Combined effects of cigarette smoking and alcohol consumption on perinatal outcome

Selecting a birth weight standard for an indigenous population in a LMIC: A prospective comparative study

OBJECTIVES

The aim of the present study was to compare birth weight (BW) distribution and proportion of BWs below or above specified percentiles in low-risk singleton pregnancies in healthy South African (SA) women of mixed ancestry with expected values according to four BW references and to determine the physiological factors affecting BW.

METHODS

This was an ancillary study of a prospective multinational cohort study, involving 7060 women recruited between August 2007 and January 2015 in two townships of Cape Town, characterized by low socioeconomic status, and high levels of drinking and smoking. Detailed information about maternal and pregnancy characteristics, including harmful exposures, was gathered prospectively, allowing us to select healthy women with uncomplicated pregnancies without any known harmful exposures. In this cohort we compared the median BW and the proportion of BWs P90, 95 and 97 according to four reference standards (INTERGROWTH-21st, customized according to the method described by Mickolajczyk, Fetal Medicine Foundation and revised Fenton reference) with expected values. Appropriate parametric and nonparametric tests were used, and sensitivity analysis was performed for infant sex, first trimester bookings and women of normal body mass index (BMI). Multiple regression was used to explore effects of confounders. Written consent and ethics approval was obtained.

RESULTS

The cohort included 739 infants. The INTERGROWTH-21st standard was closest for the actual BW-distribution and categories. Below-expected BW was associated with boys, younger, shorter, leaner women, lower parity and gravidity. Actual BW was significantly influenced by maternal weight, BMI, parity and gestational age.

CONCLUSION

Of the four references assessed in this study, the INTERGROWTH-21st standard was closest for the actual BW distribution. Maternal variables significantly influence BW.

An incentive-based text-messaging intervention to reduce maternal alcohol use during pregnancy and lactation in South Africa (MaRISA study): Findings from a single-arm pilot study

BACKGROUND

South Africa has the highest rate of fetal alcohol spectrum disorders (FASD) globally. As with alcohol use during pregnancy, alcohol consumption while breastfeeding adversely impacts infant development. We pilot tested an incentive-based text-messaging intervention to reduce alcohol use during pregnancy and lactation in South Africa.

METHODS

A single-arm pilot trial was conducted over 3 months in healthcare facilities in Cape Town, South Africa. Pregnant and breastfeeding participants tested positive for recent alcohol use by urinalysis. The three-month intervention had two components, contingency management of alcohol abstinence confirmed by urinalysis twice weekly and weekly health-related text messaging from an evidence-based brief intervention. We collected twice weekly urine samples for measurement of ethyl glucuronide (EtG), an alcohol biomarker, and measures of self-reported alcohol and drug use, violence exposure, and mental health at six weeks and three months post-enrollment.

RESULTS

Sixty participants were enrolled, of whom 31 were pregnant and 29 lactating. The number of days with four or more drinks in the past month decreased from 9 days at baseline, on average, to 1-3 days (p-value range: 0.144-0.010) at follow-up timepoints. There were statistically significant increases in the proportions of participants with alcohol-negative urine tests (p < 0.001). The percentages of participants breastfeeding while using alcohol decreased from baseline to the end of 3 months in the overall sample and among those enrolled postpartum, though these were not significant (p-value range: 0.255-0.147). Maternal depression scores also decreased among participants enrolled postpartum (p = 0.054). Emotional abuse by the main partner, but neither physical nor sexual abuse, significantly decreased at both follow-ups in the overall sample (p = 0.032) and among participants enrolled while pregnant (p = 0.015).

CONCLUSIONS

This study is among the first to pilot test an incentive-based text-messaging intervention for maternal alcohol use and other outcomes such as depression and violence exposure. Further testing is warranted in a well-powered, randomized controlled trial.

Chronic oral disease burden at the first 1000 days: Intergenerational risk factors, BRISA cohort

OBJECTIVE

To analyze multiple-causal models, including socioeconomic, obesity, sugar consumption, alcohol smoking, caries, and periodontitis variables in pregnant women with early sugar exposure, obesity, and the Chronic Oral Disease Burden in their offspring around the first 1000 days of life.

METHODS

The BRISA cohort study, Brazil, had two assessments: at the 22nd-25th gestational weeks and during the child's second year (n = 1141). We proposed a theoretical model exploring the association between socioeconomic and pregnancy factors (age, smoking, alcohol, sugars, obesity, periodontitis, and caries) and child's variables (sugars and overweight) with the outcome, Chronic Oral Disease Burden (latent variable deduced from visible plaque, gingivitis, and tooth decay), using structural equation modeling.

RESULTS

Caries and periodontitis were correlated in pregnant women. Addictive behaviors in the gestational period were correlated. Obesity (Standardized coefficient - SC = 0.081; p = 0.047) and added sugar consumption (SC = 0.142; p = 0.041) were observed intergenerationally in the pregnant woman-child dyads. Sugar consumption by the children (SC = 0.210; p = 0.041) increased the Chronic Oral Disease Burden.

CONCLUSIONS

Poor caries and periodontal indicators were correlated in pregnant women and their offspring. Obesity and sugar consumption act intergenerationally. Oral health in early life may change life trajectory since the worst oral conditions predict main NCDs.

Folic acid supplements and perinatal mortality in China

Introduction

Periconceptional use of multivitamins containing folic acid prevents external major birth defects, especially neural tube defects. We aimed to explore the effects of maternal folic acid supplementation alone on perinatal mortality with or without external major birth defects plus neural tube defects.

Methods

From the China-US Collaborative Project for Neural Tube Defects Prevention, we identified 222, 303 singleton pregnancies with detailed information on periconceptional folic acid use, defined as folic acid supplementary before the last menstrual date until to the end of the first trimester. Perinatal mortality included stillbirths after 20 weeks' gestation and early neonatal deaths within 7 days of delivery.

Results

Among the fetuses or infants of women who did not take folic acid, the rate of perinatal mortality was 2.99% and 1.62% at least 20 weeks' gestation in the northern and southern regions. Among the fetuses or infants of the women with periconceptional use of folic acid, the rates were 1.85% and 1.39% in the northern and southern region. The estimated relative risk for perinatal mortality [adjusted risk ratio (RR), 0.72; 95% confidence interval (CI), 0.61- 0.85], stillbirth (adjusted RR, 0.78; 95% CI, 0.64-0.96), early neonatal mortality (adjusted RR, 0.61; 95% CI, 0.45-0.82), and neonatal death (adjusted RR, 0.64; 95% CI, 0.49-0.83) in northern China was significantly decreased in association with periconceptional folic acid supplementation. Compared with northern, there was a lesser effect in southern China.

Conclusion

Periconceptional intake of 400μg folic acid daily reduces the overall risk perinatal mortality, as well as the risk from external major birth defects and neural tube defects, especially in northern China.

Maternal and paternal risk factors for fetal alcohol spectrum disorders: Alcohol and other drug use as proximal influences

OBJECTIVE

To explore and analyze the significance of proximal influences of maternal and paternal traits associated with bearing a child with a fetal alcohol spectrum disorder (FASD).

METHODS

Aggregated, maternal interview-collected data (N = 2515) concerning alcohol, tobacco, and other drug use were examined to determine risk for FASD from seven cross-sectional samples of mothers of first-grade students who were evaluated for a possible diagnosis of FASD.

RESULTS

Mothers of children with fetal alcohol syndrome (FAS) reported the highest alcohol use throughout pregnancy, proportion of binge drinking, drinks per drinking day (DDD), drinking days per week, and total drinks per week. Mothers of children with FAS also consumed significantly more alcohol than mothers of children with partial FAS (PFAS), alcohol-related neurodevelopmental disorder (ARND), or typically developing controls. Mothers of children with PFAS and ARND reported similar drinking patterns, which exposed fetuses to 3-4 times more alcohol than mothers of controls, but the PFAS group was more likely than the ARND group to abstain in latter trimesters. Fathers of all children were predominantly drinkers (70%-85%), but more fathers of children with FASD binged heavily on more days than fathers of controls. Compared to the few mothers of controls who used alcohol during pregnancy, the ARND group binge drank more (3+ DDD) throughout pregnancy and drank more DDD before pregnancy and first trimester. Regression analysis, controlling for tobacco use, indicated that mothers who reported drinking <1 DDD were significantly more likely than abstainers to bear a child with FASD (OR = 2.75) as were those reporting higher levels such as 5-5.9 DDD (OR = 32.99). Exclusive, first-trimester maternal drinking increased risk for FASD five times over that of abstinence (p < 0.001, OR = 5.05, 95% CI: 3.88-6.58), first- and second-trimester drinking by 12.4 times, and drinking all trimesters by 16 times (p < 0.001, OR = 15.69, 95% CI: 11.92-20.64). Paternal drinking during and prior to pregnancy, without adjustment, increased the likelihood of FASD significantly (OR = 1.06 and 1.11, respectively), but the significance of both relationships disappeared when maternal alcohol and tobacco use were controlled.

CONCLUSIONS

Differences in FASD risk emerged from the examination of multiple proximal variables of maternal alcohol and tobacco use, reflecting increased FASD risk at greater levels of maternal alcohol consumption.

Associations between prenatal alcohol and tobacco exposure on Doppler flow velocity waveforms in pregnancy: a South African study

BACKGROUND

The negative impact of prenatal alcohol and tobacco exposure (PAE and PTE) on fetal development and birth outcomes are well described, yet pathophysiologic mechanisms are less clear. Our aim was to investigate (1) the associations between quantity, frequency and timing (QFT) of PAE and PTE with blood flow velocities in arteries of the fetal-placental-maternal circulation and (2) the extent to which combined effect of QFT of PAE and/or PTE and Doppler flow velocity waveforms (FWV) predict infant birth weight.

METHODS

The Safe Passage Study is a cohort based in urban Cape Town, South Africa. Recruitment occurred between 2007 and 2015. Information on QFT of PAE and PTE was collected prospectively at up to 4 occasions during pregnancy using a modified Timeline Follow-Back approach. Ultrasound examinations consisted of Doppler flow velocity waveforms of the uterine, umbilical (UA) and fetal middle cerebral arteries for the pulsatility index (PI) at 20-24 and 34-38 weeks. Exclusion criteria included: twin pregnancies, stillbirths, participants exposed to other drugs. The sample was divided into three groups (controls, PAE and PTE) and included 1396 maternal-fetal-dyads assessed during the second trimester; 1398 assessed during the third trimester.

RESULTS

PTE was associated with higher UA PI values in second and third trimesters (p < 0.001), compared to the PAE and control group. The total amount of cigarettes smoked during pregnancy was positively correlated with UA PI values (r = 0.087, p < 0.001). There was a positive correlation between cigarettes smoked per day in trimester one (r = 0.091, p < 0.01), and trimester two (r = 0.075, p < 0.01) and UA PI (in trimester two), as well as cigarettes smoked per day in trimester two (r = 0.058, p < 0.05) and trimester three (r = 0.069, p < 0.05) and the UA PI in trimester three. Generalized additive models indicated that PAE in trimester two, PTE in trimester one and Doppler FWV in trimester three were significant predictors of birth weight in this sample.

CONCLUSION

In our study, PTE in trimesters two and three resulted in increased vascular resistance of the placenta. These findings highlight nuance in associations between PAE, PTE and blood flow velocities in arteries of the fetal-placental-maternal circulation and birth weight, suggesting that quantity and timing are important factors in these relationships.

Maternal factors and child health conditions at birth associated with preterm deaths in a tertiary health facility in Ghana: A retrospective analysis

Background

Preterm birth continues to be a leading cause of death for children under the age of 5 globally. This issue carries significant economic, psychological, and social costs for the families affected. Therefore, it is important to utilize available data to further research and understand the risk factors for preterm death.

Objective

The objective of this study was to determine maternal and infant complications that influence preterm deaths in a tertiary health facility in Ghana.

Methods

A retrospective analysis of data on preterm newborns was conducted at the neonatal intensive care unit of Korle Bu Teaching Hospital (KBTH NICU) in Ghana, covering the period January 2017 to May 2019. Pearson's Chi-square test of association was used to identify factors that were significantly associated with preterm death after admission at the NICU. The Poisson regression model was used to determine the risk factors of preterm death before discharge after admission to the NICU.

Results

Of the 1,203 preterm newborns admitted to the NICU in about two and half years, 355 (29.5%) died before discharge, 7.0% (n = 84) had normal birth weight (>2.5 kg), 3.3% (n = 40) had congenital anomalies and 30.5% (n = 367) were born between 34 and 37 gestational week. All 29 preterm newborns between the 18-25 gestational week died. None of the maternal conditions were significant risk factors of preterm death in the multivariable analysis. The risk of death at discharge was higher among preterm newborns with complications including hemorrhagic/hematological disorders of fetus (aRRR: 4.20, 95% CI: [1.70-10.35], p = 0.002), fetus/newborn infections (aRRR: 3.04, 95% CI: [1.02-9.04], p = 0.046), respiratory disorders (aRRR: 13.08, 95% CI: [5.50-31.10], p < 0.001), fetal growth disorders/restrictons (aRRR: 8.62, 95% CI: [3.64-20.43], p < 0.001) and other complications (aRRR: 14.57, 95% CI: [5.93-35.77], p < 0.001).

Conclusion

This study demonstrate that maternal factors are not significant risk factors of preterm deaths. Gestational age, birth weight, presence of complications and congenital anomalies at birth are significantly associated with preterm deaths. Interventions should focus more on child health conditions at birth to reduce the death of preterm newborns.

Alcohol consumption and tobacco exposure among pregnant women in Ibadan, Nigeria

BACKGROUND

Alcohol consumption and tobacco exposure during pregnancy are hazardous behaviours which are increasing significantly in low and middle-income countries, including sub-Saharan Africa. However, they have received little attention in Nigeria's maternal health research and services. The prevalence, pattern and predictors of alcohol consumption and tobacco exposure among pregnant women in Ibadan, Nigeria, were investigated.

METHODS

This is a part of a prospective cohort study among pregnant women in Ibadan, Nigeria (Ibadan Pregnancy Cohort Study (IbPCS), which investigated the associations between maternal obesity, lifestyle characteristics and perinatal outcomes in Ibadan. Alcohol consumption and tobacco exposure of 1745 pregnant women were assessed during enrollment by self-reports using an interviewer-administered questionnaire. Bivariate and multiple logistic regression analyses examined the associations at a 5% level of statistical significance.

RESULTS

The prevalence of pre-pregnancy alcohol consumption and alcohol consumption during pregnancy were 551 (31.7%) and 222 (12.7%), respectively, i.e. (one in every eight pregnancies is exposed to alcohol). Palm wine (52%) and beer (12%) were the most common alcohol consumed among pregnant women. The predictors of alcohol consumption during were pre-pregnancy alcohol use [AOR = 10.72, 95% CI: 6.88-16.70) and religion i.e. Muslims were less likely to consume alcohol during pregnancy compared to Christians: [AOR = 0.60, 95% CI: 0.40-0.92). The prevalence of tobacco exposure in the index pregnancy was 64 (3.7%), i.e. one in every 27 pregnancies is exposed to tobacco. In contrast, cigarette smoking, second-hand smoke and smokeless tobacco were 0.4, 1.7 and 1.8%, respectively. Pre-pregnancy cigarette smoking was reported by 33(1.9%) and was the most significant predictor [AOR = 12.95; 95% CI: 4.93, 34.03) of tobacco exposure during pregnancy in our study population.

CONCLUSIONS

Alcohol consumption and tobacco exposure are not uncommon and have been an ongoing but neglected threat to maternal and child health in Nigeria. Alcohol and tobacco control policy and programmes to prevent the use among pregnant and reproductive-age women in Nigeria should be implemented primarily during antenatal care.

The tragedy of smoking, alcohol, and multiple substance use during pregnancy

BACKGROUND

Antenatal substance use is a significant public health concern in South Africa (SA). Information on smoking, drinking and drug use during pregnancy was collected prospectively for the Safe Passage Study of the PASS (Prenatal Alcohol in Sudden infant death syndrome and Stillbirth) Network.

OBJECTIVES

Data from 4 926 pregnant women in a community near Tygerberg Academic Hospital, Cape Town, were examined to determine whether associations between different substance use groups and postnatal infant outcomes at birth and 1 year were significant.

METHODS

Gestational age (GA) was determined by earliest ultrasound. Maternal data were collected at enrolment or first antenatal visit. Substance use data were obtained at up to four occasions. Birthweight data were derived from medical records, and birthweight z-scores (BWZs) were specifically calculated using INTERGROWTH-21st study data. Statistical analyses were done with Statistica version 13.  Results. Women who used more substances enrolled later, were younger, and had smaller mid-upper arm circumferences (MUACs), less education and lower monthly income than women who used no substances (control group). Infants born to women who used more substances had lower GA at delivery, birthweight and BWZ than infants from the control group. At 1 year, infants born to women who used more substances had a lower weight, shorter length and smaller head circumference. Education was positively associated with all infant outcomes at birth and 1 year. MUAC was positively associated with infant BWZ, and weight and length at 1 year. Income was negatively associated with BWZ, but positively associated with all 1-year outcomes.

CONCLUSION

Substance use during pregnancy affects infant outcomes at birth and 1 year of age. The addictive properties of substance use make cessation difficult, so prevention strategies should be implemented long before pregnancy. Higher maternal education, associated with better infant outcomes at birth and 1 year and acting as a countermeasure to substance use, is of paramount importance.

Racial/ethnic variations in alcohol and cigarette use by pregnancy status among 20- to 44-year-old women, NHANES 2001-2018

OBJECTIVES

This study examines alcohol consumption and smoking behaviors by pregnancy status and race/ethnicity in order to inform improved interventions designed to assist women of all races to avoid alcohol and tobacco use during pregnancy for their health and to prevent potential fetal exposure.

METHODS

This retrospective secondary data analysis utilized nationally representative National Health and Nutrition Examination Survey data between 2001 and 2018. Smoking and alcohol use were evaluated by race/ethnicity and pregnancy risk. Sexual behavior, reproductive health, and prescription drug use determined pregnancy risk, categorized as low pregnancy risk, at risk of becoming pregnant, and pregnant. Binary and multinomial multivariable logistic regression were used to examine associations.

RESULTS

The final sample consisted of 10,019 women of which 11.8% were Mexican American, 7.7% other Hispanic, 65.5% white, and 15% black (weighted percentages). White low pregnancy risk and pregnancy risk smoked most frequently in respective pregnancy risk groups (p < 0.001). Among pregnant women, smoking prevalence was highest among black women (14.0%, p < 0.01). Pregnancy risk women were more likely to smoke and pregnant women were less likely to smoke compared with low pregnancy risk. Low pregnancy risk and pregnancy risk Hispanics had a lower prevalence of binge drinking, but prevalence decreased less among pregnant Hispanics than other racial/ethnic groups. In adjusted analyses, pregnancy risk black women had more than 2 times the odds of combined smoking and alcohol consumption compared with low pregnancy risk black women.

CONCLUSION

Women who may become pregnant need interventions and improved policy to prevent alcohol use and smoking. Culturally appropriate alcohol and smoking cessation interventions before pregnancy and improved contraception access are needed.

Alcohol's Impact on the Fetus

BACKGROUND

Alcohol is a teratogen and prenatal exposure may adversely impact the developing fetus, increasing risk for negative outcomes, including Fetal Alcohol Spectrum Disorder (FASD). Global trends of increasing alcohol use among women of childbearing age due to economic development, changing gender roles, increased availability of alcohol, peer pressure and social acceptability of women's alcohol use may put an increasing number of pregnancies at risk for prenatal alcohol exposure (PAE). This risk has been exacerbated by the ongoing COVID-19 pandemic in some countries.

METHOD

This literature review presents an overview on the epidemiology of alcohol use among childbearing age and pregnant women and FASD by World Health Organization regions; impact of PAE on fetal health, including FASD; associated comorbidities; and social outcomes.

RESULTS/CONCLUSION

The impact of alcohol on fetal health and social outcomes later in life is enormous, placing a huge economic burden on countries. Prevention of prenatal alcohol exposure and early identification of affected individuals should be a global public health priority.

Association of Prenatal Exposure to Maternal Drinking and Smoking With the Risk of Stillbirth

IMPORTANCE

Prenatal smoking is a known modifiable risk factor for stillbirth; however, the contribution of prenatal drinking or the combination of smoking and drinking is uncertain.

OBJECTIVE

To examine whether prenatal exposure to alcohol and tobacco cigarettes is associated with the risk of stillbirth.

DESIGN, SETTING, AND PARTICIPANTS

The Safe Passage Study was a longitudinal, prospective cohort study with data collection conducted between August 1, 2007, and January 31, 2015. Pregnant women from Cape Town, South Africa, and the Northern Plains region of the US were recruited and followed up throughout pregnancy. Data analysis was performed from November 1, 2018, to November 20, 2020.

EXPOSURE

Maternal consumption of alcohol and tobacco cigarettes in the prenatal period.

MAIN OUTCOMES AND MEASURES

The main outcomes were stillbirth, defined as fetal death at 20 or more weeks' gestation, and late stillbirth, defined as fetal death at 28 or more weeks' gestation. Self-reported alcohol and tobacco cigarette consumption was captured at the recruitment interview and up to 3 scheduled visits during pregnancy. Participants were followed up during pregnancy to obtain delivery outcome.

RESULTS

Of 11663 pregnancies (mean [SD] gestational age at enrollment, 18.6 [6.6] weeks) in 8506 women for whom the pregnancy outcome was known by 20 weeks' gestation or later and who did not terminate their pregnancies, there were 145 stillbirths (12.4 per 1000 pregnancies) and 82 late stillbirths (7.1 per 1000 pregnancies). A total of 59% of pregnancies were in women from South Africa, 59% were in multiracial women, 23% were in White women, 17% were in American Indian women, and 0.9% were in women of other races. A total of 8% were older than 35 years. In 51% of pregnancies, women reported no alcohol or tobacco cigarette exposure (risk of stillbirth, 4 per 1000 pregnancies). After the first trimester, 18% drank and smoked (risk of stillbirth, 15 per 1000 births), 9% drank only (risk of stillbirth, 10 per 1000 pregnancies), and 22% smoked only (risk of stillbirth, 8 per 1000 pregnancies). Compared with the reference group (pregnancies not prenatally exposed or without any exposure after the first trimester), the adjusted relative risk of late stillbirth was 2.78 (98.3% CI, 1.12-6.67) for pregnancies prenatally exposed to drinking and smoking, 2.22 (98.3% CI, 0.78-6.18) for pregnancies prenatally exposed to drinking only after the first trimester, and 1.60 (98.3% CI, 0.64-3.98) for pregnancies prenatally exposed to smoking only after the first trimester. The adjusted relative risk for all stillbirths was 1.75 (98.3% CI, 0.96-3.18) for dual exposure, 1.26 (98.3% CI, 0.58-2.74) for drinking only, and 1.27 (98.3% CI, 0.69-2.35) for smoking only compared with the reference group.

CONCLUSIONS AND RELEVANCE

These results suggest that combined drinking and smoking after the first trimester of pregnancy, compared with no exposure or quitting before the end of the first trimester, may be associated with a significantly increased risk of late stillbirth.

The Intricate Interactions between Maternal Smoking and Drinking During Pregnancy and Birthweight Z-Scores of Preterm Births

BACKGROUND

The extent to which smoking and drinking in a local community is associated with nutrition and Z-scores of infants from spontaneous preterm deliveries, is uncertain.

AIM

To investigate associations of different levels of maternal smoking and drinking in spontaneous preterm birth with infant birthweight Z-scores.

METHODS

Information, including gestational age (determined by earliest ultrasound), maternal arm circumference (measured at enrolment), smoking-drinking data (obtained up to 4 occasions), birthweight data (obtained from medical records) and birthweight Z-scores (calculated from INTERGROWTH- 21st study), collected over a period of nine years was used to compare 407 spontaneous preterm births with 3 493 spontaneous term births Analyses of variance, correlations and multiple regression were performed in STATISTICA.

RESULTS

Women with spontaneous preterm birth, had significantly lower gravidity and smaller arm circumference when compared to women with spontaneous birth at term. Women with spontaneous preterm birth drank more and heavier during pregnancy, and more smoked. Gestational age at birth was significantly longer in heavy-smokers-heavy-drinkers compared to heavy-smokers-no-drinkers (7.1 days) and in no-smokers-heavy-drinkers when compared to no-smokers-no-drinkers (11.2 days). Birthweight was significantly lower in low-smokers-heavy-drinkers when compared to low-smokers-no-drinkers (240g) and in heavy-smokers-low-drinkers when compared to no-smokers-low-drinkers (273g). Birthweight Z-scores were significantly lower in low-smokers-heavy-drinkers when compared to low-smokers-low-drinkers and low-smokers-no-drinkers; and, also significantly lower in heavy-smokers-low-drinkers when compared to low-smokers-low-drinkers and no-smokers-low-drinkers.

CONCLUSION

Alcohol aggravates the detrimental effect of smoking on birthweight and birthweight Z-scores but seems to counteract the negative association of smoking with gestational age.

Prioritization of interventions in pursuit of maternal health policy objectives to mitigate stillbirth risks. An exploratory qualitative study at subnational level in Uganda

Background

Global calls for renewed efforts to address stillbirth burden highlighted areas for policy and implementation resulting in national level translations. Information regarding adapted strategies to effect policy objectives into service delivery by frontline health workers remains scanty especially at subnational level. The study explored strategies prioritized to mitigate stillbirth risk in the context of operationalizing recommendations from the global campaigns at a subnational level in Uganda.

Methods

A cross-sectional qualitative exploratory study was conducted among a purposively selected sample of sixteen key informants involved in delivery of maternal and child health services in Mukono district. Analysis followed thematic content analysis deductively focusing on those policy priorities highlighted in the global stillbirth campaigns and reflected at the national level in the different guidelines. Results.

Interventions to address stillbirth followed prioritization of service delivery aspects to respond to identified gaps. Efforts to increase uptake of family planning services for example included offering it at all entry points into care with counseling forming part of the package following stillbirth. Referrals were streamlined by focusing on addressing delays from the referring entity while antenatal care attendance was boosted through provision of incentives to encourage mothers to comply. Other prioritized aspects included perinatal death audits and improvements in data systems while differentiated care focused on aligning resources to support high risk mothers. This was in part influenced by the limited resources and skills which made health workers to adapt routine to fit implementation context.

Conclusions

The resource availability determined aspects of policy to prioritize while responding to stillbirth risk at subnational level by frontline health workers. Their understanding of risk, feasibility of implementation and the desire for optimal health systems performance worked to define the nature of services delivered calling for purposeful consideration of resource availability and implementation context while prioritizing stillbirth reduction at subnational level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06046-z.

Association between tobacco and/or alcohol consumption during pregnancy and infant development: BRISA Cohort

Fetuses exposed to alcohol and/or tobacco are at risk for perinatal adversities. However, little is currently known about the association of the separate or concomitant use of alcohol and tobacco with infant motor and cognitive development. Thus, the objective of the present study was to investigate the association between maternal consumption of alcohol and/or tobacco during pregnancy and the motor and cognitive development of children starting from the second year of life. The study included 1006 children of a cohort started during the prenatal period (22-25 weeks of pregnancy), evaluated at birth and reevaluated during the second year of life in 2011/2013. The children were divided into four groups according to the alcohol and/or tobacco consumption reported by their mothers at childbirth: no consumption (NC), separate alcohol consumption (AC), separate tobacco consumption (TC), and concomitant use of both (ACTC). The Bayley Scale of Infant and Toddler Development Third Edition screening tool was used for the assessment of motor and cognitive development. Adjusted Poisson regression models were used to determine the association between groups and delayed development. The results indicated that only the ACTC group showed a higher risk of motor delay, specifically regarding fine motor skills, compared to the NC group (RR=2.81; 95%CI: 1.65; 4.77). Separate alcohol or tobacco consumption was not associated with delayed gross motor or cognitive development. However, the concomitant use of the two substances increased the risk of delayed acquisition of fine motor skills.

Profile of Mothers of Children with Fetal Alcohol Spectrum Disorder: A Population-Based Study in Canada

Objective: To compare the characteristics of mothers of children with Fetal Alcohol Spectrum Disorder (FASD) with mothers of typically developing control children. Methods: The study utilized a cross-sectional, observational design, using active case ascertainment. Biological mothers were interviewed using a standardized retrospective questionnaire to collect data on demographics, living environment, pregnancy history, nutrition, alcohol and other drug use prior to and following pregnancy recognition. Results: A total of 173 mothers were interviewed. Of these, 19 had a child who was diagnosed with FASD, five had a child who had received a deferred FASD diagnosis, and 37 had children who were selected into the control group as typically developing children. The remaining 112 mothers had children who did not meet diagnostic criteria for FASD. The mothers of children with FASD did not differ significantly from mothers of the control group children with respect to age, ethnicity, marital status, and employment status at the time of pregnancy. However, mothers of children with FASD had lower levels of education (p < 0.01) and were more likely to have received financial support (p < 0.05) at the time of pregnancy, to have smoked tobacco (p < 0.001), and to have used marijuana or hashish (p < 0.01) prior to pregnancy recognition, compared with mothers of control children. All mothers of children with FASD reported alcohol consumption prior to pregnancy recognition; however, only 10.5% reported alcohol consumption following pregnancy recognition. None of the mothers interviewed reported any drug use following pregnancy recognition. Conclusions: Population-based preventive interventions, including repeated screening, monitoring, and education regarding the effects of alcohol use, as well as other substances, before and during pregnancy, are needed to eliminate risk for FASD and other negative consequences on child and maternal health.

Are antenatal interventions effective in improving multiple health behaviours among pregnant women? A systematic review protocol

BACKGROUND

Maternal behaviours in pregnancy associated with adverse pregnancy, birth and health outcomes include tobacco smoking, poor nutrition, alcohol consumption and low physical activity, collectively referred to as the SNAP risk factors. Due to the high prevalence, co-occurrence and possible interactive health effects of such health behaviours in pregnancy, antenatal interventions that support pregnant women to improve multiple SNAP behaviours have a greater potential impact on the health outcomes of women and their children than interventions addressing single behaviours. The objective of this review is to determine the effectiveness of interventions delivered as part of antenatal care that aim to improve multiple SNAP behaviours among pregnant women.

METHODS

Seven electronic databases will be searched for potentially eligible studies. Eligible studies will include those where pregnant women are attending antenatal care. Studies that examine the effect of an intervention that addresses multiple SNAP behaviours (≥ 2 behaviours) during pregnancy and are delivered or instigated through antenatal care in a healthcare service will be included. Systematic reviews of randomised controlled trials (RCTs), RCTs, cluster RCTs, stepped-wedge RCTs and non-randomised control trials will be eligible. Studies that include a no-intervention control, wait-list control group, standard/usual care, or another active single behavioural intervention (e.g. addressing one behaviour only) will be considered. Two independent reviewers will conduct study screening, data extraction and risk of bias assessment. Discrepancies will be resolved by consensus or a third reviewer if required. A random effects model will be used to synthesise the results. Alternative synthesis methods will be investigated in instances where a meta-analysis is not appropriate, such as summarising effect estimates, combining P values, vote counting based on direction of effect, or synthesis in narrative form.

DISCUSSION

The review will synthesise the evidence on the effect of interventions that address multiple SNAP behaviours in antenatal care and will help researchers, policy-makers and health services to develop and deliver best practice integrated models of antenatal care that have the potential to impact on both the short- and long-term health outcomes for women and their children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095315.

Associations of maternal smoking and drinking with fetal growth and placental abruption

OBJECTIVE

To investigate pregnant women from the Safe Passage Study for the individual and combined effects of smoking and drinking during pregnancy on the prevalence of clinical placental abruption.

STUDY DESIGN

The aim of the original Safe Passage Study was to investigate the association of alcohol use during pregnancy with stillbirths and sudden infant deaths. Recruitment for this longitudinal study occurred between August 2007 and October 2016. Information on smoking and drinking was collected prospectively at up to 4 occasions during pregnancy where a modified timeline follow-back method was used to assess the exposure to alcohol. Placentas were examined histologically in a subset of pregnant women. For this study we examined the effects of smoking and drinking on fetal growth and the prevalence rate of placental abruption. High smoking constituted of 10 or more cigarettes per day and high drinking of four or more binge drinking episodes or 32 and more standard drinks during pregnancy. Placental abruption was diagnosed in two ways, by the clinical picture or the macroscopic and microscopic examination of the placenta.

RESULTS

When compared to the non-drinking/non-smoking group, the high drinking/high smoking group were significantly older, had a higher gravidity, had a lower household income and booked later for prenatal care; fewer of them were employed and had toilet and running water facilities in their houses. Clinical placental abruption was diagnosed in 49 (0.87 %) of 5806 pregnancies. Histological examination was done in 1319 placentas; macroscopic and microscopic diagnosis of placental abruption was made in 8.2 % and 11.9 % of placentas respectively. These 49 cases were then correlated with seven smoking/drinking patterns during pregnancy. When compared to rates for no smoking/no drinking (0.11 %) and low smoking/no drinking (0.55 %), the prevalence rate of placental abruption was significantly higher (p < .005) in the low smoking/low drinking group (1.25 %). There was also a significant relationship between low maternal employment and methamphetamine use with placental abruption.

CONCLUSION

As many conditions and habits are associated with placental abruption, it is impossible to single out one specific cause but concomitant drinking and smoking seem to increase the risk of placental abruption.

Altered Maternal Plasma Fatty Acid Composition by Alcohol Consumption and Smoking during Pregnancy and Associations with Fetal Alcohol Spectrum Disorders

Objective: Polyunsaturated fatty acids are vital for optimal fetal neuronal development. The relationship between maternal alcohol consumption and smoking with third trimester plasma fatty acids were examined and their association with Fetal Alcohol Spectrum Disorders (FASD).Methods: Moderate to heavy alcohol-using and low/unexposed comparison women were recruited during mid-pregnancy from two prenatal clinics in Ukraine. The participants' infants underwent physical and neurobehavioral exams prior to one-year of age and classified as having FASD by maternal alcohol consumption and neurobehavioral scores. A subset of mother-child pairs was selected representing three groups of cases and controls: Alcohol-Exposed with FASD (AE-FASD, n = 30), Alcohol-Exposed Normally Developing (AE-ND, n = 33), or Controls (n = 46). Third trimester maternal plasma samples were analyzed for fatty acids and levels were compared across groups.Results: The percent of C18:0 (p < 0.001), arachidonic acid (AA, C20:4n-6, p = 0.017) and C22:5n-6 (p = 0.001) were significantly higher in AE-FASD women than controls or AE-ND women. Alcohol-exposed women who smoked had lower C22:5n-3 (p = 0.029) and docosahexaenoic acid (DHA, C22:6n-3, p = 0.005) and higher C22:5n-6 (p = 0.013) than women consuming alcohol alone or abstainers.Conclusion: Alterations in fatty acid profiles were observed in moderate to heavy alcohol-consuming mothers with infants classified with FASD compared to alcohol-exposed normally developing infants or controls.

The causal web of foetal alcohol spectrum disorders: a review and causal diagram

Foetal alcohol spectrum disorders (FASDs) are a leading cause of developmental disability. Prenatal alcohol use is the sole necessary cause of FASD, but it is not always sufficient. Multiple factors influence a child's susceptibility to FASD following prenatal alcohol exposure. Much of the FASD risk factor literature has been limited to discussions of association, rather than causation. While knowledge of predictor variables is important for identifying who is most at risk of FASD and for targeting interventions, causal knowledge is important for identifying effective mechanisms for prevention and intervention programmes. We conducted a systematic search and narrative synthesis of the evidence and used this to create a causal diagram (directed acyclic graph; DAG) to describe the causal pathways to FASD. Our results show that the aetiology of FASD is multifaceted and complex. FASD risk is determined by a range of lifestyle, sociodemographic, maternal, social, gestational, and genetic factors. The causal diagram that we present in this review provides a comprehensive summary of causal risk factors for FASD and can be used as a tool to inform data collection and statistical modelling strategies to minimise bias in future studies of FASD.

What Do We Know About Prevalence and Management of Intoxicated Women During Labor and Delivery?

Objective. To review the published literature on women who were intoxicated at delivery and outcomes for their infants. Methods. A systematic literature review was utilized to identify articles meeting our inclusion criteria. After screening using titles and abstracts, we identified 34 articles requiring full-text review. Each of these were reviewed by at least 2 of the authors. We identified 12 articles that met our inclusion criteria. Results. We identified case reports of 16 mothers who delivered with a blood alcohol concentration (BAC) ranging from 42.1 to 473 mg/dL. Three of the pregnancies (18.8%) ended with a stillbirth, 5 (31.3%) were infant deaths, 6 (37.5%) lived, and 2 (12.5%) had no fetal or infant outcome reported. The BAC for the stillborn infants ranged from 120 to 460 mg/dL. The BAC among the infant deaths ranged from 96 to 715 mg/dL. Among surviving infants, the BAC ranged from 38.4 to 246.5 mg/dL. Conclusion. We identified no deaths with a BAC <96 mg/dL. However, it is not clear if this represents the lower level of BAC where mortality risk increases. In this article, we present 9 suggestions to improve detection and management of these mothers and their infants.

Prenatal Alcohol Exposure and the Associated Risk of Elevated Blood Pressure: A Cross-sectional Analysis of 3- to 17-Year-Olds in Germany

BACKGROUND

As the prevalence of obesity and high blood pressure increases among the population, early action is needed to reduce blood pressure. Certain lifestyles during pregnancy have negative effects resulting in high blood pressure for children and adolescents. Using data from the "German Health Interview and Examination Survey for Children and Adolescents" (KiGGS), this study analyzed: (i) the association between low-to-moderate prenatal alcohol exposure (PAE) and the risk of increased systolic and diastolic blood pressure and (ii) whether associations were modified by socioeconomic status (SES), prenatal smoke exposure (PSE), and body mass index (BMI) of the children and adolescents.

METHODS

We applied multivariate logistic regression analyses and stratified analyses by SES, PSE, and BMI with cross-sectional data from the KiGGS study (N = 14,253) to examine the association between PAE and prehypertension or hypertension in 3- to 17-year-olds.

RESULTS

Of the surveyed children and adolescents, 13.7% had a systolic prehypertension and 11.5% had a diastolic prehypertension. A further 7.5% were identified as having systolic hypertension and 6.0% diastolic hypertension. In the regression analyses, PAE resulted in a decreased risk of systolic prehypertension (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.70, 0.99) and diastolic prehypertension (OR: 0.82, 95% CI: 0.68, 0.98). Risk reductions were not significant in surveyed children and adolescents with hypertension. Interactions between PAE and SES, PSE, and offspring BMI were not significant.

CONCLUSIONS

Contrary to our initial hypothesis, PAE reduces the risk of prehypertension. Animal studies suggest that vasodilation is induced by nitric oxide in small quantities of PAE.

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.

Investigating Mechanisms of Stillbirth in the Setting of Prenatal Substance Use

Introduction

Intrauterine fetal demise affects between 0.4-0.8% of pregnancies worldwide. This significant adverse pregnancy outcome continues to be poorly understood. In utero exposure to substances increases the risk of stillbirth to varying degrees according to the type of substance and degree of exposure. The aim of this qualitative narrative review is to investigate common biologic relationships between stillbirth and maternal substance use.

Methods

A PubMed literature search was conducted to query the most commonly used substances and biologic mechanisms of stillbirth. Search terms included "stillbirth," "intrauterine fetal demise," "placenta," "cocaine," "tobacco," "alcohol," "methamphetamines," "opioids/ opiates," and "cannabis."

Results

There are very few studies identifying a direct link between substance use and stillbirth. Several studies demonstrate associations with placental lesions of insufficiency including poor invasion, vasoconstriction, and sequestration of toxic substances that inhibit nutrient transport. Restricted fetal growth is the most common finding in pregnancies complicated by all types of substance use.

Discussion

More research is needed to understand the biologic mechanisms of stillbirth. Such knowledge will be foundational to understanding how to prevent and treat the adverse effects of substances during pregnancy.

Differential correlations between maternal hair levels of tobacco and alcohol with fetal growth restriction clinical subtypes

Maternal exposure to tobacco and alcohol is a known cause, among others, for fetal growth restriction (FGR). Clinically, FGR can be subclassified into two forms: intrauterine growth restriction (IUGR) and small for gestational age (SGA), based on the severity of the growth retardation, and abnormal uterine artery Doppler or cerebro-placental ratio. This study aimed at investigating any differential correlation between maternal exposures to these toxins with the two clinical forms of FGR. Therefore, a case-control study was conducted in Barcelona, Spain. Sixty-four FGR subjects, who were further subclassified into IUGR (n = 36) and SGA (n = 28), and 89 subjects matched appropriate-for-gestational age (AGA), were included. The levels of nicotine (NIC) and ethyl glucuronide (EtG), biomarkers of tobacco and alcohol exposure, respectively, were assessed in the maternal hair in the third trimester. Our analysis showed 65% of the pregnant women consumed alcohol, 25% smoked, and 19% did both. The odds ratios (ORs) of IUGR were 21 times versus 14 times for being SGA with maternal heavy smoking, while with alcohol consumption the ORs for IUGR were 22 times versus 37 times for the SGA group. The differential correlations between these toxins with the two subtypes of FGR suggest different mechanisms influencing fetal weight. Our alarming data of alcohol consumption during pregnancy should be considered for further confirmation among Spanish women.

Self-report measure as a useful tool to identify prenatal substance use and predict adverse birth outcomes

Objectives

The purpose of the current study was to examine whether a self-report measure identifies prenatal substance use and predicts resulting adverse birth outcomes in a large cohort using electronic medical records.

Methods

Pregnant patients who were admitted between 2014 and 2015 at Christiana Care Health System and delivered singleton birth were included in the analyses ( N = 11,020). Participant demographic information, pregnancy comorbidities, self-reported substance use, and birth outcomes were retrieved from electronic medical records. Detailed descriptive analyses of prenatal substance use were conducted, and logistic models were evaluated for the associations between substance use and each birth outcome (preterm birth, low birth weight, neonatal intensive care unit admission).

Results

The average maternal age was 30 years (standard deviation: 6), 37% receiving Medicaid. Over 58% were White, 26% were Black, and 13% were Hispanic. Cigarette smoking only showed the highest prevalence among substance users (53%). Self-reported cigarette smoking and illicit drug use other than marijuana significantly predicted all three adverse birth outcomes (Adjusted Odds Ratio [AOR] range: 1.33 (95% Confidence Interval [CI]: 1.08–1.64)–3.09 (95% CI: 2.03–4.67)). Nonresponders to the cigarette smoking question also significantly predicted two adverse birth outcomes of preterm birth delivery (AOR: 4.16; 95% CI: 1.27–14.71) and having low birth weight babies (AOR: 3.50; 95% CI: 1.04–12.61). Conclusions/Importance: Prenatal cigarette smoking only had the highest prevalence, and co-use with illicit drugs was also high, leading to significant associations with adverse birth outcomes. The study findings indicate that the self-report measurement is a useful tool to identify prenatal substance use and predict resulting adverse birth outcomes.

Drinking and smoking patterns during pregnancy: Development of group-based trajectories in the Safe Passage Study

Precise identification of drinking and smoking patterns during pregnancy is crucial to better understand the risk to the fetus. The purpose of this manuscript is to describe the methodological approach used to define prenatal drinking and smoking trajectories from a large prospective pregnancy cohort, and to describe maternal characteristics associated with different exposure patterns. In the Safe Passage Study, detailed information regarding quantity, frequency, and timing of exposure was self-reported up to four times during pregnancy and at 1 month post-delivery. Exposure trajectories were developed using data from 11,692 pregnancies (9912 women) where pregnancy outcome was known. Women were from three diverse populations: white (23%) and American Indian (17%) in the Northern Plains, US, and mixed ancestry (59%) in South Africa (other/not specified [1%]). Group-based trajectory modeling was used to identify 5 unique drinking trajectories (1 none/minimal, 2 quitting groups, 2 continuous groups) and 7 smoking trajectories (1 none/minimal, 2 quitting groups, 4 continuous groups). Women with pregnancies assigned to the low- or high-continuous drinking groups were less likely to have completed high school and were more likely to have enrolled in the study in the third trimester, be of mixed ancestry, or be depressed than those assigned to the none/minimal or quit-drinking groups. Results were similar when comparing continuous smokers to none/minimal and quit-smoking groups. Further, women classified as high- or low-continuous drinkers were more likely to smoke at moderate-, high-, and very high-continuous levels, as compared to women classified as non-drinkers and quitters. This is the first study of this size to utilize group-based trajectory modeling to identify unique prenatal drinking and smoking trajectories. These trajectories will be used in future analyses to determine which specific exposure patterns subsequently manifest as poor peri- and postnatal outcomes.

Unrealistic optimism with regard to drinking during pregnancy among women of childbearing age in a South African community

Drinking alcohol during pregnancy is a risk factor in a range of adverse birth outcomes, including fetal alcohol spectrum disorders, and is a major health concern. For this behaviour to change one of the necessary conditions is for women to have an accurate perception of the risks drinking during pregnancy poses. A major obstacle to this is the presence of unrealistic optimism which leads to women believing they are less at risk than others. This study examined a sample of women ( N = 129) from a community in the Northern Cape Province in South Africa with a high prevalence of fetal alcohol spectrum disorder for signs of unrealistic optimism. A questionnaire about the perception of personal and general risk was administered during a one-on-one interview and responses compared. Neither a Student’s t-test ( t(115) = −1.720, p = .088, 95% confidence interval [−0.180, 0.013]) nor a Wilcoxon matched-pairs signed-rank test ( z = −1.72, p = .285) showed a significant difference. The perception of risk posed by drinking during pregnancy to others, knowledge of fetal alcohol spectrum disorder, and the perception of how easy it would be for the participant to quit drinking were significant predictors of the perception of personal risk. Only the perception of personal risk predicted the perception of general risk. There was no evidence that participants believed themselves to be less at risk than their peers when it came to the risks of drinking during pregnancy. Future directions for research into unrealistic optimism and drinking during pregnancy are discussed.

Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care

INTRODUCTION

Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs).

STUDY DESIGN

RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016.

SETTING/PARTICIPANTS

Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18-44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers.

INTERVENTION

Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources.

MAIN OUTCOME MEASURES

Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up.

RESULTS

In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of -0.233 (95% CI=-0.239, -0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, -0.233; 95% CI=-0.019, -0.521).

CONCLUSIONS

CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern.

TRIAL REGISTRATION

This study is registered at clinicaltrials.gov NCT01032772.

Nondaily Smokers' Characteristics and Likelihood of Prenatal Cessation and Postpartum Relapse

INTRODUCTION

This study aimed to calculate the prevalence of pre-pregnancy nondaily smoking (<1 cigarette/day), risk factors, and report of prenatal provider smoking education; and assess the likelihood of prenatal cessation and postpartum relapse for nondaily smokers.

METHODS

We analyzed data from 2009 to 2011 among women with live-born infants participating in the Pregnancy Risk Assessment Monitoring System. We compared characteristics of pre-pregnancy daily smokers (≥1 cigarette/day), nondaily smokers, and nonsmokers (chi-square adjusted p < .025). Between nondaily and daily smokers, we compared proportions of prenatal cessation, postpartum relapse (average 4 months postpartum), and reported provider education. Multivariable logistic regression calculated adjusted prevalence ratios (APR) for prenatal cessation among pre-pregnancy smokers (n = 27 360) and postpartum relapse among quitters (n = 13 577).

RESULTS

Nondaily smokers (11% of smokers) were more similar to nonsmokers and differed from daily smokers on characteristics examined (p ≤ .001 for all). Fewer nondaily smokers reported provider education than daily smokers (71.1%, 86.3%; p < .001). A higher proportion of nondaily compared to daily smokers quit during pregnancy (89.7%, 49.0%; p < .001), and a lower proportion relapsed postpartum (22.2%, 48.6%; p < .001). After adjustment, nondaily compared to daily smokers were more likely to quit (APR: 1.65; 95% confidence interval [CI]: 1.58-1.71) and less likely to relapse postpartum (APR: 0.55; 95% CI: 0.48-0.62).

CONCLUSIONS

Nondaily smokers were more likely to quit smoking during pregnancy, less likely to relapse postpartum, and less likely to report provider education than daily smokers. Providers should educate all women, regardless of frequency of use, about the harms of tobacco during pregnancy, provide effective cessation interventions, and encourage women to be tobacco free postpartum and beyond.

IMPLICATION

Nondaily smoking (<1 cigarette/day) is increasing among US smokers and carries a significant risk of disease. However, smoking patterns surrounding pregnancy among nondaily smokers are unknown. Using 2009-2011 data from the Pregnancy Risk Assessment Monitoring System, we found pre-pregnancy nondaily smokers compared to daily smokers were 65% more likely to quit smoking during pregnancy and almost half as likely to relapse postpartum. Providers should educate all women, regardless of frequency of use, about the harms of tobacco during pregnancy, provide effective cessation interventions, and encourage women to be tobacco free postpartum and beyond.

Pregnancy outcome in more than 5000 births to women with viral hepatitis: a population-based cohort study in Sweden

Previous studies have shown inconsistent results with respect to hepatitis B (HBV), hepatitis C (HCV) and pregnancy outcome. The aim of this study was to investigate pregnancy outcome in women with HBV or HCV. In a nationwide cohort of births between 2001 and 2011 we investigated the risks of adverse pregnancy outcomes in 2990 births to women with HBV and 2056 births to women with HCV using data from Swedish healthcare registries. Births to women without HBV (n = 1090 979), and births without HCV (n = 1091 913) served as population controls. Crude and adjusted relative risks (aRR) were calculated using Poisson regression analysis. Women with HCV were more likely to smoke (46.7 vs. 8.0%) and to have alcohol dependence (18.9 vs. 1.3%) compared with population controls. Most women with HBV were born in non-Nordic countries (91.9%). Maternal HCV was associated with a decreased risk of preeclampsia (aRR: 0.39, 95% CI: 0.24–0.64), but an increased risk of preterm birth (aRR: 1.32, 95% CI: 1.08–1.60) and late neonatal death (7–27 days: aRR: 3.79, 95% CI: 1.07–13.39) Preterm birth were also more common in mothers with HBV, aRR: 1.21 (95% CI: 1.02–1.45). Both HBV and HCV are risk factors for preterm birth, while HCV seems to be associated with a decreased risk for preeclampsia. Future studies should corroborate these findings.

Concurrent Trajectories of Female Drinking and Smoking Behaviors Throughout Transitions to Pregnancy and Early Parenthood

The purpose of this longitudinal study was to investigate whether there are distinct etiological processes explaining dual usage of alcohol and conventional cigarettes by mothers from preconception through the early parenting years. Data on 8800 biological mothers were drawn from the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B), representative of US births in 2001. A general growth mixture model (GGMM) was used to empirically identify developmental trajectories of maternal smoking and drinking over the 5-6-year study period. Six classes defined by alcohol consumption and cigarette smoking were identified. These included a nonsmoking, low probability of drinking class (41%), and two drinking classes displaying no smoking with either moderate (26%) or escalating high (8%) probability drinking. Additionally, two predominantly smoking classes were identified, one displaying temporary reduction in smoking during pregnancy and low probability of drinking (11%) and one following a trajectory of persistent heavy smoking with a declining probability of drinking (9%). The sixth class was described by temporary reduction in smoking during pregnancy with high probability of drinking (6%). Covariates differentially predicted class membership, e.g., having a high school degree but not further education predicted concurrent drinking and smoking, and breastfeeding for more than 6 months is protective against concurrent use. Prior to conception, during prenatal care, and in post-natal clinical visits, whether for personal or pediatric care, screening women of reproductive age via characteristics that predict heterogeneity in smoking and drinking trajectories may help guide prevention and treatment options.

A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations

BACKGROUND

Although this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support.

METHODS

In this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies.

RESULTS

In the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to ¼ of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25-30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude.

CONCLUSIONS

Simple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage.

Smoking during pregnancy in association with maternal emotional well-being

OBJECTIVE

The aim of the study was to investigate psychosocial predictors of smoking during pregnancy.

MATERIALS AND METHODS

It was a cross-sectional analysis of a prospective birth-cohort study. The participants were 514 mothers of full-term infants. Women completed questionnaires during hospital stay after delivery. Questionnaire included items on sociodemographic characteristics, planning and emotional acceptance of pregnancy, reproductive history, health-related behavior, emotional well-being, and relationships with a partner.

RESULTS

Smoking during pregnancy was reported by 14.8% of the participants. Prenatal smoking was associated with secondary or lower education, maternal age less than 20 years, childbirth outside of marriage, history of elective abortion, unplanned pregnancy, lack of positive emotional acceptance of pregnancy by mother and father, emotional distress and alcohol consumption during pregnancy. Smoking during pregnancy remained significantly associated with prenatal alcohol consumption, previous elective abortion, and lack of positive emotional acceptance of pregnancy by mother even after adjustment for maternal age, education, and family structure.

CONCLUSIONS

Results support an idea of complexity of the relationships among smoking, alcohol use, and emotional well-being. Lack of positive emotional acceptance of pregnancy by mother and history of elective abortions can be considered as possible associates of smoking during pregnancy and suggest that strengthening of positive attitudes toward motherhood could add to lower smoking rates among pregnant women.

Alcohol use, smoking and their co-occurrence during pregnancy among Canadian women, 2003 to 2011/12

INTRODUCTION

The co-occurrence of alcohol use and smoking during pregnancy has been shown to have a negative synergistic effect on fetal and perinatal risks. The objectives were to: 1) obtain an estimate of the prevalence of smoking during pregnancy in Canada by province and territory from 2003 to 2011/12; 2) determine if the prevalence of smoking during pregnancy has increased or decreased over time; 3) investigate whether smoking status is differentially associated with alcohol use during pregnancy; and 4) examine the risk factors predictive of alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy.

METHODS

Secondary data analysis was conducted using five cycles of the Canadian Community Health Survey (CCHS; 2003, 2005, 2007/08, 2009/10 and 2011/12). The prevalence of smoking during pregnancy, and 95% confidence interval (CI) was calculated by province and territory and by year. The likelihood ratio test was used to determine if the prevalence of smoking during pregnancy has increased or decreased over time. The relationship between smoking status and alcohol use during pregnancy was explored using a quasi-Poisson regression model. A multinomial logistic regression model was utilized to determine which factors were predictive of alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy.

RESULTS

In Canada, between 2003 and 2011/12, the weighted pooled prevalence of smoking during pregnancy was 14.3% (95% CI: 13.6%-15.0%). Women who smoked daily during pregnancy, occasionally during pregnancy, or had a lifetime history of smoking (but did not smoke while pregnant) were 2.54 (95% CI: 2.11-3.06, P < 0.0001), 2.71 (95% CI: 2.25-3.27, P < 0.0001), and 2.09 (95% CI: 1.85-2.37, P < 0.0001), respectively, times more likely to have consumed alcohol during pregnancy, compared to pregnant women who were lifetime non-smokers when controlling for age, household income, ethnicity and CCHS cycle. Risk factors that predicted alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy differed.

CONCLUSION

It is apparent that smoking in any capacity, whether during pregnancy or not, increases the likelihood that a woman consumed alcohol while pregnant. Ascertaining smoking status among pregnant women and women of childbearing age could be a useful screening method for identifying those at-risk of consuming alcohol during pregnancy, and vice versa.

Depression symptoms during pregnancy: Evidence from Growing Up in New Zealand

BACKGROUND

Depression during pregnancy has significant implications for pregnancy outcomes and maternal and child health. There is a need to identify which family, physical and mental health factors are associated with depression during pregnancy.

METHODS

An ethnically and socioeconomically diverse sample of 5664 pregnant women living in New Zealand completed a face-to-face interview during the third trimester. Antenatal depression (AD) symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Maternal demographic, physical and mental health, and family and relationship characteristics were measured. The association between symptoms of AD and maternal characteristics was determined using multiple logistic regression.

RESULTS

11.9% of the participating women had EPDS scores (13+) that indicated probable AD. When considering sociodemographic predictors of AD symptoms, we found that women from non-European ethnicities, specifically Pacific Islander, Asian and other, were more likely to suffer from AD symptoms. Greater perceived stress during pregnancy and a diagnosis of anxiety both before and during pregnancy were also associated with greater odds of having AD according to the EPDS.

LIMITATIONS

The women were in their third trimester of pregnancy at the interview. Therefore, we cannot discount the possibility of recall bias for questions relating to pre-pregnancy status or early-pregnancy behaviours.

CONCLUSIONS

AD is prevalent amongst New Zealand women. Ethnicity, perceived stress and anxiety are particularly associated with a greater likelihood of depression during pregnancy. Further attention to supporting maternal mental health status in the antenatal period is required.

Fetal alcohol spectrum disorders

Prenatal alcohol exposure (PAE) is one of the most prevalent and modifiable risk factors for somatic, behavioral, and neurological abnormalities. Affected individuals exhibit a wide range of such features referred to as fetal alcohol spectrum disorders (FASD). These are characterized by a more or less specific pattern of minor facial dysmorphic features, growth deficiency and central nervous system symptoms. Nevertheless, whereas the diagnosis of the full-blown fetal alcohol syndrome does not pose a major challenge, only a tentative diagnosis of FASD can be reached if only mild features are present and/or maternal alcohol consumption during pregnancy cannot be verified. The respective disorders have lifelong implications. The teratogenic mechanisms induced by PAE can lead to various additional somatic findings and structural abnormalities of cerebrum and cerebellum. At the functional level, cognition, motor coordination, attention, language development, executive functions, memory, social perception and emotion processing are impaired to a variable extent. The long-term development is characterized by disruption and failure in many domains; an age-adequate independency is frequently not achieved. In addition to primary prevention, individual therapeutic interventions and tertiary prevention are warranted; provision of extensive education to affected subjects and their caregivers is crucial. Protective environments are often required to prevent negative consequences such as delinquency, indebtedness or experience of physical/sexual abuse.

Prospective study of maternal alcohol intake during pregnancy or lactation and risk of childhood asthma: the Norwegian Mother and Child Cohort Study

BACKGROUND

Many women drink during pregnancy and lactation despite recommendations to abstain. In animals, alcohol exposure during pregnancy and lactation influences lung and immune development, plausibly increasing risk of asthma and lower respiratory tract infections (LRTIs). Studies in humans are few.

METHODS

In the Norwegian Mother and Child Cohort Study, we examined maternal alcohol intake during pregnancy and lactation in relation to risk of current asthma at 36 months (49,138 children), recurrent LRTIs by 36 months (39,791 children), and current asthma at 7 years (13,253 children). Mothers reported frequency and amount of alcohol intake each trimester and the first 3 months following delivery. We calculated adjusted relative risk (aRR), comparing children of drinkers to nondrinkers, using Generalized Linear Models.

RESULTS

A total of 31.8% of mothers consumed alcohol during first trimester, 9.7% during second trimester, and 15.6% during third trimester. Infrequent and low-dose prenatal alcohol exposure showed a modest statistically significant inverse association with current asthma at 36 months (aRRs ~ 0.85). No association was seen with the highest alcohol intakes during the first trimester when alcohol consumption was most common. RRs of maternal alcohol intake during pregnancy with recurrent LRTIs were ~1, with sporadic differences in risk for some metrics of intake, but without any consistent pattern. For current asthma at 7 years, similar inverse associations were seen as with current asthma at 36 months but were not statistically significant. Among children breastfed throughout the first 3 months of life, maternal alcohol intake during this time was not significantly associated with any of the 3 outcomes.

CONCLUSIONS

The low levels of alcohol exposure during pregnancy or lactation observed in this cohort were not associated with increased risk of asthma or recurrent LRTIs. The slight inverse associations of infrequent or low-dose prenatal alcohol exposure with asthma may not be causal.

Population-based study of smoking behaviour throughout pregnancy and adverse perinatal outcomes

There has been limited research addressing whether behavioural change in relation to smoking is maintained throughout pregnancy and the effect on perinatal outcomes. A cohort study addressed lifestyle behaviours of 907 women who booked for antenatal care and delivered in a large urban teaching hospital in 2010-2011. Adverse perinatal outcomes were compared for "non-smokers", "ex-smokers" and "current smokers". Of the 907 women, 270 (30%) reported smoking in the six months prior to pregnancy, and of those 160 (59%) had stopped smoking and 110 (41%) continued to smoke at the time of the first antenatal visit. There was virtually no change in smoking behaviour between the first antenatal visit and the third trimester of pregnancy. Factors associated with continuing to smoke included unplanned pregnancy (OR 1.9; 95% CI 1.3, 2.9), alcohol use (OR 3.4; 95% CI 2.1, 6.0) and previous illicit drug use (OR 3.6; 95% CI 2.1, 6.0). Ex-smokers had similar perinatal outcomes to non-smokers. Current smoking was associated with an average reduction in birth weight of 191 g (95% CI -294, -88) and an increased incidence of intrauterine growth restriction (24% versus 13%, adjusted OR 1.39 (95% CI 1.06, 1.84). Public Health campaigns emphasise the health benefits of quitting smoking in pregnancy. The greatest success appears to be pre-pregnancy and during the first trimester where women are largely self-motivated to quit.

The association between binge drinking and birth outcomes: results from the Born in Bradford cohort study

BACKGROUND

Various human and animal studies suggest that peak alcohol exposure during a binge episode, rather than total alcohol exposure, may determine fetal development. Research about the impact of binge drinking on birth outcomes is sparse and inconclusive. Data from the Born in Bradford cohort study were used to explore the impact of binge drinking on birth outcomes.

METHODS

Interview-administered questionnaire data about the lifestyle and social characteristics of 10 851 pregnancies were linked to maternity and birth data. The impact of self-reported binge drinking (5 units: 40 g of pure alcohol) on two birth outcomes (small for gestational age (SGA) and preterm birth (<37 weeks)) was assessed using multivariate logistic regression models, while adjusting for confounders.

RESULTS

The percentage of women classified as binge drinkers fell from 24.5% before pregnancy to 9% during the first trimester and 3.1% during the second trimester. There was a significant association between SGA birth and binge drinking (all categories combined; OR 1.68, 95% CI 1.15 to 2.47, p=0.01). No association was observed between moderate drinking and either birth outcome, or between binge drinking and preterm birth.

CONCLUSIONS

Binge drinking during the second trimester of pregnancy was associated with an increased risk of SGA birth. No association was found between any level of alcohol consumption and premature birth. This work supports previous research showing no association between SGA and low-alcohol exposure but adds to evidence of a dose-response relationship with significant risks observed at binge drinking levels.

CHOICES: an integrated behavioral intervention to prevent alcohol-exposed pregnancies among high-risk women in community settings

CHOICES is an integrated behavioral intervention for prevention of prenatal alcohol exposure in women at high risk for alcohol-exposed pregnancies. The intervention uses motivational interviewing and cognitive-behavioral strategies, and targets adoption of effective contraception and reduction of alcohol use. The CHOICES intervention includes four manual-guided counseling sessions delivered by behavioral health counselors and one contraceptive session with a family planning clinician. CHOICES's efficacy has been established through a series of randomized controlled trials in settings including primary care, university hospital-based obstetrical/gynecology practices, urban jails, substance abuse treatment settings, and a media-recruited sample in three large cities. This article describes the CHOICES line of research including the epidemiology, feasibility, and efficacy studies. It also details the CHOICES intervention and the components of each session. In addition, the authors describe current studies testing modifications of the CHOICES intervention, the dissemination efforts to date, and implications for social work practice.

Mothers with alcoholic liver disease and the risk for preterm and small-for-gestational-age birth

AIMS

To study pregnancy outcome in women with alcoholic liver disease (ALD).

METHODS

Using the Swedish nation-wide Patient and Medical Birth Registers, we investigated risk of adverse pregnancy outcome in 720 women diagnosed with ALD before and 1720 diagnosed after birth and compared them with 24 460 population-based control births.

RESULTS

Women with ALD diagnosed before or after birth were generally of higher age and body mass index, more likely to smoke cigarettes during pregnancy and to have a low socio-economic status compared with controls. Women diagnosed with ALD before birth had an increased risk of moderately and very preterm birth, adjusted odd ratio (OR) = 1.53 (95% confidence interval (CI): 1.37-1.72 and 1.15-2.06 95%), respectively. Infants of mothers with ALD before birth were more often small-for-gestational age, adjusted OR = 1.22 (95% CI: 1.05-1.43), and were at increased risk for low Apgar scores (<7) at 5 min, adjusted OR = 1.49 (95% CI: 1.15-1.92) compared with controls. Similar associations with slightly lower-risk estimates were found among women diagnosed with ALD after birth.

CONCLUSIONS

ALD is associated with adverse-birth outcomes, highlighting the importance of screening women for alcohol dependence in antenatal care.

Prenatal alcohol exposure, blood alcohol concentrations and alcohol elimination rates for the mother, fetus and newborn

Fetal alcohol spectrum disorders (FASDs) are a common cause of intellectual impairment and birth defects. More recently, prenatal alcohol exposure (PAE) has been found to be a risk factor for fetal mortality, stillbirth and infant and child mortality. This has led to increased concern about detection and management of PAE. One to 2 h after maternal ingestion, fetal blood alcohol concentrations (BACs) reach levels nearly equivalent to maternal levels. Ethanol elimination by the fetus is impaired because of reduced metabolic capacity. Fetal exposure time is prolonged owing to the reuptake of amniotic-fluid containing ethanol by the fetus. Alcohol elimination from the fetus relies on the mother's metabolic capacity. Metabolic capacity among pregnant women varies eightfold (from 0.0025 to 0.02 g dl(-1)  h(-1)), which may help explain how similar amounts of ethanol consumption during pregnancy results in widely varying phenotypic presentations of FASD. At birth physiological changes alter the neonate's metabolic capacity and it rapidly rises to a mean value of 83.5% of the mother's capacity. FASDs are highly recurrent and younger siblings have increased risk. Detection of prenatal alcohol use offers an important opportunity for office-based interventions to decrease exposure for the remainder of pregnancy and identification of women who need substance abuse treatment. Mothers of children with FAS have been found to drink faster, get drunk quicker and to have higher BACs. A modest increase in the prevalence of a polymorphism of alcohol dehydrogenase, which increases susceptibility to adverse outcomes from PAE has been reported. Lastly, detection of alcohol use and appropriate management would decrease risk from PAE for subsequent pregnancies.

Reducing alcohol use during pregnancy: listening to women who drink as an intervention starting point

OBJECTIVES

This study assesses factors that contribute to alcohol consumption during pregnancy and identifies potential intervention strategies to reduce consumption.

METHODS

The study sample includes 142 pregnant women who attended a public hospital for prenatal health care in Perth, Western Australia. All participants returned a self-completion survey.

RESULTS

Women who discontinued drinking during pregnancy were significantly more likely to be engaged in full time home duties and had completed less formal education. Women who continued to drink were more likely to have drunk in previous pregnancies and during the preconception period. Nearly 40% of high risk women reported a negative comment in response to their drinking. One-third of women in the risky group were advised by a health professional not to drink alcohol. Women were most likely to drink in their own home or at the home of a friend.

CONCLUSIONS

Participatory research with women who drink while pregnant can assist in identifying potential intervention strategies that have resonance with this group and therefore more potential for creating behaviour change. Implications. The World Health Organization recognises, and has done for over 10 years, that alcohol use during pregnancy which results in Foetal Alcohol Spectrum Disorder is the leading cause of environmental-related birth defects and mental retardation in the Western world.