The effect of maternal betel quid exposure during pregnancy on adverse birth outcomes among aborigines in Taiwan

Abstract

In considering documented developmental toxicity and teratogenicity found in earlier research, maternal betel quid chewing may very well be linked to a higher risk of adverse birth outcomes. The aim of this study was to investigate the significance of betel quid chewing, together with the use of cigarettes or alcohol, either independently or combined, on birth-related outcomes. A total of 1264 aboriginal women who had just given birth in 10 hospitals in Southern and Eastern Taiwan were recruited. Information on their maternal and newborn characteristics was obtained from medical charts and by performing personal interviews using a validated questionnaire. Maternal areca nut chewing during pregnancy was found to be significantly associated with both birth weight loss (−89.54 g) and birth length reduction (−0.43 cm). A significantly lower male newborn rate (aOR = 0.62) was observed among aboriginal women with a habit of betel quid chewing during pregnancy. The use of this substance conveyed a 2.40- and 3.67-fold independent risk of low birth weight and full-term low birth weight, respectively. An enhanced risk (aOR = 3.26–5.99) of low birth weight was observed among women concomitantly using betel quid, cigarette and alcohol during gestation. Our findings suggest that betel quid chewing during pregnancy has a substantial effect on a number of birth outcomes, including sex ratio at birth, lower birth weight and reduced birth length.

Introduction

Betel quid is a substance that has long been widespread in Southeast Asia and in migrant communities originating from these regions (Gupta and Warnakulasuriya, 2002). It is the fourth most commonly used drug in the world after tobacco, alcohol and caffeine (Winstock, 2002). In Taiwan, among aboriginal people, 46.5% of men and 38.0% of women were reported to be current betel quid users; on the other hand, the prevalence of the use of this substance was 9.8% in men and 1.6% in women in general population (Ko et al., 1992). Additionally, a previous study found that 23.7% of aboriginal women chewed betel quid during pregnancy, as compared to 0.78% of non-aboriginal women in Taiwan (Lua et al., 1995).

The most popular ingredients in betel quid in Taiwan are betel (also named areca) nut, slaked lime and a piece of unripe fruit from the species Piper betel. Betel quid itself has been commercialized in Taiwan, and can be easily purchased from various stands located in the community. According to the report from Ko et al., lesser educated older men, blue collar workers, smokers and drinkers were at a higher risk of chewing betel quid (Ko et al., 1992). Although tobacco is an important additive in areca nut products (termed “pan”) in India and Southeast Asia in general (Warnakulasuriya et al., 2002), it is not an ingredient added to betel quid products in Taiwan. Therefore, it may be difficult to compare the individual adverse effects of betel quid alone to areas where the tobacco-added areca nut product is prevalent. It has been claimed that betel quid chewing produces a sense of well being, euphoria, a warm sensation in the body, a heightened alertness, and that it helps one to stay alert for work (Chu, 2002). Some consumers also use it to prevent morning sickness (Nelson and Heischober, 1999). However, the adverse effect of arecoline (the major alkaloid component of the betel nut) has been well documented (Chang et al., 2004). In addition, its cytotoxicity and carcinogenic effects have also recently been recognized (IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2004; Lee et al., 2005). Lately, cases of neonatal withdrawal syndrome have also been reported in the newborns of women who had chewed betel nut during pregnancy, and arecoline has been detected accordingly in the meconium and placenta (Garcia-Algar et al., 2005, Lopez-Vilchez et al., 2006). These findings add to the evidence of adverse birth outcomes associated with maternal betel quid use during pregnancy.

Chronic exposure to toxic environmental agents, which predominantly affect the reproductive system, has been suggested to have an effect on the male to female birth ratio for such users (Fukuda et al., 2002). In comparison to when both parents are nonsmokers, a previous study found that the male to female offspring ratio was lower in populations where either one or both of the parents smoked more than 20 cigarettes per day (Fukuda et al., 2002). While the association between low birth weight and maternal use of alcohol, cigarettes or drugs during pregnancy has been widely discussed (Larroque et al., 1993, Okah et al., 2005, Smith et al., 2006, Windham et al., 2000), corresponding data has so far been limited as to the relationship between maternal betel chewing during pregnancy and its potentially adverse birth outcomes (Yang et al., 1999, Yang et al., 2001).

In Taiwan, there are twelve aboriginal tribes constituting nearly 2.1% of the entire population (Council of Indigenous People, 2006); the health status for aborigines was found to be worse than for the rest of the Taiwanese population (Ko et al., 1994). Betel quid chewing in conjunction with the ingestion of alcohol and/or the use of cigarettes is a prevalent habit in female aboriginal populations (Ko et al., 1995, Yang et al., 1996) with segments of the aboriginal female population continuing to use such substances during gestation (Lua et al., 1995). While adverse birth outcomes have been linked to betel chewing during pregnancy (Yang et al., 1999, Yang et al., 2001), the joint effect of areca nut along with cigarette and alcohol usage has not been well established. This large-scale study was conducted so as to investigate the independent and combined effects of these substances on important birth-related outcomes.