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Brief Reports Indian Pediatrics 2001; 38: 271-275 |
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Incidence of Low Birth Weight in Rural Ballabgarh, Haryana |
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Low birth weight (LBW) is one of the important causes for the high infant mortality rate (IMR) in developing countries. In India, during the year 1991, the IMR was 80 per 1000 live births and Neonatal Mortality Rate (NNMR) was 51 per 1000 live births(1). LBW babies have been reported to lag behind their heavier counterparts in development for the rest of their lives(2,3). Long term sequelae of LBW in terms of higher burden of non communicable diseases has also been reported(4). The incidence of low birth weight in the country is estimated to be around 40%. The basis for this has mainly come from hospital based data(5,6). The data shows a wide range from 2.7% to 40%. In rural India, almost 90% of deliveries occur at domiciliary level and are conducted by traditional birth attendants. Weighing them soon after birth poses a considerable challenge. However, the need for this information is essential for planning purposes as well as for management of newborns. We have earlier reported a low neonatal mortality rate (NNMR) in the study area of Ballabgarh as compared to the national average. The IMR in the study area was 66.6 per 1000 live births and the NNMR was 22.5 per 1000 live births in 1991(7). A higher birth weight could be one possible explanation for the lower NNMR. As community based studies on birth weight are scarce in rural Indian setting, we decided to conduct this study to assess the magnitude of LBW in rural Haryana, a state in northern India. We also wanted to test the feasibility of involving the multipurpose health workers in measurement of birth weight as a part of their routine activity.
The Comprehensive Rural Health Services Project (CRHSP), Ballabgarh is run by the All India Institute of Medical Sciences, New Delhi in active collaboration with the state government of Haryana. The field practice area consists of two Primary Health Centers (PHC) namely Dayalpur and Chhainsa and eight subcenters covering a total of 28 villages. In 1991, the total popula-tion served by CRHSP was around 63,000. For this study, two subcenter villages and two non subcenter villages under PHC Dayalpur were selected by convenient sampling. The total population of the four villages was around 10,000. The data was collected for two years from January 1991 to December 1992. The health care in these villages is provided along the national pattern. Each subcenter is staffed by a male and female multipurpose worker (M and F MPWs) and approximately serves a population of about 7,000. The workers visit the villages during the morning hours based on a pre-arranged beat schedule for the delivery of health care services. In the afternoon of each day, the workers sit in their subcenter and update the records. Thus, they are available on almost all working days in the subcenter village. In the other villages under the subcenter, they are available during the forenoon only on the days they are expected to visit the village as per the pre-arranged schedule. Female workers as a part of their routine activity registered the women in the antenatal period and followed them up till delivery. At the time of registration, details regarding last mens-trual period were asked for the calculation of gestational age and expected date of delivery. Trained birth attendants (dais) usually conducted the deliveries as they are available in the village at all times. Female workers maintained close contact with the dais to register births as and when they occurred. Two MPW (F) and one Health Assistant Female (HA-F) were trained by one of the authors (SKK) in taking the measurements at the hospital at Ballabgarh. Birth weights were recorded in the field using Salter scale. The weighing scales were calibrated regularly using a standard weight. Before each recording, the workers were asked to check the zero error and correct it by turning the screw by the side of the Salter scale. They were asked to weigh the child within forty eight hours of delivery. All efforts were made to weigh the child without clothes. The data was entered into Dbase package and analyzed using EPIINFO package(8).
As per the records as well as field verifications, the antenatal registration in the study area was around 95%. During the study period of two years, there were 660 births in the four villages. The measurements were available for 614 newborns (93.0%). The main reason for not being able to measure was because, the mother had gone outside the village for delivery, a standard social practice. The mean birth weight was 2846 grams ± 378 grams. The incidence of low birth weight (<2500 g) in the study area was 8.8% (95% C.I. : 6.7%-11.2%) with only two (0.3%) newborns having a birth weight of <1800 grams. Birth weight had a normal distribution which was skewed to left. There was a clustering of birth weight around 2500 grams (Table I). There were a total of 38 (6.2%) preterm deliveries. Two of them were before 28 weeks of gestation and one more before 32 weeks. All the newborns with a gestational period between 32 to 36 weeks had a birth weight above 2500 grams.
We have reported a low incidence (8.8%) of low birth weight from our study area. Even if one assumes the higher estimate of 11.2% (upper confidence interval) from the present study, the incidence, as compared to reported incidence in India is still low. The national estimate, based on mainly hospital data, is 33%(5,6). In one of the earliest community based study in India, Rao et al. reported a incidence of LBW to be 27.2% during 1969 to 73(9). The Child Survivial and Safe Motherhood based data (center based delivery in 14 districts in 10 states), estimated the incidence of LBW to be 18.4%. However, the reliability of this data is questionable(6). The low incidence reported in this study could be due to chance, bias or be real. However, the sample size of the study was adequate to estimate an incidence of 10% with an absolute precision of 2.5% at 5% significance level. From our unpublished experiences, we have seen that there is a variation in the birth weight in the villages under CRHSP. As the villages were not randomly selected, it is possible that these four villages selected for the present study may not represent the region. Also, we found a clustering of birth weight around 2500 grams. In such a case, even a minor shift of the curve to the right (even by 100 grams) would markedly reduce the incidence of LBW babies. In fact, a similar observation was documented in South India(10). They measured the birth weight of rural singleton newborns during the period 1969 to 73 and 1989 to 93. The mean birth weight increased by only 78 grams but the incidence of low birth weight decreased from 27.2% to 15.9% in the period of twenty years. Our study found that 6.2% of deliveries were premature (<36 weeks). This rate has been reported to be between 7.1% to 22.3% in various studies with about 13.7% in a rural multicentric study by ICMR(11). In our study only 2% of the LBW babies were preterm, this has been reported to be in the range of 33%(4). Some of the newborns, though classi-fied as preterm had birth weight above 2500 grams. This indicates that the assessment of gestational age may have been inaccurate in some cases. In community settings, ascertainment of date of last menstrual period could be difficult. This could be due to the fact that the women in rural areas do not remember their date of last menstrual period. This could be due to the poor literacy status of the women and the fact that they do not feel it to be important to remember. This problem increases if the registration of pregnancy is late, which is quite common. We do not have any community based data on the birth weight from the past to know whether this low incidence of low birth weight reflects an improvement from the past or whether this pattern existed in this area from the beginning. Incidentally the Ballab-garh hospital data showed that there is an increase in the incidence of low birth weight over a period of time in the newborns born in the hospital from 23.4% in 1982 to 28.9% in 1991(12,13). However, being a self selected sample, this does not necessarily reflect the situation in the community. Most of the women who deliver in the hospital are from the urban area, as distinct from the study area which was rural. We are unable to specify any particular reason(s) for this low incidence. Ballabgarh block is like any other rural north Indian block. The socio-cultural and nutri-tional profile of mothers are likely to be similar. In conclusion, we have reported a low incidence of LBW in the area which at present, seems inexplicable. Hospital based data do not reflect the actual incidence of LBW. We have shown the feasibility of measuring birth weight using MPW-F. Contributors: SKK conceived the idea, trained the workers and corrected the draft; he will act as the guarantor of the paper. GK supervised data collec-tion, data entry and analysis, KA supervised data collection, data analysis and drafted the manuscript. CSP was responsible for data analysis and correction of draft.
Funding:
None.
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