Int J Ment Health Addiction https://doi.org/10.1007/s11469-018-9888-6 O R I G I N A L A RT I C L E

Effect of Khat Use During Pregnancy on the Birth Weight of Newborn in Jimma, Ethiopia Kenfe Tesfay 1,2 & Mubarek Abera 3 & Mekitie Wondafrash 4 & Markos Tesfaye 3

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract Today, drug misuse and abuse is becoming a major problem worldwide. Birth weight of a newborn remains an important predictor of infant and child morbidity and mortality. In 2006, approximately one in four newborns in Jimma Zone, Ethiopia, had low birth weight. About 19% of pregnant women attending antenatal care in heath institutions of Jimma Zone were using khat during pregnancy. However, there is a lack of research on predictors of low birth weight especially the potential effect of khat use during pregnancy. To examine the effect of khat use during pregnancy on birth weight of newborn in Jimma town, Ethiopia. Institution-based case-control study design was conducted on a total of 336 mothernewborn pairs recruited at birth from public health facilities in Jimma town during April–June, 2013. One hundred twelve mothers who gave a live birth at term with a birth weight of < 2.5 kg were considered as cases, and 224 mothers who gave a live birth at term with a birth weight of ≥ 2.5 kg were considered as controls. Study subjects were selected consecutively. Maternal khat use during pregnancy was assessed using the Composite International Diagnostic Interview (CIDI) scale. Data were analyzed using Statistical Package for Social Sciences software (SPSS) for Windows version 16. Logistic regression analysis was employed * Kenfe Tesfay [email protected] Mubarek Abera [email protected] Mekitie Wondafrash [email protected] Markos Tesfaye [email protected]

1

Psychiatry Nursing Department, Mekelle University, Mekelle, Ethiopia

2

Department of Psychiatry, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

3

Department of Psychiatry, Jimma University, Jimma, Ethiopia

4

Department of Population and Family Health, Jimma University, Jimma, Ethiopia

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to examine the independent effect of maternal khat use during pregnancy on the birth weight of the newborn. The internal reliability (Cronbatch’s α) for the CIDI scale was 0.74. The odds of low birth weight among babies born from mothers who used khat during pregnancy were 12 times higher compared to those born from non-users. The odds of low birth weight among babies born from mothers who gained weight less than 10 kg during pregnancy were 11 times higher than those born from mothers who gained weight greater than 10 kg during pregnancy. The odds of low birth weight among babies born from mothers who had a birth interval of less than 3 years from the previous delivery were 3.5 times higher compared to those babies born from mothers who had a birth interval of greater than 3 years. Maternal khat use during pregnancy is strongly associated with low birth weight of the newborn. The observed association between maternal khat use during pregnancy and low birth weight of the newborn calls for public health interventions to reduce maternal khat use during pregnancy and its consequence on the health of the newborn. Keywords Khat use . Birth weight . Ethiopia Maternal substance misuse and abuse during pregnancy is becoming an important public health problem worldwide. Both in low- and middle-income countries (LMICs) as well as high-income countries (HICs), birth weight of newborn remains an important factor affecting infant and child morbidity and mortality (UNICEF n.d.). Maternal nutrition and her overall general health status during pregnancy are important predictors for the birth weight of the newborn which in turn is a powerful predictor of infant growth and survival (National Institute for Medical Research, Mwanza Research Centre, and Siza 2008). World Health Organization (WHO) defines low birth weight (LBW) as a birth weight which is less than 2500 g at birth irrespective of their gestational age (Chhabra et al. 2004). Birth weight is the first weight of the newborn or fetus obtained immediately after birth and should preferably be measured with in the first hours of life before significant weight loss has occurred (Ronnenberg et al. 2009). This internationally agreed cut-off point for LBW is based on epidemiological observations in that infants weighing less than 2500 g at birth are approximately 20 times more likely to die than their counterparts (UNICEF n.d.). Every year worldwide, about 16% of live births or about 20 million infants are born with LBW and 90% of them are born in LMIC (National Institute for Medical Research, Mwanza Research Centre, and Siza 2008). LBW accounts for 22% of the newborn in Africa and around 13 to 15% in Sub-Saharan Africa, with little variation across the region as a whole (UNICEF n.d.). The Demographic and Health Survey (DHS) 2005 has reported the prevalence of LBW in Ethiopia to be 14%. The prevalence of newborns with LBW was 22.5% in Jimma Zone in 2006 (Tema 2006). As reported by the department of health statistics, maternal substance abuse during pregnancy continues to be a major problem in London. More than 90% of females presented to agencies after abusing drugs belong to the age group 15–39 years old (Department of Health Statistical Bulletin n.d.). A study in Liverpool has reported 30.8% incidence of LBW among mothers who have used a drug during pregnancy (Pinto et al. 2010). The comorbidity between substance use and maternal mood disturbance is also high, both of which could synergistically contribute for LBW among the newborn. A study on interactive associations between maternal mood and substance use in Minnesota state USA indicates that those women with low mood

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and tobacco use during pregnancy were twice more likely to have a LBW infant as compared to their counterparts (Gyllstrom et al. 2011). Recent reports indicate that up to 80–90% of men and 10–60% of women in East Africa and the Arabian Peninsula chewed khat. In Ethiopia, there is a wide variation in the prevalence of khat chewing across various studies (0.3–64.7%) (Hassan et al. 2003). According to a study conducted in Jimma Zone, 19% of pregnant women attending antenatal care (ANC) at different health centers had used khat during their pregnancy (Nakajima et al. 2017). Few studies have also documented that LBW was associated with maternal khat use during pregnancy (Hassan et al. 2005; Mwenda et al. 2003). Khat use during pregnancy may result in poor maternal appetite and reduced food intake through which it decreases the mean birth weight of the offspring (Al-Hegami 2001; Jansson et al. 1988). However, the effect of khat use during pregnancy is not well studied in Africa and almost nil in Ethiopia. It is important to bear in mind that most people who chew khat have also additional risky behaviors (such as smoking, alcohol consumption, poor nutrition) which may contribute to an adverse outcome of pregnancy including LBW and dropping out from ANC. The findings of this study will, therefore, have important public health implications for interventions aimed at promoting child health. Therefore, this study aimed to assess the effect of khat use during pregnancy on the birth weight of newborns.

Materials and Methods Jimma University Specialized Hospital (JUSH), Shenengibe Hospital, and four Jimma health center public health facilities were included in the study from the Jimma City, Oromia Region, Ethiopia. Jimma City is situated south west of the capital city, Addis Ababa. The projected total population of the city was 130, 254 and JUSH is serving as referral hospital for about 15 million people around the area. To address our research questions, a case-control study design was implemented to assess the effect of maternal khat use during pregnancy on birth weight of the newborn at Jimma, Ethiopia. The source population was all women who had visited the health institutions and gave birth for alive and term babies during the study period. Cases were selected mothers who delivered for alive and term babies with a birth weight of < 2500 g. Controls were selected mothers who delivered for alive and term babies with a normal birth weight, i.e., 2500 to 4000 g. A 1:2 case to control ration was used. Mothers who had stillbirth and twin birth were excluded from the study. Sample size was calculated using OpenEpi version 2.3 software with the assumption of 95% confidence interval, 80% power, and assuming substance use among the cases 35% (main exposure variable) and 20% for controls (Jacksona et al. 2007) and with a case to control ratio of 1:2. Accordingly, 112 cases and 224 controls (a total sample size of 336) were included from the two hospitals and four health centers. The sample size was allocated for all institutions based on proportional to size ratio and cases and controls were selected consecutively. Thus, a sample of 12 cases and 24 controls were taken from four health centers each, from Jimma University Specialized Hospital (32 cases, 64 controls) and from Shenengibe Hospital (31 cases, 62 controls). In addition to specific interviewer-administered questions designed to assess substance use status during pregnancy, the Composite International Diagnostic Interview (CIDI) scale for substance use disorder was used to screen for substance use during pregnancy. CIDI is a short

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screening version for all types of substance abuse and addiction. (Robins et al. 1988) Substance abuse consists of four items and a scoring result > = 1 is considered as Babuse.^ Substance dependence consists of seven items and a scoring result > = 3 is considered as Bdependent.^ This scale has been widely used and translated into the local language in Ethiopia.

Khat BKhat^ refers to the psychoactive leaves (Catha edulis). The fresh leaves of khat contain the amphetamine-like stimulants cathinone and cathine which are extractable by the action of enzymes in saliva (Kalix 1984). It has a stimulant effect to the central nervous system (CNS) and the effect of cathinone is enhanced more when combined with caffeine intake and cigarette smoking (Zein 1983). Khat chewing is a legal pastime and socio-culturally accepted experience in countries such as Ethiopia, Somalia, and Yemen (Dhaifalah and Santavy 2004). Indeed, the earliest mention of khat in this region comes from the chronicles of the Ethiopian King, Amdetseyon (from 1314 to 1344 A.D) (Getahun and Krikorian 1973). A structured interviewer-administered questionnaire was used to collect information from the participating mother. It was developed in English and was translated to the local language (Afan Oromo and Amharic) which was again back translated to English by an independent person to check for consistency. There were six trained nurses for data collection. The principal investigator and one nurse supervised the data collection process. All data collectors and supervisor were trained for 2 days before the data collection period by the principal investigator on the objectives of the study and how to interview, fill out the questionnaire on newborn weight measurement, and handle questions asked by clients during interviewing. A data collection instrument was pretested and necessary modifications were made on the instrument. Data analysis was carried out using SPSS version 16 statistical software. Data were cleaned and explored to check for outliers, consistencies, and missed values. Bivariate analysis was employed to determine the presence of association between the main exposure variable (khat use during pregnancy) and the covariates with the outcome variable. To control the effect of confounding factors, covariates with a P value < 0.2 in the bivariate analysis were entered in to multivariate binary logistic regression model by using a backward stepwise variable selection method. Finally, P value of < 0.05 was declared statistically significant for the main exposure and all the covariates in the final model. Ethical approval was sought from the research ethical review committee of College Health Sciences of Jimma University. Written informed consent was obtained from every study subject before the interview. All the information collected from the study subjects was handled confidentially through anonymity and conducting the interview in private place. Mothers who delivered a LBW baby were consulted/referred to a child health service unit.

Result Sociodemographic Characteristics and Other Related Issues A total of 112 cases and 224 controls were included in the study with a response rate of 100%. Fifty-eight (51.8%) cases and 104 (46.4%) controls were female babies. Regarding the mothers, majority of the cases 100 (89.3%) and controls 203 (90.6%) were in the age category of 15–30 years. More than half of the cases (67.9%) and almost

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half of the controls (43.3%) were illiterate. About 87 (88.8%) cases and 183 (85.9%) controls earn below the average annual income of World Bank 2015 report for lowincome countries. Majority of the cases and controls were daily laborer followed by housewife by occupation. More than three fourth (88.4%) of the cases and controls (91.5%) had attended ANC. Most of the participants from cases 110 (98.2%) and controls 217 (96.9%) were engaged in light household activities during pregnancy (Table 1).

Obstetric and Gynecologic Related Characteristics Majority of the mothers, 188 (83.9%) from controls and 107 (95.5%) from cases, had a birth interval of less than 3 years. One hundred fifty-five (69.2%) controls and 52 (46.4%) cases gained less than 10 kg weight during pregnancy (see the details in (Table 2). Low educational status, living in rural place, weight gain of less than 10 kg during pregnancy, having less than 3 years birth interval from previous delivery, not receiving dietary counseling during pregnancy, not taking additional food during pregnancy, not taking iron folate supplement during pregnancy, less than four ANC visits during pregnancy, and presence of pregnancy-related hypertension all were associated with LBW of newborns in the bivariate analysis (Table 3).

Table 1 Sociodemographic characteristics of study participants, Jimma City, 2013 Variables

Sex of the child

Category

Male Female Classification mother’s age 15–30 31–45 > 45 Educational status of the mothers Non-literate Primary education Above primary education Marital status of the mothers Single Married Divorced/separated Occupation of the mothers Unemployed Housewife Daily laborer Government employee NGO employee Farmer Self-employee Student Other Monthly income Below average Above average Household size <5 >=5 Place of residence Urban Rural

Normal birth weight/ control

Low birth weight/ case

N

%

N

%

120 104 203 20 1 97 73 54 3 217 4 7 12 150 12 14 4 5 20 3 183 30 147 66 152 72

53.6 46.4 90.6 8.9 0.4 43.3 32.6 24.1 1.3 96.9 1.8 3.1 5.4 67.0 5.4 6.2 1.8 2.2 8.9 1.3 85.9 14.1 69.0 31.0 67.9 32.1

54 58 100 12 0 76 23 13 7 104 1 0 9 68 7 3 6 8 8 0 87 11 83 15 79 33

48.2 51.8 89.3 10.7 0.0 67.9 20.5 11.6 6.2 92.9 0.9 0.0 8.0 60.7 6.2 2.7 5.4 7.1 7.1 0.0 88.8 11.2 84.7 15.3 70.5 29.5

Int J Ment Health Addiction Table 2 Obstetric and gynecologic related issues of study participants, Jimma City, 2013 Variables

Category

Weight gain during pregnancy

< 10 kg > = 10 kg Birth interval <3 years > = 3 years Dietary counseling during pregnancy Yes No Additional food during pregnancy Yes No Iron foliate supplement during pregnancy Yes No Partner (psychological and financial) Yes support during pregnancy No Antenatal care Yes No Frequency of antenatal care <4 >=4 Chronic illnesses Yes No Mental illness Yes No Pregnancy-related hypertension Yes No Attacked by husband during pregnancy Yes No Weight of last neonate Small Moderate Big Pregnant household works Works nothing Light work Double and more work Mental distress No Yes

Normal birth weight/ control

Low birth weight/ case

N

%

N

%

155 69 188 36 203 21 203 21 199 25 189 35 205 19 207 17 93 131 10 214 4 220 22 202 23 78 29 7 217 9 185 39

69.2 30.8 83.9 16.1 90.6 9.4 90.6 9.4 88.8 11.2 84.4 15.6 91.5 8.5 92.4 7.6 41.5 58.5 4.5 95.5 1.8 98.2 9.8 90.2 17.7 60.0 22.3 3.1 96.9 4.0 82.6 17.4

52 60 107 5 100 12 85 27 84 28 75 37 99 13 91 21 62 50 1 111 5 107 24 88 7 32 14 2 110 3 88 24

46.4 53.6 95.5 4.5 89.3 10.7 75.9 24.1 75.0 25.0 67.0 33.0 88.4 11.6 81.2 18.8 55.4 44.6 0.9 99.1 4.5 95.5 21.4 78.6 13.2 60.4 26.4 1.8 98.2 2.7 78.6 21.4

Substance Use-Related Characteristics Maternal khat use during pregnancy, maternal khat abuse, and khat use in the year before pregnancy were higher in percentage among the cases as compared to controls. Fifty-eight (51.8%) of the cases were using khat in the year before pregnancy, 60 (53.6%) of the cases used khat during pregnancy period, and 30.4% of cases abused it (Fig. 1). Thirty-seven (62.7%) of cases and 33 (56.9%) of controls who have chewed khat during pregnancy were using it every day followed by 8 (13.6%) of cases and 10 (17.2%) of controls who were using khat 3 to 4 days per week. Forty-eight (80%) of the cases and 26 (46.4%) of the controls had chewed khat throughout their pregnancy period. The internal reliability (Cronbach’s α) of the Composite International Diagnostic Interview (CIDI) scale to screen for substance used during pregnancy was 0.74. Among the substance use-related factors, khat use in the year before pregnancy, khat use during pregnancy, and khat abuse during pregnancy were associated with LBW of the newborn in the bivariate analysis (Table 4).

Int J Ment Health Addiction Table 3 Association of sociodemographic and other related issues with low birth weight of newborn, Jimma City, Ethiopia, 2013 Variables

Category

Birth weight of newborn Normal N (%)

Educational status of the mothers

Non-literate Primary education Above primary education Place of residence Urban Rural Weight gain < 10 kg > = 10 kg Birth interval <3 years > = 3 years Dietary counseling during pregnancy Yes No Additional food during pregnancy Yes No Iron foliate supplement during pregnancy Yes No Frequency of ANC <4 >=4 Pregnancy-related hypertension Yes No

Crude odds ratio (COR) (95% CI)

Low N (%)

97 (43.3) 76 (67.9) 73 (32.6) 23 (20.5) 54 (24.1) 13 (11.6) 152 (67.9) 79 (70.5) 72 (32.1) 33 (29.5) 155 (69.2) 52 (46.4) 69 (30.8) 60 (53.6) 188 (83.9) 107 (95.5) 36 (16.1) 5 (4.5) 203 (90.6) 100 (89.3) 21 (9.4) 12 (10.7) 203 (90.6) 85 (75.9) 21 (9.4) 27 (24.1) 199 (88.8) 84 (75.0) 25 (11.2) 28 (25.0) 207 (92.4) 91 (81.2) 17 (7.6) 21 (18.8) 4 (1.8) 5 (4.5) 220 (98.2) 107 (95.5)

3.3 (1.7, 6.4) 1.3 (0.6, 2.8) 1 1 2.3 (1.6, 4.1) 4 (1.7, 10.8) 1 3.9 (1.9, 7.8) 1 1 3.1 (1.6, 5.7) 2.7 (1.5, 4.8) 2.6 (1.6, 4.5) 1.7 (1.1, 2.8) 1 2.5 (1.3, 4.7) 1

Fig. 1 Percentage distribution of cases and controls in relation with different types of substance use, Jimma City, Ethiopia, 2013

Int J Ment Health Addiction Table 4 Association of substance use during pregnancy-related factors with birth weight of newborn, Jimma City, Ethiopia, 2013 Variables

Khat use 1 year before pregnancy Khat use during pregnancy Khat abuse

Category

Yes No Yes No Yes No

Birth weight of newborn Normal N (%)

Low N (%)

71 (31.7) 153 (68.3) 60 (26.8) 164 (73.2) 26 (11.6) 198 (88.4)

58 (51.8) 54 (48.2) 60 (53.6) 52 (46.4) 34 (30.4) 78 (69.6)

COR (95% CI)

2.3 (1.4, 3.7) 1 3.1 (1.9, 5.0) 1 3.3 (1.9, 5.9) 1

Independent Predictors of Newborn Low Birth Weight The goodness of fit for the final model was checked by Hosmer and Lemeshow and likelihood ratio test and was found to be a fit model. All variables with a P value of < 0.2 in the bivariate analysis were candidate variable for multivariable analysis. The effect of maternal khat use during pregnancy on the birth weight of newborns was examined in the multivariate analysis. Accordingly, the odds of having LBW among the newborn from mothers who used khat during pregnancy were 12 times higher compared to those of newborn from non-users (AOR = 12.3; 95% CI 2.30, 65.92). In addition to the main exposure (khat use during pregnancy), weight gain of less than 10 kg during pregnancy and having birth interval of less than 3 years from the previous pregnancy were found to be independent predictors of LBW among the newborns (Table 5). The odds of LBW among newborn from mothers who gained weight less than 10 kg during pregnancy were 11 times higher than those of newborn born from mothers who gained weight greater than 10 kg (AOR = 11.2; 95% CI 1.27, 98.39). The odds of LBW among newborn from mothers who have history of less than 3 years birth interval of previous pregnancy were 3.5 times higher compared to those of newborn from mothers who have greater than 3 years birth interval (AOR = 3.5; 95% CI1.40, 8.69).

Discussion To the knowledge of the investigators, this is the first study in Ethiopia to explore khatrelated factors associated with LBW among newborn. Few studies include khat as a Table 5 Multivariate analysis and factors independently associated with newborn low birth weight, Jimma City, Ethiopia, 2013 Variables

Category

P value

Adjusted odds ratio (AOR) (95%CI)

Weight gain during pregnancy

< 10 g > = 10 g < 3 years > = 3 years Yes No

0.03

11.2 (1.27, 98.39) 1 3.5 (1.40, 8.69) 1 12.3 (2.30, 65.92) 1

Birth interval Khat use during pregnancy

0.007 0.003

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covariate to determine factors of LBW. However, this study assessed the effect of maternal khat use during pregnancy and other common substances in Ethiopia and found that maternal khat use during pregnancy is associated with LBW of the newborn. Findings of this study shed light on why a significant number of mothers in Jimma City in Ethiopia may give birth to a baby with LBW. In addition, in line with other studies, inadequate weight gain during pregnancy and having low birth space and their association with LBW problem were identified. Maternal khat use during pregnancy was associated with LBW of newborn. However, khat use in the year before pregnancy was not associated with LBW of newborn in the current study. This might imply that mothers who chew khat before pregnancy and did not continue using khat during pregnancy have lower risk of giving birth to an infant with LBW. In this study, most of pregnant mothers who chewed khat during pregnancy had a tendency to chew almost every day and throughout their pregnancy time. This could lead to poor appetite of pregnant mothers as khat has a known effect of decreasing appetite in many people (Lemieux et al. 2015) and has vaso-constrictive effect on placental vessels (Lemieux et al. 2015; Jansson et al. 1987). Hence, poor appetite of pregnant mothers could lead to a poor nutritional status of the mother and inadequate weight gain during pregnancy which was identified as a factor for LBW in this and in other previous studies. In Africa, studies showed that maternal substance use like alcohol and cigarette during pregnancy had a contribution to LBW of newborn. In addition, this study shows the presence of a strong association between khat and LBW of newborns. Using case-control study is a realistic way to identify cause and effect relationship. However, since measuring birth weight of institutionally delivered infant is difficult at community level, this study is conducted at a health facility. Data was collected by health professionals working in the delivery room. Therefore, social desirability bias may happen and can result in minimization of the substance use report. Interviewing mothers by staff working in the same institution for social desirability bias and mothers’ ability to recall issues during pregnancy period as recall bias, still-born exclusion, and self-exclusion of pregnant women who gave birth at home were the limitations of the study.

Conclusion Women who use khat during pregnancy had higher probability of having a newborn with LBW than their counterparts. Therefore, the observed association between khat use and LBW calls for public health interventions to reduce the use of khat during pregnancy. There is a need for a comprehensive health promotion program to be developed and implemented as an integral part of ANC to reduce khat use during pregnancy by offering advice in the ANC unit or referring to substance counseling services. Furthermore, prospective studies need to be conducted to understand the mechanisms of the effect of khat use on pregnancy outcomes. Compliance with Ethical Standards Ethical approval was sought from the research ethical review committee of College Health Sciences of Jimma University. Written informed consent was obtained from every study subject before the interview. Conflict of Interest The authors declare that they have no conflict of interest.

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