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Cited by 43Gestational Diabetes Research and ManagementMaternal and Neonatal HealthcarePregnancy and preeclampsia studies

Associations between periconceptional lifestyle behaviours and adverse pregnancy outcomes

Open access
Maas, Veronique Y.F., Poels, Marjolein, Lamain-de Ruiter, Marije, Kwee, Anneke, Bekker, Mireille N., Franx, Arie, Koster, Maria P.H.·2021·BMC Pregnancy and Childbirth
DOI 10.1186/s12884-021-03935-xPMC PMC8265143

Published version of a preprint

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Abstract

Background: While the potential adverse outcomes of prenatal exposure to unhealthy lifestyle are widely evidenced, little is known about these exposures in the periconception period. We investigated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle behaviours. Methods: A secondary analysis took place within a prospective multicentre cohort study in the Netherlands, including 3,684 pregnant women. Baseline characteristics and preconceptional and first trimester lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester. Adverse pregnancy outcomes (hypertensive disorders in pregnancy (HDP), small for gestational age (SGA), gestational diabetes (GDM) and spontaneous preterm birth (sPTB)) were reported by healthcare professionals. Data were collected between 2012 and 2014 and analysed using multivariate logistic regression. Results: Women who are overweight, and especially obese, have the highest odds of developing any adverse pregnancy outcome (adjusted odds ratio (aOR) 1.61 (95 % Confidence Interval (CI) 1.31–1.99) and aOR 2.85 (95 %CI 2.20–3.68), respectively), particularly HDP and GDM. Women who prenatally continued smoking attained higher odds for SGA (aOR 1.91 (95 %CI 1.05–1.15)) compared to the reference group, but these odds decreased when women prenatally quit smoking (aOR 1.14 (95 %CI 0.59–2.21)). Women who did not use folic acid supplements tended to have a higher odds of developing adverse pregnancy outcomes (aOR 1.28 (95 %CI 0.97–1.69)), while women who prenatally started folic acid supplements did not (aOR 1.01 (95 %CI 0.82–1.25)). Conclusions: Our results indicate that smoking cessation, having a normal body mass index (BMI) and initiating folic acid supplements preconceptionally may decrease the risk of adverse pregnancy outcomes. Therefore, intervening as early as the preconception period could benefit the health of future generations.

AI snapshot

Written from the paper’s full text.

TL;DR

In a Dutch prospective multicentre cohort of 3,684 pregnant women, periconceptional lifestyle behaviours were associated with adverse pregnancy outcomes, with the strongest odds for obesity, particularly HDP and GDM, and for smoking with SGA/sPTB. The authors conclude that smoking cessation, normal BMI, and preconception folic acid initiation may reduce adverse pregnancy outcomes, supporting intervention as early as the preconception period.

Key findings

  • Among 3,684 women, 712 (19.3%) experienced the composite adverse pregnancy outcome; specific outcomes were HDP 298 (8.1%), GDM 184 (5.0%), sPTB 127 (3.4%), and SGA 133 (3.6%).
  • Overweight and obesity were associated with higher odds of the composite outcome (aOR 1.61, 95% CI 1.31–1.99 and aOR 2.85, 95% CI 2.20–3.68, respectively), with obesity showing the highest odds for GDM (aOR 6.85, 95% CI 4.39–10.71) and HDP (aOR 3.80, 95% CI 2.68–5.40); underweight was associated with SGA (aOR 2.64, 95% CI 1.17–5.96).
  • Preconception smoking was associated with sPTB (aOR 1.76, 95% CI 1.05–2.93); continued prenatal smoking was associated with SGA (aOR 1.91, 95% CI 1.05–1.15 as reported), whereas quitting prenatally showed lower SGA odds (aOR 1.14, 95% CI 0.59–2.21).
  • No preconception folic acid use tended to be associated with the composite outcome (aOR 1.28, 95% CI 0.97–1.69), while prenatal folic acid initiation was not (aOR 1.01, 95% CI 0.82–1.25); alcohol use discontinued prenatally was associated with lower GDM odds (aOR 0.65, 95% CI 0.46–0.93), and no associations were found for fruit intake or vitamin use.

Methods

  • Secondary analysis within the RESPECT prospective multicentre cohort in the central Netherlands, December 2012–January 2014, recruiting pregnant women <14 weeks’ gestation from 31 midwifery practices and six hospitals; 4,347 were assessed and 3,684 included after exclusions.
  • A self-administered first-trimester questionnaire assessed preconception (three months before conception) and first-trimester lifestyle behaviours, including tobacco, alcohol, supplement use, fruit intake, and pre-pregnancy BMI; adverse outcomes (HDP, SGA <3rd percentile, GDM, sPTB) were reported by healthcare professionals after birth.
  • Multivariate logistic regression estimated crude and adjusted odds ratios, adjusted for maternal age, educational level, ethnicity, parity, and mode of conception; missing data (1,111 cases, 30.2%, with at least one missing value) were handled by multiple imputation with ten imputations and Rubin’s rules.

Limitations

  • The authors state underrepresentation of non-Caucasian and lower educated women; self-reported lifestyle data; dependence on women’s perception of conception timing for preconception versus first-trimester distinction; inability to assess dose-response relationships or validate with blood markers; and that the study measured associations only, without a sample size calculation for this aim, so results should be interpreted with caution.
  • Evident in the text: the reported 95% CI for continued prenatal smoking and SGA (1.05–1.15) appears inconsistent with the reported aOR of 1.91 and likely reflects a typographical error.
  • Evident in the text: the composite outcome includes fetal death, but the results focus on HDP, GDM, sPTB, and SGA, and the paper does not report separate fetal death estimates.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12884-021-03935-x

Cites

59 of 59 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

34 of 68 cited sources checked · 11 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Only 57% of pregnant women were aware that obesity increases the overall risk of pregnancy- and birth complications and that weight loss before pregnancy can reduce the overall risk for complications.

    “A previous study showed that only 57 % of pregnant women were aware of the fact that obesity increases the overall risk of pregnancy- and birth complications and that weight loss before the pregnancy can reduce to overall risk for complications [37].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [37] Nitert MD, Foxcroft KF, Lust K, Fagermo N, Lawlor DA, O’Callaghan M, et al. Overweight and obesity knowledge prior to pregnancy: a survey study. BMC Pregnancy Childbirth. 2011;11:96. source
  • Findingown data

    Women who quit smoking in the first trimester have similar odds of developing SGA compared to non-smokers.

    “we found that women who quit smoking in the first trimester did have similar odds of developing SGA compared to non-smokers, as previous studies have also suggested [40, 41, 43].”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [40] Bernstein IM, Mongeon JA, Badger GJ, Solomon L, Heil SH, Higgins ST. Maternal smoking and its association with birth weight. Obstet Gynecol. 2005;106(5 Pt 1):986–91. source
    • cites [41] Reeves S, Bernstein I. Effects of maternal tobacco-smoke exposure on fetal growth and neonatal size. Expert Rev Obstet Gynecol. 2008;3(6):719–30. source

      The Smoking cessation during pregnancy section says that stopping in the first trimester produces infants with anthropometric measures similar to those of women who never smoked. It also reports no increased risk of low birthweight among women who quit by the third trimester. Neither passage establishes similar odds of SGA specifically for first-trimester quitters and nonsmokers. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [43] Polakowski LL, Akinbami LJ, Mendola P. Prenatal smoking cessation and the risk of delivering preterm and small-for-gestational-age newborns. Obstet Gynecol. 2009;114(2 Pt 1):318–25. source
  • Premisecitation

    These processes are vulnerable to disturbance of epigenetic mechanisms, leading to an altered profile of embryonic gene expression that persists throughout both pregnancy and childhood.

    “These processes are vulnerable to disturbance of epigenetic mechanisms, leading to an altered profile of embryonic gene expression that persists throughout both pregnancy and childhood [9].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [9] Fleming TP, Watkins AJ, Velazquez MA, Mathers JC, Prentice AM, Stephenson J, et al. Origins of lifetime health around the time of conception: causes and consequences. Lancet. 2018;391(10132):1842–52. source

      The Periconceptional developmental programming and ART section says embryo culture can alter gene expression and epigenetic patterns, and that ART-induced epigenetic profiles may persist through pregnancy into childhood. But it does not establish that an altered profile of embryonic gene expression itself persists for that period. The Diversity and commonality subsection cautions that epigenetic changes are not necessarily linked directly to changes in gene expression. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    Mechanisms affecting fetal growth predominantly act beyond the first trimester.

    “A previous systematic review showed that cessation of smoking before and shortly after becoming pregnant was not associated with SGA and this suggests that the mechanisms affecting fetal growth predominantly act beyond the first trimester [46].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [46] Abraham M, Alramadhan S, Iniguez C, Duijts L, Jaddoe VW, Den Dekker HT, et al. A systematic review of maternal smoking during pregnancy and fetal measurements with meta-analysis. PLoS One. 2017;12(2):e0170946. source

      The Discussion says that cessation before or shortly after conception was not associated with reduced fetal size and suggests that mechanisms affecting fetal growth act predominantly in the second half of pregnancy. This supports the citing sentence’s proposed timing, but the source reports fetal size, not the stated SGA outcome. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Premisecitation

    A 10% lower preconception BMI is associated with clinically meaningful risk reduction in pre-eclampsia, GDM, preterm birth, macrosomia, and stillbirth.

    “a population-based study showed that a 10 % lower preconception BMI was associated with clinically meaningful risk reduction in pre-eclampsia, GDM, preterm birth, macrosomia, and stillbirth [4].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [4] Schummers L, Hutcheon JA, Bodnar LM, Lieberman E, Himes KP. Risk of adverse pregnancy outcomes by prepregnancy body mass index: a population-based study to inform prepregnancy weight loss counseling. Obstet Gynecol. 2015;125(1):133–43. source

      The Discussion reports clinically meaningful risk differences associated with a 10% difference in prepregnancy BMI for preeclampsia, gestational diabetes, indicated preterm delivery, macrosomia, and stillbirth. The claim says “preterm birth” without specifying indicated delivery; the Results report no significant relationship with spontaneous preterm delivery before 32 weeks. Page numbers were not provided in the passages. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 21
  • May combine two claims. 18

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Adverse pregnancy outcomes are associated with long-term effects on health, for example, hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM) are independently associated with an increased risk for cardiovascular disease and type II diabetes.

    “Adverse pregnancy outcomes are associated with long-term effects on health, for example, hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM) are independently associated with an increased risk for cardiovascular disease and type II diabetes [2].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [2] Fraser A, Nelson SM, Macdonald-Wallis C, Cherry L, Butler E, Sattar N, et al. Associations of pregnancy complications with calculated cardiovascular disease risk and cardiovascular risk factors in middle age: the Avon Longitudinal Study of Parents and Children. Circulation. 2012;125(11):1367–80. source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The prevalence of adverse maternal and neonatal pregnancy outcomes has only moderately decreased over recent decades.

    “Despite major advances in clinical research and medical technology, the prevalence of adverse maternal and neonatal pregnancy outcomes, such as preeclampsia and preterm birth, has only moderately decreased over the recent decades [1].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [1] Atrash HK, Johnson K, Adams M, Cordero JF, Howse J. Preconception care for improving perinatal outcomes: the time to act. Matern Child Health J. 2006;10(5 Suppl):S3-11. source

      The Introduction (page not specified in our copy) says improvement in U.S. maternal and infant outcomes slowed during 1980–2000, and maternal mortality declined only 12.8%. But it reports that preterm births increased, not decreased, while infant mortality continued to fall substantially; it gives no trend for preeclampsia. The claim captures the broad slowdown but not the trends for its named examples. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Health promotion activities, such as education, advice and a general health assessment, are likely to improve pregnancy outcomes, by early identification of risk factors encouraging behavioural change.

    “Health promotion activities, such as education, advice and a general health assessment, are likely to improve pregnancy outcomes, by early identification of risk factors encouraging behavioural change [15–17].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [15] Whitworth M, Dowswell T. Routine pre-pregnancy health promotion for improving pregnancy outcomes. Cochrane Database Syst Rev. 2009;4(4):CD007536. https://doi.org/10.1002/14651858.CD007536.pub2. source

      The Background (‘Description of the intervention’) describes education, advice and health assessment as a proposed way to improve pregnancy outcomes through behavioural change or early identification of risk factors. But the Abstract (‘Main results’) says there is a lack of evidence on effects on pregnancy outcomes, so ‘likely to improve’ is stronger than this review supports. Page numbers are not available in the supplied passages. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [16] Zhao G, Ford ES, Tsai J, Li C, Ahluwalia IB, Pearson WS, et al. Trends in health-related behavioral risk factors among pregnant women in the United States: 2001–2009. J Womens Health (Larchmt). 2012;21(3):255–63. source
    • cites [17] Hoover EA, Louis JM. Optimizing Health: Weight, Exercise, and Nutrition in Pregnancy and Beyond. Obstet Gynecol Clin North Am. 2019;46(3):431–40. source

  • May combine two claims.

    Premisecitation

    Higher amounts of preconception physical activity are associated with a lower risk of GDM and pre-eclampsia.

    “previous meta-analyses suggest that higher amounts of preconception physical activity are associated with a lower risk of GDM and pre-eclampsia [35, 36].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [35] Tobias DK, Zhang C, van Dam RM, Bowers K, Hu FB. Physical activity before and during pregnancy and risk of gestational diabetes mellitus: a meta-analysis. Diabetes Care. 2011;34(1):223–9. source

      The Results (Total physical activity > Prepregnancy) report a lower GDM risk among women in the highest versus lowest prepregnancy physical-activity groups. This paper does not report an association with pre-eclampsia, so it supports only the GDM part of the sentence. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [36] Aune D, Saugstad OD, Henriksen T, Tonstad S. Physical activity and the risk of preeclampsia: a systematic review and meta-analysis. Epidemiology (Cambridge, Mass). 2014;25(3):331–43. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Heavy alcohol consumption during pregnancy increases the risk of low birth weight and preterm birth.

    “Several previous studies indicated that (heavy) alcohol consumption during pregnancy increases the risk of low birth weight and preterm birth, while light alcohol consumption may possibly have a mildly protective effect on these outcomes [50, 51].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [50] Henderson J, Gray R, Brocklehurst P. Systematic review of effects of low-moderate prenatal alcohol exposure on pregnancy outcome. BJOG. 2007;114(3):243–52. source
    • cites [51] Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Dose-response relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG. 2011;118(12):1411–21. source

  • May combine two claims.

    Premisecitation

    Lifestyle changes, such as reducing alcohol use and smoking, losing weight, improving fruit and vegetable consumption, can reduce the prevalence of adverse pregnancy outcomes, especially when initiated in early pregnancy or even before conception.

    “Evidence suggests that lifestyle changes, such as reducing alcohol use and smoking, losing weight, improving fruit and vegetable consumption, can reduce the prevalence of adverse pregnancy outcomes, especially when initiated in early pregnancy or even before conception [4–7].”
    Quote in the paperSubstantial claim3 of 4 sources checked
    • cites [4] Schummers L, Hutcheon JA, Bodnar LM, Lieberman E, Himes KP. Risk of adverse pregnancy outcomes by prepregnancy body mass index: a population-based study to inform prepregnancy weight loss counseling. Obstet Gynecol. 2015;125(1):133–43. source

      The Discussion reports that lower prepregnancy BMI was associated with lower risks of several adverse pregnancy outcomes and proposes using the findings for preconception weight-loss counseling. The study was observational, so it does not establish that losing weight causes those reductions. The cited passages do not support the sentence's claims about reducing alcohol use or smoking, increasing fruit and vegetable consumption, or initiating changes in early pregnancy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [5] Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: caffeine, smoking, alcohol, drugs and other environmental chemical/radiation exposure. Reprod Health. 2014;11 Suppl 3:S6. source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [6] Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception care: nutritional risks and interventions. Reprod Health. 2014;11 Suppl 3:S3. source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [7] Elsinga J, de Jong-Potjer LC, van der Pal-de Bruin KM, le Cessie S, Assendelft WJ, Buitendijk SE. The effect of preconception counselling on lifestyle and other behaviour before and during pregnancy. Womens Health Issues. 2008;18(6 Suppl):S117-25. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Cessation of smoking before and shortly after becoming pregnant was not associated with SGA.

    “A previous systematic review showed that cessation of smoking before and shortly after becoming pregnant was not associated with SGA and this suggests that the mechanisms affecting fetal growth predominantly act beyond the first trimester [46].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [46] Abraham M, Alramadhan S, Iniguez C, Duijts L, Jaddoe VW, Den Dekker HT, et al. A systematic review of maternal smoking during pregnancy and fetal measurements with meta-analysis. PLoS One. 2017;12(2):e0170946. source

      The Discussion reports that cessation before or shortly after becoming pregnant was not associated with reduced fetal size and suggests that effects on growth act predominantly in the second half of pregnancy. The Results measure fetal size, however, rather than reporting whether cessation was associated with small for gestational age (SGA). (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductcitation

    Missing values were imputed using multiple imputation, with ten imputations, and Rubin's rules were applied to combine results.

    “Missing values were imputed using multiple imputation [22, 33]. All variables and outcomes were used in the imputation model and ten imputations were performed. The results shown are the results after multiple imputation. Rubin’s rules were applied to combine the results into summary estimates [34].”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [22] Lamain-de Ruiter M, Kwee A, Naaktgeboren CA, de Groot I, Evers IM, Groenendaal F, et al. External validation of prognostic models to predict risk of gestational diabetes mellitus in one Dutch cohort: prospective multicentre cohort study. BMJ. 2016;354:i4338. source
    • cites [33] Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ. 2009;338:b2393. source
    • cites [34] Rubin D. Multiple imputation for nonresponse in surveys. Wiley Online Library; 1987. source

  • May combine two claims.

    Findingown data

    Smoking is associated with a higher odds of sPTB and birth of SGA neonates.

    “In accordance with previous studies, we indeed found that smoking is associated with a higher odds of sPTB and birth of SGA neonates [38–41].”
    Quote in the paperSubstantial claim1 of 4 sources checked
    • cites [38] Shah NR, Bracken MB. A systematic review and meta-analysis of prospective studies on the association between maternal cigarette smoking and preterm delivery. Am J Obstet Gynecol. 2000;182(2):465–72. source
    • cites [39] McCowan LM RC, Dekker GA, et al. Risk factors for small-for-gestational-age infants by customised birthweight centiles: Data from an international prospective cohort study. BJOG. 2010;117(13):1599–607. source
    • cites [40] Bernstein IM, Mongeon JA, Badger GJ, Solomon L, Heil SH, Higgins ST. Maternal smoking and its association with birth weight. Obstet Gynecol. 2005;106(5 Pt 1):986–91. source
    • cites [41] Reeves S, Bernstein I. Effects of maternal tobacco-smoke exposure on fetal growth and neonatal size. Expert Rev Obstet Gynecol. 2008;3(6):719–30. source

      The Abstract (page unavailable) reports higher odds of preterm delivery before 37 weeks among heavy smokers, but does not specify spontaneous preterm birth (sPTB). The Smoking & birthweight section (page unavailable) reports an association between maternal smoking and SGA neonates. Thus, the SGA finding is supported, while the spontaneous qualifier for preterm birth is not established by this paper. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Alcohol is suggested to lower levels of inflammation markers and endothelial dysfunction, increase insulin sensitivity, and increase HDL cholesterol concentrations, which may lower the risk of type 2 diabetes mellitus and possibly GDM.

    “Alcohol is suggested to lower levels of inflammation markers and endothelial dysfunction, increase insulin sensitivity, increase HDL cholesterol concentrations, which, for example, may lower the risk of type 2 diabetes mellitus and possibly also GDM [47–49].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [47] Koppes LL, Dekker JM, Hendriks HF, Bouter LM, Heine RJ. Moderate alcohol consumption lowers the risk of type 2 diabetes: a meta-analysis of prospective observational studies. Diabetes Care. 2005;28(3):719–25. source

      The discussion (p. 6) identifies increased HDL cholesterol, anti-inflammatory effects, and enhanced insulin sensitivity as plausible mechanisms; the conclusions (p. 2) report a lower type 2 diabetes risk with moderate alcohol consumption. The paper does not address endothelial dysfunction or gestational diabetes (GDM), so it does not support those parts of the claim. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [48] Howard AA, Arnsten JH, Gourevitch MN. Effect of alcohol consumption on diabetes mellitus: a systematic review. Ann Intern Med. 2004;140(3):211–9. source
    • cites [49] Bouthoorn SH, Silva LM, Murray SE, Steegers EA, Jaddoe VW, Moll H, et al. Low-educated women have an increased risk of gestational diabetes mellitus: the Generation R Study. Acta Diabetol. 2015;52(3):445–52. source

  • May combine two claims.

    Premisecitation

    Tobacco- and alcohol consumption are two of the most critical teratogens for prenatal development.

    “Tobacco- and alcohol consumption are two of the most critical teratogens for prenatal development [10, 11].”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [10] Murphy DJ, Mullally A, Cleary BJ, Fahey T, Barry J. Behavioural change in relation to alcohol exposure in early pregnancy and impact on perinatal outcomes–a prospective cohort study. BMC Pregnancy Childbirth. 2013;13:8. source

      The Results (Sub-group analyses of women who drink and smoke; page not provided) report substantially higher intrauterine growth restriction among women who both drank and smoked during pregnancy. This supports a risk to fetal growth, but the paper does not identify tobacco and alcohol as two of the most critical teratogens or compare their importance with other prenatal exposures. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [11] Kawashima A, Koide K, Ventura W, Hori K, Takenaka S, Maruyama D, et al. Effects of maternal smoking on the placental expression of genes related to angiogenesis and apoptosis during the first trimester. PloS one. 2014;9(8):e106140 e. source

      The Introduction (page not provided) describes smoking during pregnancy as a major public-health concern and links tobacco exposure to placental and pregnancy complications. The Discussion (page not provided) also describes cigarette-smoke components as pathogenic during pregnancy. The paper does not address alcohol consumption or establish that tobacco and alcohol are two of the most critical prenatal teratogens. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Several studies aimed to implement preconception care (PCC) programs and some successfully led to an improved level of knowledge regarding PCC and subsequent improved periconceptional lifestyle behaviours.

    “Several studies aimed to implement PCC programs and some successfully led to an improved level of knowledge regarding PCC and subsequent improved periconceptional lifestyle behaviours [7, 18–20].”
    Quote in the paperNot a substantial claim2 of 4 sources checked
    • cites [7] Elsinga J, de Jong-Potjer LC, van der Pal-de Bruin KM, le Cessie S, Assendelft WJ, Buitendijk SE. The effect of preconception counselling on lifestyle and other behaviour before and during pregnancy. Womens Health Issues. 2008;18(6 Suppl):S117-25. source
    • cites [18] Poels M, van Stel HF, Franx A, Koster MPH. The effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care. Eur J Contracept Reprod Health Care. 2018;23(1):38–44. source
    • cites [19] Sijpkens MK, van Voorst SF, de Jong-Potjer LC, Denktaş S, Verhoeff AP, Bertens LCM, et al. The effect of a preconception care outreach strategy: the Healthy Pregnancy 4 All study. BMC Health Serv Res. 2019;19(1):60. source

      The Methods describe an implemented PCC outreach strategy, and the Conclusion reports a small, temporary increase in PCC uptake. The Results describe participants’ existing knowledge, but the paper does not report improved knowledge or subsequent improvements in periconceptional lifestyle behaviours. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [20] van der Windt M, van der Kleij RM, Snoek KM, Willemsen SP, Dykgraaf RHM, Laven JSE, et al. Impact of a blended periconception lifestyle care approach on lifestyle behaviors: Before-and-after study. J Med Internet Res. 2020;22(9):e19378. source

      The Discussion (Main Findings; page not specified) reports that targeted lifestyle components improved after the 24-week periconception intervention. The paper does not report an improvement in knowledge about preconception care or establish that improved knowledge led to the behavior changes; the Discussion (The Black Box of eHealth) says the mechanism remains unclear. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An unhealthy diet, lifestyle behaviours and exercising pattern are progressively becoming part of Western society, including among a high percentage of women in their reproductive age.

    “Our results are relevant since an unhealthy diet, lifestyle behaviours and exercising pattern are progressively becoming part of Western society, including among a high percentage of women in their reproductive age [5, 6, 16].”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [5] Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: caffeine, smoking, alcohol, drugs and other environmental chemical/radiation exposure. Reprod Health. 2014;11 Suppl 3:S6. source

      The Discussion (page unavailable) says a growing number of women in their reproductive years consume caffeine, alcohol, tobacco or illicit drugs. The Introduction (page unavailable) also reports substantial alcohol use and smoking among US women. These passages support the lifestyle-behaviour portion, but do not address unhealthy diet or exercise patterns, or establish a trend across Western society. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [6] Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception care: nutritional risks and interventions. Reprod Health. 2014;11 Suppl 3:S3. source

      The Diet, exercise and weight loss section (page not supplied) identifies poor-quality diets and physical inactivity as concerns that disproportionately affect mothers and young children. The Discussion describes maternal overweight and obesity as a growing problem worldwide. The paper does not establish that these behaviours are becoming more common specifically in Western society or quantify a high percentage of women of reproductive age engaging in them. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [16] Zhao G, Ford ES, Tsai J, Li C, Ahluwalia IB, Pearson WS, et al. Trends in health-related behavioral risk factors among pregnant women in the United States: 2001–2009. J Womens Health (Larchmt). 2012;21(3):255–63. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Awareness of preconception health and care is low.

    “Although some studies suggest that awareness of preconception health and care is low, pregnancy planning appears relatively common, indicating a missed and unexploited opportunity for intervention [56–58].”
    Quote in the paperNot a substantial claim3 of 3 sources checked
    • cites [56] Stephenson J, Patel D, Barrett G, Howden B, Copas A, Ojukwu O, et al. How do women prepare for pregnancy? Preconception experiences of women attending antenatal services and views of health professionals. PloS One. 2014;9(7):e103085-e. source
    • cites [57] Bitzer J, von Stenglin A, Bannemerschult R. Women’s awareness and periconceptional use of folic acid: data from a large European survey. Int J Womens Health. 2013;5:201–13. source

      The Discussion reports low awareness of the need for periconceptional folic acid and describes missed opportunities to counsel women who planned a pregnancy. It supports the sentence’s point about a specific preconception intervention, but does not assess awareness of preconception health and care more broadly. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [58] Inskip HM, Crozier SR, Godfrey KM, Borland SE, Cooper C, Robinson SM. Women’s compliance with nutrition and lifestyle recommendations before pregnancy: general population cohort study. BMJ. 2009;338:b481. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Early initiation (ideally before conception) of folic acid supplements decreases the risk for congenital malformations such as neural tube defects.

    “Although we found no difference in adverse pregnancy outcomes between women who started folic acid supplements before or during the pregnancy, it is widely evidenced that early initiation (ideally before conception) of folic acid supplements does decrease the risk for congenital malformations such as neural tube defects [52].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [52] De-Regil LM, Fernandez-Gaxiola AC, Dowswell T, Pena-Rosas JP. Effects and safety of periconceptional folate supplementation for preventing birth defects. Cochrane Database Syst Rev. 2010;10(10):CD007950. https://doi.org/10.1002/14651858.CD007950.pub2. source

  • May combine two claims.

    Premisecitation

    Vulnerable women often have multiple unhealthy lifestyle behaviours and are specifically hard to reach.

    “This is particularly the case for vulnerable women, who often have multiple unhealthy lifestyle behaviours and are specifically hard to reach [54].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [54] M’Hamdi H I, van Voorst SF, Pinxten W, Hilhorst MT, Steegers EA. Barriers in the Uptake and Delivery of Preconception Care: Exploring the Views of Care Providers. Matern Child Health J. 2017;21(1):21–8. source

      In “Lack of a Comprehensive PCC Program” (page unavailable), providers identify future parents with low socioeconomic status or living in deprived neighborhoods as especially hard to reach. An obstetrician mentions people who smoke, drink, and are obese in deprived neighborhoods, but the paper does not establish that vulnerable women often have multiple unhealthy lifestyle behaviours. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Light alcohol consumption may possibly have a mildly protective effect on low birth weight and preterm birth.

    “Several previous studies indicated that (heavy) alcohol consumption during pregnancy increases the risk of low birth weight and preterm birth, while light alcohol consumption may possibly have a mildly protective effect on these outcomes [50, 51].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [50] Henderson J, Gray R, Brocklehurst P. Systematic review of effects of low-moderate prenatal alcohol exposure on pregnancy outcome. BJOG. 2007;114(3):243–52. source
    • cites [51] Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Dose-response relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG. 2011;118(12):1411–21. source

  • May combine two claims.

    Findingown data

    Women who continue to smoke have increased odds for sPTB, although not significant.

    “our results show that women who quit smoking and women who continue to smoke (although not significant) both have increased odds for sPTB [42–44].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [42] Moore E, Blatt K, Chen A, Van Hook J, DeFranco EA. Factors Associated with Smoking Cessation in Pregnancy. Am J Perinatol. 2016;33(6):560–8.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [43] Polakowski LL, Akinbami LJ, Mendola P. Prenatal smoking cessation and the risk of delivering preterm and small-for-gestational-age newborns. Obstet Gynecol. 2009;114(2 Pt 1):318–25. source
    • cites [44] Jaddoe VW, Troe EJ, Hofman A, Mackenbach JP, Moll HA, Steegers EA, et al. Active and passive maternal smoking during pregnancy and the risks of low birthweight and preterm birth: the Generation R Study. Paediatr Perinat Epidemiol. 2008;22(2):162–71. source

  • May combine two claims.

    Findingown data

    Women who were obese before pregnancy had the highest odds of developing adverse pregnancy outcomes, particularly HDP and GDM.

    “Women who were obese before pregnancy had the highest odds of developing adverse pregnancy outcomes, particularly HDP and GDM.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Women who used alcohol preconceptionally were significantly more often Caucasian, higher educated, nulliparous, pregnant by spontaneous conception, had a lower pre-pregnancy BMI, and used more folic acid supplements compared to women who did not use alcohol preconceptionally.

    “we indeed found that women who used alcohol preconceptionally were significantly more often Caucasian, higher educated, nulliparous, were pregnant by spontaneous conception, had a lower pre-pregnancy BMI and used more folic acid supplements compared to women who did not use alcohol preconceptionally (data not shown).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Adverse neonatal outcomes, for example, preterm birth and small for gestational age (SGA), can have long-term consequences among surviving infants, such as medical disabilities, impaired cognitive development, learning difficulties and behavioural- and psychological problems.

    “Likewise, adverse neonatal outcomes, for example, preterm birth and small for gestations age (SGA), can have long term consequences among surviving infants, such as medical disabilities, impaired cognitive development, learning difficulties and behavioural- and psychological problems [3].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Moster D, Lie RT, Markestad T. Long-term medical and social consequences of preterm birth. N Engl J Med. 2008;359(3):262–73. source

  • May combine two claims.

    Premisecitation

    The potential effect of healthy periconceptional lifestyle behaviours on reducing multiple adverse pregnancy outcomes together is yet understudied, and it has been studied only in small sample sizes.

    “The potential effect of healthy periconceptional lifestyle behaviours on reducing multiple adverse pregnancy outcomes together is yet understudied, and it has been studied only in small sample sizes [7, 21].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [7] Elsinga J, de Jong-Potjer LC, van der Pal-de Bruin KM, le Cessie S, Assendelft WJ, Buitendijk SE. The effect of preconception counselling on lifestyle and other behaviour before and during pregnancy. Womens Health Issues. 2008;18(6 Suppl):S117-25. source
    • cites [21] Jourabchi Z, Sharif S, Lye MS, Saeed A, Khor GL, Tajuddin SHS. Association Between Preconception Care and Birth Outcomes. Am J Health Prom. 2019;33(3):363–71. source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The study distinguished lifestyle behaviours between the preconception period and the first trimester.

    “Also, we distinguished lifestyle behaviours between the preconception period and the first trimester, a distinction rarely made in previous studies.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Women's perception of when conception exactly occurred is accurate enough to distinguish preconception from first-trimester exposure to unhealthy lifestyle behaviours.

  • May combine two claims.

    Premisecitation

    The maternal metabolic environment of women who are overweight or obese tends to affect placental development and these women are therefore more prone to develop adverse pregnancy outcomes like GDM or pre-eclampsia.

    “The maternal metabolic environment of women who are overweight or obese tends to affect placental development and these women are therefore more prone to develop adverse pregnancy outcomes like GDM or pre-eclampsia [14].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Catalano PM, Shankar K. Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ. 2017;356:j1. source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Adjusted odds ratios were calculated by multivariate analysis taking into account potential confounders (maternal age, educational level, ethnicity, parity and mode of conception).

    “Subsequently, adjusted ORs were calculated by multivariate analysis, taking potential confounders into account (maternal age, educational level, ethnicity, parity and mode of conception).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Pregnancy outcomes were reported by healthcare professionals through standardized forms.

    “After birth, healthcare professionals reported the presence or absence of pregnancy outcomes through standardized forms.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Cigarette smoke contains substances that affect placental endothelial function, which can lead to ischemic vascular changes impacting placental growth and functions.

    “Cigarette smoke contains substances that affect placental endothelial function, which can lead to the development of ischemic vascular changes impacting placental growth and functions [45].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [45] Aliyu MH, Lynch ON, Wilson RE, Alio AP, Kristensen S, Marty PJ, et al. Association between tobacco use in pregnancy and placenta-associated syndromes: a population-based study. Arch Gynecol Obstet. 2011;283(4):729–34. source

  • May combine two claims.

    Study design and conductreasoning

    The study accounted for missing data by using multiple imputation, which decreases the risk of selection bias and allows investigation of multiple exposures and outcomes.

    “A possible strength of this study is that we used a large, multicentre, population-based cohort where we accounted for missing data by using multiple imputation, which decreases the risk of selection bias and allows to investigate multiple exposures and outcomes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    PCC is known to increase the health and well-being of prospective parents.

    “PCC is known to increase the health and well-being of prospective parents, still, the uptake of PCC-consults remains remarkably low [53].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [53] World Health O. Meeting to develop a global consensus on preconception care to reduce maternal and childhood mortality and morbidity: World Health Organization Headquarters, Geneva, 6–7 February 2012: Meeting report. 2013.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The sample size calculation was not performed for the current aim of this paper.

    “the sample size calculation was not performed for the current aim of this paper”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    Women should be encouraged to change unhealthy lifestyle behaviours, preferably before conception.

    “Overall, our findings indicate that women should be encouraged to change unhealthy lifestyle behaviours, preferably before conception.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The distinction between preconception and first-trimester exposure depends upon women's perception of when conception exactly occurred.

    “However, to be able to make the distinction between preconception and first trimester exposure to unhealthy lifestyle behaviours depends upon women’s perception of when conception exactly occurred.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Data on lifestyle behaviours were collected using self-administered questionnaires.

    “In addition, the data on lifestyle behaviours is collected by the use of self-administered questionnaires.”
    Quote in the paperNot a substantial claim
33 of 33

  • The paper relies on this without support.

    Women accurately recalled their preconceptional and first trimester lifestyle behaviours.

    “In the questionnaire, women were asked to recall their lifestyle behaviours in the three-month period before conception and then again for their current lifestyle behaviours (in the first trimester).”

  • The paper relies on this without support.

    Missing data were missing at random for multiple imputation.

    “Missing values were imputed using multiple imputation [22, 33].”

  • The paper relies on this without support.

    The adjusted analyses controlled for all relevant confounders, so the observed associations are not due to unmeasured confounding.

    “Subsequently, adjusted ORs were calculated by multivariate analysis, taking potential confounders into account (maternal age, educational level, ethnicity, parity and mode of conception).”

  • The paper relies on this without support.

    Within the periconception period, gametogenesis, organogenesis and placental development occur.

    “Within this period, gametogenesis, organogenesis and placental development occur.”

  • The paper relies on this without support.

    Women's perception of when conception exactly occurred is accurate enough to distinguish preconception from first-trimester exposure to unhealthy lifestyle behaviours.

    “However, to be able to make the distinction between preconception and first trimester exposure to unhealthy lifestyle behaviours depends upon women’s perception of when conception exactly occurred.”
5 of 5

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Overweight confidence interval differs between Results and Table 3

    Minor

    The Results text gives 1.13 as the lower confidence limit for the adjusted composite-outcome odds ratio of 1.61; Table 3 gives 1.31 for the same estimate.

  • GDM vitamin-use percentage is incorrect

    Minor

    Table 2 reports 51 women in this category among 184 women with GDM. That is 27.7%, not 17.7%.

    Reported 17.7 · recomputed 27.717391

  • Smoking-SGA estimate lies outside its reported confidence interval

    Minor

    The adjusted odds ratio of 1.91 is outside its stated 95% confidence interval of 1.05-1.15. The interval is therefore inconsistent with the estimate used to support the smoking-SGA result.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. World Health O. Meeting to develop a global consensus on preconception care to reduce maternal and childhood mortality and morbidity: World Health Organization Headquarters, Geneva, 6–7 February 2012: Meeting report. 2013.

Cited by

Still being checked.

Related

Authors
Maas, V. Y. F., Poels, M., Lamain-de Ruiter, M., Kwee, A., Bekker, M. N., Franx, A., & Koster, M. P. H.
Affiliations
  • Erasmus MC (NL)
  • Utrecht University (NL)
Corresponding author
Koster, Maria P.H.
ORCID
Venue
BMC Pregnancy and Childbirth
Publisher
Springer Science and Business Media LLC
Published
2021-07-07
Volume
21
Issue
1
Pages
492-492
ISSN
1471-2393 (ISSN-L)
DOI
10.1186/s12884-021-03935-x
PMC
PMC8265143
OpenAlex
W3179543999
Semantic Scholar
6537831efeb55c661bb7b4804ccbcc3472b3b96f
Cited by
43
References
59
Citations by year
2026: 6 · 2025: 7 · 2024: 18 · 2023: 5 · 2022: 5 · 2021: 2
FWCI
5.85
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Pregnancy and Childbirth (publishedVersion, cc-by)
  • Research Square (acceptedVersion, cc-by)
  • PubMed (publishedVersion)
  • EUR Research Repository (Erasmus University Rotterdam) (publishedVersion, other-oa)
  • PubMed Central (submittedVersion, cc-by)
  • EUR Research Repository (Erasmus University Rotterdam) (submittedVersion, other-oa)
  • RePub (Erasmus University Rotterdam) (submittedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
Funders
The Netherlands Organization for Health Research and Development (grant no. 209020004 and grant no. 209040005)
Topics
  • Health Sciences › Medicine › Obstetrics and Gynecology › Gestational Diabetes Research and Management
  • Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
  • Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy and preeclampsia studies
Keywords
adverse pregnancy outcomes, hypertensive disorders of pregnancy, small for gestational age, gestational diabetes mellitus, preterm birth, maternal obesity, overweight, smoking cessation, maternal smoking, folic acid supplementation, body mass index
MeSH terms
Adult, Female, Folic Acid, Humans, Infant, Newborn, Infant, Small for Gestational Age, Life Style, Netherlands, Obesity, Pregnancy, Pregnancy Complications, Pregnancy Outcome, Pregnancy Trimester, First, Prospective Studies, Smoking, Health Behavior, Logistic Models, Odds Ratio, Smoking Cessation, Diabetes, Gestational, Preconception Care, Dietary Supplements, Reproductive Behavior, Hypertension, Pregnancy-Induced, Premature Birth

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-20.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-20.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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