Comparative Analysis of Birth Weight in a Hospital Over a Decade: Low Birth Weight Still a Major Problem

Address for correspondence Dr. Sandeep Sachdeva Department of Community Medicine, PGIMS, Rohtak, India E-mail: drsachdeva@hotmail.com How to cite this article ? Sachdeva S, Nanda S, Sachdeva R. Comparative Analysis of Birth Weight in a Hospital Over a Decade: Low Birth Weight Still a Major Problem. J Nepal Paediatr Soc 2013;33(1):15-20. Comparative Analysis of Birth Weight in a Hospital Over a Decade: Low Birth Weight Still a Major Problem


Introduction
C onsiderable progress has been made in last three decades resulting in overall development which inter-alia paved way in reducing childhood morbidity and mortality across the globe, yet 8.8 million children die every year before their fi fth birthday 1 .Nearly 49% (4.29 million) of children death occurred in fi ve countries-India, Nigeria, Democratic Republic of the Congo, Pakistan, and China 2 .Of the various putative causative factors, malnutrition still remains one of the major concerns, challenge and issue especially in developing countries to be overcome.Low birth weight (LBW) has been aptly identifi ed as a major determinant of child health with immediate consequence during infancy and longterm impact on health outcomes in adult life.LBW is an outcome of either preterm birth or intrauterine growth restriction (IUGR) and is known to be an underlying factor in 60-80% of neonatal deaths.
According to the latest available international estimates 15% of all newborns were born with low birth weight (<2500g) in the world and selected countries like China (2%), Australia (7%), Japan (8%), UK (8%), USA (8%), Gambia (20%), Nepal (21%) & Bangladesh accounted with 22% respectively.The picture with respect to LBW in India was 28% this decade (2011) with slight improvement from 33% during last decade (2000), accounting a reduction of 5 units 3 .With this background a cross-sectional comparative descriptive study was undertaken to determine magnitude of newborn weight in a government hospital and to explore association of low birth weight with selected variables.
The study was conducted in one of the publically funded teaching institution of northern India which provides specialist's tertiary care services to patients largely belonging to lower/ middle socio-economic strata of the society with rural and urban background serving 4-5 adjoining districts.It caters to an avg.daily outpatient (OPD) attendance of 5000 patients and more than 80,000 annual admissions supported by 1750 inpatient beds.Birth weight of all new born was recorded using weighting scale immediately after birth upto onehour.All standard operating procedure of labor room were undertaken e.g.calibration of weighing instrument before recording weight of newborn, adequate lightening etc. to name a few.
The maternal and newborn variables included in the study were age, occupation & education of mother, usual place of residence, booked/un-booked ante-natal (ANC) status, estimated period of gestation, gravida, hemoglobin, birth weight, sex and outcome (live/ mortality).Considering feasibility it was envisaged to collect pertinent information of all singleton intramural births occurring during randomly selected four months of the year 2011.Similarly log books of labor room were retrieved and reviewed for the corresponding timeframe of 2001 to record birth weight and other variables.Atleast one of the investigators was present during both the study time frame.During this period, weighing machine was replaced atleast four times because of maintenance issues but of the same company and make.The machine was placed at the same location/ site in the labor room during both the time frame.
Data collection was carried out by resident on duty after orientation training under the supervision of investigators using structured proforma after taking clearance from authority and verbal consent of mothers in a non-judgmental and confi dential manner.The staff nurses involved in labor room activities was also given re-orientation training.All mothers were provided casebased advise regarding breast feeding, immunization, post natal care, family planning, nutrition, follow up etc. Detail information of all intramural births was then entered into MS excel spread sheet and analysis carried out using software statistical package (SPSS ver.16).Some of the information was not available (8.0%) and such case entries were excluded from fi nal analysis.Standard defi nition as relevant to birth weight considered in the present study was LBW (<2500g), Very LBW (<1500g), Extremely LBW (<1000g); Aneamia according to hemoglobin (Hb) level as mild (10-10.99gm/dl),moderate (7-9.99gm/dl),severe (less than 7gm/dl) and no aneamia (atleast 11gm/dl).

Results
There were a total of 2812 & 1577 births recorded for the sampled period during 2011 and 2001.Majority (34.7%) of mothers (2011) did not attend to school while majority (37.9%) had atleast 9-year of schooling during 2001 while age-structure & gravida status of mothers for both periods was similar.Higher proportion of mother (72%) was resident of district of location of study institution (2001)

Association of LBW with selective variables:
Details are shown in Table-2.Rising level of education was protective against LBW.Majority of LBW occurred to mother in age group of 20-29 years followed by 30/ above and less than 19 years but this observation was statistically non-signifi cant.Mothers with their fi rst pregnancy gave birth to higher proportion of LBW births in comparison to higher gravida mothers in the recent year [<0.001].For both time frame, higher proportion of LBW birth was observed amongst un-booked, pre-term mothers and whose residence was from outside the district of location of study institute (<0.001).Statistically signifi cant (<0.001) and higher perinatal mortality was noticed in LBW neonates.Higher proportion of females were born with LBW during 2011 (<0.001).(2001).India, the largest democracy & second most populous country in the world is striving strongly on all fronts of human development especially economic value yet lagging on social issues.Over the years there has been intense promotion for institutional deliveries in the country with concomitant increased program funding, infrastructure development, easy access to communication and free transport facilities for pregnant and poor patients.However, nation-wide data on birth is still not available since most of these occur at home i.e. 52.3% (61.3% in rural and 29% in urban areas) 4 with latest fi gure of 60% (Sample Registration System, 2010).
Inspite of certain inherent limitations as hospital usually attracts high risk mothers with nongeneralizability of study fi ndings still it refl ects a grim situation with respect to neonatal birth weight.Another trend being observed in this region especially in the light of large scale migration of labor due to infrastructure and agriculture development with issues like poverty, social security, manual physical labor and poor nutrition with profound infl uence on birth weight could also add on to listed limitations.
The multi-factorial complex inter-linked factors leading to LBW could be grouped into biological (maternal, placental, fetal etc), social-economic determinantspoverty, demography, education, cultural & nutritional practices, infections (e.g.malaria etc), health system (availability, access, quality & compliance), tobacco exposure, or environmental related issues 14,15,16,17,18,19,20 .Much has been deliberated & documented on enlisted parameters.In the back-drop of various factors enlisted and variables examined in present study, authors would broaden the discussion to cover environmental issues in particular.
Carbon monoxide (CO) in particular and nicotine are regarded as the agents most likely to be responsible for detrimental effects on intrauterine growth 21 .CO results from incomplete combustion of bio-fuels (wood, dung, and fi ber residues) as well as fossil fuels such as coal and gas that is used for cooking and heating biomass and also tobacco.Studies have shown that exposure to biofuels is associated with carboxy-heamoglobin (COHb) levels of 2.5-13% 22,23 .This compound does not readily give up oxygen to peripheral organs and tissue including foetus thus leading to growth restriction.A study carried out Guatemala confi rmed that children born to mothers habitually cooking on open fi res had the lowest mean birth weight of 2,819 g; those using a chimney stove had an intermediate mean of 2,863 g; and those using the cleanest fuels (electricity or gas) had the highest mean of 2,948 g (p<0.0001).The proportion of low birth weights in these three groups was 19.9% (open fi re), 16.8% (chimney stove), and 16.0% (electricity/gas) 24 .A study carried out in south India, reported that exposure to bio-mass fuel was associated with an adjusted 49% increased risk of LBW 25 .
It may not be un-reasonable to interpret that biofuels used by Indian women for cooking or heating may be one of the likely causes of LBW in addition to studied co-variables.Considering environmental issues, nearly 65.4% of rural & 26.5% of urban households in India used fi re wood for cooking.In Haryana, nearly 61.8% [76.6% (rural) and 22% (urban)] used fuel other than (LPG, electricity, or kerosene) suggesting dung/ crop/fi ber residue etc. while 11% of household used woods for cooking.On the health front, more than 50% mothers are anaemic while mothers who consumed IFA supplements were only 29.0% (urban, 31.7%-28.1%,rural) 26 .Similarly, adult prevalence of tobacco use at national level among males is 48% and that among females is 20% while prevalence of smoking among males is 24% and 3% among females including 1% each of pregnant and breastfeeding women (NFHS-3, Haryana) 27 .Similarly higher proportion of rural (58%) than urban (39%) adults were exposed to second hand smoke in their homes.
Considering background discussion it may not be surprising to visualize the interface that substantial gain on newborn birth weight will be achieved in conjunction with development of related sectors (e.g.energy/ tobacco control/poverty alleviation), tuberculosis/ malaria control, modifi cation of cultural practices, improving health compliance and time-frame needed to do so etc. India, accounts for one of the highest magnitude of LBW newborn, a surrogate indicator for prevailing malnutrition & inequity in the society leading to inter-generational effect especially among women.Directly and/or in-directly country is bearing & draining huge resources when the consequences are translated from the perspective of health, loss of productivity and psycho-social cost into fi nancial terms.Maternal and child health is considered as one of the major thrust areas in country with many concentrated interventions underway by government of India still a lot needs to be done in this direction.

Conclusion
To conclude, with a pinch of salt, we have faltered in achieving health & family welfare goals as envisaged in Health-for-All (e.g. to bring down LBW to 10% by the year 2000), National Population Policy (2000) and National Health Policy (2002) etc. High aspirations, hopes & targets, which are though necessary for guiding path & raising moral of health team, have resulted in modest progress only.But to reiterate, integrated strategies, actions & will is the hallmark required to bring down the scale of malnutrition and improvement in related sectors so as to achieve at least some of the Millennium Development Goals (MDG, 2015) or else it would still remain just one of the many fancy dreams and charter of wish-lists to be achieved by, to be realistically saying, at least not before year 2030.

Table 1 :
Distribution of neonatal birth weight in the government hospital, Rohtak

Table 2 : Association of Low Birth Weight (LBW) according to selected variables
Comparative Analysis of Birth Weight in a Hospital Over a Decade: Low Birth Weight Still a Major Problem