Page mackup July-14.qxd 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 References: 1. Michele Blocg et al. tobacco use & secondhand smoke exposure during pregnancy: An investigative survey of women in 9 developing nations. Am J Pub Health 2 0 0 8 ; 9 8 : 1 8 3 3 - 1 8 3 8 . http://dx.doi.org/10.2105/AJPH.2007.117887 2. Gupta P.C, Ray C.S. smokeless tobacco in India and Southeast Asia. Respirology 2003;8: 419-31. http://dx.doi.org/10.1046/j.1440-1843.2003.00507.x 3. Pratinidhi A, Gandham S, Shrotri A, Patil A, Pardeshi S. Use of 'Mishri (ST)' A Smokeless form of tobacco during Pregnancy and its Perinatal Outcome. Indian J Com Med 2010;35:14-18. http://dx.doi.org/10.4103/0970-0218.62547 4. Gupta P.C, Subramoney S. smokeless tobacco use and risk of still birth: A cohort study in Mumbai, India. Epidemiology 2006;17:47-51. http://dx.doi.org/10.1097/01.ede.0000190545.19168.c 4 5. Hoque M, Rahaman E, Dey P.R. pregnancy outcome of mothers who used smokeless tobacco for five years or more. Bang J Child Health 2011;35:6-10. 6. Gupta P.C, Sreevidya S. Smokeless tobacco use, birth weight and gestational age: Population based prospec- tive study of 1217 women in Mumbai, India. BMJ 2 0 0 4 ; 3 2 8 : 1 5 3 8 . http://dx.doi.org/10.1136/bmj.38113.687882.EB 7. Pardeshi S, Pratinidhi A.K, Gupte A. Use of 'Mishri (ST)' – A Smokeless form of Tobacco during pregnan- cy and its effect on the outcome of pregnancy. Res J Krishna Institute, Karad 2008;1:8-14. 8. Global Adult Tobacco Survey India Report 2009-2010. Ministry of Health and Family Welfare, Government of India, New Delhi. 9. Subramoney S, Gupta P.C. Anaemia in pregnant women who use Smokeless tobacco. Nicotine and Tobacco Research 2008;10(5):917-920. http://dx.doi.org/10.1080/14622200802027206 10. Subramoney S, Gupta P.C. Correspondence: Anaemia in pregnancy. India J Med Res 2008;128:780-781. 11. Marzenna Króll, Ewa Florek, Wojciech Piekoszewski, Renata Bokiniec and Maria K. Kornacka The Influence of Prenatal Exposure to Tobacco Smoke on Neonatal Body Proportions J Women's Health Care 2012;1:4 http://dx.doi.org/10.4172/2167-0420.1000117 12. Lindley AA, Becker S, Gray RH, Herman AA .Effect of continuing or stopping smoking during pregnancy on infant birth weight, crown-heel length, head circum- ference, ponderal index, and brain:body weight ratio. Am J Epidemiol 2000;152:219 - 225. http://dx.doi.org/10.1093/aje/152.3.219 13. Samper MP, Jiménez-Muro A, Nerín I, Marqueta A, Ventura P, et al. Maternal active smoking and newborn body composition. Early Hum Dev2012;88:141-145. http://dx.doi.org/10.1016/j.earlhumdev.2011.07.015 14. Pichini S, Garcia-Algar O, Mu-oz L, Vall O, Pacifici R, et al. Assessment of chronic exposure to cigarette smoke and its change during pregnancy by segmental analysis of maternal hair nicotine. J Expo Anal Environ Epidemiol 2003;13:144-151. http://dx.doi.org/10.1038/sj.jea.7500264 Pratinidhi A, Ganganahalli P, Kakade SV 405