Household air pollution linked to stillbirths

The Clean Household Air for Newborns (CHANge) Trial, led by Associate Professor Camille Raynes-Greenow from the Sydney School of Public Health, is a community-based cluster randomised controlled trial that will assess the impact of clean cooking stoves on perinatal mortality and address this global public health problem marked by inequality.

Perinatal mortality includes both stillbirth and early neonatal death. A stillbirth is defined for international comparisons as the death of a baby born without any signs of life from 28 weeks of pregnancy. An early neonatal death occurs in the first 7 days of life. Globally, the stillbirth rate is 2.6 million a year, and around 2.5 million children die shortly after life. Almost all of these deaths occur in low-to-middle income countries, such as Pakistan, Bangladesh, India, the Congo and China - combined, they account for 98% of these deaths (in 2017).

The United Nations’ Every Newborn Action Plan has set a goal of 12 stillbirths per 1,000 births by 2030 for all countries. “This is an ambitious goal, but we know that because there are major differences between rates across countries there are opportunities for intervention,” says Associate Professor Camille Raynes-Greenow. One such intervention in low-to-middle income countries is around the use of polluting-fuels for cooking. 

In Bangladesh, like in many low-to-middle income countries, households rely on polluting fuels in traditional stoves for cooking. Women are the main cooks for the family and spend a large amount of the day cooking. Houses are small and confined, and the kitchen is often a part of the living space or even the sleeping space and are poorly ventilated. This type of traditional cooking is very common.

“A traditional cooking stove includes many things – like a fire pit with a grate over it, or more commonly in Bangladesh, a handmade clay stove. These stoves use all sorts of fuel: sticks, cow dung, rubbish and crop residue. They are not efficient in combusting these fuels, so they produce pollutants,” says Associate Professor Raynes-Greenow.

In addition to causing a myriad of health problems (e.g. respiratory), household air pollution may also be linked to the high rate of stillbirths and early neonatal deaths across South Asia and Africa.

In a recent feasibility study done in Bangladesh, Associate Professor Raynes-Greenow and her team found that substituting traditional cooking stoves with liquefied petroleum gas (LPG) stoves was well-received by the community and was a feasible alternative to traditional cooking. 

“LPG is a much cleaner cooking fuel that doesn’t produce the same amount of pollutants. LPG stoves are also much easier to use as women and children do not need to scavenge for fuel, and they are easier to ignite. They also don’t produce soot, so people, pots and walls are much cleaner - but most importantly, they don’t produce the smoke and pollutants that cause health problems,” Associate Professor Raynes-Greenow says.

The clinical trial

Based on positive results from the feasibility study, and with funding from the National Health and Medical Research Council (NHMRC), the team are conducting a cluster randomised controlled trial with 5,000 women in early pregnancy from rural communities in Bangladesh. The trial is conducted in collaboration with the International Centre for Diarrhoeal Disease Research (ICDDR), Bangladesh, and the Research Triangle Institute (RTI), USA. 

Families are either receiving LPG stoves or continuing with existing practices (traditional cooking). Those with LPG stoves are receiving support to transition to LPG cooking. Participants are visited monthly by field staff up until one month after the baby is born.

The primary aim of the trial is the impact of LPG stoves on reducing perinatal mortality. It will also determine the cost-effectiveness of LPG stoves.

Potential impact 

“Our trial will produce high-quality evidence for the effectiveness of LPG in reducing perinatal mortality. With this, we can influence the policy makers in Bangladesh and other South Asian countries of the need to adopt cleaner fuels. Women and children are health priorities in many of these countries – so our evidence will be compelling,” says Associate Professor Raynes-Greenow.

“All families experience grief at the loss of a baby – they may also experience shame and blame. If we can reduce this in any way, we will be making a major contribution to improving their lives.”

The adoption of cleaner fuel will also improve general health for the wider family, and community. Household air pollution is linked to a plethora of noncommunicable diseases such as stroke, heart disease, lung cancer and pneumonia.

“Each year, close to 4 million people die prematurely from illness attributable to household air pollution from polluting stoves and fuel. We can make a major contribution to providing evidence to support faster adoption of cleaner cooking fuels."

"This has the potential save millions of lives”

More information on the impact of household air pollution from the World Health Organisation (WHO).

Associate Professor Camille Raynes-Greenow

Robinson Fellow, SOAR Fellow, Sydney School of Public Health

Maternal and child health is the cornerstone of a life lived healthily. Healthy women grow healthy children, who then go on to have healthy children themselves. My research is focussed on interventions in the (mostly) perinatal period that can improve outcomes for women and children.