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Xing WY, Sun JN, Liu FH, Shan LS, Yin JL, Li YZ, Xu HL, Wei YF, Liu JX, Zheng WR, Zhang YY, Song XJ, Liu KX, Liu JC, Wang JY, Jia MQ, Chen X, Li XY, Liu C, Gong TT, Wu QJ. Per- and polyfluoroalkyl substances and human health outcomes: An umbrella review of systematic reviews with meta-analyses of observational studies. JOURNAL OF HAZARDOUS MATERIALS 2024; 472:134556. [PMID: 38735187 DOI: 10.1016/j.jhazmat.2024.134556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/27/2024] [Accepted: 05/04/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Although evidence on the association between per- and polyfluoroalkyl substances (PFASs) and human health outcomes has grown exponentially, specific health outcomes and their potential associations with PFASs have not been conclusively evaluated. METHODS We conducted a comprehensive search through the databases of PubMed, Embase, and Web of Science from inception to February 29, 2024, to identify systematic reviews with meta-analyses of observational studies examining the associations between the PFASs and multiple health outcomes. The quality of included studies was evaluated using the A Measurement Tool to Assess Systematic Reviews (AMSTAR) tool, and credibility of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. The protocol of this umbrella review (UR) had been registered in PROSPERO (CRD 42023480817). RESULTS The UR identified 157 meta-analyses from 29 articles. Using the AMSTAR measurement tool, all articles were categorized as of moderate-to-high quality. Based on the GRADE assessment, significant associations between specific types of PFASs and low birth weight, tetanus vaccine response, and triglyceride levels showed high certainty of evidence. Moreover, moderate certainty of evidence with statistical significance was observed between PFASs and health outcomes including lower BMI z-score in infancy, poor sperm progressive motility, and decreased risk of preterm birth as well as preeclampsia. Fifty-two (33%) associations (e.g., PFASs and gestational hypertension, cardiovascular disease, etc) presented low certainty evidence. Additionally, eighty-five (55%) associations (e.g., PFASs with infertility, lipid metabolism, etc) presented very low certainty evidence. CONCLUSION High certainty of evidence supported that certain PFASs were associated with the incidence of low birth weight, low efficiency of the tetanus vaccine, and low triglyceride levels.
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Affiliation(s)
- Wei-Yi Xing
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jia-Nan Sun
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fang-Hua Liu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Li-Shen Shan
- Department of Pediatric, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jia-Li Yin
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yi-Zi Li
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - He-Li Xu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yi-Fan Wei
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jia-Xin Liu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wen-Rui Zheng
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ying-Ying Zhang
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xin-Jian Song
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ke-Xin Liu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jia-Cheng Liu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jia-Yi Wang
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ming-Qian Jia
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xing Chen
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiao-Ying Li
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Chuan Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Ting-Ting Gong
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Qi-Jun Wu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China; Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China; Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China; Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China; NHC Key Laboratory of Advanced Reproductive Medicine and Fertility (China Medical University), National Health Commission, Shenyang, China.
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Ru H, Lee AL, Rappazzo KM, Dzierlenga M, Radke E, Bateson TF, Wright JM. Systematic review and meta-analysis of birth weight and perfluorohexane sulfonate exposures: examination of sample timing and study confidence. Occup Environ Med 2024; 81:266-276. [PMID: 38724253 DOI: 10.1136/oemed-2023-109328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/28/2024] [Indexed: 06/06/2024]
Abstract
We examined the association between mean birth weight (BW) differences and perfluorohexane sulfonate (PFHxS) exposure biomarkers.We fit a random effects model to estimate the overall pooled effect and for different strata based on biomarker sample timing and overall study confidence. We also conducted an analysis to examine the impact of a continuous measure of gestational age sample timing on the overall pooled effect.We detected a -7.9 g (95% CI -15.0 to -0.7; pQ=0.85; I2=0%) BW decrease per ln ng/mL PFHxS increase based on 27 studies. The 11 medium confidence studies (β=-10.0 g; 95% CI -21.1 to 1.1) showed larger deficits than 12 high (β=-6.8 g; 95% CI -16.3 to 2.8) and 4 low confidence studies (β=-1.5 g; 95% CI -51.6 to 48.7). 10 studies with mid-pregnancy to late-pregnancy sampling periods showed smaller deficits (β=-3.9 g; 95% CI -17.7 to 9.9) than 5 post-partum studies (β=-28.3 g; 95% CI -69.3 to 12.7) and 12 early sampling studies (β=-7.6 g; 95% CI -16.2 to 1.1). 6 of 12 studies with the earliest sampling timing showed results closer to the null.Overall, we detected a small but statistically significant BW deficit across 27 studies. We saw comparable BW deficit magnitudes in both the medium and high confidence studies as well as the early pregnancy group. Despite no definitive pattern by sample timing, larger deficits were seen in postpartum studies. We also saw results closer to the null for a subset of studies restricted to the earliest biomarker collection times. Serial pregnancy sampling, improved precision in gestational age estimates and more standardised reporting of sample variation and exposure units in future epidemiologic research may offer a greater understanding of the relationship between PFHxS on BW and any potential impact of pregnancy haemodynamics.
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Affiliation(s)
- Hongyu Ru
- Office of Research and Development, Center for Public Health and Environmental Assessment; Chemical and Pollutant Assessment Division, US Environmental Protection Agency, Research Triangle Park, North Carolina, USA
| | - Alexandra L Lee
- Office of Research and Development, Center for Public Health and Environmental Assessment; Chemical and Pollutant Assessment Division, US Environmental Protection Agency, Research Triangle Park, North Carolina, USA
| | - Kristen M Rappazzo
- Office of Research and Development, Center for Public Health and Environmental Assessment; Public Health and Environmental Systems Division, US Environmental Protection Agency, Research Triangle Park, North Carolina, USA
| | - Michael Dzierlenga
- Office of Research and Development, Center for Public Health and Environmental Assessment; Chemical and Pollutant Assessment Division, US Environmental Protection Agency, Research Triangle Park, North Carolina, USA
| | - Elizabeth Radke
- Office of Research and Development, Center for Public Health and Environmental Assessment; Chemical and Pollutant Assessment Division, US Environmental Protection Agency, Washington, District of Columbia, USA
| | - Thomas F Bateson
- Office of Research and Development, Center for Public Health and Environmental Assessment; Chemical and Pollutant Assessment Division, US Environmental Protection Agency, Washington, District of Columbia, USA
| | - J Michael Wright
- Office of Research and Development, Center for Public Health and Environmental Assessment; Chemical and Pollutant Assessment Division, US Environmental Protection Agency, Cincinnati, Ohio, USA
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Chowdhury SF, Prout N, Rivera-Núñez Z, Barrett E, Brunner J, Duberstein Z, Kannan K, Salafia CM, Shah R, Miller RK, O'Connor TG. PFAS alters placental arterial vasculature in term human placentae: A prospective pregnancy cohort study. Placenta 2024; 149:54-63. [PMID: 38518389 PMCID: PMC10997442 DOI: 10.1016/j.placenta.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION Perfluoroalkyl substances (PFAS) are synthetic chemicals used in industrial and consumer goods that are widely detected in human populations and are associated with adverse health outcomes, including perinatal health risks and child health. One mechanism of influence may be the impact of PFAS exposure on placental structure and function. OBJECTIVES The objective of this study is to investigate the relationship between maternal prenatal exposure to PFAS and measures of placental vascularization, and to assess whether changes in vascularization play a role in mediating the impact of PFAS on birth outcomes. METHODS Using data from a prospective cohort study, we examined associations between second trimester PFAS (individually and as mixtures using Bayesian kernel machine regression) and placental arterial vasculature in term placentae (N = 158); secondarily we evaluated the degree to which alterations in placental arterial vasculature explained associations between PFAS exposure and birth outcomes. Placental arterial vasculature features were collected from arterial tracings of each placental image. RESULTS In both linear regression and mixture models, natural log-transformed perfluorooctanoic acid concentrations were negatively associated with surface vasculature, indexed by the mean distance from arterial end point to perimeter (β = -0.23, 95% CI: -0.41, -0.041); additionally, maximum arterial tortuosity was negatively associated with placental weight (β = -0.19, 95% CI: -0.34, -0.051). There were no reliable differences in effect by fetal sex. DISCUSSION The findings provide some of the first evidence of PFAS exposure shaping a key measure of placental vascular function, which may underlie the impact of PFAS on perinatal and child health risks.
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Affiliation(s)
- Sadia Firoza Chowdhury
- Wynne Center for Family Research, University of Rochester, 601 Elmwood Avenue., Rochester, NY, 14642, USA; Translational Biomedical Sciences Program, University of Rochester, 601 Elmwood Avenue., Rochester, NY, 14642, USA.
| | - Nashae Prout
- Wynne Center for Family Research, University of Rochester, 601 Elmwood Avenue., Rochester, NY, 14642, USA; Toxicology Graduate Program, University of Rochester, 601 Elmwood Avenue., Rochester, NY, 14642, USA.
| | - Zorimar Rivera-Núñez
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, 08854, USA; Environmental and Occupational Health Sciences Institute, Rutgers University, 170 Frelinghuysen Rd., Piscataway, NJ, 08854, USA.
| | - Emily Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, 08854, USA; Environmental and Occupational Health Sciences Institute, Rutgers University, 170 Frelinghuysen Rd., Piscataway, NJ, 08854, USA; Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, USA.
| | - Jessica Brunner
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, USA.
| | - Zoe Duberstein
- Wynne Center for Family Research, University of Rochester, 601 Elmwood Avenue., Rochester, NY, 14642, USA; Psychology, University of Rochester, Meliora Hall, P.O. Box 270266, Rochester, NY, 14627, USA.
| | - Kurunthachalam Kannan
- Department of Pediatrics and Department of Environmental Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA.
| | - Carolyn M Salafia
- Placental Analytics LLC, 187 Overlook Circle, New Rochelle, NY, 10804, USA; Institute for Basic Research, 1550 Forest Hill Road, Staten Island, NY 10314, USA; New York Presbyterian- Brooklyn Methodist Hospital, 550 6th Street, Brooklyn, NY, 11215, USA; Queens Hospital Center, 82-68 164th Street, Queens, New York, 11432, USA.
| | - Ruchit Shah
- Placental Analytics LLC, 187 Overlook Circle, New Rochelle, NY, 10804, USA.
| | - Richard K Miller
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, USA.
| | - Thomas G O'Connor
- Wynne Center for Family Research, University of Rochester, 601 Elmwood Avenue., Rochester, NY, 14642, USA; Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, USA; Psychology, University of Rochester, Meliora Hall, P.O. Box 270266, Rochester, NY, 14627, USA; Department of Psychiatry, University of Rochester, 300 Crittenden Blvd., Rochester, NY, 14642, USA; Department of Neuroscience, University of Rochester, 601 Elmwood Avenue., Rochester, NY, 14642, USA.
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Liu B, Lu X, Jiang A, Lv Y, Zhang H, Xu B. Influence of maternal endocrine disrupting chemicals exposure on adverse pregnancy outcomes: A systematic review and meta-analysis. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2024; 270:115851. [PMID: 38157800 DOI: 10.1016/j.ecoenv.2023.115851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
Maternal endocrine disrupting chemicals (EDCs) exposure, the common environmental pollutants, was capable of involving in adverse pregnancy outcomes. However, the evidence of their connection is not consistent. Our goal was to comprehensively explore the risk of EDCs related to adverse pregnancy outcomes. One hundred and one studies were included from two databases before 2023 to explore the association between EDCs and adverse pregnancy outcomes including miscarriage, small for gestational age (SGA), low birth weight (LBW) and preterm birth (PTB). We found that maternal PFASs exposure was positively correlated with PTB (OR:1.13, 95% CI:1.04-1.23), SGA (OR:1.10, 95% CI:1.04-1.16) and miscarriage (OR:1.09, 95% CI:1.00-1.19). The pooled estimates also showed maternal PAEs exposure was linked with PTB (OR:1.16, 95% CI:1.11-1.21), SGA (OR:1.20, 95% CI:1.07-1.35) and miscarriage (OR:1.55, 95% CI:1.33-1.81). In addition, maternal exposure to some specific class of EDCs including PFOS, MBP, MEHP, DEHP, and BPA was associated with PTB. Maternal exposure to PFOS, PFOA, PFHpA was associated with SGA. Maternal exposure to BPA was associated with LBW. Maternal exposure to MMP, MEHP, MEHHP, MEOHP, BPA was associated with miscarriage. Maternal PFASs, PAEs and BPA exposure may increase adverse pregnancy outcomes risk according to our study. However, the limited number of studies on dose-response hampered further explanation for causal association.
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Affiliation(s)
- Bin Liu
- Department of Orthopaedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China; Department of Medical Aspects of Specific Environments, School of Basic Medicine, Anhui Medical University, Hefei, China
| | - Xiaoling Lu
- Department of Orthopaedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China; Department of Medical Aspects of Specific Environments, School of Basic Medicine, Anhui Medical University, Hefei, China
| | - Antong Jiang
- Department of Medical Aspects of Specific Environments, School of Basic Medicine, Anhui Medical University, Hefei, China
| | - Yanming Lv
- Department of Toxicology, School of Public Health, Harbin Medical University, Harbin, China
| | - Hongmei Zhang
- Department of Toxicology, School of Public Health, Harbin Medical University, Harbin, China
| | - Bin Xu
- Department of Orthopaedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China; Department of Medical Aspects of Specific Environments, School of Basic Medicine, Anhui Medical University, Hefei, China.
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Pan D, Song Y, Liu S, Zeng X, Pang Q, Zhang Y, Wu H, Tan HJJ, Liao Q, Liang J, Huang D, Qiu X. Association between perfluoroalkyl and polyfluoroalkyl substances exposure and fetal overgrowth: A prospective birth cohort study conducted in China. ENVIRONMENTAL RESEARCH 2023:116175. [PMID: 37257750 DOI: 10.1016/j.envres.2023.116175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Prenatal exposure to perfluoroalkyl and polyfluoroalkyl substances (PFASs) has been associated with gestational diabetes mellitus, obesity or overweight in childhood, but data on fetal overgrowth outcomes including macrosomia and large for gestational age (LGA) and among gestational age diverse infants remain scarce. OBJECTIVE To evaluate the association between maternal PFASs exposure and macrosomia and LGA, with exploration of the interaction between PFASs exposure and gestational age on fetal overgrowth. METHODS A total of 1441 mother-infants pairs from Guangxi Zhuang Birth Cohort of China were analyzed. Nine PFASs were measured in maternal serum using ultra-high liquid performance chromatographytandem mass spectrometry. Multivaraible logistical regression and generalized additive models were performed for individual PFAS exposures, piecewise regression analysis was used to estimate the breakpoint values for the non-linear dose-response relationships. Bayesian Kernel Machine Regression was performed for PFASs mixture. RESULTS In single pollutant models, maternal PFDA and PFOA exposure showed U-shaped relationship with macrosomia and LGA. When PFDA concentration exceeded 0.32 ng/mL was significantly positively associated with risks of LGA and macrosomia (OR=4.66, 95%CI: 1.26, 17.17; OR=14.43, 95%CI: 2.64, 79.02; respectively), while a negatively association was observed when level below 0.32 ng/mL. When PFOA concentration exceeded 1.20 ng/mL was significantly associated with increased risk of macrosomia (OR=7.75, 95%CI: 1.36, 44.06). In mixed exposure models, mixture of PFASs was positively associated with macrosomia, as well as associated with LGA when all the PFASs were at their 30th percentile or below. The maximum risk of LGA was reached when concentrations of PFUnA, PFDA, or PFBS were at the highest concentrations and the gestational age at the minimum of this study. CONCLUSIONS Maternal exposure to PFDA, PFOA and PFASs mixture were non-monotonically associated with macrosomia and LGA, the direction of the associations depends on the level of exposure.
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Affiliation(s)
- Dongxiang Pan
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Yanye Song
- The Third Affiliated Hospital of Guangxi Medical University, Nanning, 530031, Guangxi, China
| | - Shun Liu
- Department of Child and Adolescent Health & Maternal and Child Health, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Xiaoyun Zeng
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Qiang Pang
- Department of Cardiology, Debao Maternal and Child Health Hospital, Debao, 533700, Guangxi, China
| | - Yuanxiao Zhang
- Obstetrical Department, Pingguo Maternal and Child Health Hospital, Pingguo, 531400, Guangxi, China
| | - Huiping Wu
- Obstetrical Department, Jingxi People's Hospital, Jingxi, 533800, Guangxi, China
| | - Hui Juan Jennifer Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore
| | - Qian Liao
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Jun Liang
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Dongping Huang
- Department of Sanitary Chemistry, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China.
| | - Xiaoqiang Qiu
- Department of Epidemiology and Health Statistics, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China.
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