Indian Pediatr 2012;49:
The Ignominy of Low birth Weight in South Asia
Zulfiqar A Bhutta
Noordin Noormahomed Sharieff Professor and Founding
Chair, Division of Women and Child Health.
The Aga Khan University, Karachi, Pakistan.
Although estimates vary, it is recognized that more than 20 million
infants worldwide, representing 16% of all births in developing countries,
are born with low birth weight (LBW). The vast majority, over 95%, of
these births are in developing countries . More than two thirds (68%)
of all LBW infants are born with evidence of intrauterine growth
retardation (IUGR), the majority in South-Central Asia, where more than a
quarter (27%) of all infants weigh less than 2500 g at birth . Such
IUGR infants mostly include those born at term (about 9.6% of all newborns
weigh between 2000 and 2499 g at birth). They may also include preterm
infants (an estimated 1.3% infants born globally weighing between
1500-1999 g at birth) or those born with a combination of prematurity and
IUGR. Term IUGR infants have much higher rates of morbidity and neonatal
complications including a higher risk of mortality . It is estimated
that newborn infants weighing between 2000–2499 g (those representing the
majority with term IUGR) are 2.8 (95% CI 1.8-4.4) times more likely to die
during the neonatal period than those weighing more than 2499 g at birth.
Despite limited data from community settings, it is also known that the
corresponding relative risks of dying from birth asphyxia and infectious
diseases are 2.3 (95% CI 1.3-4.1) and 2.0 (95% CI 1.2-3.4) for those
weighing 2000-2499g at birth . More importantly, the well documented
long term effects of LBW, coupled with post-natal factors also highlight
important links with the growing epidemic of non-communicable diseases
Recognized major risk factors associated with term LBW
include maternal undernutrition, frequently reflected with low maternal
body-mass index , as well as placental insufficiency associated with
severe morbidity such as pre-eclampsia. The potential role of multiple
micronutrient deficiencies in affecting birth weight is underscored by
several studies from South Asia attributing the IUGR to specific
deficiencies and corroborated by the recognized effect of multiple
micronutrient supplementation in pregnancy on increasing the birth weight
. These distal determinants of LBW are manifestations of a number of
proximal factors including poverty and marginalization. These social
determinants of LBW were poignantly underscored by the classic enunciation
of the "Asian enigma" by the late Professor Ramalingaswami, et al.
, who highlighted the importance of gender inequality, lack of female
empowerment and the key role played by the environment and caring
practices in determining maternal and childhood undernutrition. Over the
last two decades, numerous scholars and nutrition scientists from the
region have explored the risk factors associated with LBW and suggested
solutions. In this issue of the journal, Mumbare, et al.  once
again underscore the importance of maternal undernutrition, poor education
and lack of antenatal care in a cohort of term LBW infants born in a
hospital setting in Maharashtra. Notwithstanding the limitations of a
hospital-based cohort and the large proportion of infants excluded from
the analysis, these findings are a stark reminder that little has changed.
South Asia must stand out as one of the most
unfortunate regions of the world. Despite enormous resources, steady
economic growth and dividends of a young population, inequity remains a
major issue and major pockets of poverty remain. The issues and solutions
to the challenge of LBW were highlighted decades ago as falling within the
domain of human rights rather than health alone. While economists and
politicians argue over the definitions of poverty, many women remain
underserved, frequently bereft of fundamental rights and access to health,
education and adequate nutrition. While much progress has been made in
initiating large scale public health programs aimed at service delivery
through community health workers, unconditional poverty alleviation
strategies and conditional cash transfers, the emphasis is still on quick
fixes rather than fundamental societal change. In contrast to Latin
America and much of Southeast Asia, progress in key interventions such as
female education and empowerment, enhancement of age at marriage and first
pregnancy and access to family planning remain painfully slow. If South
Asia is to make progress in human development, addressing maternal and
fetal undernutrition through concerted multi-sector initiatives, community
education and preconception care are key.
Competing interests: None stated; Funding:
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