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Correlates of low birth weight in term pregnancies: a retrospective study from Iran
BMC Pregnancy and Childbirthvolume 8, Article number: 12 (2008)
Low birth weight (LBW) is considered as a major multifaceted public health concern. Seventy-two percent of LBW infants are born in Asia. An estimation of 8% LBW infants has been reported for Eastern Mediterranean region including Iran. This study investigated contributory factors of LBW in singleton term births in Tehran, Iran. Tehran is a multicultural metropolitan area and a sample from the general population in Tehran could be regarded as a representative sample of urban population in Iran.
This was a retrospective study using data from 15 university maternity hospitals in Tehran, Iran. Data on all singleton term births in these hospitals were extracted from case records during a one calendar year. Study variables included: maternal age, maternal educational level, history of LBW deliveries, history of preterm labor, cigarette smoking during pregnancy, number of parities, chronic diseases and residential area (Tehran versus suburbs of Tehran). In order to examine the relationship between LBW and demographic and reproductive variables the adjusted logistic regression analysis was performed.
In all, data for 3734 term pregnancies were extracted. The mean age of women was 25.7 (SD = 5.3) years and 5.2% of term births were LBW. In addition to association between LBW and maternal age, significant risk factors for LBW were: history of LBW deliveries [adjusted odds ratio (OR) = 2.53, 95% confidence interval (CI) = 1.06–6.03], smoking during pregnancy (OR = 4.64, 95% CI = 1.97–10.95) and chronic diseases (OR for hypertension = 3.70, 95% CI = 2.25–6.06, OR for others = 2.04, 95% CI = 1.09–3.83).
The findings indicate that in addition to maternal age, history of LBW deliveries; smoking during pregnancy and chronic diseases are significant determinants of LBW in this population. This is consistent with national and international findings indicating that maternal variables and risk behaviors during pregnancy play important roles on LBW.
Low birth weight (LBW) is a reliable indicator in monitoring and evaluating the success of maternal and child health programs and has been defined as a birth weight less than 2500 gr . It is estimated that worldwide 15.5% of all live births per year are LBW and more than 95 percent of LBW infants are born in developing countries. Seventy-two percent of LBW infants are born in Asia, although large differences exist in WHO Asian regions and its sub-regions. It is estimated that there are 8% of LBW infants in Eastern Mediterranean region including Iran .
A baby's low weight at birth is either the result of preterm birth or of intrauterine growth retardation (IUGR) . The latter implies that fetus's growth has been inhibited and thus the fetus has not attained the potential growth. The diagnosis of IUGR is usually based on small size for gestational age (SGA). However, IUGR is not completely equal to SGA and there is need to develop standardized and population-specific growth charts to well differentiate these clinical terms in practice .
The evidence suggests preterm birth as a main cause of newborn mortality and morbidity . Indeed, LBW due to IUGR as a poor birth outcome affects the person throughout life course and is associated with a higher risk of developmental impairments including cognitive development , medical and health outcomes in adulthood [6, 7]. Giving birth to a LBW infant is influenced by several determinants including maternal variables [8–10], socio-economic status  and environmental factors .
This study investigated the contribution of socio-demographic and reproductive-obstetrical risk factors on LBW in all singleton term births that referred from Tehran and its suburbs to the main general and teaching hospitals in Tehran during a one calendar year (2005).
A retrospective study was conducted in 15 maternity wards of the main general and teaching hospitals in Tehran, Iran. The ethics committee of Tehran University of Medical Sciences approved the study. Using hospital records, data on all singleton term births (≥37 gestational weeks) of married pregnant women in these hospitals during year 2005 were extracted. Studied variables included maternal age, maternal education, number of parities, history of LBW deliveries (HLBW), history of preterm labor (HPL), cigarette smoking during pregnancy, chronic diseases and residential area (Tehran versus suburbs of Tehran). Mothers' chronic diseases were considered as categorical variable: 1) none (no report of any disease in case notes), 2) hypertension (most reported condition) and 3) others. The latter included renal, heart, respiratory, arthritis and several other chronic diseases. There were no other LBW related data available. Birth outcome was defined as LBW and covered IUGR as well. All term LBW babies had been examined by a gynecologist. According to sonography results and weight chart for gestational ages, the diagnosis of IUGR was established.
The regression analysis was performed to calculate crude and adjusted odds ratios and to examine the predictive effect of variables studied on risk for LBW. LBW was considered as dependent variable and was categorized into two groups: <2500 gr. and ≥2500 gr. Other variables were entered into the model as key independent variables and except "maternal age and number of deliveries"; all other variables were entered into the model as categorical data.
In all, 3734 pregnant women were studied. The mean age of mothers and the mean duration of pregnancy were 25.7 (SD = 5.3) years and 39.03 (SD = 1.36) weeks respectively. Overall, 5.2% of term births were LBW and of these 4% had been recognized as IUGR babies. The mean birth weight was 3.2 (SD = 0.47) Kg. Self-reported cigarette smoking was 1.2% (n = 45). Table 1 presents the distribution of LBW determinants (total and LBW statistics).
The findings of regression analysis for crude and adjusted odds ratios (OR) of LBW and its determinants are shown in table 2. It was found that significant risk factors for LBW were: maternal age (OR = 0.96, 95% CI = 0.92–1.00), positive history of LBW deliveries (OR = 2.53, 95% CI = 1.06–6.03), smoking during pregnancy (OR = 4.64, 95% CI = 1.97–10.95) and mothers' history of chronic diseases (OR for hypertension = 3.70, 95% CI = 2.25–6.06, OR for others = 2.04, 95% CI = 1.09–3.83).
Maternal education did not show a significant relation with LBW, but increased risk was observed for less educated mothers (OR = 3.22) and those with secondary educational level (OR = 3.44). Although residential area (Tehran versus suburbs of Tehran) was not significant, an increased risk (OR = 1.24) was observed for women referred from suburbs of Tehran.
This paper evaluated the LBW contributions in a representative sample of singleton term births in the university hospitals in Tehran, Iran during 2005. The findings showed that most of the term LBW babies are recognized as IUGR (4% of 5.2%). Evidence suggests in developing countries most of LBW infants are due to IUGR . In a simple definition, IUGR babies are considered those who are gestationally full-term (≥37 weeks) but of a birth weight <2500 gr. When there are no birth-weight-for-gestation percentiles for a population similar to the one being studied, this definition is quite useful and applicable .
Based on adjusted logistic regression analysis, maternal age was a protective factor for LBW and one year age increase, showed a 4% risk reduction (Table 2). A study from Zahedan, Iran on prevalence and risk factors of LBW in 1109 hospital births showed maternal younger age is related to a LBW baby . Similar findings from international studies have shown lower maternal age for giving birth to a LBW infant . This study provided data on a representative sample of term births in Tehran, Iran and thus would be a proper base of age effect on LBW and IUGR.
The present study indicated that obstetric history of previous LBW deliveries was a significant risk factor for LBW (OR = 2.53). The findings from this study with a relatively large sample of singleton term births in Tehran, Iran compares well to the findings from other studies. A large study by Kramer indicated risk of delivering an IUGR infant was 2.75 times greater for women with one or more previous LBW infants than for women with no history of LBW deliveries . Another study from Egypt has confirmed the importance of previous history of LBW infants (after adjusting for other risk variables) on increased chance of giving birth to a LBW infant .
We did not find a significant relationship between LBW and number of parities (p = 0.84). Studies on the topic have shown primiparous women have a greater risk of IUGR than multiparous women .
Also, cigarette smoking was found as a risk factor for LBW (OR = 4.64), although it was self-reported. Evidence suggests the strong effect of cigarette smoking during pregnancy on LBW even after controlling for other variables [17–19]. Policies focused on smoking during pregnancy should be properly emphasized in maternal and child health care services by establishing interventional and educational programs.
Maternal history of chronic diseases including hypertension and other chronic conditions increased the risk of giving birth to a LBW infant by 3.70 and 2.04 folds respectively. Documented research has confirmed that maternal diseases increase the risk of delivering LBW infants [20, 21].
Although, maternal educational level in illiterate-primary and secondary-high school grades increased the risk of LBW (OR = 3.32 & 3.44 respectively), there was not a significant association. Well established studies have indicated that mothers with lower educational level give birth more to LBW neonates [8, 11, 22].
Finally, residential area (Tehran versus suburbs of Tehran) in adjusted analysis did not show a statistical significant relationship with LBW, but an increased risk (OR = 1.24) was observed for pregnant women from suburbs of Tehran. Investigating quality of primary care may explain the region differences in LBW. Studies on LBW have suggested significant associations with socioeconomic indicators and area deprivation. Women with lower socio-economic status and those living in deprived areas give birth more to LBW infants [8, 23, 24].
This study provided data on several risk factors for LBW and IUGR in Tehran, Iran. As LBW would induce complications during infancy period and life course, prevention and control of its determinant factors should be considered in primary health care settings in order to improve mother and child health.
Low Birth Weight
Intra Uterine Growth Retardation
Small for Gestational Age
History of LBW Deliveries
History of Preterm Labor
World Health Organization: International statistical classification of diseases and related health problems. Tenth revision. 1992, Geneva, Switzerland: World Health Organization
Wardlaw T, Blanc A, Ahman E: LBW: country, regional and global estimate. 2004, New York: United Nations Children's Fund and World Health Organization
Bakketeig LS: Current growth standards, definitions, diagnosis and classification of fetal growth retardation. Eur J Clin Nutr. 1998, 52: S1-S4. 10.1038/sj.ejcn.1600534.
Gortmaker SL, Wise P: The first injustice: socioeconomic disparities, health services technology and infant mortality. Annu Rev Sociol. 1997, 23: 147-70. 10.1146/annurev.soc.23.1.147.
Hack M, Klein K, Taylor HG: Long term developmental outcomes of LBW infants. Future Child. 1995, 5: 176-96. 10.2307/1602514.
Boardman JD, Finch BK, Hummer RA: Race/ethnic differences in respiratory problems among a nationally representative cohort of young children in the United States. Popul Res Policy Rev. 2001, 20: 187-206. 10.1023/A:1010686630034.
Blair C, Ramey CT: Early intervention for low-birth-weight infants and the path to second-generation research. The effectiveness of early intervention. Edited by: Guralnick M. 1997, Baltimore: Paul H. Brookes Publishing Company, 52-2
Roudbari M, Yaghmaei M, Soheili M: Prevalence and risk factors of low-birth-weight infants in Zahedan, Islamic Republic of Iran. East Mediterr Health J. 2007, 13: 838-45.
Watson-Jones D, Weiss HA, Changalucha JM, Todd J, Gumoduka B, Bulmer J, Balira R, Ross D, Mugeye K, Hayes R, Mabey D: Adverse birth outcomes in United Republic of Tanzania-impact and prevention of maternal risk factors. Bull World Health Organ. 2007, 85: 9-18.
Bukowski R, Smith GCS, Malone FD, Ball RH, Nyberg DA, Comstock CH, Hankins GD, Berkowitz R, Gross SJ, Dugoff L, Craigo SD, Timor-Tritsch IE, Carr SR, Wolfe HM, D'Alton ME: Fetal growth in early pregnancy and risk of delivering LBW infant: prospective cohort study. BMJ. 2007, 334: 836-91. 10.1136/bmj.39129.637917.AE.
Finch BK: Socioeconomic gradients and low birth-weight: empirical and policy considerations. Health Serv Res. 2003, 38: 1849-41. 10.1111/j.1475-6773.2003.00204.x.
Wang X, Ding H, Ryan L, Xu X: Association between air pollution and LBW: a community-based study. Environ Health Perspect. 1997, 105: 514-20. 10.2307/3433580.
Villar J, Belizan JM: The relative contribution of prematurity and fetal growth retardation to low birth weight in developing and developed societies. Am J Obstet Gynecol. 1982, 143: 793-8.
Keily JL, Brett KM, Yu S, Rowley DL: Low birth weight and intrauterine growth retardation. CDC'S Public Health Surveillance for Women, Infants and Children. [http://www.cdc.gov/reproductivehealth/Products&Pubs/DatatoAction/pdf/birout3.pdf]
Kramer MS: Determinants of low birth weight: methodological assessment and meta-analysis. Bull World Health Organ. 1987, 65: 663-737.
Mansour E, Eissa AN, Nofal LM, Salam I: Incidence and factors leading to LBW in Egypt. Int J Pediatr. 2002, 1: 223-30.
Doctor BA, O'Riordan MA, Krichner HL, Shah D, Hack M: Perinatal correlates and neonatal outcomes of small for gestational age infants born at term gestation. Am J Obstet Gynecol. 2001, 185: 652-6. 10.1067/mob.2001.116749.
Jaddoe VW, Verburg BO, de Ridder MA, Hofman A, Mackenbach JP, Moll HA, Steegers EA, Witteman JC: Maternal smoking and fetal growth characteristics in different periods of pregnancy: the generation R study. Am J Epidemiol. 2007, 165: 1207-1215. 10.1093/aje/kwm014.
Delpisheh A, Yvonne K, Shaheen R, Bernard JB: Socio-economic status, smoking during pregnancy and birth outcomes: an analysis of cross-sectional community studies in Liverpool (1993–2001). J Child Health Care. 2006, 10: 140-8. 10.1177/1367493506062553.
Jamal N, Khan M: Maternal risk factors associated with LBW. J Coll Physicians Surg Pak. 2003, 13: 25-8.
Schwartz R, Sacks P: Etiology and outcome of LBW and preterm infants. Health Econ. 2002, 11: 206-10.
Grjibovski AM, Bygren LO, Svartbo B: Socio-demographic determinants of poor infant outcome in north-west Russia. Paediatr Perinat Epidemiol. 2002, 16: 255-62. 10.1046/j.1365-3016.2002.00429.x.
Dibben CH, Sigala M, Macfarlane A: Area deprivation, individual factors and LBW in England: is there evidence of an "area effect"?. J Epidemiol Community Health. 2006, 60: 1053-9. 10.1136/jech.2005.042853.
Thompsom L, Goodman D: Study finds LBW rates vary widely across U.S. [http://dms.dartmouth.edu/news/2005_h2/print/07nov2005_thompson]
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/8/12/prepub
The Authors would like to give their thanks to Dr Fatemeh Ramazanzadeh for her guidance and also, efforts to conduct the study under the financial support of the Vali-e-Asr Reproductive Health Research Center, Tehran University of Medical Sciences.
The author(s) declare that they have no competing interests.
MV and ST designed and conducted the study. MV and AM analyzed the data and wrote the paper. All authors read and approved the manuscript.
About this article
- Eastern Mediterranean Region
- Term Birth
- Maternal Educational Level
- Adjusted Logistic Regression Analysis
- Child Health Care Service