Rationale Studies identify prenatal household air pollution (HAP) exposure and maternal psychological distress (PMPD) as independent factors contributing to gestational ill-health and adverse birth outcomes. Objective We investigated the impact of PMPD on fetal biometric parameters (FBP) in HAP-exposed pregnant Nigerian women. Methods The randomized controlled trial (RCT; ClinicalTrials.gov NCT02394574) investigated effects of HAP exposure in pregnant Nigerian women (n = 324), who customarily cooked with polluting fuels (firewood or kerosene). Half of the women (intervention group) were given CleanCook ethanol stoves to use for 156 days during the study. Once a month, all women were administered an abridged version of the SF-12v2TM health-related quality of life questionnaire to assess psychological distress. Using mixed effects linear regression models, adjusted for relevant covariates, we analyzed associations between the women’s exposure to PM2·5 (particulate matter with an aerodynamic diameter<2·5 microns) from HAP, their PMPD scores, and FBP (ultrasound estimated fetal weight [UEFW], head circumference [HC], abdominal circumference [AC], femur length [FL], biparietal diameter [BPD], estimated gestational age [GA] and intrauterine growth restriction [IUGR]), and birth anthropometric measures (birth weight [BW] and birth length [BL]). Results PMPD negatively impacted UEFW, HC, FL, BPD and BL (p<0·05). Controls (kerosene/firewood users) experienced significantly higher PMPD compared with ethanol-stove users (p<0·05). The mediation analysis revealed that the proportion of the outcome (fetal biometrics, birth anthropometrics, IUGR and GA), which can be explained via PMPD by groups (intervention vs. control) after adjusting for confounding variables was 6·2% (0·062). No significant correlation was observed between levels of PM2.5 exposure and PMPD scores. Conclusions PMPD was an independent mediator of adverse fetal biometric parameters in pregnant women, who were exposed to HAP from burning of firewood/kerosene. Formulating preventative measures to alleviate maternal distress during pregnancy and reducing exposure to HAP is important from public health perspectives.

Background Low birthweight, intrauterine growth restriction (IUGR) and perinatal mortality have been associated with air pollution. However, intervention studies that use ultrasound measurements to assess the effects of household air pollution (HAP) on fetal biometric parameters (FBP) are rare. We investigated the effect of a cookstove intervention on FBP and IUGR in a randomized controlled trial (RCT) cohort of HAP-exposed pregnant Nigerian women. Methods We recruited 324 women early in the second trimester of pregnancy. Between 16 and 18 weeks, we randomized them to either continue cooking with firewood/kerosene (control group) or receive a CleanCook stove and ethanol fuel (intervention group). We measured fetal biparietal diameter (BPD), head circumference (HC), femur length (FL), abdominal circumference (AC) and ultrasound-estimated fetal weight (U-EFW) in the second and third trimesters. The women were clinically followed up at six regular time points during their pregnancies. Once during the women’s second trimester and once during the third, we made 72-h continuous measurements of their personal exposures to particulate matter having aerodynamic diameter < 2.5 μm (PM 2.5 ). We adopted a modified intent-to-treat approach for the analysis. Differences between the intervention and control groups on impact of HAP on fetal growth trajectories were analyzed using mixed effects regression models. Results There were no significant differences in fetal growth trajectories between the intervention and control groups. Conclusions Larger studies in a setting of low ambient air pollution are required to further investigate the effect of transitioning to a cleaner fuel such as ethanol on intrauterine growth. Trial registration ClinicalTrials.gov NCT02394574 ; September 2012

Rationale: Lung function is adversely affected by exposure to household air pollution (HAP). Studies investigating the impact of prenatal and postnatal HAP exposure on early childhood lung development are limited, especially from Sub-Saharan Africa. Objective: We used oscillometry to investigate the impact on lung function of prenatal and postnatal HAP exposure of children born to Nigerian women who participated in a randomized controlled cookstove intervention trial. Methods: We performed oscillometric measurements (R: airway resistance; X: airway reactance; Fres: resonant frequency; AX: reactance area) in 223 children starting at age of 2 years (ethanol stove, n = 113; firewood/kerosene, n = 110). Personal exposure monitoring assessed mothers' prenatal exposure to particulate matter less than 2.5 mu m in aerodynamic diameter (PM2.5). Postnatal HAP exposure was measured by determining household PM2.5 levels. We employed linear regression analysis to examine the association of prenatal and postnatal HAP exposures with children's lung function. Models were adjusted for age, gender, weight, height, group (intervention or control), birthweight and gestational age. Results: Mean age of the children was 2.9 years (standard deviation = 0.3); 120 were boys (53.8%) and 103 were girls (46.2%). Higher postnatal PM2.5 exposures were significantly associated with higher airway reactance at 5 Hz (X5 Hz; p=0.04) in adjusted models. There were no significant associations between prenatal or postnatal PM2.5 exposure levels and other oscillometry parameters in adjusted regression analysis. Conclusions: This is the first study to use oscillometry to explore the relationship between HAP exposure and lung function in children as young as 2 years. The findings provide some evidence that increased postnatal HAP exposure may result in poorer lung function in children, although larger studies are needed to confirm observed results. This study indicates that oscillometry is a low-cost and effective method to determine lung function in early childhood. (c) 2020 The Authors. Published by Elsevier B.V.

BACKGROUND:Maternal exposure to ambient air pollution affects placental growth markers. OBJECTIVES:Investigate impact of household air pollution (HAP) on placental growth markers. METHODS:Two groups of pregnant women were identified: firewood/kerosene stove-users (A, n=33) and bioethanol stove-users (B, n=44) that participated in a randomized control trial in Ibadan, Nigeria. A third group of non-smoking and presumed liquefied petroleum gas-using Chicago women (C, n=19) were included in this exploratory pilot to assess for possible differences between similar racial groups. Levels of placental growth factor (PlGF) and soluble fms-like tyrosine kinase 1 (sFlt-1) were measured in maternal and cord plasma using ELISA. RESULTS:Maternal and cord blood sFlt-1 and PlGF did not differ significantly between women of groups A and B. Nevertheless, both groups differed significantly from the Chicago group in that group A women had lower maternal sFlt-1 (1372.50 vs. 3194.19) but higher PlGF (1607.87 vs. 442.80), and higher cord blood sFlt-1 (2925.02 vs. 107.53) and PlGF (223.68 vs. 6.92), all p≤0.001. Group B showed similar trends (all p≤0.002). Maternal PlGF levels were positively correlated to minutes of HAP exposure when PM2.5 concentration was above 100μg/m3 in Nigerian women. CONCLUSIONS:Maternal levels of PlGF and cord blood levels of sFlt-1 and PlGF in Nigerian women with varying HAP exposures were significantly higher than Chicago-based women who had no presumed HAP exposure. It suggests that in-utero exposure to HAP influenced levels of angiogenic factors involved in normal placentation and growth and could represent compensation for pollutants exposure to preserve fetal viability.

Background: Household air pollution (HAP) exposure has been linked to adverse pregnancy outcomes. Objectives: A randomized controlled trial was undertaken in Ibadan, Nigeria to determine the impact of cooking with ethanol on pregnancy outcomes. Methods: Three-hundred-twenty-four pregnant women were randomized to either the control (continued cooking using kerosene/firewood stove, n = 162) or intervention group (received ethanol stove, n = 162). Primary outcome variables were birthweight, preterm delivery, intrauterine growth restriction (IUGR), and occurrence of miscarriage/stillbirth. Results: Mean birthweights for ethanol and controls were 3076 and 2988 g, respectively; the difference, 88 g, (95% confidence interval: - 18 g to 194 g), was not statistically significant (p = 0.10). After adjusting for covariates, the difference reached significance (p = 0.020). Rates of preterm delivery were 6.7% (ethanol) and 11.0% (control), (p = 0.22). Number of miscarriages was 1(ethanol) vs. 4 (control) and stillbirths was 3 (ethanol) vs. 7 (control) (both non-significant). Average gestational age at delivery was significantly (p = 0.015) higher in ethanol-users (39.2 weeks) compared to controls (38.2 weeks). Perinatal mortality (stillbirths and neonatal deaths) was twice as high in controls compared to ethanol-users (7.9% vs. 3.9%; p = 0.045, after adjustment for covariates). We did not detect significant differences in exposure levels between the two treatment arms, perhaps due to large seasonal effects and high ambient air pollution levels. Conclusions: Transition from traditional biomass/kerosene fuel to ethanol reduced adverse pregnancy outcomes. However, the difference in birthweight was statistically significant only after covariate adjustment and the other significant differences were in tertiary endpoints. Our results are suggestive of a beneficial effect of ethanol use. Larger trials are required to validate these findings.

Rationale: Hypertension during pregnancy is a leading cause of maternal mortality. Exposure to household air pollution elevates blood pressure (BP).Objectives: To investigate the ability of a clean cookstove intervention to lower BP during pregnancy.Methods: We conducted a randomized controlled trial in Nigeria. Pregnant women cooking with kerosene or firewood were randomly assigned to an ethanol arm (n = 162) or a control arm (n = 162). BP measurements were taken during six antenatal visits. In the primary analysis, we compared ethanol users with control subjects. In subgroup analyses, we compared baseline kerosene users assigned to the intervention with kerosene control subjects and compared baseline firewood users assigned to ethanol with firewood control subjects.Measurements and Main Results: The change in diastolic blood pressure (DBP) over time was significantly different between ethanol users and control subjects (P = 0.040); systolic blood pressure (SBP) did not differ (P = 0.86). In subgroup analyses, there was no significant intervention effect for SBP; a significant difference for DBP (P = 0.031) existed among preintervention kerosene users. At the last visit, mean DBP was 2.8 mm Hg higher in control subjects than in ethanol users (3.6 mm Hg greater in control subjects than in ethanol users among preintervention kerosene users), and 6.4% of control subjects were hypertensive (SBP ≥140 and/or DBP ≥90 mm Hg) versus 1.9% of ethanol users (P = 0.051). Among preintervention kerosene users, 8.8% of control subjects were hypertensive compared with 1.8% of ethanol users (P = 0.029).Conclusions: To our knowledge, this is the first cookstove randomized controlled trial examining prenatal BP. Ethanol cookstoves have potential to reduce DBP and hypertension during pregnancy. Accordingly, clean cooking fuels may reduce adverse health impacts associated with household air pollution.Clinical trial registered with www.clinicaltrials.gov (NCT02394574).

Background: Household air pollution (HAP) is associated with adverse pregnancy outcomes. Objectives: Investigate impact of in-utero HAP exposure on placental development and chronic hypoxia. Methods: Markers of chronic placental hypoxia [Hofbauer cells (HBC), syncytial knots (SK), chorionic vascular density(cVD) and hypoxia-inducible factor (HIF)] were stained by hematoxylin-eosin and/or immunohistochemically in placenta samples collected from firewood-/kerosene-users (A, n=16), and ethanol-users (B, n=20) that participated in a randomized controlled intervention trial in Ibadan, Nigeria. A third group of non-smoking and presumed natural gas-using Chicago women (C, n=12) were included in this exploratory pilot to assess for possible differences in placenta histology between similar racial groups. All patients had uncomplicated pregnancies and delivered at term. Results: HBC, SK and cVD were significantly increased among firewood-/kerosene-users compared to ethanolusers and natural gas-using Chicago women (HBC medians 5.5, 3.5, and 2.0, respectively; SK means 55.6, 41.8 and 30.1; cVD means 8.8, 6.2, and 5.2; all p < 0.01). HIF expression was significantly higher in Group A compared to B and C (all p < 0.001). Conclusions: In-utero exposure to HAP is associated with pathologic changes and HIF expression consistent with chronic hypoxia in placenta of firewood/kerosene-users compared to ethanol-users with less HAP exposure and Chicago women with no presumed HAP exposure. Presence of chronic hypoxic signature in placenta of women exposed to HAP has implications for adverse pregnancy complications and future growth and development of the young children. Future larger studies need to focus on HAP exposure and placental disorders like preeclampsia and long-term health impact of in-utero exposure to HAP. (c) 2017 The Authors. Published by Elsevier B.V.

High Adoption Rates of an Ethanol Cookstove Associated with Reductions in Exposure to Particulate Matter in a Randomized Controlled Trial in Ibadan, NigeriaAbstract Number:3019 Donee Alexander, Amanda Northcross, Matt Shupler, John Oluseye, Tope Ibigbami, Godson Ana, Morhasson Bello, Oladosu Ojengbede*, and Christopher O Olopade Donee Alexander University of Chicago, United States , Amanda Northcross The George Washington University, School of Public Health and Health Services, United States , Matt Shupler The George Washington University, Sch of Pub Health & Health Services, United States , John Oluseye Healthy Life for All Foundation, Nigeria , Tope Ibigbami Healthy Life for All Foundation, Nigeria , Godson Ana University of Ibadan, Ctr for Population and Reproductive Health, Nigeria , Morhasson Bello University of Ibadan, Ctr for Population and Reproductive Health, Nigeria , Oladosu Ojengbede* University of Ibadan, Ctr for Population and Reproductive Health, Nigeria , and Christopher O Olopade University of Chicago, Center for Global Health, United States AbstractHousehold air pollution (HAP) from inefficient cookstoves is responsible for almost four million premature deaths in developing countries annually, with 95,000 annual deaths in Nigeria attributed to HAP according to the World Health Organization (WHO). In urban areas of Nigeria, 50-55% of the population utilizes kerosene as their primary fuel source. Combustion of kerosene produces a large array of substances, including particulate matter (PM) and carbon monoxide (CO) that can adversely affect health. Studies collecting samples from households burning kerosene have revealed levels of PM2.5 (PM < 2.5 microns) and CO far beyond the WHO-recommended values of 25 µg/m3 (24-hour mean) and 8.7 ppm (8-hour mean), respectively. The greatest exposure burden to HAP in Nigeria is among women and children, as they typically assume the bulk of the cooking duties. Unfortunately, the use of kerosene is perpetuated due to a government subsidy on kerosene in Nigeria, which makes it more affordable than firewood for cooking and household energy needs.Using a randomized controlled trial design, this study evaluates the effectiveness of an ethanol cookstove to reduce exposures to household air pollution and improve birth outcomes. Three hundred women in the early second trimester of pregnancy who use kerosene or wood as their primary fuel for cooking are being recruited from primary healthcare centers (PHCs) in Ibadan, Nigeria, with 50% randomized to the ethanol cookstove group. Personalized exposure monitoring of PM2.5 and CO is conducted for two 72-hour periods, once in the second and third trimesters, respectively. Additionally, all stoves in both the ethanol and control homes are equipped with stove use monitors (SUMs), which are small data-logging temperature sensors that monitor stove use.HAP emitted by burning unclean fuels within the home affects both human health and the environment. Despite this evidence, the adoption of cleaner stoves has been hindered by difficulties surrounding their dissemination and implementation. Households are reluctant to adopt technology that is difficult to maintain, less convenient, or offers fewer options than traditional methods. Moreover, when new stoves are introduced to a household, stove and fuel stacking commonly occur, which may diminish the intended benefits. With the global commitment to distribute 100 million clean cookstoves to vulnerable homes by 2020, more studies showing practice-based evidence of adoption are needed to realize these goals.Here we present data from a small subset of kerosene and ethanol users. Initial SUMs data show that all intervention homes are using their ethanol stove as their primary cookstove. Questionnaire results indicate that women are using their stove on a daily basis. These results are confirmed by the SUMs data, which show that, on average, women who receive the ethanol cookstove use it 2.3 (±0.5) times per day compared to 2.2 (±0.5) times per day for the kerosene group. Only 18% of ethanol cookstove users practice 'stove stacking'. Of those ethanol homes that utilize a second stove, they do so less than 10% of the time.Preliminary exposure results of a small subset of data suggest a 20% reduction 72-hour mean PM during the second trimester and a 35% reduction in the third trimester in the ethanol group compared to kerosene users. Exposures to PM were higher in both groups in the third trimester compared to the second trimester. These results suggest that, even in urban settings with high ambient air pollution, clean cookstove interventions can still reduce personal exposure to PM.