Association of Prenatal Exposure to Maternal Drinking and Smoking With the Risk of Stillbirth
Authors: Hein Odendaal, Kimberly A. Dukes, Amy J. Elliott, Marian Willinger, Lisa M. Sullivan, Tara Tripp, Coen Groenewald, Michael M. Myers, William P. Fifer, Jyoti Angal, Theonia K. Boyd, Larry Burd, Jacob B. Cotton, Rebecca D. Folkerth, Gary Hankins, Robin L. Haynes, Howard J. Hoffman, Perri K. Jacobs, Julie Petersen, Nicolò Pini, Bradley B. Randall, Drucilla J. Roberts, Fay Robinson, Mary A. Sens, Peter Van Eerden, Colleen Wright, Ingrid A. Holm, Hannah C. Kinney, Travis Baker, Rebecca A. Young, Idania Ramirez, Laura Spurchise, Derek Petersen, Gregory Toland, Michael Carmen, Cheri Raffo, Cindy Mai, Jamie Collins, Patti Folan, Ingrid A. Holm, David S. Paterson, Richard A. Belliveau, Richard D. Goldstein, Kevin G. Broadbelt, Kyriacos Markianos, Hanno Steen, Hoa Tran, Kristin Rivera, Megan Minter, Claire F. Maggiotto, Kathryn Schissler, Whitney Adler, Elizabeth Berg, Christa Friedrich, Jessica Gromer, Margaret Jackson, Luke Mack, Bethany Norton, Liz Swenson, Deborah Tobacco, Amy Willman, Deana A. Him, Lisa B. Robe, Mary Berdahl, Donna Black, Jocelyn Bratton, Chaleen Brewer, Melissa Berry, Cathy Christophersen, Sue Cote, Kari Daron, Alexandra Draisey, Sara Fiedler, Kathy Harris, Lyn Haug, Lynn Heath, Ann Henkin, Tara Herman, Jessica Holsworth, Kimberly Lucia, Laura Medler, Libby Nail, Amber Ogaard, Debby Olson, Mary Reiner, Carol Robinson, Brooke Schmitt, Monique S. Bob, Lacey Stawarski, Sherri T. Fingers, Rachel Thies, Mary Thum, Elizabeth Wheeler, Lisa W. Bull, Steve W. Hat, Amy Wilson, Neva Zephier, Misti Zubke, Heidi Bittner, Jeffrey Boyle, Donna Gaspar, Cheryl Hefta, Michael McNamara, Karna Colby, Kent Donelan, Don Habbe, Catherine Stoos, H. Eugene Hoyme, Amy Mroch, Erna Carstens, Lucy Brink, Lut Geerts, Greetje de Jong, Pawel Schubert, Shabbir Wadee, Johan Dempers, Elsie Burger, Janetta Harbron, J. David Nugent, Carmen Condon, Joseph Isler, Margaret C. Shair, Yvonne Sininger, Chuan-Ming Li, Caroline Signore, Ken Warren, Elizabeth Thom, Phillip Cato, James W. Collins, Terry Dwyer, George Macones, Philip A. May, Richard M. Pauli, Raymond W. Redline, Michael Varner, Dale Hereld
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Prenatal smoking is a known modifiable risk factor for stillbirth; however, the contribution of prenatal drinking or the combination of smoking and drinking is uncertain. <h3>Objective</h3> To examine whether prenatal exposure to alcohol and tobacco cigarettes is associated with the risk of stillbirth. <h3>Design, Setting, and Participants</h3> The Safe Passage Study was a longitudinal, prospective cohort study with data collection conducted between August 1, 2007, and January 31, 2015. Pregnant women from Cape Town, South Africa, and the Northern Plains region of the US were recruited and followed up throughout pregnancy. Data analysis was performed from November 1, 2018, to November 20, 2020. <h3>Exposure</h3> Maternal consumption of alcohol and tobacco cigarettes in the prenatal period. <h3>Main Outcomes and Measures</h3> The main outcomes were stillbirth, defined as fetal death at 20 or more weeks' gestation, and late stillbirth, defined as fetal death at 28 or more weeks' gestation. Self-reported alcohol and tobacco cigarette consumption was captured at the recruitment interview and up to 3 scheduled visits during pregnancy. Participants were followed up during pregnancy to obtain delivery outcome. <h3>Results</h3> Of 11663 pregnancies (mean [SD] gestational age at enrollment, 18.6 [6.6] weeks) in 8506 women for whom the pregnancy outcome was known by 20 weeks' gestation or later and who did not terminate their pregnancies, there were 145 stillbirths (12.4 per 1000 pregnancies) and 82 late stillbirths (7.1 per 1000 pregnancies). A total of 59% of pregnancies were in women from South Africa, 59% were in multiracial women, 23% were in White women, 17% were in American Indian women, and 0.9% were in women of other races. A total of 8% were older than 35 years. In 51% of pregnancies, women reported no alcohol or tobacco cigarette exposure (risk of stillbirth, 4 per 1000 pregnancies). After the first trimester, 18% drank and smoked (risk of stillbirth, 15 per 1000 births), 9% drank only (risk of stillbirth, 10 per 1000 pregnancies), and 22% smoked only (risk of stillbirth, 8 per 1000 pregnancies). Compared with the reference group (pregnancies not prenatally exposed or without any exposure after the first trimester), the adjusted relative risk of late stillbirth was 2.78 (98.3% CI, 1.12-6.67) for pregnancies prenatally exposed to drinking and smoking, 2.22 (98.3% CI, 0.78-6.18) for pregnancies prenatally exposed to drinking only after the first trimester, and 1.60 (98.3% CI, 0.64-3.98) for pregnancies prenatally exposed to smoking only after the first trimester. The adjusted relative risk for all stillbirths was 1.75 (98.3% CI, 0.96-3.18) for dual exposure, 1.26 (98.3% CI, 0.58-2.74) for drinking only, and 1.27 (98.3% CI, 0.69-2.35) for smoking only compared with the reference group. <h3>Conclusions and Relevance</h3> These results suggest that combined drinking and smoking after the first trimester of pregnancy, compared with no exposure or quitting before the end of the first trimester, may be associated with a significantly increased risk of late stillbirth.