title: Risk of stillbirth in the relation to water disinfection by-products: a population-based case-control study in Taiwan.
abstract: BACKGROUND
  Few epidemiological studies that have assessed the relation between water disinfection by-products (DBPs) and the risk of stillbirth provide inconsistent results. The objective was to assess the relation between exposure to water disinfection by-products and the risk of stillbirth.
  
  
  METHODS
  We conducted a population-based case-control study of 3,289 cases of stillbirth and a random sample of 32,890 control subjects from 396,049 Taiwanese newborns in 2001-2003 using information from the Birth Registry and Waterworks Registry in Taiwan. We compared the risk of stillbirth in four disinfection by-product exposure categories based on the levels of total trihalomethanes (TTHMs) representing high (TTHMs 20+ µg/L), medium (TTHMs 10-19 µg/L), low exposure (TTHMs 5-9 µg/L), and 0-4 µg/L as the reference category. In addition, we conducted a meta-analysis of the results from the present and 5 previous studies focusing on stillbirth.
  
  
  RESULTS
  In logistic regression analysis adjusting for gender, maternal age, plurality, conception of season and population density of the municipality where the mother lived during pregnancy, the odds ratio (OR) for stillbirth was 1.10 (95% CI 1.00-1.21) for medium exposure and 1.06 (95% 0.96-1.17) for high exposure compared to reference category. In the meta-analysis, the summary odds ratio for stillbirth (1.11, 95% CI: 1.03, 1.19) was consistently elevated.
  
  
  CONCLUSIONS
  The present study is consistent with the hypothesis that the risk of stillbirth is related to prenatal exposure to disinfection by-products. This finding on stillbirth is consistent with previous epidemiologic studies, which strengthens the weight of evidence.
authors.affiliation: Department and Graduate Institute of Occupational Safety and Health, College of Public Health, China Medical University, Taichung, Taiwan, Republic of China. bfhwang@mail.cmu.edu.tw
authors.forename: Bing-Fang
authors.initials: BF
authors.lastname: Hwang
authors.forename: Jouni J K
authors.initials: JJ
authors.lastname: Jaakkola
mesh_terms: D016022:Case-Control Studies; D004203:Disinfection; D004781:Environmental Exposure; D005260:Female; D006801:Humans; D008297:Male; D011159:Population Surveillance; D011247:Pregnancy; D012307:Risk Factors; D050497:Stillbirth / Q000453:epidemiology*; D013624:Taiwan / Q000453:epidemiology