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is available at https://doi.org/10.1289/EHP10544.
Birth Outcomes, Health, and Health Care Needs of Childbearing Women following
Wildfire Disasters: An Integrative, State-of-the-Science Review
Jo Evans,1,2 Amita Bansal,3,4 Danielle A.J.M. Schoenaker,5,6,7 Nicolas Cherbuin,8 Michael J. Peek,2,3 and
Deborah L. Davis1,9
1
School of Midwifery, University of Canberra, Canberra, Australian Capital Territory, Australia
2
Centenary Hospital for Women and Children, Canberra Health Services, Canberra, Australian Capital Territory, Australia
3
ANU Medical School, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
4
John Curtin School of Medical Research, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
5
School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
6
NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
7
School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales,
Australia
8
Centre for Research on Ageing, Health and Wellbeing, Research School of Population Health, Australian National University, Canberra, Australian Capital
Territory, Australia
9
ACT Government, Health Directorate, Canberra, Australian Capital Territory, Australia
BACKGROUND: The frequency and severity of extreme weather events such as wildfires are expected to increase due to climate change. Childbearing
women, that is, women who are pregnant, soon to be pregnant, or have recently given birth, may be particularly vulnerable to the effect of wildfire
exposure.
OBJECTIVES: This review sought to systematically assess what is known about birth outcomes, health, and health care needs of childbearing women
during and after exposure to wildfires.
METHODS: An integrative review methodology was utilized to enable article selection, data extraction, and synthesis across qualitative and quantita-
tive studies. Comprehensive searches of SCOPUS (including MEDLINE and Embase), CINAHL, PubMed, and Google Scholar identified studies for
inclusion with no date restriction. Included studies were independently appraised by two reviewers using the Crowe Critical Appraisal Tool. The find-
ings are summarized and illustrated in tables.
RESULTS: Database searches identified 480 records. Following title, abstract, and full text screening, sixteen studies published between 2012 and 2022
were identified for this review. Eleven studies considered an association between in utero exposure to wildfire and impacts on birth weight and length
of gestation. One study reported increased rates of maternal gestational diabetes mellitus and gestational hypertension following exposure; whereas
one study reported differences in the secondary sex ratio. Two studies reported higher incidence of birth defects following in utero exposure to wild-
fire smoke. Three studies reported increased mental health morbidity, and one study associated a reduction in breastfeeding among women who evac-
uated from a wildfire disaster.
DISCUSSION: Evidence indicates that wildfire exposure may be associated with changes to birth outcomes and increased morbidity for childbearing
women and their babies. These effects may be profound and have long-term and wide-ranging public health implications. This research can inform
the development of effective clinical and public health strategies to address the needs of childbearing women exposed to wildfire disaster. https://doi.
org/10.1289/EHP10544
Note: CCAT domains and items assessed within the domain [Refer to: Crowe Critical Appraisal Tool (CCAT) User Guide Version 1.422 for further detail]. Preliminaries refer to title, abstract, and text. Introduction refers to background and
lection protocol. Ethical matters includes participant ethics and researcher ethics. Results refers to analysis, integration, interpretation method, essential analysis, outcome, output, and predictor analysis. Discussion includes interpretation, gener-
objectives. Design refers to research design, intervention, treatment, exposure; outcome, output, predictor, measure; bias. sampling refers to sampling method, sample size, sampling protocol. Data collection refers to collection method and col-
Phillips Verstraeten DeYoung
3 3.5
4 3.5
4 2.5
R2
66.875
et al.38
3 2
4 3
4 4
4 2
4 3
and exclusion criteria, and recruitment strategy.
“Data collection” included an assessment of data collection
R1
protocols and suitability of methods for individual study designs;
4.5
3.5
3.5
R2
use of tools to enhance data quality, validity, and reliability;
85.625
et al.37
4
4
efforts to eliminate bias; control for confounding and effect modi-
fiers; and assessment of how nonparticipation and incomplete or
R1
5
4
5
5
4
4
4
5
missing data were treated.
4.5
4.5
4.5
R2
“Ethical matters” included an assessment of participant ethics,
Brémault-
83.175
et al.39
4
2
3
4
5
including equity and informed consent (where applicable), pri-
R1
5
4
4
3
4
5
5
5
vacy and anonymity consideration, and an assessment of
researcher ethics comprising ethical approval (where appropri-
et al.34 O’Donnell23
4.5
4.5
4.5
R2
ate), identification of conflicts of interest, and sources of funding.
94.375
5
5
5
5
“Results” included an assessment of the suitability and
robustness of analysis; integration and interpretation methods,
R1
5
5
4
4
5
5
4
5
including statistical and nonstatistical methods; demographic
data and subgroup analyses (where relevant); and whether analy-
4 4.5
4 4.5
4 4.5
R2
Holstius
88.125
4 5
4 5
4 5
4 5
4 4
sis and interpretation methods were suited to research design and
R1
objectives.
“Discussion” included an assessment of how study results
O’Donn- O’Donnell
R2
Behie24
4
5
3
3
3
5
4
5
could be interpreted and could build on current evidence and con-
81.5
and
sidered limitations and the role of bias as well as the generaliz-
R1
ability of findings and recommendations for further research.
5
4
3
4
3
5
4
5
Although the CCAT allows the appraisal framework to be
4 4.5
4 4.5
R2
Behie25
ell and
83.75
4 4
4 4
3 4
4 5
5 5
4 4
used across study designs, it also introduces a level of subjectiv-
R1
ity to the process. Appraisers are encouraged to publish scores
for each domain rather than only totals so that a more granular
R2
96.365
5
5
5
4
5
5
5
5
et al.33
understanding of the appraisal is presented. The strength of this Abdo
framework lies in the comprehensive, consistent, and standar-
R1
5
5
5
4
4
5
5
5
dized framework provided for the appraisal across a variety of
Costello28 McDermott29 et al.30 et al.31 and Zhao32
3.5
2.5
R2
research designs.
McCoy
2
4
3
2
4
5
66.5
Overall, all 16 studies were deemed of sufficient quality to be
R1
Table 2.
4 5
5 5
4 4
4 4
4 4
5 5
5 5
5 5
91.25
Data Extraction and Synthesis
Features of included studies were extracted in tabular format to
facilitate analysis and comparison across studies by one researcher
R2
Jones and
2
3
3
3
4
4
4
4
R2
et al.36
83.75
Results
et al.35
Amini
85.62
4 3
5 5
4 5
4 4
5 5
4 4
4 5
R1
Search Results
alization and concluding remarks.
96.25
score/100
Introduction
152 had outcomes that were not relevant to the objectives of this
Reviewer 1.
Reviewer 2.
Discussion
Sampling
086001-5
Precipitation data derived from the trimester within the boundaries of
Climate Prediction Center and the mother’s home municipality
National Oceanic and Atmospheric Comparison: dose–response measured
Administration (NOAA) as an increase of 100 wildfire
records
Requia, W.J., Papatheodorou, S., Brazil Time-stratified Administrative data: birth certificate Exposure window: in utero at time of Risk of preterm birth increased following exposure
Koutrakis, P., Mukherjee, R., Wildfire smoke case-crossover data from Ministry of Health–Brazil wildfire smoke exposure to PM2:5 during a “wildfire wave”
& Roig, H.L. exposure study of Satellite imagery: National Institute of Each trimester exposure was based on • [OR 1.41 (95% CI: 1.31, 1.51)] first trimester ex-
2022 2001–2018 190,911 pre- Spatial Research–Brazil/Instituto the average of daily estimated wildfire posure in southeast region
Increased preterm birth follow- term births Nacional de Pesquisas Espaciais exposure, pollutant concentrations • [OR 1.04 (95% CI: 1.01, 1.07)] first trimester ex-
ing maternal wildfire smoke 2001–2018 (INPE) at an image resolution from (PM2:5 , CO, NO2 , and O3 ) and mete- posure in Midwest region
exposure in Brazil. 375 m × 375 m to 5 km × 4 km orological variables. • [OR 1.05 (95% CI: 1.01, 1.09)] second trimester
Ambient air pollution and weather Spatial resolution of birth data was based exposure in north region
data: Environmental Information on the mother’s home municipality. • [OR 1.06 (95% CI: 1.04, 1.07)] second trimester
System for Health/Instituto Nacional 5,572 municipalities were grouped into exposure in south region
de Pesquisas Espaciais (INPE) 5 regions
PM2:5 : ground observations of the Comparison: exposure to a “wildfire
Aerosol Robotic Network wave” vs. nonexposure. The “wildfire
(AERONET) wave” concept was adopted to capture
Precipitation data derived from the periods with high wildfire occurrences:
Climate Prediction center and A “wildfire wave” was any average
National Oceanic and Atmospheric value of wildfire records and PM2:5
Administration (NOAA) concentration that exceeded the 90th
percentile of the time series.
086001-6
Perez., & Yao, R. 2007–2010 births 2007– Geospatial fire imaging from The Geospatial • 7.8 vs. 5.7 per 10.000 births [aRR 1.28 (95% CI:
2021 2010 California Department of Forestry Wildfire exposure was defined as the 1.07, 1.54)] first trimester exposure
The association between wild- and Fire Protection (CAL FIRE) mother’s primary residence zip code • 12.5 vs. 5.7 per 10,000 births [aRR 2.21 (95% CI:
fire exposure in pregnancy within 15 miles of the edge of a 1.40, 3.48)] preconception exposure (up to 30 d
and fetal gastroschisis: A wildfire prior to pregnancy)
population-based cohort Comparison: exposed vs non-exposed
study.
Requia, W.J., Kill. E., Brazil Retrospective Administrative data: birth certificate Exposure window: in utero at time of Cleft lip/palate: increased incidence following
Papatheodorou, S., Wildfire smoke cohort study data from Ministry of Health–Brazil wildfire smoke exposure exposure
Koutrakis, P., & exposure of 16,825,497 Satellite imagery: National Institute of Temporal-spatial • [OR 1.007 (95% CI: 1.001; 1.013)] (second
Schwartz, J.D. 2001–2018 births between Spatial Research–Brazil/Instituto Spatial resolution of birth data was trimester)
2021 2001 and Nacional de Pesquisas Espaciais based on the mother’s home munici-
Prenatal exposure to wildfire- 2018 (INPE) pality. 5,572 municipalities were Congenital anomalies of the respiratory system
related air pollution and Ambient air pollution including daily grouped into five regions increased following exposure
• [OR 1.007 (95% CI: 1.002; 1.023)] (second trimes-
birth defects in Brazil. PM2:5 levels and weather data: Birth defects were categorized using
Environmental Information System International Statistical ter exposure)
for Health/Instituto Nacional de Classification of Diseases and Congenital anomalies of the nervous system in-
Pesquisas Espaciais (INPE) Related Health Problems (ICD) creased following exposure
Precipitation data derived from the codes • [OR 1.002 (95% CI: 1.001; 1.003)] (first trimester
Climate Prediction Center and Comparison: dose–response—sum of exposure in south, north and midwestern regions)
National Oceanic and Atmospheric wildfire records
Administration (NOAA)
086001-7
trimester)
• [OR 1.144 (95% CI: 1.064, 1.230; p = 0:0003)]
(1st trimester)
Gestational Hypertension: increased incidence fol-
lowing exposure
• [OR 1.204 (95% CI: 1.083, 1.339; p = 0:0006)]
(any trimester)
• [OR 1.140 (95% CI: 1.071, 1.231; p = 0:0001)]
(first trimester)
• [OR 1.124 (95% CI: 1.044, 1.211; p = 0:0020)]
(second trimester)
NICU admission: reduced incidence following
exposure
• [OR 0.957 (95% CI: 0.926, 0.989; p = 0:0093)]
(any trimester)
Assisted ventilation: reduced incidence following
exposure
• [OR 0.875 (95% CI: 0.837, 0.915; p < 0:0001)]
(any trimester)
O’Donnell, M.H., & Canberra, ACT, Retrospective Administrative data: neonatal collec- Exposure window: in utero at time of Male birth weight
Behie, A.M. Australia cohort study tion, ACT Government Health Canberra Bushfire (births occurred • 197 g heavier in the severely affected area com-
2015 “Canberra bush- of 48,408 Directorate Epidemiology Section between February and October pared with the moderately affected area (F = 5:73,
Effects of wildfire disaster fire” births between (Population Health Informatics) 2009) in fire-affected statistical local p < 0:003, df = 2)
exposure on male birth government areas)
086001-8
• increased incidence of preterm 28–31/40 birth
dential address at the time of the
fires. (z = 0:5; p = 0:043)
• increased incidence of preterm 32–36/40 birth
(z = 0:5; p = 0:043)
Gestational Age: second trimester exposure
• increased incidence of preterm 20–27/40 birth
(50% increase) (z-value 2.0; p = 0:043)
• increased incidence of preterm 32–36/40 birth
(z = 1:1; p = 0:022)
• increased incidence of postterm >41=40 birth
(z = 1:0; p = 0:022)
Gestational Age: first trimester exposure
• increased incidence of postterm >41=40 birth
(z = 1:8; p = 0:000)
Holstius, D.M., Reid, C.E., South Coast Air Retrospective Administrative neonatal collection: Exposure window: in utero at time of Mean birth weight at term: reduction following ex-
Jesdale, B.M., & Basin, cohort study Birth Statistical Master File (Center fires: 21 October 2003–10 posure compared to nonexposed pregnancies
Morello-Frosch, R. California, of 886,034 for Health Statistics, Department of November 2003 from earlier/later years
2012 USA births between Health Services, California) Temporal-spatial
086001-9
• Trauma, fear, and risk
Australia Survey and Morbidity–Victorian State Dept described as “severely affected,”
• Evacuation, displacement, separation, effect on
“Black Saturday Semistructured Health areas where deaths and property
bushfires” interviews Fire-affected Statistical and Local damage occurred; “moderately relationships
• Resilience and resilience strategies
7 February 2009 Government Area geodata affected,” where property damage
• Social outcomes – tobacco and alcohol use, vio-
(31-day event) Self-selected survey and interview occurred, and; “least affected,”
participants recruited via social where no damage occurred and lence against women
• Access to health care, support, and counselling
media and internet forums, govern- linked to maternal residential address
ment websites and health care pro- at the time of the fires
viders For the Black Saturday bushfires:
Survey (30 questions), 43 respondents Fire exposure was divided into “fire-
Semi-structured interview, 7 partici- affected” and “not affected” local
pants government areas (LGA) and linked
to maternal residential address at the
time of the fires.
Brémault-Phillips, S., Pike, Fort McMurray, Qualitative anal- 54 self-selected participants recruited Resident of Fort McMurray Wood Qualitative themes explored following exposure and
A., Olson, J., Severson, E., Alberta, ysis of via social and mainstream media Buffalo in May 2016, evacuated evacuation:
& Olson D. Canada expressing completed: from Fort McMurray because of the • Fear: for one’s life or the life of a loved one, loss
2020 Fort McMurray writing • a questionnaire and demographic wildfire, and pregnant at the time of of home or possessions, inability to mother, long-
Wood Buffalo journals survey the wildfire or became pregnant term consequences
wildfire within 6 months of the wildfire
086001-10
Scale
DeYoung, S.E., Chase, J., Fort McMurray, Mixed Methods 164 participants recruited through pur- Resident of Fort McMurray Wood Infant feeding:
Branco, M.P., & Park, B. Alberta, Survey posive sampling recruited via social Buffalo in May 2016, evacuated • decreased exclusive breastfeeding with women
2018 Canada Qualitative anal- media and local mainstream news- from Fort McMurray because of the more likely to have exclusively breastfed infants
The Effect of Mass Fort McMurray ysis of free papers completed a 30-question sur- wildfire and also feeding infants prior to exposure/evacuation (OR 1.96)
Evacuation on Infant Wood Buffalo text vey which consisted of both open- (birth–36 months) during the evacu- • increased artificial formula feeding (10.9% before
Feeding: The Case of the wildfire ended items and items with categori- ation and aftermath of fire vs. 12.3% after evacuation)
2016 Fort McMurray May 2016 cal responses.
Wildfire (32-day event)
Qualitative themes:
• Evacuation stressors—lack of social support, lo-
gistics of evacuation
• Food security/nutrition concerns—lack of healthy
options/choice
• Perception of low supply/lactation concerns—
pressure to wean, lack of privacy, lack of lactation
support
• Breastfeeding as a source of comfort and security
Note: aRR, adjusted relative risk; CI, confidence interval; df, degrees of freedom; LBW, low birth weight; OR, odds ratio; PTSD, posttraumatic stress disorder; RR, relative risk.
Brémault-Phillips — — — — — — — a a
— a
et al.39
Verstraeten et al.37 — — — — — — — a
— — a
DeYoung et al.38 — — — — — — — — — a a
Note: —, no data; D, decrease; I, increase; NE, no effect; NICU, neonatal intensive care unit.
a
Thematic qualitative finding.
differences in birth weight by sex, male babies born in the or no difference in gestational age at birth for babies born to
severely affected area were on average 197 g heavier in compari- women who resided in severely affected areas in comparison with
son with male babies born in the moderately affected area follow- least-affected areas following the 2003 Canberra Bushfires,23,25
ing in utero exposure to the 2003 Canberra bushfire.23,25 These although each 1-lg=m3 increase in concentration of wildfire-
studies also reported an increased incidence of macrosomia, generated PM2:5 was associated with increased incidence of pre-
which birth weight greater than the 90th centile for gestational term birth for babies born to women exposed to wildfire smoke in
age, for male babies following in utero exposure to this bushfire, Colorado during the period 2007–2015 at any time during preg-
with the largest increase occurring for males born between nancy (OR = 1:078; 95% CI: 1.016, 1.139; p = 0:013), with
4,501 and 5,000 g.23,25 increased effect for second trimester exposure (OR = 1:132; 95%
Where timing of exposure to wildfire and association with birth CI: 1.088, 1.178; p < 0:0001).33 Incidence of preterm birth was
weight were considered, results varied. Both first trimester expo- higher by 1.2%, from a base of 10% for women exposed to mega-
sure33,35 and all trimester exposure32,34 were associated with fires in comparison with nonexposure in the United States during
lower birth weight. Proximity of exposure and severity of expo- the period 2010–2017,29 and a higher risk of preterm birth with
sure to wildfire disaster was also associated with lower birth each additional day of wildfire smoke exposure in California
weight,24,25,29 whereas elevated exposure to wildfire-related during the period 2006–2012 at any time during pregnancy
PM2:5 was associated with lower birth weight, with a dose– [relative risk ðRRÞ = 0:49%; 95% CI: 0.41%, 0.59%], with a
response relationship observed.33 larger effect for second trimester (RR = 0:83%; 95% CI: 0.71%,
Eight studies reported on wildfire exposure and gestational 0.96%) and third trimester (RR = 0:68%; 95% CI: 0.49%, 0.87%)
age at birth.23–25,27–29,33,36 Findings varied between studies and exposure.27
fire events. Findings included increased odds of preterm birth Birth defects. Two studies examined the association between
after exposure to “wildfire-wave” related PM2:5 with differences exposure to wildfire and birth defects.30,31 One study of wildfire
between Brazil’s geographic regions and trimester of exposure exposure in California between 2007 and 2010 reported that first
[OR ðodds ratioÞ = 1:41 ; 95% confidence interval (CI): 1.31, trimester exposure, in comparison with no exposure, was associ-
1.51] following first trimester exposure in southeast region, ated with higher rates of gastroschisis: 7.8 vs. 5.7 per 10,000 births
(OR = 1:04; 95% CI: 1.01, 1.07) following first trimester exposure (aRR = 1:28; 95% CI: 1.07, 1.54).30 This study also found that pre-
in Midwest region (OR = 1:05; 95% CI: 1.01, 1.09) following sec- pregnancy wildfire exposure (up to 30 d before pregnancy) com-
ond trimester exposure in north region, and (OR = 1:06; 95% CI: pared to no prepregnancy exposure resulted in higher rates of
1.04, 1.0) following second trimester exposure in south region36; gastroschisis: 12.5 vs. 5.7 per 10.000 births (aRR = 2:17; 95% CI:
increased risk of preterm birth following exposure to the 2018 1.42, 3.52).30
Camp Fire, California (adjusted relative risk ðaRRÞ = 1:10; 95% A study of wildfire-related air pollution exposure in Brazil
CI: 1.03, 1.17) when compared to births that occurred a year ear- 2001–2018 reported that an increase in exposure to wildfire
lier, with a dose–response effect evident when comparing exposure (measured as an increase in number of wildfire records)
between the highest and lowest tertiles.28 increased odds of cleft lip/cleft palate and second trimester ex-
The incidence of preterm birth in areas affected by fire was posure (OR = 1:007; 95% CI: 1.001, 1.013), congenital anoma-
higher by 50% for babies born at 20–27 wk gestation in the lies of the respiratory system following second trimester
3 months following the 2009 Black Saturday bushfires in Victoria, exposure (OR = 1:002; 95% CI: 1.002, 1.023), and congenital
Australia, and both preterm and postterm birth rates were higher anomalies of the nervous system following first trimester expo-
for second and third trimester exposure to the fires in comparison sure (OR = 1:001; 95% CI: 1.001, 1.003) in the South, North
with births in areas that were not affected by fire.24 There was little and Midwest regions in Brazil.31