Educational Inequalities in Perinatal Outcomes: The Mediating Effect of Smoking and Environmental Tobacco Exposure

OBJECTIVE: Socioeconomic status (SES) is adversely associated with perinatal outcomes. This association is likely to be mediated by tobacco exposure. However, previous studies were limited to single perinatal outcomes and devoted no attention to environmental tobacco exposure. Therefore, this study aimed firstly to explain the role of maternal smoking in the association between maternal education and preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA), and secondly to explain whether environmental tobacco smoke mediates these associations further. STUDY DESIGN: This study was nested in a population-based cohort study in the Netherlands, the Amsterdam Born Children and their Development (ABCD) study. Analyses were done in a sample of 3821 pregnant women of Dutch origin, using logistic regression analysis. RESULTS: Least educated women, who were more often smoking and exposed to environmental tobacco smoke, had a significantly higher risk of PTB (OR 1.95 [95% CI: 1.19-3.20]), LBW (OR 2.41 [95% CI: 1.36-4.27]) and SGA (OR 1.90 [95% CI 1.32-2.74]) than highly educated women. The mediating effect of smoking in the least educated women was 43% for PTB, 55% for LBW and 66% for SGA. Environmental tobacco smoke did not explain these associations further. After adjustment for maternal smoking, the association between lower maternal education and pregnancy outcomes was no longer significant. CONCLUSIONS: Smoking explains to a considerable extent the association between lower maternal education and adverse perinatal outcomes. Therefore, tobacco-interventions in lower educated women should be primarily focussed on maternal smoking to reduce PTB, LBW, and SGA. Additional attention to environmental tobacco exposure does not seem to reduce educational inequalities in perinatal outcomes

Ovulation induction using low-dose step-up rFSH in Vietnamese women with polycystic ovary syndrome

The aim of this study was to assess the effectiveness and safety of a low-dose step-up protocol with a recombinant FSH starting dose of 25 IU for ovulation induction in anovulatory patients with polycystic ovary syndrome (PCOS) and a normal or low body mass index (BMI). In this prospective, non-comparative, open trial, 183 PCOS patients who had three unsuccessful cycles of ovulation induction with clomiphene citrate received recombinant FSH (Puregon((R))) 25 IU/day for 14 days, the dose was then increased by 25 IU every 5 days if there was no follicle of >12 mm diameter (maximum 150 IU/day). Human chorionic gonadotrophin was administered when the lead follicle was >/=18 mm, and intrauterine insemination was performed 36 h later. Duration of stimulation was 15.9 +/- 4.8 days and total FSH dose was 484 +/- 257 IU. A developing follicle was observed in 96.7% of cycles, of which 62.1% had unifollicular development and 15.8% were cancelled due to over-response. The clinical and ongoing pregnancy rates were 35.5% and 33.9%, respectively. There were no multiple pregnancies, and only one case of mild ovarian hyperstimulation syndrome. A low-dose step-up protocol with a recombinant FSH starting dose of 25 IU/day is effective and safe in anovulatory Vietnamese PCOS patients with a low or normal BMI.V.T.N. Lan, R.J. Norman, G.H. Nhu, P.H. Tuan, H.M. Tuon