title: Impact of exposure to cooking fuels on stillbirths, perinatal, very early and late neonatal mortality - a multicenter prospective cohort study in rural communities in India, Pakistan, Kenya, Zambia and Guatemala.
abstract: BACKGROUND
  Consequences of exposure to household air pollution (HAP) from biomass fuels used for cooking on neonatal deaths and stillbirths is poorly understood. In a large multi-country observational study, we examined whether exposure to HAP was associated with perinatal mortality (stillbirths from gestation week 20 and deaths through day 7 of life) as well as when the deaths occurred (macerated, non-macerated stillbirths, very early neonatal mortality (day 0-2) and later neonatal mortality (day 3-28). Questions addressing household fuel use were asked at pregnancy, delivery, and neonatal follow-up visits in a prospective cohort study of pregnant women in rural communities in five low and lower middle income countries participating in the Global Network for Women and Children's Health's Maternal and Newborn Health Registry. The study was conducted between May 2011 and October 2012. Polluting fuels included kerosene, charcoal, coal, wood, straw, crop waste and dung. Clean fuels included electricity, liquefied petroleum gas (LPG), natural gas and biogas.
  
  
  RESULTS
  We studied the outcomes of 65,912 singleton pregnancies, 18 % from households using clean fuels (59 % LPG) and 82 % from households using polluting fuels (86 % wood). Compared to households cooking with clean fuels, there was an increased risk of perinatal mortality among households using polluting fuels (adjusted relative risk (aRR) 1.44, 95 % confidence interval (CI) 1.30-1.61). Exposure to HAP increased the risk of having a macerated stillbirth (adjusted odds ratio (aOR) 1.66, 95%CI 1.23-2.25), non-macerated stillbirth (aOR 1.43, 95 % CI 1.15-1.85) and very early neonatal mortality (aOR 1.82, 95 % CI 1.47-2.22).
  
  
  CONCLUSIONS
  Perinatal mortality was associated with exposure to HAP from week 20 of pregnancy through at least day 2 of life. Since pregnancy losses before labor and delivery are difficult to track, the effect of exposure to polluting fuels on global perinatal mortality may have previously been underestimated.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01073475.
authors.affiliation: Lata Medical Research Foundation, Nagpur, Maharashtra 440022 India.
authors.forename: Archana B
authors.initials: AB
authors.lastname: Patel
authors.affiliation: RTI International, Research Triangle Park, North Carolina, 27709 USA.
authors.forename: Sreelatha
authors.initials: S
authors.lastname: Meleth
authors.affiliation: Department of Community Health Sciences & Family Medicine, Aga Khan University, Karachi, Pakistan.
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
authors.affiliation: KLE University's JN Medical College, Belgaum, Karnataka India.
authors.forename: Shivaprasad S
authors.initials: SS
authors.lastname: Goudar
authors.affiliation: Moi University School of Medicine, Eldoret, Kenya.
authors.forename: Fabian
authors.initials: F
authors.lastname: Esamai
authors.affiliation: IMSALUD, San Carlos University, Guatemala City, Guatemala.
authors.forename: Ana L
authors.initials: AL
authors.lastname: Garces
authors.affiliation: University Teaching Hospital, Lusaka, Zambia.
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.affiliation: RTI International, Research Triangle Park, North Carolina, 27709 USA.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.affiliation: Center for Research of Mothers and Children, NIH, Rockville, MD 20852 USA.
authors.forename: Linda L
authors.initials: LL
authors.lastname: Wright
authors.affiliation: Center for Research of Mothers and Children, NIH, Rockville, MD 20852 USA.
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.affiliation: RTI International, Research Triangle Park, North Carolina, 27709 USA.
authors.forename: Janet L
authors.initials: JL
authors.lastname: Moore
authors.affiliation: Department of Community Health Sciences & Family Medicine, Aga Khan University, Karachi, Pakistan.
authors.forename: Sarah
authors.initials: S
authors.lastname: Saleem
authors.affiliation: Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202 USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
authors.affiliation: Department of Obstetrics/Gynecology, Columbia University, New York, NY 10032 USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
authors.affiliation: Department of OB-GYN, Christiana Care, Newark, DE 19718 USA.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.affiliation: Department of Pediatrics, University of Colorado, Aurora, CO 80045 USA.
authors.forename: K Michael
authors.initials: KM
authors.lastname: Hambidge
authors.affiliation: Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233 USA.
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.affiliation: Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02114 USA.
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
keywords: Cooking fuels; Household air pollution; Mortality; Neonatal; Perinatal