Birth Outcomes in a Prospective Pregnancy-Birth Cohort Study of Environmental Risk Factors in Kuwait: The TRACER Study

Adherence to the Mediterranean diet during pregnancy is associated with lower odds of excessive gestational weight gain and postpartum weight retention: results of the Mother-Infant Study Cohort

During the first 1000 d of life, gestational weight gain (GWG) and postpartum weight retention (PPWR) are considered critical determinants of nutritional status. This study examined the effect of adherence to the Mediterranean diet (MD) during pregnancy on GWG and PPWR at 2 and 6 months among women in the United Arab Emirates (UAE), using data from the Mother-Infant Study Cohort. The latter is a prospective study, for which pregnant women were recruited (n 243) during their third trimester and were followed up for 18 months. Data on socio-demographic characteristics and anthropometric measurements were obtained. An eighty-six-item FFQ was used to examine dietary intake during pregnancy. Adherence to the MD was assessed using the alternate MD (aMED) and the Lebanese MD (LMD). Adherence to the MD, PPWR2 (2 months) and PPWR6 (6 months) were considered high if participants belonged to the third tertile of the respective measures. Results indicated that 57·5 % of participants had excessive GWG while 50·7 % and 45 % retained ≥ 5 kg at 2 and 6 months postpartum, respectively. After adjustment, adherence to both MD scores was associated with lower odds of excessive GWG (aMED, OR:0·41, 95 % CI:0·18, 0·93; LMD, OR:0·40, 95 % CI: 0·16, 0·98). Adherence to MD was also associated with PPWR2 (aMED: OR: 0·23, 95 % CI: 0·06, 0·88) and PPWR6 (aMED OR:0·26; 95 % CI:0·08-0·86; LMD, OR:0·32; 95 % CI: 0·1, 0·98). The findings of this study showed that adherence to the MD may reduce GWG and PPWR and, hence, underscored the importance of promoting the MD for better health of the mother and infant.

Socioeconomic Risk Factors for Preterm Birth in the state of Qatar: A Population-based Study

Objectives:

To review the demographics and socioeconomic determinants of preterm birth (PTB) compared to term births among the Qatari population.

Methods:

This was a retrospective data analysis of 59,308 births. Data were retrieved from a Population-based Cohort Study. Data were gathered from the PEARL-Peristat maternal newborn registry for 2011, 2012, 2017, and 2018. We compared the preterm births group (delivery < 37 weeks) with the term group (delivery ≥ 37 weeks) regarding socioeconomic factors, including maternal nationality, religion, level of education, mother’s occupation, family income, housing, consanguinity, early childbearing, high-risk pregnancy, smoking, assisted conception, antenatal care, and place of delivery.

Results:

The prevalence of preterm birth was 9%. There were more Saudi nations in the preterm group compared to term (33% vs. 28%, p-value < 0.001). There were more preterm births than term births among working mothers (40% vs. 35%), high-risk pregnancies (24% vs. 18%), those that has used assisted conception (18% vs. 3%), those without antenatal care (11% vs. 5.6%), and those delivered in a tertiary women hospital (88.5% vs. 84.5%) (all p-values < 0.001). There were more women living in villas (41% vs. 38%, p = 0.01) and more smokers (0.8% vs. 0.5%, p = 0.030) in the preterm group than in the term group. There were no differences between the two groups regarding religion, level of maternal education, family income, and early childbearing.

Conclusion:

In our population, we identified several factors associated with preterm births. (www.actabiomedica.it)

Antenatal depressive symptoms and adverse perinatal outcomes

Background

The association of antenatal depression with adverse pregnancy, birth, and postnatal outcomes has been an item of scientific interest over the last decades. However, the evidence that exists is controversial or limited. We previously found that one in five women in Kuwait experience antenatal depressive symptoms. Therefore, the aim of this study was to examine whether antenatal depressive symptoms are associated with preterm birth (PTB), small for gestational age (SGA), or large for gestational age (LGA) babies in this population.

Methods

This was a secondary analysis based on data collected in the Transgenerational Assessment of Children’s Environmental Risk (TRACER) Study that was conducted in Kuwait. Logistic regression analysis was used to examine whether antenatal depressive symptoms assessed using the Edinburgh Depression Scale (EDS) were associated with preterm birth, small for gestational age, and large for gestational age babies.

Results

A total of 1694 women had complete information about the outcomes of interest. Women with depressive symptoms in pregnancy had increased, albeit non-significant, odds of having PTB (OR = 1.41; 95%CI: 0.81, 2.45), SGA babies (OR = 1.26; 0.80, 1.98), or LGA babies (OR = 1.27; 0.90, 1.79). Antenatal depressive symptoms had similar increased odds for the three outcomes even after adjusting for several covariates though none of these reached statistical significance.

Conclusions

In the present study, the depressive symptoms in pregnancy did not predict adverse birth outcomes, such as PTB, SGA, and LGA, which adds to the currently non-conclusive literature. However, further research is needed to examine these associations, as the available evidence is quite limited.

Factors associated with small- and large-for-gestational-age in socioeconomically vulnerable individuals in the 100 Million Brazilian Cohort

BACKGROUND

Evidence points to diverse risk factors associated with small- (SGA) and large-for-gestational-age (LGA) births. A more comprehensive understanding of these factors is imperative, especially in vulnerable populations.

OBJECTIVES

To estimate the occurrence of and sociodemographic factors associated with SGA and LGA births in poor and extremely poor populations of Brazil.

METHODS

The study population consisted of women of reproductive age (14-49 y), whose last child was born between 2012 and 2015. INTERGROWTH 21st consortium criteria were used to classify weight for gestational age according to sex. Multinomial logistic regression modeling was performed to investigate associations of interest.

RESULTS

Of 5,521,517 live births analyzed, SGA and LGA corresponded to 7.8% and 17.1%, respectively. Multivariate analysis revealed greater odds of SGA in children born to women who self-reported as black (OR: 1.21; 95% CI: 1.19, 1.22), mixed-race (parda) (OR: 1.08; 95% CI: 1.07, 1.09), or indigenous (OR: 1.11; 95% CI: 1.06, 1.15), were unmarried (OR: 1.08; 95% CI: 1.07, 1.08), illiterate (OR: 1.47; 95% CI: 1.42, 1.52), did not receive prenatal care (OR: 1.57; 95% CI: 1.53, 1.60), or were aged 14-20 y (OR: 1.21; 95% CI: 1.20, 1.22) or 35-49 y (OR: 1.12; 95% CI: 1.10, 1.13). Considering LGA children, higher odds were found in infants born to women living in households with ≥3 inadequate housing conditions (OR: 1.11; 95% CI: 1.10, 1.12), in indigenous women (OR: 1.22; 95% CI: 1.19, 1.25), those who had 1-3 y of schooling (OR: 1.18; 95% CI: 1.17, 1.19), 1-3 prenatal visits (OR: 1.16; CI 95%: 1.14, 1.17), or were older (OR: 1.26; 95% CI: 1.25, 1.27).

CONCLUSIONS

In poorer Brazilian populations, socioeconomic, racial, and maternal characteristics are consistently associated with the occurrence of SGA births, but remain less clearly linked to the occurrence of LGA births.

Maternal and birth cohort studies in the Gulf Cooperation Council countries: a systematic review and meta-analysis

BACKGROUND

We systematically reviewed and chronicled exposures and outcomes measured in the maternal and birth cohort studies in the Gulf Cooperation Council (GCC) countries and quantitatively summarized the weighted effect estimates between maternal obesity and (1) cesarean section (CS) and (2) fetal macrosomia.

METHODS

We searched MEDLINE-PubMed, Embase, Cochrane Library, Scopus, and Web of Science electronic databases up to 30 June 2019. We considered all maternal and birth cohort studies conducted in the six GCC countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE)). We categorized cohort studies on the basis of the exposure(s) (anthropometric, environmental, medical, maternal/reproductive, perinatal, or socioeconomic) and outcome(s) (maternal or birth) being measured. Adjusted weighted effect estimates, in the form of relative risks, between maternal obesity and CS and fetal macrosomia were generated using a random-effects model.

RESULTS

Of 3502 citations, 81 published cohort studies were included. One cohort study was in Bahrain, eight in Kuwait, seven in Qatar, six in Oman, 52 in Saudi Arabia, and seven in the UAE. Majority of the exposures studied were maternal/reproductive (65.2%) or medical (39.5%). Birth and maternal outcomes were reported in 82.7% and in 74.1% of the cohort studies, respectively. In Saudi Arabia, babies born to obese women were at a higher risk of macrosomia (adjusted relative risk (aRR), 1.15; 95% confidence interval (CI), 1.10-1.20; I2 = 50%) or cesarean section (aRR, 1.21; 95% CI, 1.15-1.26; I2 = 62.0%). Several cohort studies were only descriptive without reporting the magnitude of the effect estimate between the assessed exposures and outcomes.

CONCLUSIONS

Cohort studies in the GCC have predominantly focused on reproductive and medical exposures. Obese pregnant women are at an increased risk of undergoing CS delivery or macrosomic births. Longer-term studies that explore a wider range of environmental and biological exposures and outcomes relevant to the GCC region are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017068910.

The diabesity epidemic in the light of evolution: insights from the capacity-load model

The global nutrition transition, which embraces major changes in how food is produced, distributed and consumed, is associated with rapid increases in the prevalence of obesity, but the implications for diabetes differ between populations. A simple conceptual model treats diabetes risk as the function of two interacting traits: 'metabolic capacity,' which promotes glucose homeostasis, and 'metabolic load', which challenges glucose homoeostasis. Population variability in diabetes prevalence is consistent with this conceptual model, indicating that the effect of obesity varies by ethnicity. Evolutionary life history theory can help explain why variability in metabolic capacity and metabolic load emerges. At the species level (hominin evolution), across human populations and within individual life courses, phenotypic variability emerges under selective pressure to maximise reproductive fitness rather than metabolic health. Those exposed to adverse environments may express or develop several metabolic traits that are individually beneficial for reproductive fitness, but which cumulatively increase diabetes risk. Public health interventions can help promote metabolic capacity, but there are limits to the benefits that can emerge within a single generation. This means that efforts to curb metabolic load (obesity, unhealthy lifestyles) must remain at the forefront of diabetes prevention. Such efforts should go beyond individuals and target the broader food system and socioeconomic factors, in order to maximise their efficacy.

Pre-pregnancy BMI, gestational weight gain and birth outcomes in Lebanon and Qatar: Results of the MINA cohort

Accumulating evidence has highlighted the role of maternal nutritional status on fetal development, birth outcomes and child health. The Mother and Infant Nutritional Assessment (MINA) cohort is a 3-year follow-up study of pregnant women and their children in Qatar and Lebanon. This study reports on the characteristics and determinants of pre-pregnancy BMI and Gestational Weight Gain (GWG) of MINA particiants, as well as birth outcomes. A total of 272 pregnant women were recruited during their first trimester from primary healthcare centers as well as private clinics in Beirut (n = 194) and Doha (n = 147). During the first visit, data collection included pre-pregnancy weight, sociodemographic and lifestyle characteristics. The weight before delivery and neonatal outcomes were extracted from the medical records. GWG was calculated as the difference between weight before delivery and pre-pregnancy weight and was classified into insufficient, adequate, and excessive, as per the IOM criteria. Overall, 42.1% of women had a pre-pregnancy BMI≥25 Kg/m² (58% in Qatar vs 30.8% in Lebanon, p<0.001). Only 30.2% of women had adequate GWG, while 25.7% and 44.1% of women had insufficient and excessive GWG, respectively. In the cohort 68.7% of infants had a weight adequate-for-gestational age (AGA), 6.7% were SGA and 24.6% were LGA. The proportions of LGA were higher with greater GWG (p<0.05). After adjustment, Qatari women were 3 times more likely to be overweight or obese before pregnancy while a higher education level was associated with significantly lower odds of pre-pregnancy BMI≥25 Kg/m². Pre-pregnancy BMI≥25 Kg/m² and regular breakfast consumption were predictors of excessive GWG (OR: 3.20, CI: 1.48–6.91; OR: 2.84, CI: 1.15–7.02, respectively). The high prevalence of pre-pregnancy overweight and excessive GWG among MINA participants underscores the need for culture-specific intervention programs to promote healthy body weight in women of childbearing age, and prevent excessive weight gain during pregnancy.

Postnatal depressive symptoms in women with and without antenatal depressive symptoms: results from a prospective cohort study

Evidence exists that the risk factors for depression in the antenatal and postnatal period may differ, but only a handful of studies looked at depression longitudinally. The aims of this study were (1) to estimate the prevalence of postnatal depressive symptoms in Kuwait where data about postnatal depression are scarce and identify its determinants and (2) to compare these risk factors between women who had experienced antenatal depressive symptoms and those that did not. Data collected in the TRansgenerational Assessment of Children's Environmental Risk (TRACER) Study in Kuwait were used in this analysis. The sample was restricted to the 1348 women who answered the Edinburgh Postnatal Depression Scale (EPDS) both antenatally and postnatally. The prevalence of postnatal depressive symptoms, defined by an EPDS score ≥ 10, was 11.7%. Overall, antenatal depressive symptoms were the strongest determinant of postnatal depressive symptoms. Multivariable logistic regression analysis showed that in women with depressive symptoms in pregnancy, having a lower household income was the most significant risk factor for postnatal depressive symptoms. Among women without antenatal depressive symptoms, those who had lower income, were Kuwaitis, experienced other problems in pregnancy such as perceived stress, PTSD symptoms and social isolation, and those who delivered a boy had higher odds of postnatal depressive symptoms. Antenatal depressive symptoms and other psychosocial characteristics can predict postnatal depressive symptoms. Therefore, maternal mental health issues should be detected during the antenatal period and support should be provided in order to lower the risk of postnatal depression and its sequelae.

Depressive symptoms and comorbid problems in pregnancy - results from a population based study

OBJECTIVE

To estimate the prevalence of antenatal depressive symptoms, identify relevant risk factors, and assess comorbid mental health problems, among pregnant women enrolled in a population based study.

METHODS

This was a secondary analysis of data collected from 1916 pregnant women who participated in the TRansgenerational Assessment of Children's Environmental Risk (TRACER) study in Kuwait, and had answered the Baseline Questionnaire and completed the Edinburgh Depression Scale (EDS). Logistic regression models were used to examine the association of depressive symptoms with baseline socio-demographic characteristics and psychosocial indicators.

RESULTS

The prevalence of antenatal depressive symptoms, using a cut-off of EDS score ≥ 10, was 20.1%. Depressive symptoms were reported more by women of lower family income and had self-reported history of depression prior to pregnancy, with women in the third trimester having higher odds of antenatal depressive symptoms compared to those in the second trimester. Pregnancy-related anxiety, higher perceived stress levels, and post-traumatic stress disorder symptoms were comorbid with the presence of depressive symptoms.

CONCLUSION

The findings showed that one in five pregnant women in Kuwait experiences antenatal depressive symptoms and that these symptoms are comorbid with other mental health problems. Screening for antenatal depression and providing support to pregnant women should be considered.

The Mother-Infant Study Cohort (MISC): Methodology, challenges, and baseline characteristics

BACKGROUND

The United Arab Emirates (UAE) exhibits alarming high prevalence of Non-Communicable Diseases (NCDs) and their risk factors. Emerging evidence highlighted the role of maternal and early child nutrition in preventing later-onset NCDs. The objectives of this article are to describe the design and methodology of the first Mother and Infant Study Cohort (MISC) in UAE; present the baseline demographic characteristics of the study participants; and discuss the challenges of the cohort and their respective responding strategies.

METHODS

The MISC is an ongoing two-year prospective cohort study which recruited Arab pregnant women in their third trimester from prenatal clinics in Dubai, Sharjah and Ajman. Participants will be interviewed six times (once during pregnancy, at delivery, and at 2, 6, 12 and 24months postpartum). Perinatal information is obtained from hospital records. Collected data include socio-demographic characteristics, lifestyle, dietary intake and anthropometry; infant feeding practices, cognitive development; along with maternal and infant blood profile and breast milk profile.

RESULTS

The preliminary results reported that 256 completed baseline assessment (mean age: 30.5±6.0 years; 76.6% multiparous; about 60% were either overweight or obese before pregnancy). The prevalence of gestational diabetes was 19.2%. Upon delivery, 208 women-infant pairs were retained (mean gestational age: 38.5±1.5 weeks; 33.3% caesarean section delivery; 5.3% low birthweight; 5.7% macrosomic deliveries). Besides participant retention, the main encountered challenges pertained to cultural complexity, underestimation the necessary start-up time, staff, and costs, and biochemical data collection.

CONCLUSIONS

Despite numerous methodological, logistical and sociocultural challenges, satisfactory follow-up rates are recorded. Strategies addressing challenges are documented, providing information for planning and implementing future birth cohort studies locally and internationally.

Coupling external with internal exposure metrics of trihalomethanes in young females from Kuwait and Cyprus

The Eastern Mediterranean and the Middle Eastern regions are both understudied in terms of possible environmental health risks for their populations. Water scarcity and desalination treatment provide the general population of countries from these regions (e.g., Kuwait and Cyprus) with unique tap water characteristics. This study investigated the association between external (tap water and 24 h personal air samples) and internal (urine) THM exposure metrics that reflected information about THM-related habits and activities collected using questionnaires and time activity diaries. The study population comprised of young females residing in either Kuwait (n=13) or Cyprus (n=22). First morning urine voids were collected on 2 consecutive days. Urinary creatinine-adjusted total THM (TTHM) levels were higher in Kuwait (median (interquartile range): 1044 (814, 1270) ng/g) than in Cyprus (691 (510, 919) ng/g, P<0.05). Median personal air TTHM levels in Kuwait (1.4 (0.7, 1.7) μg/m³) were higher than those in Cyprus (0.9 (0.5, 1.4) μg/m³), but did not reach statistical significance (P=0.17). Median tap water TTHM in Kuwait (6.7 (5.4, 11.6) μg/l) did not correlate with urinary or air THM and they were lower than those in Cyprus (29.5 (20.1, 48.0) μg/l; P<0.01). Despite that tap water did not contain chloroform (TCM), TCM was detected in both air and urine samples in Kuwait, suggesting other TCM exposure sources, such as household cleaning activities. Total duration of activities and mopping were significantly correlated with air and urine THM in Kuwait, as reported in the time activity diary. Personal air and urine exposure metrics were correlated in Kuwait (TTHM ρ=0.62, P<0.05), but not in Cyprus (TTHM ρ=-0.32, P>0.05). Time-activity diaries and urinary THM seemed to be useful measures of THM exposures in Kuwait. Coupling both external with internal exposure metrics could find use in population health studies towards further refining the association between environmental exposures and health outcomes.

Pregnancy outcomes in relation to different types of diabetes mellitus and modes of delivery in macrosomic foetuses in Bahrain

Objectives

The mode of delivery in diabetic patients is debatable. This study was designed to assess the pattern of delivery of macrosomic babies with a high prevalence of diabetes mellitus in Bahrain.

Methods

This retrospective analysis was conducted on mothers who delivered babies weighing ≥4.0 Kgs from 2001 to 2011 at Bahrain Defence Force Hospital. Data regarding patients' age, weight, mode of delivery, diabetic status, gestational age and parity were recorded. The main outcome was the effect of diabetes mellitus on the decision to allow vaginal delivery for macrocosmic babies. Other outcomes were failed trial of labour, parity, maternal age and foetal weight on the trial of labour and neonatal morbidity associated with vaginal births.

Results

The incidence of macrosomic babies was 2.2% of total births. Pre-existing diabetes mellitus was 3.9% of the study cohort. The rate of elective Caesarean section increased from 12.5% in non-diabetic mothers to 50% in patients with pre-existing diabetes. In cases of allowing a trial of labour, approximately 70% of patients with pre-existing diabetes had successful vaginal delivery. Patients with a previous delivery were less likely to undergo emergency procedures, but had the same probability for elective Caesarean compared with primigravida. Patient's age and foetal weight had no influence on successful trial of vaginal birth.

Conclusions

There was a trend to offer more elective Caesarean sections in patients with macrosomic babies in the presence of pre-existing diabetes. The majority of patients who were offered a trial of labour achieved vaginal delivery with minimal morbidity.