Factors affecting asthma control in pregnancy: A cross-sectional study

Background and Objective: Asthma control in pregnant women remains of utmost importance; suboptimal control can have adverse repercussions on both fetal and maternal health. The objective was to identify the factors that affect asthma control in pregnant Pakistani women presenting to a tertiary care hospital. Methods: This descriptive, cross-sectional research was conducted at KRL General Hospital between 1st November 2022 to 30th April 2023. Non-probability technique was used to sample one hundred and forty-five pregnant women with confirmed bronchial asthma irrespective of their trimester presented. Data regarding demographics and factors affecting asthma control was collected. Results: The mean age was 30.39 ± 4.33 years, with two-thirds (65%) being multiparous. Approximately 48% of participants were non-compliant with treatment, and less than 40% achieved adequate asthma control. A chi-squared test applied showed that multiparity (p = 0.003), treatment compliance (p < 0.001), BMI (p < 0.001), and proper inhaler technique (p < 0.001) were statistically significant factors affecting asthma control in pregnant women while, the level of education and household income did not exhibit a significant association. Multiple regression analysis qualified higher BMI, multiparity, treatment compliance, and inhaler technique as significant predictors of asthma control amongst pregnant women. Conclusion: Ensuring asthma control during pregnancy is important. This study identified BMI, multiparity, inhaler technique, and treatment compliance as factors that affect asthma control in pregnant women. Addressing these factors through regular antenatal check-ups can significantly mitigate risks and promote the optimal health of both maternal and fetal lives.


INTRODUCTION
Asthma is characterized by chronic airway inflammation with respiratory symptoms, including chest tightness and wheezing with variable airflow limitation. 1 It is a major healthcare problem that asthma to develop hypertension in pregnancy, 7 preeclampsia, 7 gestational diabetes 8 and an increased risk of contracting a urinary tract infection. 9Fetal complications include post-birth Neonatal ICU admission, small for gestational age, low birth weight, 10 prematurity birth asphyxia, 11 and an increased risk of having congenital malformations. 7Maternal Asthma leads to an increased risk of childhood Asthma and Pneumonia. 7iterature search has identified covariates that can adversely affect asthma control, which include age, parity, obesity, socioeconomic status, education, and smoking. 12Also, asthma exacerbation during pregnancy can adversely affect the perinatal and infant health outcomes. 13By monitoring pregnant women with asthma, healthcare providers can promptly identify and take proactive measures to mitigate the impact of asthma exacerbations and reduce maternal and fetal complications. 7his study aims to identify the factors influencing asthma control in pregnant women within the Pakistani population.To the best of our knowledge, this is the first local study of its kind that addresses this clinical dilemma, providing valuable guidance at a local level on effectively managing the burden of maternal asthma.

METHODS
The research was conducted at KRL General Hospital, which is a 350 bedded teaching hospital with dedicated Pulmonology and OB/GYN clinical units.The duration of the study was six months from 1 st November 2022 to 30 th April 2023.Ethical Approval: Before collecting data, permission was taken from the local ethics committee with the following reference number 'KRL-HI-PUB-ERC/29 dated 15-12-202'.Informed consent was obtained from all participants.
The study design was a descriptive cross-sectional.The sampling technique was nonprobability convenience sampling.The sample size was calculated using the WHO samples size calculator.The sample size of the target population was 145 with a confidence interval of 95% and absolute precision of 8% with a prevalence of well-controlled asthma of 38%. 5 Inclusion & Exclusion Criteria: All pregnant women with asthma, regardless of the trimester of pregnancy, were eligible to participate.It is essential that the asthma diagnosis be confirmed by a pulmonologist and supported by spirometry with reversibility testing (an increase in FEV1 of ≥ 12% or 200mls after bronchodilator challenge) as per Global Initiative for Asthma (GINA) guidelines. 1 On the other hand, pregnant ladies with self-reported asthma without physician confirmation and with other obstructive lung diseases like COPD and Bronchiectasis were excluded.
Data was collected from patients presenting to the Department of OB/GYN and Pulmonology with a history of asthma who were expected to deliver at Effect modifiers were controlled through stratification of age, residence status, parity, gravida, family monthly income, occupational status, educational status, and duration of asthma to see the effect of these on the outcome variable.Post-stratification Chi-square test was applied and a p-value of ≤ 0.05 was considered significant.To assess the potential relationship between Asthma control and the factors influencing it, a Spearman correlation analysis was employed.This analysis aimed to determine whether a significant association existed between Asthma control and the aforementioned factors.The multivariate regression model was to used examine the impact of variables on asthma, considering their combined effects.

RESULTS
A total of 145 pregnant women were included in this study irrespective of the trimester who were booked at KRL Hospital.The participants mean age was 30.39 years (SD = 4.33), ranging from 18 to 45 years.The average duration of Asthma was 5.39 years with an interquartile range (IQR) of 4.00 to 7.00.The mean GINA assessment score was 1.64 with an IQR of 0.00 to 3.00.
Majority of the patients, 65% (n=95), were multiparous, 54.5% of the participants (n=79) lived in rural areas and 67.65% (n=98) were unemployed.Regarding education level, approximately 43% completed a bachelor's degree, while the remaining were educated up to grade 12

or less (Table-I).
A chi-squared test applied showed that multiparity (p = 0.003), treatment compliance (p < 0.001), BMI (p < 0.001), and proper inhaler technique (p < 0.001) were statistically significant factors affecting asthma control in pregnant women.However, the level of education and household income did not exhibit a significant association with asthma control in our study population.
Multiple regression analysis qualified higher BMI, multiparity, treatment compliance, and inhaler technique as significant predictors of asthma control amongst pregnant women [F (9.135) =18.924 p < 0.001 R 2 = 0.558].The standardized Beta Coefficient is also reported for each variable in the regression model in Table -IV.

DISCUSSION
][9][10] This study has revealed that asthma control was influenced Interestingly, we found that as the parity increased, our target population showed better asthma control, contrary to the results in studies conducted elsewhere. 14,15We can attribute this finding to relatively small sample size of our study population and the study design itself; which only measured control at one point in time.Further studies with a higher sample size and ideally a prospective cohort study design may provide more reliable evidence.
Keeping in line with Murphy et al; 16 we also observed association between higher body mass index and inadequate asthma control.It is hereby suggested that women of childbearing age be encouraged to lose weight before planning to conceive.It has been observed that obesity leads to the development of reduced lung volumes, bronchial hyperresponsiveness, and inability to initiate deep breathing movements.It is further complicated by impaired immune function which may contribute to the worsening of asthma in obese patients. 17ealthcare professionals managing women with asthma who are pregnant or are planning to conceive should identify people who are at high risk; i.e., smokers, obese, or those who have history of poor treatment adherence. 12All these modifiable risk factors should be addressed in order to mitigate the adverse outcome associated with maternal asthma. 13In our study, slightly over 50% of our study participants were compliant with their treatment, indicating significant room for improvement.Robijn et al reported 38% of pregnant women being noncompliant to asthma treatment specifically the use of inhaled corticosteroids. 18Williams et al concluded that individuals maintaining a compliance rate of 75% would experience notable prevention of severe asthma exacerbations. 19ver 60% of our study population had an improper inhaler technique.The majority of individuals are unaware that possessing a suboptimal inhaler technique constitutes a problem.An Italian study 20 reported up to 44% and an Indian study 21 reported 37% of the patients having poor inhaler technique.An improper inhaler technique can lead to poor disease control. 20Our Study reports a relatively higher proportion with inadequate inhaler technique.We may attribute this to a small sample size in comparison to both these studies.Realistically, a lack of knowledge of correct inhaler technique reflects poor control and it is vital to identify this as simple education about correct technique can lead to improved control and reduced morbidity.
The utilization of inhalation devices allows for the delivery of medication directly to the airways, resulting in a concentrated dose and quicker therapeutic effects, while minimizing systemic side effects. 1 However, acquiring the appropriate skills for proficient inhaler technique is essential to achieve optimal drug delivery.According to GINA 1 almost 70 to 80% of patients with asthma have a suboptimal inhaler technique.GINA has recommended the use of placebo inhalers and spacing devices to train patients by demonstration.Additionally, it is advised to periodically reevaluate and retrain patients as necessary.
Limitations: This study is subject to certain limitations, including its single-center design and relatively small sample size.To gain a more comprehensive understanding of how maternal asthma impacts perinatal and postnatal outcomes, future research should consider conducting similar studies involving multiple centers and employing a prospective cohort study design.Furthermore, following patients throughout the postnatal period would provide valuable insights, enabling a more holistic approach to addressing this issue.

CONCLUSION
Our study has demonstrated BMI, multiparity, inhaler technique, and treatment compliance as factors that affect asthma control in pregnant women.It is

Table - I
: Baseline characteristics of study population.KRL hospital.To assess asthma control, an Asthma symptom control questionnaire outlined by GINA 1 was used and frequency of daytime symptoms, night-time awakening, short-acting beta-agonist use, and exercise limitation, to assess the patient's asthma control were recorded.

Table -
II: Association of individual factors with GINA Score.

Table -
IV: Multivariate Analysis for Factors Associated with Asthma Control. the modifiable risk factors amongst these may be addressed at every follow-up visit to ensure a better outcome for both the mother and the fetus.It's essential to highlight that correct inhaler technique and advise for treatment compliance be given and documented with each antenatal visit.