Effects of maternal smokeless tobacco use on selected pregnancy outcomes in Alaska Native women: a case-control study

Individual- and community-level risk factors for maternal morbidity and mortality among Native American women in the USA: a systematic review

INTRODUCTION AND OBJECTIVE

Maternal morbidity and mortality (MMM) is a public health concern in the USA, with Native American women experiencing higher rates than non-Hispanic White women. Research on risk factors for MMM among Native American women is limited. This systematic review comprehensively synthesizes and critically appraises the literature on risk factors for MMM experienced by Native American women.

METHODS AND ANALYSIS

A systematic search was conducted on 10 October 2022 in PubMed, Embase, CINAHL and Scopus for articles published since 2012. Selection criteria included observational studies set in the USA, involving Native American women in the perinatal period, and examining the relationship between risk factors and MMM outcomes. Three reviewers screened and extracted data from the included studies, with risk of bias assessed using the National Institutes of Health Quality Assessment Tools. Data were analysed descriptively.

RESULTS

15 studies were included. All studies used administrative databases, with settings, including nationwide (seven studies), statewide (four studies) and Indian reservations (four studies). The majority of studies focused on hypertensive disorders of pregnancy (eight studies) and severe maternal morbidity (SMM) (four studies). 26 risk factors were identified. Key risk factors included Native American race (six studies), rural maternal residency (four studies), overweight/obese body mass index (two studies), maternal age (two studies), nulliparity (two studies) and pre-existing medical conditions (one study).

CONCLUSION

This review identified risk factors associated with MMM among Native American women, including rural residency, overweight or obesity and advanced maternal age. However, the findings also reveal a scarcity of research specific to this population, limiting the ability to fully understand these risk factors and develop effective interventions. These results emphasise the need for further research and culturally relevant studies to inform public health and address disparities for Native American women, particularly those in rural areas.

PROSPERO REGISTRATION NUMBER

CRD42022363405.

The maternal health of American Indian and Alaska Native people: A scoping review

Indigenous people in the United States experience disadvantage in multiple domains of health. Yet, their maternal health receives limited research attention. With a focus on empirical research findings, we conduct a scoping review to address two questions: 1) what does the literature tell us about the patterns and prevalence of maternal mortality and morbidity of American Indian and Alaska Native (AI/AN) people? and 2) how do existing studies explain these patterns? A search of CINAHL, Embase and Medline yielded 4757 English-language articles, with 66 eligible for close review. Of these, few focused specifically on AI/AN people's maternal health. AI/AN people experience higher levels of maternal mortality and morbidity than non-Hispanic White people, with estimates that vary substantially across samples and geography. Explanations for the maternal health of AI/AN people focused on individual factors such as poverty, cultural beliefs, and access to healthcare (e.g. lack of insurance). Studies rarely addressed the varied historical and structural contexts of AI/AN tribal nations, such as harms associated with colonization and economic marginalization. Research for and by Indigenous communities and nations is needed to redress the effective erasure of AI/AN people's maternal health experiences and to advance solutions that will promote their health and well-being.

Higher blood nicotine concentrations following smokeless tobacco (pituri) and cigarette use linked to adverse pregnancy outcomes for Central Australian Aboriginal pregnancies

BACKGROUND

In central Australia, Aboriginal women use wild tobacco plants, Nicotiana spp. (locally known as pituri) as a chewed smokeless tobacco, with this use continuing throughout pregnancy and lactation. Our aim was to describe the biological concentrations of nicotine and metabolites in samples from mothers and neonates and examine the relationships between maternal self-reported tobacco use and maternal and neonatal outcomes.

METHODS

Central Australian Aboriginal mothers (and their neonates) who planned to birth at the Alice Springs Hospital (Northern Territory, Australia) provided biological samples: maternal blood, arterial and venous cord blood, amniotic fluid, maternal and neonatal urine, and breast milk. These were analysed for concentrations of nicotine and five metabolites.

RESULTS

A sample of 73 women were enrolled who self-reported: no-tobacco use (n = 31), tobacco chewing (n = 19), or smoking (n = 23). Not all biological samples were obtained from all mothers and neonates. In those where samples were available, higher total concentrations of nicotine and metabolites were found in the maternal plasma, urine, breast milk, cord bloods and Day 1 neonatal urine of chewers compared with smokers and no-tobacco users. Tobacco-exposed mothers (chewers and smokers) with elevated blood glucose had higher nicotine and metabolite concentrations than tobacco-exposed mothers without elevated glucose, and this was associated with increased neonatal birthweight. Neonates exposed to higher maternal nicotine levels were more likely to be admitted to Special Care Nursery. By Day 3, urinary concentrations in tobacco-exposed neonates had reduced from Day 1, although these remained higher than concentrations from neonates in the no-tobacco group.

CONCLUSIONS

This research provides the first evidence that maternal pituri chewing results in high nicotine concentrations in a wide range of maternal and neonatal biological samples and that exposure may be associated with adverse maternal and neonatal outcomes. Screening for the use of all tobacco and nicotine products during pregnancy rather than focusing solely on smoking would provide a more comprehensive assessment and contribute to a more accurate determination of tobacco and nicotine exposure. This knowledge will better inform maternal and foetal care, direct attention to targeted cessation strategies and ultimately improve long-term clinical outcomes, not only in this vulnerable population, but also for the wider population.

NOTE TO READERS

In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader group of Australian First Peoples. That choice has been maintained in the reporting of the research findings.

Assessment of the Relationship Between Smoking and Depression in Pregnant Women

Smoking during pregnancy has negative effects on both maternal and fetal health. One of these negative maternal effects is the potential for depression. A high rate of cigarette smoking in pregnancy is an important public health issue since it affects not only the pregnant woman but also the newborn and its healthy development. The aim of this study is to investigate the relationship between smoking, influencing factors, and depression prevalence in pregnant Syrian refugees and pregnant citizens of the Republic of Turkey (TR). Pregnant citizens in the TR and pregnant Syrian refugees who were registered at health centers between 15.04.2017 and 15.10.2017 in the border city of Ceylanpınar in the Province of Şanlıurfa in Syria were visited in their living areas in the district center and at a tent village, respectively. A total of 414 pregnant women agreed to participate in the study and were included in the survey. To collect data for the cross-sectional study, a sociodemographic and pregnancy characteristics questionnaire was used, in addition to the Fageström Test for Nicotine Dependence (FTND) and the Beck Depression Inventory (BDI). The rate of smoking in all pregnant women was determined to be 49.3% (n = 204) before pregnancy and 37.9% (n = 157) during pregnancy. A statistically significant difference was found between age groups and educational status in relation to smoking status (p = 0.005, p = 0.001). There was also a statistically significant difference between the smoking status of pregnant women and that of their partners and family members (p = 0.001, p = 0.002). The percentage of pregnant women who were passive smokers was 80.2% (n = 332), and a statistically significant difference was found between passive smoking and smoking status (Fisher; 0.000). The presence of risk for depression was detected in 49.8% (n = 206) of all pregnant women surveyed; the rate of depression risk was 50.5% (n = 104) in pregnant TR citizens and 49.5% (n = 102) in pregnant refugees, with no significant difference between the two groups. There was a statistically significant difference between smoking status in pregnancy and the presence of depression risk (p = 0.001). 32.5% of pregnant women were highly nicotine dependent. A moderate positive correlation was determined between the FTND and BDI scores of pregnant women (r = 0.346; p = 0.001). It was found that one-third of all pregnant women smoked and that one of every two showed a risk for depression. A statistically significant correlation was found between smoking status and risk for depression. No statistically significant difference was determined between the two groups, despite high levels of smoking, nicotine dependence, and depression in both. These data suggest the need to develop new preventive strategies in regard to smoking among pregnant women.

Central Australian Aboriginal women's pregnancy, labour and birth outcomes following maternal smokeless tobacco (pituri) use, cigarette use or no-tobacco use: a prospective cohort study

BACKGROUND

Outcomes related to maternal smoked tobacco (cigarette) use have been substantially examined over the past 50 years with resultant public health education targeted towards the reduction of use during pregnancy. However, worldwide the effects of maternal smokeless tobacco use have been less well explored and in Australia, there has been no examination of maternal outcomes in relation to the use of Australian Nicotiana spp. (tobacco plant) as a smokeless tobacco, colloquially known as pituri. The aim of this study is to describe the maternal outcomes of a group of central Australian Aboriginal women in relation to their self-reported tobacco use.

METHODS

Eligible participants were > 18 years of age, with a singleton pregnancy, > 28 weeks gestation, and who planned to birth at the Alice Springs Hospital (the major regional hospital for central Australia, in the Northern Territory, Australia). The sample consisted of 73 conveniently recruited women categorized by tobacco-use status as no-tobacco users (n = 31), pituri chewers (n = 19), and smokers (n = 23).

RESULTS

There were differences in the groups in relation to teenage pregnancies; 35% of no-tobacco users, compared with 5% of pituri users, and 13% of smokers were <  20 years of age. The chewers had a higher rate (48%) of combined pre-existing and pregnancy-related elevated glucose concentrations compared with smokers (22%) and no-tobacco users (16%).The pituri chewers had the lowest rate (14%) of clinically significant post-partum hemorrhage (> 1000 ml) compared with 22% of smokers and 36% of the no-tobacco users.

CONCLUSIONS

This is the first research to examine pituri use in pregnancy and the findings indicate possible associations with a range of adverse maternal outcomes. The use of smokeless tobacco needs to be considered in maternal healthcare assessment to inform antenatal, intrapartum and postpartum care planning.

IMPLICATIONS FOR PUBLIC HEALTH

Female smokeless tobacco use is a global phenomenon and is particularly prevalent in low and middle income countries and in Indigenous populations. The findings contribute to the developing knowledge around maternal smokeless tobacco use and maternal outcomes. Maternal screening for a broader range of tobacco and nicotine products is required.

NOTE TO READERS

In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader First Peoples. That choice has been maintained in the reporting of the research findings.

Environmental & occupational exposure & female reproductive dysfunction

All individuals are exposed to certain chemical, physical, biological, environmental as well as occupational factors. The data pertaining to role of these factors on female reproduction are scanty as compared to male. The available data suggest the adverse effects of certain toxicants, viz., metals such as lead, cadmium and mercury, pesticides such as bis(4-chlorophenyl)-1,1,1-trichloroethane and organic solvent such as benzene, toluene and ionizing radiation on the female reproductive system affecting directly the organ system or impacting in directly through hormonal impairments, molecular alterations, oxidative stress and DNA methylation impairing fertility as well as pregnancy and its outcomes. Thus, there is a need for awareness and prevention programme about the adverse effects of these factors and deterioration of female reproductive health, pregnancy outcome and offspring development as some of these chemicals might affect the developing foetus at very low doses by endocrine disruptive mechanism.

Tobacco and Pituri Use in Pregnancy: A Protocol for Measuring Maternal and Perinatal Exposure and Outcomes in Central Australian Aboriginal Women

Maternal tobacco smoking is a recognized risk behavior that has adverse impacts onmaternal and fetal health. However, in some populations, the use of smokeless tobacco exceeds theuse of smoked tobacco. In central Australia, Aboriginal populations utilize wild tobacco plants(Nicotiana spp.) as a smokeless product. These plants are known by a variety of names, one of whichis pituri. The plants are masticated and retained in the oral cavity for extended periods of time andtheir use continues throughout pregnancy, birth, and lactation. In contrast to the evidence related tocombusted tobacco use, there is no evidence as to the effects of pituri use in pregnancy. CentralAustralian Aboriginal women who were at least 28 weeks pregnant were stratified into three tobaccoexposure groups: (a) Pituri chewers, (b) smokers, and (c) non-tobacco users. Routine antenatal andbirth information, pre-existing and pregnancy-related maternal characteristics, fetal characteristics,and biological samples were collected and compared. The biological samples were analysed fortobacco and nicotine metabolite concentrations. Samples from the mother included venous blood,urine, hair and colostrum and/or breast milk. From the neonate, this included Day 1 and Day 3 urineand meconium, and from the placenta, arterial and venous cord blood following delivery. This is thefirst study to correlate the pregnancy outcomes of central Australian Aboriginal women with differenttobacco exposures. The findings will provide the foundation for epidemiological data collection inrelated studies. Note to readers: In this article, the term "Aboriginal" was chosen by central Australianwomen to refer to both themselves and the Aboriginal people in their communities. "Indigenous" waschosen to refer to the wider Australian Aboriginal and Torres Strait Islander people.

Factors Associated with Low Birth Weight in Indigenous Populations: a systematic review of the world literature

Abstract Objectives: we aimed to identify etiological factors for low birth weight (LBW), prematurity and intrauterine growth restriction (IUGR) in the Indigenous Population. Methods: for this systematic review, publications were searched in Medline/PubMed, Scopus, Web of Science, and Lilacs until April 2018. The description in this review was based on the PRISMA guideline (Study protocol CRD42016051145, registered in the Centre for Reviews and Dissemination at University of York). We included original studies that reported any risk factor for one of the outcomes in the Indigenous Population. Two of the authors searched independently for papers and the disagreements were solved by a third reviewer Results: twenty-four studies were identified, most of them were from the USA, Canada and Australia. The factors associated were similar to the ones observed in the non-indigenous including unfavorable obstetric conditions, maternal malnutrition, smoking, and maternal age at the extremes of childbearing age, besides environmental factors, geographic location, and access to health care in indigenous communities. Conclusions: etiologic factors for LBW in Indigenous Population have been receiving little attention, especially in Latin America. The three outcomes showed common causes related to poverty and limited access to healthcare. New studies should ensure explicit criteria for ethnicity, quality on the information about gestational age, and the investigation on contextual and culture-specific variables.

Developmental toxicity of nicotine: A transdisciplinary synthesis and implications for emerging tobacco products

While the health risks associated with adult cigarette smoking have been well described, effects of nicotine exposure during periods of developmental vulnerability are often overlooked. Using MEDLINE and PubMed literature searches, books, reports and expert opinion, a transdisciplinary group of scientists reviewed human and animal research on the health effects of exposure to nicotine during pregnancy and adolescence. A synthesis of this research supports that nicotine contributes critically to adverse effects of gestational tobacco exposure, including reduced pulmonary function, auditory processing defects, impaired infant cardiorespiratory function, and may contribute to cognitive and behavioral deficits in later life. Nicotine exposure during adolescence is associated with deficits in working memory, attention, and auditory processing, as well as increased impulsivity and anxiety. Finally, recent animal studies suggest that nicotine has a priming effect that increases addiction liability for other drugs. The evidence that nicotine adversely affects fetal and adolescent development is sufficient to warrant public health measures to protect pregnant women, children, and adolescents from nicotine exposure.

The association between maternal smoking and placenta abruption: a meta-analysis

BACKGROUND

Several epidemiological studies have determined that maternal smoking can increase the risk of placenta abruption. To date, only a meta-analysis has been performed for assessing the relationship between smoking and placenta abruption. This meta-analysis was conducted to estimate the association between smoking and the risk of placenta abruption.

METHODS

A literature search was conducted in major databases such as PubMed, Web of Science, and Scopus from the earliest possible year to April 2016. The heterogeneity across studies was explored by Q-test and I² statistic. The publication bias was assessed using Begg's and Egger's tests. The results were reported using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random effects model.

RESULTS

The literature search yielded 1167 publications until April 2016 with 4 309 610 participants. Based on OR estimates obtained from case-control and cohort studies, there was a significant association between smoking and placenta abruption (1.80; 95% CI: 1.75, 1.85). Based on the results of cohort studies, smoking and placenta abruption had a significant association (relative risk ratio: 1.65; 95% CI: 1.51, 1.80).

CONCLUSIONS

Based on reports in epidemiological studies, we showed that smoking is a risk factor for placenta abruption.

Hormonal contraception among electronic cigarette users and cardiovascular risk: a systematic review

BACKGROUND

Women who use combined hormonal contraceptives and cigarettes have an increased risk for cardiovascular (CV) events. We reviewed the literature to determine whether women who use hormonal contraceptives (HC) and electronic cigarettes (e-cigarettes) also have an increased risk.

STUDY DESIGN

Systematic review.

METHODS

We searched for articles reporting myocardial infarction (MI), stroke, venous thromboembolism, peripheral arterial disease or changes to CV markers in women using e-cigarettes and HC. We also searched for indirect evidence, such as CV outcomes among e-cigarette users in the general population and among HC users exposed to nicotine, propylene glycol or glycerol.

RESULTS

No articles reported on outcomes among e-cigarette users using HC. Among the general population, 13 articles reported on heart rate or blood pressure after e-cigarette use. These markers generally remained normal, even when significant changes were observed. In three studies, changes were less pronounced after e-cigarette use than cigarette use. One MI was reported among 1012 people exposed to e-cigarettes in these studies. One article on nicotine and HC exposure found both exposures to be significantly associated with acute changes to heart rate, though mean heart rate remained normal. No articles on propylene glycol or glycerol and HC exposure were identified.

CONCLUSION

We identified no evidence on CV outcomes among e-cigarette users using HC. Limited data reporting mostly acute outcomes suggested that CV events are rare among e-cigarette users in the general population and that e-cigarettes may affect heart rate and blood pressure less than conventional cigarettes. There is a need for research assessing joint HC and e-cigarette exposure on clinical CV outcomes.

Substance Use in the Perinatal Period

Perinatal substance use remains a major public health problem and is associated with a number of deleterious maternal and fetal effects. Polysubstance use in pregnancy is common and can potentiate adverse maternal and fetal outcomes. Tobacco is the most commonly used substance in pregnancy, followed by alcohol and illicit substances. The treatments for perinatal substance use are limited and consist mostly of behavioral and psychosocial interventions. Of these, contingency management has shown the most efficacy. More recently, novel interventions such as progesterone for postpartum cocaine use have shown promise. The purpose of this review is to examine the recent literature on the use of tobacco, alcohol, cannabis, stimulants, and opioids in the perinatal period, their effects on maternal and fetal health, and current treatments.

Community and federal collaboration to assess pregnancy outcomes in Alaska Native women, 1997-2005

The objectives are to report the estimated prevalence of pregnancy complications and adverse pregnancy outcomes in a defined population of Alaska Native women and also examine factors contributing to an intensive and successful collaboration between a tribal health center and the Centers for Disease Control and Prevention. Investigators abstracted medical record data from a random sample of singleton deliveries to residents of the study region occurring between 1997 and 2005. We used descriptive statistics to estimate the prevalence and 95% confidence intervals of selected pregnancy complications and adverse pregnancy outcomes. Records were examined for 505 pregnancies ending in a singleton delivery to 469 women. Pregnancy complication rates were 5.9% (95% CI 4.0, 8.4) for gestational diabetes mellitus, 6.1% (95% CI 4.2, 8.6%) for maternal chronic hypertension and 11.5% (95% CI 8.8, 14.6) for pregnancy associated hypertension, and 22.9% (95% CI 19.2-26.5 %) for anemia. The cesarean section rate was 5.5% (95% CI 3.5, 7.5) and 3.8% (95% CI 2.3, 5.8) of newborns weighed >4,500 g. Few previous studies reported pregnancy outcomes among Alaska Native women in a specific geographic region of Alaska and regarding the health needs in this population. We highlight components of our collaboration that contributed to the success of the study. Studies focusing on special populations such as Alaska Native women are feasible and can provide important information on health indicators at the local level.