Publications by authors named "Jenna Kanner"

11 Publications

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Joint effects of ethnic enclave residence and ambient volatile organic compounds exposure on risk of gestational diabetes mellitus among Asian/Pacific Islander women in the United States.

Environ Health 2021 May 8;20(1):56. Epub 2021 May 8.

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Drive, MSC, Bethesda, MD, 7004, USA.

Background: Asian/Pacific Islander (API) communities in the United States often reside in metropolitan areas with distinct social and environmental attributes. Residence in an ethnic enclave, a socially distinct area, is associated with lower gestational diabetes mellitus (GDM) risk, yet exposure to high levels of air pollution, including volatile organic compounds (VOCS), is associated with increased GDM risk. We examined the joint effects of ethnic enclaves and VOCs to better understand GDM risk among API women, the group with the highest prevalence of GDM.

Methods: We examined 9069 API births in the Consortium on Safe Labor (19 hospitals, 2002-2008). API ethnic enclaves were defined as areas ≥66th percentile for percent API residents, dissimilarity (geographic dispersal of API and White residents), and isolation (degree that API individuals interact with another API individual). High levels of 14 volatile organic compounds (VOC) were defined as ≥75th percentile. Four joint categories were created for each VOC: Low VOC/Enclave (reference group), Low VOC/No Enclave, High VOC/Enclave, High VOC/No Enclave. GDM was reported in medical records. Hierarchical logistic regression estimated odds ratios (OR) and 95% confidence intervals (95%CI) between joint exposures and GDM, adjusted for maternal factors and area-level poverty. Risk was estimated for 3-months preconception and first trimester exposures.

Results: Enclave residence was associated with lower GDM risk regardless of VOC exposure. Preconception benzene exposure was associated with increased risk when women resided outside enclaves [High VOC/No Enclave (OR:3.45, 95%CI:1.77,6.72)], and the effect was somewhat mitigated within enclaves, [High VOC/Enclave (OR:2.07, 95%:1.09,3.94)]. Risks were similar for 12 of 14 VOCs during preconception and 10 of 14 during the first trimester.

Conclusions: API residence in non-enclave areas is associated with higher GDM risk, regardless of VOC level. Ethnic enclave residence may mitigate effects of VOC exposure, perhaps due to lower stress levels. The potential benefit of ethnic enclaves warrants further study.
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http://dx.doi.org/10.1186/s12940-021-00738-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106843PMC
May 2021

Asthma Medication Regimens in Pregnancy: Longitudinal Changes in Asthma Status.

Am J Perinatol 2021 Apr 21. Epub 2021 Apr 21.

Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.

Objective:  This study aimed to assess the impact of common asthma medication regimens on asthma symptoms, exacerbations, lung function, and inflammation during pregnancy.

Study Design:  A total of 311 women with asthma were enrolled in a prospective pregnancy cohort. Asthma medication regimen was categorized into short-acting β agonist (SABA) alone, SABA + inhaled corticosteroid (ICS), SABA + ICS + long-acting β agonist (LABA), and no asthma medications (reference). We evaluated asthma control at enrollment (< 15 weeks' gestation) and its change into trimesters 2 and 3, including per cent predicted forced expiratory volume in 1 second (%FEV1) and peak expiratory flow (%PEF), pulse oximetry, fractional exhaled nitric oxide (FeNO), asthma symptoms (asthma attacks/month, night symptoms/week), and severe exacerbations. Linear mixed models adjusted for site, age, race, annual income, gestational age, body mass index, and smoking, and propensity scores accounted for asthma control status at baseline.

Results:  Women taking SABA + ICS and SABA + ICS + LABA had better first trimester %PEF (83.5% [75.7-91.3] and 84.6% [76.9-92.3], respectively) compared with women taking no asthma medications (72.7% [66.0-79.3]). Women taking SABA + ICS + LABA also experienced improvements in %FEV1 (+11.1%,  < 0.01) in the third trimester and FeNO in the second (-12.3 parts per billion [ppb],  < 0.01) and third (-11.0 ppb,  < 0.01) trimesters as compared with the trajectory of women taking no medications. SABA + ICS use was associated with increased odds of severe exacerbations in the first (odds ratio [OR]: 2.22 [1.10-4.46]) and second (OR: 3.15 [1.11-8.96]) trimesters, and SABA + ICS + LABA use in the second trimester (OR: 7.89 [2.75-21.47]). Women taking SABA alone were similar to those taking no medication.

Conclusion:  Pregnant women taking SABA + ICS and SABA + ICS + LABA had better lung function in the first trimester. SABA + ICS + LABA was associated with improvements in lung function and inflammation across gestation. However, both the SABA + ICS and SABA + ICS + LABA groups had a higher risk of severe exacerbation during early to mid-pregnancy.

Key Points: · Medication regimens may affect perinatal asthma control.. · Intensive regimens improved lung function/inflammation.. · Women on intensive regimens had more acute asthma events..
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http://dx.doi.org/10.1055/s-0041-1727233DOI Listing
April 2021

Air pollution exposure and risk of adverse obstetric and neonatal outcomes among women with type 1 diabetes.

Environ Res 2021 Jun 18;197:111152. Epub 2021 Apr 18.

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Drive, Bethesda, MD, 20892, USA; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, 401 Kimball Tower, Buffalo, NY, 14214, USA.

Aims/hypothesis: Women with type 1 diabetes have increased risk for poor obstetric outcomes. Prenatal air pollution exposure is also associated with adverse outcomes for women and infants. We examined whether women with type 1 diabetes are more vulnerable than other women to pollution-associated risks during pregnancy.

Methods: In singleton deliveries from the Consortium on Safe Labor (2002-2008), obstetric and neonatal outcomes were compared for women with type 1 diabetes (n = 507) and women without autoimmune disease (n = 204,384). Preconception, trimester, and whole pregnancy average air pollutant exposure (ozone (O), carbon monoxide (CO), particulate matter >10 μm (PM), PM > 2.5 μm (PM), sulfur dioxide (SO), nitrogen oxides (NO)) were estimated using modified Community Multiscale Air Quality models. Poisson regression models with diabetes*pollutant interaction terms estimated relative risks and 95% confidence intervals for adverse outcomes, adjusted for maternal characteristics and geographic region.

Results: For whole pregnancy exposure to SO, women with type 1 diabetes had 15% increased risk (RR:1.15 95%CI:1.01,1.31) and women without autoimmune disease had 5% increased risk (RR:1.05 95%CI:1.05,1.06) for small for gestational age birth (p = 0.09). Additionally, whole pregnancy O exposure was associated with 10% increased risk (RR:1.10 95%CI:1.02,1.17) among women with type 1 diabetes and 2% increased risk (RR:1.02 95%CI:1.00,1.04) among women without autoimmune disease for perinatal mortality (p = 0.08). Similar patterns were observed between PM exposure and spontaneous preterm birth.

Conclusions: Pregnant women with type 1 diabetes may be at greater risk for adverse outcomes when exposed to air pollution than women without autoimmune disease.
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http://dx.doi.org/10.1016/j.envres.2021.111152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190832PMC
June 2021

Chronic exposure to air pollution and risk of mental health disorders complicating pregnancy.

Environ Res 2021 05 26;196:110937. Epub 2021 Feb 26.

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Drive, Bethesda, MD, 20892, USA; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, USA. Electronic address:

Background: Air pollution is associated with mental health in the general population, but its influence on maternal mental health during pregnancy has not been assessed.

Objective: We evaluated the relationship between unspecified mental disorders complicating pregnancy and depression with average air pollution exposure during 3-months preconception, first trimester and whole pregnancy.

Methods: Ambient air pollution was derived from a modified Community Multiscale Air Quality model and mental health diagnoses were based on electronic intrapartum medical records. Logistic regression models assessed the odds of unspecified mental disorder complicating pregnancy (n = 11,577) and depression (n = 9793) associated with an interquartile range increase in particulate matter (PM) less than 2.5 μm (PM), PM, carbon monoxide (CO), nitrogen dioxide (NO), nitrogen oxide (NO), sulfur dioxide (SO), and ozone (O). Pregnancies without mental health disorders were the reference group (n = 211,645). Models were adjusted for maternal characteristics and study site; analyses were repeated using cases with no additional mental health co-morbidity.

Results: Whole pregnancy exposure to PM, PM, NO, and NO was associated with a 29%-74% increased odds of unspecified mental disorders complicating pregnancy while CO was associated with 31% decreased odds. Results were similar for depression: whole pregnancy exposure to PM, PM, NO, and NO was associated with 11%-21% increased odds and CO and O were associated with 16%-20% decreased odds. SO results were inconsistent, with increased odds for unspecified mental disorders complicating pregnancy and decreased odds for depression. While most findings were similar or stronger among cases with no co-morbidity, PM and NO were associated with reduced risk and SO with increased risk for depression only.

Discussion: Whole pregnancy exposure to PM, PM, NO, and NO were associated with unspecified mental disorder complicating pregnancy and depression, but some results varied for depression only. These risks merit further investigation.
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http://dx.doi.org/10.1016/j.envres.2021.110937DOI Listing
May 2021

Does maternal race or ethnicity modify the association between maternal psychiatric disorders and preterm birth?

Ann Epidemiol 2021 04 24;56:34-39.e2. Epub 2020 Oct 24.

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD. Electronic address:

Purpose: Preterm birth risk has been linked to maternal racial and ethnic background, particularly African American heritage; however, the association of maternal race and ethnicity with psychiatric disorders and preterm birth has received relatively limited attention.

Methods: The Consortium on Safe Labor (2002-2008) is a nationwide U.S. cohort study with 223,394 singleton pregnancies. Clinical data were obtained from electronic medical records, including maternal diagnoses of psychiatric disorders. Relative risk (RR) and 95% confidence intervals (CI) were estimated for the association between maternal psychiatric disorders and preterm birth (<37 completed weeks) using log-binomial regression with generalized estimating equations. The interaction effect of maternal psychiatric disorders with race and ethnicity was also evaluated.

Results: Non-Hispanic White (RR, 1.42; 95% CI, 1.35-1.49), Hispanic (RR, 1.44; 95% CI, 1.29-1.60), and non-Hispanic Black (RR, 1.21, 95% CI, 1.13-1.29) women with any psychiatric disorder were at increased risk for delivering preterm infants, compared with women without any psychiatric disorder. However, non-Hispanic Black women with any psychiatric disorder, depression, bipolar disorder, and schizophrenia had a significantly lower increase in preterm birth risk than non-Hispanic White women.

Conclusions: Despite the significant association between maternal psychiatric disorders and preterm birth risk, psychiatric disorders did not appear to contribute to racial and ethnic disparities in preterm birth.
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http://dx.doi.org/10.1016/j.annepidem.2020.10.009DOI Listing
April 2021

Gestational and Postpartum Weight Trajectories Among Women With and Without Asthma.

Am J Epidemiol 2021 05;190(5):744-754

Asthma leads to increased weight gain in nonpregnant populations, but studies have not examined this association within the context of pregnancy. The association between asthma and perinatal weight trajectories was examined in the Breathe-Wellbeing, Environment, Lifestyle, and Lung Function Study (2015-2019). Multilevel linear spline models were adjusted for age, race/ethnicity, income, marital status, education, cigarette smoking, parity, study site, and prepregnancy body mass index were used to examine differences in perinatal weight trajectories between women with (n = 299) and without (n = 101) asthma. Secondary analyses were conducted to assess whether associations differed by asthma phenotypes. At 40 weeks' gestation, women with asthma gained 16.2 kg (95% confidence interval (CI): 14.6, 17.7) and women without asthma gained 13.1 kg (95% CI: 10.9, 15.4). At 3 months postpartum, women with asthma retained 10.4 kg (95% CI: 8.9, 11.9) and women without asthma retained 8.0 kg (95% CI: 5.9, 10.2). Among women with asthma, exercise-induced asthma and step 3 asthma medications were associated with excess gestational weight gain. These study findings suggest women with asthma gain and retain more weight during pregnancy and postpartum than do women without asthma.
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http://dx.doi.org/10.1093/aje/kwaa248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096479PMC
May 2021

Ambient temperature and stillbirth: Risks associated with chronic extreme temperature and acute temperature change.

Environ Res 2020 10 19;189:109958. Epub 2020 Jul 19.

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Drive, Bethesda, MD, USA. Electronic address:

Background: Ambient temperature events are increasing in frequency and intensity. Our prior work in a U.S. nationwide study suggests a strong association between both chronic and acute temperature extremes and stillbirth risk.

Objective: We attempted to replicate our prior study by assessing stillbirth risk associated with average whole-pregnancy temperatures and acute ambient temperature changes in a low-risk U.S.

Population:

Methods: Singleton deliveries in the NICHD Consecutive Pregnancies Study (Utah, 2002-2010; n = 112,005) were identified using electronic medical records. Ambient temperature was derived from the Weather Research and Forecasting model. Binary logistic regression determined the adjusted odds ratio (aOR) and 95% confidence interval (95% CI) for stillbirth associated with whole-pregnancy exposure to extreme cold (<10th percentile) and hot (>90th percentile) versus moderate (10th-90th percentiles) average temperature, adjusting for maternal demographics, season of conception, hypertensive disorders of pregnancy, and gestational diabetes. In a case-crossover analysis, we estimated the stillbirth aOR and 95% CI for each 1° Celsius increase during the week prior to delivery using conditional logistic regression. In both models, we adjusted for relative humidity, ozone, and fine particulates.

Results: We observed 500 stillbirth cases among 498 mothers. Compared to moderate temperatures, whole-pregnancy exposure to extreme cold (aOR: 4.42, 95% CI:3.43, 5.69) and hot (aOR: 5.06, 95% CI: 3.34, 7.68) temperatures were associated with stillbirth risk. Case-crossover models observed a 7% increased odds (95% CI: 1.04, 1.10) associated with each 1° Celsius increase during the week prior to delivery.

Discussion: Both chronic and acute ambient temperature were associated with odds of stillbirth in this low-risk population, similar to our prior nationwide findings. Future increases in temperature extremes are likely and the observed risk in a low-risk population suggests this association merits attention.
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http://dx.doi.org/10.1016/j.envres.2020.109958DOI Listing
October 2020

Air Pollution Exposure Monitoring among Pregnant Women with and without Asthma.

Int J Environ Res Public Health 2020 07 7;17(13). Epub 2020 Jul 7.

Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA.

: We monitored exposure to fine particulates (PM), ozone, nitrogen dioxide (NO), and ambient temperature for pregnant women with and without asthma. : Women ( = 40) from the Breathe-Well-Being, Environment, Lifestyle, and Lung Function Study (2015-2018) were enrolled during pregnancy and monitored for 2-4 days. Daily pollutants were measured using personal air monitors, indoor air monitors, and nearest Environmental Protection Agency's stationary monitors based on GPS tracking and home address. : Personal-monitor measurements of PM, ozone, and NO did not vary by asthma status but exposure profiles significantly differed by assessment methods. EPA stationary monitor-based methods appeared to underestimate PM and temperature exposure and overestimate ozone and NO exposure. Higher indoor-monitored PM exposures were associated with smoking and the use of gas appliances. The proportion of waking-time during which personal monitors were worn was ~56%. Lower compliance was associated with exercise, smoking, being around a smoker, and the use of a prescription drug. : Exposure did not vary by asthma status but was influenced by daily activities and assessment methods. Personal monitors may better capture exposures but non-compliance merits attention. Meanwhile, larger monitoring studies are warranted to further understand exposure profiles and the health effects of air pollution during pregnancy.
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http://dx.doi.org/10.3390/ijerph17134888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369909PMC
July 2020

Association of Maternal Exposure to Persistent Organic Pollutants in Early Pregnancy With Fetal Growth.

JAMA Pediatr 2020 02;174(2):149-161

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland.

Importance: Prenatal exposure to persistent organic pollutants (POPs) has been associated with birth size, but data on fetal growth and among racially/ethnically diverse pregnant women remain scarce.

Objectives: To assess the association between maternal plasma POPs in early pregnancy and fetal growth and by infant sex and maternal race/ethnicity.

Design, Setting, And Participants: This cohort study used the National Institute of Child Health and Human Development Fetal Growth Studies-Singleton cohort, which recruited nonobese, low-risk pregnant women before 14 weeks' gestation between July 1, 2009, and January 31, 2013, in 12 community-based clinics throughout the United States. Participants self-identified their race/ethnicity, self-reported their behavioral risk factors, and were followed up throughout their pregnancy. Data were analyzed from July 31, 2018, to June 3, 2019.

Exposures: Levels of 76 POPs in early gestation plasma were measured: 11 perfluoroalkyl and polyfluoroalkyl substances, 1 polybrominated biphenyl, 9 polybrominated diphenyl ethers (PBDEs), 44 polychlorinated biphenyls (PCBs), and 11 organochlorine pesticides (OCPs). The bayesian kernel machine regression method was used to examine chemical class mixtures, and generalized additive mixed model was used to analyze individual chemicals.

Main Outcomes And Measures: Fourteen fetal biometrics were measured, including head circumference, abdominal circumference, and femur length, within 5 ultrasonography appointments.

Results: A total of 2284 low-risk pregnant women were included: 606 women (26.5%) self-identified as white with a mean (SD) age of 30.3 (4.4) years, 589 (25.8%) as black with a mean (SD) age of 25.5 (5.5) years, 635 (27.8%) as Hispanic with a mean (SD) age of 27.1 (5.5) years, and 454 (19.9%) as Asian with a mean (SD) age of 30.5 (4.5) years. A comparison between the 75th and 25th percentile of exposure revealed that the OCP mixture was negatively associated with most fetal growth measures, with a reduction of 4.7 mm (95% CI, -6.7 to -2.8 mm) in head circumference, 3.5 mm (95% CI, -4.7 to -2.2 mm) in abdominal circumference, and 0.6 mm (95% CI, -1.1 to -0.2 mm) in femur length. Higher exposure to the PBDE mixture was associated with reduced abdominal circumference (-2.4 mm; 95% CI, -4.0 to -0.5 mm) and femur length (-0.5 mm; 95% CI, -1.0 to -0.1 mm), and the dioxin-like PCB mixture was associated with reduced head circumference (-6.4 mm; 95% CI, -8.4 to -4.3 mm) and abdominal circumference (-2.4 mm; 95% CI, -3.9 to -0.8 mm). Associations with individual chemicals were less consistent. There were some interactions by fetal sex, although most of the results did not vary by maternal race/ethnicity. For example, oxychlordane (-0.98 mm; 95% CI, -1.60 to -0.36 mm; P for interaction <.001), trans-nonachlor (-0.31 mm; 95% CI, -0.54 to -0.08 mm; P for interaction = .005), and p,p'-dichlorodiphenyldichloroethylene (-0.19 mm; 95% CI, -0.22 to -0.09 mm; P for interaction = .006) were associated with shorter femur length among boys only.

Conclusions And Relevance: This study found that, among pregnant women with low POP levels, a mixture of OCPs was negatively associated with most fetal growth measures and that mixtures of PBDEs and dioxin-like PCBs were associated with reduced abdominal circumference. These findings suggested that, although exposures may be low, associations with fetal growth are apparent.
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http://dx.doi.org/10.1001/jamapediatrics.2019.5104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990715PMC
February 2020

Ethnic Enclaves and Pregnancy and Behavior Outcomes Among Asian/Pacific Islanders in the USA.

J Racial Ethn Health Disparities 2020 04 14;7(2):224-233. Epub 2019 Nov 14.

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Drive, MSC, Bethesda, MD, 7004, USA.

Objectives: Ethnic enclaves are ethnically, spatially, and socially distinct communities that may promote health through access to culturally appropriate resources and reduced exposure to discrimination. This study examined ethnic enclave residence and pregnancy outcomes among Asian/Pacific Islander (API) women in the USA.

Design: We examined 9206 API births in the Consortium on Safe Labor (2002-2008). Ethnic enclaves were defined as hospital regions with high percentage of API residents (> 4%), high dissimilarity index (> 0.41; distribution of API and white residents within a geographic area), and high isolation index (> 0.03; interaction between API and white residents in an area). Gestational diabetes mellitus (GDM), preterm birth (PTB), small for gestational age (SGA), and smoking and alcohol use during pregnancy were reported in medical records supplemented with ICD-9 codes. Hierarchical logistic regression models estimated associations between ethnic enclaves and pregnancy outcomes, adjusted for maternal factors, area-level poverty, and air pollution.

Results: Women in enclaves had lower odds of GDM (OR 0.61; 95%CI 0.45, 0.82), PTB (OR 0.74; 95%CI 0.56, 0.99), and SGA (OR 0.68; 95%CI 0.52, 0.89) compared with women in non-enclaves. Prenatal smoking and alcohol use appeared less likely in enclaves, but estimates were imprecise. Within enclaves, about 10.5% of homes speak an API language, compared with 6.0% in non-enclaves. The mean percent of foreign-born API populations was 67.4% in enclaves and 68.8% in non-enclaves.

Conclusions: API women residing in ethnic enclaves had better pregnancy outcomes than API women residing in non-enclave areas. Access to culturally appropriate social supports and resources may be important for health promotion among API populations.
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http://dx.doi.org/10.1007/s40615-019-00650-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104626PMC
April 2020

Air Pollution and Preterm Birth: Do Air Pollution Changes over Time Influence Risk in Consecutive Pregnancies among Low-Risk Women?

Int J Environ Res Public Health 2019 09 12;16(18). Epub 2019 Sep 12.

Division of Intramural Population Health Research, Epidemiology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710B Rockledge Drive, Bethesda, MD 20895, USA.

Since the 2000s, air pollution has generally continued to decrease in the U.S. To investigate preterm birth (PTB) risk associated with air pollutants in two consecutive pregnancies, we estimated exposures using modified Community Multiscale Air Quality models linked to the NICHD Consecutive Pregnancy Study. Electronic medical records for delivery admissions were available for 50,005 women with singleton births in 20 Utah-based hospitals between 2002-2010. We categorized whole pregnancy average exposures as high (>75th percentile), moderate (25-75) and low (<25). Modified Poisson regression estimated second pregnancy PTB risk associated with persistent high and moderate exposure, and increasing or decreasing exposure, compared to persistent low exposure. Analyses were adjusted for prior PTB, interpregnancy interval and demographic and clinical characteristics. Second pregnancy PTB risk was increased when exposure stayed high for sulfur dioxide (32%), ozone (17%), nitrogen oxides (24%), nitrogen dioxide (43%), carbon monoxide (31%) and for particles < 10 microns (29%) versus consistently low exposure. PTB risk tended to increase to a lesser extent for repeated PTB (19-21%) than for women without a prior PTB (22-79%) when exposure increased or stayed high. Area-level changes in air pollution exposure appear to have important consequences in consecutive pregnancies with increasing exposure associated with higher risk.
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http://dx.doi.org/10.3390/ijerph16183365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6765877PMC
September 2019