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Indian Journal of Community Medicine

Maternal Health and Low Birth Weight among Institutional Deliveries

Author(s): Mohammad Zafar Idris, Anuradha Gupta, Uday Mohan, Anand Kumar Srivastava, Vinita Das*

Vol. 25, No. 4 (2000-10 - 2000-12)

Upgraded Deptt. of Community Medicine, *Deptt. of Obstetrics and Gynaecology, King George's Medical College, Lucknow

Abstract:

Research question: Whether incidence of low birth weight has declined, during last two decades?

Objective: To study the incidence of low birth weight and its association with maternal health correlates.

Study design: Cross-sectional study.

Predictor variables: Maternal diseases, nutrition, physical work, past obstetric complications, complications of pregnancy and utilization of ANC services.

Outcome variable: Birth weight of newborn.

Setting: Queen Mary Hospital; K.G. Medical College, Lucknow.

Participants: 889 mothers along with their 901 newborns.

Statistical analysis: Incidence rate, Z score, Population attributable risk.

Results: Overall incidence of low birth weight was 32.2% and mean birth weight 2669.7gms 447 S.D. High incidence of LBW was found to be significantly associated with maternal complications of current pregnancy, past obstetric history, maternal diseases, ANC status, dietary intake and nature of work during pregnancy.

Keywords: Maternal health, Low birth weight, Antenatal care, Dietary intake

Introduction:

Low birth weight is a major cause of infant mortality and is considered as a sensitive index of nation's health and development. A low birth weight infant is also at increased risk of being impaired physically or intellectually. The frequency of infants weighing 2500 gms. or less at birth has for a long served as one of the important indicators of quality of reproductive performance.

The incidence of LBW continues to be high in India, particularly in Hindi speaking states, despite adoption of Health Policy in 1983 for bringing it down to below 10 percent by the year 2000 under Health for All by Year 2000.

Studies conducted in the past have shown high prevalence of low birth weight in Lucknow. During past two decades, several intervention programmes including CSSM and RCH, have been launched all over the state to improve the health status of mothers and children. It was in this context, the present study was designed to find out the current status of incidence of LBW and associated maternal health factors in institutionally delivered newborns.

Material and Methods:

The present study was conducted at Queen Mary Hospital, attached to department of Obstetrics and Gynaecology of K.G. Medical College, Lucknow. The study population comprised of mothers along with newborns delivered at Queen Mary Hospital during study period. An appropriate sample of 934 mothers was to be drawn by systematic random sample method by including all the mothers delivering on alternate days during the months of August to April. Mothers were interviewed next day of delivery and the available health records were reviewed.

A pre-tested schedule was used to record the information regarding identification of mothers, their relevant bio-social variables, past obstetrical history, complications of pregnancy, illness during pregnancy, utilization of antenatal care, history of dietary intake and nature of physical activity during pregnancy, along with the birth weight and sex of new born. The information, thus collected, was analyzed and tested for statistical significance. Odds ratio and population attributable risk were calculated by considering the mothers having low birth weight delivery as cases and normal deliveries as control group.

Observations:

A total of 889 (95.1% of estimated) mothers along with their 901 newborn including 30(3.3%) stillborns, were included in the present study. 12(1.34%) mothers had twin deliveries.

Incidence of low birth weight:

Table I: Birth weight in relation to sex of newborn.

Birth weight (Grams) Male Female Total
No. (%) No. (%) No. (%)
<1000 0 (0) 1 (0.2) 1 (0.1)
1001-1500 6 (1.3) 5 (1.2) 11 (1.2)
1501-2000 22 (4.6) 25 (5.9) 47 (5.2)
2001-2500 113 (23.8) 118 (27.6) 231 (25.6)
2501-3000 234 (49.3) 198 (46.3) 432 (47.9)
3001-3500 87 (18.3) 73 (17.1) 160 (17.7)
Total 474 (52.6) 427 (47.4) 901 (100)
Mean birth weight 2691.7gms ± 444 S.D. 2645.6gms±451 S.D. 2669.7gms±447 S.D.

Overall mean birth weight was found to be 2669.7 gms. 447 S.D. 32.2% newborns were weighing 2500 grams or less. Among low birth weight babies, only 1(0.3%) was weighing less than 1000 grams while majority (79.6%) were in the weight group of 2001-2500 grams. Amongst normal birth weight babies, majority (70.7%) were in the weight group of 2501-3000 grams and only 3.1% were weighing more than 3500 grams. The difference between male and female infants was not significant.

Maternal Health and LBW:

Table II: Maternal health parameters and low birth weight.

Health parameters No. ofdeliveries Low birth weight Odds ratio p value/PAR*
No. (%)
Past adverse outcomes 259 (28.7%) 115 (44.4) 2.13 p<.01
Abortion/Miscarriage 82 26 (31.7) 1.23 NS
Still birth 21 14 (66.6) 5.23 p<.01
Neonatal death 44 23 (52.3) 2.92 p<.01
Previous LBW delivery 67 32 (47.7) 2.44 p<.01
Previous LSCS 32 13 (40.6) 1.82 NS
Others 13 7 (53.8) 2.67 p<.01
Normal 642 (71.3%) 175 (27.2) 1.00 15.5%
Maternal illness 109 (12.1%) 50 (45.8) 1.95 p<.05
Acute infection 18 12 (66.6) 4.60 p<.01
Chronic infections 07 3 (42.8) 1.72 p<.01
Severe anaemia 46 21 (45.6) 1.93 p<.01
Cardiovascular disorders 08 3 (37.5) 1.38 NS
Diabetes mellitus 15 5 (33.3) 0.50 NS
Others 15 6 (40.0) 1.53 p<.05
None 792 (87.9%) 240 (30.3) 1.00 17.3%
Complications of pregnancy 78 (8.6%) 47 (60.2) 3.61 p<.01
Pre-eclampsia/eclampsia 31 24 (77.4) 8.18 p<.001
Antepartum haemorrhage 15 9 (60.0) 3.58 p<.01
Rh incompatibility 13 6 (46.1) 2.04 NS
Hydramnios 7 3 (42.8) 1.79 NS
Malpresentations & others 12 5 (41.6) 1.70 NS
None 823 (91.4) 243 (29.5) 1.00 8.3%*
Utilisation of antenatal care
Adequate (>_3) 528 (58.6) 98 (18.5) 1.00 42.5%*
Inadequate (1-2) 261 (28.9) 129 (49.4) 4.28 p<.01
Nil (0) 112 (12.4) 63 (56.2) 5.64D p<.01
Total 901 290 (32.2) -

*Population attributable risk

1. Past obstetric history and LBW:

A total of 259 mothers (28.75%) had previous adverse obstetric history and 44.40% of them had LBW deliveries. The difference between normal history and history of still birth, neonatal death, previous LBW delivery was found to be statistically significant (z=3.94; p<.01, z=3.54; p<.01, z=3.4; p<.01 respectively).

2. Significant maternal illness during pregnancy and LBW:

A total of 109 mothers (12.1%) had significant illness during their pregnancy and 45.8% of them delivered LBW babies. Highest incidence (66.6%) of LBW was observed among mothers who had significant acute infection, followed by 45.6%, 42.8% and 37.5% among severely anaemic, with chronic infections and cardiovascular disorders respectively and was lowest (33.3%) in diabetic mothers. The difference between mothers with and without illness was statistically significant, (z=2.06, p<.05). The difference between infectious and non-infectious diseases was also found to be statistically significant (z=3.16, p<.01).

3. Complications of pregnancy and LBW:

8.6 percent mothers had some complications of pregnancy and the incidence of LBW amongst them was 60.26%. Toxaemia of pregnancy was associated with highest (77.42%) incidence of low birth weight followed by haemorrhage (60.0%), Rh incompatibility (46.15%), Hydramnios (42.86%) and malpresentations and others (41.6%). The difference between normal and complicated cases was found to be statistically significant (z=5.55, p<.05).

4. Utilization of antenatal care and LBW:

Highest incidence of low birth weight (56.25%) was observed in the mother who did not receive any antenatal care, followed by 49.43% in those taking inadequate care and the difference between the two groups was not found to be significant. The lowest incidence (18.56%) was observed among those availing adequate care and the difference between them and those availing irregular or no care was found to be statistically highly significant (z=9.01, p<.001).

Nutritional parameters and LBW:

Table III: Dietary intake, physical activity and LBW.

Nutritional parameters Deliveries Low birth weight incidence Relative risk p value/PAR*
No. (%) No. %
Additional dietary intake
None 278 (30.8) 104 (37.4) 2.1 p<.001
Inadequate 459 (50.9) 157 (34.2) 1.9 p<.001
Adequate 164 (18.2) 29 (17.6) 1.0 45.3%*
Physical activity during pregnancy
Sedentary 296 (32.9) 79 (26.6) 1.3 p<.01
Mild/normal 281 (31.2) 57 (20.3) 1.0 36.9%*
Moderate+ 324 (35.9) 154 (47.5) 2.3 p<.001
Total 901 290 (32.2) - -

*Population attributable risk.

1. Additional dietary intake during pregnancy and LBW:

The incidence of LBW was maximum (37.4%) among those taking no additional diet, followed by 34.2% among those taking inadequate additional diet, while it was lowest (17.6%) among mothers taking adequate additional diet during pregnancy. The difference between mothers taking adequate additional diet and those taking either inadequate or no additional diet was statistically highly significant (z=4.31, p<.001).

2. Physical activity during pregnancy and LBW:

The incidence of LBW was highest (47.5%) amongst mothers engaged in moderate to heavy activity, followed by those in sedentary activity (26.6%) and was lowest amongst those having normal or mild activity during their pregnancy. The difference between moderate to hard working mothers and either those engaged in sedentary or mild work was statistically highly significant (z=7.01, p<.001 and z=5.35, p<.001).

Discussion:

The incidence of LBW, was found to be high (32.2%). Overall, mean birth weight was 2669gms. 447 S.D. The incidence of LBW has shown a very disturbing increase during last twenty years when it was reported to be only 18.2% with mean birth weight of 2876.6 gms. by Azam et al (1980)1 and 23.1% by Krishnan et al (1988)2 from the same institution. Similarly, high incidence has also been reported by UNICEF-ICMR (1987)3 from slums and rural areas and Parmar et al (1987)4. However, comparatively lower rates have been observed by Lawolyn et al (1994)5 from Ibadan, Nigeria and Malvanker et al (1992)6 from Ahmedabad city. Past history of obstetric complications was found to be associated with increased incidence of LBW deliveries. These results are similar to those made by Malvanker et al (1992), who reported that poor obstetric history was an independent risk factor for both term and preterm LBW infants while Soltani et al (1991)7 observed that abnormal birth during previous pregnancy along with other factors were associated with LBW deliveries in subsequent pregnancies. Past history of adverse outcome was also found to be significantly associated with adverse outcome in the present pregnancy. Bukketia et al (1993)8, Luke et al (1993)9 and Raine et al (1994)10 have reported similar findings; signifying that women with previous history of complications and adverse outcome were more likely to have LBW deliveries in subsequent pregnancies. The relationship between maternal diseases and low birth weight is a controversial subject. Maternal diseases, both infectious and chronic diseases, in the present study, were found to be significantly associated with increasing incidence of LBW. Severe anaemia (Hb<7gm%) was found to be significantly associated with LBW. The role of severe anaemia in pre-maturity and low birth weight is well established3.

Mothers taking adequate additional diets were having significantly lower incidence of LBW in comparison to those either taking inadequate or no additional diet during their current pregnancy. These findings are similar to Raman et al (1981)11 and Bhatia et al (1983)12, both observed that the intrauterine growth improved significantly with increasing intake of calories in rural and urban pregnant women. Toxaemia of pregnancy was found to be associated with the maximum (77.4%) incidence of low birth weight and its association with low birth weight was highly significant. Deorari et al (1985)13 and Lin Rx (1993)14, observed that eclampsia and pre-eclampsia were the major risk factors associated with LBW. Moderate to heavy physical activity during pregnancy was significantly associated with low birth weight in the present study. These results conform to finding of UNICEF-ICMR (1987)3 and Pomerance et al (1974)15. Different authors have given different explanations, Pomerance et al (1974)15 and Naeye (1981)16 have observed that hard work in standing position and hot climate, reduces the placental blood flow. A significantly higher incidence of low birth weight was found among those mothers who received inadequate or no care at all, compared to those receiving adequate antenatal care. These findings are similar to those made by Soltani et al (1991)7 and Ferraz et al (1990)17.

Thus, the results of the present study reveal that the incidence of low birth weight is still high in the area and achievement of goal of less than 10 percent, set under the HFA by 2000 AD is still a distant dream. The control of associated risk factors, particularly, additional dietary intake (PAR=45.3%) and optimal utilization of antenatal care (PAR=42.5%) during pregnancy, need to be addressed on priority basis to achieve the target of 10% incidence of low birth weight.

References:

  1. Azam MA: Study of birth weight of children with special reference to maternal serum proteins. Thesis: Submitted to Lucknow University, Lucknow for Award of M.D. in Social and Preventive Medicine (1980).
  2. Krishnan V, Idris MZ, Srivastava VK, Bhushan V et al: High risk scoring and pregnancy outcome in institutional deliveries. Indian J Community Medicine, (1988) October, Vol XIII, No.4, 176-9.
  3. UNICEF-ICMR report: UNICEF project - 1984: Extracted from future 1986, 17: 53-7, Indian J Paediatrics, 1987; 801-18.
  4. Parmar VR, Bahl L, Sood KK, Randhawa I: Anthropometric measurement and prevalence of low birth weight in Himachal Pradesh. Indian Pediatr 1987; 24: S61-S65.
  5. Lawolyn TO: Maternal weight and weight gain in Africans: its relationship to birth weight. J Tropical Pediatr 1991; 37(4): 166-72.
  6. Malvanker DV, Gray RH, Trivedi CR: Risk factors for pre-term and term low birth weight in Ahmedabad, India. Int J Epidemiol 1992; 21(2): 263-72.
  7. Soltani MS, Guediche MN, Bachir A, Ghanem H et al: Factors associated with low birth weight in Tunisian Sahel. Arch Fr Pediatr 1991; 46(6): 405-6.
  8. Bakketeia LS, Yachen G, Hoffman HY, Lindmark G et al: Pregnancy risk factors for small for gestational age births among parous women. Int Scandinavia Acta Obstet Gynaec Scan 1993; 74(4): 273-9.
  9. Luke B, Williams C, Minoque J, Keith L: The changing pattern of infant mortality in the USA, The role of prenatal factors and their obstetrical influences. Int J Obstetrics Gynaecol 1993; 40(3): 199-212.
  10. Raine T, Powel S, Krohn MA: The risk of reporting low birth weight and role of prenatal care. J Obstet Gynaecol 1994; 84(4): 485-9.
  11. Raman L: Anaemia in pregnancy - Post Graduate Obstetric & Gynaecology, Madras, Orient Longman Publishers 1981; 20: 393-69.
  12. Bhatia BG, Banerjee M, Agrawal DK, Agrawal KN: Foetal growth-relationship with maternal dietary intakes. Ind J Pediatr 1983; 50: 113-20.
  13. Deorari AK, Paul VK, Singh M: Perinatal outcome in hypertensive diseases of pregnancy. Indian Pediatr 1985; 22: 877-81.
  14. Lin Rx: Maternal medical and obstetric complications are major risk factors for low birth weight. Chang Hua Fu Chan Ko Tsa China 1993; 28(1): 24-6.
  15. Pomerance JJ, Gluck L, Lynch A: Physical fitness in pregnancy - its outcome on pregnancy outcome. Am J Obstet Gynaecol 1974; 179: 867-76.
  16. Naeye RL: Nutritional/non-nutritional interaction that affect the pregnancy outcome. Am J Clin Nutr 1981; 34: 727-32.
  17. Ferraz EM, Ggray RH, Cunha TM: Determinant of preterm delivery and intrauterine growth retardation in North East Brazil. Int J Epidemiol 1990; 19(18): 101-8.
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