You are on page 1of 5

Vol. 59 No.

2 May - August 2013

Royal Thai Air Force Medical Gazette 9

The Association between Antenatal Care and Low Birth Weight newborn at
Bhumibol Adulyadej Hospital, Thailand
Teenat Kanjanasingh, MD., Buppa Smanchat, MD., Sinart Prommas, MD.
Department of Obstetrics and Gynecology, Bhumibol Adulyadej Hospital, Bangkok, Thailand

Objective : To study the association between antenatal care and low birth weight newborn.
Material and Method : Case control study, There were 2312 pregnant women who delivered at Bhumibol
Adulyadej Hospital during January 1 to July 31, 2011. Study group was 168 pregnant women who delivered
newborn whose body weight less than 2500 grams and control group was 168 pregnant women who
delivered newborn which birth weight 2500 to 4000 grams selected by systematic random sampling. Multifetal
pregnancy, still birth and newborn with severe congenital anomaly incompatible with life were excluded
from this study.
Results : Antenatal care equal or greater than 4 visits was not correlated with low birth weight newborn
(OR 0.92, 95 % CI 0.722.10). Good antenatal care was the protective factor of low birth weight newborn (OR
1.91, 95 % CI 1.053.45). Other protective factors of low birth weight newborn were body weight before
pregnancy greater than 45 kilograms (OR 2.80, 95 % CI 1.29 6.09), total weight gain during pregnancy
equal or greater than 10 kilograms (OR 2.88, 95 % CI 1.28 - 6.48). Risk factor of low birth weight was
obstetric complication (OR 0.09, 95 % CI 0.03-0.23).
Conclusion : Antenatal care equal or greater than 4 visits was not the protective factor for low birth weight
newborn. But good antenatal care was the protective factor of low birth weight newborn.
Keywords : Antenatal care, Low birth weight
Royal Thai Air Force Medical Gazette, Vol. 59 No.2 May - August 2013

Introduction
Low birth weight (LBW) has been defined
by World Health Organization as weight at birth less
than 2,500 grams (g) (5.5 pounds). A babys low
weight at birth is either the result of preterm birth
(before 37 weeks of gestation) or restricted fetal
(intrauterine) growth. Low birth weight is closely
associated with fetal and neonatal mortality and
morbidity, inhibited growth and cognitive
development, and chronic diseases later in life1.
In Thailand, 10th National Economic and
Social Development Plan (2007-2011)2 were aimed to
reduce the LBW incidence to lower than 7 % of all
births. The incidence of LBW in Bhumibol Adulyadej

Hospital was 11.37 % in 20113. It is important to


identified risk factors of low birth weight to protect
this problem.
Maternal risk factors of low birth weight
had been identified in many studies. Antenatal care
less than 4 visits is the one of many factors that had
been prove to be significant risk factor in many
study4-7. Anyhow in the result of Tripeds study8,
antenatal care less than 4 visits was the significant
protective factor in Maharat Nakhon Ratchasima
Hospital that was inconsistent with other study.
The antenatal care may be dependent factors that
give different result in different study. So study
of this factor may give information to improve

10 Royal Thai Air Force Medical Gazette

effectiveness of antenatal care in our hospital.


The objective of this study is to identified whether
number of antenatal care is the protective factor of
low birth weight or not.

Material and Method


This study was approved by the Ethics
Committee of Bhumibol Adulyadej hospital at March
23, 2012. The sample size was calculated by single
group per proportion formula. P1 was prevalence of
low birth weight in ANC < 4 visits from Sappipats
study5. Sample size per group was 116 cases. The
medical records of mother who gave birth during
January 1 to 31 July 31, 2011 were reviewed. All
mothers who delivery low birth weight newborn in
that period were included in study group. Control
group was mothers who delivery normal birth weight
newborn (2,500-4,000 grams) at same period selected
by systematic random sampling. The exclusion
criteria were multifetal pregnancy, stillbirth, severe
congenital anomaly with incompatible with life and
incomplete medical record.
Main objective factors were ANC > 4 times
and good ANC which defined by ANC at least
1 visits in first and second trimester and 2 visits in
third trimester (WHO2001)9. Other factors were height,
pre-pregnancy body weight, body mass index
before pregnancy, total weight gain during
pregnancy, maternal age < 20 years, obstetric
complications, maternal underlying diseases, bad
obstetric history, body weight, smoking and alcohol
drinking.

Statistic Analysis
Data were presented as frequency. The
results were analyzed by univariate analysis followed

Vol. 59 No.2 May - August 2013

by multiple logistic regression analysis including all


of the significant factors from univariate analysis.
The association of maternal factors and LBW were
shown in Odds ratio (OR) and 95 % confidence
interval (95 % CI). A p-value < 0.05 was considered
statistical significance. All analysis were performed
with SPSS version 18.0.

Result
Form January 1 to July 31, 2011, there were
2312 deliveries in Bhumibol Adulyadej Hospital.
There were 209 low birth weight deliveries, accounted
for 9.04 %. According to the study criteria, the study
group was 168 low birth weight cases. The control
group was 168 normal birth weight cases.
Table 1 showed the maternal demographic
data in both groups, including age, parity, and
history of abortion, occupation, income and
education. All data of two groups were not different
significantly.
In univariate analysis (table 2), the
significant protective factor of low birth weight were
ANC > 4 visits, good ANC, pre-pregnancy body
weight > 45 kg, total weight gain during
pregnancy > 10 kg. The risk factors of low birth
weight were bad obstetric history and obstetric
complication.
Multivariate analysis (Table 3) demonstrated
that the significant protective factors were good ANC
(OR=1.91, 95 % CI = 1.05-3.45), pre-pregnancy body
weight > 45 kg (OR=2.80 95 % CI = 1.29-6.09), total
weight gain during pregnancy > 10 kg (OR = 2.88,
95 % CI = 1.28-6.48). The risk factor was obstetric
complication (OR = 0.09, 95 % CI = 0.03-0.23).

Royal Thai Air Force Medical Gazette 11

Vol. 59 No.2 May - August 2013

Table 1 Demographic Data


Characters
Maternal age (years)
< 20
20-34
>35

Low birth weight (n=168) (%) Normal birth weight (n=168) (%) p-value
0.68
32 (19.05)
101 (60.12)
35 (20.83)

27 (16.07)
117 (69.64)
24 (14.29)
0.74

Parity
Nullipara
Parity =1
Parity > 2

88 (52.38)
55 (32.74)
25 (14.88)

81 (48.21)
60 (35.72)
27 (16.07)

Abortion

37 (22.02)

38 (22.62)

Gestational age
GA < 37 wk
GA > 37 wk

94 (55.95)
74 (44.05)

24 (14.28)
144 (85.72)

Occupation
Unemployed
Business
Government
Employed
Student
Income (Baht)
<10000
10,000-20,000
20,001-30,000
>30000
Education
No education
Primary
Secondary
Bachelor
>Bachelor

0.96

0.06
56 (33.33)
13 (7.74)
12 (7.14)
85 (50.60)
2 (1.19)

72 (42.86)
16 (9.52)
4 (2.38)
72 (42.86)
4 (2.38)
0.52

35 (20.83)
92 (54.77)
21 (12.50)
20 (11.90)

46 (27.38)
86 (51.19)
21 (12.50)
15 (8.93)
0.19

6 (3.57)
28 (16.67)
99 (58.93)
29 (17.26)
6 (3.57)

2 (1.19)
32 (19.05)
104 (61.90)
29 (17.26)
1 (0.6)

12 Royal Thai Air Force Medical Gazette

Vol. 59 No.2 May - August 2013

Table 2 Univariate analysis


Protective Factors

Low birth weight Normal birth weight Odds


(N = 168) (%)
(N=168) (%)
Ratio

ANC > 4
Good ANC
Age < 20 year
Pre-pregnancy body weight > 45 kg
Pre-pregnancy body mass index > 20
Height > 145 cm
Total weight gain > 10 kg
Maternal underlying disease
Bad obstetric history*
Obstetric complication**
Smoking
Alcohol drinking

132 (78.57)
62 (36.90)
32 (19.05)
96 (57.14)
85 (50.59)
164 (97.61)
82 (48.80)
11 (6.54)
12 (7.14)
43 (25.59)
6 (3.57)
4 (2.38)

149 (88.69)
86 (51.19)
27 (16.07)
134 (79.76)
97 (57.74)
165 (98.21)
137 (81.54)
9 (5.35)
3 (1.78)
8 (4.76)
3 (1.78)
1 (0.59)

1.66
1.26
1.10
1.78
1.05
4.07
2.40
0.98
0.94
0.78
0.98
0.98

95% CI
1.02-2.70
1.04-1.57
0.84-1.43
1.26-2.52
0.72-1.70
0.46-36.05
1.70-3.40
0.93-1.04
0.90-0.99
0.71-0.85
0.94-1.01
0.95-1.01

* Bad obstetric history included prior preterm birth, prior low birth weight, prior stillbirth, prior fetus with
congenital anomaly, prior early neonatal death
** Obstetric complication included gestation hypertension, preeclampsia, eclampsia, fetal growth
restriction, abnormal amniotic fluid, and placenta previa and placenta abruption
Table 3 Multiple logistic regression analysis
Protective Factors
ANC > 4
Good ANC
Total weight gain > 10 kg during pregnancy
Pre-pregnancy body weight > 45 kg
Bad obstetric history
Obstetric complication

Adjusted Odds ratio

95 % CI

0.92
1.91
2.88
2.80
0.22
0.09

0.72-2.10
1.05-3.45
1.28-6.48
1.29-6.09
0.04-1.00
0.03-0.23

Discussion
The result from the multiple logistic
regression analysis models showed that number
of antenatal care 4 visits or more was not the
significant protective factor of low birth weight
(OR = 0.92, 95 % CI = 0.72-2.10). While in other
studies, number of antenatal care less than 4 time
was the significant risk factor of low birth weight4-7
Despite Tripeds study showed antenatal care less

than 4 visits was the significant protective factor of


low birth weight in Maharat Nakhon Ratchasima
hospital8. When the number of visits is considered,
it seems that only number of antenatal care was
only not justified the protective factor. When study
was conducted in tertiary care hospital, mother with
spontaneous preterm birth and other high risk
pregnancy was referred to our hospital. These cases
may have high visits of antenatal care. So antenatal

Royal Thai Air Force Medical Gazette 13

Vol. 59 No.2 May - August 2013

care visits may not correlated with low birth weight


in our hospital. However, antenatal care should
be recommended to all mothers, but frequency of
antenatal care visits should depend on health
problem and risk of pregnancy of individuals.
Good ANC was the significant protective
factor in our study. According to the antenatal
care protocol of Bhumibol Adulyadej hospital10, we
recommended low risk mothers should come to
antenatal care first visit at gestational age equal or
less than 12 weeks and sequent visit at gestational
age 26, 32, 38, 40 and 41 weeks. And if any risk or
problem had been detected, frequency of visit of
antennal care will increase according to individual
problem. These mothers had first visits in first
trimester and visits of antenatal care should greater
than 4, so these mothers, chance to detect and
prevent low birth weight are more likely. The
quality of antenatal care is important and should be
study in the future.
Other significant protective factors were
pre-pregnancy body weight > 45 kg (OR = 2.80,
95 % CI = 1.29-6.09) and total weight gain > 10 kg
during pregnancy (OR = 2.88, 95 % CI = 1.28-6.48).
The pre-pregnancy body weight < 45 kg was the
significant risk factor for low birth weight in
Sappipats study which supported our study. Total
weight gain < 10 kg during pregnancy was the
significant risk factor in many studies4-8 supported
with our study. Pre-pregnancy body weight and
total weight gain during pregnancy should be
in attention of health care providers who perform
antenatal care of pregnancy women especially in
pregnant teenagers. They usually have low
bodyweight and afraid of putting too much weight
during pregnancy.
The significant risk factor for low birth
weight in our study was obstetric complication
included gestation hypertension, preeclampsia,
eclampsia, fetal growth restriction, abnormal
amniotic fluid, placenta previa and placenta
abruption. This result was consistent with Sappipats
study5. Some studies6,7 shown that pregnancy induced
hypertension was the significant risk factor.
However, our sample size, which was
calculated based on number of antenatal care, may
not cover these significant factors.

Conclusion
This case control study showed that at least
4 visits of antenatal care 4 visits was not the
protective factor for low birth weight. Good ANC
in Bhumibol Adulyadej Hospital was the significant
protective factor. Other significant protective factor
was pre-pregnancy body weight > 45 kg and total
weight gain > 10 kg during pregnancy whereas the
significant risk factor was obstetric complication.

Reference
1.

United Nations Childrens Fund and World


Health Organization. Low birth weight:
country, regional and global estimates.
New York: UNICEF; 2004.
2. Tenth National Economic and Social
Development Plan 2007-2011. National
Economic and Development Board.
3. Bhumibol Adulyadej Hospital statistics 2011.
4. Chumnijarakij T, Nuchprayoon T, Chitinand
S, Onthuam Y, Quamkul N, Dusitsin N. et al.
Maternal Risk Factors for low birth weight
newborn in Thailand. J Med Assoc Thai 1992;
75:445-52.
5. Sappipat N. Maternal risk factors of low birth
weight at Kalasin hospital. Bull Dept Med Serv
2007;15:1-14.
6. Priyona E, Isaranurag S, Chompikul J.
Maternal risk factors for low birth weight
infant at Fatmawati general hospital, Jakarta,
Indonesia. J Pub Health Dev 2008;6:123-33.
7. Tritilanunt S. Maternal risk factors for low birth
weight infants in Panomsarakham Hospital.
Chachoengsao Province. Journal of Health
Systems Research 2008; 2(suppl 4):886-90.
8. Triped O, Arj-Ong S, Aswakul O. Maternal risk
factors of low birth weight at Maharat Nakhon
Ratchasima hospital. Thai J Obstet Gynecol
2012;20:12-20.
9. Prenatal care. In: Cunningham FG, Leveno KJ,
Bloom SL, Hauth JC, Rouse DJ, Spong CY,
et al. Williams Obstetrics. 23rd Ed. New York:
McGrew-Hill; 2010.P.189-211.
10. Bhumibol Adulyadej Hospitals clinical
practice guideline Obstetrics and Gynecology
2007.