Naoko Kozuki1, Joanne Katz2, Anne C C Lee3, Joshua P Vogel4, Mariangela F Silveira5, Ayesha Sania6, Gretchen A Stevens7, Simon Cousens8, Laura E Caulfield1, Parul Christian1, Lieven Huybregts9, Dominique Roberfroid10, Christentze Schmiegelow11, Linda S Adair12, Fernando C Barros13, Melanie Cowan14, Wafaie Fawzi15, Patrick Kolsteren16, Mario Merialdi17, Aroonsri Mongkolchati18, Naomi Saville19, Cesar G Victora5, Zulfiqar A Bhutta20, Hannah Blencowe21, Majid Ezzati22, Joy E Lawn23, Robert E Black1. 1. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 2. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; jkatz1@jhu.edu. 3. Department of Newborn Medicine, Brigham and Women's Hospital, Boston, MA; 4. School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia; UN Development Programme/UN Population Fund/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research. 5. Post-graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil; 6. Department of Global Health and Population. 7. Department of Health Statistics and Information Systems, and. 8. Maternal Reproductive and Child Health Center, and. 9. Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium; Poverty, Nutrition and Health Division, International Food Policy Research Institute, Washington, DC; 10. Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium; 11. Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; 12. University of North Carolina School of Public Health, Chapel Hill, NC; 13. Post-graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil; Post-graduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil; 14. Prevention of Noncommunicable Diseases Department, WHO, Geneva, Switzerland; 15. Department of Global Health and Population, Department of Nutrition, and Department of Epidemiology, Harvard School of Public Health, Boston, MA; 16. Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium; Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium; 17. UN Development Programme/UN Population Fund/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, BD, Franklin Lakes, NJ; 18. ASEAN Institute for Health Development, Mahidol University, Salaya, Nakhon Pathom, Thailand; 19. Institute for Global Health, Institute of Child Health, University College London, London, United Kingdom; Mother and Infant Research Activities, Kathmandu, Nepal; 20. Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Center for Global Child Health, Hospital for Sick Children, Toronto, Canada; 21. Maternal Reproductive and Child Health Center, and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; 22. Medical Research Council - Public Health England (MRC-PHE) Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, United Kingdom; 23. Maternal Reproductive and Child Health Center, and Saving Newborn Lives/Save the Children USA, Washington, DC; and Research and Evidence Division, UK Aid, London, United Kingdom.
Abstract
BACKGROUND: Small-for-gestational-age (SGA) and preterm births are associated with adverse health consequences, including neonatal and infant mortality, childhood undernutrition, and adulthood chronic disease. OBJECTIVES: The specific aims of this study were to estimate the association between short maternal stature and outcomes of SGA alone, preterm birth alone, or both, and to calculate the population attributable fraction of SGA and preterm birth associated with short maternal stature. METHODS: We conducted an individual participant data meta-analysis with the use of data sets from 12 population-based cohort studies and the WHO Global Survey on Maternal and Perinatal Health (13 of 24 available data sets used) from low- and middle-income countries (LMIC). We included those with weight taken within 72 h of birth, gestational age, and maternal height data (n = 177,000). For each of these studies, we individually calculated RRs between height exposure categories of < 145 cm, 145 to < 150 cm, and 150 to < 155 cm (reference: ≥ 155 cm) and outcomes of SGA, preterm birth, and their combination categories. SGA was defined with the use of both the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) birth weight standard and the 1991 US birth weight reference. The associations were then meta-analyzed. RESULTS: All short stature categories were statistically significantly associated with term SGA, preterm appropriate-for-gestational-age (AGA), and preterm SGA births (reference: term AGA). When using the INTERGROWTH-21st standard to define SGA, women < 145 cm had the highest adjusted risk ratios (aRRs) (term SGA-aRR: 2.03; 95% CI: 1.76, 2.35; preterm AGA-aRR: 1.45; 95% CI: 1.26, 1.66; preterm SGA-aRR: 2.13; 95% CI: 1.42, 3.21). Similar associations were seen for SGA defined by the US reference. Annually, 5.5 million term SGA (18.6% of the global total), 550,800 preterm AGA (5.0% of the global total), and 458,000 preterm SGA (16.5% of the global total) births may be associated with maternal short stature. CONCLUSIONS: Approximately 6.5 million SGA and/or preterm births in LMIC may be associated with short maternal stature annually. A reduction in this burden requires primary prevention of SGA, improvement in postnatal growth through early childhood, and possibly further intervention in late childhood and adolescence. It is vital for researchers to broaden the evidence base for addressing chronic malnutrition through multiple life stages, and for program implementers to explore effective, sustainable ways of reaching the most vulnerable populations.
BACKGROUND: Small-for-gestational-age (SGA) and preterm births are associated with adverse health consequences, including neonatal and infant mortality, childhood undernutrition, and adulthood chronic disease. OBJECTIVES: The specific aims of this study were to estimate the association between short maternal stature and outcomes of SGA alone, preterm birth alone, or both, and to calculate the population attributable fraction of SGA and preterm birth associated with short maternal stature. METHODS: We conducted an individual participant data meta-analysis with the use of data sets from 12 population-based cohort studies and the WHO Global Survey on Maternal and Perinatal Health (13 of 24 available data sets used) from low- and middle-income countries (LMIC). We included those with weight taken within 72 h of birth, gestational age, and maternal height data (n = 177,000). For each of these studies, we individually calculated RRs between height exposure categories of < 145 cm, 145 to < 150 cm, and 150 to < 155 cm (reference: ≥ 155 cm) and outcomes of SGA, preterm birth, and their combination categories. SGA was defined with the use of both the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) birth weight standard and the 1991 US birth weight reference. The associations were then meta-analyzed. RESULTS: All short stature categories were statistically significantly associated with term SGA, preterm appropriate-for-gestational-age (AGA), and preterm SGA births (reference: term AGA). When using the INTERGROWTH-21st standard to define SGA, women < 145 cm had the highest adjusted risk ratios (aRRs) (term SGA-aRR: 2.03; 95% CI: 1.76, 2.35; preterm AGA-aRR: 1.45; 95% CI: 1.26, 1.66; preterm SGA-aRR: 2.13; 95% CI: 1.42, 3.21). Similar associations were seen for SGA defined by the US reference. Annually, 5.5 million term SGA (18.6% of the global total), 550,800 preterm AGA (5.0% of the global total), and 458,000 preterm SGA (16.5% of the global total) births may be associated with maternal short stature. CONCLUSIONS: Approximately 6.5 million SGA and/or preterm births in LMIC may be associated with short maternal stature annually. A reduction in this burden requires primary prevention of SGA, improvement in postnatal growth through early childhood, and possibly further intervention in late childhood and adolescence. It is vital for researchers to broaden the evidence base for addressing chronic malnutrition through multiple life stages, and for program implementers to explore effective, sustainable ways of reaching the most vulnerable populations.
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