PROTOCOL

REFERENCE ID: 2018-00689

TITLE

Correlation of placental weight, birth weight of infant and mid-upper arm circumference at 3 months of age, with the
BMI of mother at term gestation.

INTRODUCTION

Maternal and child malnutrition is a widely prevalent problem in India, and a major cause of morbidity and mortality
globally. Around 45% of deaths in children under the age of 5 years are linked to under nutrition [1] and 8.5 million
infants less than 6 months of age are stunted [2].

Growth during infancy and childhood is dependent on fetal growth, which is in turn influenced by the interaction
between maternal factors, placenta and the fetus. The birth weight and placental weight are good indicators of
newborn parameters. The placental weight has a direct and non-linear relation to the birth weight, and is an important
predictor of the birth weight [3], and significantly correlates with early childhood growth in full term infants [4].

The newborn birth weight, perinatal morbidity, and mortality also have a strong connection with the nutrition status
of the mother. Available studies show that low weight and BMI at conception or delivery, as well as poor weight gain
during pregnancy is associated with low birth weight, prematurity and maternal delivery complications [5]. A study by
Stephenson BR, et.al., [6] concluded that the maternal BMI and placental weight can predict neonatal outcome and
postnatal complications.

However, there are a limited number of studies that correlate the above-mentioned variables to the mid-upper arm
circumference [MUAC] of an infant. In toto, little has been published on the use and interpretation of anthropometric
measurements in infants aged less than 6 months. It has been shown that a single MUAC measurement in infants
around the age of 6-14 weeks has a predictive value with respect to infant mortality [2]. Furthermore, various studies
indicate that MUAC has a better discriminatory and predictive value than weight-for-length, in determining infants at
risk for under nutrition and death [2], and that weight-for-length is a very indirect measure of muscle and fat mass,
unlike MUAC [7]. MUAC can also be accurately, affordably, and reliably measured with ease, and is less susceptible
to standard error [8].

Thus, this study will be undertaken with the purpose of correlating the placental weight, birth weight and MUAC
with the BMI of the mother, and will help in the better understanding of the factors influencing infant health status
and mortality.

OBJECTIVES

1. To determine the association between placental weight, birth weight of infant and mid-upper arm circumference at
3 months of age, with the BMI of mother at term gestation.

METHODOLOGY

Sample size: Assuming at least 35% prevalence of maternal malnutrition in India, at 8% of precision, with 10%
anticipated loss to follow up, at 95% confidence level, a sample size of 150 is needed.

Study design: Longitudinal study.

Subject inclusion criteria: Mothers at term gestation [38-40 weeks] delivering at JSS hospital by C-section or
normal vaginal delivery

Subject exclusion criteria:

1. Congenital anomalies detected on antenatal scan
2. Intra-uterine growth retardation
3. Maternal chronic illnesses
4. Pregnancy induced complications [gestational diabetes mellitus, pregnancy-induced hypertension]
Sampling technique: Purposive sampling.

Method of data collection: The study will be conducted in compliance with ‘Ethical principles for Medical
Research involving human subjects’ of Helsinki Declaration. Ethical clearance will be taken from the JSS
institutional ethical committee. Confidentiality of each participant will be ensured and any possible ethical concerns
will be resolved prior to starting the survey.
Before examining the subject, a written consent will be obtained from the mother. The consent form will clearly
explain the purpose of the study and will also note that the results of the study will not be attributed to any subject
and confidentiality will be maintained. The consent form will be prepared in Kannada and English language. It will
be handed over to the mother if the mother is literate, otherwise, the examiner will read out the matter in the consent
form to the mother and take her signature or thumb impression. If the mother does not agree to provide written
consent, she will be dropped from the study subsequently.

Following this, the height and weight of the mothers at term gestation will be recorded, and their BMI will be
calculated using the above variables. After delivery, the birth weight of the newborn, and the placental weight will be
recorded. The mothers will be advised to exclusively breast feed the infants, and avoid any pre-lacteal/supplementary
feeds. They will be instructed to follow up at the 3rd month, when the mid-upper arm circumference of the infant will
be measured, using an inch tape. The right arm of the infant will be used for measurement, to maintain uniformity.

Analysis: The responses will be analysed using simple statistical analysis. Descriptive tables along with cross
tabulation will be done where appropriate. Statistical tests of significance may also be applied wherever suitable,
within a confidence interval of 95 %.

IMPLICATIONS

The results of this study will re-emphasize on the prevailing under nutrition amongst pregnant women in the
community, and thus help in anticipating the expected neonatal outcomes and complications. Furthermore, it will
throw light on the situation of under nutrition amongst infants, and predict the growth of the infant and the
probability of occurrence of malnutrition. Lastly, it will also establish the effectiveness of MUAC in detecting
malnutrition in infants; hence proving it’s usefulness as a measuring tool. Thus, with a single measurement, the
examiner will be able to identify infants that are undernourished, and at the same time, get a picture about the
nutritional status of the mother during conception. This will help in the timely institution of appropriate treatment,
ultimately contributing to the reduced incidence of complications like severe acute malnutrition, and death.

REFERENCES

1. WHO. Malnutrition. WHO;2017 [updated May 2017]. Available from

http://www.who.int/mediacentre/factsheets/malnutrition/en/

2. Mwangome MK, Fegan G, Fulford T, Prentice AM, Berkley JA. Mid-upper arm circumference at age of
routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the
Gambia. Bulletin of the World Health Organization. 2012;90(12):887-894.

3. Sanin LH, Lopez SR, Olivares ET, Terrazas MC, Silva MA, Carrillo ML. Relation between birth weight
and placenta weight. Biol Neonate. 2001 Aug;80(2):113-117.

4. Soliman AT, Eldabbagh M, Saleem W, Zahredin K, Shatla E, Adel A. Placental weight: Relation to
maternal weight and growth parameters of full-term babies at birth and during childhood. J Trop
Pediatr. 2013 Oct;59(5):358-364.

5. Ehrenberg HM, Dierker L, Milluzzi C, Mercer BM. Low maternal weight, failure to thrive in pregnancy,
and adverse pregnancy outcomes. Am J Obstet Gynecol. 2003 Dec;189(6):1726-30.

6. Stephenson BR, Johnson J, Varghese TD, Bose JA, Nair PS, Francis A, et al. Correlation of maternal
BMI and neonatal BMI with placental weight in rural South Kerala-India. Indian Journal of Neonatal
Medicine and Research. 2016 Oct;4(4)

7. Sandiford P, Paulin F, Briend A, Golden M, Grellety Y, Prudhon C, et al. Use of mid-upper-arm

circumference for nutritional screening of refugees. The Lancet. 1995 Apr;345(8957):1119-1120.
8. Tadesse A, Tadesse E, Berhane Y, Ekstrom E. Comparison of mid-upper arm circumference and
weight-for-height to diagnose severe acute malnutrition: A study in Southern Ethiopia. Nutrients. 2017
Mar;9(3):267.