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Bangladesh Journal of Medical Science Vol. 13 No. 04 October’14

401

Original article

Untoward obstetric outcome among Smokeless Tobacco (ST – Mishri) users in Western
Maharashtra

Pratinidhi A1, Ganganahalli P2, Kakade SV3

Introduction:

Tobacco use is widely recognized as one of the lead-
ing threats to global health. Historically, the preva-
lence of smoking among women in the developing
world has been very low, in part because of strong

cultural constraints against women's smoking1. The
use of new tobacco products is increasing not only
among men but also among children, teenagers,and
women of reproductive age group, Mishri is one

among them2. Mishri is prepared by roasting tobac-
co leaves, principal constituent alkaloid nicotine
being 1 to 7%. Various studies have estimated the

prevalence of the use of Mishri from 17% - 45%3,4.
Smoking is an established cause of adverse pregnan-
cy outcome. It is associated with higher rates of
abortion, ectopic pregnancy, still birth, placenta pre-
via, abruptio placentae, premature rupture of mem-

branes, preterm birth, intrauterine growth retardation

and sudden infant death syndrome3,5. Low birth
weight and preterm birth are powerful determinants
of morbidity and mortality in newborn babies and
infants. It has been known for last few decades that
babies born to mothers who smoke weigh less than
babies whose mothers don’t. There are indications
that using smokeless tobacco could be as detrimen-

tal to fetal health as cigarette smoking6.
Objective

To compare outcome of pregnancy among women
using Mishri and not using Mishri during pregnancy
at Krishna hospital, Karad
Material and Methods:

The study was conducted in Krishna hospital for the

period of six months (from 01st January to 30th June
2011). All pregnant women admitted to Krishna hos-

Corresponds to:
Dr. Praveen Ganganahalli, Assistant Professor, Dept. of Community Medicine, Krishna Institute of Medical
Sciences, Karad (Satara) 415110, Maharashtra, Email: dr.pravin2000@gmail.com 

Abstract:

Background: Use of tobacco and new products is increasing not only among men but also 
among children, teenagers, women of reproductive age group. Mishri (ST) is one among 
them. Smoking is an established cause of adverse pregnancy outcome. There are indications 
that using smokeless tobacco could be as detrimental to fetal health as cigarette smoking. 
Objective: To compare the outcome of pregnancy among women who were using Mishri 
during pregnancy and those not using it at Krishna hospital, Karad. Materials and Methods: 
Pregnant women using Mishri during pregnancy were selected for study from Krishna 
hospital, Karad and equal numbers of pregnant women not using tobacco were selected as 
comparison group after matching for age and parity. Observations: The proportion of 
pregnant women using Mishri during pregnancy was 12%. A significant number of users was 
found to be anemic (69.8%). Significantly higher number of Mishri users experienced 
complications like Oligohydramnios, fetal distress, delivery before EDD (91.9%) and birth of 
Low birth weight babies (81.7%) with short stature and increased Ponderal Index. 
Conclusion: Special attention should be given to avoid or at least reduce the use of Mishri 
during pregnancy as a part of routine antenatal care to reduce the adverse perinatal outcome.
Keywords: smokeless tobacco (ST); Mishri; pregnant women; anaemia; low birth weight; 
length at birth; Ponderal Index

1. Dr. Asha Pratinidhi, Director of Research, Krishna Institute of Medical Sciences University, Karad

2. Dr. Praveen Ganganahalli, Assistant Professor, Dept. of Community Medicine, Krishna Institute of
Medical Sciences, Karad.

3. Dr. Satish.V Kakade , Statistician/Associate Professor, Dept. of Community Medicine, Krishna Institute
of Medical Sciences, Karad.

DOI: http://dx.doi.org/10.3329/bjms.v13i4.15215
Bangladesh Journal of Medical Science Vol. 13 No. 04 October '14. Page: 401-405



pital for delivery and using Mishri (ST) during preg-
nancy were enrolled as study subjects and those
pregnant women who were not using any form
tobacco as control subjects after matching for age
and parity. Data collection was done by using a
structured and pretested proforma on the day of
delivery, which included personal profile, socio-
demographic profile, obstetrics profile, details of
delivery and its outcome and anthropometry of new-
born babies. Statistical analysis was done for signif-
icance and association. Informed verbal consent
from the pregnant women and clearance from
Institutional ethical committee and hospital adminis-
tration was obtained prior to the study.
Results:

A total of 12% (258) of hospital deliveries were
found using Mishri (ST) during pregnancy in six
months of study period. Equal numbers of control
subjects were selected after matching for age and

parity. 
Among all the users 29% were teenagers, 68% were
primis, 78% were housewives, and 77% belonged to
class III according to modified B.G Prasad classifi-
cation. There was no significant difference between
users and nonusers of Mishri (ST) regarding these
variables.
Significant numbers of Mishri (ST) users were found
anemic at the time of delivery compared to nonusers
of Mishri (ST). Mean hemoglobin (g%) was found
significantly less (t=-15.24, p=0.000) among users
(10.4±0.90) compared to nonusers of Mishri (ST)
(11.6±1.05). The complications like oligohydram-
nios and fetal distress was found to be significantly
more among users of msihri although Pregnancy
Induced Hypertension (PIH), past history of sponta-
neous abortion was found more among users as com-
pared to nonusers did not reach the level of statisti-
cal significance (table I).

S i g n i f i c a n t
number of
users of Mishri
(91.9%) deliv-
ered before the
expected date
of delivery
compared to
nonusers of
M i s h r i
(74.4%). Mean
number of days
before EDD
among users
was found to
be 5 which was
s i g n i f i c a n t l y
less compared
to nonusers
( 2 . 2 d a y s )
( t = 8 . 6 4 ,
p=0.000).
There was no
significant dif-
ference in rela-
tion to type of
delivery, out-
come of preg-
nancy and gen-
der of the baby.
The apparently
higher rate of
still births

Untoward obstetric outcome among Smokeless Tobacco users

402

Variables 

Mishri (ST) 

users (n=258 ) 

Non Mishri (ST) 

users (n=258) 

Total 

 

(n=516) 
Χ

2 

value 
p value 

Number (%) Number (%) Number (%)  

Anaemia         
Present 

Absent 
 

180(69.8) 

78 (30.2) 

42(16.3) 

216 (83.7) 

219 (42.4) 

297 (57.6) 
144.58 0.000 

Oligohydramnios 

 
Present 

Absent 

 

 
17(6.6) 

241 (93.4) 

 

 
07(2.7) 

251 (97.3) 

 

 
24 (4.6) 

492 (95.4) 

4.37 0.037 

Fetal distress 

 

Present 
Absent 

 

 

29(11.2) 
229(88.8) 

 

 

14(5.4) 
244(94.6) 

 

 

43 (8.4) 
473 (91.6) 

5.70 0.017 

Pregnancy Induced 

Hypertension 

 
Present 

Absent 

 

 
 

 

22(8.5) 
236 (91.5) 

 

 
 

 

15(5.8) 
243 (94.2) 

 

 
 

 

37 (7) 
479 (93) 

1.42 0.232 

Past history of 

spontaneous abortion 
 

Present 

Absent 

 

 
 

11 (4.3) 

247 (95.7) 

 

 
 

07 (2.7) 

251 (96.5) 

 

 
 

18 (3.5) 

498 (96.5) 

0.92 0.337 

Table I: Comparison of complications associated with pregnancy.



among users as compared to nonusers of Mishri was
not found statistically significant (table II).
Significant number of Mishri users (81.7%) deliv-

ered babies with
birth weight less
then 2.5kg com-
pared to nonusers
( 6 . 2 % )

( ? 2 = 2 9 9 . 7 ,
p<0.000). Mean
birth weight (Kg)
of babies born to
Mishri users was
about 600gm
lesser than babies
born to nonusers
of Mishri. A sig-
nificant number
of babies born to
Mishri users
(82.9%) were
found to shorter
than babies born
to nonusers of
Mishri (1.9%)

( ? 2 = 3 4 6 . 5 ,
p < 0 . 0 0 0 ) . T h e
Ponderal Index of
newborn babies
was calculated by
the formula
PI=birth weight
(gm) x 100 /
(length at birth in

cm)3 & found that Ponderal index of babies born to
the mothers using Mishri was significantly higher
than the babies born to the

nonusers.(X2=12.03,p<0.000).
Discussion:

The study revealed that 12% of
pregnant women have been using
Mishri during pregnancy among all
hospital deliveries, which is lower
as compared  to that observed by

Gupta P.C6 (17%) and Pardeshi et

al7 (51%), however, Global Adult
Tobacco Survey Report India

2009-108 has shown the preva-
lence of Mishri use among women
in Maharashtra to be 8%.

Pardeshi et al7 have also found that
27.3% teenage pregnant women,

Pratinidhi A, Ganganahalli P, Kakade SV

403

Variables 

Mishri (ST) 

Users (n=258) 

Non Mishri (ST) 

users (n=258) 

Total 

 

(n=516) 
Χ

2 

value 

p 

value 

Number (%) Number (%) Number (%)  

Delivery  

 

Before due date 
 

On due date (EDD)  

 
After due date 

 

 

237 (91.9) 
 

15 (5.8) 

 
06 (2.3) 

 

 

192 (74.4) 
 

50 (19.4) 

 
16 (6.2) 

 

 

429 (83.1) 
 

65 (12.5) 

 
22 (4.4) 

7.674 0.006 

Type of delivery 

 
Vaginal 

 

Operative 

 

 
209(81) 

 

49 (19) 

 

 
204(79.1) 

 

54 (20.9) 

 

 
413 (80) 

 

103 (20) 

.303 0.582 

Outcome 

 

Live birth 
 

Stillbirth 

 

 

253(98.1) 
 

05 (1.9) 

 

 

256(99.2) 
 

02(0.8) 

 

 

509 (98.6) 
 

07 (1.4) 

.579 0.447 

Gender of baby 

 

Male 

 
Female 

 

 

112(43.4) 

 
146 (56.6) 

 

 

134(51.9) 

 
124 (48.1) 

 

 

246 (47.6) 

 
270 (52.4) 

3.76 0.052 

Table II: Comparison of obstetric outcome among users & nonusers of Mishri (ST)

Variables 

Mishri (ST)  

 

users (n=258) 

Non Mishri

(ST) users 

(n=258) 
t 
 

value 

p  

 

value 

Mean ± S.D Mean ± S.D 

Birth weight 
(Kg) 

2.2 ± 0.24 2.8 ± 0.27 -25.33 0.001 

Length of baby 

(Cm) 
43 ± 5.4 52 ± 1.8 -24.14 0.001 

Ponderal index 2.857 ± 1.207 1.948 ± 0.216 12.03 0.0001 

Table III: Anthropometric profile of babies born to subjects.



48% illiterate, 90.9% housewives, 35% pregnant
women from lower class have been using Mishri
during pregnancy, which is similar to our observa-
tions.

Gupta P.C6 have found anaemia among 68.6% of
pregnant women using smokeless tobacco compared

to nonusers (16.3%) & Pardeshi et al7 have found it
to be 44.2% vs. 37%, which is comparable to our
finding. Mean hemoglobin (g%) was found to be 10

by Subramanhya S9 among smokeless tobacco users
which is almost similar to that of present study10.4
(g%). This is substantiated by the findings of

Subramanhya S10 who have reported that Anaemia
was significantly associated with smokeless tobacco
(OR=1.7; 95% CI=1.2-2.5).

Pratinidhi et al3 in their previous study have demon-
strated that fetal distress and Pregnancy induced
hypertension is significantly associated with Mishri
use. The present study revealed similar trend. 

Gupta P.C6 have previously observed that delivery
took place 6.2 (days, mean) before the EDD among
the ST users which was reported to be 5.6 (days) by

Pardeshi et al7 and in the present study it is 5 (days).
This suggests ST use might be linked to relatively
early delivery by nearly one week than the EDD.

Pratinidhi et al3 also have found the Relative Risk of
preterm delivery among smokeless tobacco users to
be 2.8 times higher than nonusers which has been

1.4 in the study by Gupta et al6.

Pratinidhi et al3 have demonstrated 19.3% LBW
babies among Mishri (ST) users compared to  9%
among nonusers where as proportion has beeen
found to be 28.6% and 19.9% respectively by Gupta

P.C6. However in the present study proportion of
LBW babies has been found to be exceptionally high
i.e.,81.7% among the babies of ST users as com-

pared to 6.2% among nonusers. Babies born to ST
users has been found to be 400 (g) lighter by

Pratinidhi et al3 and Pardeshi et al7 and 189 (g) by

Gupta P.C6. In the present study ST user mother has
delivered babies 600 (g) lighter that the babies of
nonuser mothers. 
No studies have so far found to compare the length
of babies at birth among Mishri (ST) users compared
to nonusers of Mishri (ST). There have been stud-

ies11-14 stating higher and lower Ponderal Index
among newborns of smokers as compared to new-
borns of nonsmokers respectively. This is due to dif-
ferential reduction in weight and length of the foe-
tuses due to nicotine effect of the smoking by the
mothers. In the present study the Ponderal Index is
significantly higher among the newborns of mothers
using Mishri (ST) as compared to the newborns of
the non users of Mishri (ST) indicating more nico-
tine effect on length as compared to the weight of the
baby.

Hoque et al5 in their study, conducted in
Bangladesh, have found the rate of still birth of
about two times higher among smokeless tobacco
users as compared to nonusers (p<0.001). They have
also found that frequency of preterm deliveries,
LBW, spontaneous abortions are significantly more
among smokeless tobacco users as compared to non
users. In the present study we have found a signifi-
cantly high proportion of preterm and LBW babies
born to ST users as compared to the non ST users. 
Conclusion:

Use of Mishri is increasing among women who are
pregnant and is not only known to affect general
health but also pregnancy and its outcome. So spe-
cial attention need be given to avoid or at least
reduce the use of Mishri during pregnancy as a part
of routine antenatal care.

Untoward obstetric outcome among Smokeless Tobacco users

404



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Pratinidhi A, Ganganahalli P, Kakade SV

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