Behavioral Influences On Preterm Birth

A special interest in behavioral influences on preterm birth is well justified, given that these are subject to change and could reduce the frequency of preterm birth directly. As previously reviewed in some detail (Berkowitz and Papiernik, 1993; Savitz and Pastore, 1999), a large number of observational studies of a range of health behaviors, including tobacco and alcohol use, nutrition, and physical activity, have been conducted. Although each of these behaviors poses specific challenges in discerning cause-and-effect relationships, two key, generic concerns crosscut them all. First, it is a challenge to measure many of these behaviors with accuracy because of their inherent complexity, the inability of individuals to completely recall past behaviors (e.g., diet and physical activity), or the stigma associated with the behavior (e.g., alcohol and illicit drug use). The challenge is especially heightened for women who are pregnant. This inaccurate recall ability is accompanied by the potential for a distorted recall of the facts when these behaviors are assessed after pregnancy outcomes have occurred, as well as by a likely dilution of measures of association because of random error. Second, the decisions about these behaviors that women make render them highly susceptible to confounding, in which any true causal effects of the behavior of interest on preterm birth are distorted by the association of that behavior with antecedent factors like socioeconomic conditions or with other behaviors. For example, smoking during pregnancy has become increasingly strongly linked to lower socioeconomic condition, much more so than smoking by other segments of the population (Cnattingius, 2004), so that isolation of the effect of smoking per se from the socioeconomic context is challenging. In addition, unfavorable health behaviors tend to cluster, so that women with poor diets often also exhibit other potentially detrimental behaviors, such as a lack of physical activity, and vice versa.

For a number of these behaviors, observational studies are inherently limited, no matter how carefully conducted and how attentive investigators are to controlling for other exposures (which are themselves difficult to measure accurately and to thus fully control). Nonetheless, when considered in conjunction with other lines of research involving mechanistic studies and randomized trials, observational studies of behavioral influences on preterm birth, when it is feasible to conduct such studies, have been highly informative. The subsections that follow review tobacco use, alcohol use, illicit drug use, nutrition, sexual activity, physical activity, employment, and douching.

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