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Birth Weight and Exposure to Kitchen Wood Smoke during Pregnancy in Rural Guatemala Author(s): Erick Boy, Nigel Bruce, Hernn Delgado Source: Environmental Health Perspectives, Vol. 110, No. 1 (Jan., 2002), pp. 109-114 Published by: Brogan & Partners Stable URL: http://www.jstor.org/stable/3455306 . Accessed: 29/09/2011 13:32
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Children'sHealthArticles

Birth Weight and Exposure to Kitchen Wood Smoke during Pregnancy in Rural Guatemala
Erick Boy,1 Nigel Bruce,2 and Hernan Delgado3
of 1TheMicronutrientInitiative,Ottawa, Ontario,Canada;2Departmentof Public Health, University of Liverpool,Liverpool,UK;31nstitute Nutritionof CentralAmerica and Panama, Guatemala City, Guatemala

with reduced whetherdomesticuse of wood fuel is associated In this study,we aimedto establish We factors. studied social,andeconomicconfounding of birthweight,independent keymaternal, We 1,717 women and newbornchildrenin ruraland urbancommunitiesin ruralGuatemala. in birthattendants six ruraldisby throughhome birthsreported traditional identifiedsubjects city tricts(n = 572) andall publichospitalbirthsin Quetzaltenango duringthe studyperiod(n = and 1,145). All wereseenwithin 72 hr of delivery, datawerecollectedon the type of household amongwomenin Smoking factors. and fuelused,firetype,andsocioeconomic otherconfounding cookingon open fires Childrenbornto mothershabitually was the studycommunity negligible. (n = 861) had the lowest mean birth weight of 2,819 g [95% confidence interval (Cl), meanof 2,863 g (95% 2,790-2,848]; thoseusinga chimneystove(n = 490) had an intermediate or CI, 2,82g2,902); and those usingthe cleanestfuels (electricity gas, n = 365) had the highest mean of 2,948 g (95% CI, 2,898-2,998) (p < 0.0001). The percentageof low birth weights stove),and 16.0%(elec(c 500 g) in thesethreegroupswas 19.9%(openfire), 16.8%(chimney with fuel type, but tricity/gas),(trendp = 0.08). Confoundingfactorswere stronglyassociated wood usersstill had a birthweight 63 g lower (p = 0.05; 95% CI, 0.4-126). afteradjustment birthweightin a human betweenbiofueluse andreduced This is the firstreportof an association the despiteadjustment, betterconfounding Althoughthereis potentialfor residual population. throughcarbonmonoxide documentedevidenceon passivesmokingand a feasiblemechanism exposuresuggestthis associationmay be real.Becausetwo-thirdsof householdsin developing age countriesstill rely on biofuelsand women of childbearing performmost cookingtasks,the K<y biocouldbe substantial. words: if risk attributable arisingfromthis association, confirmed, HealthPerspect fuel, carbon monoxide, indoor air pollution, low birth weight. Environ 2001] 110:109-114 (2002). [Online19 December

l Opl O9-114boy/abstact.html .niebs.nih.gov/doss/2002/l http://eApnetl Low birthweight(LBW),definedas birth as weight< 2,500 g, is well established an importantriskfactorfor infant mortality Well over90%of all LBW and morbidity. babiesare born in developingcountries, where approximately18% of newborns for weighlessthan2,500 g2 In Guatemala, fell the period1990-1994, 14%of all births into this category(1), althoughthere are (2). withinthe country variations substantial LBWresultsfrom a wide rangeof factors birth,intrauterine premature thatdetermine of or growth retardation, combinations both that of theseoutcomes(3). Any conditions deliveryof interferewith transplacental maycausevaryoxygenincluded, nutrients, growth and ing degrees typesof intrauterine (IUGR).Of the environmental retardation factorslinkedwith reducedbirthweight, and smoking bothactive passivetobacco studbeen hasprobably the mostextensively with is smoking associated a ied (48). Active mean reductionin birth weight of up to smoking a smaller has passive 200 g, whereas at estimated 20-120 g (!L12). effect variously reported weighted a A recentmeta-analysis of decrement of estimate 28 g, witha greater to was 40 g whenpooling restricted themore studies (8). homogeneous
HealthPerspectives * Environmental

Tobacco Smoke, Biofuels, and Low Birth Weight have Although 4,000substances been over onlya few smoke, identified cigarette in from out dozen singled asimportant a are monoxide (CO) Carbon health perspective. and in particular possiblynicotineare regarded the agentsmostlikelyto be as effects on for responsible detrimental growth (10,13,14. CO results intrauterine of combustionanybiofrom incomplete the and includes tobacco biofuels mass, which as and residues) wellas (wood, dung, fiber are fossilfuelssuchascoalandgas,which (15). Once and usedforcooking heating to with inhaled, combines hemoglobin CO (COHb), much a form carboxyhemoglobin that more stable compound doesnotreadily tissues giveup2 to peripheral andorgans, including fetus. the parof of In terms emissions suspended gases, ticulates pollutant thecombustion and is biomass qualitatively of woodandother although of similar theburning tobacco, to have Studies shown without nicotine. the with to is thatexposure biofuels associated (16,17), covering of COHb levels 2.5-13% through heavy the range seenforpassive not (18,19). It is therefore active smoking

of that to expect theeffiect pasunreasonable wouldalso on sivesmoking birthweight exposed women habitually to apply pregnant as smoke, is thecase levels biofuel of to high (20921). However, countries in developing between similarity the despite theoretical smoking prolonged and tobacco passive to indoorexposure high levelsof wood of we smoke, arenot aware anyprevious the that studies haveexamined published on fetal eiectsof thelatter human growth. in of Around two-thirds households as still on countries rely biofuels developing there primary (22),andunless is a fuel their and change energy development in major countries, usewill such in policy developing future for continue theforseeable (23).It is in use that nowrecognized indoor of biofilel not for is responsible only communities rural air levels of some thehighest ofambient pol(15) ever lution recorded butalsoforabout to of burden exposure airhalftheglobal essential pollutants Itis therefore (24). borne smoke expoof the to examine effect indoor Our countries. and in sure LBW developing to objectives:quanhad study thefollowing use of tifythe influence biofuels on birth and weight,andto measure controlfor factors as confounding such materpotential status, and health nutritional naleducation, conoltlons. anesocloeconomlc
| * . a. .

Methods
The on information stfilyarea. Background a in was study performed Quetzaltenango, Guatemala, in province western mountainous of was the where prevalenceLBW estimated at 18%in 1988 (24). In the National by performed the Survey, Micronutients Health 1995(25),the in of Ministry Public cor(Hb of prevalenceanaemia < 11 g/dL) among and for rected altitude pregnancy womenages15-48 yearsin the western regional was highlands 39%,the highest value for the country.Malariais not of districts because the in endemic thestudy 70% m). altitude (2,300-2,700 Atleast high
to correspondence E. Boy,The Micronutrient Address Initiative, 250 Albert Street, Ottawa, Ontario, (613) 782-6804. Fax: K1G3H9.Telephone: Canada eboy@micronutrient.org (613) 782-6838. E-mail: Agency This studywasfundedby the UnitedStates for InternationalDevelopment (USAID/ROCAP 670/F-13),Guatemala. Received 6 November 2000; accepted 29 June 200 1.

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Children'sHealth * Boy et al.

questions the Results on included and occur of alldeliveries athome, 95%of The interview and (wood, coal, We studied1,717mothers children. birth typeof fuelusedforcooking of these withtheassistance traditional of of the 1 electricity,gas) and (if wood or coal) Table shows number children norattendants. (< weight 2,500g) forthe on in this was Thestudy performed6 of the22 whether wasburned anopenfireor malandlowbirth of in and births thecity,each We province well in a stovewith a chimney. included hospital home as districts Quetzaltenango of of districts, thegroup all and ciga- thesixnamed that Women their womenreporting theysmoked and capital. astheprovincial of percentages The of the and births = rettes recorded number cigarettes otherdistricts. overall (n from babies recruited home were birth 18.8% thehospital group for socioeco- LBWwere per consumed day.We assessed births 572)and hospital (n= 1,145). birth group. This for on through questions house and17.1% thehome 6 deliveries. During consecutive nomicstatus Home (p= even is nonsignificant 0.4055) the material, difference particularly floor data months (October-March), werecol- construction, from are the on and when cityresidents excluded the questions literacy women in andalsothrough on lected prenatally 572pregnant all induded The were (p Questionnaires checked, analysis= 0.2512). sample status. by theirsecondor thirdtrimester seven marital during births occurred thestudy by hospital that visit a livingwithin andif necessaryrepeat wasmade field trained female workers but only period, probably about30%of errors. to supervisorrectify the six districts(SanJuan,Almolonga, thefield where from births thesixdistricts these age the home gestational using Sibilia, Sija). and Wecalculated Concepcion, Olintepeque, (Sibilia, Sija), For recruited. twodistricts period com- were and a townships within 20-km dateof thelastmenstrual were Alldistrict 30% certificates counted: and were age post- allbirth Pregnant pared to thegestational estimated it capital. radius theprovincial of had births, respectively, been characteristics25%of these the by to work- natally grading somatic referredthefield women either were included the study.Because in were babies, which registered effectively or traditional attendants of thenewborn birth ers volunteer by place have 30% weight was about would taken in hospiformat Birth (26). workers the on a pictorial at by directly identified thefield 40-50% all of included around deliver- tal,thestudy to 50 Subjects measured thenearest g (home within district. each larger villages low This births. relatively percentage The deliveries). neonates home was by or if were includedthenewborn alive the ies) 25 g (hospital to of from in naked indoors a warm derives therestrictionrecruitment and 72 deliv- were weighed visit time thefirst (within hrafter of The rural to thelarger communities. implicadeclined Whena mother communities environment. more ery). smaller, remote The 1. further of are all tions this considered inTable to that (8% were excluded ensure fieldworkers completely undress baby of cases, her simreported ashirt cap of Almolonga), and ofsizes Only14(0.82%) thewomen and as from to wereavailable identify examine were Of worn thebaby weighed, smoking by duringpregnancy. the 313 72 ilar those tO as within hr. many neonatespossible four(1.28%) hos- andthis from deliveries. consecutive 1411 was Hospital weight subtracted thetotal womenwith LBWbabies, Of regional weight during pregnancy. the 1,404 occurring thepublic in baby. The smoked pitalbirths for recorded thedressed %) weight births, (0.71 smoked. 10 City the timebetween andtheweighing the normal of hospital Quetzaltenango during in birth (p was Maternal anthropo- Thisdifference notsignificant= 0.3). of was sameperiodas for recruitment home child alsorecorded. smoking have who reported were to measurements read thenearest Thewomen birthswereincludedin the study (n = metric in procedures (27). been included theanalysis. by standard were 1,145). Subjects examined a trained 0.1 cm,following by was Birthweight typeoffuel.Approxia stadiometer used in height, stationary nurse professional stationed thehospital For with cooked of one-half thewomen deliveries a nonex- mately For neonatal proce- atthehospital. home hospital assoonasroutine with one-third wood measuring (180cm)seton a woodin anopenfire, tape within first tensible the and dures permitted always and with equipped a chimney, onedelivery. these,188 babies straight (verified a plumb per- stoves Of 24 hr after line with wall within six pendicular level ground)was used. quarter thecleaner (Table In the fuels 2). to residing with were born women to lived 14 most on addition, women, ofwhom in field was by calf districts covered theproject workers Maternal circumferencemeasured In with by thecity,cooked coal. allsubsequent The standing, leg assessing homedeliveries. remaining theright withthewoman have the the in dis- sliding measuring around naked analyses, coalusers beengrouped tape deliveries occurred other the 950hospital to according whether was perimeter identi- withthewoodusers calf themaximum until tricts theprovince. of coal 3 point atleast consecu- theyused in anopenfireor in a chimon To help ensurethathome-delivered fiedatthesame analysis birth of In 3 after neonates seen were within days birth, tiveoccasions. portable Salter spring neystove. thisunivariate The provalues decrease mean the in district scales g intervals) stadiometers used weight, group had and fieldworkers to reside their (50 fuels from gressively 2,948g fortheclean (2), monthly. We stillbirths multi- forneonates calibrated were township. excluded stove anatomic to with plebirths children gross (3), between users 2,863g forthechimney group the We analyzed association fire A with weight adjustment and2,819g fortheopen group. simiwho (2), children died fueltypeandbirth deformities andother prevalence for regression with lartrendis observed LBW (12 using beforebeingmeasured of the home forconfounding linear 2). of the GLMprocedure the SASInstitute (Table 0 hospital deliveries). deliveries; meanbirth between The differences by version 6.0; were software (SAS/STAT Field workers trained E. Boyin statistical weightforcleanfuelsandall woodusers procedures. SAS Cary, and Institute, NC,USA). all interview examination
Table 1. Numberand percentage of babies by place of birth,birthweight, and districtof residence (totaln= 1,717). Residence City SanJuan Almolonga Olintepeque Sija Sibilia Concepcion Other districts Subtotal < 2,5009 (%) 114 (17.9) 8 (21.6) 3 (60) 10 (17.5) 10 (13.8) 2 (18.2) 2 (33.3) 66 (20.6) 215(18.8) Hospitaldeliveries(n= 1,145) 2 2,5009 (%) 522 (82) 29 (78.3) 2 (40) 47 (82.4) 62 (86.1 ) 9 (81.8) 4 (66.7) 255 (79.4) 930(81.1) Total 636 37 5 57 72 11 6 321 1,145 < 2,5009 (%) 0 (0) 29129.3) 14 (8.6) 3 (9.4) 17 (16.8) 11(14.7) 24 (23.5) 0 (0) 98(17.1) Homedeliveries (n= 572) 2 2,5009 1%) 0 (0) 70 (70.7) 149(91.4) 29 (80.6) 84 (83.2) 64 (85.3) 78 (76.5) 0 (0) 474(82.9) Total 0 99 163 32 101 75 102 0 572

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Children'sHealth * Low birthweight and cooking smoke in Guatemala

combined between fuels open and clean and fireusers highly are significant < 0.0001). (p Although percent the LBW shows same the pattern, differences nonsignificant, the are even though the chi-square trend for approaches significance 0.076). (p= Other farctors associated lowbirth with weight. Table shows distribution a 3 the of range keymaternal, andeconomic of social, variables, including typeof fuel,forthe the LBW(< 2,500 g) groupandthe normal birth weight group. average of the The age neonates the timeof measurement at was 15.4ffi 10.6hrforthehospital deliveries and 41.8t 20.3hrforhome deliveries 35.5, (t= p < 0.0001). However, was evidence there no of an association between timeof the the measurement birth and weight. mean The ageat measurement 24.3ffi 19.4hrfor was thenormal weight neonates 23.6ffi 17.9 and hrforLBW babies 0.596, = 0.6),and (t= p thePearson correlation coefficient between ageat measurement birth and weight was 0.018(p= 0.4).Notshown thetable in are theassociations between birth weight and neonatal andsex.Although age 20%of

female 16.5% malenewborns and of had Most of these findings are to be LBW, female was sex onlymarginally associ- expectedfamilies therural rely in areas far atedwitha higher incidence LBW (chi- more woodfuel,arepoorer lesswell of on and square 3.47,p = 0.062).As expected, the nourished, havelowerlevelsof literand incidence LBW among of prematurely born acy butthestrength these of associations is neonates (37%)washigherthanamong notable. timeuntilexaminationthe The of thoseborn2 37 weeks gestation was (13.8%) neonate significantly (p< 0.001) longer (chi-square p < 0.0001). 521.9, forthewood-using because usugroup they Theresults Table show LBW is in 3 that allylivedfarther the district from centers significantly associated younger with mater- where fieldassistants the lived.However, nalage, smaller maternal circumference, this factorshouldnot biasthe outcome calf andshorter stature (measures nutritional because data of these show evidence any no of status), lesser parity, younger gestational association between timeof measurethe age,maternal illiteracy, marital status, dirt ment birth and weight (Table 3). floor(economic proxy), thelack status and Multivariate analysis. Whenfueltype of vitamin-mineral supplements the wasentered thethree during as categories presented pregnancy. in Table (clean chimney 2 fuel, stove, open Factors associated with typeoffuel. fire),adjusted meanbirthweightswere Table shows associations 4 the between the 2,834 (gas/electricity), (wood/coal 2,765 typeof fuelusedandthematernal, social, stove chimney), 2,733(open with and fire). andeconomic factors may that confound difference nonsignificant, was an Theoverall association between exposure biofuel to air butthe difference between cleanfuel the pollution birth and and weight. There statis- grousp the chimney are stovegroupwas tically strong associations allof thefac- marginally with significant = 0.054).Because (p tors studied, from apart maternal which thisthree-level age, categorization moved fuel ismore marginal 0.042). (p= typeoutof themodel, because difand the ference between twocategories wood the of Table 2. Mean birthweights and numberof births(%)of LBWbabies, bytype of fuel and stove. users(chimney stoveandopenfire)was quitesmall(32 g), we alsoperformed the Openfire Stove with Electricity Birthweight statistics withoutchimney analysis onlytwocategories. 5 using chimney Table or gas Total shows explanatory the variables giving the Number (%) 871 (50.7) 489 (28.5) 357 (20.8) 1717 (100) best Themodel fit. r-squared is0.097. Meanbirth weight(9)* 2,819 2,863 2,948 2,858 SD(95% 440 (2,790-2,848) 443 (2 824-2,902) 478 (2,898-2,998) 451 (2,837-2,879) Cl) Several important factors remained indeNumber LBW** 2,5009) (%) k 173(19.9) 82 (16.8) 57 (16.0) 312 (18.2) pendently associated LBW, with including fueltype,gestational < 37 weeks age (chi*t-Test:mean birthweight differences: electricity/gas vs. all wood, p < 0.0001;electricity/gas vs. open fire, p < 0.0001. **%2 Test for percent LBW differences:all categories p = 0.2;electricity/gasvs. open fire p = 0.1;trend p = 0.08. square 52.9,p < 0.0001).Female was sex marginally associated LBW with (chi-square Table 3. Maternal and household characteristics of LBWbabies (< 2,500 g) and normal birthweight 3.47,p = 0.06. The adjusted meanbirth babies (2 2,5009}. weightswere2,772 g for the woodfuel group 2,835kgforgas/electricity and users, Subject LBW Normalbirthweight Statistic characteristics (n= 313) (n= 1,404) (p-value) witha mean reduction birth in weight associated wood of 63 g (p= 0.05; with use 95% Continuous variablesa CI,0.4-126). general results conIn the are Maternal age 23.7(6.3) 25.3(6.1) 3.92(0.0001 Maternal circumference calf (cm) 29.4(2.2) 30.7{2.2) 8.63(0.0001 ) sistent thefindings theunivariate with from Maternal height(cm) 145.015 9) 146.4(5.6) 3.70(0.0002) analysis: strongest The associations with Parity 2.1(2.6) 2.6 (2.6) 2.93(0.004) birthweightarewithcalfcircumference, Agewhenchildassessed(hours) 23.6(18.0) 24.3(19.4) 0.55(0.6) parity, material, area residence. floor and of (4R.ctstinnsl sns .SS {1 .qQ {1 7\ 17 {nnnn1 8 Regarding theonlycategory previparity, of ous birthssignificantly differentfrom nulliparity > 1. Subcategories nonwas for nulliparous women vs. 1 vs.2 vs.> 3, for (0 instance) showed significant no association withtheriskof LBW. theother On hand, thesomewhat surprising finding urban that dwellers a lower weight rural had birth than dwellers probably is explained thefact by thatwomen livingin thecitywhousethe public hospital theleast offamong are well Quetzaltenango residents.
7 R} 4 77

df, degrees of freedom. aMeanISD)withineach categoryof birth weight, using t-test.bNumber withineach categoryof birth 1%) weight, usingx2.

Discussion In theprovince Quetzaltenango,estiof it is mated hospital that births account only for about 30%of allbirths, about and 50% of
l l l

Environmental HealthPerspectives *

VOLUME 1101 NUMBER I January 1 2002

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Children'sHealth * Boy et al. perdayin thehousewhilethe fireis lit (32. pre- Ambient within births occurring thecity (28).The are 24-hrCO levels about5-10 air WorldHealthOrganization births of dominance hospital-based in this ppm and use 25-50ppm during of thefire The current to exposure recommend ofthe (16v31,33). In this partof Guatemala, qualityguidelines that study means it isnotrepresentative but whole community, this methodof day CO of no morethan 10 ppm for an 8-hr time-weighted Naeher al. reported et and of was because theprac- timeconcentrations recruitment adopted lunch, and period 30 ppmfor 1 hr (18), levelsthat (breakfast, in reached exceeded homes or and of tical difficultiesidentifying examining dinner of times) 22.9ppm(SD+ 28.1)for arefrequently biomass openfires. on burning and open users in homebirths especially thesmaller (22). fire Are these levels sufficient to cause The value communities. average more remote in exposed of levels people Studies COHb is than to biofuels shown for of 18% LBW thesample higher of have levels 1.5-2.5% IUGR?Becauseit is now well established of UNICEF estimate 14%(1) (16),34% (34),upto 13% Given thenational (175. the that smoking, including environmental be for high would expected butin linewithwhat these for tobacco smoke (ETS) (899911,1223$, is (room) levels, findings ambient of (29. COHb consistent anethnographic associatedwith LBW, the COHb levels poor this relatively provinceGuatemala with are smoking expoand may the Although sample notbe repre- study thispart western Guatemala that foundwithactive passive of in indication the community, most found women sentative thewhole of between 4.6-6.8hr sureshouldserveas an adequate spend that any issue important is whether significant of into bias been has introduced therelationship Table 4. Distribution potentialconfoundingfactors bytype of fuel/stove. This Potential between typeandbirthweight. fuel Electricity/gas Wood fuel families with confounding couldoccurif wood-using Statistic (n= 357) (n= 1,360) factor clean-fuel users Continuous and/or higher weights birth t-Test (*value) of weight each means within category birth variables: (SD) birth weights beendispro- Maternal have withlower -2.04(0.04) U 24.5(5.7) 25.1(6.4) age that excluded. know wood We portionately )U 6.66(0.0001 31.2(2.6) (cm)30.2 Maternal circumference (2.2) calf of members thecommuusers thepoorer are )U hospital it is thebetbirths (1.8) -7.28(0.0001 nity, among and Parity 2.72(2.8) 1.80 U (10.6)-14.37(0.0001) child (hr) 26.7(20.0) 15.0 Agewhen assessed (tendency use to clinicusers ter-off private risk clean lower of LBW) thatarenot fuel, Amongthe homebirths,it is included. more the mainly from smaller, remote those These that communities arenot included. to womenarelikelyto be poorer, usean stove(and of openfireinstead a chimney and heavily exposed), to beat hence more be higher risk of having an LBW baby. sample bias the Therefore, from incomplete of to the canbeexpected reduce estimate any LBW between fueland wood true association most for wood users at-risk because rural the among whom poorer women LBW are those was difficult. recruitment most confounding for Thepotential residual through needs beconsidered, to in thisstudy df, strong of limitations measurement, associa- Abbreviations: degrees of freedom;E,equal variance;U, unequalvariance. and confounders fueltype, Table 5. Variablesin final model giving best fit, with adjustedmean birthweights, effect on birthweight, tionsbetween the factors and significance. However, other andbyomission. with associated LBW in this Explanatory independently Studentt Difference(g) Birthweight with study(Table5) areconsistent well- variables {p-value) (95%Cl) SE (9) least-square means (9) risk and established factors, thisobservation Parity to adds weight theviewthattheseresults, 0 -3.75 105 (50-160) 23.6 2,751 comof the though representative whole not (0.0002) 20.9 2 856 1+ biased. munity, notseriously are W.0 25a'0i: ff CtES' X0 TbaT g'; ' jg)DE XX key Exposurelevels. Another issueis woodfuel usersreallydid have whether particularly Fueltype to to higher exposure pollutants, 1.97 63 (0.4-126) 28.2 2,835 Electricity/gas of they the CO,andwhether level exposure (0.049) 17.8 2,772 Wood to fetal was experienced sufficient impair was exposure not meagrowth. Although study, there is in sured directly thecurrent from evidence Guatemala Areaof residence fairly substantial 3.19 90 (35-145) 20.3 2,848 Rural (15,17,24,33,34) (16,29-32) andelsewhere (0.002) 24.3 2 759 Urban from Studies many toanswer questions. these that have parts theworld shown women of of air to high areexposed very levels indoor 24-hr Typical values Calfcircumference pollution biofuels: from -8.82 186(144-229) 20.3 2,711 are matter (PM)1o around <30.4 forparticulate (0.0001 ) 20.6 2,897 > 30.4 1,000 pg/m3or higher(15,21,24,33).
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Children'sHealth * Low birthweight and cooking smoke in Guatemala

of this.Background COHblevels nonin smokers typically are 1.2-1.5%, smokers in 3-4%,andreaching 10% heavy 2 in smokers(18).Scherer al.(19)reported et COHb levels 1-3%after hrof ETSexposure, of 8 withambient time-weighted concenroom trations 3,000-4,000 of pg/m3 respirable of suspended particulates 24 ppmof CO. and Thesevalues entirely are consistent with those found biofuel for exposure open with fires Guatemala many in and other develop. .

urban pollution air during pregnancy and birth weight studied a well-defined was in cohort between and1991.After 1988 controlling gestational residence, for age, maternalage,year birth, sexof infant, of and the authors founda significant relationship between weight maternal birth and exposure to sulfur dioxide totalsuspended and particles(TSP) during third the trimesterpregof nancy.The estimated reduction birth in weightwas7.3 g and6.9 g for each100 lng countrles. ,ug/m3 increase SO2andTSP,respecin Data were Animal studies.Astrupet al. (35) tively. on COlevels notreported. reported studies effectof smoking of on In an ecologic study 45 districts the of in pregnant women of breathing and increased Czech Republic, Bobak al. (39)reported et concentrationsCOon pregnant of rabbits. an adjusted oddsratiofor LBWof 1.10 (1.01-1.20) anincrease 50 ,ug/m3 for of in Women smoke a mean who had COHbof 1.92% meanbirthweight235 g less SO2.In thisanalysis, and effects TSPand of thanthose a nonsmoking of group. Rabbits NOX nonsignificant, COwasnot were and breathing ppm produced 90 Two recent time-series studCO a COHb of studied. further the Republic reported have 8-9%anda reduction mean weight iesfrom Czech in birth of 11%. contrast,study similar In a of CO associations between IUGR fineparticuand exposure rats, in (40) aromatic hydrocarwhere ppmproduced lates andpolycyclic 90 COHbof 8.8%,foundno reduction in bons (PAHs)(41), both of which are birth weight(36). In thesame study,rats prominent components woodsmoke. of In breathing study, adjusted ratio an odds for reduced oxygen (13%) have theformer did lower birth weights, effect an thought be IUGR each ,ug/m3 to for 20 increase PM1o in caused reduced consumption. by food exposure thefirstgestational in monthof Insummary, although categorization 1.50(95% 1.15-1.96) reported. the CI, was In of fuel type usedin this studyand, by thelatter study, exposure PAHs early to in assumption, levelsof exposure (first month)prothe were pregnancy gestational crude, is likely discriminate it to reasonably duced incremental an adjusted ratio odds for well.There goodevidence thewood- IUGR 1.22(1.07-1.39)foreach10 ng is that of fuelusers in (especially withopenfires) increase PAHs. those areexposed hazardous of CO and to levels Magnitude of effect. This studyhas other pollutants that and these levels suf- shownthatafteradjustment relevant are for ficient cause to IUGR. assumes it is confounding This that variables, women using wood COexposure some (or other biomass smoke fuelhadchildren a mean with birth weight constituent) thannicotine is the some63 g (0.4-126) less thanthat for rather that predominant mechanism which by cigarette women using cleaner Allowing the fuels. for smoking causes LBW. Exposurein reality classification introduced the relais error by verycomplex determined thetype tively and by crude categorization of exposure, this andcondition theof wood(orother of bio- effect could expected begreater be to among fuel), combustion (open stove women the consistently exposed indoor to biodevice fire, of varying quality stateof repair), and the fuelpollution poorly from ventilated open timethatwomen spend thekitchen, in and fires. thecontamination atorfrom Although introduced variations errors by levels adjacent homes relatives friends. of and Future studies in setting, measurement, of exposure type of thisandrelated health outcomes should, if andother factors, wellasrandom (as as error resources permit, include measurement reflected thewideconfidence direct in interval and ofexposure. marginal significance), it unwise make to Studies ambient pollution of air and overinterpret actual the magnitude the of birthweight. arenotaware anyother effect birth We of on weight, is nevertheless there a human population studies exposure of to degree consistency of between study this and biofuel birth and weight, several but studies thoseon active smoking, passive smoking, air Active smoking is published recently reported have effects of andurban pollution. ambientair pollutants birthweight associated effects upto 200 g, ETS on with of (38-40). Ritz et al. (37) studiedover around 30-40 g. A study from South India 125,000 births LosAngeles reported reportedreduction 63 g associated in and a of with among nonsmoking women, anadjusted ratio LBW third- ETSexposure odds for with trimester exposure COof > 5.5 ppm(3- although didnotmention smoke to it cook or month average) 1.22(1.03-1.44). the othersources airpollution(42). The of In of studyfromChina(38), the relationship effect in theChinese would seen study yield in weight around g of 70 betweenmaternal exposure ambient a reduction birth to
Environmental HealthPerspectives *
VOLUME 110 I NUMBER I January l 2002

forthe24-hrmean levels 1,000pg/m3 of reported openfirehomesin western for Guatemala equivalent level (the PMlo would be a littlelowerthanTSPin the caseof indoor biofuel pollution) Thiscalcula(38). tion,hovvever, assumeslinear a relationship somewhat beyond data the range which for themaximum was ,ug/m3. TSP 618 Theconsistencythisstudy those of with of smoking, ETS,andambient pollution suggests this association birth that with weight indeed is significant,does plauas the sibility a mechanism of mediated through CO exposure COHb(although and this doesnotexclude other potential contributingmechanisms). effect indepenThe was dentof the confounding factors studied, albeit marginally, although problem the of dealing confounding inobservawith factors tional studies health on effects environof mentalrisk factorssuch as indoorair pollution recognized Some is (43). evidence of a dose-response relationship found, was p = 0.08 (Table2), although wasnot this apparent adjustment. should after There be no concern about temporal the relationship because cansafely we assume theexpothat sure woodsmoke present to was during the pregnancy among those reporting they that cooked wood.It is possible some with that women usingwoodduring mostof pregnancy changed to a cleaner and later fuel reported astheir this main during fuel pregnancy. thisbias but would to underestitend matethe trueeffect.Thereis alsosome supporting evidence animal from studies of exposure tobacco to smoke.
Attributable of indoor pollution rzsk air exposure. Overall, evidence the suggests that

there be anassociation may between exposure biofuel to pollution reduced and birth weight, although doesneedconfirmathis tion.Mosthouseholds developing in countriesstill relyon biofuels theirdaily for cooking heating and needs; rises more this to than 80%in ruralareasof someof the world's poorest countries Women, (23). particularly during theirchildbearing years, carry farthegreatest by burden cooking of duties exposure indoor pollution. and to air Thiscombinationhighlevels CO and of of other pollutants, exposurevery numof large bersof pregnant women many over hours eachday,andhighbaseline levels LBW of implies theglobal that attributable for risk LBW-associated mortality morbidity and couldbe verysubstantial. Although the meanreduction birthweightresulting in fromthisexposure not be as great may as thatseenwithactive smoking, importhe tance shifting distribution evena of the by small amount a population a high in with prevalence LBW of should perhaps be not underestimated (44).
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REFERENCES AND NOTES

1. Bellamy C. The State of the World's Children1997. Oxford:Oxford University Pressfor UNICEF, 1997. 2. BocalettiA, Boy E, DelgadoH.Mortalidad materna hospitaleria Guatemala: en estudiodescriptivo 26 hospide tales nacionales distribudos por regiones de salud (Guatemala 1988). Revistade la SociedadGuatemalteca de Obstetriciai 2:3842 (1988). 3. Kramer Determinants low birthweight:methodMS. of ological assessment and meta-analysis. Bull WHO 65(5}:663-737 {1987). 4. Martin Bracken TR, MD.Association low birth of weight with passive smoke exposure in pregnancy. Am J Epidemiol 124:633-642 (1986). 5. Spitzer Lawrence DalesR,Hill Archer Clark W, V, G, M, P, Abenhaim Hardy Sampalis Pinfold et al. Links L, J, J, SP, benNeen passivesmoking disease: a best-evidence and synthesis. A reportof the WorkingGroupon Passive Smoking. InvestMed 13:1742; discussion486 489 Clin
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6. WalshR. Effectsof maternal smokingon adverse pregnancy outcomes:examination the criteriaof causaof tion.Hum 66:1059-1092 Biol {1994). 7. Chomitz Cheung Lieberman The roleof lifestylein V, L, E. preventing birth low weight.Future Child 5:121-138 (1995). 8. Windham Eaton Hopkins Evidence an associG, A, B. for ationbetween environmental tobacco smoke exposure and birth weight: a meta-analysis and new data. Paediatr Perinat Epidemiol 13:35-57 (1999). 9. Rubin Krasilnikoff Leventhal WeileB, Berget DH, PA, JM, A. Effect of passive smoking on birthweight. Lancet 23:415417(1986). 10. Gidding Morgan Perry Isabel-Jones Bricker S, W, C, J, T. American Heart Association. Activeandpassivetobacco exposure: seriouspediatric a healthproblem. Circulation 90:2581-2590 {1994). 11. Fortier Marcoux BrissonJ. Passive smoking I, S, during pregnancyand the riskof delivering small-for-gestaa tionalage infant. J Epidemiol Am 139{3):29F302 (1994). 12. Lazzaroni BonassiS, Maniello Morcaldi Repetto F, E, L, E, RuoccoA, Calvi CotellessaG.Effectof passive smokA, ing during pregnancy selected perinatal on parameters. Internat Epidemiol J 19(4):96F965 (1990). 13. LongoLD. biological The effects of carbonmonoxide on the pregnantwoman,fetus, and newborninfant.AmJ Obstet Gynecol 129:69-103 (1997). 14. Seidman Mashiach Involuntary D, S. smoking pregand nancy. J Obstet Eur Gynecol Reprod 41:105-116 Biol (1991). 15. SmithKR.Biofuels,Air Pollution, and Health: Global A Review. NewYork:Plenum Press,1987;6F61. 16. Dary O, Pineda O, Belizan J. Carbon monoxide in dwellingsin poorrural areas of Guatemala. Environ Bull Contam Toxicol 26:2F30(1981). 17. BeheraD, DashS, Malik Bloodcarboxyhaemoglobin S. levels followingacute exposure to smoke of biomass fuel.Indian MedRes88:522-542 J {1988). 18. WHO.Revised Air Quality Guidelines for Europe. Copenhagen:World Health Organization, 1999. 19. SchererG, ConzeC, Meyerinck Sorsa M, Adikofer L, F. Importanceof exposure to gaseous and particulate phase components tobacco smokein active and pasof sive smokers.IntArchOccupEnviron Health 62:459466
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PSMI-EU/CONAPLAM. Technical Reportof the [Final National Micronutrient Deficiency Survey]Informe la de Encuesta Nacional de Micronutrientes. Guatemala City:MOH Press,1995. Capurro Konichezky FonsecaD, Caldeyro-Barcia H, S, R. Metodo Simplificadopara el Diagnostico de la Edad Gestacionalen el Recien Nacido.J Pediatr93:120-122 (1978). Lohman Roche AF, MartorellR. Anthropometric TG, Standardization Reference Manual. Champaign, IL:Human Kinetics Books,1988. Instituto Nacional de Estadistica (INE). Encuesta Nacionalde Salud MeternoInfantil 1995.Washington, DC:DHS/MACRO International, 1995. Inc., NaeherLP,SmithKR, Leaderer Mage D, Grajeda BP, R. Indoor outdoorPM25 COin high-and low-denand and sity Guatemalan villages.J ExpoAnalEnviron Epidemiol 6:544551(2000). Naeher LP,LeadererBP, SmithKR.Particulatematter andcarbonmonoxide highland in Guatemala: indoor and outdoor levels from traditional and improvedwood stoves andgas stoves. Indoor 10(3):20F205 Air (2000). Engle P, HurtadoE. Smoke exposure of women and young childrenin Highland Guatemala: predictionand recallaccuracy.Hum Organ 56(4):408-417 (1997). Norboo T, Yahya M, Bruce NG, Heady JA, Ball KP. Domestic pollution respiratory and illnessin a Himalayan village.IntJ Epidemiol 20:749-757 (1991). Collings SitholeSD, Martin Indoor DA, KS. wood smoke pollution causing lower respiratory disease in children. TropDoct20:151-155 (1990). Schulte-Hobein Schwartz-Bickenbach AbtS, Plum B, D, C,NauH.Cigarette smokeexposureanddevelopment of infants throughout firstyear of life:influenceof pasthe sive smokingand nursingon cotinine levels in breast milk infant's and urine. ActaPaediatr 81:55>557 (1992). Astrup OlsenHM, P, TrolleD, Kjeldsen Effectof modK. erate carbonmonoxide exposureon fetal development. Lancet 2:1220-1222 (1972). Garvey Longo Chronic level maternal DJ, LD. low carbon monoxide exposureand fetal growthand development. BiolReprod 19:8-14 (1978). RitzB, YuF.The effect of ambientcarbonmonoxide on low birth weight among children born in southern California between 1989 and 1993. EnvironHealth Perspect107:17-25 (1999). WangX, DingH,RyanL,XuX. Associationbetween air pollution low birth and weight:a community-based study. Environ Health Perspect105:514-520 (1997). BobakM, LeonD. Pregnancy outcomesand outdoor air pollution: ecological study in districtsof the Czech an Republic 1986-8.OccupEnviron 56:539-543 Med (1999). Dejmek SelevanSG,Benes I,Solansky SramRJ.Fetal J, I, growthand maternal exposureto particulate matter during pregnancy. EnvironHealthPerspect 107:475-480
(1999).

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the National nstitutes of Health-National tnstitMe of Environmental HealthSciences, to provide you with the Tnostcurrent and credible information available to help you make decisions about your health and the environment. Each month we delve into the issues you care about such as:

water,air,and soifpollution urbansprawl populationand wortdhealth toxicpesticides environmental productsand services

20. ChenBH,HongCJ,PandeyMR, Smith Indoor polKR. air lution developing in countries 43:27-138 (1990). 21. BruceN, Perez-Padilla Albalak Indoor pollution R, R. air in developing countries: major a environmental puband lic health challenge for the new millennium. WHO Bull 78:1078-1092 (2000). Z. WHO. Health EnvironmentSustainable and in Development (WHO/EHG/97.8). Geneva:World HealthOrganization, 1997. 23. World Resources Institute, UNEP,UNDP,and World Bank.WorldResources 1998-99: Guideto the Global A Environment. Oxford:Oxford University Press,1988;65-67. 24. Boy E, Delgado H, Echeverria J. Caracteristicas antropometricas maternasy patronesecograficos del crecimiento fetal durante el embarazo normal. In: Resultadosde Investigacionesdel ProyectoTRO/MC/ EAPS. Guatemala City:lNCAP, 1991. 25. Ministryof Public Health and Social Assistance of Guatemala/lNCAP-PAHO/USAID/LAC-HNS/UNICEF/

41. Dejmek SolanskyI, Benes I, Lenicek SramRJ.The J, J, impact polycyclic of aromatic hydrocarbons fine parand ticles on pregnancyoutcome.Environ HealthPerspect 108:11 164(2000). 59-1 42. MathaiM, Vijayasri Babu S, Jeyaseelan L.Passive R, maternal smoking birthweight a SouthIndian and in population. J Obstet Br Gynaecol 99:342-343 (1992). 43. BruceN, Neufeld,Boy E,West C.Quantifying effect the of indoorbiofuelair pollutionon respiratory health in observationalstudies:the role of confounding factors amongwomen in highlandGuatemala. J Epidemiol Int 27:45F458 (1998). 44. WHO. Quality Air Guidelines Europe. ed (draft). for 2nd Environmental Tobacco Smoke.Geneva:World Health Organization, 1998;11.

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* Environmental HealthPerspectives