Shafiq 2021 Oi 211138 1639512959.44906

Original Investigation | Global Health
Association of Maternal Inflammation During Pregnancy With Birth Outcomes

and Infant Growth Among Women With or Without HIV in India
Mehr Shafiq, MPH; Jyoti S. Mathad, MD; Shilpa Naik, MD; Mallika Alexander, MD; Su Yadana, MS; Mariana Araújo-Pereira, PhD; Vandana Kulkarni, MS;
Prasad Deshpande, MS; Nathella Pavan Kumar, PhD; Subash Babu, MBBS, PhD; Bruno B. Andrade, MD, PhD; Cheng-Shiun Leu, PhD; Saltanat Khwaja, MD;
Ramesh Bhosale, MD; Aarti Kinikar, MD; Amita Gupta, MD; Rupak Shivakoti, PhD
Abstract Key Points

Question Is elevated inflammation in
IMPORTANCE The association of elevated levels of specific inflammatory markers during pregnancy
pregnant women with or without HIV
with adverse birth outcomes and infant growth could indicate pathways for potential interventions.
associated with adverse birth outcomes
and infant growth deficits?
OBJECTIVE To evaluate whether higher levels of certain inflammatory markers during pregnancy
are associated with preterm birth (PTB), low birth weight (LBW), and infant growth deficits. Findings In this cohort study of
pregnant women in Pune, India, higher
DESIGN, SETTING, AND PARTICIPANTS In this cohort study of pregnant women with or without levels during pregnancy of interleukin
HIV, 218 mother-infant pairs were followed up from pregnancy through 12 months post partum from 17A were associated with increased odds
June 27, 2016, to December 9, 2019. Pregnant women aged 18 to 40 years and between 13 and 34 of both preterm birth and low birth
weeks of gestation who were receiving antenatal care were enrolled in a cohort stratified by HIV weight. Higher levels of interleukin 1β
status; sampling was based on convenience sampling from women receiving antenatal care at were associated with increased preterm
Byramjee Jeejeebhoy Government Medical College. birth and infant growth deficits.
Meaning This study suggests that

EXPOSURES Levels of multiple circulating inflammation markers during the third trimester of
elevated inflammation during
pregnancy.
pregnancy is associated with adverse
birth outcomes and infant growth
MAIN OUTCOMES AND MEASURES The primary study outcome was PTB (<37 weeks’ gestation).
deficits, and future studies should test
Secondary outcomes were LBW (<2500 g) and repeated measures (delivery; 6 weeks post partum;
whether modulating specific
and 3, 6, and 12 months post partum using multivariable generalized linear models) of infant growth
inflammatory pathways could reduce
outcomes (length-for-age, weight-for-age, and weight-for-length z scores).
adverse birth outcomes and growth
deficits.
RESULTS The median age of the 218 women at enrollment was 23 years (IQR, 21-27 years). In
multivariable models, higher pregnancy levels of interleukin 17A were associated with increased odds
of both PTB (adjusted odds ratio [aOR], 2.62; 95% CI, 1.11-6.17) and LBW (aOR, 1.81; 95% CI, + Supplemental content
1.04-3.15). Higher levels of interleukin 1β were associated with increased PTB (aOR, 1.47; 95% CI, 1.15- Author affiliations and article information are
1.89) and infant growth deficits (lower length-for-age z score: adjusted β = −0.10; 95% CI, −0.18 to listed at the end of this article.
−0.01; lower weight-for-age z score: adjusted β = −0.07; 95% CI, −0.14 to 0.001).
CONCLUSIONS AND RELEVANCE This study suggests that increased levels of certain systemic
inflammatory markers, including interleukin 1β and interleukin 17A, during pregnancy were
associated with adverse birth outcomes and infant growth deficits. Future studies should evaluate
whether potential interventions to modulate specific inflammatory pathways during pregnancy
could improve birth outcomes and infant growth.
JAMA Network Open. 2021;4(12):e2140584. doi:10.1001/jamanetworkopen.2021.40584
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open. 2021;4(12):e2140584. doi:10.1001/jamanetworkopen.2021.40584 (Reprinted) December 22, 2021 1/10
Downloaded from jamanetwork.com by Sabrina NM on 04/04/2024

JAMA Network Open | Global Health Association of Maternal Inflammation During Pregnancy With Birth Outcomes
Introduction
Pregnancy is characterized by major changes in maternal immunity. Trimester-specific changes have
also been observed, with an immunosuppressive and anti-inflammatory profile in midpregnancy to
late pregnancy compared with a more proinflammatory profile during labor.1-3 Alterations to this
profile have been associated with adverse pregnancy and birth outcomes; for example, increased
systemic levels of proinflammatory biomarkers (such as interleukin 6 [IL-6], tumor necrosis factor,
IL-1β, and C-reactive protein) during midpregnancy to late pregnancy were associated with preterm
birth (PTB).4 However, there are limited data on whether other systemic biomarkers of inflammation,
such as those associated with gut integrity, monocyte activation, or helper T (TH) cell responses (eg,
TH2 or TH17), are also associated with PTB.
Data are also lacking on how maternal levels of these inflammatory markers are associated with
infant birth weight despite low birth weight (LBW) being another common and clinically significant
adverse birth outcome, especially in resource-limited settings. Furthermore, despite data supporting
the association of perinatal factors with health outcomes during childhood and adulthood within the
developmental origins of health and disease framework,5 studies have not examined whether and
how maternal inflammation during pregnancy is associated with infant growth outcomes. For
instance, it is not known whether higher maternal levels of specific systemic inflammatory markers
during pregnancy are associated with infant length and weight measures related to stunting, wasting,
and being underweight. Understanding the association of maternal inflammatory responses during
pregnancy with birth and infant outcomes could potentially help identify interventions (eg, anti-
inflammatory agents) that could reduce adverse birth outcomes and infant growth deficits.6
To address these gaps in research, we measured inflammatory markers, informing on aspects
of general inflammation and acute phase response, inflammasome activation, gut integrity,
monocyte activation, and TH responses in pregnant women from a cohort study in India. We then
assessed the association of these markers with adverse birth outcomes (PTB and LBW) and infant
growth (length-for-age z score [LAZ], weight-for-age z score [WAZ], and weight-for-length z
score [WLZ]).
Methods
Study Design and Population
We conducted a longitudinal cohort study of pregnant women (PRACHITi [Pregnancy Associated
Changes in Tuberculosis Immunology] study) in Pune, India, from June 27, 2016, to December 9,
2019.7 We enrolled adult pregnant women aged 18 to 40 years and between 13 and 34 weeks of
gestation (confirmed by early pregnancy ultrasonography) who were receiving antenatal care at
Byramjee Jeejeebhoy Government Medical College, a tertiary care hospital that serves primarily
low-income populations and is a referral center for HIV care. The study excluded pregnant women
with active tuberculosis or severe anemia at entry, as well as women who were taking antibiotics for
more than 14 days, had a history of an autoimmune or immunosuppressive disease, or were taking
immunosuppressive medication. As the primary aim of the PRACHITi study was to compare immune
responses during pregnancy by HIV status, women were enrolled in a cohort (N = 218) stratified by
HIV status (69 HIV positive and 149 HIV negative).8 Sample size was determined based on the
PRACHITi study’s goals. Sampling within each stratum was based on convenience sampling of those
who met the eligibility criteria.
This study received approval from the institutional review boards of The Johns Hopkins
University, Columbia University, Weill Cornell Medicine, and Byramjee Jeejeebhoy Government
Medical College. Written informed consent was obtained from all mothers. All guidelines for human
experimentation from the US Department of Health and Human Services were followed. This study
followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
reporting guideline for observational studies.

Data Collection and Laboratory Procedures

We collected sociodemographic information and clinical data from study participants at enrollment.
The gestational age of the mothers was determined by ultrasonography performed in early
pregnancy. Follow-up visits were conducted during the third trimester (for those enrolled in the
second trimester), at delivery, 6 weeks post partum, and 3, 6, and 12 months post partum.
Gestational age at delivery, along with infant length and weight at each visit, were recorded
thereafter. Further details on data collection can be found in the eMethods in the Supplement.
During these visits, heparin plasma samples were extracted from maternal blood samples and stored
until further assessment of immune biomarkers. As detailed previously,7 single-plex immunoassays
were performed on third-trimester plasma samples according to the manufacturer’s (R&D Systems)
directions for soluble CD163, soluble CD14 (sCD14), intestinal fatty acid–binding protein, C-reactive
protein, alpha 1-acid glycoprotein, and interferon β. Multiplex immunoassays (Luminex assays; R&D
Systems) measuring interferon γ, IL-1β, IL-6, IL-13, IL-17A, and tumor necrosis factor were also
performed on these samples. These immune biomarkers were chosen based on their importance to
birth outcomes and HIV.9
Statistical Analysis
We generated descriptive statistics of sample characteristics for the overall sample as well as by the
PTB and LBW status of infants. Preterm birth was defined as birth prior to 37 weeks of gestation, and
LBW was defined as birth weight less than 2500 g. The Fisher exact test was used to assess
differences in study population characteristics by PTB and LBW for categorical variables, and the
Wilcoxon rank sum test was used for continuous variables owing to the violation of normality
assumption for the t test. All P values were from 2-sided tests, and results were deemed statistically
significant at P < .05.
We compared median levels of each inflammatory marker during the third trimester between
women with PTB and women with term births using the Wilcoxon rank sum test. All inflammatory
markers were transformed to the log2 scale to approximate normality. To evaluate the association
between each inflammatory marker at the third trimester and birth outcomes (ie, PTB [primary
outcome] and LBW [secondary and exploratory outcome]), we used logistic regression models with
PTB or LBW as separate binary outcome variables. Multivariable model 1 adjusted for maternal age,
mid–upper arm circumference (MUAC, a more reliable indicator of maternal nutritional status during
pregnancy),10 HIV status, parity, smoking, and history of PTB. Multivariable model 2 additionally
adjusted for maternal educational level, anemia, and latent tuberculosis infection (LTBI) status.
To evaluate the association between each inflammatory marker at the third trimester and infant
growth, we first computed 3 different variables at each time point for LAZ, WAZ, and WLZ using the
World Health Organization child growth standards.11 We used a generalized linear model with an
identity-link function to assess the association of inflammation with infant LAZ, WAZ, and WLZ
(separate analysis for each continuous infant growth outcome variable). Multivariable model 1
adjusted for maternal age, MUAC, HIV status, parity, and smoking. Multivariable model 2 additionally
adjusted for maternal educational level, anemia, and LTBI. We used a generalized estimating
equation method with an exchangeable working correlation matrix and a robust variance estimator
to account for the within-individual correlation owing to repeated outcome measures of infant
growth at multiple time points of 0 (time of delivery) and 3, 6, and 12 months.
We also conducted exploratory analyses, using similar approaches, to assess whether the
association of inflammatory markers with birth outcomes and infant growth differed by strata of HIV
infection status. Our analyses for this study are focused on hypothesis generation, and therefore we
report and interpret effect estimates and 95% CIs. All analyses were conducted in SAS software,
version 9.4 (SAS Institute Inc).

Results
The median age of the 218 women at enrollment during pregnancy was 23 years (IQR, 21-27 years)
(Table). A total of 73 of 216 women (34%) reported a monthly income below India’s poverty line
of 10 255 Indian rupees (US $138.19),12 and 52 (24%) reported having an educational level of
primary school or less. A total of 62 women (28%) were undernourished, defined as MUAC less than
23 cm10; 193 women (89%) were nonsmokers; and 18 women (8%) had a history of PTB. Based on
the stratified design of the parent study, 69 women (32%) had HIV infection. All women with HIV
were receiving antiretroviral therapy, and 52 of them (75%) were receiving efavirenz-based
regimens. Twenty-five of the women (12%) in this cohort gave birth to PTB infants. The study
population characteristics did not differ significantly by PTB status.
Maternal Inflammation During Pregnancy and Birth Outcomes

Preterm Birth
The median gestational age at which we measured the biomarkers was 29.3 weeks (IQR, 28.5-30.4
weeks). We compared the median log2-transformed levels of third-trimester inflammatory markers
by birth status (ie, PTB vs term births) using the Wilcoxon rank sum test (eFigure in the Supplement).
Median log2 IL-1β and IL-17A levels were significantly higher in women with PTB compared with
women with term births (IL-1β, 4.55 vs 2.40 pg/mL; P = .002; IL-17A, 2.56 vs 2.27 pg/mL; P = .008).
We used univariable (N = 218) and multivariable (n = 211) logistic regression models to assess
the association between inflammation during pregnancy and PTB. In univariable models, higher
levels of IL-1β (odds ratio [OR], 1.39; 95% CI, 1.10-1.75), IL-6 (OR, 1.21; 95% CI, 0.99-1.49), and IL-17A
(OR, 2.58; 95% CI, 1.13-5.88) were associated with increased odds of PTB (Figure 1). Similar results
were observed for IL-1β and IL-17A in multivariable models adjusting for age, MUAC, smoking, HIV
status, parity, and history of PTB (IL-1β: adjusted OR [aOR], 1.47; 95% CI, 1.15-1.89; IL-17A: aOR, 2.62;
95% CI, 1.11-6.17). Similar results were observed in models further adjusting for anemia, educational
level, and LTBI for IL-1β (aOR, 1.52; 95% CI, 1.15-2.01) and IL-17A (aOR, 2.36; 95% CI, 0.99-5.64)
Table. Characteristics of the Study Population During Their Third Trimester by Preterm Birth Status
No. (%)a
Preterm births Term births
Characteristic Overall (N = 218) (n = 25 [12%]) (n = 193 [89%]) P valueb
Age, median (IQR), y 23 (21-27) 23 (22-26) 23 (20-27) .43
Monthly income, No./total No. (%)
≤ 10 255 (US $138.19) 73/216 (34) 12/24 (50) 61/192 (32)
.11
> 10 255 (US $138.19) 143/216 (66) 12/24 (50) 131/192 (68)
Educational level
None to primary 52 (24) 8 (32) 44 (23)
Middle school to high school 139 (64) 15 (60) 124 (64) .57
After high school 27 (12) 2 (8) 25 (13)
Mid–upper arm circumference, cm
<23.0 62 (28) 10 (40) 52 (27)
23.0-30.5 142 (65) 15 (60) 127 (66) .23
>30.5 14 (6) 0 14 (7)
Smoking status
Yes 25 (12) 4 (16) 21 (11)
.50
No 193 (89) 21 (84) 172 (89)
History of preterm birth a
Percentages may not total 100% because of
Yes 18 (8) 4 (16) 14 (7) rounding.
.13 b
No 200 (92) 21 (84) 179 (93) P values were calculated using the Fisher exact test
HIV for categorical variables and the Wilcoxon rank sum
Yes 69 (32) 8 (32) 61 (32) test for continuous variables to determine the
.99 difference between mothers who had preterm
No 149 (68) 17 (68) 132 (68)
deliveries and mothers who had term deliveries.

(eTable 1 in the Supplement). Furthermore, we also had data on second-trimester inflammatory

markers from a smaller subset of these women (n = 166) and saw a similar association of IL-1β (aOR,
1.41; 95% CI, 1.02-1.96) and IL-17A (aOR, 4.65; 95% CI, 1.39-15.55), measured using the mean of
second-trimester and third-trimester values, with PTB.
Low Birth Weight

Data on birth weight and inflammatory markers were available from 213 pregnant women. Thirty
percent (n = 64) of the infants in this cohort were born with LBW; the study population
characteristics did not differ significantly by LBW status apart from a higher proportion of
undernourished women among those who had LBW infants than among those who had normal-
weight infants (25 of 64 [39%] vs 34 of 149 [23%]; P = .05) (eTable 2 in the Supplement).
We used univariable and multivariable logistic regression models to assess the association
between inflammation during pregnancy and LBW. Maternal IL-17A levels were positively associated
with LBW in univariable models (OR, 1.81; 95% CI, 1.06-3.08) (Figure 1). When adjusting for age,
MUAC, smoking, HIV status, parity, and history of PTB, similar results were observed for the
association of IL-17A levels with LBW (aOR, 1.81; 95% CI, 1.04-3.15). Results for IL-17A levels were also
statistically significant when further adjusting for anemia, education, and LTBI (aOR, 1.96; 95% CI,
1.09-3.49) (eTable 1 in the Supplement) and in models using the mean of second-trimester and third-
trimester values (n = 162) (aOR, 2.30; 95% CI, 1.18-4.49).
Figure 1. Association of Inflammatory Markers With Preterm Birth (PTB) and Low Birth Weight (LBW)
PTB LBW
Biomarker Odds ratio Favors Favors Odds ratio Favors normal Favors
(log2) Model (95% CI) term birth PTB (95% CI) birth weight LBW
Univariable 0.92 (0.74-1.15) 0.94 (0.80-1.09)
IFN-β
Multivariable 0.90 (0.72- 1.13) 0.91 (0.80- 1.16)
Univariable 0.93 (0.73-1.19) 0.96 (0.80-1.15)
CRP
Multivariable 0.91 (0.70-1.17) 0.96 (0.80-1.16)
Univariable 1.48 (0.85-2.56) 1.25 (0.87-1.81)
AGP
Multivariable 1.43 (0.80-2.57) 1.22 (0.83-1.79)
Univariable 1.01 (0.73-1.40) 0.93 (0.73-1.18)
I-FABP
Multivariable 1.02 (0.71-1.47) 0.91 (0.70-1.18)
Univariable 0.81 (0.56-1.18) 1.05 (0.88-1.25)
IFN-γ
Multivariable 0.83 (0.58-1.19) 1.08 (0.90-1.29)
Univariable 1.39 (1.10-1.75) 1.14 (0.96-1.34)
IL-1β
Multivariable 1.47 (1.15-1.89) 1.16 (0.98-1.38)
Univariable 0.72 (0.45-1.14) 0.76 (0.54-1.08)
sCD14
Multivariable 0.74 (0.46-1.20) 0.72 (0.49-1.05)
Univariable 1.48 (0.88-2.51) 1.36 (0.91-2.02)
CD163
Multivariable 1.50 (0.88-2.57) 1.36 (0.90-2.05)
Univariable 1.14 (0.80-1.63) 1.24 (0.93-1.64)
TNF
Multivariable 1.12 (0.75-1.67) 1.25 (0.93-1.67)
Univariable 1.21 (0.99-1.49) 1.08 (0.93-1.24)
IL-6
Multivariable 1.23 (0.99-1.53) 1.05 (0.90-1.22)
Univariable 2.58 (1.13-5.88) 1.81 (1.06-3.08)
IL-17A
Multivariable 2.62 (1.11-6.17) 1.81 (1.04-3.15)
Univariable 1.20 (0.89-1.62) 1.11 (0.89-1.37)
IL-13
Multivariable 1.20 (0.86-1.64) 1.14 (0.92-1.43)
0 1 2 3 4 0 1 2 3 4
Odds ratio (95% CI) Odds ratio (95% CI)
The odds of PTB and LBW per increase in log2 concentrations (and 95% CIs) of each circumference, HIV status, parity, smoking, and history of PTB. AGP indicates alpha 1-acid
inflammation marker (third trimester). Only the univariable model and multivariable glycoprotein; CRP, C-reactive protein; I-FABP, intestinal fatty acid–binding protein; IFN,
model 1 are shown here. Multivariable model 1 adjusted for maternal age, mid–upper arm interferon; IL, interleukin; sCD14, soluble CD14; and TNF, tumor necrosis factor.

Maternal Inflammation During Pregnancy and Infant Growth

Length-for-Age z Score
Follow-up data for the first year of the infant’s life that were needed to calculate LAZ, WAZ, and WLZ
were available for 205 infants. We used univariable and multivariable generalized linear models with
the generalized estimating equation method to assess the association between inflammation during
the third trimester and LAZ during the first year of the infant’s life. Increased levels of maternal IL-1β
were associated with a mean decrease in LAZ in univariable (β = −0.08; 95% CI, −0.17 to 0.01) and
multivariable (adjusted β = −0.10; 95% CI, −0.18 to −0.01) models when adjusting for maternal age,
MUAC, HIV status, parity, and smoking (model 1) (Figure 2). Similar results were observed in models
that further adjusted for anemia, educational level, and LTBI (adjusted β = −0.11; 95% CI, −0.21 to
−0.02) (eTable 3 in the Supplement). On the other hand, increased levels of sCD14 were associated
with a mean increase in LAZ in model 1 (adjusted β = 0.13; 95% CI, −0.04 to 0.31) (Figure 2).
Weight-for-Age z Score
We used the same generalized linear models with the generalized estimating equation approach to
assess the association between inflammatory markers and WAZ during the first year of the infant’s
life. Similar to the LAZ results, IL-1β was negatively associated with WAZ (adjusted β = −0.07; 95% CI,
−0.14 to 0.001 in multivariable model 1), whereas sCD14 was positively associated with WAZ
(adjusted β = 0.18; 95% CI, 0.04-0.32 in multivariable model 1) (Figure 2). Furthermore, C-reactive
protein was also positively associated with WAZ (adjusted β = 0.09; 95% CI, 0.003-0.19 in
multivariable model 1). Results were similar for IL-1β (adjusted β = −0.08; 95% CI, −0.16 to −0.003),
sCD14 (adjusted β = 0.20; 95% CI, 0.05-0.35), and C-reactive protein (adjusted β = 0.09; 95% CI,
0.004-0.18) in multivariable model 2 (eTable 3 in the Supplement).
Figure 2. Association of Inflammatory Markers With Infant Growth
LAZ WAZ WLZ

Biomarker Favors Favors Favors Favors Favors Favors
(log2) Model Adjusted β (95% CI) lower LAZ higher LAZ Adjusted β (95% CI) lower WAZ higher WAZ Adjusted β (95% CI) lower WLZ higher WLZ
Univariable –0.02 (–0.09 to 0.05) –0.01 (–0.07 to 0.06) 0.01 (–0.05 to 0.07)
IFN–β
Multivariable –0.01 (–0.08 to 0.06) 0.001 (–0.06 to 0.07) 0.01 (–1.87 to 0.07)
Univariable 0.05 (–0.05 to 0.16) 0.10 (–0.005 to 0.20) 0.10 (0.01 to 0.20)
CRP
Multivariable 0.05 (–0.05 to 0.15) 0.09 (0.003 to 0.19) 0.10 (0.02 to 0.19)
Univariable –0.02 (–0.11 to 0.08) 0.03 (–0.08 to 0.14) 0.05 (–0.08 to 0.17)
AGP
Univariable –0.02 (–0.13 to 0.10) 0.05 (–0.06 to 0.16) 0.05 (–0.05 to 0.15)
I–FABP
Univariable –0.01 (–0.06 to 0.05) –0.02 (–0.07 to 0.02) –0.01 (–0.06 to 0.04)
IFN–γ
Multivariable –0.003 (–0.08 to 0.07) –0.01 (–0.07 to 0.04) 0.005 (–0.05 to 0.06)
IL–1β
Multivariable –0.10 (–0.18 to –0.01) –0.07 (–0.14 to 0.001) –0.03 (–0.11 to 0.05)
Univariable 0.04 (–0.13 to 0.22) 0.11 (–0.04 to 0.27) 0.09 (–0.07 to 0.26)
sCD14
Multivariable 0.13 (–0.04 to 0.31) 0.18 (0.04 to 0.32) 0.09 (–0.08 to 0.26)
Univariable –0.16 (–0.39 to 0.07) –0.11 (–0.32 to 0.11) 0.02 (–0.18 to 0.22)
CD163
Univariable 0.02 (–0.09 to 0.13) –0.02 (–0.12 to 0.09) –0.04 (–0.14 to 0.06)
TNF
Multivariable 0.03 (–0.10 to 0.16) –0.002 (–0.12 to 0.11) –0.03 (–0.14 to 0.08)
IL–6
Multivariable 0.005 (–0.06 to 0.07) –0.02 (–0.08 to 0.04) –0.03 (–0.09 to 0.03)
IL–17A
IL–13
Multivariable –0.04 (–0.14 to 0.06) –0.04 (–0.12 to 0.04) –0.04 (–0.13 to 0.06)
–1 0 1 –1 0 1 –1 0 1
Adjusted β (95% CI) Adjusted β (95% CI) Adjusted β (95% CI)
The mean increase in length-for-age z score (LAZ), weight-for-age z score (WAZ), and multivariable model 1 are shown here. Multivariable model 1 adjusted for maternal age,
weight-for-length z score (WLZ) over the time points of delivery, 6 weeks, and 3 months, mid–upper arm circumference, HIV status, parity, and smoking. AGP indicates alpha
6 months, and 12 months post partum are shown per increase in log2 concentrations 1-acid glycoprotein; CRP, C-reactive protein; I-FABP, intestinal fatty acid–binding protein;
(and 95% CIs) of each inflammation marker (third trimester). The univariable model and IFN, interferon; IL, interleukin; sCD14, soluble CD14; and TNF, tumor necrosis factor.

Weight-for-Length z Score
For WLZ, only maternal C-reactive protein was positively associated with WLZ during the first year of
life. This association was observed in the univariable model (β = 0.10; 95% CI, 0.01-0.20),
multivariable model 1 (adjusted β = 0.10; 95% CI, 0.02-0.19) (Figure 2), and multivariable model 2
(adjusted β = 0.10; 95% CI, 0.02-0.19) (eTable 3 in the Supplement).
Exploratory Analyses of Birth Outcomes and Infant Growth by HIV Status

Although our power was limited to assess whether HIV status was associated with inflammation and
birth outcomes, exploratory analyses suggested that IL-1β was associated with PTB in both women
with HIV (aOR, 1.88; 95% CI, 1.07-3.31) and women without HIV (aOR, 1.32; 95% CI, 0.98-1.79).
Our results on the association between higher maternal sCD14 levels and higher LAZ and WAZ
were surprising. An analysis from this cohort had noted that sCD14 levels were significantly higher
among pregnant women with HIV compared with those without HIV.8 Thus, based on prior literature
that suggests that infants of mothers with HIV have growth deficits at birth, we hypothesized that
these results could be partly explained by maternal HIV status. In stratified analysis, in which the
positive association of sCD14 with LAZ (adjusted β = 0.42; 95% CI, 0.11-0.73) and WAZ (adjusted
β = 0.32; 95% CI, 0.06-0.58) was confirmed, this hypothesis was supported and observed only
among mothers with HIV.
Discussion
In our maternal-infant cohort study from Pune, India, higher levels of various inflammatory markers
during pregnancy were independently associated with adverse birth outcomes and infant growth
deficits. For example, higher levels of IL-1β during pregnancy were associated with increased PTB and
growth deficits, and IL-17A was positively associated with PTB and LBW. These results suggest a need
for future studies to test whether modulating specific inflammatory pathways (eg, those associated
with the inflammasome pathway or the TH17 pathway) could be associated with birth outcomes and
growth deficits. If these findings are confirmed, future studies should identify and test such an
intervention for improved maternal-infant health outcomes.
In our study, we observed a positive association of high maternal IL-1β levels with PTB, which is
in line with existing literature.3,13 Interleukin 1β is a cytokine involved in inducing systemic and local
immune responses to pathogens, and it does so by enhancing transcription or messenger RNA
stability of other proinflammatory genes. This infection-induced proinflammatory environment is
consequently shown to be associated with preterm labor.13 In addition, IL-1β can also increase
prostaglandin levels, which could be associated with increased myometrial contractions and eventual
preterm labor. These results were also confirmed by our exploratory analyses that showed that
higher levels of IL-1β were positively associated with PTB in women with HIV and those without HIV.
In addition, maternal IL-1β levels were associated with the infant growth indicators LAZ and WAZ, in
which higher levels of this cytokine were associated with less infant growth. Given that there is
limited literature on the association with inflammation during pregnancy and infant growth, to our
knowledge, this finding with IL-1β is novel and warrants further confirmation. Although inflammatory
markers are known to reduce levels of insulinlike growth factor 1,14 which is associated with linear
growth, further research into the potential mechanisms is needed.
Levels of IL-17A were associated with both PTB and LBW. Interleukin 17A, a cytokine produced
by TH17 and other immune cells, plays a crucial role in the defense against various microbial
pathogens. While the reasons for increased PTB with IL-17A are unclear, higher levels of IL-17A
associated with excess inflammation can result in tissue damage. In fact, limited data suggest that
IL-17A in the feto-maternal interface could be associated with PTB,15 and future studies should
evaluate whether and how circulating levels of IL-17A as measured in this study are associated with
PTB. Similar associations were also observed for IL-17A and LBW, another novel association observed
by our study. Whether this association is being driven by concurrent PTB needs further assessment.

Overall, IL-17A levels could have potential prognostic utility for PTB and LBW, and if this association is
causal, interventions to target IL-17A could hypothetically reduce adverse birth outcomes.
Our results also showed a positive association between maternal sCD14 levels and higher LAZ
or WAZ. As this result was surprising, we hypothesized that this result could be partly explained by
maternal HIV status. More specifically, prior analysis from this cohort had noted that pregnant
mothers with HIV had higher levels of sCD14.8 Thus, we conducted a stratified analysis for which our
results showed that this association was true only in women with HIV. This finding suggests that
infants from mothers with higher sCD14 levels start with low LAZ and WAZ at birth and then “catch
up” over time. If future studies confirm these results, it would indicate that, while infants born to
HIV-infected mothers with high sCD14 levels are likely to be born with growth deficits, they are able
to partly recover these deficits through the first year of life.
This study addresses several gaps in the literature related to maternal inflammation and infant
health outcomes. Our results, particularly the associations of maternal inflammation during
pregnancy with infant growth outcomes, are novel. Furthermore, this study examines multiple
inflammatory markers, providing insights into different inflammatory pathways associated with
general inflammation, monocyte activation, gut integrity, and inflammasome activation. As most
existing research on some of these inflammatory markers and PTB have been conducted in Western
countries, our study provides valuable data from India with its unique immune, metabolic,16 and
nutritional profile.17
Limitations
There are some limitations to this study. The sample size was limited with respect to PTB outcomes
and particularly the stratified analyses. Larger studies with formal interaction analyses may be
required to highlight how these findings differ by relevant effect modifiers. Our cohort had a high
percentage of women with HIV owing to the parent study design, and 28% were undernourished;
therefore, our results may not be generalizable to other populations with different characteristics.
Additionally, our results associated with HIV largely represent individuals receiving efavirenz-based
antiretroviral therapy regimens, and we do not know the generalizability to populations receiving
other antiretroviral therapies. Given that we included mothers up to 34 weeks’ gestation, the
possibility of selection bias against mothers who delivered before they could be enrolled in the study
cannot be discounted. Our findings associated with the secondary outcomes of LBW and growth
outcomes were exploratory and will need to be confirmed in future studies. In addition, there may be
some unmeasured or unknown confounders that could potentially explain the observed
associations. Despite these limitations, our results suggest that specific inflammatory markers during
pregnancy are associated with adverse birth outcomes and early infant growth.
Conclusions
This cohort study found that increased levels of certain inflammatory markers, particularly IL-1β and
IL-17A, during pregnancy were associated with adverse birth outcomes and infant growth deficits. If
future studies confirm these associations, the mechanisms by which these biomarkers are associated
with these outcomes need further study to evaluate whether potential interventions could improve
birth outcomes and infant growth.
ARTICLE INFORMATION
Accepted for Publication: October 29, 2021.
Published: December 22, 2021. doi:10.1001/jamanetworkopen.2021.40584
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Shafiq M
et al. JAMA Network Open.

Corresponding Author: Rupak Shivakoti, PhD, Department of Epidemiology, Columbia University Mailman School
of Public Health, 722 W 168th St, New York, NY 10032 (rs3895@cumc.columbia.edu).
Author Affiliations: Department of Epidemiology, Columbia University Mailman School of Public Health, New
York, New York (Shafiq, Yadana, Shivakoti); Department of Medicine, Weill Cornell Medical College, New York, New
York (Mathad); Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College,
Pune, India (Naik, Bhosale); Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical
Research Site, Pune, India (Alexander, Kulkarni, Deshpande, Khwaja); Instituto Goncalo Moniz, Fundação Oswaldo
Cruz, Salvador, Brazil (Araújo-Pereira, Andrade); Multinational Organization Network Sponsoring Translational and
Epidemiological Research Initiative, Salvador, Brazil (Araújo-Pereira, Andrade); Faculdade de Medicina,
Universidade Federal da Bahia, Salvador, Brazil (Araújo-Pereira, Andrade); National Institutes of Health, National
Institute for Research in Tuberculosis, International Center for Excellence in Research, Chennai, India (Kumar,
Babu); Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil (Andrade); Universidade Salvador,
Laureate Universities, Salvador, Brazil (Andrade); Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública,
Salvador, Brazil (Andrade); Department of Biostatistics, Columbia University Mailman School of Public Health, New
York (Leu); Department of Paediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India (Kinikar);
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (Gupta).
Author Contributions: Dr Shivakoti had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Mathad, Naik, Alexander, Khwaja, Kinikar, Shivakoti.
Acquisition, analysis, or interpretation of data: Shafiq, Alexander, Yadana, Araújo-Pereira, Kulkarni, Deshpande,
Kumar, Babu, Andrade, Leu, Bhosale, Kinikar, Gupta, Shivakoti.
Drafting of the manuscript: Shafiq, Naik, Kulkarni, Kumar, Khwaja, Kinikar, Shivakoti.
Critical revision of the manuscript for important intellectual content: Shafiq, Mathad, Alexander, Yadana, Araújo-
Pereira, Deshpande, Babu, Andrade, Leu, Bhosale, Kinikar, Gupta, Shivakoti.
Statistical analysis: Shafiq, Araújo-Pereira, Andrade, Leu, Khwaja, Kinikar, Shivakoti.
Obtained funding: Mathad, Shivakoti.
Administrative, technical, or material support: Naik, Alexander, Yadana, Kulkarni, Deshpande, Kumar, Babu,
Khwaja, Bhosale, Kinikar, Gupta.
Supervision: Mathad, Alexander, Kulkarni, Kinikar, Gupta, Shivakoti.
Conflict of Interest Disclosures: Drs Gupta and Shivakoti reported receiving grants from the National Institutes
of Health (NIH) during the conduct of the study. No other disclosures were reported.
Funding/Support: Research reported in this publication was supported by the Eunice Kennedy Shriver National
Institute of Child Health and Human Development of the NIH under award R00HD089753 (Dr Shivakoti) and
R01HD081929 (Dr Gupta). Dr Mathad received grant K23AI129854 from the National Institute of Allergy and
Infectious Diseases (NIAID). Additional support for this work was the NIH-funded Johns Hopkins Baltimore-
Washington-India Clinical Trials Unit for NIAID Networks (grant UM1AI069465 to Dr Gupta). Dr Andrade is a senior
investigator from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil. Dr Araújo-
Pereira received a research fellowship from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
(CAPES; finance code 001). The authors also acknowledge in-kind support from Persistent Systems.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official
views of the NIH.
Additional Contributions: We thank the study participants for their time and contributions as well as the study
staff who meticulously collected detailed data.
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SUPPLEMENT.
eMethods.
eFigure. Levels of Third Trimester Inflammatory Markers by Preterm Birth Status (N = 218)
eTable 1. Association of Inflammatory Markers With PTB and LBW (Multivariable Model II)
eTable 2. Characteristics of the Study Population During Their Third Trimester by Low Birth Weight Status
(N = 213)
eTable 3. Association of Inflammatory Markers With LAZ, WAZ, and WLZ (Multivariable Model II)

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Original Investigation | Global Health

Association of Maternal Inflammation During Pregnancy With Birth Outcomes

Abstract Key Points

Meaning This study suggests that

JAMA Network Open. 2021;4(12):e2140584. doi:10.1001/jamanetworkopen.2021.40584

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Data Collection and Laboratory Procedures

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Maternal Inflammation During Pregnancy and Birth Outcomes

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(eTable 1 in the Supplement). Furthermore, we also had data on second-trimester inflammatory

Low Birth Weight

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Maternal Inflammation During Pregnancy and Infant Growth

Figure 2. Association of Inflammatory Markers With Infant Growth

LAZ WAZ WLZ

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Exploratory Analyses of Birth Outcomes and Infant Growth by HIV Status

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