Effect of Household Air Pollution Exposure during Pregnancy on Birth Weight Dr. Sudipto Roy, Tshencho Dorji, Pema Tshewang, Tshewang Dorji, Pema Khandu and Tara Devi Laabar

Background Birth weight is an important indicator of the probability of newborn not only to survive but also whether he/she will have healthy growth and development (Dorji P, 2015) Evidences available on consistent association of exposure to solid fuel and low birth weight and stillbirths (WHO, 2016) 94% of the Bhutanese rural households consume firewood as their energy source against 6% in the urban areas (DRE/UNDP, 2013)

Background contd. Research shows that even 10µg/m³ of PM 2.5 is associated with 4 grams decrease in birth weight (Balakrishnan et al., 2016) 12 studies found 35% increase in LBW in HH use of biomass compared to clean fuel (Amegah, 2014) Out of 3999 live births 194 were preterm and 192 were recorded as low birth weight (Birth Register, 2014, JDWNRH)

Research Question and Objectives RESEARCH QUESTION: What is the effect of exposure of pregnant women to household air pollution on the birth weights of their newborns?

OBJECTIVES: 1. To determine the association between birth weight of babies born to women who deliver at JDWNRH and their exposure to household air pollution during pregnancy 2. To determine the association between gestational age of babies born to women who deliver at JDWNRH and their exposure to household air pollution during pregnancy

Methods Study design: – Hospital based Case-control design – Cases will be mothers who deliver babies with birth weight lower than 2500 grams – Controls will be mothers who deliver babies with birth weight equal to or more than 2500 grams – Cases and controls will be matched for their maternal age and parity Study site: – Jigme Dorji Wangchuk National Referral Hospital, Thimphu

Methods contd. Study duration: – 18 months (April 2016 to September 2017) Exposure assessment: – HAP exposure will be determined by obtaining information from study women by visiting their houses post discharge (observation) and using validated questionnaire and primary and secondary stove and fuel type duration of cooking kitchen size ventilation Space heating device

Methods contd. Health outcome: – Birth weights of all study newborns will be measured by trained staff using calibrated electronic weight machines as soon as the babies are born in the hospital – Gestation age 1 st ultrasound Last Menstrual period

Methods contd. Inclusion criteria: Women who registered for antenatal care in JDWNRH in first or second trimester All live births including normal and caesarean deliveries Exclusion criteria: Women who register in third trimester in JDWNRH Women who have not received antenatal care at the hospital Women referred to JDWNRH from other districts due to obstetric complications

Other Covariates to be considered Age of mother Socioeconomic characteristics: – Education, occupation and income Obstetric history: – Gravida, Para, Live births, stillbirths, Abortion, previous preterm &LBW birth, interval between current and previous pregnancy Gestational age at birth: – LMP, USG dating No. of ANC visits

Other covariates.. Complications during current pregnancy: – eclampsia, pre-eclampsia, hypertension, diabetes, vaginal bleeding Medical history of mother Habits: tobacco, alcohol, drugs and betel nut (doma) chewing Intake of Iron-folate and calcium tablets and duration Nutrition: Change in maternal weight over duration of pregnancy

Study Timeline ACTIVITIES MONTHS Apr- 16 May- 16 Jun- 16Jul-16 Aug- 16 Sep- 16 Oct- 16 Nov- 16 Dec- 16 Jan- 17 Feb- 17 Mar- 17 Apr- 17 May- 17 Jun- 17Jul-17 Aug- 17 Sep- 17 Proposal Development including study questionnaire design Funding search Ethics Committee approval Training of study staff and sensitization of JDWNRH hospital management Enrollment and data collection Data entry Data analysis Manuscript writing/publicati on

Resources and Budget Equipment: 2 Electronic weight machines Training of health personnel Recruitment of field staff Statistical and database consults Stationeries and others Participant compensation Approx. budget – USD 15000

Statistical Analysis We plan to perform binary tests of associations between the primary outcome, i.e. birth weights in the two groups with overall exposure to HAP including specific heating and cooking devices during pregnancy We will perform binary logistic regression to look for association between these two variables controlling for other co-variates We will also look at associations between gestational age in the two groups and HAP exposure, controlling for other co-variates

Discussion Points Sample size considerations Actual biomass use among study women

Workshop Feedback Resource persons were highly knowledgeable with very rich experiences Bringing in participants from various departments and agencies was a great idea Need for research evidences to reach the public for awareness and advocacy

Future Plans Follow up on the proposal, try for funding and get it materialized Sensitization of the relevant stakeholders on HAP and its effects Comparative studies on HAP exposure in different regions of the country

Thank You