Knowledge and Risk Perception of Betel Nut with Tobacco Chewing during Pregnancy and Breastfeeding among Women in Palau

Background/Purpose:  Betel nut with tobacco chewing is highly prevalent in the Republic of Palau, even amongst pregnant women. Clinical records showed 76% of Palauan women chew betel nut with tobacco while pregnant and the odds of delivering a full-term low birthweight infant were marginally higher for women who chewed betel nut with tobacco during pregnancy (adjusted Odds Ratio=2.4; 95%CI: 1.0-6.0, p = 0.049) compared to women who did not.  With such high prevalence of use, and potential risk of adverse birth outcomes, we conducted a survey to explore knowledge, risk perceptions, and reasons for use of betel nut with tobacco during pregnancy and breastfeeding.

Methods: We conducted a cross-sectional study among a convenience sample of women ages 18-45 years from July 11, 2014 - September 24, 2014 (N = 1,345) representing 40% of women in Palau. Women were recruited via radio and print announcements and in neighborhoods and workplaces. Interviews were in person. Descriptive statistics were performed only on Palauan respondents [ever and not ever pregnant] (n= 909).

Results/Outcomes: Among reproductive-age Palauan respondents who have ever been pregnant (N = 617), 69.4% used tobacco during their most recent pregnancy.  Among those who breastfed, 71.3% used tobacco. Among respondents who used tobacco while pregnant or breastfeeding, the majority of tobacco use was betel nut with tobacco chewing (98.4% and 99.0%, respectively).  Among all reproductive-age respondents, cigarette smoking was reported as more harmful than betel nut with tobacco chewing during pregnancy (97.1% and 73.5%, respectively). Similarly for breastfeeding, 94.3% reported cigarette smoking as very harmful, while 68.7% thought betel nut with tobacco chewing was harmful.  Among all reproductive-age respondents who used betel nut with tobacco chewing during pregnancy and breastfeeding, the most commonly reported reasons for use were: addiction/habit (38.9%); stimulant effects (22.0%); and culture/family pressure (11.3%).

Conclusion: Chewing betel nut with tobacco during pregnancy and breastfeeding was highly prevalent among a convenience sample of ever pregnant Palauan women.  The majority of all reproductive-aged respondents were aware that betel nut with tobacco chewing during pregnancy and breastfeeding is harmful, but reasons for use included nicotine dependence, stimulant effects, and cultural factors.