{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T19:07:32Z","timestamp":1782846452108,"version":"3.54.5"},"reference-count":63,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Public Health Surveill"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n \n Ambient ozone (O\n 3<\/jats:sub>\n ) exposure has been found to be associated with gestational hypertension, which, in turn, increases the risk of term low birth weight (LBW). As such, gestational hypertension acts as a potential mechanism mediating restricted fetal growth; however, few epidemiological studies have quantified this specific mediation pathway.\n <\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n \n This study aims to examine whether gestational hypertension serves as a mediator of the association between prenatal O\n 3<\/jats:sub>\n exposure and term LBW.\n <\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We conducted a population-based cohort study using the Cheeloo Lifespan Electronic Health Research Data-library, including 3,394,739 singleton term live births in Shandong Province, China, from January 1, 2016, to December 31, 2022. We used high-resolution spatiotemporal models based on residential addresses for exposure assessment. In addition to term LBW, we examined term small for gestational age (SGA) to capture fetal growth restriction while accounting for gestational age at birth. Given the low prevalence of these outcomes, we used logistic regression models where odds ratios approximated relative risks. A 4-step mediation analysis using logistic regression was conducted, followed by a counterfactual-based causal mediation analysis, to test the mediating role of gestational hypertension.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n The mean (SD) O\n 3<\/jats:sub>\n concentration was 113.90 (13.03) \u03bcg m\n \u20133<\/jats:sup>\n . Each IQR increase in O\n 3<\/jats:sub>\n was positively associated with the risks of term LBW (relative risk 1.055, 95% CI 1.034-1.077) and term SGA (relative risk 1.037, 95% CI 1.026-1.048). Using the traditional approach, gestational hypertension mediated 19.94% of the risk for term LBW and 13.41% for term SGA. Under the counterfactual framework, the contribution rates were 38.82% (term LBW) and 19.96% (term SGA) when excluding exposure-mediator interaction, and 35.15% (term LBW) and 18.82% (term SGA) when accounting for such interaction.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n \n Our findings showed that gestational hypertension was a significant mediator of the association between O\n 3<\/jats:sub>\n exposure and risks of term LBW. Consequently, a multitiered strategy\u2014encompassing stricter air quality standards, integrating O\n 3<\/jats:sub>\n risk education into routine prenatal care, and taking proactive measures to minimize personal exposure\u2014is essential to prevent potential adverse impacts on developing fetuses and mothers.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/81412","type":"journal-article","created":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T20:45:01Z","timestamp":1775681101000},"page":"e81412-e81412","source":"Crossref","is-referenced-by-count":0,"title":["Gestational Hypertension as a Mediator of Prenatal Ozone Exposure and Term Low Birth Weight: Birth Cohort Study"],"prefix":"10.2196","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-6317-3816","authenticated-orcid":false,"given":"Yuxin","family":"Zhang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-8534-3953","authenticated-orcid":false,"given":"Quanjun","family":"Liu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-2770-2319","authenticated-orcid":false,"given":"Mengwei","family":"Song","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-4443-3512","authenticated-orcid":false,"given":"Qiulin","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2838-2183","authenticated-orcid":false,"given":"Qingbo","family":"Zhao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-9279-5206","authenticated-orcid":false,"given":"Qingqing","family":"Tao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-3738-0070","authenticated-orcid":false,"given":"Chenchen","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8633-8859","authenticated-orcid":false,"given":"Qin","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3997-6767","authenticated-orcid":false,"given":"Qing","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2026,4,8]]},"reference":[{"issue":"10389","key":"R1","doi-asserted-by":"publisher","first-page":"1692","DOI":"10.1016\/S0140-6736(23)00354-9","article-title":"Small vulnerable newborns-big potential for impact","volume":"401","author":"Ashorn","journal-title":"Lancet"},{"issue":"9755","key":"R2","doi-asserted-by":"publisher","first-page":"1853","DOI":"10.1016\/S0140-6736(10)61461-4","article-title":"Causes of neonatal and child mortality in India: a nationally representative mortality survey","volume":"376","author":"Million Death Study Collaborators","journal-title":"Lancet"},{"issue":"9890","key":"R3","doi-asserted-by":"publisher","first-page":"417","DOI":"10.1016\/S0140-6736(13)60993-9","article-title":"Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis","volume":"382","author":"Katz","journal-title":"Lancet"},{"issue":"s446","key":"R4","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1111\/j.1651-2227.2004.tb00236.x","article-title":"The developmental origins of chronic adult disease","volume":"93","author":"Barker","journal-title":"Acta Paediatr"},{"key":"R5","doi-asserted-by":"publisher","DOI":"10.3389\/fmed.2021.793990","article-title":"Low birthweight as a risk factor for non-communicable diseases in adults","volume":"8","author":"Bianchi","journal-title":"Front Med (Lausanne)"},{"key":"R6","doi-asserted-by":"publisher","DOI":"10.12715\/apr.2014.1.2","article-title":"Population attributable risks of neurobehavioral disorders due to low birth weight in US children","volume":"1","author":"Ha","journal-title":"Adv Pediatr Res"},{"issue":"10","key":"R7","doi-asserted-by":"publisher","first-page":"1078","DOI":"10.1164\/rccm.200610-1441OC","article-title":"Respiratory symptoms in the first 7 years of life and birth weight at term: the PIAMA Birth Cohort","volume":"175","author":"Caudri","journal-title":"Am J Respir Crit Care Med"},{"issue":"1","key":"R8","doi-asserted-by":"publisher","first-page":"134","DOI":"10.3945\/an.114.007781","article-title":"World Health Organization. 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