Cooking with liquefied petroleum gas or biomass and fetal growth outcomes: a multi-country randomised controlled trial

William Checkley; Lisa M Thompson; Shakir Hossen; Laura Nicolaou; Kendra N Williams; Stella M Hartinger; Marilu Chiang; Kalpana Balakrishnan; Sarada S Garg; Gurusamy Thangavel; Vigneswari Aravindalochanan; Ghislaine Rosa; Alexie Mukeshimana; Florien Ndagijimana; John P McCracken; Anaité Diaz-Artiga; Sheela S Sinharoy; Lance Waller; Jiantong Wang; Shirin Jabbarzadeh; Yunyun Chen; Kyle Steenland; Miles A Kirby; Usha Ramakrishnan; Michael Johnson; Ajay Pillarisetti; Eric D McCollum; Rachel Craik; Eric O Ohuma; Victor G Dávila-Román; Lisa de las Fuentes; Suzanne M Simkovich; Jennifer L Peel; Thomas F Clasen; Aris T Papageorghiou; Household Air Pollution Intervention Network (HAPIN) Investigators

doi:10.1016/S2214-109X(24)00033-0

Cooking with liquefied petroleum gas or biomass and fetal growth outcomes: a multi-country randomised controlled trial

Lancet Glob Health. 2024 May;12(5):e815-e825. doi: 10.1016/S2214-109X(24)00033-0.

Authors

William Checkley¹, Lisa M Thompson², Shakir Hossen³, Laura Nicolaou³, Kendra N Williams³, Stella M Hartinger⁴, Marilu Chiang⁵, Kalpana Balakrishnan⁶, Sarada S Garg⁶, Gurusamy Thangavel⁶, Vigneswari Aravindalochanan⁶, Ghislaine Rosa⁷, Alexie Mukeshimana⁸, Florien Ndagijimana⁸, John P McCracken⁹, Anaité Diaz-Artiga¹⁰, Sheela S Sinharoy¹¹, Lance Waller¹², Jiantong Wang¹², Shirin Jabbarzadeh¹², Yunyun Chen¹², Kyle Steenland¹³, Miles A Kirby¹⁴, Usha Ramakrishnan¹¹, Michael Johnson¹⁵, Ajay Pillarisetti¹⁶, Eric D McCollum¹⁷, Rachel Craik¹⁸, Eric O Ohuma¹⁹, Victor G Dávila-Román²⁰, Lisa de las Fuentes²⁰, Suzanne M Simkovich²¹, Jennifer L Peel²², Thomas F Clasen¹³, Aris T Papageorghiou²³; Household Air Pollution Intervention Network (HAPIN) Investigators

Collaborators

Household Air Pollution Intervention Network (HAPIN) Investigators:
Gloriose Bankundiye, Dana Boyd Barr, Vanessa Burrowes, Alejandra Bussalleu, Devan Campbell, Eduardo Canuz, Adly Castañaza, Maggie Clark, Mary Crocker, Oscar De León, Ephrem Dusabimana, Lisa Elon, Juan G Espinoza, Irma Pineda Fuentes, Ahana Ghosh, Dina Goodman, Savannah Gupton, Sarah Hamid, Steven Harvey, Mayari Hengstermann, Ian Hennessee, Phabiola Herrera, Marjorie Howard, Penelope P Howards, Lindsay Jaacks, Katherine Kearns, Jacob Kremer, Margaret A Laws, Pattie Lenzen, Jiawen Liao, Amy Lovvorn, Jane Mbabazi, Julia N McPeek, Rachel Meyers, J Jaime Miranda, Erick Mollinedo, Libny Monroy, Krishnendu Mukhopadhyay, Bernard Mutariyani, Luke P Naeher, Abidan Nambajimana, Durairaj Natesan, Azhar Nizam, Jean de Dieu Ntivuguruzwa, Ricardo Piedrahita, Naveen Puttaswamy, Elisa Puzzolo, Ashlinn Quinn, Karthikeyan D Rajamani, Sarah Rajkumar, Rengaraj Ramasami, Alexander Ramirez, P Barry Ryan, Sudhakar Saidam, Zoe Sakas, Sankar Sambandam, Jeremy Sarnat, Kirk Smith, Damien Swearing, Ashley Toenjes, Lindsay Underhill, Jean D Uwizeyimana, Viviane Valdes, Amit Verma, Megan Warnock, Wenlu Ye, Bonnie Young, Ashley Younger, Libny Y Monroy-Alarcón, Adly Castañaza Gonzalez de Durante, Claudia López-Ortega, Maria F Gonzalez, Lakshminarayanan Sowrirajan, Shanthi P Paramanandam, K Shanmugavadivu, V Sudharsanan, Suresh Seshadri, Adhemir E Yupanqui-Fredes, Mario Hancco-Gomez, Ronald Apaza, Juan F Persivale-Calle, Elizabeth Quispe, Carlos Leon-Ponce, Victor Villar-Gonzales, Rebeca Andrade-Salas, Jhon E Herrera, Luzdelia Ramos-Mamani, Yessica Lopez, Giovanna Quiza, Yadel Hinojosa, Madeluz Gomez-Quispe, Gery Frisancho-Parada, Danielle I Mendoza-Apaza, Luz R Quispe-Flores, Niyitegeka F Xavier, Grace Utfimana, Elie Tuzayisenga, Valens Nkurunziza

Affiliations

¹ Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA. Electronic address: wcheckl1@jhmi.edu.
² Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA.
³ Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
⁴ Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru.
⁵ Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Perú.
⁶ ICMR Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India.
⁷ Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
⁸ Eagle Research Center Limited, Kigali, Rwanda.
⁹ Epidemiology and Biostatistics Department, University of Georgia, Athens, GA, USA; Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
¹⁰ Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
¹¹ Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
¹² Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA.
¹³ Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
¹⁴ Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
¹⁵ Berkeley Air Monitoring Group, Berkeley, CA, USA.
¹⁶ Division of Environmental Health Sciences, University of California at Berkeley, Berkeley, CA, USA.
¹⁷ Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
¹⁸ Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK.
¹⁹ Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, UK.
²⁰ Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St Louis, St Louis, MO, USA.
²¹ Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville, MD, USA; Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington, DC, USA.
²² Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA.
²³ Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital, Oxford, UK. Electronic address: aris.papageorghiou@wrh.ox.ac.uk.

Abstract

Background: Household air pollution might lead to fetal growth restriction during pregnancy. We aimed to investigate whether a liquefied petroleum gas (LPG) intervention to reduce personal exposures to household air pollution during pregnancy would alter fetal growth.

Methods: The Household Air Pollution Intervention Network (HAPIN) trial was an open-label randomised controlled trial conducted in ten resource-limited settings across Guatemala, India, Peru, and Rwanda. Pregnant women aged 18-34 years (9-19 weeks of gestation) were randomly assigned in a 1:1 ratio to receive an LPG stove, continuous fuel delivery, and behavioural messaging or to continue usual cooking with biomass for 18 months. We conducted ultrasound assessments at baseline, 24-28 weeks of gestation (the first pregnancy visit), and 32-36 weeks of gestation (the second pregnancy visit), to measure fetal size; we monitored 24 h personal exposures to household air pollutants during these visits; and we weighed children at birth. We conducted intention-to-treat analyses to estimate differences in fetal size between the intervention and control group, and exposure-response analyses to identify associations between household air pollutants and fetal size. This trial is registered with ClinicalTrials.gov (NCT02944682).

Findings: Between May 7, 2018, and Feb 29, 2020, we randomly assigned 3200 pregnant women (1593 to the intervention group and 1607 to the control group). The mean gestational age was 14·5 (SD 3·0) weeks and mean maternal age was 25·6 (4·5) years. We obtained ultrasound assessments in 3147 (98·3%) women at baseline, 3052 (95·4%) women at the first pregnancy visit, and 2962 (92·6%) at the second pregnancy visit, through to Aug 25, 2020. Intervention adherence was high (the median proportion of days with biomass stove use was 0·0%, IQR 0·0-1·6) and pregnant women in the intervention group had lower mean exposures to particulate matter with a diameter less than 2·5 μm (PM_2·5; 35·0 [SD 37·2] μg/m³vs 103·3 [97·9] μg/m³) than did women in the control group. We did not find differences in averaged post-randomisation Z scores for head circumference (0·30 vs 0·39; p=0·04), abdominal circumference (0·38 vs 0·39; p=0·99), femur length (0·44 vs 0·45; p=0·73), and estimated fetal weight or birthweight (-0·13 vs -0·12; p=0·70) between the intervention and control groups. Personal exposures to household air pollutants were not associated with fetal size.

Interpretation: Although an LPG cooking intervention successfully reduced personal exposure to air pollution during pregnancy, it did not affect fetal size. Our findings do not support the use of unvented liquefied petroleum gas stoves as a strategy to increase fetal growth in settings were biomass fuels are used predominantly for cooking.

Funding: US National Institutes of Health and Bill & Melinda Gates Foundation.

Translations: For the Kinyarwanda, Spanish and Tamil translations of the abstract see Supplementary Materials section.

Publication types

Randomized Controlled Trial

MeSH terms

Adolescent
Adult
Air Pollutants*
Biomass
Cooking
Female
Fetal Development*
Humans
India
Infant, Newborn
Male
Pregnancy
United States
Young Adult

Substances

Air Pollutants

Associated data

ClinicalTrials.gov/NCT02944682

Grants and funding

UM1 HL134590/HL/NHLBI NIH HHS/United States