Yet Another War: Major determinants of Low Birth Weight
Low birth weight (LBW) has been defined by the World Health Organization (WHO) as birth weight of less than 2,500 grams (or 5.5 pounds). In spite of consistent efforts to improve the quality of maternal and child health, LBW remains a major public health problem in many parts of the world. Globally, more than 20 million infants are born with LBW, about 15.5% of all live births. The prevalence of LBW in developed countries is 7% whereas in developing countries its 16.5%, with the highest prevalence in South Asia (27%) including Pakistan (19%) (Wardlaw, Blanc, Zupan & Ahman, 2004).
LBW is classified as either; preterm birth (before 37 weeks of gestation) or intrauterine growth restriction (IUGR). Majority of LBW in developing countries is due to IUGR, while most LBW in industrialized countries is due to preterm birth (Pojda & Kelley, 2000). Out of total estimated IUGR babies, Asia accounts for 75% and Pakistan comprises of 25% (Shamim, Khan, Rana, & Ahmed, 1999).
I still remember the day when I gave birth to my baby boy; the first question I asked after knowing his sex was, “How much did he weigh?” Birth weight is not only the predictors of mother’s health status but also a newborn’s probability for survival, development and long-term health. LBW is one of the major determinants of infant morbidity and mortality. It has been found by Singh, Chouhan, and Sidhu (2009) that LBW infants are forty times more likely to die within their first four weeks of life than normal birth weight infants. Approximately every ten seconds, an infant from a developing country dies from a disease or infection that can be attributed to LBW.
Numerous studies indicate that Infants with LBW are more likely to have abnormal cognitive development, neurological impairment, lower IQ, poor performance in schools and in their jobs as adults. Wardlaw et al suggested that a child born with LBW has a greater risk of illness and death from cardiovascular disease, hypertension and diabetes mellitus later in his/her adulthood (. 2004). This results in more frequent hospitalization and outpatient visits.
The costs of medical care and other services are enormous for the family members. All these could effect on quality of the life of parents, their living arrangements, and future relationships. LBW not only affect the individual and family but the community as well. It increases the disease burden on the community at large. These evidences suggest that LBW is a public health issue which needs to be rectified. Moreover, LBW is also an important indicator for monitoring the achievement of MDG.
Determinants of Low Birth Weight
Major determinants of LBW in developing countries are poor maternal nutritional status at conception, low maternal gestational weight gain due to inadequate dietary intake, short maternal stature, multiple births, low socioeconomic status, inadequate prenatal care and medical complications during pregnancy. However in developed countries, causes include; poor nutrition during pregnancy, history of preterm deliveries, multiple births, teen pregnancies, smoking, substance abuse and medical complications
LBW is strongly associated with malnutrition of mother before conception and during pregnancy. Bhutta ZA et al suggested that poor nutrition of fetus begins in utero and extends throughout the life cycle through intergeneration. . Anemia is prevalent during pregnancy, the primary cause being iron deficiency due to chronic inadequate dietary intake, the physiologic demands of the fetus and expansion of maternal blood volume.
The fetus depends on mother for nutrition and energy which indicates that the pregnant women should not only increase their weight but also increase essential nutrients. Recent study by Janjua (2009) in Pakistan found that mothers with low intake of vitamin C and poor nutritional status during pregnancy were more likely to give birth to LBW infant. Poor folate status at conception increases the risk for neural tube defect, LBW and other malformations On the whole, because of poverty and illiteracy women unable to afford healthy diet and access health care services.
(b) Gender Inequality
Gender inequality is another important aspect which exists in many developing countries but most common in South Asia. This gender inequality found to have detrimental effect on women and fetus health. Omani and Sen (2003) has identified the five fundamental phenomenon in South Asia related to gender inequality which are interconnected; (i) The starting point of this chain is gender bias (ii) gender inequality leads to maternal under nutrition (iii) maternal under nutrition results in intra-uterine growth retardation for the fetus which leads to high prevalence of LBW (iv) LBW leads to child under nutrition and also (v) results in higher than expected prevalence of adult ailments.
Unfortunately, despite the fact that women are primary care givers in the family, they are deprived of their social status. Another important aspect is that because of gender inequality and discrimination poor women are more vulnerable to physical and sexual abuse and the resultant adverse effects.
(c) Under-Utilization of maternal health care services
Sheikh et al (2004) identified different factors have been identified as a leading cause of poor utilization of health care services which include; cultural beliefs, socio-demographic status, women’s autonomy, economic condition, physical and financial accessibility, disease pattern and health service issues. In Pakistan, more than 80% of deliveries are performed by traditional birth attendants who are untrained or semi trained (Shaikh & Hatcher, 2007). Further, women non-compliance with the treatment and referral advice found to result in adverse outcome.
Usually women are not allowed to access health care facilities alone or take decision to spend money on health care. Women are economically dependent on their spouse who may be unwilling to pay for health care expenditure which deprives her to access health care facilities during emergency condition. Even the lack of community members’ knowledge about symptoms which require medical care can lead to delays in recognition hence could result in severe complications.
It has been found by National Institute of population studies (2008) that antenatal visits for women (4 or more) were 28% in Pakistan. According to national women’s health information center, lack of prenatal care means five times higher risk of still birth and a three times higher risk of having a baby with LBW (Danielsson, 2009).
It has been found that women have strong belief that decreased food intake during pregnancy are safer for the mother. This custom has been reported in Kenya, Oman, Sudan, Iran, Somalia and India (Hutter, 1996). Such reduction of food intake during pregnancy, controverts international standards which recommend that pregnant women should take an extra 285 kcal per day throughout the pregnancy (Clugston, 2002).
The study conducted by Hutter (1996) in rural south India found that 54.4% women claimed to reduce food intake late in pregnancy, 42.4% eat normally and only 2.7% increased food intake. Reasons behind this custom were the physical problems arising from an overloaded stomach such as indigestion, acidity, vomiting, heavy stomach, tiredness, breathlessness and not being able to work or walk freely This belief can be counteracted by giving nutritional education to these women that focus on eating specific nutritious food rather than eating more. There is still a very wide gap between latest medical developments and practiced cultural norms which is mainly due to lack of education and poor access to health care facilities.
(a) Macroeconomic condition
Government of Pakistan spends 0.8% of its annual budget on health care, even lower than Bangladesh (1.2%) and Sri Lanka (1.4%) (Shaikh & Hatcher, 2004). In fact, cost has been a major problem in seeking appropriate health care in Pakistan. Moreover, highly constrained health budget are limiting the country’s ability to provide universal access to essential maternal services. Another important thing is that an increase in the health sector budget by 10.8% was announced in 2007-08, in which more than 90% spent on the hospitals and personnel expenditure and only Rs. 318 million was earmarked for public health services (Ahmed & Shaikh, 2008). Therefore, people at community site are deprived of their basic health rights and quality of health care services.
(b) Low Per Capita Income
Per capital income of the most South Asian countries is below par. According to the International Monetary Fund (2011) data for 2010, per capita income of Pakistan is $ 2,721 per annum (world average is $ 10,922) and it is ranked 137th amongst the total 183 surveyed countries. One third of the population in Pakistan lives below the poverty line (less than US$1) (Ahmed & Shaikh, 2008). Researchers have showed that unexpected health care costs that exceed 10% of monthly household income can be catastrophic and constitute an extreme burden that may push a household in to deeper poverty (Perkins et al., 2009).
LBW is one of the most serious public health issues especially in developing countries. It constitutes a major health problem to the individual infant, family and to the society. To address this issue successfully, major determinants of LBW such as malnutrition, gender inequality, poverty, education, access to antenatal care, eradication of false cultural beliefs must be addressed in long term strategies. The reduction of LBW also forms an important contribution to the Millennium Development Goal (MDG) for reducing child mortality. Wardlaw et al. (2004) stated that “Children can be ensured a healthy start in life if women start pregnancy healthy and well nourished, and go through pregnancy and childbirth safely” (p. 27).
About the author:
Shahina Pirani did her Bachelors of Science in Nursing (BScN) in 2001 from AKUSONAM, Aga Khan University, Pakistan. She has worked in medicine ward for around 5 years and has also served as a research assistant in AKUSON for 3 years. Currently, pursuing her Masters from AKUSONAM. She can be reached at: firstname.lastname@example.org
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