Volume 10, Issue 2 (June 2025)
J Environ Health Sustain Dev 2025, 10(2): 2589-2607 |
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Raeisi S, Mirbalouchzehi A, Yazdandoust M. The Dual Burden of Air Pollution During Pregnancy: A Systematic Review of Physical and Psychological Consequences. J Environ Health Sustain Dev 2025; 10 (2) :2589-2607
URL: http://jehsd.ssu.ac.ir/article-1-902-en.html
URL: http://jehsd.ssu.ac.ir/article-1-902-en.html
Department of Environmental Health Engineering, School of Public Health and Allied Medical Sciences, Iranshahr University of Medical Sciences, Iranshahr, Iran
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Figure 1: PRISMA flow diagram in this study
Table 1: Number of studies conducted on psychological abnormalities resulting from pregnant mothers'
exposure to air pollution
Table 3: Number of studies conducted on physical abnormalities resulting from pregnant
mothers' exposure to air pollution
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The Dual Burden of Air Pollution During Pregnancy: A Systematic Review of Physical and Psychological Consequences
Sakineh Raeisi 1, Ali Mirbalouchzehi 2, Mehran Yazdandoust 3*
1 Environmental Health Engineering Student, Student Research Committee, Iranshahr University of Medical Sciences, Iranshahr, Iran.
2 Department of Public Health, School of Public Health and Allied Medical Sciences, Iranshahr University of Medical Sciences, Iranshahr, Iran.
3 Department of Environmental Health Engineering, School of Public Health and Allied Medical Sciences, Iranshahr University of Medical Sciences, Iranshahr, Iran.
Sakineh Raeisi 1, Ali Mirbalouchzehi 2, Mehran Yazdandoust 3*
1 Environmental Health Engineering Student, Student Research Committee, Iranshahr University of Medical Sciences, Iranshahr, Iran.
2 Department of Public Health, School of Public Health and Allied Medical Sciences, Iranshahr University of Medical Sciences, Iranshahr, Iran.
3 Department of Environmental Health Engineering, School of Public Health and Allied Medical Sciences, Iranshahr University of Medical Sciences, Iranshahr, Iran.
| A R T I C L E I N F O | ABSTRACT | |
| REVIEW ARTICLE | Introduction: Air pollution affects pregnant women and fetuses, leading to health complications. It increases risks like low birth weight, preterm labor and hypertension. Moreover, mental health issues such as depression and autism spectrum disorders may arise. Materials and Methods: This systematic review was conducted by examining data from four databases, including Google Scholar, PubMed, Web of Science, and Scopus covering the period from 2020 to 2024. The keywords used included "air pollution," "pregnant women," "fetal health," "pregnancy complications," "particulate matter," and "mental health". Using specific criteria, 109 studies were found. After excluding unrelated articles, 63 studies were analyzedand key information was extracted. Results: Air pollution significantly affects the physical and mental health of pregnant women. It increases the risk of depression, anxiety and autism spectrum disorders, with PM2.5 and NO2 being major contributors. Physical complications like preterm labor, gestational diabetes, miscarriage and preeclampsia are strongly linked to pollution. Lower-income women face higher exposure and mental health risks due to socioeconomic factors. Furthermore, living in urban areas and near pollution sources elevates health risks for mothers and fetuses. The second and third trimesters are the most vulnerable periods, highlighting the need for effective interventions. Conclusion: Air pollution severely affects the physical and mental health of pregnant women and fetuses, especially during the second and third trimesters. Preventive measures like air quality improvement and policy-making are crucial to protect maternal and fetal health. |
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Article History: Received: 17 March 2025 Accepted: 20 May 2025 |
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*Corresponding Author: Mehran Yazdandoust Email: Mehranyazdan20@gmail.com Tel: +98 930 5380844 |
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Keywords: Air Pollution, Pregnancy Outcome, Mental Health. |
Citation: Raeisi S, Mirbalouchzehi A, Yazdandoust M. A Systematic Review of the Effects of Air Pollution during Pregnancy: Physical and Psychological Impacts. J Environ Health Sustain Dev. 2025; 10(2): 2589-607.
Introduction
Air pollution is a major environmental and public health challenge worldwide with detrimental effects on both physical and mental health. This issue is particularly significant during pregnancy, which is a crucial period for maternal and fetal health. Pregnant women are more vulnerable to environmental pollutants due to physiological changes such as increased ventilation rates and altered oxygen transport capacity1. Studies have shown that pollutants such as particulate matter (PM2.5, PM10), nitrogen dioxide (NO2), and ozone (O3) can lead to adverse outcomes, including low birth weight, preterm birth, gestational diabetes, hypertensive disorders, respiratory problems, preeclampsia, and fetal growth restriction2-4. In addition to its physical effects, air pollution can also affect the mental health of pregnant women. Evidence suggests that exposure to pollutants may be associated with increased stress, anxiety, postpartum depression, and a higher risk of autism spectrum disorders in offspring 5-7. Furthermore, air pollution can increase oxidative stress and inflammation in the mother’s body, which negatively affects fetal health7. These effects impact both maternal health and the child's psychosocial and developmental outcomes8, 9. The underlying mechanisms of these effects include inflammation, hormonal dysregulation, and damage to the blood-brain barrier, which may result in neurological changes in the fetus10, 11.
Socioeconomic status also plays a crucial role in air pollution severity. Women living in lower-income areas or with limited access to healthcare services are generally at a greater risk. These groups often face challenges such as reliance on biomass fuels for cooking or heating, which can increase pollutant exposure2, 12. Moreover, some studies indicate that mothers residing in areas with lower income levels and higher inequality are at a greater risk of preterm delivery; average household income is lower in these regions than in areas with normal deliveries13, 14. Geographic factors also contribute significantly to this issue. Pregnant women in urban and industrial regions, particularly developing countries, are more exposed to severe pollution 15. Additionally, geographic location and environmental conditions, such as proximity to pollution sources or population density, can exacerbate the impact of air pollution16, 17. In densely populated urban areas such as Beijing and Los Angeles, high levels of PM2.5 have been associated with negative maternal and fetal health outcomes. Similarly, in rural areas, such as Nagpur, India, the use of polluting fuels has led to an increase in diseases16, 18.
Given growing concerns about the effects of air pollution on maternal and fetal health, a comprehensive examination of its physical and psychological impacts on pregnant women is essential. This review article aims to analyze the existing findings on this topic while identifying factors that influence the severity of these effects. To facilitate the understanding of these impacts, tables and charts that assisted in data analysis were utilized. This review aims to present a comprehensive picture of the effects of air pollution on the health of pregnant mothers and to identify the factors influencing the severity of these impacts.
Materials and Methods
A systematic review was conducted to evaluate the physical and psychological effects of air pollution in pregnant women. Data collection followed the PRISMA guidelines by searching five major databases: Google Scholar, PubMed, Web of Science, Scopus, and ScienceDirect within the period from 2020 to 2024. The search used topic-related keywords, including air pollution, pregnancy, mental health, physical health, AND, OR PM, combined with logical operators (AND, OR). The Prisma diagram (Figure 1) clearly illustrates the article selection process and includes the number of initial articles, articles removed, and final articles included in the ultimate analysis.
The inclusion criteria were articles published in the last five years, studies examining the physical and psychological effects of air pollution on pregnant women, and studies that had full text and sufficient data. The exclusion criteria were duplicate articles, irrelevant studies, and those lacking sufficient scientific quality. In the initial phase, 109 relevant articles were identified through the database searches. The titles and abstracts were screened to exclude studies that did not meet the relevant criteria. In the second phase, the full texts of the remaining articles were reviewed and 63 articles were selected for the final analysis. Key information from the selected articles was extracted and organized into tables. The collected data were categorized according to their physical and psychological effects and systematically analyzed to identify patterns or contradictions. Finally, the findings are presented in tables and the qualitative data analysis.
Air pollution is a major environmental and public health challenge worldwide with detrimental effects on both physical and mental health. This issue is particularly significant during pregnancy, which is a crucial period for maternal and fetal health. Pregnant women are more vulnerable to environmental pollutants due to physiological changes such as increased ventilation rates and altered oxygen transport capacity1. Studies have shown that pollutants such as particulate matter (PM2.5, PM10), nitrogen dioxide (NO2), and ozone (O3) can lead to adverse outcomes, including low birth weight, preterm birth, gestational diabetes, hypertensive disorders, respiratory problems, preeclampsia, and fetal growth restriction2-4. In addition to its physical effects, air pollution can also affect the mental health of pregnant women. Evidence suggests that exposure to pollutants may be associated with increased stress, anxiety, postpartum depression, and a higher risk of autism spectrum disorders in offspring 5-7. Furthermore, air pollution can increase oxidative stress and inflammation in the mother’s body, which negatively affects fetal health7. These effects impact both maternal health and the child's psychosocial and developmental outcomes8, 9. The underlying mechanisms of these effects include inflammation, hormonal dysregulation, and damage to the blood-brain barrier, which may result in neurological changes in the fetus10, 11.
Socioeconomic status also plays a crucial role in air pollution severity. Women living in lower-income areas or with limited access to healthcare services are generally at a greater risk. These groups often face challenges such as reliance on biomass fuels for cooking or heating, which can increase pollutant exposure2, 12. Moreover, some studies indicate that mothers residing in areas with lower income levels and higher inequality are at a greater risk of preterm delivery; average household income is lower in these regions than in areas with normal deliveries13, 14. Geographic factors also contribute significantly to this issue. Pregnant women in urban and industrial regions, particularly developing countries, are more exposed to severe pollution 15. Additionally, geographic location and environmental conditions, such as proximity to pollution sources or population density, can exacerbate the impact of air pollution16, 17. In densely populated urban areas such as Beijing and Los Angeles, high levels of PM2.5 have been associated with negative maternal and fetal health outcomes. Similarly, in rural areas, such as Nagpur, India, the use of polluting fuels has led to an increase in diseases16, 18.
Given growing concerns about the effects of air pollution on maternal and fetal health, a comprehensive examination of its physical and psychological impacts on pregnant women is essential. This review article aims to analyze the existing findings on this topic while identifying factors that influence the severity of these effects. To facilitate the understanding of these impacts, tables and charts that assisted in data analysis were utilized. This review aims to present a comprehensive picture of the effects of air pollution on the health of pregnant mothers and to identify the factors influencing the severity of these impacts.
Materials and Methods
A systematic review was conducted to evaluate the physical and psychological effects of air pollution in pregnant women. Data collection followed the PRISMA guidelines by searching five major databases: Google Scholar, PubMed, Web of Science, Scopus, and ScienceDirect within the period from 2020 to 2024. The search used topic-related keywords, including air pollution, pregnancy, mental health, physical health, AND, OR PM, combined with logical operators (AND, OR). The Prisma diagram (Figure 1) clearly illustrates the article selection process and includes the number of initial articles, articles removed, and final articles included in the ultimate analysis.
The inclusion criteria were articles published in the last five years, studies examining the physical and psychological effects of air pollution on pregnant women, and studies that had full text and sufficient data. The exclusion criteria were duplicate articles, irrelevant studies, and those lacking sufficient scientific quality. In the initial phase, 109 relevant articles were identified through the database searches. The titles and abstracts were screened to exclude studies that did not meet the relevant criteria. In the second phase, the full texts of the remaining articles were reviewed and 63 articles were selected for the final analysis. Key information from the selected articles was extracted and organized into tables. The collected data were categorized according to their physical and psychological effects and systematically analyzed to identify patterns or contradictions. Finally, the findings are presented in tables and the qualitative data analysis.
Figure 1: PRISMA flow diagram in this study
Results
Given the significant impact of air pollution on the physical and mental health of pregnant women, examining the various dimensions of its effects are of particular importance. Table 1 summarizes the number of studies conducted on mental disorders caused by pregnant mothers' exposure to air pollution, and clearly depicts the relationship between pollution and various disorders.
Given the significant impact of air pollution on the physical and mental health of pregnant women, examining the various dimensions of its effects are of particular importance. Table 1 summarizes the number of studies conducted on mental disorders caused by pregnant mothers' exposure to air pollution, and clearly depicts the relationship between pollution and various disorders.
Table 1: Number of studies conducted on psychological abnormalities resulting from pregnant mothers'
exposure to air pollution
| Reference | Disease | Number of studies |
Number of cases |
| 6, 19, 20 | Depression and anxiety | 3 | 1157 |
| 7, 21 | Autism spectrum disorders | 2 | 475 |
| 22 | Psychosocial problems | 1 | 360 |
| 5, 20 | Depression and psychological stress and their impact on immune responses in infants | 2 | - |
| 23 | Postpartum depression | 1 | 90 |
Table 2 provides further details on the types of disorders and specific conditions related to pollution. This table summarizes studies linking pregnant mothers' exposure to air pollution with psychological disorders in their offspring. Pollutants such as PM2.5, PM10, NO2, O3, benzene, toluene, and black carbon are associated with increased risks of prenatal psychosocial stress, depression, anxiety, autism spectrum disorders, and postpartum depression. Study designs included prospective cohort, case-control, and longitudinal cohort studies with sample sizes ranging from 29 to 2153 participants. Affected ages ranged from 23 to 33 years, with some studies noting impacts on participants under 23 years of age. Exposure settings varied between indoor, outdoor, and both, with one study conducted during spring and another during rainy seasons
Table 2: Psychological disorders and abnormalities resulting from pregnant mothers' exposure to air pollution
| Reference | Disease | Study Type | Country | Sample Size | Responsible pollutant |
Indoor /Outdoor |
Age Group Affected | Season |
| 5 | Prenatal Psychosocial Stress | Prospective cohort Study | South Korea | 2153 | PM2.5 PM10 O3 |
Outdoor | 33 | Spring |
| 6 | Depression and Anxiety | Prospective cohort Study | South Korea (Seoul) | 1048(221depression,827 anxiety) |
NO2 O3 < PM2.5 < PM10 |
Indoor | 32-33 | - |
| 19 | Depression | Prospective cohort Study | California | 29(180controls) | NO2 PM2.5 |
Outdoor | 29-30 | - |
| 7 | Autism Spectrum Disorders | Case-control study | California | Total 957 199 (Autism Spectrum Disorder) ASD without intellectual disability, 180 ASD with intellectual disability |
PM2.5 | Outdoor | 29 | - |
| 22 | Psychosocial problems | Prospective cohort Study | South Africa | 360 | PM10 Benzene Toluene |
Indoor | 26.87 | - |
| 20 | Depression and psychosocial stress | Longitudinal Prospective cohort | USA | Total 463 80 with depression |
PM2.5 BC 1 |
Outdoor | %94 of participants under age 23 | - |
| 23 | Postpartum depression | Prospective cohort study | Mexico | 90(419 controls) | PM2.5 | Both | 27.4 | Rainy |
| 21 | Autism spectrum disorders | Observational study | USA | 96 | PM2.5 | Outdoor | - | - |
[1] Black carbon
Tables 3 and 4 examine the physical abnormalities caused by air pollution and provide comprehensive information about the various effects on the physical health of pregnant mothers.
Table 3: Number of studies conducted on physical abnormalities resulting from pregnant
mothers' exposure to air pollution
| Reference | Disease | No. of studies | No. of Cases |
| 2, 24 | Anemia | 2 | 1149 |
| 3, 25 | Preeclampsia | 2 | 2988 |
| 16, 17, 26-30 31, 32 14, 33, 13 | Preterm labor | 12 | - |
| 12, 16, 34, 18, 35-38 | Respiratory problems and asthma | 7 | - |
| 26, 31, 32, 39-42 | Gestational diabetes | 6 | 19685 |
| 17, 29, 35, 43 | Miscarriage | 4 | 7704 |
| 44-47 | Autoimmune thyroid disease | 4 | 3768 |
| 48 | Effect of exposure to PM on hematological indices in women ready for pregnancy | 1 | - |
| 49 | Infertility | 1 | - |
| 15, 50-52 | Hypertension disorders | 4 | 3575 |
| 53 | Anencephaly | 1 | 663 |
| 37, 54 | Congenital anomalies (cardiovascular, gastrointestinal) | 2 | - |
| 55 | Antiphospholipid syndrome | 1 | 182 |
| 56 | Kidney function disorder | 1 | 10052 |
| 57 | Oxidative stress | 1 | 100 |
| 58 | Lead-induced injuries | 1 | - |
| 59 | Glucose intolerance | 1 | - |
| 60 | Polycystic ovary syndrome | 1 | 1652 |
| 61 | Pregnancy Complications (APPO) | 1 | - |
| 62 | Reduced fertility in IVF patients | 1 | - |
| 63 | Biological stress | 1 | - |
| 64 | Heavy metal poisoning | 1 | - |
| 65 | Selenium deficiency in pregnant woman | 1 | 13 |
| 66 | Macrosomia | 1 | 15348 |
| 36 | Respiratory infection, heart disease, lung cancer | 1 | - |
| 67, 68 | No specific disease mentioned (impact of air pollution on pregnant women's health) | 2 | 1368 |
Table 4: Physical diseases and abnormalities resulting from pregnant mothers' exposure to air pollution
| Reference | Disease | Study type | Country | Sample size | Responsible pollutant |
Indoor /Outdoor |
Age group affected | Season |
| 2 | Anemia | Randomized controlled multicountry trial | Guatemala, India, Peru, Rwanda | 853 (2310 controls) | PM2.5, CO (less association) | Indoor | 18-35, mostly under 25 | Cold and warm months |
| 3 | Preeclampsia | longitudinal study | USA | 1066 | PM2.5, O3, NO2 | Outdoor | 31.9 | All seasons |
| 16 | Preterm birth, gestational diabetes, respiratory issues, postpartum depression | Prospective cohort | USA (Los Angeles, California) | 63(2) | PM2.5 | Both | 28.7 | - |
| 17 | Miscarriage, preterm birth, low birth weight | Retrospective cohort | Nepal | 1716 total, 74 preterm births, 25 miscarriages, 221 low birth weight (1449 with at least one adverse outcome) | PM2.5 | Outdoor | 24 | Wet and dry |
| 44 | Thyroid autoimmunity | Prospective cohort | China | 1759 (15664 controls) | PM2.5 | Outdoor | 31-32 | Various seasons |
| 26 | Gestational diabetes, preterm birth | Case-control study | South Korea | 60 (cases studied), 10 with gestational diabetes, 4 preterm births | < PM2.5 | Indoor | - | - |
| 48 | Effects of PM on hematological Indices in women preparing for pregnancy | Prospective cohort | China | 1,203,565 | PM1, PM2.5 (more) | Outdoor | 18-25 | - |
| 54 | Congenital anomalies (cardiovascular, gastrointestinal) | Retrospective cohort | South Korea | 1624 total, 216 with anomalies | PM2.5 | Outdoor | 33.8 | - |
| 15 | Hypertension disorders in pregnancy | Retrospective cohort | China | 440 (8336 controls) | PM2.5 | Outdoor | 30.5 | - |
| 53 | Anencephaly | Case-control | China | 663 (7950 controls) | PM10 | Outdoor | 20-34 | Spring |
| 34 | Respiratory infections | Retrospective cohort | Israel | 57,331 total, 1871 cases | PM2.5 | Outdoor | 28.2 | - |
| 39 | Gestational diabetes | Prospective cohort | China | 394 (4783 controls) |
PM2.5 | Outdoor | 30 | - |
| 42 | Adverse pregnancy outcomes | Retrospective cohort | Peru | 123,034 total, 16% mothers with gestational diabetes (19685) | PM2.5 | Outdoor | 22-39 | - |
| 45 | Thyroid disorders | Prospective cohort | China | 921 (1521 controls) | PM2.5 | Outdoor | 28 | - |
| 46 | Hypothyroidism | Retrospective case-control | China | 795 (2385 controls) | PM | Outdoor | 31 | Winter |
| 12 | Pregnancy complications (preterm birth, respiratory issues) | Population-based Cohort | USA (Texas) | 7,043,598 totals | NO2 | Outdoor | 26.8 | - |
| 68 | Health problems | Cross-sectional questionnaire-based | Poland | 1095 (3451) | < PM2.5 PM2.5 | Outdoor | 31-35 | - |
| 38 | Asthma | Multicenter Prospective cohort | USA | 311 | PM2.5 | Both | 30 | - |
| 67 | No specific disease mentioned (impact of air pollution on pregnant women's health) | Prospective Cohort | New York | 273 (224 controls) | NO2 PM |
Both | 33 | - |
| 55 | Antiphospholipid syndrome | Pilot study | China | 182 (189 controls) | PM2.5 PM10 |
Outdoor | 31-32 | All seasons |
| 56 | Renal dysfunction | Prospective cohort | China | 1052 (2350 controls) | PM2.5 | Outdoor | 35 | Winter |
| 27 | Preterm birth | Retrospective cohort | China | 7974 | PM2.5 | Outdoor | Over 35 | - |
| 57 | Oxidative stress | Case-control | China | 200 total, 100 cases | PM2.5 | Outdoor | 32 | - |
| 58 | Lead exposure injuries | Cross-sectional | Japan | 87 | Lead | Indoor | 32.2 | Winter and autumn |
| 40 | Gestational diabetes | Observational cohort | Finland | 6189 total, 1003 (5186 controls) | PM10 | Outdoor | 30 | - |
| 28 | Preterm birth | Prospective cohort | France (Guadeloupe) | 906 | Desert dust, PM10 | Outdoor | - | Spring and summer |
| 50 | Hypertension disorders | Prospective cohort | China | 7658 studied, 410 cases (7248 controls) | PM2.5 | Outdoor | 28.3 | Cold |
| 59 | Glucose intolerance | Cross-sectional | Iran (Sabzevar) | 250 | PM1 PM2.5 PM10 |
Outdoor | 28 | Summer |
| 24 | Anemia | Cross-sectional | Ethiopia | 732 total, 296 (436 controls) | Indoor pollution from fuels | Indoor | 25-34 | - |
| 43 | Miscarriage | Epidemiological observational study | Australia | 967694 controls, 4287 cases | < PM2.5 < PM10 O3 |
Outdoor | < 35 | - |
| 60 | Polycystic ovary syndrome (PCOS) | Retrospective Cohort | Chi/na (Shanghai) | 14295 totals, 1652 with PCOS (Polycystic Over Syndrome), 12543 without PCOS | < PM2.5 < PM10 O3 NO2 SO2 CO |
Outdoor | < 30 | Summer |
| 41 | Gestational diabetes syndrome | Retrospective cohort | China | 372 (9820 controls) | PM10 PM2.5 NO2 |
Outdoor | Over 35 | - |
| 61 | Pregnancy complications | Prospective cohort | South Korea | 1200 total participants, 333 cases studied | < PM2.5 < PM10 |
Both | 33.6 | All seasons |
| 62 | Reduced fertility in IVF (In Vitro Fertilization) patients | Prospective cohort | Spain (Barcelona) | 194 | PM, especially PM2.5, PM10 | Indoor | Over 35 | - |
| 25 | Preeclampsia | Retrospective Cohort | China | 116042 total, 2988 cases (113054 controls) | NO2, O3, PM2.5, PM10 | Outdoor | Over 35 and under 20 | Cold and warm seasons |
| 29 | Preterm birth, miscarriage | Retrospective cohort | London | 581774 total, 33712 preterm births, 3392 miscarriages | O3 PM2.5 |
Outdoor | Over 35 | Spring |
| 52 | Hypertension disorders in pregnancy HDP (Hypertensive Disorders of Pregnancy) | Prospective cohort | Italy (Lombardy) | 528 | PM2.5 PM10 |
Outdoor | 33 | Winter |
| 30 | Preterm birth | Cross-sectional | China (Hubei Province) | 429865 totals studied, 2.98% affected | <PM2.5 | Outdoor | 26-27 | - |
| 31 | Preterm birth, gestational diabetes | Multicenter prospective cohort | Korea | 662 studied, 138 with pregnancy complications, 61 preterm births | PM2.5 PM10 |
Indoor | Over 35 | Winter and spring |
| 32 | Pregnancy complications (preterm birth, gestational diabetes) | Retrospective cohort | Kansas | 41936 preterm births, 20455 gestational Diabetes, 24258 hypertension disorders | O3, NO2 | Outdoor | 27 | - |
| 51 | Hypertension disorders | Retrospective cohort | China (Handan) | 2197 (9820 controls) | PM2.5, PM10, O3, NO2 | Indoor | 25-35 | - |
| 33 | Preterm birth | Retrospective Cohort | Brazil | 313286 studied, 21928 preterm births | PM | Outdoor | 25 | - |
| 49 | Infertility | Cross-sectional | Poland | 511 | PM2.5, O3, CO, NOx, SO2 | Outdoor | 31-39 | - |
| 63 | Biological stress | Prospective Cohort | Belgium | 133 | PM2.5, NO2, BC | Outdoor | 26-30 | All seasons |
| 14 | Preterm birth | Retrospective | California | 966652 population studied, 88895 preterm births | PM2.5, O3 | Outdoor | Under 20 and over 35 | Spring and summer |
| 18 | Respiratory diseases | Cross-sectional | India | 60 | Indoor air pollution, PM environmental toxins | Indoor | 23 | - |
| 47 | Hypothyroidism | Retrospective | Greece | 293 | < PM2.5 | Indoor | 30.9 | Winter |
| 64 | Heavy metal poisoning | Cross-sectional | Israel | 143 | Nitrogen oxides, PM, sulfur dioxide | Both | 28 | - |
| 65 | Selenium deficiency in pregnant women | Cross-sectional | China | 273 studied, 13 with selenium deficiency, 65 high levels, 195 normal | Indoor air pollution from coal burning | Indoor | 26.45 | - |
| 35 | Respiratory issues (asthma, cough, sneezing), eye irritation, suffocation, miscarriage | Qualitative phenomenological study | Ethiopia | 15 | PM from biomass fuels (wood, agricultural waste) | Indoor | 27 | - |
| 66 | Macrosomia | Retrospective Cohort | China | 197,877 totals (15,348 cases, 182,529 controls) | PM2.5, SHS | Both | 25 | Spring and winter |
| 36 | Respiratory infections, cardiovascular disease, lung cancer | Feasibility study | Bangladesh | Total population 30, data from 22 individuals | < PM2.5 CO |
Indoor | - | - |
| 69 | Respiratory and health issues (fatigue, headache, eye problems) | Cross-sectional study | Western Kenya | 251 | Smoke from wood burning (PM, CO, VOCs), NOx | Indoor | 36.49 | - |
| 37 | Negative effects on reproductive health (respiratory, cardiovascular issues, infertility) | Cross-sectional study | Pakistan, India, Bangladesh | Approximately 1.7 billion (14.325 million Pakistan, 600,105 India, 17.205 million Bangladesh) | Pollutants from cooking fuels | Indoor | - | - |
| 13 | Preterm birth | Cross-sectional study | California | 341123 (3,753,799) | < PM2.5, NO2, O3 | Outdoor | - | - |
Discussion
Effects of Air Pollution on Mental Health
The results presented in Table 2 indicate that air pollution affects not only the physical health but also the mental health of pregnant women. Pollutants, such as NO2, PM2.5, and O3, are specifically associated with an increased risk of mental health disorders, including depression, anxiety, and autism spectrum disorders (ASD)6, 7. These findings highlight the critical need to improve air quality in the living environments of pregnant women and call for effective measures to reduce air pollution and support this vulnerable group in society6, 7.
Effects on the Fetus
Studies have shown that air pollution can have varying effects on the fetus during different trimesters of pregnancy. In particular, the second trimester has been identified as a sensitive period for fetal brain development. Exposure to air pollution during this phase has been linked to future cognitive and behavioralproblems6, 7. Additionally, psychological stress caused by air pollution can negatively affect fetal growth. Research indicates that women exposed to high levels of air pollution are more likely to have fetuses with growth impairments and behavioral disorders 5.
Geographical Context
Geographical location, particularly in low- and middle-income countries (LMICs), can profoundly affect the mental health of pregnant women. In these regions, urban air pollution is mainly driven by industrialization, and heavy traffic places pregnant women at a heightened risk. Additionally, poor environmental conditions and limited access to green spaces exacerbate psychological problems. Pregnant women in these areas often face greater socioeconomic challenges, which can further contribute to mental health problems6, 22.
Some studies have focused on urban areas, such as Seoul and Los Angeles, where high population density and heavy traffic significantly increase air pollution levels. In Los Angeles, many participants were from low-income communities, highlighting their increased vulnerability to pollution5, 19. Furthermore, research conducted in South Africa and Massachusetts identified proximity to highways and use of alternative fuels as risk factors for pregnant women20, 22.
Effects of Air Pollution on Physical Health
The results presented in Tables 3 and 4 demonstrate that air pollution significantly affected the physical health of pregnant women. Pollutants, such as NO2, PM2.5, PM10, and O3, are specifically associated with an increased risk of physical conditions, including respiratory problems, preterm birth, infertility, and preeclampsia. Additionally, air pollution can lead to increased oxidative stress and inflammation in the mother's body, which can adversely affect fetal health. These findings underscore the urgent need to focus on improving air quality in the living environment of pregnant women and implementing effective measures to reduce air pollution exposure.
Effects on the Fetus
Research indicates that the impact of air pollution on the fetus varies across different stages of pregnancy, with potentially serious consequences for both maternal and fetal health. During the first trimester, the fetus is highly dependent on maternal thyroid hormones, and any disruption in these hormones can significantly affect fetal growth and development45. Exposure to PM2.5 during this period is directly linked to an increased risk of gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP), with a reported relative risk (RR) of 3.89 (95% CI: 1.45–10.43)15. Additionally, a 26% increase in congenital anomalies has been observed for every 7.23 µg/m³ rise in PM2.5 concentration54. Thus, this period is recognized as a critical window for the adverse effects of air pollution.
In the second trimester, the effects of PM2.5, and NO2 become more pronounced, particularly concerning maternal and fetal health. PM2.5, during this phase, is strongly associated with an increased risk of HDP and preterm birth32, 50. This stage is also linked to a higher likelihood of fetal anomalies and growth impairments due to elevated concentrations of NO₂ and PM2.519.
Although the effects of air pollution remain significant in the third trimester, they are particularly evident in the reduced estimated glomerular filtration rate (eGFR) and increased risk of anemia in pregnant women24, 56. Moreover, the highest risk for preterm birth is associated with cumulativePM2.5exposurethroughout pregnancy14. These effects can lead to severe complications, such as preterm delivery and low birth weight.
Overall, the most substantial effects of air pollution were observed during the first and second trimesters, which are critical periods for fetal growth and development. Exposure during these sensitive windows increases the risk of complications such as GDM, HDP, congenital anomalies, preterm birth, and growth impairments19, 45, 50.
It is important to note that there is considerable heterogeneity among the studies included in this systematic review. Differences in study design (e.g., cohort vs. case-control), population characteristics (e.g., maternal age, socioeconomic status, and underlying health conditions), and methods of exposure assessment (e.g., direct environmental monitoring, satellite-based estimates, or self-reported data) may significantly influence the reported outcomes. For instance, while some studies estimated PM2.5 concentrations using modeling techniques, others relied on stationary air quality monitoring stations or participant surveys. Additionally, the timing and duration of exposure assessment (e.g., a specific trimester vs. the entire pregnancy) varied across studies, which could explain some inconsistencies in the results.10, 14, 67
Therefore, these differences should be carefully considered when interpreting the overall findings as they may affect the strength and generalizability of the associations between air pollution and pregnancy outcomes.
Geographical Context
Research has shown that the incidence of anemia in pregnant women is significantly higher in countries with severe air pollution. India has the highest prevalence, with 51.8% of pregnant women affected, followed by Peru (26.5%), Rwanda (15.4%), and Guatemala (6.3%). The primary cause of this condition is air pollution resulting from the use of biomass fuels for cooking and heating, which is strongly associated with exposure to PM2.5) and carbon monoxide (CO)2. Women residing in urban areas, particularly in Los Angeles, are exposed to higher levels of PM2.5, owing to traffic and industrial emissions16. In Nepal, urban residency has been linked to adverse effects on birth weight17.
In China, the highest prevalence of autoimmune thyroid disorders has been observed among women with annual incomes below $27,597 USD, highlighting the relationship between economic status and health outcomes44. Similarly, Daegu, South Korea, reported the highest incidence of autoimmune diseases in the region54. Studies conducted in major industrial cities, such as Shanghai and Beijing, have revealed that air pollution from industrial activities and traffic is particularly severe in these areas15. In Lima, the eastern regions with unique geographical conditions and the highest PM2.5 concentrations also reported the highest prevalence of anemia42.
Poland accounts for 36 of the 50 most polluted cities in the European :union: owing to its dense industrial activity and reliance on fossil fuels49. In California, poverty and socioeconomic inequalities are major contributors to the increased risk of preterm birth in polluted regions14. Additionally, rural areas such as Butajira in Ethiopia face heightened pollution levels due to poor socioeconomic conditions and reliance on polluting fuels, exacerbating health risks for pregnant women35.
Economy and Income
Economic status and income play critical roles in the severity of the physical and psychological effects of air pollution on pregnant women. Studies indicate that pregnant women living in poor economic conditions are more likely to experience psychological stress, which may stem from limited access to adequate healthcare, lack of supportive resources, and financial concerns. Financial crises and economic insecurity often lead to feelings of hopelessness and an inability to meet their own and their fetuses’ needs, increasing the risk of anxiety disorders and depression during pregnancy22.
Even among women with relatively higher incomes, such as those earning more than $2,738.59 per month, approximately 50% reported annual incomes below $30,000, reflecting the existing economic challenges5, 19. Additionally, 35.6% of the mothers relied on public insurance, highlighting their middle or low economic status7. Pregnant women living in lower-income areas are generally exposed to higher levels of air pollution, underscoring the socioeconomic disparities in air pollution exposure3. Furthermore, the average household income in regions with higher rates of preterm births is lower than that in areas with normal deliveries14.
Low economic status not only increases pregnant women’s exposure to air pollution but also limits their access to medical services. This situation leads to greater reliance on polluting fuels, which increases the risk of diseases such as anemia24. Conversely, women with higher incomes and better access to healthcare were able to mitigate the negative effects of air pollution. For instance, 67.2% of women with annual incomes exceeding $6,870 or those with university education reported better physical and mental health outcomes43, 50.
In summary, economic status is a key determinant of the severity of the physical and psychological effects of air pollution in pregnant women. Women living in poor economic conditions face simultaneous challenges from financial stress and the physical impact of exposure to air pollution.
Another important limitation of the included studies is the limited consideration of individual-level confounding factors that may have significantly influenced the observed associations between air pollution and pregnancy outcomes. For instance, maternal smoking, dietary habits, physical activity, and alcohol consumption can independently affect fetal development and may correlate with environmental exposure levels5, 11. Pre-existing conditions, such as diabetes, hypertension, or asthma, may increase physiological vulnerability to air pollutants and thus amplify health risks, independent of pollution levels. Access to healthcare services, including prenatal checkups and mental health support, can also moderate the impact of air pollution but was rarely accounted for in the reviewed studies. Furthermore, differences in maternal education and health literacy influence how well mothers can avoid or respond to pollution exposure, particularly in high-risk environments7, 21, 22. Failure to consistently adjust for these variables may result in either an overestimation or underestimation of the true effects of air pollution. Therefore, future studies should incorporate these factors through robust multivariate analyses or matched-cohort designs to isolate the direct impact of air pollution with greater accuracy12, 21.
Mean Age of Pregnant Women
The mean age of pregnant women varies significantly across studies and plays a crucial role in the physical and psychological effects of air pollution. In most studies, the mean age is approximately 26.9 years, which is considered a critical period for the psychological and physical development of pregnant women. Women who become pregnant at this age may face unique challenges such as hormonal changes and social pressures, which can increase the risk of psychological issues5, 6.
In some studies, the mean maternal age ranged from 26.87 to 33 years, with others reporting an average of 29. These data suggest that pregnancy is more common among younger women, although factors such as economic status, education, and cultural attitudes may influence this trend7, 19. Additionally, research has shown that younger women are more affected by air pollution, emphasizing the importance of considering maternal age in studies on the effects of air pollution22.
Some studies have specifically examined the mean age of mothers within groups that are affected by certain conditions. For instance, one study reported a mean maternal age of 25.4, with 48.7% under 25 and 36.6% over 25 2. Another study highlighted differences in the mean age of mothers with conditions such as PCOS or gestational diabetes mellitus (GDM); for example, the mean age of women with PCOS was approximately 29.49 compared to 32.46 for those without PCOS60. Women aged > 35 years are also at higher risk of conditions such as GDM or preeclampsia25, 41.
Overall, studies indicate that the average age of pregnant women generally falls between 25 and 35 51. However, variations across studies highlight the influence of factors such as socioeconomic status, education level, and environmental conditions on this metric. Furthermore, the association between advanced maternal age and increased risk of preterm birth or pregnancy-related complications underscores the importance of considering maternal age in research on the physical and psychological effects of air pollution27. These findings suggest that maternal age is a critical variable that requires close attention in future studies regarding the impact of air pollution on pregnancy outcomes.
Factors Influencing Exposure
The exposure of pregnant women to PM2.5, PM10, and other air pollutants is influenced by a range of factors, including individual characteristics, socioeconomic conditions, geographical and environmental factors, and lifestyle behaviors. Studies have shown that air pollution, particularly from PM and volatile organic compounds (VOCs), can lead to physical and psychological health problems in pregnant women. These include an increased risk of anxiety disorders, depression, and even behavioral and cognitive disorders in children 5, 6.
Individual factors, such as maternal age, education level, socioeconomic status, and pre-pregnancy body mass index (BMI) are significant determinants of air pollution exposure. Younger women and those with lower educational levels are typically more affected by air pollution6. Behavioral habits, such as smoking or using polluting fuels for cooking, can also increase exposure to PM2.5. The use of solid fuels, such as coal or wood, in poorly ventilated indoor environments has been linked to reduced hemoglobin levels and a higher prevalence of anemia in pregnant women2, 34.
Geographical factors also play critical roles in PM exposure. Living near pollution sources, such as highways or industrial areas, significantly increases exposure levels22. In rural areas where open fires are often used for cooking or where homes lack proper ventilation, indoor PM2.5 concentrations can be particularly high 38, 69. Regression models estimating exposure based on participants' residential addresses have identified location and traffic density as key determinants of pollution levels 7.
Socioeconomic conditions further influenced PM exposure. Pregnant women living in poverty or income inequality are often more exposed to air pollution because of limited access to healthcare services and residence in areas with poorer air quality14. Additionally, low socioeconomic status can exacerbate psychological stress from family problems or a lack of social support, compounding the physical and mental effects of air pollution21.
Overall, the factors influencing PM exposure represent a complex interplay of individual, environmental, and socioeconomic variables that directly or indirectly affect the physical and mental health of pregnant women. These findings highlight the need for policies aimed at reducing pollution sources, improving the living conditions of pregnant women, and providing socioeconomic support to mitigate the adverse effects of air pollution.
Conclusion
These studies demonstrate that air pollution has significant physical and psychological effects on pregnant women and their fetuses. Pollutants such as PM2.5, PM10, NO2, and O3 are specifically associated with an increased risk of mental health disorders, including depression, anxiety, autism spectrum disorders, and psychological stress, as well as physical complications, such as preterm birth, gestational diabetes, preeclampsia, anemia, respiratory issues, miscarriage, and congenital anomalies. Exposure to air pollution during pregnancy not only threatens maternal mental health but also affects fetal development by altering immune responses.
Research highlights that the second and third trimesters are the most sensitive periods to the adverse effects of air pollution. Socioeconomic factors also play a crucial role in the severity of these effects. Women living in low-income areas or with limited access to healthcare are at higher risk. Geographical location is another key factor; residing in densely populated urban areas or near pollution sources, such as highways, increases exposure levels. Seasonal variations also influence the severity of pollution effects, with PM2.5, having the most pronounced impact during winter months.
These findings emphasize the urgent need for preventive measures to reduce the exposure of pregnant women to air pollution. Environmental policies aimed at reducing pollutant emissions, improving urban air quality, increasing access to adequate healthcare services, and providing social and economic support to pregnant women should be prioritized. Public education on the risks of air pollution and strategies for minimizing exposure can also play a vital role in mitigating negative outcomes. Ultimately, ensuring clean air in the living environment of pregnant women must be a primary focus of public health policies to prevent physical and psychological complications and safeguard the health of future generations. Given the diversity in study designs, differences in study populations, and variations in exposure assessment methods, generalization of the findings from this systematic review should be approached with caution. The use of advanced analytical methods and meta-analyses in future studies provided that data homogeneity can contribute to more precise and reliable results.
Acknowledgement
The authors would like to thank Iranshahr University of Medical Sciences for supporting the study.
Conflict of Interest
The authors declare that they have no conflicts of interest.
Funding
This study did not receive any funding support.
Ethical Consideration
This study was conducted without ethical approval.
Code of Ethics
This review article is an independent scientific research and has not been registered as a university research project; nevertheless, all relevant research ethics principles have been duly respected.
Author's contributions
All the authors contributed equally to this article.
This is an Open-Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work for commercial use.
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Effects of Air Pollution on Mental Health
The results presented in Table 2 indicate that air pollution affects not only the physical health but also the mental health of pregnant women. Pollutants, such as NO2, PM2.5, and O3, are specifically associated with an increased risk of mental health disorders, including depression, anxiety, and autism spectrum disorders (ASD)6, 7. These findings highlight the critical need to improve air quality in the living environments of pregnant women and call for effective measures to reduce air pollution and support this vulnerable group in society6, 7.
Effects on the Fetus
Studies have shown that air pollution can have varying effects on the fetus during different trimesters of pregnancy. In particular, the second trimester has been identified as a sensitive period for fetal brain development. Exposure to air pollution during this phase has been linked to future cognitive and behavioralproblems6, 7. Additionally, psychological stress caused by air pollution can negatively affect fetal growth. Research indicates that women exposed to high levels of air pollution are more likely to have fetuses with growth impairments and behavioral disorders 5.
Geographical Context
Geographical location, particularly in low- and middle-income countries (LMICs), can profoundly affect the mental health of pregnant women. In these regions, urban air pollution is mainly driven by industrialization, and heavy traffic places pregnant women at a heightened risk. Additionally, poor environmental conditions and limited access to green spaces exacerbate psychological problems. Pregnant women in these areas often face greater socioeconomic challenges, which can further contribute to mental health problems6, 22.
Some studies have focused on urban areas, such as Seoul and Los Angeles, where high population density and heavy traffic significantly increase air pollution levels. In Los Angeles, many participants were from low-income communities, highlighting their increased vulnerability to pollution5, 19. Furthermore, research conducted in South Africa and Massachusetts identified proximity to highways and use of alternative fuels as risk factors for pregnant women20, 22.
Effects of Air Pollution on Physical Health
The results presented in Tables 3 and 4 demonstrate that air pollution significantly affected the physical health of pregnant women. Pollutants, such as NO2, PM2.5, PM10, and O3, are specifically associated with an increased risk of physical conditions, including respiratory problems, preterm birth, infertility, and preeclampsia. Additionally, air pollution can lead to increased oxidative stress and inflammation in the mother's body, which can adversely affect fetal health. These findings underscore the urgent need to focus on improving air quality in the living environment of pregnant women and implementing effective measures to reduce air pollution exposure.
Effects on the Fetus
Research indicates that the impact of air pollution on the fetus varies across different stages of pregnancy, with potentially serious consequences for both maternal and fetal health. During the first trimester, the fetus is highly dependent on maternal thyroid hormones, and any disruption in these hormones can significantly affect fetal growth and development45. Exposure to PM2.5 during this period is directly linked to an increased risk of gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP), with a reported relative risk (RR) of 3.89 (95% CI: 1.45–10.43)15. Additionally, a 26% increase in congenital anomalies has been observed for every 7.23 µg/m³ rise in PM2.5 concentration54. Thus, this period is recognized as a critical window for the adverse effects of air pollution.
In the second trimester, the effects of PM2.5, and NO2 become more pronounced, particularly concerning maternal and fetal health. PM2.5, during this phase, is strongly associated with an increased risk of HDP and preterm birth32, 50. This stage is also linked to a higher likelihood of fetal anomalies and growth impairments due to elevated concentrations of NO₂ and PM2.519.
Although the effects of air pollution remain significant in the third trimester, they are particularly evident in the reduced estimated glomerular filtration rate (eGFR) and increased risk of anemia in pregnant women24, 56. Moreover, the highest risk for preterm birth is associated with cumulativePM2.5exposurethroughout pregnancy14. These effects can lead to severe complications, such as preterm delivery and low birth weight.
Overall, the most substantial effects of air pollution were observed during the first and second trimesters, which are critical periods for fetal growth and development. Exposure during these sensitive windows increases the risk of complications such as GDM, HDP, congenital anomalies, preterm birth, and growth impairments19, 45, 50.
It is important to note that there is considerable heterogeneity among the studies included in this systematic review. Differences in study design (e.g., cohort vs. case-control), population characteristics (e.g., maternal age, socioeconomic status, and underlying health conditions), and methods of exposure assessment (e.g., direct environmental monitoring, satellite-based estimates, or self-reported data) may significantly influence the reported outcomes. For instance, while some studies estimated PM2.5 concentrations using modeling techniques, others relied on stationary air quality monitoring stations or participant surveys. Additionally, the timing and duration of exposure assessment (e.g., a specific trimester vs. the entire pregnancy) varied across studies, which could explain some inconsistencies in the results.10, 14, 67
Therefore, these differences should be carefully considered when interpreting the overall findings as they may affect the strength and generalizability of the associations between air pollution and pregnancy outcomes.
Geographical Context
Research has shown that the incidence of anemia in pregnant women is significantly higher in countries with severe air pollution. India has the highest prevalence, with 51.8% of pregnant women affected, followed by Peru (26.5%), Rwanda (15.4%), and Guatemala (6.3%). The primary cause of this condition is air pollution resulting from the use of biomass fuels for cooking and heating, which is strongly associated with exposure to PM2.5) and carbon monoxide (CO)2. Women residing in urban areas, particularly in Los Angeles, are exposed to higher levels of PM2.5, owing to traffic and industrial emissions16. In Nepal, urban residency has been linked to adverse effects on birth weight17.
In China, the highest prevalence of autoimmune thyroid disorders has been observed among women with annual incomes below $27,597 USD, highlighting the relationship between economic status and health outcomes44. Similarly, Daegu, South Korea, reported the highest incidence of autoimmune diseases in the region54. Studies conducted in major industrial cities, such as Shanghai and Beijing, have revealed that air pollution from industrial activities and traffic is particularly severe in these areas15. In Lima, the eastern regions with unique geographical conditions and the highest PM2.5 concentrations also reported the highest prevalence of anemia42.
Poland accounts for 36 of the 50 most polluted cities in the European :union: owing to its dense industrial activity and reliance on fossil fuels49. In California, poverty and socioeconomic inequalities are major contributors to the increased risk of preterm birth in polluted regions14. Additionally, rural areas such as Butajira in Ethiopia face heightened pollution levels due to poor socioeconomic conditions and reliance on polluting fuels, exacerbating health risks for pregnant women35.
Economy and Income
Economic status and income play critical roles in the severity of the physical and psychological effects of air pollution on pregnant women. Studies indicate that pregnant women living in poor economic conditions are more likely to experience psychological stress, which may stem from limited access to adequate healthcare, lack of supportive resources, and financial concerns. Financial crises and economic insecurity often lead to feelings of hopelessness and an inability to meet their own and their fetuses’ needs, increasing the risk of anxiety disorders and depression during pregnancy22.
Even among women with relatively higher incomes, such as those earning more than $2,738.59 per month, approximately 50% reported annual incomes below $30,000, reflecting the existing economic challenges5, 19. Additionally, 35.6% of the mothers relied on public insurance, highlighting their middle or low economic status7. Pregnant women living in lower-income areas are generally exposed to higher levels of air pollution, underscoring the socioeconomic disparities in air pollution exposure3. Furthermore, the average household income in regions with higher rates of preterm births is lower than that in areas with normal deliveries14.
Low economic status not only increases pregnant women’s exposure to air pollution but also limits their access to medical services. This situation leads to greater reliance on polluting fuels, which increases the risk of diseases such as anemia24. Conversely, women with higher incomes and better access to healthcare were able to mitigate the negative effects of air pollution. For instance, 67.2% of women with annual incomes exceeding $6,870 or those with university education reported better physical and mental health outcomes43, 50.
In summary, economic status is a key determinant of the severity of the physical and psychological effects of air pollution in pregnant women. Women living in poor economic conditions face simultaneous challenges from financial stress and the physical impact of exposure to air pollution.
Another important limitation of the included studies is the limited consideration of individual-level confounding factors that may have significantly influenced the observed associations between air pollution and pregnancy outcomes. For instance, maternal smoking, dietary habits, physical activity, and alcohol consumption can independently affect fetal development and may correlate with environmental exposure levels5, 11. Pre-existing conditions, such as diabetes, hypertension, or asthma, may increase physiological vulnerability to air pollutants and thus amplify health risks, independent of pollution levels. Access to healthcare services, including prenatal checkups and mental health support, can also moderate the impact of air pollution but was rarely accounted for in the reviewed studies. Furthermore, differences in maternal education and health literacy influence how well mothers can avoid or respond to pollution exposure, particularly in high-risk environments7, 21, 22. Failure to consistently adjust for these variables may result in either an overestimation or underestimation of the true effects of air pollution. Therefore, future studies should incorporate these factors through robust multivariate analyses or matched-cohort designs to isolate the direct impact of air pollution with greater accuracy12, 21.
Mean Age of Pregnant Women
The mean age of pregnant women varies significantly across studies and plays a crucial role in the physical and psychological effects of air pollution. In most studies, the mean age is approximately 26.9 years, which is considered a critical period for the psychological and physical development of pregnant women. Women who become pregnant at this age may face unique challenges such as hormonal changes and social pressures, which can increase the risk of psychological issues5, 6.
In some studies, the mean maternal age ranged from 26.87 to 33 years, with others reporting an average of 29. These data suggest that pregnancy is more common among younger women, although factors such as economic status, education, and cultural attitudes may influence this trend7, 19. Additionally, research has shown that younger women are more affected by air pollution, emphasizing the importance of considering maternal age in studies on the effects of air pollution22.
Some studies have specifically examined the mean age of mothers within groups that are affected by certain conditions. For instance, one study reported a mean maternal age of 25.4, with 48.7% under 25 and 36.6% over 25 2. Another study highlighted differences in the mean age of mothers with conditions such as PCOS or gestational diabetes mellitus (GDM); for example, the mean age of women with PCOS was approximately 29.49 compared to 32.46 for those without PCOS60. Women aged > 35 years are also at higher risk of conditions such as GDM or preeclampsia25, 41.
Overall, studies indicate that the average age of pregnant women generally falls between 25 and 35 51. However, variations across studies highlight the influence of factors such as socioeconomic status, education level, and environmental conditions on this metric. Furthermore, the association between advanced maternal age and increased risk of preterm birth or pregnancy-related complications underscores the importance of considering maternal age in research on the physical and psychological effects of air pollution27. These findings suggest that maternal age is a critical variable that requires close attention in future studies regarding the impact of air pollution on pregnancy outcomes.
Factors Influencing Exposure
The exposure of pregnant women to PM2.5, PM10, and other air pollutants is influenced by a range of factors, including individual characteristics, socioeconomic conditions, geographical and environmental factors, and lifestyle behaviors. Studies have shown that air pollution, particularly from PM and volatile organic compounds (VOCs), can lead to physical and psychological health problems in pregnant women. These include an increased risk of anxiety disorders, depression, and even behavioral and cognitive disorders in children 5, 6.
Individual factors, such as maternal age, education level, socioeconomic status, and pre-pregnancy body mass index (BMI) are significant determinants of air pollution exposure. Younger women and those with lower educational levels are typically more affected by air pollution6. Behavioral habits, such as smoking or using polluting fuels for cooking, can also increase exposure to PM2.5. The use of solid fuels, such as coal or wood, in poorly ventilated indoor environments has been linked to reduced hemoglobin levels and a higher prevalence of anemia in pregnant women2, 34.
Geographical factors also play critical roles in PM exposure. Living near pollution sources, such as highways or industrial areas, significantly increases exposure levels22. In rural areas where open fires are often used for cooking or where homes lack proper ventilation, indoor PM2.5 concentrations can be particularly high 38, 69. Regression models estimating exposure based on participants' residential addresses have identified location and traffic density as key determinants of pollution levels 7.
Socioeconomic conditions further influenced PM exposure. Pregnant women living in poverty or income inequality are often more exposed to air pollution because of limited access to healthcare services and residence in areas with poorer air quality14. Additionally, low socioeconomic status can exacerbate psychological stress from family problems or a lack of social support, compounding the physical and mental effects of air pollution21.
Overall, the factors influencing PM exposure represent a complex interplay of individual, environmental, and socioeconomic variables that directly or indirectly affect the physical and mental health of pregnant women. These findings highlight the need for policies aimed at reducing pollution sources, improving the living conditions of pregnant women, and providing socioeconomic support to mitigate the adverse effects of air pollution.
Conclusion
These studies demonstrate that air pollution has significant physical and psychological effects on pregnant women and their fetuses. Pollutants such as PM2.5, PM10, NO2, and O3 are specifically associated with an increased risk of mental health disorders, including depression, anxiety, autism spectrum disorders, and psychological stress, as well as physical complications, such as preterm birth, gestational diabetes, preeclampsia, anemia, respiratory issues, miscarriage, and congenital anomalies. Exposure to air pollution during pregnancy not only threatens maternal mental health but also affects fetal development by altering immune responses.
Research highlights that the second and third trimesters are the most sensitive periods to the adverse effects of air pollution. Socioeconomic factors also play a crucial role in the severity of these effects. Women living in low-income areas or with limited access to healthcare are at higher risk. Geographical location is another key factor; residing in densely populated urban areas or near pollution sources, such as highways, increases exposure levels. Seasonal variations also influence the severity of pollution effects, with PM2.5, having the most pronounced impact during winter months.
These findings emphasize the urgent need for preventive measures to reduce the exposure of pregnant women to air pollution. Environmental policies aimed at reducing pollutant emissions, improving urban air quality, increasing access to adequate healthcare services, and providing social and economic support to pregnant women should be prioritized. Public education on the risks of air pollution and strategies for minimizing exposure can also play a vital role in mitigating negative outcomes. Ultimately, ensuring clean air in the living environment of pregnant women must be a primary focus of public health policies to prevent physical and psychological complications and safeguard the health of future generations. Given the diversity in study designs, differences in study populations, and variations in exposure assessment methods, generalization of the findings from this systematic review should be approached with caution. The use of advanced analytical methods and meta-analyses in future studies provided that data homogeneity can contribute to more precise and reliable results.
Acknowledgement
The authors would like to thank Iranshahr University of Medical Sciences for supporting the study.
Conflict of Interest
The authors declare that they have no conflicts of interest.
Funding
This study did not receive any funding support.
Ethical Consideration
This study was conducted without ethical approval.
Code of Ethics
This review article is an independent scientific research and has not been registered as a university research project; nevertheless, all relevant research ethics principles have been duly respected.
Author's contributions
All the authors contributed equally to this article.
This is an Open-Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work for commercial use.
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Type of Study: Systematic Review |
Subject:
Air and waste management
Received: 2025/03/17 | Accepted: 2025/05/20 | Published: 2025/06/29
Received: 2025/03/17 | Accepted: 2025/05/20 | Published: 2025/06/29
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