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Effects of air pollution in early life on infant and maternal health

co-PI: Frida Soesanti and Nina Dwi Putri (former PI Nikmah Salamia Idris deceased, August 2019), University of Indonesia - Cipto Mangunkusumo National General Hospital
USG-Supported Partner: Kerstin Klipstein-Grobusch, University Medical Center Utrecht
Project dates: February 2015 - August 2020

[On August 6, 2019, PEER received word that Dr. Nikmah had passed away after a two-year illness. The staff of the PEER Program and its sponsors at the U.S. Agency for International Development offer their deepest condolences to her family, friends, and co-workers. She was a dedicated researcher whose work has helped many women and children, and its impacts will continue to be felt in the future despite her untimely passing. Dr. Nikmah will be remembered as a treasured friend and colleague--may she rest in peace.]

Maternal and neonatal morbidity and mortality appear to be a rather intractable problem worldwide, and their Millennium Developmental Goals (MDG 4 & 5) are mostly not achieved. One of the underlying reasons may be that reductions in mortality and morbidity do not solely depend on care access and quality of care, but due to adverse effects of air pollution on communities. In Indonesia, MDGs 4 & 5 have not been reached, while air pollution levels are high, particularly in major cities. Based on recent western observations on pollution and pregnancy outcomes, we aim to assess if prenatal exposure to air pollution increases the risk for pregnancy complications and the risk for adverse maternal and neonatal health. We intend to study this in healthy pregnant women living in and around Jakarta who are being recruited for an ongoing breastfeeding behavior intervention trial (BRAVO). Jakarta is arguably one of the most polluted cities in the world, with large exposure contrasts between many residential areas, making it an ideal setting for such a study. In contrast to many other studies, our proposal aims to measure pollution exposure, i.e., particles and the major gaseous pollutant NO2, at the individual level using sophisticated technology that is in principle available at a large scale. It will also obtain vital organ function measurements in neonatal offspring that are well validated and innovative as their association with air pollution was never investigated before.

The project team will enroll 600 healthy pregnant women early in pregnancy. Long-term measurements of particle matter and the major gaseous pollutant NO2 will be taken in individual homes to obtain pollution exposure levels. Women and offspring will be followed until six months after birth to record pregnancy complications, maternal lung function, neonatal indicators of fetal health, infant function, and structure measurements of the respiratory tract and circulatory tract, and infant disease, particularly infections. The aim is to establish relationships between pollutant exposure in pregnancy and maternal and neonatal health indicators.

The ultimate objective is to answer the above research question, but also put air pollution and health more prominently on the agenda of Indonesian policy makers. Currently, economic considerations are prioritized over long-term health effects of air pollution. A more comprehensive insight into the health consequences provided by local research should raise awareness. This is particularly important if long-term consequences turn out to have a price that outweighs short-term economy.

Part of this initiative is to build research capacity in Indonesia, enabling local partners to develop the necessary tools and skills to effectively address air pollution related to health problems and guide the development and implementation of evidence-based policies. The latter will also be a strong leverage in the work of our USG-supported partner who aims to build research capacity in various African countries, facing similar air pollution and maternal and child health problems as in Southeast Asia.

PH 2-3 Indonesia photo 1PH 2-3 Indonesia photo 2PH 2-3 Indonesia photo 3

Summary of Recent Activities:

As of June 2020, the research team completed data collection and are working on statistical analyses. Data collection comprised of measuring of air pollution by mobile campaign and smoking exposure by passive nicotine sampler. Health outcome measurements on the study subjects are ongoing and include: maternal obstetric data, pregnancy induced hypertension, nutritional analysis, blood test, maternal lung function, ultrasound to assess foetal growth (foetal-maternal obstetric), hair and nail sampling, vaginal swab sampling, placental and blood cord sampling (only if mothers consented) and birth outcomes. Health outcome measurements on the infants include: growth, infection episodes, lung function, and cardiovascular outcomes. Follow-up on infant outcomes is being conducted via WhatsApp during the COVID-19 pandemic. The PEER project has been able to build capacity of early career researchers by engaging one Indonesian Utrecht University based PhD student and one PhD student from the Faculty of Public Health, University of Indonesia. The University of Indonesia student has started to collect data on an additional measurement of infant developmental status at the age of 6 months. The research team has engaged in multiple collaborations with the PEER project. A collaboration with the Eijkman Institute of Molecular Biology, Jakarta allows for biological sample storage and analyses. The team plans to collaborate with the Province Laboratory to analyse the biological samples (hair/nail) collected for nicotine content and is currently exploring the possibility to obtain saliva samples to assess mucosal immunity in collaboration with the University Medical Centre Utrecht, the Netherlands. To promote our research activities, the project maintains a website (

PEER Health Cycle 2 Recipients