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Improving Birth Outcomes: Meeting the Challenge in the Developing World (2003)

Chapter: 6. The Problem of Low Birth Weight

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Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
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PART IV
Additional Causes of Neonatal Mortality and Morbidity

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Summary of Findings: The Problem of Low Birth Weight

  • Although reliable data on the magnitude and global distribution of low birth weight (LBW) are limited, it is estimated that approximately 16 percent of all neonates in developing countries weigh less than 2,500 grams at birth and that more than 20 million such infants are born each year.

  • LBW may result from intrauterine growth restriction (IUGR) or preterm delivery. In developing countries, gestational age is frequently not known, which makes it difficult to distinguish between these two conditions. Nonetheless, most LBW in developing countries appears to be disproportionately due to high rates of IUGR, rather than preterm birth. Current interventions are more effective for IUGR than preterm birth.

  • The least-developed countries have the highest rates of infant mortality and the highest rates of LBW. Since countries have been more successful in reducing infant mortality than LBW, future efforts should focus on reducing mortality in all neonates and infants regardless of their weight.

  • Poor nutritional status is the principal cause of IUGR in developing countries. Although clinical trials have shown that increasing the food intake of pregnant women increases fetal growth, public health programs on larger populations of women have not been more than minimally effective in reducing IUGR. Malaria prophylaxis and intensive smoking cessation programs have been effective in reducing IUGR.

  • For preterm birth, the leading causes are genitourinary infection, multiple birth, pregnancy-induced hypertension, and low prepregnancy weight. Additional risk factors include malaria and cigarette smoking. Antibiotic treatments of pregnant women appear to be effective for asymptomatic bacteriuria, are not clearly effective for bacterial vaginosis, and are not effective for trichomoniasis or chlamydia. Antihypertensive treatment has not been effictive in lowering the risks of IUGR or preterm birth. Malaria prophylaxis, intensive counseling on smoking cessation, and fish oil supplementation are effective. Where resources permit, women with documented cervical incompetence may benefit from a cerclage procedure.

  • Two strategies for reducing neonatal and infant mortality among LBW infants that do not depend on expensive care or technology include breastfeeding and/ or use of expressed breast milk and Kangaroo mother care.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

6
The Problem of Low Birth Weight

Although reliable data on the magnitude and global distribution of low birth weight (LBW, birth weight <2,500 grams) remain limited (de Onis et al., 1998a), World Health Organization estimates that more than 20 million LBW infants are born each year, affecting approximately 16 percent of all newborns in developing countries. LBW is an important risk factor for neonatal and postneonatal mortality. Moreover, LBW neonates who survive infancy are at increased risk for health, growth, and developmental problems, and those who are small for their gestational age may be predisposed to developing chronic adult disorders such as hypertension, type 2 diabetes, and heart disease.

This chapter reviews the prevalence, causes, and consequences of intrauterine growth restriction (IUGR) and preterm birth in developing countries and potential interventions for preventing these two types of LBW. It should be noted that most research on IUGR and preterm birth has been conducted in developed countries and thus may have limited programmatic and policy implications for low-resource nations. This chapter therefore emphasizes the need for studies that reflect the economic, nutritional, and cultural heterogeneity among developing countries, and in particular, those that differentiate between IUGR and preterm birth.

PATTERNS OF OCCURRENCE

In addressing the problem of LBW, it is necessary to distinguish LBW due to restricted fetal growth (IUGR) from that due to preterm birth (deliv-

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

ery <37 completed weeks of gestation) (Kramer, 1987). An infant may be LBW because (s)he is either born small for gestational age (SGA), a proxy for IUGR, or is born early (preterm birth).1 The distinction depends upon the infant’s gestational age, which is not known for many LBW infants born in developing countries. To address this problem, methods have recently been developed for estimating the magnitude of IUGR and preterm delivery where conventional diagnosis is impossible. Where the prevalence of LBW is very high, it is known that most LBW infants are growth-restricted rather than preterm (Villar and Belizan, 1982; de Onis and Habicht, 1996). WHO estimates that each year, 13.7 million infants are born with LBW at term (≥37 weeks), and as many as 30 million infants are born with IUGR (many of these IUGR infants weigh more than 2,500 g and are therefore not LBW). WHO also estimates that 6.8 million infants are born both preterm and LBW; this figure underestimates the total number of preterm births occurring annually, because it excludes the large fraction of mildly preterm infants (34-36 weeks) weighing ≥2,500 g at birth.

Table 6-1 summarizes data on the prevalence of LBW, IUGR, and preterm birth among countries participating in the WHO Collaborative Study of Maternal Anthropometry and Pregnancy Outcomes (World Health Organization, 1995). As seen in the table, the distribution of IUGR varies widely among developing countries. The greatest burden from this problem is borne by specific countries—those with limited resources, large populations, and high fertility rates. As many as 30-50 percent of infants born in South-Central Asia are IUGR, compared with 15-25 percent in Africa and 10-20 percent in Latin America (World Health Organization, 1995). In some developing countries, such as those on the Indian subcontinent, the majority of newborns suffer at least some degree of fetal growth restriction. Preterm birth rates vary less than IUGR rates. All of these rates should be interpreted cautiously, however, given the absence of universal birth registration and poor gestational age data in many developing countries.

In areas where scales are not available to determine birth weight, other newborn anthropometric measurements can provide useful information at the individual and population levels. Studies in various settings have evaluated the use of arm, chest, and calf circumferences as surrogate measures for birth weight, and in particular for identifying LBW infants (Raman et al., 1992; World Health Organization, 1993). Currently, WHO recommends the use of chest circumference; newborns with chest circumferences

1  

SGA is defined by WHO as a birth weight below the tenth percentile for gestational age based on the sex-specific reference by Williams et al. (1982). Some SGA infants are merely constitutionally small rather than truly growth-restricted. Conversely, some IUGR infants who would otherwise be constitutionally large do not meet standard criteria for SGA. Nonetheless, SGA is often used as a convenient proxy for IUGR.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

TABLE 6-1 Pregnancy Outcome Among Countries Participating in WHO Collaborative Study

Country

LBW

(% of live births)

IUGR

(% of live births)

Preterm Birth

(% of live births)

Argentina

6.3

9.7

7.2

China

4.2

9.4

7.5

Colombia

16.1

17.8

15.7

Cuba

8.1

14.7

7.2

Gambia

12.1

13.5

13.5

Guatemala

12.5

25.3

15.8

India (Pune)

28.2

54.2

9.7

Indonesia

10.5

19.8

18.5

Ireland

5.6

6.9

6.2

Malawi

11.6

26.1

8.2

Myanmar

17.8

30.4

24.6

Nepal (Rural)

14.3

36.3

15.8

Sri Lanka

18.4

34.0

14.0

Thailand

9.6

17.0

21.3

United Kingdom

6.2

12.3

4.6

US/CDC (Black)

10.6

11.2

16.6

US/CDC (Hispanic)

4.8

5.8

10.2

US/CDC (White)

6.0

6.9

9.3

Vietnam

5.2

18.2

13.6

 

SOURCE: World Health Organization, 1995.

<29 cm are designated as “highly at risk” and those with circumference ≥29 but <30 cm as “at risk” (World Health Organization, 1993).

CAUSES OF IUGR AND PRETERM BIRTH

The importance of a risk factor for either preterm birth or IUGR is a function of its associated relative risk, as well as the prevalence of exposure to that factor in a specific population setting (Kramer, 1987). As shown in Table 6-2, risk factors for IUGR in developing countries include low maternal prepregnancy weight or body mass index2 (BMI); low gestational weight gain; short maternal stature; pregnancy-induced hypertension; and, where prevalent, cigarette smoking and (for primiparae) malaria. Important causes of preterm delivery include genitourinary infection, multiple pregnancy, pregnancy-induced hypertension, low prepregnancy BMI, incompetent cervix, history of prior preterm birth, cigarette smoking (where prevalent), and

2  

BMI is a measure of nutritional status and is calculated as (wt in kg)/(ht2 in m2).

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

TABLE 6-2 Determinants of IUGR and Preterm Birth in Developing Country Settings (listed in decreasing order of importance)

IUGR

Preterm Birth

  • Low energy intake/gestational weight gain

  • Low pre-pregnancy body mass index

  • Short stature

  • Malariaa

  • Cigarette smokingb

  • Primiparity

  • Pregnancy-induced hypertension

  • Congenital anomalies

  • Other genetic factors

  • Genitourinary infection

  • Multiple birth

  • Pregnancy-induced hypertension

  • Low pre-pregnancy body mass index

  • Incompetent cervix

  • Prior preterm birth

  • Abruptio placentae

  • Strenuous work

  • Cigarette smokingb

aFor primiparae in malaria-endemic areas only.

bAssuming a prevalence of 10-20 percent.

SOURCE: Kramer and Victora, 2001.

strenous physical labor (Kramer, 1987; Kramer and Victora, 2001). Although pregnancy-induced hypertension and low prepregnancy BMI are highly prevalent in developing countries, the role of genital tract infection (the leading cause of preterm birth in developed countries) remains relatively unexplored in such settings.

Maternal undernutrition (characterized by low energy intake, low gestational weight gain, low prepregnancy BMI, and short stature) accounts for a large proportion of IUGR in developing countries. This is due to the high relative risk for IUGR associated with these factors, as well as their high prevalence. Mean values for these anthropometric factors are summarized in Table 6-3 for countries participating in the WHO Collaborative Study of Maternal Anthropometry and Pregnancy Outcomes (World Health Organization, 1995). Regardless of energy intake or weight gain during pregnancy, women in the lowest quartile of height have an odds ratio (OR) of 1.9 (95 percent confidence interval [CI] 1.8-2.0) of delivering an IUGR infant compared with those in the upper quartile. Similarly elevated risks are seen among those in the lowest quartile of prepregnancy BMI (OR = 1.8 [1.7-2.0]) or of weight gain (OR = 1.8 [1.5-2.2]) (World Health Organization, 1995). Adolescent girls with a low gynecological age (years after menarche) may be at particularly high risk for delivering a growth-restricted infant, possibly as a result of maternal/fetal competition for nutrients (Scholl et al., 1995), and should be considered as a high-risk subgroup in future studies.

Public health professionals have reported that women in developing countries are often reluctant to increase dietary intake during pregnancy,

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

TABLE 6-3 Maternal Anthropometric Measures (Means) Among Countries Participating in WHO Collaborative Study

Country

Height (cm)

Prepregnancy BMI

Weight gain (kg)

Argentina

157

22.4

10.8

Myanmar

151

19.8

China

160

19.5

11.7

Colombia

155

23.3

10.1

Cuba

157

21.8

4.6

Gambia

157

19.7

6.5

Guatemala

148

20.8

7.1

India (Pune)

150

18.3

Indonesia

149

20.2

Ireland

158

23.7

11.0

Malawi

155

21.0

4.7

Nepal (Rural)

150

19.5

Sri Lanka

150

18.8

Thailand

153

20.8

8.0

UK

159

22.2

11.6

US/CDC (Black)

162

23.1

13.5

US/CDC (Hispanic)

158

23.7

12.8

US/CDC (White)

163

22.6

14.4

Vietnam

152

19.6

5.6

 

SOURCE: World Health Organization, 1995.

and may even willfully restrict energy intake, in order to avoid delivery complications associated with a large infant (so-called “eating down”). This phenomenon has been documented in South India (Hutter, 1996), but there are few data to indicate how widespread such beliefs and practices are in developing countries, or the extent to which they can be changed through public health interventions. Clearly, more research is needed to know whether women’s reluctance to gain weight is justified and whether public health interventions can be developed that would improve fetal growth without jeopardizing maternal or fetal survival and well-being.

There is no doubt that maternal dietary intake influences fetal growth and that insufficient energy intake reduces fetal size. Perhaps the most dramatic evidence for this comes from the pregnancy experiences of women during the Dutch famine of 1944-1945. When energy rations were reduced from 1700 to 700 kcal/day for women in the third trimester of pregnancy, mean birth weight decreased by more than 300 g; there was no change in the mean length of gestation (Stein et al., 1975; Susser and Stein, 1994).

Few data have been published on the customary dietary intakes of pregnant women in developing countries. Available data—widely recognized as imprecise—suggest daily intakes averaging 1,500 kcal and ranging

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

TABLE 6-4 Reported Energy Intakes of Pregnant Women in Developing Countries

Source

Country

Energy Intake (kcal/d)

Prentice (wet season)

Gambia

1,350-1,450

Oomen and Malcolm

New Guinea

1,360

Gopalan

India

1,400

Venkatacnalam

India

1,410

Lechtig et al.

Guatemala

1,500

Gebre-Medhin and Gobezie

Ethiopia

1,540

Rajalakshmi

Ethiopia

1,540

Mora et al.

Colombia

1,620

Prentice (dry season)

Gambia

1,600–1,700

Arroyave

Guatemala

1,720

Maletnlema and Bavu

Tanzania

1,850

Demarchi et al.

Iraq

1,880

Bagchi and Bosc

India

1,920

Thanangkul and Amatyakul

Thailand

1,980

Mata et al.

Guatemala

2,060

 

SOURCES: Institute of Medicine, 1992; Whitehead and Paul, 1982; Prentice, 1980.

from 1,300 to 2,100 kcal/day (Table 6-4), as compared with an average of 2,000 kcal/day in industrialized countries. Whether these lower caloric intakes are inadequate is unclear, however.

Women in developing countries are typically shorter and lighter than women in industrialized countries and likely perform more physical labor. Observational studies in the Gambia report negative effects on fetal growth when limited food intake and strenuous physical activity are combined (Prentice et al., 1983). An observational study from Ethiopia found that women who did not perform strenuous work (housewives with domestic help or women with sedentary jobs) gained more weight during pregnancy and had heavier infants (among those born at term) than women engaging in more physically demanding work (Tafari et al., 1980). Similarly, a Guatemalan study reported that women with three or more children at home and no household help, as well as those employed in manual work outside the home, were at significantly higher risk for delivering an IUGR infant (Launer et al., 1990). Another observational study from Zaire (Manshande et al., 1987) found a positive association between both gestational age and birth weight (among female newborns only) and a longer maternal stay in a maternity rest home; however, this result could also reflect the simple fact that women who delivered later stayed longer in the rest home. Although pregnant women in developing countries are unlikely to greatly reduce their physical activity, additional research is needed to document the work burden of women in developing countries during pregnancy (Institute of Medi-

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

cine, 1992). Because of the strong potential for both confounding and selection bias in observational studies of physical activity, randomized trials would be very helpful in assessing the causal impact of reductions in physical work on pregnancy outcomes in developing countries.

As noted earlier, cigarette smoking is a strong risk factor for IUGR, and it is also a weaker but nonetheless important determinant of preterm birth (Kramer, 1987; Cnattingius and Haglund, 1997; Kyrklund-Blomberg and Cnattingius, 1998). Maternal smoking is an increasingly significant cause of IUGR in developing countries, rising in parallel with cigarette smoking in many areas. Table 6-5 presents the estimated prevalence of cigarette smoking among women aged 15 years or older in various regions of the world, ranging from about 26 percent of women in Eastern Europe and Central Asia to 1 percent of women in South Asia.

Heavy alcohol consumption is an established risk factor for a set of dysmorphic features known as fetal alcohol syndrome, of which IUGR is one component. Because few women consume alcohol at these levels, however, the overall (population-level) public health impact on IUGR is small (Kramer, 1987). Further study of the effects of lower levels of alcohol intake on fetal growth is needed (Lundsberg et al., 1997).

Malaria is a major cause of anemia and has been associated with reduced birth weight and with an elevated risk of IUGR in primiparous women, who make up 30-50 percent of pregnant women. WHO estimates that 30 million pregnancies occur each year in malaria-endemic regions of the world. In these areas, malaria constitutes a serious threat to maternal and fetal well-being.

Several studies from developed countries suggest that bacterial vaginosis, and perhaps other types of genital tract infection/colonization, may initiate spontaneous preterm labor and rupture of membranes (Hillier

TABLE 6-5 Prevalence of Smoking Among Women 15 Aged Years or Older by Region

Region

Prevalence (%)

East Asia and Pacific

4

Eastern Europe and Central Asia

26

Latin America and Caribbean

21

Middle East and North Africa

5

South Asia

1

Sub-Saharan Africa

10

World

12

 

SOURCE: World Bank, 1999.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

et al., 1995; Chaim et al., 1997). Studies from developing countries have tended to focus on the relationship between genital tract infection and fetal and/or early neonatal death (Naeye et al., 1977; Ross et al., 1982; Moyo et al., 1995; Osman et al., 1995), rather than its role in preterm birth.

The maternal environment plays a far larger role in fetal growth than do genetic factors (Walton and Hammond, 1938; Brooks et al., 1995), especially in developing countries (Kramer, 1987). Congenital anomalies are strongly associated with IUGR (Khoury et al., 1988), however. Moreover, moderately high recurrence risks for IUGR within individual women (Bakketeig et al., 1986; Wolfe et al., 1987; Basso et al., 1999), intergenerational (especially mother-to-daughter) associations (Klebanoff and Yip, 1987; Klebanoff et al., 1989; Magnus et al., 1997; Klebanoff et al., 1997), concordance in twins (Clausson et al., 2000) and nontwin siblings (Johnstone and Inglis, 1974; Beaty et al., 1997), and inbreeding effects (Khoury and Cohen, 1987) all point to an important genetic contribution to fetal growth.

Increased recurrence risks (Hoffman and Bakketeig, 1984; Kristensen et al., 1995; Menard et al., 1996; Mercer et al., 1999; Adams et al., 2000; Bloom et al., 2001) and intergenerational associations (Porter et al., 1997; Hennessy and Alberman, 1998) suggest that genetic factors may also play a role in preterm birth, but that role appears less important than for IUGR (Klebanoff and Yip, 1987; Klebanoff et al., 1997; Clausson et al., 2000).

A short interval (<6 months) between pregnancies is often cited as a determinant of preterm birth or IUGR (Zhu et al., 1999; Shults et al., 1999), but few studies have controlled for the outcome of the previous pregnancy and the tendency of preterm birth or IUGR to repeat in subsequent pregnancies (Erickson and Bjerkedal, 1978; Klebanoff, 1999). Moreover, intervals <6 months are infrequent in developing countries where prolonged and exclusive breastfeeding are prevalent.

CONSEQUENCES OF IUGR AND PRETERM BIRTH

Effects on Mortality

Despite the lack of reliable data on the risks of morbidity and mortality associated with IUGR and preterm delivery in developing country settings, several patterns are clear. The least-developed countries generally have the highest rates of IUGR and of infant mortality. Yet because normal-weight infants are at relatively high risk of infant death (compared with those in most developed countries), the relative risk3 (RR) associated with IUGR

3  

The relative risk indicates the strength of the association between a risk factor (e.g., poor nutrition or cigarette smoking) and a health outcome (e.g., infant mortality, IUGR, or preterm birth). It is calculated by dividing the risk in the group exposed to the risk factor by the risk in the unexposed group.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

(and with preterm birth) are considerably lower than in more-developed countries.

Thus, for example, a 1982 study from southern Brazil reported an overall infant mortality rate of 38.1 per 1,000 live births, an IUGR rate of 9.0 percent, and a preterm birth rate of 6.3 percent. Relative risks of infant death were 4.5 for IUGR and 10.2 for preterm birth (Victora et al., 1987; Barros et al., 1992). In Bangladesh, on the other hand, a 1993-1996 study reported an infant mortality rate of 107.3 per 1,000, and IUGR and preterm birth rates of 69.2 and 17.1 percent, respectively (Arifeen, 1997). In the latter setting, the relative risks of infant death associated with IUGR and preterm birth were only 1.2 and 1.6, respectively.

Industrialized countries have succeeded in reducing infant mortality without a large reduction in prevalence of LBW. Population-based data from southern Brazil (Pelotas) suggest a similar picture. Between 1982 and 1993, infant mortality fell by 50 percent (from 39 to 19 per 1,000) despite an increase in the LBW rate from 9.0 to 9.8 percent (Barros et al., 1996). Modest reductions in IUGR in developed countries appear to be attributable primarily to an increase in the size of term infants (Kessel et al., 1984; Arbuckle and Sherman, 1989; Skjaerven et al., 2000; Orskou et al., 2001; Robertson et al., 2002), which parallels increases in maternal height, prepregnancy BMI, and gestational weight gain and a reduction in maternal smoking (Kramer, 2002a,b). With the possible exception of France (Papiernik et al., 1985; Bréart et al., 1995) and Finland (Olsén et al., 1995), developed countries have not reported reductions in preterm birth. In fact, recent data from Canada (Joseph et al., 1998) and the United States (Demissie et al., 2001) show a significant increase. In Canada, part of the increase appears to be an artifactual result of the use of ultrasound (correction of earlier errors of gestational age dating based on the last menstrual period) and increased registration of births weighing <500 g. A true smaller increase in preterm birth appears to be associated with increasing obstetric intervention (induction and cesarean section), multiple gestation (secondary to treatment of infertility), and demographic changes (older maternal age, more unmarried mothers) (Joseph et al., 1998; Kramer et al., 1998; Demissie et al., 2001).

Substantial reductions in neonatal and infant mortality have been achieved despite these trends in preterm birth because of improvements in the care provided to high-risk mothers and newborns, including neonatal intensive care (Richardson et al., 1998; Kalter et al., 1998; Gould et al., 2000). In some developing countries, the pattern has been similar. Brazil, for example, has witnessed continued declines in infant mortality despite a significant increase in preterm births (Silva et al., 1998; Bettiol et al., 2000). Mortality reductions associated with improved home care among both LBW and normal-birth-weight newborns in rural India are an impressive

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

example of what can be done in even the most resource-constrained areas of the world (Bang et al., 1999).

Effects on Morbidity, Growth, and Development

IUGR, particularly when severe, can lead to hypoglycemia, hypocalcemia, and polycythemia in the early neonatal period (Kramer et al., 1990). These metabolic consequences of fetal malnutrition and hypoxia require monitoring for detection and prompt treatment to prevent death and serious neurologic sequelae. Such monitoring and treatment are possible, however, only in health care facilities with the requisite personnel and equipment, and are therefore infeasible for births occurring at home or in rudimentary care settings, which predominate in the developing world.

Most IUGR infants survive the early neonatal period without these complications. Yet data suggest that they remain at increased risk for infection (Villar et al., 1990; Barros et al., 1992; Ashworth, 1998). Moreover, although they show some catch-up growth in the first 6 months of life, the catch-up is incomplete in many affected children; indeed, even in developed countries, IUGR infants remain shorter, on average, throughout childhood and into adulthood relative to their normal-birth-weight peers (Albertsson-Wikland and Karlberg, 1994; Strauss, 2000). The resulting short stature and reduced muscle mass and strength may have adverse consequences for physical work capacity (Martorell et al., 1998), an important economic consideration in many developing countries. Moreover, a recent study reports that Guatemalan women with heights of 146 cm (1 standard deviation below the mean) were at a 2.5-fold higher risk of nonelective cesarean section compared with those with heights of 160 cm (1 standard deviation above the mean) (Merchant et al., 2001). Finally, IUGR in girls increases the risk of IUGR in the girls’ own offspring, and several generations may be required to achieve optimal fetal growth (Ramakrishnan et al., 1999). A recent study reports that Filipino infants with low gestational age-adjusted birth weight had later menarche, on average, whereas those with lower birth length (adjusted for both birth weight and gestational age) had earlier menarche (Adair, 2001).

Mild neurocognitive deficits and behavioral problems have also been consistently reported in children and adolescents who were growth-restricted in utero (Goldenberg et al., 1998; Hack, 1998; Strauss, 2000; Larroque et al., 2001; Paz et al., 2001). However, most published studies report data from developed countries; more research is needed to address the long-term neurocognitive effects of IUGR in developing countries.

Various body proportionality indices have been used to relate different dimensions of fetal growth, particularly among growth-restricted infants. The most commonly used of these indices is Rohrer’s ponderal index, a

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

measure of birth weight relative to birth length (100 × birth weight in g ÷ birth length3 in cm3). Infants with high ponderal indices are relatively heavy for their length (or, equivalently, relatively short for their weight); those with low ponderal indices are thin, with low weight for length. Based on the ponderal index, a number of studies have used the concepts of proportionate (also called “symmetric” or “stunted”) and disproportionate (“asymmetric” or “wasted”) growth restriction (Rosso and Winick, 1974; Miller and Merritt, 1979; Villar and Belizan, 1982).

The importance of this distinction is unclear, however. Many investigators have inferred that differences in proportionality reflect differences in timing of in utero growth restriction, based on highly diagrammatic velocity curves published by Tanner (1989) suggesting a deceleration in length in the second trimester. In fact, however, studies based on serial ultrasound measurements (Campbell and Newman, 1971) or prostaglandin-induced pregnancy terminations (Birkbeck et al., 1975a,b; Kaul et al., 1986) clearly demonstrate that crown-to-heel length, biparietal diameter, and head circumference increase linearly throughout the second trimester. Moreover, proportionality among IUGR infants is strongly confounded by the severity of the growth restriction; disproportionate IUGR infants tend to be more severely growth-restricted than their proportionate counterparts (Kramer et al., 1989).

The above-noted Scandinavian study found no difference in IQ at age 5 years in infants with asymmetric versus symmetric IUGR (Sommerfelt et al., 2000). Recent data from Brazil indicate no difference in catch-up growth in disproportionate versus proportionate IUGR infants once birth weight for gestational age (severity of IUGR) is adjusted for using multivariate analysis (Horta, 2001). In a small Guatemalan study, proportionate IUGR infants (n = 38) born in 1969-1977 were shorter and lighter and had lower developmental scores than those with disproportionate IUGR (n = 21) despite similar birth weights (Villar et al., 1984). But, a more recent publication based on the same sample studied at age 5 years found no remaining deficits in weight, height, or verbal or memory cognitive function in proportionate IUGR infants (Gorman and Pollitt, 1992). A study of Guatemalan infants born in 1984-1986 revealed an increased risk of severe neonatal morbidity in disproportionate IUGR infants, however, even after controlling for their lower birth weight (Villar et al., 1990).

In recent years, researchers have identified an additional area of concern regarding the adverse consequences of IUGR: the fetal origins of adult disease (Barker, 1992; Leon, 1998). Robust associations have been reported with subsequent hypertension, type 2 diabetes, and coronary heart disease. While most early studies in this area were based in the United Kingdom and other developed countries, the reported associations have also been documented for several developing countries, including India

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

(Fall et al.,1998; Bavdekar et al., 1999), Zimbabwe (Woelk et al., 1998), South Africa (Levitt et al., 1999), and Brazil (Barros and Victora, 1999); by contrast, no significant association between IUGR and blood pressure was observed in school-aged children from Argentina (Bergel et al., 2000). Whether these associations are causal remains to be established, however, as does their importance in explaining geographic and temporal trends in adult chronic diseases (Joseph and Kramer, 1996; Kramer, 2000).

More research on the relationship between IUGR and adult chronic disease is clearly required, particularly from developing-country settings, where IUGR is especially prevalent. Some studies suggest that the shift from energy scarcity to plenty may be particularly important. In India, for example, the rise in obesity coupled with deficits in fetal growth may be contributing to the current “epidemic” of insulin resistance and type 2 diabetes in that country (Yajnik, 2001). Nonetheless, conventional adult risk factors appear to explain most of the variation in prevalence of coronary heart disease among developing countries (Li et al., 1994).

Extremely preterm infants (those born at <32 weeks of gestation) are unlikely to survive in developing-country settings without access to neonatal intensive care. Even in developed countries, extremely preterm infants who survive are at increased risk of severe morbidity in infancy and childhood, including retinopathy of prematurity (a major cause of blindness) and chronic lung disease (bronchopulmonary dysplasia4), which can lead to a requirement for oxygen for many months and long-term reactive airway complications of common viral respiratory infections (McCormick, 1985; Institute of Medicine, 1985; Page et al., 1993). The most serious long-term morbidity associated with extreme preterm birth, however, is neurocognitive, including cerebral palsy, mental retardation, seizure disorders, and less severe neurobehavioral deficits (Robertson et al., 1992; Stewart et al., 1999; Hack et al., 2000).

Mildly preterm infants (gestational age 32-36 weeks) have somewhat elevated risks of respiratory distress syndrome, infection, and both neonatal and postneonatal mortality (Dollfus et al., 1990). Although the magnitude of these risks is lower than in more premature infants, their greater numbers have a substantial impact on both morbidity and mortality at the population level (Kramer et al., 2000). Unfortunately, almost all of the research on the long-term consequences of preterm birth comes from developed countries.

4  

Bronchopulmonary dysplasia, or chronic lung disease of prematurity, can lead to oxygen dependency, recurrent wheezing, and complications of common viral respiratory infections.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

INTERVENTIONS TO PREVENT PRETERM BIRTH AND IUGR

Sources of Evidence

The following sections review the available evidence concerning interventions to prevent preterm birth and IUGR in developing country settings. The discussion relies primarily on evidence from randomized controlled trials (RCTs) and systematic reviews of RCTs in the Cochrane Database of Systematic Reviews (CDSR), which provide the most rigorous evidence of the effects of these interventions on reducing preterm birth and IUGR. In the absence of RCTs, other methodologically less-rigorous scientific information is considered, although the potential for confounding in observational studies of clinical and public health interventions suggests the need for caution in interpreting the study results. This is particularly true for nutritional interventions, because of the strong associations among specific macro- and micronutrients and the robust relationship between dietary compliance and beneficial pregnancy outcomes. The non-RCT evidence reviewed here was identified from a computerized search of MEDLINE (with restriction to publications in English or French) based on the following medical subject headings and logic: infant, premature; infant, LBW; birth weight; infant, small-for-gestational age; fetal growth retardation; and labor, premature.

Prepregnancy Energy/Protein Supplementation

Interventions to increase maternal BMI before pregnancy may be impractical in many settings because their target is so broad: all women of childbearing age, rather than those who are currently pregnant. The committee is aware of programs targeting newly married women and adolescent girls as a means of improving nutritional status (including BMI) before the first pregnancy, but could find no documentation of evaluation of the impact of these programs on birth outcomes. The only RCT of preconceptional nutritional supplementation is from Taiwan (Blackwell et al., 1973). In this study, supplementation began after a previous pregnancy and continued through the index (study) pregnancy. The effects of this combined pre- and intrapregnancy supplementation did not appear to be larger than the effects reported for trials in which supplementation was restricted to pregnancy (Kramer, 2002b). An observational study of supplemented women in Guatemala (Villar and Rivera, 1988) showed an enhanced effect on fetal growth associated with high levels of continuing nutritional supplementation through a prior pregnancy, the subsequent interbirth interval, and the index pregnancy, as compared with supplementation during the index pregnancy only. Because each woman decided whether to take the

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

supplement and how much of it to take, however, such an association is prone to confounding by self-selection. More research is needed to identify and evaluate strategies for enhancing maternal nutritional status before pregnancy as a means of improving birth outcomes, especially given the above-noted intergenerational tendency toward suboptimal fetal growth.

Energy/Protein Supplementation During Pregnancy

Controlled clinical trials providing food supplements to pregnant women have yielded only modest effects in enhancing fetal growth and in reducing IUGR (de Onis et al., 1998b; Rush, 2001). A Cochrane systematic review examines 13 of these trials, including studies from Colombia, Indonesia, Taiwan, and the Gambia, as well as studies among undernourished women in several developed countries (Kramer, 2002a). In these trials, the supplements were balanced with respect to their protein and energy content (≤25 percent of the energy content was derived from protein). Overall, balanced energy/protein supplementation appears to have only a modest effect on mean birth weight (weighted mean difference = 25 g [95 percent CI = −4 to +55 g]), but a more substantial effect on reducing IUGR (RR = 0.68 [95 percent CI = 0.57-0.80]). No evidence was found that these effects are larger in undernourished than in well-nourished women. However, the magnitude of the birth weight increase was substantially larger (136 g) in the Gambia (Ceesay et al., 1997), where the supplement provided an additional 900 kcal per day, as compared with a 200 to 250 kcal per day increase in most of the other trials. Supplementation is not associated with an increase in mean gestational age (weight mean difference = −0.1wk [95 percent CI = −0.2 to +0.1wk]) or a significant reduction in preterm birth (RR = 0.83 [95 percent CI = 0.65-1.06]).

Nutritional Advice

Improvements in energy intake could occur through the provision of nutritional advice during prenatal care or as part of broader community-based mass media strategies. The committee could not find examples of these approaches in developing countries, however. The CDSR contains a systematic review of four trials from developed countries in which nutritional advice was given to pregnant women to increase their energy and protein intakes (Kramer, 2002b). Although the results suggest such advice can be successful in increasing dietary intake, no significant effect was seen on mean birth weight or IUGR. One trial (Kafatos et al., 1989) reported a significant reduction in preterm birth (RR = 0.45 [0.22-0.92]) in women randomized to receive nutritional advice, but that result is inconsistent with the total absence of effect on mean gestational age (weighted mean differ-

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

ence = −0.1 [−0.4 to +0.2] wk). The relevance of these findings for developing-country populations is not known.

Micronutrient Supplementation

There is little evidence that supplementation with specific micronutrients improves fetal growth or lowers the risk of IUGR or preterm birth. A systematic review in the CDSR associates magnesium supplementation with reduced risks for both preterm birth (RR = 0.73 [95 percent CI =0.57-0.94]) and IUGR (RR = 0.70 [95 percent CI = 0.53-0.93]), but the quality of the trials included in the review is poor (Makrides and Crowther, 2002). No significant effect on reducing preterm birth or IUGR has been found in a systematic review of trials of supplementation with iron (Mahomed, 2002b) or folate (Mahomed, 2002a), even in combination (Mahomed, 2002c). In the case of zinc, the most recent Cochrane review (Mahomed, 2002d) reports a significant effect of supplementation in reducing preterm birth (RR = 0.74 [95 percent CI = 0.56-0.98]), although not IUGR (RR = 0.90 [95 percent CI = 0.64-1.28]). However, the encouraging result for preterm birth has not been confirmed in two recent trials from Peru (Caulfield et al., 1999) and Bangladesh (Osendarp et al., 2000), which are not included in the Cochrane review. A systematic review of maternal iodine supplementation (in iodine-deficient areas) revealed a significant increase in mean birth weight (147g, 95 percent CI 51-244 g), although no data were reported on preterm birth or IUGR (Mahomed and Gülmezoglu, 2002). In the systematic review by Atallah et al. (2002), no effect of calcium supplementation on reducing preterm birth is evident overall (RR = 0.95 [95 percent CI = 0.82-1.10]), but a strong effect was noted in four small trials in women at high risk for hypertension (RR = 0.42 [0.23-0.78]).

Diets rich in fish oil contain high concentrations of n-3 long-chain polyunsaturated fatty acids. Such diets have been reported to prolong gestation and augment fetal growth, perhaps by inhibiting prostaglandin synthesis and/or through their antioxidant properties (Olsén, 1993). The evidence from observational studies and randomized trials is mixed (Olsén et al., 1991, 1992; Onwude et al., 1995; Reece et al., 1997; Sattar et al., 1998), although six recent multicenter trials suggest a protective benefit, at least in singleton pregnancies (Olsén et al., 2000). No systematic review of the existing trials has yet been published (Makrides et al., 2002).

Further randomized trials are needed before evidence-based recommendations can be made with respect to the role of micronutrient supplements in preventing IUGR or preterm birth. Because many women routinely receive iron and folic acid supplements during pregnancy (to prevent or treat maternal anemia), such trials should evaluate the impact on pregnancy outcomes of multiple micronutrient supplements, instead of continuing with

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

single-nutrient approaches (de Onis et al., 1998b). For example, a multivitamin mineral preparation was shown to improve a number of pregnancy outcomes (including a reduction in preterm birth) among poorly nourished HIV-positive women in Tanzania who were not receiving antiretroviral therapy (Fawzi et al., 1998).

Treatment of Genitourinary Infection

The Cochrane systematic review on treatment of asymptomatic bacteriuria reports a pooled relative risk of 0.64 (95 percent CI = 0.50-0.82) for the risk of a composite outcome of preterm delivery or LBW, based on ten controlled clinical trials of questionable methodological quality (Smaill, 2002). On the other hand, antibiotic treatment has not been shown to reduce the risk of preterm birth in women with either preterm prelabor rupture of membranes (Kenyon and Boulvain, 2002) or preterm labor with intact membranes (King and Flenady, 2002; Kenyon et al., 2001). The treatment of women with bacterial vaginosis is more controversial. Despite strong epidemiological evidence of an association between bacterial vaginosis and preterm birth (as discussed above), randomized trials of systemic antibiotic treatment with erythromycin, amoxicillin, or metronidazol and of topical clindamycin have not shown clear evidence of benefit (Brocklehurst et al., 2002). A recent large trial from the National Institutes of Health (NIH) Maternal-Fetal Medicine Network (Carey et al., 2000) showed no evidence of effectiveness overall and, in contrast to a previous trial (Hauth et al., 1995), not surprisingly a slightly increased risk of preterm birth in women with a prior history of preterm birth.

A recent publication from the same NIH network reported even more discouraging results for metronidazole treatment of women with asymptomatic trichomoniasis; treatment (versus placebo) actually led to an increased risk of preterm birth (Klebanoff et al., 2001). A single trial provided no evidence that antibiotic treatment in pregnant women with chlamydia infection reduces the risk of preterm birth (Martin, 1997).

Three studies from sub-Saharan Africa have indicated an association between use of antibiotics during pregnancy and a reduction in either LBW or prolongation of pregnancy. In a recent Kenyan study, a single oral dose of cephalosporin administered to pregnant women with poor obstetric histories was found to be associated with a significant reduction in LBW (probably due largely to preterm birth) and postpartum endometritis (Gichangi et al., 1997). Large losses to follow-up suggest the need for cautious interpretation of these results, however. A small trial in South Africa using metronidazole and ampicillin among women in early preterm

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

labor reported a significant prolongation of pregnancy, but preterm birth rates were not reported, and no reduction was observed in either neonatal death or length of neonatal hospital stay (Norman et al., 1994). Finally, a recently published trial in pregnant women living in the Rakai District of Uganda revealed that those randomized to receive a single presumptive treatment dose of azithromycin, cefixime, and metronidazole had borderline significant reductions in risk of preterm birth (RR = 0.72 [95 percent CI = 0.56-1.05]) and of early neonatal death (RR = 0.83 [95 percent CI = 0.71-0.97]) (Gray et al., 2001).

Smoking Cessation

Intensive smoking cessation interventions (as opposed to the routine advice provided in standard prenatal care) have been found moderately successful in improving fetal growth, with a pooled difference in mean birth weight of about 29 g (95 percent CI = 9-49 g) (Lumley et al., 2002). This review does not specifically report on IUGR. The modest reduction reported for LBW (RR = 0.81 [95 percent CI = 0.69-0.96]) may be due at least in part to a significant effect on preterm birth (RR = 0.84 [95 percent CI = 0.71-0.99]).

Malaria Prophylaxis and Treatment

A systematic review of antimalarial prophylaxis from the CDSR indicates an increase of approximately 100 g (weighted mean difference = 102 g, 95 percent CI = 33-171 g) in mean birth weight and a reduction of approximately 40 percent (RR = 0.59 [95 percent CI = 0.41-0.85]) in the risk of LBW for primiparous women (Garner and Gülmezoglu, 2002). No specific analysis for IUGR is presented in this Cochrane review, although the lack of a significant reduction in the risk of preterm birth among women with a first or second pregnancy (RR = 0.91 [95 percent CI = 0.64-1.29]) (based on two small trials) suggests that the effect of antimalarial prophylaxis is restricted to improving fetal growth, presumably by reducing placental parasitemia.

One small nonrandomized trial showed that a two-dose regimen of sulfadoxine-pyrimethane was associated with a nonsignificantly higher mean birth weight (2,864 versus 2,748 g) and a lower risk of LBW (17 versus 27 percent) compared with weekly chloroquine prophylaxis (Schultz et al., 1994). These results deserve further investigation in larger trials with randomized allocation because of the greater practicability of two single treatments as compared with weekly prophylaxis.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
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Other Interventions

A recent observational study from Sri Lanka reported a 53 percent reduction in very low birth weight (birth weight <1,500 g) for women who reported having taken mebendazole during the pregnancy as compared with those who did not (de Silva et al., 1999). Because of the potential for confounding differences between women who took the drug and those who did not, however, no causal inference can be drawn with confidence. Yet in light of the beneficial effect of treatment on maternal anemia (Stoltzfus and Dreyfuss, 1998), a randomized trial is likely to be unethical.

Although antenatal care could theoretically have a beneficial impact, evidence for the efficacy of early antenatal care or frequent visits to the clinic in improving intrauterine growth or gestational duration is unconvincing (Kramer, 1987; Alexander and Korenbrot, 1995). The type of antenatal care received may be more important than early initiation or frequent visits, but no definitive conclusions are possible based on the available evidence. In Latin America, for example, 2,235 women at higher-than-average risk for delivering an LBW infant were given psychosocial support and health education through four home visits between weeks 22 and 34 of gestation, but such care did not reduce the incidence of IUGR or preterm delivery (Villar et al., 1992). Indeed, despite the evidence that psychosocial stress may be an important contributor to preterm birth, social support during pregnancy has not been shown to reduce the risk (Hodnett, 2002). A recent cluster-randomized trial in Argentina, Cuba, Saudi Arabia, and Thailand investigated whether a reduced number of antenatal care visits that still included antenatal actions that are evidence-based would affect the birth outcome; no impact was observed on either preterm birth or IUGR (Villar et al., 2001). In fact, a recent systematic review of randomized trials yielded no strong evidence that the content, frequency, or timing of currently recommended antenatal care visits has an effect on reducing the incidence of IUGR or preterm delivery (Carroli et al., 2001).

One particular aspect of antenatal care of beneficial potential is the timely recognition and treatment of cervical incompetence. The diagnosis of cervical incompetence is usually based on some combination of previous second- or early third-trimester pregnancy loss and first- or early second-trimester cervical dilatation, although the criteria used are highly variable (Berry et al., 1995). Where resources permit, placement of a cerclage stitch may be beneficial in reducing the risk of preterm birth (Grant, 1989; Medical Research Council/Royal College of Obstetricians Working Party on Cervical Cerclage, 1993). The safety and efficacy of cerclage remain controversial, however, and a recent systematic review of randomized trials has yet to be published (Drakely et al., 2002).

Although pregnancy-induced hypertension is a major cause of both

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

IUGR and preterm birth, antihypertensive treatment has not proven efficacious in lowering the risks (Gülmezoglu et al., 1997). Prophylaxis with low-dose aspirin or other antiplatelet agents in women at risk of developing preeclampsia is associated with a small and statistically borderline reduction in the risk of preterm birth (RR = 0.92 [95 percent CI = 0.88-0.97]) and IUGR (RR = 0.92 [95 percent CI = 0.84-1.01]) (Knight et al., 2002).

Strategies for reducing neonatal and infant mortality among LBW infants that do not depend on neonatal intensive care or other expensive technologies would be of particular benefit to the least-developed countries. Breastfeeding and/or use of expressed breast milk represent one such “low-tech” strategy, which can reduce infection (and perhaps mortality due to infection) in LBW infants (Narayanan et al., 1980, 1981). For infants born weighing less than 2,500 g in areas where resources for perinatal and neonatal care are scarce, nurseries are overcrowded, and staffing is insufficient, the Kangaroo method of care may be a feasible therapeutic intervention for improving the survival of these neonates (Charpak et al., 1994). Kangaroo mother care is an intervention for LBW babies in which the mother acts as an “incubator” by providing skin-to-skin contact with her newborn in an effort to keep the infant’s temperature within a normal range. Further studies of this method are needed, however, to determine its efficacy in reducing mortality (Conde-Agudelo et al., 2002).

RECOMMENDATIONS

Although LBW (particularly IUGR) is very frequent in low- and middle-income countries, these countries tend to have very high infant mortality not only in LBW but also in normal-weight infants. Efforts to reduce infant mortality on a population-wide basis have thus far been more successful than efforts to reduce LBW. Therefore, while not abandoning their attempts to prevent IUGR and preterm birth, developing countries should focus their efforts on preventing infant death in normal-weight, as well as LBW, fetuses and infants, with only limited, if any, reliance on neonatal intensive care units (NICUs) and other expensive medical technologies. Antenatal maternal steroids, infant warming, oxygen, antibiotics, and nasal continuous positive airway pressure are inexpensive and feasible interventions even in resource-poor countries.

Recommendation 4. The following strategies are recommended for incorporation into preconceptional and antenatal care:

  • Early detection and timely management of asymptomatic urinary tract infection

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
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  • Intermittent prophylactic and early treatment of malaria, especially for primiparae.

  • Counseling and other forms of support to stop smoking during pregnancy.

(See Chapters 2, 3, 7, and 8 for other components of this recommendation.)

RESEARCH NEEDS

Several lines of research will be instrumental for the improvement of existing interventions to prevent IUGR and preterm birth and the creation and implementation of additional options to further address their impact. Priorities for such research include:

  • Testing strategies to improve maternal energy intake prior to and during pregnancy; such research should consider how different approaches (supplementation, nutritional advice, etc.) might be applied in different settings.

  • Designing and testing interventions to reduce the risk of preterm birth posed by bacterial vaginosis and genital tract infection.

  • Measuring the impact of IUGR and preterm birth on child morbidity, growth, and neurocognitive development.

  • Determining the long-term consequences of IUGR as a risk factor for chronic adult diseases, and the economic impact of those consequences in developing countries.

CONCLUSION

Although data on the worldwide prevalence of IUGR and preterm delivery are incomplete and of variable quality, it is reasonable to conclude that LBW due to both causes is a major public health problem throughout the developing world. Some high-income countries have succeeded in lowering their rates of IUGR. Preterm birth is more resistant to intervention; currently, proven strategies for preventing preterm birth are limited to the treatment of asymptomatic bacteriuria, smoking cessation, and (perhaps) fish oil supplementation. For certain groups of high-risk women, calcium supplementation, antiplatelet agents, and cervical cerclage (where resources permit) may be of benefit.

Maternal undernutrition is the single most important cause of IUGR in low- and middle-income countries. There is good evidence from systematic reviews of randomized trials that increasing food intake during pregnancy can increase fetal growth and reduce the risk of IUGR. However, no evidence is available that public health programs in poor countries have suc-

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

ceeded in increasing food intake and thereby reducing the risk of IUGR. Factors other than nutrition that increase the risk of IUGR, such as pregnancy-induced hypertension, cigarette smoking, and malaria during pregnancy, can be addressed through antenatal care.

As economic conditions improve in developing countries, more and better food tends to be available to pregnant women, resulting in decreased rates of IUGR. To reduce the prevalence of IUGR in low-income settings in the face of continued poverty remains a difficult challenge.

REFERENCES

Adair LS. 2001. Size at birth predicts age at menarche. Pediatrics 107(4):E59.

Adams M, Elam-Evans L, Wilson H, Gilbertz D. 2000. Rates of and factors associated with recurrence of preterm delivery. Journal of the American Medical Association 283:1591–1596.

Albertsson-Wikland K, Karlberg J. 1994. Natural growth in children born small for gestational age with and without catch-up growth. Acta Pediátrica de México 399(suppl):64–70.

Alexander GR, Korenbrot CC. 1995. The role of prenatal care in preventing low birth weight. Future of Children 5:103–120.

Arbuckle TE, Sherman GJ. 1989. An analysis of birth weight by gestational age in Canada. Canadian Medical Association Journal 140:157–165.

Arifeen SE. 1997. Birth weight, intrauterine growth retardation and prematurity: a prospective study of infant growth and survival in the slums of Dhaka, Bangladesh. Doctor of Public Health Dissertation. Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD.

Ashworth A. 1998. Effects of intrauterine growth retardation on mortality and morbidity in infants and young children. European Journal of Clinical Nutrition 52:S34–S42.

Atallah AN, Hofmeyr GJ, Duley L. 2002. Calcium supplementation during pregancy for preventive hypertensive disorders and related problems (Cochrane Review). The Cochrane Library, Issue 2.


Bakketeig LS, Bjerkedal T, Hoffman HJ. 1986. Small for gestational age births in successive pregnancy outcomes. Early Human Development 8:15–24.

Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. 1999. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 354(9194):1955–1961.

Barker DJP. 1992. Fetal and Infant Origins of Adult Disease: Papers Written by the Medical Research Council Environmental Epidemiology Unit, University of Southampton. London: British Medical Journal.

Barros FC, Victora CG. 1999. Increased blood pressure in adolescents who were small for gestational age at birth: a cohort study in Brazil. International Journal of Epidemiology 28:676–681.

Barros FC, Huttly SR, Victora CG, Kirkwood BR, Vaughan JP. 1992. Comparison of the causes and consequences of prematurity and intrauterine growth restriction: a longitudinal study in southern Brazil. Pediatrics 90:238–244.

Barros FC, Victora CG, Tomasi E, Horta BL, Menezes AMB, Cesar JA, Halpern R, Olinto MT, Post CL, Costa JD, Menezes FS, Garcia MM, Vaughan JP. 1996. Maternal and child health in Pelotas, Rio Grande do Sul, Brazil: principal conclusions from the 1982 and 1993 cohort studies [in Portuguese]. Cadernos de Saúde Pública 12(suppl 1):87-92. Available online at http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102311X1996000500013&lng=en&nrm=iso.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Basso O, Olsen J, Christensen K. 1999. Low birthweight and prematurity in relation to paternal factors: a study of recurrence. International Journal of Epidemiology 28:695–700.

Bavdekar A, Yajnik CS, Fall CHD, Bapat S, Pandit AN, Deshpande V, Bhave S, Kellingray SD, Joglekar C. 1999. Insulin resistance syndrome in 8-year-old Indian Children. Diabetes 48:2422–2429.

Beaty TH, Skjaerven R, Breazeale DR, Liang KY. 1997. Analyzing sibship correlations in birth weight using large sibships from Norway. Genetic Epidemiology 14:423–433.

Bergel E, Haelterman E, Belizán J, Villar J, Carroli G. 2000. Perinatal factors associated with blood pressure during childhood. American Journal of Epidemiology 151:594–601.

Berry CW, Brambati B, Eskes TK, Exalto N, Fox H, Geraedts JP, Gerhard I, Gonzales Gomes F, Grudzinskas JG, Hustin J. 1995. The Euro-Team Early Pregnancy (ETEP) protocol for recurrent miscarriage. Human Reproduction 10(6):1516–1520.

Bettiol H, Rona RJ, Chinn S, Goldani M, Barbieri MA. 2000. Factors associated with preterm births in Southeast Brazil: a comparison of two birth cohorts born 15 years apart. Paediatric and Perinatal Epidemiology 14:30–38.

Birkbeck JA, Billewicz WZ, Thomson AM. 1975a. Human foetal measurements between 50 to 150 days gestation, in relation to crown-heel length. Annals of Human Biology 1:173–178.

Birkbeck JA, Billewicz WZ, Thomson AM. 1975b. Fetal growth from 50 to 150 days gestation. Annals of Human Biology 2:319–326.

Blackwell RQ, Chow BF, Chinn KSK, Blackwell BN, Hsu SC. 1973. Prospective maternal nutrition study in Taiwan: rationale, study design, feasibility and preliminary findings. The Nutrition Reporter 7:517–532.

Bloom SL, Yost NP, McIntire DD, Leveno KJ. 2001. Recurrence of preterm birth in singleton and twin pregnancies. Obstetrics and Gynecology 98:379–385.

Bréart G, Blondel B, Tuppin P, Grandjean H, Kaminski M. 1995. Did preterm deliveries continue to decrease in France in the 1980s? Paediatric and Perinatal Epidemiology 9:296–306.

Brocklehurst P, Hannah M, McDonald H. 2002. Interventions for treating bacterial vaginosis in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Brooks AA, Johnson MR, Steer PJ, Pawson ME, Abdalla HI. 1995. Birth weight: nature or nurture? Early Human Development 42:29–35.


Campbell S, Newman GB. 1971. Growth of the fetal biparietal diameter during normal pregnancy. Tropical Journal of Obstetrics and Gynaecology of the British Commonwealth 78:513–519.

Carey JC, Klebanoff MA, Hauth JC, Hillier SL, Thom EA, Ernest JM, Heine RP, Nugent RP, Fisher ML, Leveno KJ, Wapner R, Varner M, National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. 2000. Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. New England Journal of Medicine 342:534–540.

Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, Lumbiganon P, Famot U, Bersgjø H. 2001. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 357:1565–1570.

Caulfield LE, Zavaleta N, Figueroa A. Leon Z. 1999. Maternal zinc supplementation does not affect size at birth or pregnancy duration in Peru. Journal of Nutrition, Health and Aging 129:1563–1568.

Ceesay SM, Prentice AM, Cole TJ, Foord F, Weaver LT, Poskitt EM, Whitehead RG. 1997. Effects on birth weight and perinatal mortality of maternal dietary supplements in rural Gambia: 5 year randomized controlled trial. British Medical Journal 315:786–790.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Chaim W, Mazor M, Lieberman JR. 1997. The relationship between bacterial vaginosis and preterm birth: a review. Archives of Gynecology and Obstetrics 259:51–58.

Charpak N, Ruiz-Pelacz JG, Charpak Y. 1994. Rey-Martinez kangaroo program: an alternative way of caring for low birth weight infants. Pediatrics 94:804–810.

Clausson B, Lichtenstein P, Cnattingius S. 2000. Genetic influence on birthweight and gestational length determined by studies in offspring of twins. British Journal of Obstetrics and Gynaecology 107:375–381.

Cnattingius S, Haglund B. 1997. Decreasing smoking prevalence during pregnancy in Sweden: the effect on small-for-gestational-age births. American Journal of Public Health 87:410–413.

Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. 2002. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants (Cochrane Review). The Cochrane Library, Issue 2.


de Onis M, Habicht JP. 1996. Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee. American Journal of Clinical Nutrition 64:650–658.

de Onis M, Blossner M, Villar J. 1998a. Levels and patterns of intrauterine growth restriction in developing countries. European Journal of Clinical Nutrition 52(S1):S5–S15.

de Onis M, Villar J, Gulmezouglu M. 1998b. Nutritional interventions to prevent intrauterine growth restriction; evidence from randomized controlled trials. European Journal of Clinical Nutrition 52:S83–S93.

de Silva NR, Sirisena JL, Gunasekera DP, Ismail MM, de Silva HJ. 1999. Effect of mebendazole therapy during pregnancy on birth outcome. Lancet 353:1145–1149.

Demissie K, Rhoads GG, Ananth CV, Alexander GR, Kramer MS, Kogan MD, Joseph KS. 2001. Trends in preterm birth and neonatal mortality among blacks and whites in the United States from 1989 to 1997. American Journal of Epidemiology 154:307–315.

Dollfus C, Patetta M, Siegel E, Cross AW. 1990. Infant mortality: a practical approach to the analysis of the leading causes of death and risk factors. Pediatrics 86(2):176–183.

Drakeley AJ, Roberts D, Alfirevic Z. 2002. Cervical cerclage for prolonging pregnancy in women with cervical incompetence [protocol] (Cochrane Review). The Cochrane Library, Issue 2.


Erickson JD, Bjerkedal T. 1978. Interpregnancy interval. Association with birth weight, stillbirth, and neonatal death. Journal of Epidemiology and Community Health 32(2):124–130.


Fall CHD, Stein CE, Kumaran K, et al. 1998. Size at birth, maternal weight, and type 2 diabetes in South India. Diabetic Medicine 15(3):220–227.

Fawzi W, Msamanga G, Spiegelman D, Urassa E, McGrath N, Mwakagile D, Antelman G, Mbise R, Herrera G, Kapiga S, Willett W, David H. 1998. Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected women in Tanzania. Lancet 351:1477–1482.


Garner P, Gülmezoglu M. 2002. Prevention versus treatment for malaria in pregnant women (Cochrane Review). The Cochrane Library, Issue 2.

Gichangi PB, Ndinya-Achola JO, Ombete J, Nagelkerke NJ, Temmerman M. 1997. Antimicrobial prophylaxis in pregnancy: a randomized placebo-controlled trial with cefetamet-pivoxil in pregnancy women with a poor obstetric history. American Journal of Obstetrics and Gynecology 177:680–684.

Goldenberg RL, Hoffman HJ, Cliver SP. 1998. Neurodevelopmental outcome of small-for-gestational-age infants. European Journal of Clinical Nutrition 52:S54–S58.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Gorman KS, Pollitt E. 1992. Relationship between weight and body proportionality at birth, growth during the first year of life and cognitive development at 36, 48, and 60 months. Infant Behavior and Development 15:279–296.

Gould JB, Benitz WE, Liu H. 2000. Mortality and time to death in very low birth weight infants: California, 1987 and 1993. Pediatrics 105:1–5.

Grant A. 1989. Cervical cerclage to prolong pregnancy. In: Chalmers I, Enkin M, Keirse MJNC (eds). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press. Pp. 633–646.

Gray RH, Wabwire-Mangen F, Kigozi G, Sewankambo NK, Serwadda D, Moulton LH, Quinn TC, O’Brien KL, Meehan M, Abramowsky C, Robb M, Wawer MJ. 2001. Randomized trial of presumptive sexually transmitted disease therapy during pregnancy in Rakai, Uganda. American Journal of Obstetrics and Gynecology 185:1209–1217.

Gülmezoglu M, de Onis M, Villar J. 1997. Effectiveness of interventions to prevent or treat impaired fetal growth. Obstetrical and Gynecological Survey 52:139–149.


Hack M. 1998. Effects of intrauterine growth retardation on mental performance and behavior, outcomes during adolescence and adulthood. European Journal of Clinical Nutrition 52:S65–S71.

Hack M, Wilson-Costello D, Friedman H, Taylor GH, Schluchter M, Fanaroff AA. 2000. Neurodevelopment and predictors of outcomes of children with birth weights of less than 1000 g: 1992–1995. Archives of Pediatrics and Adolescent Medicine 154(7):725–731.

Hauth J, Goldenberg RL, Andrews WW, DuBard MB, Copper RL. 1995. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. New England Journal of Medicine 333:1732–1736.

Hennessy E, Alberman E. 1998. Intergenerational influences affecting birth outcome. II. Preterm delivery and gestational age in the children of the 1958 British birth cohort. Paediatric and Perinatal Epidemiology 12(suppl 1):61–75.

Hillier SL, Nugent RP, Eschenbach DA, Krohn MA, Gibbs RS, Martin DH, Cotch MF, Edelman R, Pastorek JG, Rao AV, McNellis D, Regan JA, Carey JC, Klebanoff MA, for the Vaginal Infections and Prematurity Study Group. 1995. Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. New England Journal of Medicine 333:1732–1736.

Hodnett ED. 2002. Support during pregnancy for women at increased risk (Cochrane Review). The Cochrane Library, Issue 2.

Hoffman JH, Bakketeig LS. 1984. Risk factors associated with the occurrence of preterm birth. Clinical Obstetrics and Gynecology 27:539–552.

Horta BL. 2001. Determinants of catch-up growth in small-for-gestational age infants. Ph.D. thesis. Montreal: McGill University.

Hutter I. 1996. Reduction of food intake during pregnancy in rural South India. Tropical Medicine and International Health 1:399–405.


Institute of Medicine (IOM). 1985. Preventing Low Birth-Weight. Washington, DC: National Academy Press.

Institute of Medicine (IOM). 1992. Nutrition Issues in Developing Countries. Part II: Diet and Activity During Pregnancy and Lactation. Washington, DC: National Academy Press.


Johnstone F, Inglis L. 1974. Familial trends in low birth weight. British Medical Journal 3:659–661.

Joseph KS, Kramer MS. 1996. A review of the evidence on fetal and early childhood antecedents of adult chronic disease. Epidemiological Reviews 18:158–174.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Joseph KS, Kramer MS, Marcoux S, Ohlsson A, Wen SW, Allen A, Platt R. 1998. Determinants of secular trends in preterm birth in Canada. New England Journal of Medicine 339:1434–1439.


Kafatos AG, Vlachonikolis IG, Codrington CA. 1989. Nutrition during pregnancy: the effects of an educational intervention program in Greece. American Journal of Clinical Nutrition 50:970–979.

Kalter HD, Na Y, O’Campo P. 1998. Decrease in infant mortality in New York City after 1989. American Journal of Public Health 88:816–820.

Kaul SS, Bahn A, Chopra SRK. 1986. Fetal growth from 12 to 26 weeks of gestation. Annals of Human Biology 13:563–570.

Kenyon S, Boulvain M. 2002. Antibiotics for preterm premature rupture of membranes (Cochrane Review). The Cochrane Library, Issue 2.

Kenyon SL, Taylor DJ, Tarnow-Mordi W, for the ORACLE Collaborative Group. 2001. Broad-spectrum antibiotics for spontaneous preterm labour: the ORACLE II randomised trial. Lancet 357(9261):989–994.

Kessel SS, Villar J, Berendes HW, Nugent RP. 1984. The changing pattern of low birth weight in the United States—1970 to 1980. Journal of the American Medical Association 251:1978–1982.

Khoury MJ, Cohen BH. 1987. Genetic heterogeneity of prematurity and intrauterine growth retardation: clues from the old Old Order Amish. American Journal of Obstetrics and Gynecology 157:400–410.

Khoury MJ, Erickson JD, Cordero JF, McCarthy BJ. 1988. Congenital malformations and intrauterine growth retardation: a population study. Pediatrics 82:83–90.

King J, Flenady V. 2002. Antibiotics for preterm labour with intact membranes. (Cochrane Review). The Cochrane Library, Issue 2.

Klebanoff MA. 1999. The interval between pregnancies and the outcome of subsequent births. New England Journal of Medicine 340(8):643-644.

Klebanoff MA, Yip R. 1987. Influence of maternal birth weight on rate of fetal growth and duration of gestation. Journal of Pediatrics 111:287–292.

Klebanoff MA, Meirik O, Berendes HW. 1989. Second-generation consequences of small-for-dates birth. Pediatrics 84:343–347.

Klebanoff MA, Schulsinger C, Mednick BR, Secher NJ. 1997. Preterm and small-for-gestational-age birth across generations. American Journal of Obstetrics and Gynecology 176:521–526.

Klebanoff MA, Carey JC, Hauth JC, Hillier SL, Nugent RP, Thom EA Ernest JM, Heine RP, Wapner RJ, Trout W, Moawad A, Leveno KJ, Miodovnik M, Sibai BM, VanDorsten JP, Dombrowski MP, O'Sullivan MJ, Varner M, Langer O, McNellis D, Roberts JM, National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. 2001. Failure of metronidazole to prevent preterm delivery among pregnant women with asymptomatic Trichomonas vaginalis infection. New England Journal of Medicine 345(7):487–493.

Knight M, Dunley L, Henderson-Smart DJ, King JF. 2002. Antiplatelet agents for preventing and treating pre-eclampsia (Cochrane Review). The Cochrane Library, Issue 2.

Kramer MS. 1987. Determinants of low birth weight: methodological assessment and meta-analysis. Bulletin of the World Health Organization 65:663–737.

Kramer MS. 2000. Invited commentary: association between restricted fetal growth and adult chronic disease: is it causal? Is it important? American Journal of Epidemiology 152:605–608.

Kramer MS. 2002a. Balanced protein/energy supplementation in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Kramer MS. 2002b. Nutritional advice in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Kramer M, Victora C. 2001. Low birth weight and perinatal mortality. In: Semba RD, Bloem MW (eds). Nutrition and Health in Developing Countries. Totowa, NJ: Humana Press. Pp. 57–69.

Kramer MS, McLean F, Olivier M, Willis DM, Usher RH. 1989. Body proportionality and head and length “sparing” in growth-retarded neonates: a critical reappraisal. Pediatrics 84:717–723.

Kramer MS, Olivier M, McLean FH, Willis DM, Usher RH. 1990. Impact of intrauterine growth retardation and body proportionality on fetal and neonatal outcome. Pediatrics 86:707–713.

Kramer MS, Platt R, Yang H, Joseph KS, Wen SW, Morin L, Usher RH. 1998. Secular trends in preterm birth. Journal of the American Medical Association 280:1849–1854.

Kramer MS, Demissie K, Yang H, Platt RW, Sauvé R, Liston R, for the Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. 2000. The contribution of mild and moderate preterm birth to infant mortality. Journal of the American Medical Association 284:843–849.

Kristensen J, Langhoff-Roos J, Kristensen FB. 1995. Implications of idiopathic preterm delivery for previous and subsequent pregnancies. Obstetrics and Gynecology 86:800–804.

Kyrklund-Blomberg NB, Cnattingius S. 1998. Preterm birth and maternal smoking: risks related to gestational age and onset of delivery. American Journal of Obstetrics and Gynecology 179:1051–1055.


Larroque B, Bertrais S, Czernichow P, Léger J. 2001. School difficulties in 20-year-olds who were born small for gestational age at term in a regional cohort study. Pediatrics 108:111–115.

Launer LJ, Villar J, Kestler E, de Onis M. 1990. The effect of maternal work on fetal growth and duration of pregnancy: a prospective study. BJOG: An International Journal of Obstetrics and Gynaecology 97:62–70.

Leon DA. 1998. Fetal growth and adult disease. European Journal of Clinical Nutrition 52:S72– S82.

Levitt NS, Steyn K, De Wet T, Morrell C, Edwards R, Ellison GT, Cameron N. 1999. An inverse relation between blood pressure and birth weight among 5 year old children from Soweto, South Africa. Epidemiological Notes and Communicable Disease Morbidity Report 33:264–268.

Li N, Tuomilehto J, Dowse G, Virtala E, Zimmet P. 1994. Prevalence of coronary heart disease indicated by electrocardiogram abnormalities and risk factors in developing countries. Journal of Clinical Epidemiology 47:599–611.

Lumley J, Oliver S, Waters F. 2002. Interventions for promoting smoking cessation during pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Lundsberg LS, Bracken MB, Saftlas AF. 1997. Low-to-moderate gestational alcohol use and intrauterine growth retardation, low birthweight, and preterm delivery. Annals of Epidemiology 7:498–508.


Magnus P, Bakketeig LS, Hoffman H. 1997. Birth weight of relatives by maternal tendency to repeat small-for-gestational-age (SGA) births in successive pregnancies. Acta Obstetricia et Gynecologica Scandinavica 76:35–38.

Mahomed K. 2002a. Folate supplemention in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Mahomed K. 2002b. Iron supplementation in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Mahomed K. 2002c. Iron and folate supplemention in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Mahomed K. 2002d. Zinc supplemention in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Mahomed K, Gülmazoglu AM. 2002. Maternal iodine supplements in areas of deficiency (Cochrane Review). The Cochrane Library, Issue 2.

Makrides M, Crowther CA. 2002. Magnesium supplementation in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Makrides M, Duley L, Olsén SF. 2002. Fish oil and other prostaglandin precursor supplementation during pregnancy for reducing pre-eclampsia, preterm birth, low birth weight and intrauterine growth restriction [protocol] (Cochrane Review). The Cochrane Library, Issue 2. Oxford: Update Software.

Manshande JP, Eeckels R, Manshande-Desmet V, Vlietinck R. 1987. Rest versus heavy work during the last weeksof pregnancy: influence on fetal growth. British Journal of Obstetrics and Gynecology 94:1059–1067.

Martin DH, Eschenbach DA, Cotch MF, Nugent RP, Roa AV, Klebanoff MA, Lou Y, Rettig PJ, Gibbs RS, Pastorak JG, Regan JA, Kaslow RA. 1997. Double-blind placebo-controlled treatment trial of chlamydia trachomatis endocervical infections in pregnant women. Infectious Diseases in Obstetrics and Gynecology 5:10–17.

Martorell R, Ramakrishnan U, Schroeder DG, Melgar P, Neufeld L. 1998. Intrauterine growth retardation, body size, body composition and physical performance in adolescence. European Journal of Clinical Nutrition 52:S43–S53.

McCormick MC. 1985. The contribution of low birth weight to infant mortality and childhood morbidity. New England Journal of Medicine 312:82–90.

Medical Research Council/Royal College of Obstetricians (MRC/RCOG) Working Party on Cervical Cerclage. 1993. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre randomised trial of cervical cerclage. British Journal of Obstetrics and Gynaecology 100:516–523.

Menard MK, Newman RB, Keenan A, Ebeling M. 1996. Prognostic significance of prior preterm twin delivery on subsequent singleton pregnancy. American Journal of Obstetrics and Gynecology 174:1429–1432.

Mercer BM, Goldenberg RL, Moawad AH, Meis PJ, Iams JD, Das AF, Caritis SN, Miodovnik M, Menard MK, Thurnau GR, Dombrowski MP, Roberts JM, McNellis D, for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. 1999. The preterm prediction study: effect of gestational age and cause of preterm birth on subsequent obstetric outcome. American Journal of Obstetrics and Gynecology 181:1216–1221.

Merchant KM, Villar J, Kestler E. 2001. Maternal height and newborn size relative to risk of intrapartum caesarean delivery and perinatal distress. British Journal of Obstetrics and Gynaecology 108:1–8.

Miller HC, Merritt TA. 1979. Fetal Growth in Humans. Chicago: Year Book Medical Publishers.

Moyo SR, Tswana SA, Nyström L, Bergström S, Blomberg J, Ljungh A. 1995. Intrauterine death and infections during pregnancy. International Journal of Gynaecology and Obstetrics 51:211–218.


Naeye RL, Tafari N, Judge D, Gilmour D, Marboe C. 1977. Amniotic fluid infections in an African city. Journal of Pediatrics 90:965–970.

Narayanan I, Bala S, Prakash K, Verma RK, Gujral VV. 1980. Partial supplementation with expressed breast-milk for prevention of infection in low-birth-weight infants. Lancet 2(8194):561–563.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Narayanan I, Prakash K, Gujral VV. 1981. The value of human milk in the prevention of infection in the high-risk low-birth-weight infant. Journal of Pediatrics 99:496–498.

Norman K, Pattinson RC, de Souza J, de Jong P, Moller G, Kirsten G. 1994. Ampicillin and metronidazole treatment in preterm labour: a multicentre, randomised controlled trial. British Journal of Obstetrics and Gynaecology 101:404–408.


Olsén P, Läärä E, Rantakallio P, Jarvelin MR, Sarpola A, Hartikainen AL. 1995. Epidemiology of preterm delivery in two birth cohorts with an interval of 20 years. American Journal of Epidemiology 142:1184–1193.

Olsén SF. 1993. Consumption of marine n-3 fatty acids during pregnancy as a possible determinant of birth weight. Epidemiologic Reviews 15:399–413.

Olsén SF, Hansen HS, Sommer S, Jensen B, Sorensen TI, Secher NJ, Zachariassen P. 1991. Gestational age in relation to marine n-3 fatty acids in maternal erythrocytes: a study of women in the Faroe Islands and Denmark. American Journal of Obstetrics and Gynecology 164:1203–1209.

Olsén S, Sorensen JD, Secher NJ, Hedegaard M, Henriksen TB, Hansen HS, Grant A. 1992. Randomised controlled trial of effect of fish-oil supplementation on pregnancy duration. Lancet 339(8800):1003–1007.

Olsén S, Secher N, Tabor A, Lweber T, Walker J, Gluud C. 2000. Randomised clinical trials of fish oil supplementation in high risk pregnancies. British Journal of Obstetrics and Gynaecology 107:382–395.

Onwude J, Lilford R, Hjartardottir H, Staines A, Tuffnell D. 1995. A randomised double blind placebo controlled trial of fish oil in high risk pregnancy. British Journal of Obstetrics and Gynaecology 102:95–100.

Orskou J, Kesmodel U, Henriksen TB, Secher NJ. 2001. An increasing proportion of infants weigh more than 4,000 grams at birth. Acta Obstetricia et Gynecologica Scandinavica 80:931–936.

Osendarp SJM, van Raaij JMA, Ariffeen SE, Wahed MA, Baqui AB, Fuchs GJ. 2000. A randomized, placebo-controlled trial of the effect of zinc supplementation during pregnancy on pregnancy outcome in Bangladeshi urban poor. American Journal of Clinical Nutrition 71:114–119.

Osman NB, Folgosa E, Gonzales C, Bergström S. 1995. Genital infections in the aetiology of late fetal death: an incident case-referent study. Journal of Tropical Pediatrics 41:258–266.


Page JM, Schneeweiss S, Whyte HEA, Harvey P. 1993. Ocular sequelae in premature infants. Pediatrics 92:787–790.

Papiernik E, Bouyer J, Dreyfus J, Collin D, Winisdorffer G, Guegen S, Lecomte M, Lazar P. 1985. Prevention of preterm births. Pediatrics 76:154–158.

Paz I, Laor A, Gale R, Harlap S, Stevenson DK, Seidman DS. 2001. Term infants with fetal growth restriction are not at increased risk for low intelligence scores at age 17 years. Journal of Pediatrics 138:87–91.

Porter TF, Fraser AM, Hunter CY, Ward RH, Varner MW. 1997. The risk of preterm birth across generations. Obstetrics and Gynecology 90:63–67.

Prentice AM. 1980. Variations in maternal dietary intake, birthweight and breast-milk output in The Gambia. In: H Aebi, RG Whitehead (eds). Maternal Nutrition During Pregnancy and Lactation. Bern: Hans Huber Publishers. Pp. 167–183.

Prentice AM, Whitehead RG, Watkinson M, Lamb WH, Cole TJ. 1983. Prenatal dietary supplementation of African women and birth weight. Lancet 1(8323):489–492.


Ramakrishnan U, Martorell R, Schroeder DG, Flores R. 1999. Role of intergenerational effects on linear growth. Journal of Nutrition 129:544S–549S.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Raman L, Neela J, Balakrishna N. 1992. Comparative evaluation of calf, thigh and arm circumference in detecting low birth weight infants—Part II. Indian Pediatrics 29:481–484.

Reece M, McGregor J, Allen K, Harris M. 1997. Maternal and perinatal long-chain fatty acids: possible roles in preterm birth. American Journal of Obstetrics and Gynecology 176:907–914.

Richardson DK, Gray JE, Gortmaker SL, Goldmann DA, Pursley DM, McCormick MC. 1998. Declining severity adjusted mortality: evidence of improving neonatal intensive care. Pediatrics 102:893–899.

Robertson CMT, Svenson LW, Kyle JM. 2002. Birth weight by gestational age for Albertan liveborn infants, 1985 through 1998. Journal of Obstetrics and Gynaecology Canada 24:138–148.

Robertson PA, Sniderman SH, Laros RK Jr, Cowan R, Heilbron D, Goldenberg RL, Iams JD, Creasy RK. 1992. Neonatal morbidity according to gestational age and birth weight from five tertiary care centers in the United States, 1983 through 1986. American Journal of Obstetrics and Gynecology 166:1629–1641.

Ross SM, MacPherson TA, Naeye RL, Khatree MHD, Wallace JA. 1982. Causes of fetal and neonatal mortality in a South African Black community. South African Medical Journal 61:905–908.

Rosso P, Winick M. 1974. Intrauterine growth retardation: a new systematic approach based on the clinical and biochemical characteristics of this condition. Journal of Perinatal Medicine 2:147–160.

Rush D. 2001. Maternal nutrition and perinatal survival. Journal of Health, Population, and Nutrition 19:S217–S264.


Sattar N, Berry C, Greer I. 1998. Essential fatty acids in relation to pregnancy complications and fetal development. British Journal of Obstetrics and Gynaecology 105:1248–1255.

Scholl T, Hediger M, Schall J, Mead J, Fischer R. 1995. Maternal growth during adolescent pregnancy. Journal of the American Medical Association 274:26–27.

Schultz LJ, Steketee RW, Macheso A, Kazembe P, Chitsulo L, Wirima JJ. 1994. The efficacy of antimalarial regimens containing sulfadoxine-pyrimethamine and/or chloroquine in peventing peripheral and placental Plasmodium falciparum infection among pregnant women in Malawi. American Journal of Tropical Medicine and Hygiene 51:515–522.

Shults RA, Arndt V, Olshan AF, Martin CF, Royce RA. 1999. Effects of short interpregnancy intervals on small-for-gestational age and preterm births. Epidemiology 10(3):250–254.

Silva AAM, Barbieri MA, Gomes UA, Bettiol H. 1998. Trends in low birth weight: a comparison of two birth cohorts separated by a 15-year interval in Ribeirao Preto, Brazil. Bulletin of the World Health Organization 76:73–84.

Skjaerven R, Gjessing HK, Bakketeig LS. 2000. Birthweight by gestational age in Norway. Acta Obstetricia et Gynecologica Scandinavica 79:440–449.

Smaill F. 2002. Antibiotics for treatment of asymptomatic bacteriuria in pregnancy (Cochrane Review). The Cochrane Library, Issue 2.

Sommerfelt K, Andersson HW, Sonnander K, Ahlsten G, Ellertsen B, Markestad T, Jacobsen G, Hoffman HJ, Bakketeig L. 2000. Cognitive development of term small for gestational age children at five years of age. Archives of Disease in Childhood 83:25–30.

Stein Z, Susser M, Saenger G, Marolla F. 1975. Famine and Human Development. New York: Oxford University Press.

Stewart AL, Rifkin L, Amess PN, Kirkbride V, Townsend JP, Miller DH, Lewis SW, Kingsley DP, Moseley IF, Foster O, Murray RM. 1999. Brain structure and neurocognitive and behavioural function in adolescents who were born very preterm. Lancet 353:1653–1657.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

Stoltzfus RJ, Dreyfuss ML. 1998. Guidelines for the Use of Irons Supplements To Prevent and Treat Iron Deficiency Anemia. Washington, DC: International Life Sciences Institute (ILSI) Press.

Strauss RS. 2000. Adult functional outcome of those born small for gestational age. Journal of the American Medical Association 283:625–632.

Susser M, Stein Z. 1994. Timing in prenatal nutrition: a reprise of the Dutch Famine Study. Nutrition Reviews 52:84–94.


Tafari N, Naeye RL, Gobezie A. 1980. Effects of maternal undernutrition and heavy physical work during pregnancy on birth weight. British Journal of Obstetrics and Gynaecology 87:222–226.

Tanner, JM. 1989. Foetus into Man: Physical Growth from Conception to Maturity. 2nd edition. Ware, UK: Castlemead Publications.


Victora CG, Barros FC, Vaughan JP, Teixeira AMB. 1987. Birthweight and infant mortality: a longitudinal study of 5914 Brazilian children. International Journal of Epidemiology 16:239–245.

Villar J, Belizan JM. 1982. The relative contribution of prematurity and fetal growth retardation to low birth weight in developing and developed societies. American Journal of Obstetrics and Gynecology 143:793–798.

Villar J, Rivera JA. 1988. Nutritional supplementation during two consecutive pregnancies and the interim lactation period: the effect on birth weight. Pediatrics 81:51–57.

Villar J, Smeriglio V, Martorell R, Brown CH, Klein RE. 1984. Heterogeneous growth and mental development of intrauterine growth-retarded infants during the first 3 years of life. Pediatrics 74:783–791.

Villar J, de Onis M, Kestler E, Bolaños, Cerezo R, Bernedes H. 1990. The differential neonatal morbidity of the intrauterine growth retardation syndrome. American Journal of Obstetrics and Gynecology 163:151–157.

Villar J, Farnot U, Barros F, Victora C, Langer A, Belizan J. 1992. A randomized trial of psychosocial support during high-risk pregnancies. New England Journal of Medicine 327:1266–1271.

Villar J, Ba’aqeel H, Piagio G, Lumbiganon P, Belizan JM, Farnot U, Al-Mazrou Y, Carroli G, Pinol A, Donner A, Nigenda G, Mugford M, Fox-Rushby J, Hutton G, Bersgjø H, Bakketeig L, Berendes H. 2001. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet 357:1551–1564.


Walton A, Hammond J. 1938. The maternal effects on growth and conformation in Shire horse-Shetland pony crosses. Proceedings of the Royal Society of London 125(B):311–335.

Whitehead RG, Paul AA. 1982. Diet and the pregnant and lactating woman. In: Turner MR (ed). Nutrition and Health, a Perspective. Lancaster, UK: MTP Press Ltd. Pp. 159–168.

Woelk G, Emanuel I, Weiss NS, Psaty BM. 1998. Birth weight and blood pressure among children in Harare, Zimbabwe. Archives of Disease in Childhood. Fetal and Neonatal Edition 79:F119–F122.

Wolfe HM, Gross TL, Sokol RJ. 1987. Recurrent small for gestational age birth: perinatal risks and outcomes. American Journal of Obstetrics and Gynecology 157:288–293.

World Bank. 1999. Curbing the Epidemic: governments and the economics of tobacco control. World Bank Development in Practice Series, Stock No. 14519.

World Health Organization (WHO). 1993. WHO Collaborative Study of Birth Weight Surrogates. Use of a simple anthropometric measurement to predict birth weight. Bulletin of the World Health Organization 71:157–163.

Suggested Citation:"6. The Problem of Low Birth Weight." Institute of Medicine. 2003. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10841.
×

World Health Organization (WHO). 1995. Maternal anthropometry and pregnancy outcomes: WHO Collaborative Study. Bulletin of the World Health Organization 73(suppl):1–98.


Yajnik CS. 2001. The insulin resistance epidemic in India: fetal origins, later lifestyle, or both? Nutrition Reviews 1:1–9.


Zhu BP, Rolfs RT, Nangle BE, Horan JM. 1999. Effect of the interval between pregnancies on perinatal outcomes. New England Journal of Medicine 340(8):589–594.

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Next: 7. Reducing Mortality and Morbidity from Birth Defects »
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Birth outcomes have improved dramatically worldwide in the past 40 years. Yet there is still a large gap between the outcomes in developing and developed countries. This book addresses the steps needed to reduce that gap. It reviews the available statistics of low birth weight, prematurity, and birth defects; reviews current knowledge and practices of a healthy pregnancy, identifies cost-effective opportunities for improving birth outcomes and supporting families with an infant handicapped by birth problems, and recommens priority research, capacity building, and institutional and global efforts to reduce adverse birth outcomes in developing countries. The committee has based its study on data and information from several developing countries, and provides recommendations that can assist the March of Dimes, Centers for Disease Control and Prevention, and NIH in tailoring their international program and forging new partnerships to reduce the mortality and morbidity associated with adverse birth outcomes.

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