Maternal Birth Weight and Subsequent Pregnancy Outcome

Evette Hackman, PhD; Irvin Emanuel, MD; Gerald

The outcome
van

Belle, PhD; Janet Daling, PhD

stay in neonatal intensive
care

relationship between maternal birth weight and future reproductive was studied in a cohort of 748 white women with singleton pregnancies. Maternal birth weight was significantly related to stature, prepregnancy weight, pregnancy weight gain, baby's birth weight, gestational duration, relative intrauterine growth, the baby's need for neonatal intensive care, transient tachypnea of the newborn, and idiopathic respiratory distress syndrome. Mothers who weighed 2,000 g or less at birth were at elevated risk for poor pregnancy outcome, although their babies were not smaller than babies of most groups of mothers who weighed more at birth. This suggests that factors interfering with intrauterine growth have an impact on the next generation of babies. In view of the increasing survival of low-birth-weight babies, this possibility bears further investigation. (JAMA 1983;250:2016-2019)

unit

(NICU), idiopathic respiratory distress syndrome (IRDS), transient tachypnea of the newborn (TTNB), or neonatal apnea.
All other outcomes were considered favor able. Statistical analyses were performed by use of the Statistical Package for the Social Sciences.1' Multiple correlation analyses included only those subjects for whom all relevant data were available. Relative risks (RRs) and confidence inter vals (CIs) were computed by the method of Rothman and Boice.20

RESULTS

EVIDENCE has accumulated sug gesting that factors relating to the mother's childhoodher period of growth and developmentmay in fluence later reproductive perform ance.1" One British study indicated that a mother's own birth weight, which is indicative of events in her own intrauterine development, may
For editorial comment see p 2032.
also be of importance in determining her baby's relative intrauterine growth.18 This study of white Ameri
can women

included. All women were born in Wash ington after 1948, when recording of birth weight on birth certificates commenced. Birth certificates, identified by means of the mother's maiden name and date of birth, were located for 95% of the women selected from hospital records. These birth certificates provided the information on MBW as well as other data pertaining to the mother's own birth. Data about the mother's pregnancy, delivery, and preg nancy outcome were abstracted from clinic and hospital records. Data were classified according to a coding manual with specific
criteria

The Figure and Table 2 present the relationships of MBW to baby's birth weight (BBW), any unfavorable out

come, the need for NICU care, and the presence of IRDS or TTNB. An MBW of 2,000 g or less appeared to dichot

naturally with unfavorable out comes. This was confirmed by nonsig nificant x2 analyses that included only those with an MBW of more than 2,000 g. Compared with women with higher MBWs, mothers who weighed
omize series

the

respect

to these

investigated the possible relationship of maternal birth weight (MBW) to a number of future reproductive outcomes.
METHODS
en

further

developed during a pilot study. Reliability was assessed by comparing 17 subjects for whom data were inadvertent ly collected twice; there was 98% agree ment between duplicate medical record data and 100% agreement between dupli cate birth certificate data. No subjects were contacted directly. Consistent data
the fathers of the babies were not available on medical records and were therefore not included. University Hospital's Perinatal Center is a tertiary center to which 149 (19.9% ) of the mothers were referred for delivery. Twenty (2.7%) of the mothers had dia betes mellitus; 132 (17.6%) had cesarean sections. Analyses were done including and excluding these three categories of women, but the patterns of relationships of MBW with outcomes were essentially similar. Table 1 shows the age and gravidity status of the cohort. A pregnancy outcome was classified as unfavorable for any of the following rea
on

g or less at birth had signifi cantly higher RRs for the following: all unfavorable outcomes (63.6% v 26.3%; RR, 2.42; 95% CI, 1.30 to 4.52), infants who needed NICU care (60.0% v 20.9%; RR, 2.87; CI, 1.44 to 5.74), and infants with IRDS or TTNB (60% v 10.9%; RR, 5.52; CI, 2.76 to 11.05).

2,000

This cohort consisted of 748 white wom who were delivered of infants at the University of Washington Hospital, Seat tle, from July 1, 1977, through June 30, 1979. All had singleton pregnancies, and only one pregnancy per mother was
From the

For babies of mothers with MBWs of 2,000 g or less, the mean BBW was not lower than that of babies of heavier-MBW mothers. In particular, in the lowest-MBW group, only one baby was in the very-low-birth-

Hackman, Emanuel, and Daling), Pediatrics (Dr Emanuel), and Biostatistics (Dr van Belle) and the
Child

Departments

of

Epidemiology (Drs

weight category, weighing 1,380 g; weighed 1,980 and 2,200 g. The remaining seven babies varied between 2,700 and 4,100 g. Only one
two babies

(Dr Emanuel), University of Washington, Seattle. Dr Hackman is now with the Stevens Health Clinic, Edmonds, Wash. Reprint requests to Child Development and Mental Retardation Center, University of Washington, WJ-10, Seattle, WA 98195 (Dr Emanuel).

Development

and Mental Retardation Center

miscarriage, stillbirth, congenital malformation, neonatal death, required

sons:

mother with an MBW of 2,000 g or less weighed 1,500 g or less (928 g); her pregnancy ended in miscarriage. The remaining mothers weighed be tween 1,503 and 1,871 g at birth. Two mothers had cesarean sections (one

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Table 1.Maternal

Age and
100 +
>5 Total 0
2 12

DD Baby's Birth Weight

oo

Gravidity
Maternal

Any Unfavorable Outcome

or

Gravidity
_,_,

X--X NICU ...* IRDS

TTNB

- 3,300
3,200

Age,

yr 10-14 15-19

1 0 119
117

90

20-24 25-29
30

45 0

10 0 37 13 3 112 81 21 79 48 28 2 12

25 0

174 343 225

5 748
a
0!

80 + 70 + 60 +

3,100 3,000 + 2,900

a>

Total

281 231 143 54 39

had a baby with IRDS), and none had diabetes. Three of the babies had TTNB and three had IRDS. Four mothers (36.4% ) in this lowest-MBW group were themselves twins, com pared with 16 (2.2%) among the heavier-MBW mothers (P=.0002). Three (27.3%) of the lowest-MBW group were referred, compared with 146 (19.8%) of the heavier mothers (P=.27). Since there was no relation ship between referral status and MBW, referrals were included in all

i?
to

0)

C XI

50H
40--

4-2,800

<

30
20
10--r-

-f-

<2,000

analyses.

2,0012,500

2,5013,000

3,0013,500

>3,500

done by retrospective analyses (Tables 3 and 4). Table 3 shows that mean MBW increased as the following variables increased: BBW, baby's gestational duration, and baby's relative intra uterine growth. The mean MBW of normal liveborn infants is compared with that of mothers of babies with other out comes in Table 4. There were statisti cally significant differences between mothers of babies requiring NICU care and mothers of those with IRDS or with IRDS or TTNB. The P value for the comparison with mothers of babies with TTNB was .055. The mean MBW of all mothers with any unfa vorable outcome was 74 g smaller than that of mothers of normal babies, but was not significantly dif ferent. All categories included under any unfavorable outcome did not show significant differences when mean MBW was compared with that of mothers of normal babies, al though all but one were smaller. Table 5 shows the relationships between MBW and maternal stature, prepregnant weight, and pregnancy weight gain. Mothers whose MBW was above the mean were 1.9 cm taller and 3.3 kg heavier and gained 2.0 kg more during pregnancy than the lighter-MBW mothers. Mother's birth weight was not related to baby's sex, Apgar scores, or the following complications of preg nancy, labor, and delivery: pregnanwere

Certain comparisons

Maternal Birth Weight, g

of maternal birth weight to baby's birth weight, any unfavorable outcome, need for neonatal intensive care unit (NICU) care, and presence of idiopathic respiratory distress syndrome (IRDS) or transient tachypnea of newborn (TTNB). Table 2 provides specific data.

Relationship

Table 2.Maternal Birth

Weight (MBW) and Future Pregnancy Outcome

MBW,
g

=2,000
No. of

2,001-2,500
52
50

2,501-3,000
174

3,001-3,500
286

>3,500
225

pregnancies

11 10

No. of live births

165

271

213

Baby's birth weight, g*

Mean

3,019
937

2,916
851

2,902
844

3,014
762

3,223
828

SD
'All live born.

tis, abnormal bleeding, prolonged or precipitate labor, malpresentation, midforceps delivery, vacuum extrac tion, shoulder dystocia, or cesarean section. Furthermore, there was no relationship between MBW and a
score

rupture of the membranes, amnioni-

cy-induced hypertension, prolonged

of the total number of these

unrelated to MBW. Multiple correlation analysis was done to assess MBW as a preconceptional risk factor (Table 6). Referral status was entered last because the women were generally referred in the latter part of pregnancy. While referral status was not a preconceptional risk factor, adjustment for it was necessary because it was signifi cantly related to BBW. Columns 2 and

complications. The maternal postna tal complications of postpartum lac erations, hemorrhage, endometritis, and prolonged hospitalization were

significant simple correlation coeffi cients with BBW. When adjusted for all other factors, however, MBW, pre pregnant weight, and maternal smok ing were the only preconceptional factors significantly related to BBW. The multiple correlation coefficient of all preconceptional factors (excluding referral status) with BBW was .273.

3 in Table 6 present simple correla tions between the indicated risk fac tors and MBW and BBW. The last column lists the partial correlation coefficients between BBW and a spec ified risk factor after adjusting for the remaining factors in the table. For example, the value .110 in the last column is the significant partial cor relation (P<.05) between BBW and MBW after adjusting for all other risk factors. Grandmother's marital status, MBW, maternal height, prepregnant weight, and maternal smoking all had

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Table 3.Baby's Intrauterine Growth" and Maternal Birth

Table 4.Maternal Birth Weight (MBW) and

Pregnancy Outcome
g

Weight (MBW)
Outcome
N
N

MBW,
MBW, g (Mean SD)

Mean

SD

Mean Difference*
-99
-141

Normal live-born infants

467
154 61

Baby's birth weight, gt < 1,500 1,501-2,000 2,001-2,500 2,501-3,000 3,001-3,500 >3,501 Baby's gestational duration^ Preterm (<258 (259-300 days) Postterm (301 349 days) Baby's relative intrauterine growths.
Term
-

51 41 56 119

3,105507 3,147 402 3,172 532

Required NICUt IRDSt TTNBt

IRDS
or

care

23
84

TTNB

230
212

3,190515 3,218519 3,355 547

All unfavorable

outcomes*

201

3,256 515 3,157541 3,115564 3,041 669 3,094 591 3,182 559

2.05 1.98 1.93 2.58 1.64

.041 .048 .055

-215

-162
-74

.010
.101

tNICU indicates neonatal intensive care unit; IRDS, idiopathic respiratory distress syndrome; and TTNB, transient tachypnea of the newborn. ^Includes perinatal deaths, NICU care, IRDS, TTNB, apnea, and malformations.

Comparison

with mothers of normal live-born infants.

days)

158 483
62

3,136516
3,261 524
3,322 + 533

Table 5.Maternal Size and Pregnancy Weight Gain for Mothers* Above and Below Meant Maternal Birth Weight (MBW)

Small for date

Height,
105

cm

Prepregnant Weight, kg
N 334 330 Mean
'

Pregnancy Weight, Gain, kg

N
330
320 Mean SD

3,157 497 3,236 523 3,440 563

Appropriate
date

for 509
54

Large for date

'All live-born infants.

Mean MBW, g >3,256 <3,256

Mean difference
f P

Mean SD 263 265 164.51 6.53 162.626.17 -1.89 -3.41 .001

SD

61.71 13.06 58.44 11.45 -3.27

15.136.43 13.186.33

-1.95
-3.89 <001

tF=3.49; df^5,703; P=0040. *F=4.293; df=2,700; P=.0140. F=5.302; oY=2,665; P=0052. Data from Babson et al,28 with cutoff points at the tenth and 90th

-3.43
.001

percentiles.

'Mothers of all live-born babies. tMothers of normal live-born babies

only.

This was not improved by substitut ing the weight/height or weight/ height2 indexes for height and prepregnant weight in the analysis.
COMMENT

Table 6.Correlation of Maternal Birth Weight (MBW) and (BBW) With Preconceptional Factors'

Baby's Birth Weight

Simple Correlation
Coefficient
Risk Factor MBW
.018 .007

Partial

BBW
.039

Multiple Correlation Coefficient for BBW

-.013 .064

The work of Baird, his colleagues, and others in the United Kingdom has shown that some reproductive outcomes were related to factors in the childhood of motherstheir peri od of growth and development. A complex of maternal biological and behavioral attributes acquired before pregnancy were related to an individ ual's reproductive performance.1"" Women who married upward in social class showed the following tendencies compared with women who married into the same or a lower class: they had came from smaller families, higher IQs, were better educated, were taller and healthier, and rose in occupational status compared with their fathers. Upward marital mobili ty and tall stature were related to lower rates of low birth weight and perinatal mortality. Stillbirth rates were directly related to the number of siblings in a woman's family of upbringing in all social categories. An inverse relationship was also found between maternal height and anencephalus within different social class and parity groups.6 " Studies in the United States also

Grandfather's

Grandmother's

occupation gravidity

.006
.

Grandmother's marital status Grandmother's age

MBW

.104f
.055

110+

.052
-.020

.037

.160
193 .1806,
. . .

.110t
.038

height Prepregnant weight

Maternal
Mother's

.095t .128$
.036

117t
-.004

gravidity

.008

Maternal

smoking

-.060

-.176
.015

-.242
.019 .068

Mother's marital status

Maternal age Mother's referral status

.042 -.005 .044

.074

.507

-.5486.

All live-born infants

(N=488).

tP<05.

%P<X3\.
6.P5.001.

in the mother's childhood to her later bearing babies with low birth weight1421 or neural tube defects.16'" A vivid example of an intrauterine intergenerational effect is demon strated by the diethylstilbestrol sto ry. Women exposed in utero were at high risk for development of vaginal adenocarcinoma,22 various reproduc tive tract abnormalities,23 and unfa vorable pregnancy outcome.24 To our knowledge, only one other study has investigated the relation ship between the birth weights of

support the relationship of conditions

mothers and babies.18 That study found that MBW was related to the baby's relative intrauterine growth. This study supports those findings and offers further evidence that poor reproductive outcome in the next gen eration may be related to adverse intrauterine conditions of the moth er's own gestation. The data show between MBW and several future problems of pregnancy outcome. That the conditions of the mother's own intrauterine life may be important is reinforced by several additional find-

statistically significant relationships

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smaller than babies of heavier-MBW mothers (Figure). The MBW was not related to any of a number of the common complications of pregnancy, labor, and delivery, which might have partially explained the problems of pregnancy outcome that occurred. The MBW was significantly related to prepregnant weight (P=.001) and
pregnancy weight gain (r=.172; P=.001), two variables commonly used as predictors by clinicians. Last, even when adjusted for the other preconceptional variables used, MBW still remained significantly related to BBW (P<.05). The multiple correlation of all pre conceptional factors with BBW (.273) (P<.001) accounted for about 7.5% of the variance of BBW. The simple

ings. The lowest-MBW mothers ap parently were not genetically small at birth, since their babies were not

were represented by small numbers. Nevertheless, an internally consistent pattern of the association of low MBW with several problems of

problems

hypothesized that the current survi in these low-birth-weight groups will be at even higher risk for prob
vors

between pregnancy weight gain and BBW was .298 (P=.001), which accounted for 8.9% of the BBW variance. Thus, taken alto gether, these preconceptional factors predicted birth weight almost as ade

correlation

quately

as

much-used variable that is known

pregnancy

weight gain,

only after the pregnancy ends and obviously therefore is of restricted value as a predictor. Our study dealt with a cohort from a tertiary center and is not represent ative of the general population. In addition, some of the reproductive
1. Baird D: Preventive medicine in obstetrics. N Engl J Med 1952;246:561-568. 2. Baird D, Illsley R: Environment and childbearing. Proc R Soc Med 1952;46:53-59. 3. Baird D: Environmental and obstetrical factors in prematurity, with special reference to experience in Aberdeen. Bull WHO 1962;26:291\x=req-\ 295. 4. Baird D: The epidemiology of prematurity. J Pediatr 1964;65:909-924. 5. Baird D: Variations in fertility associated with changes in health status. J Chronic Dis
6. Baird D, Thomson A: The effects of obstetric and environmental factors on perinatal mortality by clinico-pathological causes, in Butler NR, Alberman ED (eds): Perinatal Problems. Edinburgh, E & S Livingstone, 1969, pp 211-226. 7. Baird D: Sociological considerations of maternal and infant capabilities, in Kretchmer N, Hasselmeyer EG (eds): Horizons in Perinatal Research. New York, John Wiley & Sons Inc, 1974, pp 10-22. 8. Baird D: The epidemiology of low birth weight: Changes in incidence in Aberdeen, 1948\x=req-\ 72. J Biosoc Sci 1974;6:323-341. 9. Baird D: Environment and reproduction. Br J Obstet Gynaecol 1980;87:1057-1067. 10. Thomson AM: Maternal stature and reproductive efficiency. Eugen Rev 1959;51:157-162. 11. Kincaid JC: Social pathology of foetal and infant loss. Br Med J 1965;1:1057-1060. 12. Emanuel I, Sever LE: Questions con-

whether or were in cluded. That there were only a small num ber of mothers with MBWs of 2,000 g or less in this series might be expected. These mothers were born before the development of intensive obstetric and neonatal care, when survival in this birth-weight group was low. These survivors probably represent the hardiest of their birthweight cohort. Furthermore, only one mother in this lowest-MBW group weighed 1,500 g or less. Recently, we have seen a remarkably increased survival of babies weighing 2,000 g or less at birth. For the United States in 1960, the infant mortality rate for white singleton babies weighing 1,000 g or less was 922 per 1,000 live births25 compared with 678 per 1,000 live births for Washington State in 1978. The corresponding figures for babies weighing 1,001 to 1,500 g were 582 and 276 per 1,000, respectively, and for babies weighing 1,501 to 2,000 g were 239 and 98 per 1,000, respectively. Moreover, this contemporary group probably represents survival from more serious intrauterine, perinatal, and postnatal problems than the group with MBWs of 2,000 g or less in this study. It might therefore be
References
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reproductive

outcome not referrals

persisted

lems of pregnancy outcome than their counterparts in this study. It should be stressed that birth weight is undoubtedly the result of the interaction between genetic and environmental factors that are poorly understood.2627 This study points to a plausible hypothesis to explain the relationship between an adverse in trauterine environment and future reproductive problems. Reduced birth weight may interfere with the growth and development of one or more organ systems, including the repro ductive and/or endocrine systems. This suggests that possibly no matter how effective prenatal, perinatal, and neonatal care become, such care alone may not prevent some problems of pregnancy outcome and underscores the urgency for increased concern for the improvement of maternal and child health. Effective efforts in this direction may result in healthier future generations.
This study was supported in part by biomdi cal research support grant RR-5714-10 from the National Institutes of Health and grant HD2274 from the National Institute of Child Health and Human Development. The Patient Data Service of University of Washington Hospital and the Vital Statistics Unit of the Washington State Department of Social and Health Services assisted with this study. Floyd Frost, PhD, provided data on birth weight-specific mortality. Bonnie WorthingtonRoberts, PhD; Gerald LaVeck, MD; and Norma Dermond also provided assistance.

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