Indian Pediatrics 2002; 39:244-253  

Birth Weight Patterns in Rural Undernourished Pregnant Women

S. Agarwal, A. Agarwal, A.K. Bansal, D.K. Agarwal and K.N. Agarwal

From the Department of Pediatrics, Insititute of Medical Sciences, Varanasi, U.P., India.

Correspondence to: Dr. Sonika Agarwal, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi 110 029, India.

E-mail: [email protected]

Manuscript received: April 26, 2000, Initial review completed: May 31, 2000,
Revision accepted: October 22, 2001.

Objective: To study the birth weight pattern in chronic as well as currently undernourished pregnant women. Design: Prospective study of rural pregnant women by following eligible women. Setting: Two adjoining blocks of rural Varanasi. Methods: 3700 pregnant women from rural areas of Varanasi for whom data for anthropometry, hemoglobin, dietary intake, birth weight, fundal height and abdominal girth at 16±2, 28±2 and 36±2 weeks of gestation were recorded. Outcome measure was birth weight pattern of newborns. Results: Of the births, 7.2% were <2250 g and 27.4% <2500 g. The weekly birth weight increments in gestation 36-42 weeks were 5-53 g, only. The fundal height did not increase during 35-39 weeks of gestation (lower by 5 cm as compared to normal). Nutrition supplement in the third trimester significantly increased fundal height and abdominal girth. Fundal height below 24.5 cm at 28 weeks of gestation (1368 women) was associated with higher low birth weight deliveries. Conclusions: Birth weight and fundal height increments during later pregnancy are low in undernourished pregnant women. Fundal height <24.5 cm at 28 weeks of gestation identified women with higher risk for lowbirth weight infants. The prevalence of low birth weight was 27.4% and of prematurity was 6.6%.

Key words: Abdominal girth, Birthweight, Fundal height, Low Birth Weight, Preterm, Maternal undernutrition.

THE proportion of babies with low birth weight (<2500 g) ranges between 13-43% in the low socio-economic strata of many countries, including some developed nations. Average birth weights in rural areas of the developing world were usually 400 to 1000 g lower than in industrialized nations, contri-buting to high levels of neonatal and postneonatal mortality in such communi-ties(1,2). These neonates have higher morbidity and mortality during first year of life, and surviving ones rank low on tests of mental development(3). For these reasons, high prevalence of LBW babies is a major public health problem and a serious obstacle to national development.

Mothers of infants with birth weight ³3000 g had weight at term 55.0 kg in India (Pune), Nepal and Sri Lanka; 61.0 kg in Indonesia, Myanmar, Thailand and Vietnam; 65.0 kg in China, Columbia and Malawi; and 73.0 kg in Ireland and United Kingdom. The pre-pregnancy weights of these women were 45.0, 50.0, 55.0 and 60.0 kg, respectively. For first three groups of countries, weight gain was similar; however for Ireland and United Kingdom women gained 3.0 kg more. Interestingly, mothers with infants <2500 g birth weight gained 4.0 kg less in all groups as compared to those ³3000 g(4). Besides weight gain during pregnancy, fundal height and abdominal girth have also been related to birth weight pattern. Investigators(5) have tried to develop charts on these parameters in relation to gestational age to predict pregnancy outcome in terms of birth weight.

The rural Varanasi data(6-9) on pregnant women are examined in this communication for weight gain, fundal height and abdominal girth in relation to birth weight pattern.

The data were collected in randomly selected 28 villages of Harahua (Integrated Child Development Services - ICDS) and 21 villages of Kashi Vidyapeeth (Non-ICDS), adjoining blocks of Varanasi, Uttar Pradesh, India. The Indian Council of Medical Research, New Delhi, and the ethical committee of the Institute of Medical Sciences, Vasanasi, approved the study. The district administration and village families gave consent for the study. The socio-demographic and biological characteristics of women in these blocks were found to be similar(6-9).

The female village workers were contacting eligible (married reproductive age) women every month for weight record and last menstrual period. The gestation was taken as completed weeks. Thus pre-pregnancy weight and subsequently during pregnancy – weight, fundal height and abdominal girth were measured at 16 ± 2, 28 ± 2 and 36 ± 2 weeks of gestation. In all live births weights were recorded within 48 hours after birth. Out of 6649 live births(7-9) data for fundal height and abdominal girth measured by field worker and checked by obstetrician at three measurements (16 ± 2, 28 ± 2 and 36 ± 2 weeks of gestation) were available only for 3700 women, with data for weight gain in pregnancy and birth weight. This happened if subject was not available on two visits during the measurement period.

Women were weighed with light clothes of known weight on Chattilon platform scale (M/s Chattilon and Sons, USA) having accuracy up to 20 g. Infants at birth were weighed without clothes on a modified Tansi Scale with accuracy of 10 g. The scales were checked daily with known weights. Fundal height was measured as the distance between the symphysis pubis and the highest point of the uterine fundus. Abdominal girth - was measured, as the circumference of the abdomen at the level of umbilicus, by cross over technique. The measurments were recorded by a fibre glass tape. Available fundal height meausrements at 28 weeks of gestation with corresponding birth weight in 1368 were used to find out if fundal height at 28 weeks has any association with birth weight, to identify risk for low birth weight deliveries.

Hemoglobin was estimated by cyan-methemoglobin method, using Drabkin’s solution and the standard provided by M/s. Ranbaxy Ltd., India. The variation in hemo-globin on two consecutive determinations (separate, finger prick sample) on every fifth woman by two laboratory technicians was 2.65%.

SPSS package was used to calculate mean ±SD, Chi square test, Analysis of variance, Tukey’s test and multiple regression analysis.

Maternal characteristics including gesta-tion, anthropometry, dietary intake, hemo-globin, weight gain in pregnancy, pregnancy interval and per capita income were different in different birth weight groups, particularly for those in weight group <2500 g (Table I) Parity was similar in these birth weight groups.

The percentile curves for birth weight are presented in Fig.1 for 3700 infants between gestational ages of 35-42 weeks. The birth weights showed marginal increment between 35-41 weeks of gestation. Distribution of infants according to birth weight is given in Table II; 7.2% and 20.2% being in weight groups <2250 g and 2251-2500 g, res-pectively. Only 8.2% births were weighing 3001 g and more. There were 6.57% preterm births.

The means in weight gain during pregnancy were 5.8 ± 1.0, 6.4 ± 1.0 and 6.9 ± 1.3 kg in birth weight groups <2500, 2500-3000 and >3000 g respectively (p <0.001). Mothers of infants ³3000 g birth weight had significantly better weight being ³50.0 kg at 36 ± 2 weeks as compared to maternal weight 44.6, 46.7 and 48.6 Kg for birth weight groups <2250, 2251-2499 and 2500-2999 g, respectively (p <0.001).

Table I__Maternal Characteristics in Birth Weight (g) Groups (Mean±SD)

Fig. 1. Birthweight percentiles for gestation (rural Varanasi).

Table II__ Distribution of Birth Weights of Live Births in Rural Varanasi

The fundal height measurements (mean ± SD) at gestations 16 ± 2, 28 ± 2 and 36 ± 2 weeks for infant birth weight groups are given in Table III. Mean fundal height values in birth weight group ³3000 g as compared to lower birth weight groups were significantly higher (p <0.001) at second and third measurements. The fundal height in relation to gestation showed a progressive increase, the percentile curves became flat between 35-39 weeks (Fig. 2). The relationship of birth weight and fundal height at 28 weeks showed that percentage of infants <2250 g decreased and ³3000 g increased significantly with rising fundal height. In fundal height group 24.5-26.0 cm, there was no infant <2250 g, 12.3% in £2499 g and 27.3% in ³3000 g. These differences were significant (c2 = 47.7; p <0.0001; Table IV).

The mean abdominal girth in first measurement was significantly higher in ³3000 g infant group by 1.7 and 1.1 cm as compared to those in <2500 g and 2500-3000 g groups (p <0.001), respectively. These differences increased further in second and third measurements (Table IV). The increase in mean abdominal girth was similar for groups 2500-2999 g and ³3000 g between measurements; however those <2499 g had lower gains by 0.4 and 0.7 cm, respectively. The mean increments between first and second measurements in birth weight groups £2499 g, 2500-2900 g and ³3000 g were 8.8, 9.3 and 9.2 cm, respectively. However, the increments between second and third measurements were similar (8.6- 8.8 cm) in these birth weight groups.

Table III__Fundal Height and Abdominal Girth Measurements (Mean±SD) in Different Birth Weight Groups

Fig. 2. Fundal height in relation to gestational age.

Table IV__ Percentage of Infants in Birth Weight(g) Groups in Relation to Fundal Height (cm) at 28 Weeks of Gestation

Individually fundal height and abdominal girth at term significantly influenced the birth weight (F = 31.4; p = 0.001 and F = 134.7; p <0.001, respectively). However, these vari-ables did not influence gestation (p = 0.26). Both the parameters had significant effect on birth weight along with the variables weight gain in pregnancy and gestation. On including other independent variables in the equation the significant positive contribution of fundal height and abdominal girth on birth weight disappeared. Only gestation, weight gain, calorie intake in third trimester and pregnancy interval had significant effect. Higher protein intake had significant negative effect on birth weight (Table V). The role of hard physical activity in third trimester, on birth weight showed significant negative effect (correla-tion coefficient = –1.7081, SE = 0.537; p <0.02). However, hard activity in third trimester did not influence the fundal height, abdominal girth or gestation(10).

The means for fundal height and abdominal girth increased by 8.2 ± 2.0 and 11.0 ± 3.9 cm in supplemented women and by 7.6 ± 2.0 and 9.1 ± 4.1 cm in unsupplemented women, respectively. These differences were significant (p <0.001). Nutrition supplement contained 400 kcal/day and 20 g protein in the last trimester.

In the present rural study data (1987-1993), low birth weight accounted for 27.4% births and preterm births for 6.6% births. Studies from urban and rural North Arcot District, Tamil Nadu (1970-72) revealed low birth weight prevalence to be 31.9%(11). Ghosh et al.(12) in 1969-72 from urban Delhi found low birth weight rate of 23%. In urban Ludhiana(13) during 1974-75 the mean birth weight was 2974 g with low birth weight rate 24.6% (this is economically rich district in India). In urban Pune(14) during 1977-79 the low birth weight rate was lower than the studies cited above, being 19.9% with 31.3% >3000 g. In the present study the mean birth weight during 36-41 weeks of gestation increased by 5-53 g per week only. These studies conclude that low birth weight deli-veries remain a public health problem in India. In contrast studies from urban Varanasi(15), South India(16) and Ludhiana(13) showed much higher weight gain (Ludhiana >100 g gain per week between 36-40 weeks of gestation). The phenomenon of later pregnancy growth arrest as in the present study was observed also in the Ethopian mothers between 35-43 weeks of gestation, the affect was possibly due to food shortage in later pregnancy(17). Such situation was also observed during war famines. The experience of World War II from Leningrad famine (period 16 months) do suggest that in women with earlier undernutrition faced with acute malnutrition, birth weight fell by 530 g and exposure in second trimester resulted in 50% births with weight <2500 g(18). In contrast at 28 weeks, Dutch famine(19) reduced birth weight by 327 g and corresponding figure for LBW was 9% only, as women had better pre-pregnancy nutrition. Lubchenco et al.(20) showed that the fetal weight growth velocity was higher varying from 100-150 g per two weeks of gestation, the gains being as high as 300-500 gm from 30-38 weeks of gestation.

Table V__Multivariate Analysis of Determinants of Birth Weight in Women of Rural Varanasi

In humans the fetal growth curve has a very characteristic shape; almost linear during 28-38 weeks of gestation followed by a progressive reduction in growth rate which is more marked and occurs earlier in the under-privileged social class. This faltering is possibly nutritional in origin(21). Shortly after birth infants regain a growth rate similar to the beginning of the third trimester of intrauterine life. Furthermore, there is no irregularity in the growth curves of prematurely born babies near their theoretical term(22). In the present study fundal height was closely related to the birth weight pattern, as it did not show much change between 34-39 weeks of gestation (Fig.2). Fundal heights even in the birth weight group >3000 g was lower by 5 cm in later pregnancy, being 23.0 and 31.9 cm at 28 and 36 weeks, respectively. At 28 weeks of gestation fundal height <24.5 cm was associated with higher low birth weight deliveries (LBW); those with measurements 24.5-26.0 cm had significantly lower LBW. Hughes et al.(23) observed that at 28 weeks of gestation birth weight in different fundal heights, namely, >30 cm, 27-30 cm, 24-27 cm and <24 cm were 3770 ± 450 g (13 out of 14 >4500 g), 3410 ± 390 g, 3170 ± 400 g and 2730 ± 440 g, respectively. The present study women receiving nutrition supplement showed increase in fundal height as well as abdominal girth, significantly. Their birth weight was higher by 56 g(9). These observations suggest that low nutrition intake is possibly an important factor in later part of pregnancy affecting fundal height and birth weight. As shown by multiple regression analysis, the role of calorie intake in third trimester is important, while higher protein intake and hard physical activity may have negative effect.

The poor gains in birth weight, fundal height and maternal weight could be associated with maternal nutrition deprivation in later pregnancy associated with hard physi-cal activity (increased energy expenditure).

In rural Varanasi the mean weight gain in pregnancy was 6.9 ± 1.1 kg only with term weight of 50-51 kg; short by 4.0 kg in contrast to Pune(14) and other developing countries data for infants with birth weight >3000 g. Thus pregnancy weight gain was less by 3.0 kg in rural Varanasi as observed earlier(24) also. Gardosdi et al.(25) argued that if maternal size is taken in consideration, Indian birth weight is lower by 109 g as compared to Europeans, with variations in fundal height charts.

In conclusion, rural chronic as well as currently under/malnourished women had lower weight gain, fundal height and infant weight at birth during 36-41 weeks of gestation. Fundal height <24.5 cm at 28 weeks of gestation had higher risk of LBW delivery. The prevalence of low birth weight was 27.4% and of prematurity was 6.6%.

The authors are indebted to Dr. Badri Saxena, Additional Director General of the Indian Council of Medical Research, New Delhi for valuable help and guidance. We are also grateful to Prof. David Rush (USAID Consultant), Jean Mayer, USDA Human Nutrition Research Center on Aging 711, Wash. St. Boston USA, for guidance in plan-ning the study. The Banaras Hindu Univer-sity, Varanasi, extended the infrastructural facilities very generously.

Contributors: SA, AA did field work and drafted the manuscript. Planning, supervision and data inter-pretation was done by KNA and DKA. AK helped in statistical analysis. KNA will act as guarantor for the manuscript.

Funding: Indian Council of Medical Research and United States Agency for International Development.

Competing interests: None stated.

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