Risk factors for small for gestational age births in Ahmedabad, India.

Intra-uterine growth retardation is an important public health problem in many developing countries. The authors conducted a case-control study of low birth weight (LBW) in three teaching hospitals and a population survey in Ahmedabad city, India during 1987-1988. To identify and quantify risk factors for small for gestational age births, we divided the low birth weight and control infants into small for gestational age (SGA, n = 617) and appropriate for gestational age (AGA, n = 1851) using an Indian birth weight by gestational age standard. Logistic regression was used to estimate adjusted odds ratios for important risk factors. Prevalence of risk factors was estimated from a community sample survey of mothers (n = 1102) who had delivered in the past year. Attributable risks were calculated from odds ratios and prevalence data. The most important risk factors for SGA was poor maternal nutritional status (weight < 51 kg) with an attributable risk of 42 per cent. Other significant risk factors were anaemia, primiparity, poor obstetric history, lack of antenatal care and hypertension during pregnancy, and birth defects, each of which contributed only moderately to the attributable risk. The analysis indicates that improvement of maternal nutrition and antenatal care might prevent a substantial portion of SGA births in this and similar populations.

Maternal weight, height and risk of poor pregnancy outcome in Ahmedabad, India.

This paper explores the relationships between maternal weight, height and poor pregnancy outcome using a data set from a case-control study of low birth weight (LBW) and perinatal mortality in Ahmedabad, India. Maternal height and weights were compared between mothers of 611 perinatal deaths, 644 preterm-LBW, and 1465 normal birth weight controls as well as 617 small-for-gestational age (SGA) and 1851 appropriate-for-gestational-age (AGA) births. Weight and height were much lower in this population compared to western standards. Low weight and height were associated with increased risk of perinatal death, prematurity and SGA. After adjusting for confounders, maternal weight remained significantly associated with poor pregnancy outcomes, whereas height was only weakly associated. Attributable risk estimates show that low weight is a much more important contributor to poor outcome than low height. Improvement in maternal nutritional status could lead to substantial improvement in birth outcome in this population.

PIP: In India, researchers analyzed three sets of case control comparisons (611 perinatal deaths vs. 1465 controls, 644 preterm low birth weight [LBW] cases vs. 1465 controls, and 617 small-for-gestational-age [SGA] cases vs. 1851 controls) to investigate the association between maternal weight, height, and weight-height indices and pregnancy outcome. They hoped to identify which maternal anthropometric measure could best predict poor perinatal health. All cases and controls were born at three teaching hospitals in Ahmedabad during 1987-1988. More than 66% of control mothers and around 75% of case mothers weighed less than 50 kg, indicating considerable maternal undernutrition. Low maternal weight was associated with all three poor perinatal outcomes (p 0.01) (adjusted odds ratio [AOR] for perinatal death = 1.6 for 46-50 kg, 1.7 for 41-45 kg, and 2.9 for 40 kg or less; AOR for preterm/LBW = 1.7, 2.5, and 4.9, respectively; AOR for SGA = 1.7, 1.7, and 2.4, respectively). The association between shortness (155 cm) and all three perinatal outcomes was only significant at 150-154 cm for perinatal death (AOR = 1.4), at 150-154 cm and 145-149 cm for preterm/LBW (AOR = 1.3 and 1.5, respectively), and at less than 145 cm and 150-154 cm (AOR = 1.5 and 1.3, respectively) (p 0.01). This association was less than that between maternal weight and perinatal outcomes. The weight-height ratio index and weight-height product index were significantly associated with all three perinatal outcomes (AOR = 1.6-4.9 and 1.4-5.2, respectively; p 0.01). Maternal weight had higher attributable risks than maternal height for perinatal death (37.1% vs. 18.1%), for preterm/LBW (55.6% vs. 18.4%), and for SGA (39.8% vs. 16.4%). Low height was probably mediated through low weight and other factors. These findings show that low weight contributes much more than low height to poor perinatal outcome. Improvement of maternal nutrition, through the Integrated Child Development Services, for example, would likely improve perinatal outcomes.

Micro-level planning using rapid assessment for primary health care services.

This paper describes the use of a rapid assessment technique in micro-level planning for primary health care services which has been developed in India. This methodology involves collecting household-level data through a quick sample survey to estimate client needs, coverage of services and unmet need, and using this data to formulate micro-level plans aimed at improving service coverage and quality for a primary health centre area. Analysis of the data helps to identify village level variations in unmet need and develop village profiles from which general interventions for overall improvement of service coverage and targeted interventions for selected villages are identified. A PHC area plan is developed based on such interventions. This system was tried out in 113 villages of three PHC centres of a district in Gujarat state of India. It demonstrated the feasibility and utility of this approach. However, it also revealed the barriers in the institutionalization of the system on a wider scale. The proposed micro-level planning methodology using rapid assessment would improve client-responsiveness of the health care system and provide a basis for increased decentralization. By focusing attention on under-served areas, it would promote equity in the use of health services. It would also help improve efficiency by making it possible to focus efforts on a small group of villages which account for most of the unmet need for services in an area. Thus the proposed methodology seems to be a feasible and an attractive alternative to the current top-down, target-based health planning in India.

PIP: The authors describe the use of a rapid assessment technique in micro-level planning for primary health care (PHC) services which has been developed in India. The technique involves collecting household-level data through a quick sample survey to estimate client needs, service coverage, and unmet need. The data are then used to develop plans designed to improve service coverage and quality for a primary health center area. Analyzing the data helps to identify village-level variations in unmet need and develop village profiles from which general interventions for overall service coverage improvement and targeted interventions for selected villages are identified. A PHC area plan is developed and the system implemented in 113 villages of three PHC centers of a district in Gujarat state. The program demonstrated the feasibility and utility of the approach, while also revealing barriers in institutionalizing the system on a broader scale. This planning methodology should improve the client responsiveness of the health system, provide a basis for increased decentralization, promote equity in the use of health services, and help improve efficiency. The methodology therefore appears to be both feasible and preferred over the current top-down, target-based health planning approach employed in India.

Risk factors for preterm and term low birthweight in Ahmedabad, India.

To identify and quantify risk factors for preterm and term low birthweight (LBW) we conducted a hospital-based case-control study, linked with a population survey in Ahmedabad, India. The case-control study of 673 term LBW, 644 preterm LBW cases and 1465 controls showed that low maternal weight, poor obstetric history, lack of antenatal care, clinical anaemia and hypertension were significant independent risk factors for both term and preterm LBW. Short interpregnancy interval was associated with an increased risk of preterm LBW birth while primiparous women had increased risk of term LBW. Muslim women were at a reduced risk of term LBW, but other socioeconomic factors did not remain significant after adjusting for these more proximate factors. Estimates of the prevalence of risk factors from the population survey was used to calculate attributable risk. This analysis suggested that a substantial proportion of term and preterm LBW births may be averted by improving maternal nutritional status, anaemia and antenatal care.

PIP: In 1987-1988, researchers compared data on 1317 low birth weight (LBW) infants and 1465 control infants born in 3 teaching hospitals in Ahmedabad, India to calculate attributable risk (AR) for factors contributing to low birth weight. 673 of the infants were full term yet LBW due to intrauterine growth retardation. 644 of LBW infants were preterm births. They also conducted a population survey in Ahmedabad to estimate the prevalence of risk factors. LBW prevalence stood at 30%. Low maternal weight, poor pregnancy history, lack of prenatal care, clinical anemia, and hypertension were all significant independent risk factors for term and preterm LBW infants (p.05). Primiparous women were more likely to have a term LBW infant than other women (p.05). Interpregnancy intervals =or 6 months was more likely to result in delivery of a preterm LBW infant than longer interpregnancy intervals (p.05). Muslim women were at a much lower risk of delivering a term LBW infant than were Hindu women (p.05). Other than primiparity for term LBW infants (AR=21.9%), maternal weight between 41-45 kg was the single greatest risk factor for LBW (AR=21.5% for term and 19.8% for preterm). Yet low maternal weight had greater adjusted odds ratios (OR) than did maternal weight between 41-45 kg (OR=6.9 and 6.2 vs. OR=3.1 and 2.9). Maternal weight was used to measure nutritional status. Clinical anemia also carried a high Ar, especially for term LBW infants (3.7-8.2% vs. 2.8-7.3% for preterm infants). Another risk factor with considerable AR was no prenatal care (5.8% for term and 14.4% for preterm). These results emphasized the need for health and nutrition interventions to reduce the incidence of both preterm and term LBW infants in urban India.

Levels and risk factors for perinatal mortality in Ahmedabad, India.

To estimate levels and determinants of perinatal mortality, we conducted a hospital-based surveillance and case-control study, linked with a population survey, in Ahmedabad, India. The perinatal mortality rate was 79.0 per 1000, and was highest for preterm low-birth-weight babies. The case-control study of 451 stillbirths, 160 early neonatal deaths and 1465 controls showed that poor maternal nutritional status, absence of antenatal care, and complications during labour were independently associated with substantially increased risks of perinatal death. Multivariate analyses indicate that socioeconomic factors largely operate through these proximate factors and do not have an independent effect. Estimates of attributable risk derived from the prevalence of exposures in the population survey suggest that improvements in maternal nutrition and antenatal and intrapartum care could result in marked reductions of perinatal mortality.

PIP: Levels and risk factors for perinatal mortality in Ahmedabad, India, were investigated through an approach that combined institutional surveillance, a case-control survey, and a linked population-based survey. In the three government teaching hospitals in Ahmedabad, there were 15,893 births in July 1987-June 1988, of which 739 were stillbirths and 517 were early (within the first week of life) neonatal deaths. The case-control study collected detailed data on 451 of these stillbirths and 160 of the early neonatal deaths while the population-based survey covered 1102 women who delivered in the study period. The perinatal mortality rate in the study hospitals was 79/1000 births (46.4/1000 for stillbirths and 34.1/1000 for early neonatal deaths). The relative risk of perinatal mortality was 21.1 (95% confidence interval, 17.8-25.2) for preterm low-birthweight infants compared to full-term normal-birthweight babies, but only 2.6 (2.1-3.2) for full-term low-birthweight infants. Multivariate analysis indicated that the risks of both stillbirth and early neonatal mortality were significantly increased by a history of previous stillbirth, prematurity in the last pregnancy, low maternal weight, clinical anemia, no prenatal care, vaginal bleeding during pregnancy, elevated diastolic blood pressure, convulsions, antepartum hemorrhage, breech delivery, Cesarean section delivery, and congenital malformations. Socioeconomic factors such as low maternal education, agricultural occupation, and lack of a toilet lost all significance after adjustment for confounding factors. Overall, these findings suggest that improved maternal nutrition and antenatal/intrapartum care could have a substantial impact on reducing perinatal mortality in India.