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APPENDIX A Risk Factors Associated with Low Birthweight The following chart lists the major risk factors for low birth- weight and notes (with an "x. ~ whether an individual factor has been associated with intrauter ine growth retardation (IUGR), preterm delivery (PTD) or both; or whether it has been linked only to low birthweight, not further specified (LBW). In some instances, a factor has been linked to all three outcome measures; in others, the association is with only one or two. For some of these factors, the committee was able to locate r elative and attr ibutable r isk values; * these appear on the char t under the headings RR and AR, respectively. In general, relative risk values were recorded only if at least one value of 1.8 or greater was found in the articles reviewed, although several values less than 1.8 that are drawn from Chapter 3 are noted on the chart. Attributable risks were recorded whenever a number was located. The control variables used by var. ious studies in computing the relative and attr ibutable r isks are not listed ; nor, in most instances , are the character istics of the populations from which the data were gathered. Documentation justifying the presence of a given factor on the chart is drawn either from the articles providing the RR or AR values, or from the data presented in Chapters 2 and 3. For those factors that have no RR or AR values on the chart and that are not discussed in Chapters 2 or 3, a reference Is provided. Reference numbers appear in parentheses, corresponding to the citations following the chart. Following the references and notes to the appendix is a list of several additional articles that discuss the risk factors associated with preterm delivery, IUGR, or both. *Chapter 1 contains a definition of relative risk and attributable risk. 241

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248 4~ s .,4 3 ~ V _ ~ C) _ ~ U] O ~ — ~ :> V ~ a v o C' C C - o Q] V V 3 ~5 Ll `4 V C -4 =: Y U] _ a: D: ~S Y ._. #5: ~: y - ~: U] o v y ~Q - 0 E Q o . - C) o 02 o :> o? X X X - N - o . X X X X X X X X X X X X ~0 ~ ~ ' sq 3 ~ E ~ ~ ~ V 3 U) `4 ~ ~J ~5 N ˇa u~ ~s v ~ ~ E ˇ ' ~ tn C rn re ~ ~ Y ~ ~ V C RS U} _t N ~ ' - ~ C ~ ~ 0 ~ O —~ C ~ ~ V ~ N A5 C O ~ ~ C O ~ ~ t) U) ~ C ~ ~ '— C ˘5 _ _ O ~ ~ ~ C ~ ~ ~ ~ ' - C ^ — — cn — ~ O ˇ - E c rl V o 0 ~ L. 0 ~ 0 _ c ~ ~ ~ a, n5 ~ C O ~ ~ _ ~ E c 3 ~ E n ~ c, ~ 3 ~ C.) ~ G. O — ~ v ~n 0 0 O eq C) Q. ~ ~ ~ ~ O c — ~ ~ ~ V V _ ~ ~ ~ ~ ~ C.) ~ :> 0 ~ ~ ~ ~— ~ ~ 0 ~ V CO ~ ~ ~ ~ :> ~ ˇ S~ ~ ~ ~ ~ C :>~ ns ~ ~ C >c ~ ~l o ~ c c 3 _ ~ ~ ~ V S -~ ~ — O ~ dJ 415 V Q O ~ C) ~ ~ ~ C) ~ Q~ ~ 00 C 04 V ~4 ~ C.) ~ ~ ~ `4 V ~ _ V X O ~ O V ˇ - ~ ~ ~ ~ ~ O ~ O ~ V ~ ~ ~ O 41.~ ~~~ ~ ~:: ~ ~ V ~ ~ ~ ~ C ~ 3 ~— ~o O C U' C ~. ~ ~ V V og V U' ~ V. - s ~ ~ V V U] S ~ V _ ~ 05 ~J' V V ~ ~ C) C 0~) ~ N V a, E V V C Q~ V ~ C ~ S 3 ~ ~ O ~ ~ ˇ— O —~ ~ 00 ~ 3 ~ ~ ˇ-~ ~ ~ ~ G~ lU x ~J _~ v Q O —~ X 5k _~ ~ O ~ ~ _~ ~4 ~ v ~ J~ :~ ~ oo ~ C ~) a~ ~ ~ a~ 0 x 0 0 c c 0 ol U) ~ ~ Is; 3 ~ U) ~S U) ~ _~ ~ U] ~ 4) S~ _ tt5 ~ ~ U~ _ :> ˇ ˇ ˇ ˇ ˇ ~ - ~3 <:e m V C) ~ ~ ~ ~n - - C o V t) C as C P. v s ~ _ _ 3 ~n 4~ al c >. _ V V _ `:: O q~ E ~r q; - ' C~ C o ~, _ O V q~ _ C O ˇ C) ' C) U] C C _ - o' V s _ V o1 3 o s {Q v Ql ~ ~ _ ˇ~4 a~ Q ~4 ~ O O r~ ˇ — oo a, c

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249 References and Notes 1. Raltr eider DF and Kohl S: Epidemiology of preterm delivery. Clin. Obstet. Gynecol. 23:27-31, 1980. Rosen MG: The biological vulnerability of the low birthweight infant. In Infants at Risk for Developmental Dysfunction. Institute of Medicine, Pub. No. 82-001, Washington, D.C., 1982. 3. See Chapter 3, Tables 3.6-3.8 and 3.10-3.12. 4. Linn S. Schoenbaum SC, Monson RR, Rosner R. Stubblefield PG, and Ryan KJ: The association of marijuana use with the outcome of pregnancy. Am. J. Public Health 73:1161-1164, 1983. ~ Prevention of preterm labor. Clin. Johnson JWC and Dubin NH. Obstet. Gynecol. 23:51-73, 1980. Mahan CS: New strategies for Dre~rentina an old Problem: Low birthweight. J. Fla. Med. _ Assoc. 70:722-727, 1983. 7. Sokol RJ: Clinical risks and laboratory evaluations of intrauterine growth retardation. National Institute of Child Health and Human Development Workshop on Intrauterine Growth Retardation, July 17-20, 1983. National Institutes of Health, Bethesda, Md. 8. Scott A, Moar V, and Ouns ted M: The relative contribution of different maternal factors in small-for-gestational-age pregnancies. Eur . J. Obstet. Gynecol. Reprod. Biol. 12 :157-265, 198 1. 9. Taffel SM and Reppel RG: I - lications of mother's weight gain on the outcome of pregnancy. Paper presented at the American Statistical Association meeting, Philadelphia, Pa., August 13-16, 1984. Forthcoming in Proceedings of the American Statistical Association, Winter, 1984-1985. 10. Butler N: Risk factors in human intrauterine growth retardation. In Size at Birth, Cuba Foundation Symposium 27, pp. 379-382. Amsterdam: Associated Science Publishers, 1974 . 11. Bakketeig LS, Hoffman HJ, and Harley BE: The tendency to repeat gestatzonal age and birthweight in successive births. Am. J. Obstet. Gynecol. 135:1086-1103, 1979. 12. Hemminki E and Starfield B: Prevention of low birthweight and pr~term birth. Milbank Mem. Fund Q. 56:339-361, 1978. 13. Br ear t G. Goujard J. Blondel B. Malllard F. Chavigny C, Sureau C, and Rumeau-Rouquette C: A comparison of two policies of ante-natal supervision for the prevention of prematur ity. Intern . J . Epidemiol. 10: 241-244, 1981. 14. Longo LD: Maternal blood volume and cardiac output during pregnancy: A hypothesis of endocrinologic control. Am. J. Physiol . 245: R720—R729, 1983 . Guyer B. Wallach LA, and Rosen SL: Birth-weight-standard~zed neonatal mortality rates and the prevention of low birth weight: How does Massachusetts compare with Sweden? N. Engl. J. Med. 306: 1230-1233, 1982.

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250 16. Marbury MC, Linn S. Monson R. Schoenbaum S. Stubblefield PG, and Ryan RJ: The association of alcohol consumption with outcome of pregnancy. Am. J. Public Health 73:1165-1168, 1983. 17. Gortmaker SL: The effects of prenatal care upon the health of the newborn. A]n. J. Public Health 69: 653-660, 1979. 18. Herbst AL, Hubby MM, Azizi F. and Makii ~M: Reproductive and gynecologic surgical exper fence in diethylstilbestrol-exposed daughters. Am. J . Obstet. Gynecol . 141 :1019-1028, 1981. 19. Committee to Study the Prevention of Low B~rthweight: Genetic factors in low birthweight infancy. Unpublished paper by JL Simpson. Washington, D.C .: Institute of Medicine , 1984 . 20. National Center for Health Statistics: LOw Birthweight: United States, 1976. Factors Associated with Prepared by S Taffel. Vital and Health Statistics, Series 21, No. 36. DREW No. (PHS) 80-19lS . Public Health Service. Washington, D.C .: U. S . Government Pr inting Off ice, Apr il 1980 . 21. Moore LG , Rounds SS , Jahnigen D, Grover RF, and Reeves JT: Infant birthweight is related to maternal arterial oxygenation at high attitude. J. Appl. Physiol . 52: 695-699, 1982. 22. Committee to Study the Prevention of Low Birthweiaht: Prevention _ of low birthweight: Environmental and occupational factors. Unpublished paper by ~ Hunt. Washington, D.C.: Institute of Medicine, 1984. 23. Mills JL, Graubard BI, Harley EE, Rhoads GO, and Berendes HW: Maternal alcohol consumption and birthweight: How much drinking during pregnancy is safe? JAMA 252:1875-1879, 1984. 24. Fedrick J and Anderson ABM: Factors associated with spontaneous preterm birth. Br. J. Obstet. Gynaecol. 83:342-350, 1976. Galbra~th RS, Karchmar EJ, Piercy WN, and Low JA: The clinical prediction of intrauterine growth retardation. Am. J. Obstet. Gynecol. 133:281-286, 1979. Vienna NJ and Polan AR: Incidence of low birth weight among Love Canal residents. Science 226:1217-1219, December 7, 1984. Hackman E, Emanuel I, van Belle G. and Daling J: Maternal birthweight and subsequent pregnancy outcome. JAMA 250:2016-2019, 1983. Additional Reading on Risks Associated With Low Birthweight Bragonier JR, Cushner IM, and Hobel CJ: Social and personal factors in the etiology of preterm birth. In Preterm Birth: Causes, Prevention and Management, edited by F FUChS and PG Stubblefield. New Yor k: MacMillan, 19 8 3 . Fedrick J and Adelstein P: Factors associated with low birthweight of infants delivered at term. Br. J. Obstet. Gynaecol. 85:1-7, 1978. Huddleston JF: Preterm labor. Clin. Obstet. Gynecol. 25:123-136, 1982. Stickle G and Ma P: Some social and medical correlates of pregnancy outcome. Am. J. Obstet. Gynecol e 127 162-166 ~ 1977 ~

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2S1 Thomasson JE and Giles HR: Identif ication and management of intrauterine growth retardation. In Controversy in Obstetrics and Gynecology III, edited by FP Zuspan and CD Christian, pp. 247-252. Philadelphia: W.B. Saunders, 1983. Widness JA and Oh W: Intrauterine growth retardation: The current approach to perinatal diagnosis and management. In Controversy in Obstetrics and Gynecology III, edited by FP Zuspan and CD Christian, pp. 265-271, Phi ladelph~a: W.B. Saunders, 1983 .