every day. Future behavioural changes and smoking cessation programmes should engage parents as a catalyst for the reduction of child mortality risk in LMICs in the SEA region.

Risk of adverse birth outcomes after maternal varenicline use: A population-based observational study in Denmark and Sweden

PURPOSE

To examine risks of adverse birth outcomes in women exposed to varenicline during pregnancy.

METHODS

Population-based cohort study including live-born and stillborn infants from 1 May 2007 to 31 December 2012. Data from health and administrative registries in Denmark and Sweden, two Nordic countries with universal health care and routine registration of major life and health events. Infants were allocated to three cohorts on the basis of their in utero exposure: the exposed cohort consisting of infants whose mothers were dispensed varenicline during pregnancy; the unexposed cohort comprised infants unexposed to varenicline, but exposed to maternal smoking in utero; and the reference cohort of infants unexposed to varenicline and maternal smoking in utero. The primary outcome was major congenital malformations diagnosed from birth to the first year of life. Secondary outcomes included stillbirth, fetal growth restriction (measured as small for gestational age), preterm delivery, preterm premature rupture of membranes, and sudden infant death syndrome. We estimated the prevalence of the primary outcome and secondary outcomes in the exposed, unexposed, and reference cohorts. Prevalence odds ratios with 95% confidence intervals (CIs) were computed using logistic regression with propensity score adjustment to control for potential confounders.

RESULTS

The combined cohort included 885 185 infants. Of these, 335 infants were exposed, 78 412 were unexposed, and the remaining 806 438 comprised the reference cohort. Major congenital malformations were detected among 3.6% of exposed infants, 4.3% of unexposed infants, and 4.2% of infants in the reference cohort. The propensity score-adjusted prevalence odds ratio for major congenital malformations was 0.80 (95% CI, 0.45-1.42) for exposed vs unexposed infants. All analyses of primary and secondary outcomes comparing exposed with unexposed infants yielded odds ratio estimates below or close to unity. Use of varenicline during pregnancy does not appear to increase the risk of major congenital malformations or other adverse birth outcomes.

Assessing the deprivation gap in stillbirths and neonatal deaths by cause of death: a national population-based study

OBJECTIVE

To investigate socioeconomic inequalities in cause-specific stillbirth and neonatal mortality to identify key areas of focus for future intervention strategies to achieve government ambitions to reduce mortality rates.

DESIGN

Retrospective cohort study.

SETTING

England, Wales, Scotland and the UK Crown Dependencies.

PARTICIPANTS

All singleton births between 1 January 2014 and 31 December 2015 at ≥24 weeks' gestation.

MAIN OUTCOME MEASURE

Cause-specific stillbirth or neonatal death (0-27 days after birth) per 10 000 births by deprivation quintile.

RESULTS

Data on 5694 stillbirths (38.1 per 10 000 total births) and 2368 neonatal deaths (15.9 per 10 000 live births) were obtained from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). Women from the most deprived areas were 1.68 (95% CI 1.56 to 1.81) times more likely to experience a stillbirth and 1.67 (95% CI 1.48 to 1.87) times more likely to experience a neonatal death than those from the least deprived areas, equating to an excess of 690 stillbirths and 231 neonatal deaths per year associated with deprivation. Small for gestational age (SGA) unexplained antepartum stillbirth was the greatest contributor to excess stillbirths accounting for 33% of the deprivation gap in stillbirths. Congenital anomalies accounted for the majority (59%) of the deprivation gap in neonatal deaths, followed by preterm birth not SGA (24-27 weeks, 27%).

CONCLUSIONS

Cause-specific mortality rates at a national level allow identification of key areas of focus for future intervention strategies to reduce mortality. Despite a reduction in the deprivation gap for stillbirths and neonatal deaths, public health interventions should primarily focus on socioeconomic determinants of SGA stillbirth and congenital anomalies.

Smoking and pregnancy: Epigenetics and developmental origins of the metabolic syndrome

Maternal smoking causes lower birth weight, birth defects, and other adverse pregnancy outcomes. Epidemiological evidence over the past four decades has grown stronger and the adverse outcomes attributed to maternal smoking and secondhand smoke exposure have expanded. This review presents findings of latent and persistent metabolic effects in offspring of smoking mothers like those observed in studies of maternal undernutrition during pregnancy. The phenotype of offspring of smoking mothers is like that associated with maternal undernutrition. Born smaller than offspring of nonsmokers, these children have increased risk of being overweight or obese later. Plausible mechanisms include in utero hypoxia, nicotine-induced reductions in uteroplacental blood flow, placental toxicity, or toxic growth restriction from the many toxicants in tobacco smoke. Studies have reported increased risk of insulin resistance, type 2 diabetes and hypertension although the evidence here is weaker than for overweight/obesity. Altered DNA methylation has been consistently documented in smoking mothers' offspring, and these epigenetic alterations are extensive and postnatally durable. A causal link between altered DNA methylation and the phenotypic changes observed in offspring remains to be firmly established, yet the association is strong, and mediation analyses suggest a causal link. Studies examining expression patterns of affected genes during childhood development and associated health outcomes should be instructive in this regard. The adverse effects of exposure to tobacco smoke during pregnancy now clearly include permanent metabolic derangements in offspring that can adversely affect life-long health.

Impact of state tobacco control policies on birth defects

While research has demonstrated the effects of tobacco control policies on birth outcomes, there is little known about their impact on birth defects. Using 2005-2015 natality data on 26,334,854 singletons from 47 US states and District of Columbia linked to state-level cigarette taxes and smoke-free restaurant legislation, we examined the impact of tobacco control policies on birth defects by maternal race/ethnicity and education. We found that among white women with less than a high school degree, every $1.00 increase in cigarette taxes reduced prenatal smoking by 3.48 percentage points and reduced the risk of their infant having any birth defect by 0.0023 percentage points. Tax increases also reduced the risk of cyanotic heart defects, cleft palate, gastroschisis, and limb reduction. We found no evidence for associations between the enactment of smoke-free legislation, prenatal smoking and birth defects. Our findings suggest that state cigarette taxes are a population-level intervention that can help reduce prenatal smoking and the risk of birth defects.

Microtia epigenetics: An overview of review and new viewpoint

INTRODUCTION

Microtia is a congenital malformation of the external and middle ear caused by the abnormal development of the first and second zygomatic arch and the first sulcus. There is currently no consensus concerning the pathogenesis and etiology of microtia; genetic and environmental factors may play a role. Gene-based studies have focused on finding the genes that cause microtia and on gene function defects. However, no clear pathogenic genes have so far been identified. Microtia is multifactorial; gene function defects cannot completely explain its pathogenesis. In recent years, the epigenetic aspects of microtia have begun to receive attention.

CONCLUSIONS

Analysis of the existing data suggests that certain key genes and pathways may be the underlying cause of congenital microtia. However, further exploration is needed.

Maternal blood biomarkers and adverse pregnancy outcomes: a systematic review and meta-analysis

Background: Pregnancy is a vulnerable period for the mother and the infant and exposures to environmental chemicals in utero can influence neonatal morbidity and mortality. There is a momentum toward understanding and exploring the current maternal biological mechanisms specific to in utero effects, to improve birth outcomes. This study aims to examine the current understanding of the role of biomarkers that may be associated with term of pregnancy, infant birth weights and infant development in utero.Methods: Electronic searches were conducted in PubMed, Embase, OvidMD, and Scopus databases; and all relevant research articles in English were retrieved. Studies were selected if they evaluated maternal blood plasma/serum biomarkers proposed to influence adverse birth outcomes in the neonate. Data were extracted on characteristics, quality, and odds ratios from each study and meta-analysis was conducted.Results: A total of 54 studies (35 for meta-analysis), including 43,702 women, 50 plasma markers and six descriptors of birth outcomes were included in the present study. The random effect point estimates for risk of adverse birth outcomes were 1.61(95%CI: 1.39-1.85, p < 0.0001) for inflammation-related biomarkers and 1.65(95%CI: 1.22-2.25, p = 0.0013) for growth factor/hormone-related biomarkers. All subgroups of plasma markers showed significant associations with adverse birth outcomes with no apparent study bias.Conclusions: The two subsets of plasma markers identified in this study (inflammation-related and growth factor/hormone-related) may serve as potentially valuable tools in the investigation of maternal molecular mechanisms, especially select pathways underlying inflammatory and immunological mediation in terms of modulating adverse infant outcomes. Future large, prospective cohort studies are needed to validate the promising plasma biomarkers, and to examine other maternal biological matrices such as cervicovaginal fluid and urine.

Maternal smoking during pregnancy and risk of phacomatoses: results from a Swedish register-based study

Background and aim

Phacomatoses are genetic syndromes often associated with an increased risk of a variety of malignant and benign neoplasms, including nervous system tumors. Little is known about the causes of de novo occurrences of phacomatoses. Therefore, the aim of this study was to assess the association between maternal smoking during pregnancy and the occurrence of de novo phacomatoses.

Methods

All individuals born in Sweden between 1982 and 2014 with information on both biological parents were identified through the Medical Birth Register (MBR), n=3,132,056. The Swedish population-based health care registers were used to identify individuals with a phacomatosis and information on maternal smoking was extracted from the MBR. Logistic regression models were used to evaluate the effect of maternal smoking during pregnancy on the risk of phacomatoses.

Results

In the study population, we identified 2074 individuals diagnosed with a phacomatosis, among which 75% were regarded as de novo occurrence. While no effect of heavy maternal smoking (10+ cigarettes/day) was observed for de novo neurofibromatosis, an increased risk was found for other phacomatoses excluding neurofibromatosis (OR =1.51, 95% CI 1.13–2.03). Indications of an increased risk for specific phacomatosis subtypes were observed for tuberous sclerosis (OR =1.39, 95% CI 0.91–2.14) and Sturge–Weber syndrome (OR =1.86, 95% CI 0.83–4.19). No association was observed for familial phacomatoses.

Conclusion

This is the first study examining the risk of de novo phacomatoses associated with heavy maternal smoking during pregnancy. Further studies are needed to confirm the associations observed and elucidate potential biological mechanisms.

Smoking cessation in pregnancy: An update for maternity care practitioners

INTRODUCTION

This paper provides an up-to-date summary of the effects of smoking in pregnancy as well as challenges and best practices for supporting smoking cessation in maternity care settings.

METHODS

We conducted a qualitative review of published peer reviewed and grey literature.

RESULTS

There is strong evidence of the effects of maternal tobacco use and secondhand smoke exposure on adverse pregnancy outcomes. Tobacco use is the leading preventable cause of miscarriage, stillbirth and neonatal deaths, and evidence has shown that health effects extend into childhood. Women who smoke should be supported with quitting as early as possible in pregnancy and there are benefits of quitting before the 15th week of pregnancy. There are a variety of factors that are associated with tobacco use in pregnancy (socioeconomic status, nicotine addiction, unsupportive partner, stress, mental health illness etc.). Clinical-trial evidence has found counseling, when delivered in sufficient intensity, significantly increases cessation rates among pregnant women. There is evidence that the use of nicotine replacement therapy (NRT) may increase cessation rates, and, relative to continued smoking, the use of NRT is considered safer than continued smoking. The majority of women who smoke during pregnancy will require support throughout their pregnancy, delivered either by a trained maternity care provider or via referral to a specialized hospital or community quit-smoking service. The 5As (Ask, Advise, Assess, Assist, Arrange) approach is recommended for organizing screening and treatment in maternity care settings. Additionally, supporting smoking cessation in the postpartum period should also be a priority as relapse rates are high.

CONCLUSIONS

There have been several recent updates to clinical practice regarding the treatment of tobacco use in pregnancy. It is important for the latest guidance to be put into practice, in all maternity care settings, in order to decrease rates of smoking in pregnancy and improve pregnancy outcomes.

Epidemiology of limb reduction defects as registered in the Medical Birth Registry of Norway, 1970-2016: Population based study

Background

Following the Thalidomide disaster, the Medical Birth Registry of Norway (MBRN) was established in 1967, with epidemiological surveillance of congenital anomalies as one main aim. Limb reduction defects (LRD) constitute a rare and heterogeneous anomaly group, where correct registration and classification is important for surveillance and research. We aimed at reviewing and recoding LRD cases in the MBRN using the same classification system for all years, and evaluate time trends, characteristics and risk factors, 1970–2016.

Methods

After reviewing and recoding LRD cases using International Classification of Diseases (ICD), 10^th version, for all years, time trends, association with major anomalies, risk factors and infant outcomes were calculated. Generalized linear models for the binomial family with log link gave relative risks (RR) with 95% confidence intervals (CI). Classification of LRD as suggested by European surveillance of congenital anomalies (EUROCAT) was attempted.

Results

Overall LRD prevalence, 1970–2016, was 4.4 per 10 000, slightly increasing during 1970–1981, followed by relatively stable rates. There were more defects in upper than lower limbs. Defects in hands/fingers were most common, but unspecific descriptions prevented classification of LRD according to EUROCAT. A majority of cases had associated anomalies, the most common being other limb defects, followed by cardiac defects and anomalies in the nervous and digestive systems. From 1999, 26% of LRD cases were terminated, more than 90% of these had associated major anomalies. Stillbirth, neonatal and infant mortality were higher among infants with LRD, also related to associated anomalies. Pre-gestational diabetes was associated with a more than three times increased risk of offspring total LRD, while no association with maternal epilepsy was found. Taking folate/multivitamin supplements before and/or during pregnancy was associated with lower risk of offspring LRD (adjusted RR 0.7; 95% CI 0.6–0.9), while daily smoking did not significantly increase the risk.

Conclusion

The MBRN now has information on LRD coded by ICD-10 from 1970, but information is not specific enough to use other recommended classification systems. Collecting radiographic descriptions and/or more details from hospital records would improve the quality of the registry data. Taking folate supplements before/during pregnancy may reduce the risk of offspring LRD.

Estimation of the preventable proportion of congenital anomalies by selected risk factors in mothers: A case study in Iran

Background: Worldwide, 1-6 percent of infants have at least one congenital anomaly that can lead to long-term consequences. This may have significant impacts on individuals, families, health-care systems, and societies. The aim of this study was to estimate the Population Attributable Fraction (PAF) of some congenital anomalies by three selected risk factors (obesity, diabetes and smoking) in the northwest of Iran and to estimate the number of preventable defects at birth in the population if we could reduce 50 percent of the exposure rate to these three risk factors at population level. Methods: The regional data on smoking, obesity, and diabetes were entered in Population Estimate of Attributable Fraction of Congenital Conditions Everywhere (PEACE) software developed by International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR). It calculates the PAF for congenital anomalies attributed to exposure to those three risk factors. Results: This study showed that main anomalies attributed to "obesity" include Spina Bifida 40.1% (95% CI: 31.7-47.7), Hydrocephaly 26.8 (95% CI: 9.3-42.3) and Anencephaly 17.4 (95% CI: 1.6-31.9). The highest attributable defect to "smoking" was Cleft lip w/out Palate 5.8% (95% CI: 4.3-7.4), whereas for "diabetes" it was Tetralogy of Fallot 33.3 (95% CI: 17.2-49.5). A similar pattern was found when assumed in the model, the impact of 50 percent reduction in the exposure to each of the risk factors on preventable cases of birth defects in the population. Conclusion: Obesity, diabetes, and smoking in women of childbearing age increased the risk of occurrence of congenital anomalies. However, obesity and diabetes had a remarkably greater impact compared to smoking. More studies are needed to investigate the role of passive smoking as a risk factor for the occurrence of birth defects.

Shisha smoking in selected nightclubs in Nigeria

Introduction

Shisha consumption is a growing public health issue all over the globe and public health awareness about its deleterious health consequences is still not sufficiently raised.

Methods

In this location-based study of nightclubs in Ibadan, Nigeria, 633 patrons of selected nightclubs were interviewed in order to obtain information on prevalence, correlates and predictors of shisha smoking.

Results

The overall prevalence of shisha smoking was 7.1%. The age of initiation into shisha smoking was lower among women, p = 0.03, but men were significantly more likely to be more frequent users, daily or weekly users, p < 0.001 and also to be current cigarette smokers, p = 0.03. There was no significant gender variability in the stage of readiness to quit. Regression analysis showed that after adjusting for age, the predictors of shisha smoking were: cigarette smoking, OR = 4.83, 95% CI (1.49-15.70) and more than 12 years of education, OR = 7.55, 95% CI (1.88 - 30.37), while being a rural dweller was a protective factor, OR = 0.05, 95% CI (0.01-0.20).

Conclusion

Shisha smoking has emerged as a prevalent public health issue in Nigeria. There is a need for an immediate response from policy providers towards shisha smoking intervention in Nigeria.

Aim and Design of pREGnant, the Dutch Pregnancy Drug Register

Information on the safety of medication use during pregnancy and breastfeeding is scarce, yet use of medication among pregnant and breastfeeding women is widespread. The pREGnant, the Dutch Pregnancy Drug Register, was set up to obtain insight into medication use among pregnant and breastfeeding women and potential effects on maternal and fetal/infant health. The systematically documented, good quality data on medication use during pregnancy and lactation in pREGnant will be used in signal detection, epidemiologic studies and counseling of healthcare providers and patients. The register has a prospective cohort design. The population is derived from pregnant women throughout the Netherlands. Data collection started in April 2014 and enrollment of women is continuous and is characterized by a relative high proportion of women born in the Netherlands with a high education compared with the general Dutch pregnant population. Data on current pregnancy, obstetric history, maternal lifestyle, health and medication use, delivery, and infant health are collected through web-based questionnaires completed by the participating women (three times during pregnancy and three times during the infant’s first year of life). If permission is given, the self-reported data can be complemented with information retrieved from Perined, the perinatal registry of the Netherlands, and from obstetric and medical records, and/or pharmacy records. Here, we provide detailed information on the design of the pREGnant, the Dutch Pregnancy Drug Register, as well as descriptive information on characteristics of the participants so far. Currently, steps are being taken to implement the register on a large scale in the Netherlands.

Effects of nicotine exposure on murine mandibular development

Nicotine is known to affect cell proliferation and differentiation, two processes vital to proper development of the mandible. The mandible, the lower jaw in mammals and fish, plays a crucial role in craniofacial development. Malformation of the jaw can precipitate a plethora of complications including disrupting development of the upper jaw, the palate, and or impeding airway function. The purpose of this study was to test the hypothesis that in utero nicotine exposure alters the development of the murine mandible in a dose dependent manner. To test this hypothesis, wild type C57BL6 mice were used to produce in utero nicotine exposed litters by adding nicotine to the drinking water of pregnant dams at concentrations of 0 μg/ml (control), 50 μg/ml (low), 100 μg/ml (medium), 200 μg/ml (high) throughout pregnancy to birth of litters mimicking clinically relevant nicotine exposures. Resultant pups revealed no significant differences in body weight however, cephalometric investigation revealed several dimensions affected by nicotine exposure including mandibular ramus height, mandibular body height, and molar length. Histological investigation of molars revealed an increase in proliferation and a decrease in apoptosis with nicotine exposure. These results demonstrate the direct effects of nicotine on the developing mandible outside the context of tobacco use, indicating that nicotine use including tobacco alternatives, cessation methods, and electronic nicotine delivering products may disrupt normal growth and development of the craniofacial complex.

Influence of periconception smoking behavior on birth defect risk

BACKGROUND

Smoking is one of the most important modifiable risk factors for adverse maternal and neonatal outcomes. Smoking during pregnancy has been associated with fetal growth restriction, adverse pregnancy outcomes, and chronic adult diseases. Existing research has evaluated the risk of smoking on congenital defects. However, no studies have evaluated how periconception smoking affects birth defects.

OBJECTIVE

The purpose of this study was to assess the association of maternal smoking and the timing of periconception exposure with congenital birth defects.

STUDY DESIGN

This study was a population-based retrospective cohort of live births in Ohio from 2006-2015 with the use of data from birth certificates. Rates of cardiovascular, musculoskeletal, gastrointestinal, and neural tube birth defects were compared between a referent group of women who did not smoke and a group of women who smoked (1) during the preconception period of 3 months before conception only and not in the first trimester and (2) in the preconception period plus throughout the first trimester of pregnancy. Multivariate logistic regression was used to quantify the relationship between periconception smoking and the rate of birth defects after adjustment for maternal race, age, pregestational diabetes mellitus, and socioeconomic factors.

RESULTS

Of the 1,436,036 live births in the study period, 75% of mothers did not smoke during the preconception period or during pregnancy. There were 334,156 women (23.3%) who smoked during pregnancy; 6.0% of the population smoked preconception only, and 17.3% of the population smoked both during the preconception period and through the first trimester. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis. Smoking that was limited to preconception only was not associated with any other individual birth defects. However, smoking through the first trimester was associated with a statistically significant increased risk of several defects that included gastroschisis and limb reduction and a composite outcome of any defect, even after adjustment for coexisting factors.

CONCLUSION

Smoking during the period of fetal organogenesis (during the first trimester of pregnancy) is associated with increased risk of some birth defects. In this study, we provide novel data that smoking during the few months before conception, even with cessation in the first trimester, may also pose a risk for fetal malformation such as gastroschisis. These findings highlight the importance of preconception women's public health education efforts and warrant further investigation.

Prevalence of pre-gestational and gestational smoking and factors associated with smoking cessation during pregnancy, Brazil, 2011-2012

Gestational smoking is associated with various adverse maternal and fetal outcomes. Over the last three decades, despite considerable advances in tobacco control policy in Brazil, gestational smoking has caused a considerable number of fetal deaths and disabilities. The aim of this study is to estimate the prevalence of pre-gestational and gestational smoking and to identify the factors associated with smoking cessation up to the 20th gestational week.

METHODS

"Birth in Brazil" was a nationwide hospital-based study conducted from February 2011 to October 2012. Smoking prevalence and smoking cessation during pregnancy was estimated through face-to-face interviews with postpartum women during hospitalization for birth care. We performed multivariate logistic regression to verify the factors associated with smoking cessation up to the 5th month of pregnancy.

RESULTS

prevalence of pre-gestational smoking of 16.1% (CI 95% 15.3%-16.9%); prevalence of smoking any time during pregnancy of 9.6% (CI 95% 9.0%-10.3%); and prevalence of smoking cessation up to the 5th month of pregnancy of 56.7% (CI 95% 54.0%-59.4%). The factors associated with smoking cessation were residence in the North, Northeast, and Central-West of Brazil, having received at least one prenatal consultation (OR 3.51 CI 95% 1.85-6.67), more years of schooling (15 or more vs less than 7 years of schooling OR 5.54 CI 95% 2.97-10.34), living with a partner (OR 1.35 CI 95% 1.01-1.79), no children prior to the index pregnancy (OR 2.77 CI 95% 2.13-3.61), and absence of alcohol use (1.74 CI 95% 1.39-2.18) or of suspected alcohol abuse (OR 1.62 CI 95% 1.07-2.45).

CONCLUSION

The estimated smoking rate during pregnancy in Brazil is still high and is associated with factors of increased maternal social vulnerability, which may contribute to the increased occurrence of unfavorable perinatal outcomes.

Maternal Occupational Oil Mist Exposure and Birth Defects, National Birth Defects Prevention Study, 1997⁻2011

Workers in various industries can be exposed to oil mists when oil-based fluids are aerosolized during work processes. Oil mists can be inhaled or deposited on the skin. Little research exists on the reproductive effects of oil mist exposure in pregnant workers. We aimed to investigate associations between occupational oil mist exposure in early pregnancy and a spectrum of birth defects using data from 22,011 case mothers and 8140 control mothers in the National Birth Defects Prevention Study. In total, 150 mothers were rated as exposed. Manufacturing jobs, particularly apparel manufacturing, comprised the largest groups of exposed mothers. Mothers of infants with septal heart defects (odds ratio (OR): 1.8, 95% confidence interval (CI): 1.0-3.3), and especially perimembranous ventricular septal defects (OR: 2.5, CI: 1.2-5.2), were more likely to be occupationally exposed to oil mists in early pregnancy than control mothers; and their rater-estimated cumulative exposure was more likely to be higher. This was the first U.S. study evaluating associations between oil mist exposure and a broad spectrum of birth defects. Our results are consistent with previous European studies, supporting a potential association between oil-based exposures and congenital heart defects. Further research is needed to evaluate the reproductive effects of occupational oil mist exposure.

Ion Channel Contributions to Wing Development in Drosophila melanogaster

During morphogenesis, cells communicate with each other to shape tissues and organs. Several lines of recent evidence indicate that ion channels play a key role in cellular signaling and tissue morphogenesis. However, little is known about the scope of specific ion-channel types that impinge upon developmental pathways. The Drosophila melanogaster wing is an excellent model in which to address this problem as wing vein patterning is acutely sensitive to changes in developmental pathways. We conducted a screen of 180 ion channels expressed in the wing using loss-of-function mutant and RNAi lines. Here we identify 44 candidates that significantly impacted development of the Drosophila melanogaster wing. Calcium, sodium, potassium, chloride, and ligand-gated cation channels were all identified in our screen, suggesting that a wide variety of ion channel types are important for development. Ion channels belonging to the pickpocket family, the ionotropic receptor family, and the bestrophin family were highly represented among the candidates of our screen. Seven new ion channels with human orthologs that have been implicated in human channelopathies were also identified. Many of the human orthologs of the channels identified in our screen are targets of common general anesthetics, anti-seizure and anti-hypertension drugs, as well as alcohol and nicotine. Our results confirm the importance of ion channels in morphogenesis and identify a number of ion channels that will provide the basis for future studies to understand the role of ion channels in development.

Smoking and alcohol use among women in Russia: Dual risk for prenatal exposure

Alcohol consumption during pregnancy can produce adverse outcomes; maternal smoking compounds this risk. We examined prevalence of smoking and associations between smoking and alcohol use in Russian women of childbearing age (N = 648). Smoking was reported by 35% of nonpregnant and 14% of pregnant women. Smoking prevalence was higher (45%) among at-risk drinkers and those at risk for an alcohol-exposed pregnancy (AEP). In a multivariate model, smoking status and city of residence significantly predicted AEP risk. Pregnant women in urban locations were more likely to smoke. Smoking and alcohol misuse often co-occur among Russian women, presenting risk for dual prenatal exposure.

Parental smoking and the risk of congenital heart defects in offspring: An updated meta-analysis of observational studies

OBJECTIVE

Although previous reviews confirmed maternal active smoking was significantly associated with risk of fetal congenital heart defects (CHDs), association between maternal passive smoking and paternal smoking and risk of CHDs is inconclusive nowadays; furthermore, a complete overview is lacking. A meta-analysis of observational studies was conducted to assess the risk of CHDs associated with maternal active and passive smoking and paternal smoking.

METHODS

Seven electronic databases were searched for qualified research up to June 2018. We summarized study characteristics and the summary risk estimates were calculated using either the random-effect model or fixed-effect model. Sensitivity and subgroup analysis were carried out to identify the potential heterogeneity moderators.

RESULTS

One hundred and twenty-five studies involving 137,574 CHDs cases in 8,770,837 study participants were included. Overall, maternal active (risk ratio (RR) = 1.25; 95% confidence interval (CI): 1.16-1.34; p < 0.01) and passive (RR = 2.24, 95% CI: 1.81-2.77; p < 0.01) smoking as well as paternal active smoking (RR = 1.74, 95% CI: 1.48-2.06; p < 0.01) were significantly associated with CHDs risk. For specific CHD subtypes, our study showed that maternal active smoking was significantly associated with risk of atrial septal defect (RR = 1.27, 95% CI: 1.02-1.59; p = 0.03) and right ventricular outflow tract obstruction (RR = 1.43, 95% CI: 1.04-1.97; p = 0.03). Relevant heterogeneity moderators have been identified by subgroup analysis. Sensitivity analysis yielded consistent results.

CONCLUSION

Maternal active smoking, maternal passive smoking as well as paternal smoking all increased the risk of CHDs in offspring. Preventing parental smoking during peri-pregnancy is a priority for CHDs prevention.

Association between violence during pregnancy and preterm birth and low birth weight in Colombia: Analysis of the demographic and health survey

To explore the association between low birth weight and preterm birth with violence during pregnancy, we conducted a cross-sectional study by using the 2010 Colombian Demographic and Health Survey. We conducted bivariate analyses, binomial logistic regression, and stratified models by age, and 14,520 women were included. There was no association between violence and low birth weight. Nonetheless, an association with preterm birth in women aged over 35 was observed (OR 1.98, 95%CI 1.23, 3.17). Prenatal care appeared to be a protective factor for both outcomes. This research unexpectedly showed that supplementation with folic acid and iron was associated with preterm birth.

Maternal smoking early in pregnancy is associated with increased risk of short stature and obesity in adult daughters

We assessed anthropometry in 22,421 adult daughters in association with their mothers’ tobacco smoking early in pregnancy (at their first antenatal visit) in Sweden, particularly their risk of short stature and obesity. Adult daughters were grouped by maternal smoking levels during pregnancy: Non-smokers (58.5%), Light smokers (24.1%; smoked 1–9 cigarettes/day), and Heavier smokers (17.4%; smoked ≥10 cigarettes/day). Anthropometry was recorded on the adult daughters at approximately 26.0 years of age. Obesity was defined as BMI ≥30 kg/m², and short stature as height more than two standard deviations below the population mean. Daughters whose mothers were Light and Heavier smokers in early pregnancy were 0.8 cm and 1.0 cm shorter, 2.3 kg and 2.6 kg heavier, and had BMI 0.84 kg/m² and 1.15 kg/m² greater, respectively, than daughters of Non-smokers. The adjusted relative risk of short stature was 55% higher in women born to smokers, irrespectively of smoking levels. Maternal smoking had a dose-dependent association with obesity risk, with offspring of Heavier smokers 61% and of Light smokers 37% more likely to be obese than the daughters of Non-smokers. In conclusion, maternal smoking in pregnancy was associated with an increased risk of short stature and obesity in their adult daughters.

Direct Effects of Nicotine Exposure on Murine Calvaria and Calvarial Cells

Despite the link between adverse birth outcomes due to pre- and peri-natal nicotine exposure, research suggests 11% of US women continue to smoke or use alternative nicotine products throughout pregnancy. Maternal smoking has been linked to incidence of craniofacial anomalies. We hypothesized that pre-natal nicotine exposure may directly alter craniofacial development independent of the other effects of cigarette smoking. To test this hypothesis, we administered pregnant C57BL6 mice drinking water supplemented with 0, 50, 100 or 200 μg/ml nicotine throughout pregnancy. On postnatal day 15 pups were sacrificed and skulls underwent micro-computed tomography (µCT) and histological analyses. Specific nicotinic acetylcholine receptors, α3, α7, β2, β4 were identified within the calvarial growth sites (sutures) and centers (synchondroses). Exposing murine calvarial suture derived cells and isotype cells to relevant circulating nicotine levels alone and in combination with nicotinic receptor agonist and antagonists resulted in cell specific effects. Most notably, nicotine exposure increased proliferation in calvarial cells, an effect that was modified by receptor agonist and antagonist treatment. Currently it is unclear what component(s) of cigarette smoke is causative in birth defects, however these data indicate that nicotine alone is capable of disrupting growth and development of murine calvaria.

Maternal age alters offspring lifespan, fitness, and lifespan extension under caloric restriction

Maternal age has a negative effect on offspring lifespan in a range of taxa and is hypothesized to influence the evolution of aging. However, the mechanisms of maternal age effects are unknown, and it remains unclear if maternal age alters offspring response to therapeutic interventions to aging. Here, we evaluate maternal age effects on offspring lifespan, reproduction, and the response to caloric restriction, and investigate maternal investment as a source of maternal age effects using the rotifer, Brachionus manjavacas, an aquatic invertebrate. We found that offspring lifespan and fecundity decline with increasing maternal age. Caloric restriction increases lifespan in all offspring, but the magnitude of lifespan extension is greater in the offspring from older mothers. The trade-off between reproduction and lifespan extension under low food conditions expected by life history theory is observed in young-mother offspring, but not in old-mother offspring. Age-related changes in maternal resource allocation to reproduction do not drive changes in offspring fitness or plasticity under caloric restriction in B. manjavacas. Our results suggest that the declines in reproduction in old-mother offspring negate the evolutionary fitness benefits of lifespan extension under caloric restriction.

Tobacco and Alcohol Consumption Rates among Chinese Women of Reproductive Age in 2004⁻2011: Rate and Sociodemographic Influencing Factors

Background: Smoking and alcohol consumption have become major public health problems among Chinese women. In this study we explore the behavioral trends in smoking and alcohol consumption of Chinese women. We also explored the changes in the sociodemographic factors that affect the smoking and alcohol consumption behaviors of Chinese women at different reproductive stages. Methods: We used the Chinese Health and Nutrition Survey data for 2004 to 2011 to investigate the trends and influential factors of tobacco and alcohol consumption among Chinese women. Data for tobacco and alcohol consumption (consumption of beer or any other alcoholic beverage and smoking of cigarettes) were extracted using questionnaires. We applied the χ² test to examine the trends of alcohol and tobacco consumption among Chinese women over the period of 2004 to 2011. We conducted two penalized logistic regressions with age as the continuous and classification variable (18–23, 24–29, 30–44, and 45–49 years), and independent variables included residence, age, and marital status. Results: Drinking rates among Chinese women significantly changed over the period of 2004 to 2011 (p = 0.018). Age was related to tobacco consumption rates for 2009 and 2011 (p < 0.05). Marital status was associated with tobacco consumption rates for 2004, 2009, and 2011 (p < 0.05). Tobacco and alcohol consumption rates from 2004 to 2011 were positively correlated (p < 0.05). Over the period of 2004 to 2011, alcohol consumption rates were higher among women living in urban areas than those among women living in rural areas (p < 0.05). High educational attainment was related to alcohol consumption. Educational attainment levels of secondary or primary schooling and university or above were related to alcohol consumption rates for 2004 to 2011 (p < 0.05). Employed women were more likely to consume alcohol than unemployed women in 2004, 2006, and 2011 (p < 0.05). Data from 2004 to 2011 showed that tobacco and alcohol use were correlated (p < 0.05) and that women aged 45–49 years old were more likely to consume tobacco than other women (p < 0.05); Conclusions: The drinking behavior of Chinese women changed considerably over the period of 2004 to 2011. Our results provide further insight on the smoking and drinking behaviors of Chinese women at different reproductive stages and the factors that influence such behaviors. Therefore, our findings on trends and factors that influence rates of tobacco and alcohol use allow for a better understanding of the smoking and drinking behaviors of Chinese women.

Quit-smoking counselling in Dutch midwifery practices: Barriers to the implementation of national guidelines

OBJECTIVE

Although smoking during pregnancy can have severe health consequences for the (unborn) child, 9% of Dutch pregnant women smoke at any time during their pregnancy. Midwives in the Netherlands are a responsible party in the provision of quit-smoking counselling for pregnant women by means of the 7-step `V-MIS' intervention, but in practice the implementation appears to be suboptimal. The purpose of the present study was to assess the provision of quit-smoking counselling by midwives, and to clarify the nature and extent of any existing barriers and needs in the provision of quit-smoking counselling in Dutch midwifery settings.

METHODS

An online questionnaire to the target population of Dutch midwives (N ≈ 3150) was set out in the spring of 2016. The questionnaire included items on the provision of quit-smoking counselling for pregnant women, and on possible barriers and needs regarding the provision of this counselling. Descriptive statistics were used to analyse weighed data from 135 midwives representative for the Dutch setting in terms of age, function, and region.

RESULTS

Eighty-one percent of the midwives inquire about smoking profile (V-MIS step 1) but only 10% go through all the V-MIS counselling steps (i.e. up to discussing postnatal passive smoking and smoke free breastfeeding, step 7). Although 74% of the midwives regard it as their task to provide quit-smoking guidance to pregnant women, 77% perceive referral to a professional as a useful strategy (mostly to the GP; 74%). For 61% of the midwives, their clients' lack of motivation undermines the provision of quit-smoking counselling. Other hindering factors are the perceived lack of free brochures (54%), simple tools or gadgets (51%), and financial consequences for the midwife (37%) and/or the client (22%).

CONCLUSION

The smoking cessation intervention strategy currently imposed in Dutch midwifery practices (V-MIS) is being used by midwives, however its implementation may considerably benefit from strengthening skills in motivational interviewing techniques, provision of supporting materials, and structural embedding of GP referral. Based on the study's findings, practical recommendations are made to facilitate the provision of quit-smoking counselling in (international) midwifery settings.

Prevalence of behavioral risk factors of cardiovascular diseases and associated socio-economic factors among pregnant women in a rural area in Southern Nepal

BACKGROUND

Cardiovascular diseases (CVDs) have dramatically infiltrated populations living in abject poverty in Low- and Middle-income Countries (LMICs), and poor maternal and child health outcomes have been frequently reported for those with CVD risk factors. However, few studies have explored the behavioral risk factors of CVDs among pregnant women in rural settings. This study aimed at determining the prevalence and identifying the socio-economic predictors of behavioral risk factors of CVDs among pregnant women in rural area in Southern Nepal.

METHODS

A Community-based cross-sectional study was conducted in 52 clusters of Dhanusha District of Nepal in a total of 426 pregnant women in their second trimester using multistage cluster sampling method. Multivariable logistic regression model was used to assess independent associations between behavioral risk factors during pregnancy and maternal socio-economic characteristics.

RESULTS

Of the 426 study participants, 86.9, 53.9, 21.3 and 13.3%, respectively, reported insufficient fruits and vegetables consumption, insufficient physical activity, tobacco use, and harmful alcohol drinking. Socio-economic factors significantly associated with more than one behavioral risk factors in expectant mothers with a primary level education (adjusted odds ratio (AOR) 2.78; 95% Confidence Interval (CI) (1.35-5.72)), 20-34 years age group (Adjusted Odds Ratio (AOR) 0.27; 95% CI (0.13-0.56)), and those with the highest wealth index (AOR 0.36; 95% CI (0.16-0.84)).

CONCLUSION

Higher prevalence of behavioral risk factors for CVDs and their socio-economic factors prevailing among pregnant women living in rural Nepal call for immediate health promotion interventions such as community awareness and appropriate antenatal counseling.

Effects of national smoke-free legislation on the rates of preterm births and low birthweights in Taiwan

This study evaluated the effects of partial and complete island-wide smoking bans on perinatal outcomes in Taiwan. Trends were determined in the yearly prevalence rates for preterm births and low birth weight (LBW) for a 1978 to 1997 pre-ban period, a 1998 to 2008 Phase 1 partial ban period, and a 2009 to 2016 Phase 2 complete ban period. Poisson regression with a yearly time-series model was employed to determine alterations in trends in prevalence rates for preterm births and LBW. Compared with pre-ban period, the rate ratio (RR) for Phase 1 preterm births was 0.969 (95% confidence interval [CI] = 0.968-0.971) and Phase 2 0.995 (95% CI = 0.992-0.998). The Phase 1 RR LBW fell 0.4% (95% CI = 0.2%-0.5%), but Phase 2 RR rose 1.7% (95% CI = 1.4%-2.1%). Data indicated that the risk of preterm births and LBW in Taiwan was reduced significantly after implementation of the smoking ban. These findings are in agreement with growing evidence suggesting that smoke-free legislation exerted a beneficial health effect on pregnant women and their newborn infants.

Characterization of maternal plasma biomarkers associated with delivery of small and large for gestational age infants in the MIREC study cohort

Objective

Neonatal morbidity and mortality can be influenced by maternal health status. Information on maternal and fetal biomarkers of adverse health outcomes is limited. This work aims at identifying maternal biomarkers associated with low and high birth weight for gestational age groups.

Design and settings

Population-based prospective cohort study of the potential adverse health effects of exposure to environmental contaminants on pregnancy and infant health.

Methods

Third trimester maternal plasma samples (n = 1588) from a pregnancy cohort (Maternal-Infant Research on Environmental Chemicals Study, MIREC) were analyzed for changes in a target spectrum of biomarkers of vascular health (e.g., matrix metalloproteinases MMPs, vascular endothelial cell growth factor VEGF), inflammation (e.g. cellular adhesion molecules CAMs, cytokines, chemokines) by affinity-based multiplex protein array analyses. Multivariate logistic regression analyses were done to examine associations between target plasma biomarkers, maternal-infant characteristics, and birth weight outcomes assessed as small for gestational age (SGA) ≤10^th percentile and large for gestational age (LGA) ≥90^th percentile groups.

Results and outcomes

Our results revealed that maternal plasma biomarkers monocyte chemoattractant protein-1 MCP-1 (p<0.05, +ve) and VEGF (p<0.05, -ve) along with parity = 1 (p<0.01, -ve) and gestational hypertension (p<0.05, +ve) were associated with SGA births. Meanwhile, LGA was associated with maternal plasma VEGF (p<0.05, +ve) and MMP-9 (p<0.05, -ve) and gestational hypertension (p<0.01, +ve), pre-pregnancy body mass index (p<0.01, +ve), parity (p<0.05, +ve) and education (p<0.05, -ve).

Conclusions

Third trimester maternal plasma biomarkers in combination with maternal health and socioeconomic characteristics can be useful in predicting SGA and LGA outcomes. Maternal vascular health and inflammatory status may contribute to both SGA and LGA births through distinct molecular mechanisms.

Smoking during pregnancy in Finland - Trends in the MATEX cohort

Aims: In Finland, smoking rates in the general population are decreasing due to increased awareness of the adverse effects and tightened tobacco legislation. However, previous studies have shown that smoking in pregnant Finnish women remained as high as in the general Finnish female population at around 15% in 2010. Our aim was to describe temporal and spatial trends in smoking behaviour, and determinants of changes in smoking behaviour between first and second pregnancy. Methods: Self-reported smoking from the Finnish Medical Birth Register covered the years 1991-2015 (N=1,435,009). The association of maternal age and socioeconomic status with smoking rate was analysed. Spatial trends were assessed at municipality level. Results: The overall smoking rate during early pregnancy remained fairly stable at around 15% from 1991 to 2015, but increased in teenage and young women below 25 years of age. The mean smoking rate (36%) was higher in these age groups than in older pregnant women (11%). Through the study period the smoking rate remained higher in blue collar workers compared with higher socioeconomic groups. Between the first and second child, on average only 4% of women started to smoke and 41% quitted. Smoking rates developed less favourably in Eastern Finland. Conclusions: The observed increase in smoking rate during pregnancy in teenage and young women is concerning. Pregnancy is a trigger point for smoking cessation in a big fraction of pregnant women. More studies are needed to explain the opposite trends of smoking rates in Northern and Western Finland compared with Eastern Finland.