Contact Kelly Ferguson ( kellferg@umich.edu ) for additional information. Produced by the Detroit Reproductive

Environmental Advocacy Matters Group: Kelly Ferguson, Natalie Sampson, Amy Schulz, Trish Koman, Chris Coombe, and Donele Wilkins. April 22, 2015. SUPPORT FOR LOWER OZONE STANDARD, DUE TO OMITTING PREGNANT WOMEN AS A VULNERABLE POPULATION IN THE NAAQS REVIEW PROCESS

R ecommendation

. We commend the EPA efforts to reduce the current ozone standard, and support the lower range (60

- 65 ppb). For the current proposed rule, pregnant women specifically, not just consequences to birth outcomes, were not included as a vulnerable population. This omission provides cause for supporting the lower range to provide an adequate margin of safety.
Omission of preg nant women in the ozone ISA

. Prenatal development is considered as a lifestage that is more susceptible to consequences of ozone exposures, and reproductive and developmental consequences to the fetus are considered. However, the ISA does not address healt h consequences to ozone exposure experienced by pregnant women specifically, and other data that support this population as being at

- risk to ozone exposure.
Pregnant women are subject to a broader range of potential health consequences from ozone exposure compared to the general population which need to be accounted for

. Ozone exposure has been linked to preeclampsia, a hypertensive disorder, as well as a number of adverse birth outcomes which can have immediate and repercussive health consequences to pregnant mothers. Preeclampsia puts mothers at an increased risk of mortality during pregn ancy and also for an increased risk of cardiovascular disease later in her life. 1 New studies have been published since the 2013 Ozone ISA was completed demonstrating strong evidence for an

ass ociation between exposure to ozone during pregnancy and the development of preeclampsia. 2 , 3 Ozone exposure is also associated w ith adverse pregnancy outcomes, including fetal mortality, premature birth, low birth weight, and birth defects. These findings have been summarized in the ozone ISA, although new convincing evidence has been added to this body of literature since 2011, 4 , 5 but the impact of these outcomes o n maternal health (both during pregnancy and later in life) are not acknowledged. These include, but are not limited to physical (e.g., C

- section) and mental (e.g., psychological distress and depression) consequences. 6

- 9
Pregnant women receive a higher dose of ozone for a given exposure level compared to the general population which should be accounted for in the ISA and Federal Register

. Pregnant women have an increase d metabolic rate (i.e., amount of oxygen consumed) compared to non

pregnant women of reproductive age. 10

- 12 Since the primary route of exposure for ozone is through inhalation, it follows that the dose would be higher in pregnant women, although, to our knowledge, this has not been dire ctly demonstrated in epidemiologic, animal, or modeling studies.
Vulnerability of pregnant women is of great concern because of the size of the population. Additionally, pregnant women represent a large proportion of the US population. For 2013, the Nation al Vital Statistics Reports from the US Department of Health and Human services estimated 3,957,577 births. 13 This underestimates the number of pregnancies, but otherwise translates to pregnant women accounting for 1.25% of the population that year. 14Contact Kelly Ferguson ( kellferg@umich.edu ) for additional information. Produced by the Detroit Reproductive

Environmental Advocacy Matters Group: Kelly Ferguson, Natalie Sampson, Amy Schulz, Trish Koman, Chris Coombe, and Donele Wilkins. April 22, 2015. References. 1. Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): population

- based retr ospective cohort study. Lancet. 2005;366(9499):1797

- 1803. 2. Hu H, Ha S, Roth J, Kearney G, Talbott EO, Xu X. Ambient Air Pollution and Hypertensive Disorders of Pregnancy: A Systematic Review and Meta

- analysis. Atmospheric environment. 2014;97:336

- 345. 3. Pedersen M, Stayner L, Slama R, et al. Ambient air pollution and pregnancy

- induced hypertensive disorders: a systematic review and meta

- analysis. Hypertension. 2014;64(3):494

- 500. 4. Ha S, Hu H, Roussos

- Ross D, Haidong K, Roth J, Xu X. The effects of air pollution on adverse birth outcomes. Environ Res. 2014;134:198

- 204. 5. Lee PC, Roberts JM, Catov JM, Talbott EO, Ritz B. First trimester exposure to ambient air pollution, pregnancy complications and adverse birth outcomes in Allegheny County, PA. Matern C

hild Health J. 2013;17(3):545

- 555. 6. Behrman RE, Butler AS, eds. Preterm birth: causes, consequences, and prevention. Washington, DC: The National Academies Press; 2007. 7. Holditch

- Davis D, Bartlett TR, Blickman AL, Miles MS. Posttraumatic stress symptom s in mothers of premature infants. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN / NAACOG. 2003;32(2):161

- 171. 8. Singer LT, Salvator A, Guo S, Collin M, Lilien L, Baley J. Maternal psychological distress and parenting stress after the bi rth of a very low

- birth

- weight infant. JAMA

. 1999;281(9):799

- 805. 9. Veddovi M, Kenny D, Gibson F, Bowen J, Starte D. The relationship between depressive symptoms following premature birth, mothers' coping style, and knowledge of infant development. Journa l of reproductive and infant psychology. 2001;19(4):313

- 323. 10. Clapp JF, 3rd, Seaward BL, Sleamaker RH, Hiser J. Maternal physiologic adaptations to early human pregnancy. American journal of obstetrics and gynecology. 1988;159(6):1456

- 1460. 11. Grindhei m G, Toska K, Estensen ME, Rosseland LA. Changes in pulmonary function during pregnancy: a longitudinal cohort study. BJOG : an international journal of obstetrics and gynaecology. 2012;119(1):94

- 101. 12. Rees GB, Broughton Pipkin F, Symonds EM, Patrick JM . A longitudinal study of respiratory changes in normal human pregnancy with cross

- sectional data on subjects with pregnancy

- induced hypertension. American journal of obstetrics and gynecology. 1990;162(3):826

- 830. 13. Hamilton B, Martin J, Osterman M, Cur tin S. Births: Preliminary Data for 2013. National vital statistics reports. 2014;63. 14. Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2013. 2014.