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O rder N u m b er 9 1 0 2 6 7 4

P h ysical characteristics, health-related behaviors and attitu d es
o f m others w h o delivered optim al and low -birth w eight infants in
M ichigan, 1987 -1 9 8 8 : A retrospective study.
(Volum es I and II)
Friesen, Carol Ann, Ph.D.
Michigan State University, 1990

C opyright © 19 9 0 b y Friesen, Carol A nn. A ll rights reserved.

UMI

300 N. Zeeb Rd.
Ann Arbor, MI 48106

PHYSICAL CHARACTERISTICS, HEALTH-RELATED BEHAVIORS AND
ATTITUDES OF MOTHERS WHO DELIVERED OPTIMAL AND LOW BIRTH
WEIGHT INFANTS IN MICHIGAN, 1 9 8 7 - 1 9 8 8 : A RETROSPECTIVE STUDY
Volume I

By
Ca r ol Ann F r i e s e n

A DISSERTATION

Submitted to
Mi c h i g a n S t a t e U n i v e r s i t y
in p a r t i a l f u l f i l l m e n t o f t he requ ir em en ts
f o r the degree of

DOCTOR OF PHILOSOPHY

D e p a r t m e n t o f Food S c i e n c e and Human N u t r i t i o n

1990

ABSTRACT
PHYSICAL CHARACTERISTICS, HEALTH-RELATED BEHAVIORS AND ATTITUDES
OF MOTHERS WHO DELIVERED OPTIMAL AND LOW BIRTH WEIGHT INFANTS IN
MICHIGAN, 1 9 8 7 - 1 9 8 8 : A RETROSPECTIVE STUDY
By
C a r o l Ann F r i e s e n

B i r t h w e i g h t i s t h e most i m p o r t a n t d e t e r m i n a n t o f an i n f a n t ' s
survival.

Low b i r t h w e i g h t (LBW; < 2 , 5 0 0 g) i s a m a j o r c o n t r i b u t o r o f

i n f a n t m o r t a l i t y and m o r b i d i t y ,
health issue.

maki ng i t s

prevention a p r i o r i t y public

The p u r p o s e o f t h i s r e t r o s p e c t i v e ,

case-control

s t u d y was

t o d e t e r m i n e f a c t o r s wh i c h d i f f e r e d b e t we e n m o t h e r s who d e l i v e r e d LBW
and o p t i m a l b i r t h w e i g h t
objectives

included:

(OBW; 3 , 5 0 0 - 4 , 0 0 0 g)

infants.

Specific

1) t o d e t e r m i n e i f a w e i g h t g a i n t o 120% o f o n e ' s

M e t r o p o l i t a n r e f e r e n c e w e i g h t - f o r - h e i g h t a t t e r m , o r a minimum g a i n o f
s e v e n k i l o g r a m s i f o b e s e p r i o r t o p r e g n a n c y , r e d u c e d t h e i n c i d e n c e of
LBW, and 2) t o i d e n t i f y c h a r a c t e r i s t i c s ,

b e h a v i o r s and a t t i t u d e s t h a t

d i f f e r e d b e t we e n m o t h e r s who d e l i v e r e d OBW and LBW i n f a n t s .
S i x h u n d r e d w h i t e and 825 b l a c k i n f a n t : m o t h e r p a i r s we r e r a ndoml y
s e l e c t e d by a c o mp u t e r s e a r c h o f Mi c h i g a n b i r t h c e r t i f i c a t e s .

Subjects

we r e i n c l u d e d i n t h e s a m p l i n g f r a me i f t h e m o t h e r was a h e a l t h y b l a c k or
w h i t e Mi c h i g a n r e s i d e n t ,

2 0 - 3 4 y e a r s o f a g e , who d e l i v e r e d a s i n g l e t o n

as h e r f i r s t o r second c h i l d ,
gestation.

A mai l

behavioral,

subjects'

and m e d i c a l d a t a f rom t h e w h i t e s u b j e c t s and

c a r e p r o v i d e r s . Onl y me d i c a l

prenatal

a f t e r a 3 7 - 4 2 week

s u r v e y was u s e d t o o b t a i n a n t h r o p o m e t r i c , n u t r i t i o n a l ,

attitudinal

th e i r prenatal

a s s i s t e d by an MD/D0,

i n f o r m a t i o n f r om t h e b l a c k

c a r e p r o v i d e r s was o b t a i n e d , due t o a 14% r e s p o n s e

r a t e f r om t h e s u b j e c t s

in t h e p i l o t .

CAROL ANN FRIESEN

R e s u l t s i n d i c a t e d t h e f o l l o w i n g we r e r i s k f a c t o r s f o r LBW: 1) a
w e i g h t g a i n t o l e s s t h a n 120% o f o n e ' s 1983 t e r m M e t r o p o l i t a n r e f e r e n c e
w e i g h t ( w h i t e and b l a c k ) ,

2) a w e i g h t g a i n o f l e s s t h a n 7 kg ( 1 5 . 5 l b s )

i f t h e m o t h e r was o b e s e p r i o r t o p r e g n a n c y ( b l a c k ) ,

3) a p r e - p r e g n a n t

w e i g h t - f o r - h e i g h t l e s s t h a n 90% o f r e f e r e n c e ( w h i t e ) ,
o f 27 pounds o r l e s s

( w h i t e and b l a c k ) .

w h i t e Mi c h i g a n m o t h e r s '

In a d d i t i o n ,

4) a w e i g h t g a i n
r e s u l t s of the

s u r v e y i n d i c a t e d t h e f o l l o w i n g r i s k f a c t o r s wer e

a s s o c i a t e d w i t h t h e d e l i v e r y o f a LBW, a s c ompar ed t o an OBW, i n f a n t :
1) m a t e r n a l b i r t h w e i g h t l e s s t h a n 2 , 5 0 0 g , 2) c i g a r e t t e c o n s u m p t i o n ,
3) c o n s u m p t i o n o f 100 g a l c o h o l / w e e k , 4) c o n s u m p t i o n o f more t h a n 300 mg
caffeine/day,

5) c o n s u m p t i o n o f a l e s s n u t r i e n t - d e n s e d i e t and 6) a more

p o s i t i v e a t t i t u d e toward we ig h t g a i n .

C o p y r i g h t by
CAROL ANN FRIESEN
1990

DEDICATION
In h o n o r o f my m o t h e r and my Grandma B l a i s e r ,
and i n memory o f my Grandma F r i e s e n
and my f a t h e r , R i c h a r d E. F r i e s e n ,
who i n s t i l l e d i n me t h e v a l u e o f h a r d w o r k . . .
r e w a r d e d by an o c c a s i o n a l
hot fudge sundae.

v

ACKNOWLEDGEMENTS

Any s u c c e s s f u l
individual,

research

results

n o t f r om t h e

efforts

b u t a s a c o o p e r a t i v e v e n t u r e among many.

of a single

I t is impossible to

c o n d u c t a s t u d y o f t h i s s c o p e w i t h o u t a c c u m u l a t i n g numer ous d e b t s t o many
special

people.

Sincere

appreciation

is

extended

to

members

of

my

guidance

committee:
To

Dr.

Sh a r o n

L.

H o e r r , D e p a r t me n t

of

N u t r i t i o n , who s e r v e d a s my m a j o r p r o f e s s o r ,
encouragement

and g u i d a n c e t h r o u g h o u t

Food

Science

and

Human

fo r her continuous support,

this

research.

I am p a r t i c u l a r l y

a p p r e c i a t i v e o f h e r f a s t t u r n o v e r t i m e and h e r a s t u t e e d i t o r i a l

comments

and s u g g e s t i o n s .
To
Nutrition,

Dr.

Rachel

of

Food

who n o t o n l y s e r v e d on my c o m m i t t e e ,

f a c u l t y mentor.
To Dr.
Nutrition,

Sc hemmel , D e p a r t me n t

I will

Judith
not

interpretation

and

Human

b u t a l s o was my s e n i o r

n e v e r f o r g e t h e r k i n d n e s s and g e n e r o s i t y .

V.

Anderson,

only

for

of the

Science

D e p a r t me n t

her a s sista n c e

attitude

assessment

of
with

Food S c i e n c e
the

instrument,

and Human

development
but

also

and

for

her

wi s dom, a d v i c e and f r i e n d s h i p .
To

Geor ge

H.

Van

Amburg,

MPH,

MS,

Chief,

Office

of

the

State

R e g i s t r a r and C e n t e r f o r H e a l t h S t a t i s t i c s , Mi c h i g a n D e p a r t m e n t o f P u b l i c
H e a l t h . Thr ough h i s e f f o r t s I r e c e i v e d b o t h t h e p e r m i s s i o n t o c o n d u c t t h i s

study

using

assistance,
addition,

the

State

supplies

of

Mi c h i g a n

and s e r v i c e s

vital

necessary to

he p r o v i d e d s t a t i s t i c a l ,

throughout

the

University"

entire

down

participation

the

statistics

Despite

road,

am s i n c e r e l y

I

complete

methodological

project.

his

and

the

financial

this

study.

and p o l i t i c a l

allegiance

to

grateful

to

counsel

that
him

In

"other
for

his

i n t h i s s t u d y and my d e v e l o p m e n t a s a r e s e a r c h e r .

To Geor ge

H.

Baker,

Jr.,

MD,

Chief,

Maternal

and

Mi c h i g a n D e p a r t me n t o f P u b l i c H e a l t h , f o r h i s p r a c t i c a l
the survey content,

as we l l

as in t h e i n t e r p r e t a t i o n

Child

Health,

insight regarding
and a p p l i c a t i o n o f

t he infor mat ion garnered in t h i s study.
In a d d i t i o n

t o my g u i d a n c e c o m m i t t e e ,

several

f a c u l t y members a t

Mi c h i g a n S t a t e U n i v e r s i t y have p l a y e d an i m p o r t a n t r o l e i n my d e v e l o p m e n t
d u r i n g my p r o g r a m.
Che nowet h,
Bill

Sandy Andr ews ,

Helferich,

as we l l

I woul d l i k e t o t h a n k Dr s . J e n n y Bond, Won Song, Wanda
J ohn P a r t r i d g e ,

Gal e S t r a s b u r g ,

I an Gr ay,

as Bar b Mutch and C h r i s Obe r g,

Da l e Romsos,

Ma u r i c e Be n n i n k ,

Lo i s Lund and Ma r t h a B r i s t o r ,

for t h e i r advice,

encouragement,

s u p p o r t and f r i e n d s h i p . Ver y s p e c i a l t h a n k s a r e e x t e n d e d t o Dr. J ohn G i l l
for his s t a t i s t i c a l

assistance.

I woul d l i k e t o e x p r e s s my a p p r e c i a t i o n and t h a n k s t o t h e C o l l e g e
of

Human

Ec ol ogy

and

Department

of

Food

Science

and

Human

Nutrition

a d m i n i s t r a t o r s who made i t p o s s i b l e f o r me t o r e c e i v e f i n a n c i a l a s s i s t a n c e
as we l l

a s an o p p o r t u n i t y t o s e r v e on s e v e r a l

tenure.

Special

t h a n k s t o Dean J u l i a

key c o m m i t t e e s d u r i n g my

R. M i l l e r and D r s .

Mary Z a b i k ,

P.

V i n c e n t H e g a r t y and Mark U e b e r s a x .
I

woul d

like

to

express

my

sincere

Department o f P u b l i c He a l th f o r i t s f i n a n c i a l

appreciation

the

support of t h i s

Mi c h i g a n
study,

and

t o a l l a s s o c i a t e d w i t h t h e D e p a r t m e n t . S p e c i f i c a l l y , I woul d l i k e t o t h a n k
Sharon

Es ch,

Pat Kisch,

Nelton

and M a r i e ,

Kat hy

t h e mai l

Bishop,

opener.

Mike Be e be e ,

JoAnne Hogan,

Bill

I ha ve n e v e r known s uc h a g r o u p o f

u p l i f t i n g p e o p l e . Each made my e x p e r i e n c e v e r y e n j o y a b l e .
I woul d b e r e m i s s
m o t h e r s and p r e n a t a l

if

I d i d n ' t e x p r e s s my a p p r e c i a t i o n

to all

c a r e p r o v i d e r s who c o m p l e t e d t h e s u r v e y i n s t r u m e n t .

I a l s o woul d l i k e t o e x p r e s s my a p p r e c i a t i o n t o La ur a Sampson,
Dietitian

the

a t t h e Cha nni ng I n s t i t u t e ,

Research

f o r h e r a d v i c e and a s s i s t a n c e w i t h

t h e W i l l e t t S e m i - Q u a n t i t a t i v e Food F r e q u e n c y Q u e s t i o n n a i r e .
W i t h o u t t h e s u p p o r t o f my f a m i l y and many s p e c i a l
n e v e r ha ve c o m p l e t e d t h i s

p r o g r a m.

I woul d l i k e

friends,

I woul d

t o t h a n k my mom and my

b r o t h e r s and s i s t e r s f o r t h e c a r d s , c o o k i e s and c a r e p a c k a g e s t h a t h e l p e d
keep me g o i n g , e s p e c i a l l y d u r i n g t h e l a s t few mo n t h s .

I a l s o wa nt t o t h a n k

two v e r y d e a r f r i e n d s b a c k i n M i n n e s o t a , Kar en V i e r e and Li z Loomi s,
t h e i r constant support.

You make comi ng home a l l

for

the b e tt e r .

A b i g " t h a n k s " t o my s o f t b a l l t e a m, t h e Lucky Dogs, who p u t up w i t h
p r o b a b l y t h e w o r s t c oach

in t h e h i s t o r y o f t h e s p o r t .

Elaine

Morris

Scott

and

Scott

and

to

my

"little

Special

thanks to

brother",

Mi chael

Gonzalez.

I w i l l mi s s you! To my l a b g r o u p , Vi cky Louden, Ga i l Moore, Gai l

Haus and ,

especially,

t o Pa t S m i t h . What woul d I have done w i t h o u t y o u r

help a f t e r the

"great

last

incredibly bearable.

few y e a r s

flood"?

Pat,

you and Ga r r y ha ve made my l i f e
You a r e a f r i e n d f o r l i f e . . . I

the

woul d

a l s o l i k e t o t h a n k Li nda Huds on, who i s u n d o u b t e d l y t h e b e s t s e c r e t a r y i n
t h e w o r l d as we l l a s a r o l e model
wa nt

to

t h a n k my PEO s i s t e r s ,

f rom whom we woul d a l l

especially

Bebermeyer.

vi i i

Margaret

benefit.

Harris

and

I also
Bl a n c h e

Lastly,

I woul d l i k e t o t h a n k t h e mos t i m p o r t a n t p e r s o n i n my l i f e ,

Aubr e y S c h r o e d e r . You g a v e me a poem l a s t C h r i s t m a s . . .now I r e t u r n i t t o
you.
" T h e r e a r e o t h e r p e o p l e whom I d e a r l y l o v e and c a r e a b o u t i n
t h i s w o r l d , b u t t h e r e i s no one e l s e q u i t e l i k e y o u . Ever y
t i m e I l o o k b a c k , o u r f r i e n d s h i p h a s b e e n one o f t h e b e s t
p a r t s o f my y e s t e r d a y s . And e v e r y t i m e I l o o k a h e a d , I s e e o u r
f r i e n d s h i p a s t h e one t h i n g I can a l w a y s c o u n t on t o g e t me
through tomorrow".

Thank y o u , Au b r e y . We made i t .

ix

TABLE OF CONTENTS

Chapter

Page

L i s t o f Tables
L i s t of Figures
I

II

xv
xxi i

INTRODUCTION
S t a t e m e n t o f t h e Pr o b l e m
Research O b j e c t i v e s
Research Hypot hesis

1
5
6
6

REVIEW OF THE LITERATURE
De mogr aphi c R i s k F a c t o r s
Me di c a l R i s k F a c t o r s P r e d a t i n g P r e g n a n c y
1. Ma t e r n a l B i r t h Wei ght
2. Ma t e r n a l W e i g h t - f o r - H e i g h t
Me di c a l Ri s k F a c t o r s Du r i n g P r e g n a n c y
1. Wei ght Gai n
2. H e m o g l o b i n / H e m a t o c r i t V a l u e s
3. D i a s t o l i c Bl ood P r e s s u r e
B e h a v i o r a l and E n v i r o n m e n t a l R i s k F a c t o r s
1. C i g a r e t t e Cons umpt i on
2. Al c ohol Cons umpt i on
3. C a f f e i n e Cons umpt i on
4. N u t r i t i o n
a. Co n f o u n d i n g F a c t o r s
b. R e s e a r c h S t u d i e s
c . Recommended N u t r i e n t A l l o w a n c e s
d. E v a l u a t i o n o f D i e t a r y I n t a k e in a
R e t r o s p e c t i v e Study
e. Diet Quality
5. Ma t e r n a l A t t i t u d e
a . A t t i t u d e Toward We i ght Gai n
Du r i n g P r e g n a n c y
b. A t t i t u d e Toward N u t r i t i o n Dur i ng
Pregnancy
c . A t t i t u d e Toward Be i ng P r e g n a n t

98
103

H e a l t h Car e Ri s k s
1. P r e n a t a l Ca r e
Summary
Co n c e p t u a l Fr amewor k: Model t o P r e d i c t B i r t h We i ght

105
105
110
112

x

8
8
9
9
13
16
16
22
25
27
28
36
44
49
49
51
62
76
83
96
96

P ag e

CHAPTER

III

Operational D efinitions

113

IV

Met hods
P i l o t Study
Subjects
De s i g n
Instruments
Procedures
Analysis
Whi t e Mi c h i g a n M o t h e r s S u r v e y
Subjects
De s i g n
Instruments
Procedures
Analysis
P h y s i c i a n s ' P r e n a t a l Ca r e S u r v e y o f B l a c k Mi c h i g a n Mo t h e r s
Subjects
D e s i g n , I n s t r u m e n t s and P r o c e d u r e s
Analysis

119
120
120
120
121
121
123
123
123
126
126
128
133
137
137
140
140

V

R e s u l t s and D i s c u s s i o n
Whi t e Mi c h i g a n M o t h e r ' s S t u d y
R e s p o n s e Ra t e
G e n e ra liz a b ility of Results to the Population
C h a r a c t e r i s t i c s o f t h e Re s p o n d i n g Sampl e P o p u l a t i o n
Co mp a r i s o n o f Ca s e s and C o n t r o l s by S e l e c t e d
Descriptive Variables
Compa r i s on o f S e l f - R e p o r t e d and Me di c a l Re c o r d Da t a
Research Hypotheses
H0,,-la,b,c,d: V alidation of Rosso's Hypothesis
H02- l a : M a t e r n a l B i r t h Wei ght
H02- l b : P r e p r e g n a n t W e i g h t - f o r - H e i g h t
H02- 2 a : M a t e r n a l We i ght Gai n
H02- 2 b : M a t e r n a l Hemogl obi n Va l u e s
H02- 2 c : M a t e r n a l D i a s t o l i c Bl ood P r e s s u r e
H02- 3 a : C i g a r e t t e Cons umpt i on
H02- 3 b : Al c o h o l I n t a k e
H02- 3 c : C a f f e i n e I n t a k e
H02- 3 d : D i e t Q u a l i t y
H02- 3 e : M a t e r n a l A t t i t u d e
H02- 4 a : K e s s n e r I nde x
C o n c e p t u a l Fr amewor k: A Model f o r P r e d i c t i n g We i ght
M u l t i p l e R e g r e s s i o n A n a l y s i s t o P r e d i c t B i r t h We i ght
Summary: Whi t e Mi c h i g a n M o t h e r ' s S t u d y

141
141
141
144
146
147

xi

148
150
150
162
169
177
183
185
189
197
201
209
219
224
227
231
234

CHAPTER

V

VI

P a ge

R e s u l t s and D i s c u s s i o n , c o n t .
P h y s i c i a n ' s P r e n a t a l Ca r e S u r v e y o f B l a c k Mi c h i g a n Women
Re s p o n s e R a t e
G e n e ra liz a b ility of Results to the Population
C h a r a c t e r i s t i c s o f t h e R e s p o n d i n g Sampl e P o p u l a t i o n
Compa r i s on o f Ca s e s and C o n t r o l s by S e l e c t e d
Descriptive Variables
Research Hypotheses
H03- l a , b , c , d : V a l i d a t i o n o f R o s s o ' s H y p o t h e s i s
HO. - l : P r e p r e g n a n t W e i g h t - f o r - H e i g h t
H04- 2 : M a t e r n a l We i ght Gai n
H04- 3 a : M a t e r n a l Hemogl obi n V a l u e s
H04- 3 b : M a t e r n a l D i a s t o l i c Bl ood P r e s s u r e
H04- 4 : K e s s n e r I n d e x
Multiple Regression Analysis to P re d ic t Birth
We i ght
Summary: P h y s i c i a n ' s P r e n a t a l Ca r e S u r v e y Of
Bl a c k Mi c h i g a n Mo t h e r s
L i m i t a t i o n s , C o n c l u s i o n s and Re c omme nda t i ons
L i m i t a t i o n s o f t h e Study
Conclusions
Re c omme nda t i ons f o r F u t u r e R e s e a r c h

237
237
238
239
241
242
242
254
260
266
269
273
275
279

282
282
284
287

Appendices
1

S i n g l e - L i n e C h a r t t o M o n i t o r P r e g n a n c y We i ght Gai n

289

2

R o s s o ' s P r e g n a n c y We i ght Gai n M o n i t o r i n g C h a r t
Based on P r e - P r e g n a n c y W e i g h t - F o r - H e i g h t

290

3

1959 M e t r o p o l i t a n L i f e I n s u r a n c e Company' s
Weight-for-Height Reference Standard

291

4

1983 M e t r o p o l i t a n L i f e I n s u r a n c e Compa ny' s
Weig ht-for-H eig ht Reference Standard

292

5

C o n v e r s i o n C h a r t t o Change I n f a n t ' s B i r t h We i ght
From Pounds and Ounces t o Grams

293

6

Human S u b j e c t s A p p r o v a l : UCRIHS - - Mi c h i g a n S t a t e
U n i v e r s i t y ' s Commi t t e e f o r t h e Revi ew and
I n v e s t i g a t i o n o f Human S u b j e c t s

294

7

Human S u b j e c t s A p p r o v a l : Mi c h i g a n D e p a r t m e n t o f
Public Health

295

8

Appr ova l o f t h e S t u d y a s a Me di c a l R e s e a r c h P r o j e c t :
The Mi c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h

296

xi i

Appendix

P a ge

9

PILOT: Mi c h i g a n M o t h e r ' s P r e g n a n c y L i f e s t y l e
Questionnaire

297

10

PILOT: The W i l l e t t S e m i - Q u a n t i t a t i v e Food
F r e q u e n c y Q u e s t i o n n a i r e (SQFFQ)

304

11

PILOT:

P h y s i c i a n ' s P r e n a t a l Ca r e S u r v e y

308

12

PILOT:

F i r s t L e t t e r t o t h e Mi c h i g a n Mo t h e r

312

13

Mi c h i g a n M o t h e r ' s Re mi nde r P o s t c a r d

313

14

PILOT: Second L e t t e r t o Mi c h i g a n Mo t h e r s

314

15

PILOT:

315

16

P h y s i c i a n ' s Re mi nde r P o s t c a r d

316

17

Mi c h i g a n M o t h e r ' s P r e g n a n c y L i f e s t y l e
Questionnai re

317

18

R e v i s e d W i l l e t t S e m i - Q u a n t i t a t i v e Food
Frequency Q u e s t i o n n a i r e

324

19

In stru ctio n s for the W ille tt Semi-Quantitative
Food F r e q u e n c y Q u e s t i o n n a i r e

328

20

Physician's Prenatal

Ca r e Su r v e y

329

21

F i r s t L e t t e r t o Mi c h i g a n Mo t h e r s

331

22

Second L e t t e r t o Mi c h i g a n Mo t h e r s

332

23

L e t t e r R e q u e s t i n g t h e S u b j e c t t o Co mp l e t e t h e
S u r v e y o r Food F r e q u e n c y Q u e s t i o n n a i r e

333

24

L e t t e r Requesting S u b j e c t ' s Reconsideration
t o Si g n t h e P h y s i c i a n ' s R e l e a s e Form

334

25

F i r s t L e t t e r S e n t t o Whi t e S u b j e c t s '

335

26

Second L e t t e r S e n t t o Whi t e S u b j e c t s '

27

F i r s t L e t t e r Sent t o Black S u b j e c t s '

28

Second L e t t e r S e n t t o Bl a c k S u b j e c t s '

29

Supporting S t a t i s t i c a l

F i r s t Letter to Physicians

Analysis

xii i

Physicians
Physicians
Physicians
Physicians

336
337
338
339

Appendix

P a ge

30

I n f a n t M o r t a l i t y R a t e i n Mi c h i g a n by 50 g B i r t h
We i ght I n t e r v a l s : 3 , 0 0 0 - 4 , 0 0 0 g , 1 9 84- 1986

358

31

Co mp a r i s o n o f t h e U n p u b l i s h e d NHANES I I We i g h t f o r - H e i g h t Da t a f o r Women Bet ween 2 0 - 2 4 Ye a r s o f
Age w i t h t h e 1983 and 1959 M e t r o p o l i t a n R e f e r e n c e
Weight-for-H eight Standards

360

32

S u r v e y R e s p o n s e Ra t e by Count y o f B i r t h : Whi t e Mi c h i g a n
Mo t h e r s and P r e n a t a l Ca r e P r o v i d e r s o f B l a c k Mi c h i g a n
Mo t h e r s

362

L i s t o f References

364

xiv

LIST OF TABLES

Page

Table
2. 1

B i r t h w e i g h t s o f 1144 r e l a t i v e s o f t h e s m a l l - f o r - d a t e
group ( n = l 15).

11

2.2

R e l a t i v e and a t t r i b u t a b l e r i s k s o f l ow b i r t h w e i g h t
by m a t e r n a l s moki ng h a b i t s .

30

2.3

S u p p l e m e n t a t i o n s t u d i e s i n v o l v i n g p r e g n a n t women and t h e i r
e f f e c t s on m a t e r n a l w e i g h t g a i n and i n f a n t b i r t h w e i g h t .

59

2.4

Ene r gy c o s t

65

2.5

P e r c e n t d e v i a t i o n b e t we e n mean n u t r i e n t i n t a k e s
d e t e r m i n e d by o n e - y e a r we i g h e d f ood r e c o r d s and
W i l l e t t SQFFQ ( n = 2 9 ) .

2. 6

P e r c e n t d e v i a t i o n b e t we e n mean d a i l y n u t r i e n t i n t a k e s a s
d e t e r m i n e d by mean i n t a k e o f f o u r one - we e k we i g h e d f ood
r e c o r d s and t h e W i l l e t t SQFFQ ( n =1 5 0 ) .

82

2.7

Compa r i s on o f n u t r i e n t s u s e d t o c a l c u l a t e v a r i o u s d i e t
q u a lity scores.

95

3.1

Recommended D i e t a r y A l l o w a n c e s (RDA) and RDA/1000 c a l o r i e s
f o r p r e g n a n t , a d u l t women.

116

4. 1

Re s p o n s e r a t e s o b t a i n e d d u r i n g t h e p i l o t t e s t .

122

4.2

E s t i m a t e d s a mp l e s i z e o f w h i t e i n f a n t s n e e de d t o d e t e c t
a d i f f e r e n c e w i t h 80% powe r , 95% c o n f i d e n c e and a 523 g SD.

124

4.3

Subject s e lection c r i t e r i a
M o t h e r ' s Survey

125

4.4

E s t i m a t e d s a mp l e s i z e o f b l a c k i n f a n t s n e e de d t o d e t e c t
a d i f f e r e n c e w i t h 80% powe r , 95% c o n f i d e n c e and a 577 g SD.

138

4.5

Subject s e le c ti o n c r i t e r i a fo r black subjects
P h y s i c i a n ' s P r e n a t a l Ca r e S u r v e y .

139

5. 1

Re s p o n s e and c o n s e n t r a t e t o t h e w h i t e m o t h e r ' s P r e g n a n c y
L ife sty le Questionnaire.

(kcal)

of pregnancy in the f i v e - c o u n t r y study.
as
the

i n t h e Whi t e Mi c h i g a n

xv

in the

81

142

P a ge

Table

5.2

Re s p o n s e r a t e t o t h e P h y s i c i a n s '
Survey f o r w h i t e s u b j e c t s .

Prenatal

Ca r e

144

5.3

C h a r a c t e r i s t i c s o f t h e s a mpl e r e s p o n d e r s ( n = 3 9 8 ) .

147

5.4

Compa r i s on o f w h i t e c a s e s and c o n t r o l s f o r s e l e c t
d e s c r i p t i v e v a r i a b l e s ( means ± SD, u n l e s s n o t e d ) .

148

5.5

Compa r i s on o f m o t h e r ' s s e l f - r e p o r t e d and p h y s i c i a n r e p o r t e d a n t h r o p o m e t r i c m e a s u r e me n t s i n t h e Whi t e
Mi c h i g a n M o t h e r ' s S t u d y .

149

5.6

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t
i f 120% o f o n e ' s r e f e r e n c e w e i g h t was n o t a t t a i n e d a t t e r m .

151

5.7

C o r r e l a t i o n b e t we e n p e r c e n t 1959 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and i n f a n t b i r t h w e i g h t .

152

5.8

C o r r e l a t i o n b e t we e n p e r c e n t 1983 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t .

154

5.9

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
i f 120% o f r e f e r e n c e w e i g h t was n o t a t t a i n e d a t t e r m :
s moke r s and o v e r w e i g h t s u b j e c t s e x c l u d e d .

156

5.10

C o r r e l a t i o n b e t we e n p e r c e n t 1959 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t w i t h s moke r s and
o v e r w e i g h t women ( p r e - p r e g n a n t wt > 120%) e x c l u d e d .

157

5.11

C o r r e l a t i o n b e t we e n p e r c e n t 1983 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t w i t h s moke r s and
o v e r w e i g h t women (> 120% p r e - p r e g n a n t wt ) e x c l u d e d .

158

5.12

Mean b i r t h w e i g h t o f i n f a n t s b or n t o women who d i d
and d i d n o t a t t a i n t o 120% o f t h e i r M e t r o p o l i t a n
r e f e r e n c e wei ght a t term.

159

5.13

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW
i n f a n t i f a woman e n t e r s p r e g n a n c y a t o r a bove 120%
o f r e f e r e n c e and g a i n s l e s s t h a n s e v e n kg.

160

5.14

Mean s e l f - r e p o r t e d m a t e r n a l b i r t h w e i g h t o f women who
d e l i v e r e d a LBW o r an OBW i n f a n t .

163

5.15

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t
by s e l f - r e p o r t e d m a t e r n a l b i r t h w e i g h t (MBW) c a t e g o r i e s .

163

xvi

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Table

5.16

C o r r e l a t i o n b e t we e n i n f a n t b i r t h w e i g h t (IBW)
and m a t e r n a l b i r t h w e i g h t (MBW) by p r e - p r e g n a n t 1983
Metropolitan r e f e re n c e weight.

164

5.17

Ma t e r n a l b i r t h w e i g h t o f women who d e l i v e r e d a LBW
o r OBW i n f a n t by t h e i r p r e - p r e g n a n t 1983 M e t r o p o l i t a n
referen ce weight category.

165

5.18

Ma t e r n a l b i r t h w e i g h t o f women who d e l i v e r e d a LBW
o r OBW i n f a n t by t h e p e r c e n t 1983 M e t r o p o l i t a n
r e f e r e n c e weight a t t a i n e d a t term.

166

5.19

E s t i m a t e d r e l a t i v e r i s k (RR) o f a LBW m o t h e r d e l i v e r i n g
a LBW i n f a n t i f t h e m o t h e r d i d n o t g a i n t o 120% o f h e r
r e f e r e n c e wei ght a t term.

167

5.20

Mean p e r c e n t p r e p r e g n a n t w e i g h t - f o r - h e i g h t
m o t h e r s o f LBW and OBW i n f a n t s .

169

5. 2 1

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l p r e p r e g n a n t r e f e r e n c e
weight-for-height.

170

5.22

Multiple re g r e s s i o n a n a ly s is of prepregnant weight
s t a t u s (% PPW) and w e i g h t g a i n on b i r t h w e i g h t .

171

5.23

R e g r e s s i o n o f p e r c e n t 1983 r e f e r e n c e w e i g h t a t t a i n e d
a t t e r m on i n f a n t b i r t h w e i g h t by p r e - p r e g n a n t
wei ght c l a s s i f i c a t i o n .

172

5.24

Mean w e i g h t g a i n o f w h i t e m o t h e r s who d e l i v e r e d LBW
and OBW i n f a n t s .

178

5.25

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t on amount o f p r e g n a n c y w e i g h t g a i n ( n = 3 5 1 ) .

179

5.26

Amount o f w e i g h t g a i n e d d u r i n g p r e g n a n c y by m o t h e r s o f
OBW and LBW i n f a n t s when s u b j e c t s we r e c a t e g o r i z e d
a c c o r d i n g t o t h e i r 1983 M e t r o p o l i t a n p r e - p r e g n a n c y
reference weight.

180

5.27

R e g r e s s i o n o f w e i g h t g a i n on b i r t h w e i g h t by w h i t e
s u b j e c t 's pre-pregnant percent of reference weight.

181

5.28

Mean h i g h and l ow h e mo g l o b i n v a l u e s r e c o r d e d d u r i n g
p r e g n a n c y b e t we e n c a s e s and c o n t r o l s .

183

xvi i

(PPW) f o r

P ag e

Table

5.29

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l h e mo g l o b i n l e v e l s r e c o r d e d
durin g pregnancy.

184

5.30

Mean h i g h and low d i a s t o l i c b l o o d p r e s s u r e (DBP)
r e a d i n g s d u r i n g p r e g n a n c y b e t we e n c a s e s and c o n t r o l s .

186

5.31

C o r r e l a t i o n b e t we e n h i g h e s t and l o w e s t d i a s t o l i c b l o o d
p r e s s u r e r e a d i n g s r e c o r d e d d u r i n g p r e g n a n c y and i n f a n t
b i r t h weight.

186

5.32

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon h i g h e s t and l o w e s t m a t e r n a l d i a s t o l i c
blood p r e s s u r e r e a d i n g s d u r i n g pregnancy.

187

5.33

Mean number o f c i g a r e t t e s consumed p e r d a y p r i o r t o
and d u r i n g p r e g n a n c y as r e p o r t e d by m o t h e r s o f c a s e s
and c o n t r o l s .

190

5.34

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
a s s o c i a t e d w i t h number o f c i g a r e t t e s consumed p e r day
during pregnancy.

191

5.35

Si mp l e r e g r e s s i o n o f number o f c i g a r e t t e s consumed p e r
day d u r i n g p r e g n a n c y on b i r t h w e i g h t ( n = 3 9 5 ) .

191

5.36

Regression a n a ly s is i n d ic a ti n g the r e l a t i o n s h i p
be t we e n number o f c i g a r e t t e s consumed p e r d a y , p e r c e n t
1983 r e f e r e n c e w e i g h t a t t a i n e d a t t e r m and b i r t h
weight.

192

5.37

Co mp a r i s o n o f i n f a n t b i r t h w e i g h t , w e i g h t g a i n and c a l o r i e s
consumed p e r da y b e t we e n s moke r s vs n o n - s m o k e r s ( n = 3 9 5 ) .

194

5.38

Mean d a i l y a l c o h o l i n t a k e a s r e p o r t e d by m o t h e r s o f
c a s e s and c o n t r o l s on t h e SQFFQ i n s t r u m e n t .

197

5.39

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
a s s o c i a t e d w i t h mat er n a l consumption o f a l c ohol d u r i n g
p r e g n a n c y as r e p o r t e d on t h e W i l l e t t SQFFQ ( n = 3 1 0 ) .

198

5.40

R e g r e s s i o n a n a l y s i s o f alc o h o l consumption p e r day,
number o f c i g a r e t t e s smoked and t h e i n t e r a c t i o n
be t we e n t h e s e v a r i a b l e s on b i r t h w e i g h t .

199

5. 41

Self-reported estimated daily intake of caffeine
b e t we e n m o t h e r s o f c a s e s and c o n t r o l s .

201

5.42

E s t i m a t e d r e l a t i v e r i s k (RR) o f low b i r t h w e i g h t by
s e l f - r e p o r t e d c a f f e i n e i n ta k e during pregnancy.

202

xvi i i

Table

Page

5.43

S i mp l e r e g r e s s i o n o f c a f f e i n e i n t a k e on b i r t h w e i g h t
and c a f f e i n e i n t a k e on number o f c i g a r e t t e s smoked
p e r da y d u r i n g p r e g n a n c y .

204

5.44

M u l t i p l e r e g r e s s i o n a n a l y s i s o f c a f f e i n e and c i g a r e t t e s
on b i r t h w e i g h t .

204

5.45

Self-reported ratin g of d ie t q u a lity (l=poor,
1 0 = e x c e l l e n t ) p r i o r t o and d u r i n g p r e g n a n c y by m o t h e r s
o f c a s e s and c o n t r o l s .

210

5.46

D a i l y m a c r o n u t r i e n t i n t a k e b e t we e n c a s e s and c o n t r o l s
a s e s t i m a t e d by v.he W i l l e t t SQFFQ.

211

5.47

E s t i m a t e d p e r c e n t o f t h e 1989 Recommended D i e t a r y
Al l o w a n c e (RDA) consumed p e r day d u r i n g p r e g n a n c y
b e t we e n m o t h e r s o f c a s e s and c o n t r o l s , w i t h o u t s u p p l e m e n t s .

212

5.48

Mean d i e t q u a l i t y s c o r e s (MAR-12) b e t we e n m o t h e r s o f
c a s e s and c o n t r o l s , w i t h o u t s u p p l e m e n t s .

213

5.49

Si mp l e r e g r e s s i o n o f c a l o r i e s , p r o t e i n and d i e t
q u a l i t y s c o r e s wi th b i r t h wei ght (n=359).

214

5.50

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon p e r c e n t o f c a l o r i e s f r om d i e t a r y p r o t e i n .

215

5.51

We i ght g a i n a t t i t u d e s c o r e s and a c t u a l w e i g h t g a i n e d
be t we e n m o t h e r s o f c a s e s and c o n t r o l s ( l = n e g a t i v e ,
5=positive).

220

5.52

We i ght g a i n a t t i t u d e s c o r e o f women who e n t e r e d
p r e g n a n c y u n d e r w e i g h t , normal w e i g h t and o v e r w e i g h t .

221

5.53

Wei ght f a c t o r a t t i t u d e s c o r e o f m o t h e r s o f c a s e s and
c o n t r o l s c a t e g o r i z e d by 1983 p r e - p r e g n a n t w e i g h t
(l=negative, 5=positive).

222

5.54

We i ght g a i n o f women who d e l i v e r e d LBW and OBW i n f a n t s
c a t e g o r i z e d by t h e i r w e i g h t g a i n a t t i t u d e s c o r e .

222

5.55

Ke s s ne r Index c l a s s i f i c a t i o n o f p r e n a t a l
m o t h e r s o f c a s e s and c o n t r o l s .

225

5.56

R e g r e s s i o n a n a l y s i s o f t h e K e s s n e r I n d e x , number o f p r e n a t a l
v i s i t s , month p r e n a t a l c a r e be ga n and e s t i m a t e d weeks
g e s t a t i o n with b i r t h weight.

226

5.57

Two m u l t i p l e r e g r e s s i o n e q u a t i o n s t o p r e d i c t b i r t h w e i g h t .

231

xix

c a r e o b t a i n e d by

P a ge

Table

5.58

Re s p o n s e r a t e t o t h e P h y s i c i a n ' s P r e n a t a l
b l a c k Mi c h i g a n m o t h e r s .

5.59

C h a r a c t e r i s t i c s o f t h e b l a c k s a mp l e r e s p o n d e r s ( n = 3 0 1 ) .

240

5.60

Compa r i s on o f m o t h e r s o f b l a c k c a s e s and c o n t r o l s f o r
s e l e c t d e s c r i p t i v e v a r i a b l e s (Means+SD, u n l e s s n o t e d ) .

241

5 . 61

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t
i f 120% o f o n e ' s r e f e r e n c e w e i g h t was n o t a t t a i n e d a t
t e r m among b l a c k Mi c h i g a n m o t h e r s .

243

5.62

C o r r e l a t i o n b e t we e n p e r c e n t 1959 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t among b l a c k s u b j e c t s .

244

5.63

C o r r e l a t i o n be t we e n p e r c e n t 1983 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t among b l a c k women.

246

5.64

Mean b i r t h w e i g h t o f i n f a n t s b o r n t o b l a c k women who
d i d and d i d n o t a t t a i n t o 120% o f t h e i r M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t e r m (Mean ± SE) .

248

5.65

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t
i f a woman e n t e r s p r e g n a n c y a t o r a bove 120% o f r e f e r e n c e
and g a i n s l e s s t h a n s e v e n kg a c c o r d i n g t o t h e b l a c k
s u b j e c t s ' me d i c a l r e c o r d s .

250

5.66

Mean p e r c e n t p r e p r e g n a n t w e i g h t - f o r - h e i g h t
b l a c k m o t h e r s o f LBW and OBW i n f a n t s .

254

5.67

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l p r e p r e g n a n t r e f e r e n c e
w e i g h t - f o r - h e i g h t among b l a c k s u b j e c t s .

255

5.68

M ul ti pl e r e g r e s s i o n a n a l y s i s o f pr ep re gn an t weight
s t a t u s (% PPW) and w e i g h t g a i n on b i r t h w e i g h t among
black subjects.

256

5.69

R e g r e s s i o n o f p e r c e n t 1983 r e f e r e n c e w e i g h t a t t a i n e d
a t t e r m on i n f a n t b i r t h w e i g h t by p r e - p r e g n a n t
w e i g h t c l a s s i f i c a t i o n among b l a c k Mi c h i g a n m o t h e r s .

257

5.70

Mean w e i g h t g a i n o f b l a c k m o t h e r s who d e l i v e r e d
and OBW i n f a n t s .

260

5. 71

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t on amount o f p r e g n a n c y w e i g h t g a i n by b l a c k
women ( n =2 2 1 ) .

xx

Ca r e S u r v e y o f

(PPW) f o r

LBW

237

261

P a ge

Table

5.72

Amount o f w e i g h t g a i n e d d u r i n g p r e g n a n c y by b l a c k
m o t h e r s o f OBW and LBW i n f a n t s when s u b j e c t s we r e
c a t e g o r i z e d a c c o r d i n g t o t h e i r 1983 M e t r o p o l i t a n
pre-pregnancy refe re n c e weight.

262

5.73

R e g r e s s i o n o f w e i g h t g a i n on b i r t h w e i g h t by b l a c k
s u b j e c t ' s prepregnant percent of reference weight.

263

5.74

Mean h i g h and l ow h e mo g l o b i n v a l u e s r e c o r d e d d u r i n g
p r e g n a n c y b e t we e n b l a c k m o t h e r s o f c a s e s and c o n t r o l s .

266

5.75

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l h e mo g l o b i n l e v e l s r e c o r d e d
d u r i n g p r e g n a n c y among b l a c k s u b j e c t s .

267

5.76

Mean h i g h and low d i a s t o l i c b l o o d p r e s s u r e (DBP)
r e a d i n g s d u r i n g p r e g n a n c y be t we e n b l a c k m o t h e r s o f
c a s e s and c o n t r o l s .

269

5.77

C o r r e l a t i o n b e t we e n h i g h e s t and l o w e s t d i a s t o l i c b l o o d
p r e s s u r e r e a d i n g s r e c o r d e d d u r i n g p r e g n a n c y and i n f a n t
b i r t h w e i g h t among b l a c k Mi c h i g a n m o t h e r s .

270

5.78

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon h i g h e s t and l o w e s t m a t e r n a l d i a s t o l i c
b l o o d p r e s s u r e r e a d i n g s d u r i n g p r e g n a n c y among b l a c k
subjects.

271

5.79

K e s s n e r I nde x c l a s s i f i c a t i o n o f p r e n a t a l
by b l a c k m o t h e r s o f c a s e s and c o n t r o l s .

273

5.80

R e g r e s s i o n a n a l y s i s o f t h e K e s s n e r I n d e x , number o f
p r e n a t a l v i s i t s , month p r e n a t a l c a r e be gan and e s t i m a t e d
weeks g e s t a t i o n w i t h b i r t h w e i g h t among i n f a n t s o f
black mothers.

274

5.81

Two m u l t i p l e r e g r e s s i o n e q u a t i o n s t o p r e d i c t b i r t h w e i g h t
of black i n fa n t s .

277

care obtained

LIST OF FIGURES

Page

Figure

5.1

R e l a t i o n s h i p b e t w e e n p e r c e n t o f 1959 r e f e r e n c e w e i g h t
a t t a i n e d a t term with b i r t h weight.

153

5.2

R e l a t i o n s h i p b e t we e n p e r c e n t o f 1983 r e f e r e n c e w e i g h t
a t t a i n e d a t term with b i r t h weight

155

5.3

B i r t h w e i g h t by p e r c e n t r e f e r e n c e w e i g h t a t t e r m a c c o r d i n g
to a s u b j e c t ' s prepregnancy weight c l a s s i f i c a t i o n .

173

5.4

E f f e c t o f i n c r e a s i n g m a t e r n a l s t a t u r e on i n f a n t b i r t h w e i g h t
by p e r c e n t 1983 M e t r o p o l i t a n R e f e r e n c e w e i g h t a t t e r m .

174

5.5

E f f e c t o f i n c r e a s i n g c i g a r e t t e c o n s u m p t i o n on b i r t h w e i g h t .

193

5.6

I mpa c t o f c a f f e i n e

203

5.7

I n t e r a c t i v e e f f e c t o f c a f f e i n e i n t a k e and s moki ng on
in fa n t b i r t h weight.

206

5.8

Model i n d i c a t i n g t h e c o r r e l a t i o n b e t we e n s e l e c t e d m a t e r n a l
c h a r a c t e r i s t i c s , a t t i t u d e s and b e h a v i o r s a s t h e y i n f l u e n c e
b i r t h weight ( p a r t i a l r e g r e s s i o n c o e f f i c i e n t s ) .

228

5.9

R e l a t i o n s h i p b e t we e n p e r c e n t o f 1959 r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m w i t h b i r t h w e i g h t among b l a c k s u b j e c t s .

245

5.10

R e l a t i o n s h i p b e t we e n p e r c e n t o f 1983 r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m w i t h b i r t h w e i g h t among b l a c k women.

247

5. 1 1

B i r t h w e i g h t by p e r c e n t r e f e r e n c e w e i g h t a t t e r m
a c c o r d i n g t o p r e p r e g n a n c y w e i g h t c l a s s i f i c a t i o n among
b l a c k Mi c h i g a n m o t h e r s .

258

i n t a k e on b i r t h w e i g h t .

xxi i

CHAPTER I

INTRODUCTION

Each y e a r ,

n e a rl y 40,000 i n f a n t s

th e ir f i r s t birthday.

in t h e United S t a t e s d i e before

In 1987, t h e i n f a n t m o r t a l i t y r a t e

(IMR) was 10. 1

d e a t h s p e r 1,000 l i v e b i r t h s ,

r a n k i n g t h e U n i t e d S t a t e s b e h i n d 21 o t h e r

in d u stria liz e d nations

1 9 8 9 ) . The b l a c k IMR i n t h e U n i t e d S t a t e s

(NCHS,

was t w i c e t h a t o f w h i t e i n f a n t s

( 1 7 . 9 vs 8 . 9 )

(NCHS, 1 9 8 9 ) .

Mi c h i g a n IMR ( 1 0 . 9 ) was h i g h e r t h a n t h e n a t i o n a l
IMR ( 2 2 . 0 ) t h e s e c o n d h i g h e s t i n t h e n a t i o n

The 1987

average, with the black

(MDPH,

1989; Hughes e t a l ,

1989).
B i r t h w e i g h t i s t h e s i n g l e mos t i m p o r t a n t d e t e r m i n a n t o f an
infant's

survival

Medicine,

and s u b s e q u e n t g r o wt h and d e v e l o p m e n t ( I n s t i t u t e

1 9 8 5 ) , w i t h low b i r t h w e i g h t

a major de te r m i n a n t of m o r t a l i t y .

( l e s s t h a n 2500 g a t b i r t h )

of
being

I t ha s be e n e s t i m a t e d t h a t a low b i r t h

w e i g h t (LBW) i n f a n t i s 40 t i m e s more l i k e l y t o d i e i n t h e f i r s t month o f
life

t h a n a nor mal w e i g h t i n f a n t

( I n s t i t u t e o f Medicine,

t h e U n i t e d S t a t e s LBW r a t e was 6 . 9 p e r 100 l i v e b i r t h s
black),

the highest level

LBW r a t e was 7 . 2

s i n c e 1979 (NCHS,

(5.5 for white i n f a n t s ,

In 1987,

(5.7 white,

In M i c h i g a n ,

a v e r a g e (MDPH,

12. 7

t h e 1987

14.4 f o r b l ac k i n f a n t s ) ,

t h e b l a c k LBW r a t e h i g h e r t h a n t h e n a t i o n a l

1

1989).

1985).

1989).

with

In a d d i t i o n t o i n c r e a s i n g t h e r i s k o f m o r t a l i t y ,
w i t h i n c r e a s e d i n f a n t m o r b i d i t y . A LBW i n f a n t ,
subsequent problems,

and t h e i n f a n t ' s

often places a substantial

s t r e s s on young f a m i l i e s

LBW i s a s s o c i a t e d

emotional

( I n s t i t u t e o f Medicine,

1985).

and f i n a n c i a l

I t ha s been

e s t i m a t e d t h a t e v e r y LBW b i r t h a v e r t e d s a v e s b e t we e n $ 1 4 , 0 0 0 and $ 3 0 , 0 0 0
in f i r s t - y e a r hospital

and l o n g - t e r m h e a l t h c a r e c o s t s a l o n e ( O f f i c e o f

Technology Assessment,

1988).

For t h e s e r e a s o n s ,

t h e p r e v e n t i o n o f LBW i n f a n t s

p u b l i c h e a l t h i s s u e a t b o t h t h e s t a t e and n a t i o n a l

is a p r i o r i t y

level

(MDPH,

DHHS, 1 9 8 9 a ) . The Year 1990 H e a l t h O b j e c t i v e s f o r t h e N a t i o n
1979) recommended t h a t ,

by t h e y e a r 1990,

1989;

(DHHS,

1) i n f a n t m o r t a l i t y be r e d u c e d

t o no more t h a n n i n e d e a t h s p e r 1000 l i v e b i r t h s , w i t h no c o u n t y ,

racial

o r e t h n i c g r o u p h a v i n g an IMR i n e x c e s s o f 12, and 2) LBW be r e d u c e d t o
no more t h a n f i v e c a s e s p e r 100 l i v e b i r t h s ,

w i t h no c o u n t y ,

e t h n i c g r o u p h a v i n g a LBW r a t e g r e a t e r t h a n n i n e .
th a t e it h e r of these goals will

be a t t a i n e d .

racial

or

I t appears u n l ik e ly

The s e e x a c t g o a l s wer e

r e p e a t e d i n t h e p r e l i m i n a r y Ye a r 2000 H e a l t h O b j e c t i v e s f o r t h e N a t i o n
(DHHS, 1 9 8 9 ) .

I f t h e y a r e t o be met , s i g n i f i c a n t p r o g r e s s mus t be made

i n i d e n t i f y i n g m o d i f i a b l e i n f a n t m o r t a l i t y r i s k f a c t o r s and i m p l e m e n t i n g
e ff e c ti v e educational

and p r e v e n t i v e p r o g r a ms t o a d d r e s s t h e s e i s s u e s .

A l t h o u g h many f a c t o r s c o n t r i b u t e t o LBW, w e i g h t g a i n d u r i n g
pregnancy c o n s i s t e n t l y accounts fo r the l a r g e s t p ro p o rtio n of v a r i a t i o n
i n t h e b i r t h w e i g h t o f i n f a n t s bor n a t t e r m ( Ande r s on e t a l , 1984; Brown
e t a l , 1986).

P re -pr egnan cy weight s t a t u s

height values),

e s p e c i a l l y i f underweight,

e f f e c t on t h e b i r t h w e i g h t o f t e r m i n f a n t s

( a s d e t e r m i n e d by w e i g h t - f o r ha s t h e s e c o n d s t r o n g e s t
( Ni s wa n d e r and J a c k s o n ,

1974;

Brown e t a l , 1 9 8 6 ) . The c l o s e a s s o c i a t i o n b e t we e n i n f a n t b i r t h w e i g h t
and h e a l t h ,

and t h e c o n c o m i t a n t r e l a t i o n s h i p b e t we e n p r e n a t a l

weight

g a i n and b i r t h w e i g h t , make w e i g h t g a i n r e c o m m e n d a t i o n s a c c o r d i n g t o
p r e - p r e g n a n t w e i g h t c l a s s i f i c a t i o n an i m p o r t a n t p u b l i c h e a l t h i s s u e
( Br own,

1988).

Ag r e e me n t on wh a t c o n s t i t u t e s a d e s i r a b l e p r e n a t a l

weight g a in ,

h o we v e r , h a s be e n ha mpe r e d by t h e l a c k o f an a c c e p t e d s t a n d a r d f o r
identifying desired
perinatal

i n f a n t o u t c o me . B i r t h w e i g h t - s p e c i f i c f e t a l ,

and n e o n a t a l

mortality rates

and Norway ha ve i n d i c a t e d

f r om t h e U n i t e d S t a t e s ,

Sweden

a b i r t h w e i g h t b e t we e n 3500 and 4000 g i s

a s s o c i a t e d w i t h t h e l o w e s t m o r t a l i t y and ca n be c o n s i d e r e d an " o p t i m a l "
b i r t h w e i g h t f o r b o t h b l a c k and w h i t e i n f a n t s

( Brown,

b i r t h we ight o f i n f a n t s born in t h e Uni ted S t a t e s ,

1 9 8 8 ) . The medi an

howe ve r ,

i s 3370 g

(DHHS, 1 9 8 7 ) . One f a c t o r p o s s i b l y c o n t r i b u t i n g t o t h i s 1e s s - t h a n - o p t i m a l
w e i g h t may be an i n s u f f i c i e n t w e i g h t g a i n r e c o mme n d a t i o n d u r i n g
pregnancy.

S i n c e 1974,

t h e Ame r i c a n C o l l e g e o f O b s t e t r i c i a n s

and

G y n e c o l o g i s t s and t h e Ame r i c a n Academy o f P e d i a t r i c s have r ecommended a
2 2 - 2 7 pound w e i g h t g a i n d u r i n g t h e c o u r s e o f a nor mal

p r e g n a n c y (AC0G,

1 9 8 2 ) , a t t h e r a t e s p e c i f i e d by a s i n g l e - l i n e c u r v e ( Appe ndi x 1) .
r es e a rc h i n d i c a t e s t h i s weight gain curve,
r ecommendations,

Re c e n t

and c o n c o m i t a n t w e i g h t g a i n

u n d e r e s t i m a t e a p p r o p r i a t e g a i n s i n u n d e r w e i g h t women,

o v e r e s t i m a t e g a i n s f o r o b e s e women, and may be i n a p p r o p r i a t e f o r v e r y
tall

o r v e r y s h o r t women ( R o s s o ,

1985; Brown,

To c o r r e c t t h e s e d i s c r e p a n c i e s ,

1986).

Ros s o ( 1985) d e v e l o p e d a m u l t i -

l i n e d w e i g h t g a i n c h a r t w h i c h c o n s i d e r e d b o t h a woman' s p r e - p r e g n a n t
w e i g h t and h e r h e i g h t

( Ap p e n d i x 2 ) . Th e s e c u r v e s we r e b a s e d on t h e

4

h y p o t h e s i s t h a t a w e i g h t g a i n t o 120% o r more o f o n e ' s r e f e r e n c e w e i g h t
(Society of Actuaries,

1959; Appe ndi x 3 ) , o r a minimum g a i n o f 7 kg i f

an i n d i v i d u a l we i g h s 120% o r more o f r e f e r e n c e p r i o r t o p r e g n a n c y ,
a s s o c i a t e d wi t h optimal

is

i n f a n t b i r t h w e i g h t . T h i s s h o u l d be t h e t a r g e t

w e i g h t women s h o u l d be a d v i s e d t o a t t a i n by t e r m ,

a c c o r d i n g t o Rosso

(1985).
R o s s o ' s c h a r t was b a s e d on d a t a f r om b l a c k and H i s p a n i c ,
year old,

non-smoking, n o n - d r i n k i n g ,

h e a l t h y women i n New York C i t y ,

v a l i d a t e d on a l o w - i n c o m e ,

n o n - s mo k i n g ,

Chilean population

1985).

( Ro s s o ,

2 0- 25

non-drinking,

and

20- 39 y e a r o l d

Be c a us e n e i t h e r p o p u l a t i o n i s

r e p r e s e n t a t i v e of the United S t a t e s ,

t h e u n d e r l y i n g p r e m i s e must be

e x a mi n e d on a more r e p r e s e n t a t i v e g r o u p b e f o r e t h e o b s e r v a t i o n can be
gen e ra liz e d to the universe of pregnant black,
b e t we e n t h e a g e s o f 2 0 - 3 4 .

In a d d i t i o n ,

r e f e r e n c e s t a n d a r d h a s been r e v i s e d

H i s p a n i c and w h i t e women

t h e 1959 M e t r o p o l i t a n L i f e

( Appe ndi x 4 ) .

Valid atio n of Rosso's

h y p o t h e s i s u s i n g t h e r e v i s e d 1983 M e t r o p o l i t a n s t a n d a r d i s w a r r a n t e d .
Many r i s k f a c t o r s ,
pregnancy weight s t a t u s ,

i n a d d i t i o n t o p r e g n a n c y w e i g h t g a i n and p r e ­
have been a s s o c i a t e d w i t h LBW. The s e i n c l u d e

demographic c h a r a c t e r i s t i c s ,
p r e g n a n c y , me d i c a l
environmental
prenatal

me d i c a l

r i s k s t h a t can be i d e n t i f i e d b e f o r e

problems d e t e c t e d d u r i n g pregnancy,

behavioral

and

r i s k s and t h e h e a l t h c a r e r i s k s o f a b s e n t o r i n a d e q u a t e

c a r e ( I n s t i t u t e o f Medicine,

1985). A d d i t io n a l

risk factors

hypo th esi zed to i n f l u e n c e b i r t h weight in clu de :

1) m a t e r n a l

(Hackman e t a l , 1983; K l e b a n o f f and Yi p,

2) low d i a s t o l i c b l o o d

pressure

( Na e ye,

1981; G r u n b e r g e r ,

1987),

L e o d o l t e r and P a r s c h a l k ,

b i r t h weight

1979) ,

5

3) b o t h l ow and h i g h m a t e r n a l

h e mo g l o b i n v a l u e s

( H i g g i n s e t a l , 1982;

Murphy e t a l , 1986; Sagen e t a l , 1 9 8 4 ) , 4) c a f f e i n e i n t a k e
Br a c k e n ,

1987),

( M a r t i n and

5) d i e t q u a l i t y d u r i n g p r e g n a n c y ( P h i l l i p s and J o h n s o n ,

1977),

i n c l u d i n g d i e t a r y p r o t e i n i n e x c e s s o f 20% o f o n e ' s c a l o r i c

intake

(Rush e t a l , 1980) and 6) a t t i t u d e s t o w a r d w e i g h t g a i n d u r i n g

p r e g n a n c y ( Pome r a nc e e t a l , 1980; P a l me r e t a l , 1 9 8 5 ) .

S t a t e m e n t o f t h e Pr obl e m

To s a y LBW i s m u l t i f a c t o r i a l
t h e p r e v e n t i o n o f LBW w i l l

i s an u n d e r s t a t e m e n t .

To t h a t end,

require s p e cific a tte n tio n to all

a s s o c i a t e d with b i r t h weight.

Based on t h e n e e d :

i n c i d e n c e o f LBW i n M i c h i g a n , as we l l

factors

1) t o r e d u c e t h e

as in t h e United S t a t e s ,

2) t o d e t e r m i n e i f a w e i g h t g a i n d u r i n g p r e g n a n c y t o 120% o f o n e ' s p r e ­
p r e g n a n t r e f e r e n c e w e i g h t a t t e r m , o r a minimum g a i n o f 7 kg i f o b e s e
p r i o r t o pregnancy,

i s a s s o c i a t e d with optimal

b i r t h w e i g h t o f 3500 t o

4000 g i n a r e p r e s e n t a t i v e s a mpl e o f w h i t e and b l a c k women and 3) t o
u n d e r s t a n d b o t h t h e i n d e p e n d e n t and i n t e r a c t i v e e f f e c t s o f m a t e r n a l
b i r t h weight,
intake,

b l o o d p r e s s u r e and h e m o g l o b i n / h e m a t o c r i t v a l u e s ,

d i e t q u a l i t y and m a t e r n a l

a t t i t u d e s on b i r t h w e i g h t , w h i l e

a c c o u n t i n g f o r t h e a c k n o wl e d g e d r i s k f a c t o r s o f r a c e ,
status

( i nc ome and e d u c a t i o n a l

and a l c o h o l

consumption,

h y p o t h e s i s we r e p r o p o s e d .

caffeine

level),

level

socioeconomic

of prenatal

care,

t h e f o l l o w i n g r e s e a r c h o b j e c t i v e s and

smoki ng

6

Research O b j e c t i v e s

The o b j e c t i v e s o f t h i s c a s e - c o n t r o l

s t u d y comparing mat er n a l

c h a r a c t e r i s t i c s and b e h a v i o r s o f m o t h e r s who we r e d e l i v e r e d o f e i t h e r an
optimal

o r a low b i r t h w e i g h t i n f a n t we r e :

1)

To d e t e r m i n e i f a w e i g h t g a i n t o 120% o r more o f o n e ' s p r e ­

pregnant r e f e r e n c e w e i g h t - f o r - h e i g h t a t term,

o r a minimum g a i n o f s e v e n

k i l o g r a m s i f p r e - p r e g n a n c y w e i g h t i s g r e a t e r t h a n 120% o f o n e ' s
reference weight,

i s a s s o c i a t e d w i t h d e l i v e r y o f an o p t i m a l

i n f a n t (OBW; 350 0 - 4 0 0 0 g ) ,
l e s s t h a n 2500 g ) ,
20 t o 34 y e a r s ;
2)

b i r t h weight

r a t h e r t h a n a l ow b i r t h w e i g h t i n f a n t

(LBW;

i n h e a l t h y b l a c k and w h i t e women b e t we e n t h e a ge s o f

and

To d e t e r m i n e wha t m a t e r n a l

characteristics

and b e h a v i o r s

d i f f e r b e t we e n mo t h e r s who d e l i v e r OBW and LBW i n f a n t s and ca n be us e d
to predict

in fa n t b i r t h weight.

R e s e a r c h Hy p o t h e s e s

HO,,:

A w e i g h t g a i n t o 120% o r more o f o n e ' s p r e - p r e g n a n t r e f e r e n c e

w e i g h t - f o r - h e i g h t a t t e r m , o r a minimum g a i n o f s e v e n k i l o g r a m s
p r e g n a n c y w e i g h t i s g r e a t e r t h a n 120% o f o n e ' s r e f e r e n c e w e i g h t ,

if pre­
d oe s

n o t r e d u c e t h e i n c i d e n c e o f LBW, and i s n o t a s s o c i a t e d w i t h an o p t i m a l
b i r t h w e i g h t b e t we e n 3500 and 4000 g,
be t we e n t h e a ge s o f 20 t o 34;

i n h e a l t h y b l a c k and w h i t e women

7

H02:

A f t e r c o n t r o l l i n g f o r the pregnancy r i s k f a c t o r s of r ac e ,

parity,

length of g e s ta tio n ,

p l u r a l i t y , p r e d i s p o s i n g medical c o n d i t i o n s ,

c o m p l i c a t i o n s o f p r e g n a n c y and a t t e n d a n t a t d e l i v e r y
selection c r i t e r ia ) ,

age,

the following maternal

(through s ubje ct

c h a r a c t e r i s t i c s and

b e h a v i o r s do n o t d i f f e r b e t we e n m o t h e r s who we r e d e l i v e r e d o f an o p t i m a l
o r a l ow b i r t h w e i g h t i n f a n t ,
in te r a c tiv e ly to predict
1.

2.

3.

4.

Me di c a l

and c a n n o t be u s e d e i t h e r i n d i v i d u a l l y o r

i n f a n t b i r t h weight

Risk F a c t o r s P r e d a t i n g Pregnancy

a)

maternal

b)

low w e i g h t - f o r - h e i g h t

Me di c a l

b i r t h weight

R i s k F a c t o r s Du r i n g P r e g n a n c y

a)

poor weight gain

b)

hemoglobin/hematocrit

c)

d i a s t o l i c blood p r e s s u r e

Behavioral/Environmental

Risk F a c t o r s

a)

c i g a r e t t e consumption

b)

alcohol

c)

c a f f e i n e consumption

d)

diet quality

e)

maternal

consumption

attitude

H e a l t h Ca r e R i s k F a c t o r s
a)

K e s s n e r I nde x

values

:

CHAPTER I I

REVIEW OF THE LITERATURE

Low b i r t h w e i g h t ( l e s s t h a n 2 , 5 0 0 g)
neonatal

i s a major d e t e r m i n a n t o f

and i n f a n t m o r t a l i t y and m o r b i d i t y ,

i mp o s i n g e c o n o mi c ,

social

and e m o t i o n a l

b u r d e n s on b o t h f a m i l i e s and t h e N a t i o n a s a w h o l e . Many

risk factors,

i n c l u d i n g d e m o g r a p h i c c h a r a c t e r i s t i c s , me d i c a l

i d e n t i f i e d b e f o r e p regnancy, medical
behavioral
care,

and e n v i r o n m e n t a l

risks

problems d e t e c t e d d u r i n g preg n a n c y ,

r i s k s and a b s e n t o r i n a d e q u a t e p r e n a t a l

ha ve been a s s o c i a t e d w i t h l ow b i r t h w e i g h t

( I n s t i t u t e o f Medicine,

1 9 8 5 ) . T h i s r e v i e w o f t h e l i t e r a t u r e f o c u s e s on t h e r e l a t i o n b e t we e n
medical,

behavioral

and e n v i r o n m e n t a l

r i s k f a c t o r s and b i r t h w e i g h t .

De mogr a phi c R i s k F a c t o r s

De mogr a phi c r i s k f a c t o r s a s s o c i a t e d w i t h l ow b i r t h w e i g h t (LBW),
include:

1) age l e s s t h a n 17 and o l d e r t h a n 3 4 , 2) b l a c k r a c e ,

socioeconomic s t a t u s ,
education

4) s i n g l e m a r i t a l

( I n s t i t u t e of Medicine,

s t a t u s and 5) l ow l e v e l

3) low
of

1 9 8 5 ) . The i n t e r r e l a t i o n s h i p s among

t h e s e f a c t o r s makes t h e p r e c i s e a s s o c i a t i o n b e t we e n any s i n g l e f a c t o r
and LBW d i f f i c u l t t o a s c e r t a i n .

8

Me di c a l

Medi cal

Risk F a c t o r s P r e d a t i n g Pregnancy

and o b s t e t r i c f a c t o r s whi c h p r e d a t e p r e g n a n c y and a r e

l i n k e d t o low b i r t h w e i g h t i n c l u d e :
2) low w e i g h t - f o r - h e i g h t ,

1) p a r i t y

( z e r o o r more t h a n f o u r ) ,

3) g e n i t o u r i n a r y a n o m a l i e s , 4) d i s e a s e s such

a s d i a b e t e s and c h r o n i c h y p e r t e n s i o n ,
i n f e c t i o n s s uch as r u b e l l a ,

5) non- i mmune s t a t u s

6) p o o r o b s t e t r i c h i s t o r y ,

for selected

including a

p r e v i o u s low b i r t h w e i g h t i n f a n t o r m u l t i p l e s p o n t a n e o u s a b o r t i o n s and
7) m a t e r n a l g e n e t i c f a c t o r s ,
( I n s t i t u t e of Medicine,

s uc h as l ow m a t e r n a l

b i r t h weight

1985). This s e c t i o n o f t h e l i t e r a t u r e w i l l

on t h e r i s k f a c t o r s o f m a t e r n a l

focu

b i r t h w e i g h t and w e i g h t - f o r - h e i g h t .

Maternal

B i r t h Wei ght

A l t h o u g h many f a c t o r s a s s o c i a t e d w i t h l ow b i r t h w e i g h t a r e
modifiable

(i.e.,

s mo k i n g ,

poor wei ght g a i n ) ,

e v i d e n c e f r om b o t h human

and ani ma l

s t u d i e s s u g g e s t t h e r e may be a t l e a s t one f a c t o r i n f l u e n c i n g

a woman' s r e p r o d u c t i v e p e r f o r m a n c e o v e r whi c h s h e ha s no c o n t r o l :

her

own b i r t h w e i g h t .

Epidemiologic St u di e s
Hackman e t al

( 19 8 3 ) e xa mi ne d a c o h o r t o f 748 w h i t e women who

d e l i v e r e d s i n g l e t o n s a t t h e U n i v e r s i t y o f Wa s h i n g t o n H o s p i t a l
t o d e t e r m i n e t h e r e l a t i o n s h i p b e t we e n m a t e r n a l

b i r t h w e i g h t (MBW) and

t h e b i r t h w e i g h t o f h e r baby (BBW). The m o t h e r s '
o b t a i n e d f rom b i r t h c e r t i f i c a t e s .

in S e a t t l

b i r t h w e i g h t s wer e

Da t a a b o u t t h e m o t h e r s '

pregnancy,

10

d e l i v e r y and out come we r e a b s t r a c t e d f r om c l i n i c and h o s p i t a l

records.

The s i m p l e c o r r e l a t i o n b e t we e n MBW and BBW ( r = 0 . 1 6 ) e x p l a i n e d 3% o f t h e
v a r i a n c e in i n f a n t b i r t h w ei g h t .
pre-pregnant weight,

A f t e r a d j u s t i n g f o r maternal

s moki ng, m a t e r n a l

s i g n i f i c a n t l y r e l a t e d t o BBW ( r = 0 . 1 1 ) .
(r=0.12)

and m a t e r n a l

age and p a r i t y ,

mother's b i r t h weight,

Thus ,

was

a c c o u n t e d f o r a p p r o x i m a t e l y 8%

(r=0.273,

p < 0.001).

c o r r e l a t i o n b e t we e n w e i g h t g a i n and BBW ( r = 0 . 2 9 8 ;
f o r 8. 9% o f t h e BBW v a r i a n c e .

MBW s t i l l

T o g e t h e r , MBW, p r e p r e g n a n t w e i g h t

s moki ng ( r = - 0 . 2 4 )

o f t h e v a r i a n c e in i n f a n t b i r t h weight

height,

p < 0.001)

the preconceptual

The s i m p l e
accounted

f a c t o r s of

p r e p r e g n a n t w e i g h t and smoki ng p r e d i c t e d b i r t h

w e i g h t a l m o s t as a d e q u a t e l y a s t h e amount o f p r e g n a n c y w e i g h t g a i n .
To s t u d y t h e a s s o c i a t i o n be t we e n m a t e r n a l
weights,

and i n f a n t b i r t h

K l e b a n o f f and Yip ( 1987) l i n k e d t h e b i r t h c e r t i f i c a t e s o f

4 3 , 8 9 1 i n f a n t s b or n i n T e n n e s s e e from 1979 t o 1984 t o t h e b i r t h
c e r t i f i c a t e s o f t h e i r m o t h e r s who wer e bor n i n T e n n e s s e e be t we e n 1959
and 1966. A h i g h l y s i g n i f i c a n t a s s o c i a t i o n
b e t we e n m a t e r n a l
and w h i t e s .

b i r t h w e i g h t and i n f a n t b i r t h w e i g h t f o r b o t h b l a c k s

Women who we i g h e d 4000 t o 4499 g a t b i r t h we r e a t t h e l o w e s t

r i s k f o r d e l i v e r y o f a s ma l l
whites,

(p < 0 . 0 0 0 1 ) was f ound

4. 8% f o r b l a c k s ) .

for gestational

age (SGA) i n f a n t

(5. 9% f o r

The r i s k o f g i v i n g b i r t h t o an SGA i n f a n t

i n cr e as e d with d e c re a s in g maternal

b i r t h weight,

r e a c h i n g a maximum o f

19.8% f o r w h i t e m o t h e r s who we i ghe d 2000 t o 2499 g a t b i r t h and 20.0%
f o r b l a c k m o t h e r s who we i g h e d 1000 t o 1499 g a t b i r t h .
preterm b i r t h ,

The r a t e o f

i n c o n t r a s t t o t h e r a t e o f d e l i v e r i n g an SGA i n f a n t ,

n o t v a r y s i g n i f i c a n t l y by m a t e r n a l
suggest maternal

b i r t h weight or race .

The s e d a t a

b i r t h w e i g h t e x e r t s a s t r o n g e r i n f l u e n c e on

did

11

i n t r a u t e r i n e g r o wt h t h a n on t h e l e n g t h o f g e s t a t i o n ,

and t h a t women who

we r e s m a l l e r t h a n a v e r a g e a t b i r t h s h o u l d be c o n s i d e r e d a t h i g h r i s k f o r
d e l i v e r y o f an SGA i n f a n t .
Ou n s t e d and Ouns t e d ( 1973) c o l l e c t e d d a t a on 405 i n f a n t s d e l i v e r e d
in the R ad clif fe

I n f i r m a r y and C h u r c h i l l

Hospital

in Oxford,

En g l a n d .

The i n f a n t s wer e d i v i d e d i n t o t h r e e g r o u p s ( n = l 1 5 / g r o u p ) : 1) s m a l l - f o r date

(SFD; b i r t h w e i g h t two s t a n d a r d d e v i a t i o n s be l ow t h e mean f o r

length of g estatio n ),

2) 1 a r g e - f o r - d a t e

(LFD; b i r t h w e i g h t two s t a n d a r d

d e v i a t i o n s above t h e mean f o r t h e l e n g t h o f g e s t a t i o n )

and 3) a l l

others

o r c o n t r o l s . Mean b i r t h w e i g h t s o f t h e m o t h e r s o f t h e SFD, c o n t r o l s
LFD i n f a n t s wer e 2919, 3258 and 3669 g, r e s p e c t i v e l y .

and

Da t a wer e

c o l l e c t e d on t h e b i r t h w e i g h t s o f 1144 r e l a t i v e s o f t h e SFD g r o u p . A
c l e a r s e q u e n c e in d e s c e n d i n g o r d e r was o b s e r v e d , w i t h t h e s t r o n g e s t
correlation

i n b i r t h w e i g h t o c c u r r i n g be t we e n t h e s u b j e c t s '

s i b l i n g s and t h e i r m o t h e r s ( T a b l e 2 . 1 ) .
l i k e l y the maternal
fetal

system,

liveborn

The a u t h o r s c o n c l u d e d i t

and n o t t h e p a t e r n a l

system,

that constrains

g r o wt h i n u t e r o .

Tabl e 2.1

B i r t h w e i g h t s o f 1144 r e l a t i v e s o f t h e s m a l 1 - f o r - d a t e
g r o u p ( n = l 15) ( Ou n s t e d and O u n s t e d , 1 9 7 3 ) .

B i r t h We i g h t , Kg

Relationship

2.63

Liveborn s i b l i n g s
F i r s t cousins through maternal
Ma t e r n a l a u n t s and u n c l e s
Fathers
F i r s t cousins through maternal

2.85
aunts

uncles

3.08
3.22
3.27
3.40

is

Mo t h e r s

12

Animal E x p e r i m e n t s
C r o s s - b r e e d i n g e x p e r i m e n t s b e t we e n l a r g e and s ma l l

s t r a i n s of

d o m e s t i c a n i m a l s c o n c u r w i t h r e s u l t s o f human s t u d i e s whi c h s u g g e s t a
strong maternal

e f f e c t on i n f a n t b i r t h w e i g h t .

The c l a s s i c a l

J ohn Hammond and h i s g r o u p a t Ca mbr i dge ( Wa l t on and Hammond,
d e m o n s t r a t e d f o a l s s i r e d by S h e t l a n d s t a l l i o n s '
artificially

i n s e m i n a t e d i n t o S h i r e dams we r e ,

wor k o f S i r
1938)

semen whi c h had been
at b irth ,

roughly the

same i n w e i g h t a s f o a l s o f t h e p u r e m a t e r n a l b r e e d . S h i r e semen u s e d t o
f e r t i l i z e S h e t l a n d dams g e n e r a t e d c r o s s - b r e d f o a l s whose b i r t h w e i g h t
was s i m i l a r t o t h a t o f p u r e S h e t l a n d s . Th u s , m a t e r n a l

regulation

d e t e r m i n e d t h e r a t e o f i n t r a - u t e r i n e g r o wt h when t h e s e e x t r e m e - s i z e d
a d u l t h o r s e s we r e c r o s s - b r e d .
and S o u t h Devon c a t t l e
(Hunter,

S i m i l a r r e s u l t s we r e o b t a i n e d when D e x t e r

( J o u b e r t and Hammond, 1 9 5 8 ) ,

1956) and l a r g e and s ma l l

breeds o f r a b b i t s

two b r e e d s o f s he e p
( Venge,

1950) wer e

crossbred.

Summary: M a t e r n a l B i r t h Wei ght
Bot h ani ma l

and human s t u d i e s s u g g e s t m a t e r n a l

b i r t h weight e x e r t s

a s t r o n g i n f l u e n c e on t h e b i r t h w e i g h t o f t h e o f f s p r i n g .

Paternal

i n f l u e n c e d o e s n o t a p p e a r t o be as h i g h l y c o r r e l a t e d t o t h e b i r t h w e i g h t
o f t h e o f f s p r i n g . Th u s , e v i d e n c e f rom b o t h ani mal
in dicate a maternal,

and n o t p a t e r n a l ,

whi ch may be g e n e t i c ( Robs on,

and human r e s e a r c h

i n f l u e n c e on i n f a n t b i r t h w e i g h t

1978) o r as a r e s u l t o f an a d v e r s e

i n t r a u t e r i n e e n v i r o n m e n t whi c h c o n c o m i t a n t l y i n t e r f e r e d w i t h t h e gr owt h
and d e v e l o p m e n t o f one o r more o r g a n s y s t e m s ,

including the reproductive

a n d / o r e n d o c r i n e s y s t e m s (Hackman e t a l , 1 9 8 3 ) .

13

Maternal We ig h t - F or - H e ig ht

Women who e n t e r p r e g n a n c y be l ow t h e i r r e f e r e n c e w e i g h t - f o r - h e i g h t
a r e a t i n c r e a s e d r i s k f o r d e l i v e r i n g a l ow b i r t h w e i g h t i n f a n t
1979; NCHS,

1980). A f t e r g e s t a t i o n a l

( Naeye,

a g e , p r e g r a v i d w e i g h t s t a t u s and

a n t e n a t a l w e i g h t g a i n ha ve t h e g r e a t e s t

i mp a c t on i n f a n t b i r t h w e i g h t ,

a c c o u n t i n g f o r a p p r o x i m a t e l y e i g h t and s i x p e r c e n t o f t h e v a r i a t i o n
b i r t h weight,

respectively

in

( M e t c o f f e t a l , 19 8 1 b ) .

In t h e U n i t e d S t a t e s , women who a r e u n d e r w e i g h t a t c o n c e p t i o n
o r more be l ow o n e ' s r e f e r e n c e w e i g h t )
low b i r t h w e i g h t i n f a n t s

have had more p r e m a t u r e b i r t h s and

(Si mpson e t a l , 1975; Tompki ns e t a l , 1955;

Edwards e t a l , 1979; Brown e t a l , 1 9 8 1 ) ,
Christianson,

1971),

low Apgar s c o r e s
contrast,

(10%

l i g h t e r placentas

shorter infants

( Na e ye ,

(Peckham and

1979) and i n f a n t s w i t h

(Edwar ds e t a l , 1 9 7 9 ) , t h a n do nor mal w e i g h t women.

In

a l t h o u g h a s s o c i a t e d w i t h a d e c r e a s e d i n c i d e n c e o f LBW, ane mi a

and p r e m a t u r e d e l i v e r i e s ,

women who e n t e r e d p r e g n a n c y o b e s e ( g r e a t e r

t h a n 135% o f r e f e r e n c e w e i g h t ) have been a t i n c r e a s e d r i s k o f
gestational

diabetes,

hypertension,

and p r i m a r y c e s a r e a n d e l i v e r y

(Abrams and P a r k e r ,

1 9 7 8 ) . Da t a f r om t h e 1980 N a t i o n a l
Su r v e y s ( T a f f e l ,
the h e a v ie st

pregnancy-induced hypertensio n
1988;

Edwards e t a l ,

N a t a l i t y and N a t i o n a l

1986) i n d i c a t e d f e t a l

(PIH)

Fetal

Mortality

d e a t h r a t e s we r e h i g h e s t among

( g r e a t e r t h a n 72 kg) women.

E n t e r i n g p r e g n a n c y u n d e r w e i g h t , combi ne d w i t h a l ow g e s t a t i o n a l
weight g a in ,

p l a c e s women a t a h i g h r i s k f o r p e r i n a t a l

mortality

( Naeye,

1979) and l ow b i r t h w e i g h t (NCHS, 1 9 8 0 ) . A s h a r p d e c l i n e i n p e r i n a t a l

14

m o r t a l i t y i s noted as mat erna l we ight g a i n r i s e s .
e xa mi ne d t h e i n f l u e n c e o f p r e n a t a l

Luke e t al

( 1984)

w e i g h t - f o r - h e i g h t and p r e n a t a l

g a i n on i n f a n t b i r t h w e i g h t i n 696 u n c o m p l i c a t e d p r e g n a n c i e s .
g r a v i d a was c l a s s i f i e d by m a t e r n a l
medium, o r t a l l

s t a t u r e as s h o r t

weight

Each

(5'2" or l e s s ) ,

( 5 ' 6 " o r m o r e ) . Mean i n f a n t b i r t h w e i g h t s p a r a l l e l e d

i n c r e a s i n g maternal d e l i v e r y weight in a l l

t h r e e g r o u p s . The e f f e c t was

mos t p r o n o u n c e d i n t h e s h o r t g r a v i d a s , wh e r e a 10% i n c r e a s e i n d e l i v e r y
w e i g h t was a s s o c i a t e d w i t h an i n c r e a s e o f 127 g i n mean b i r t h w e i g h t ,
c ompar ed w i t h 74 g and 87 g i n t h e a v e r a g e and t a l l

groups,

respectively.
Abrams and La r o s ( 1986) d e t e r m i n e d t h e e f f e c t o f m a t e r n a l
p r e p r e g n a n t w e i g h t s t a t u s and w e i g h t g a i n on b i r t h w e i g h t i n 2946 l i v e
term b i r t h s

i n San F r a n c i s c o . The s a mp l e was s t r a t i f i e d

into the four

p r e p r e g n a n c y w e i g h t - f o r - h e i g h t c a t e g o r i e s a c c o r d i n g t o body mass i n d e x
(BMI). The BMI' s we r e c l a s s i f i e d

b a s e d on t h e v a l u e s p r o p o s e d by Gar row

( 1981) t o r e f l e c t t h e 1959 M e t r o p o l i t a n R e f e r e n c e s t a n d a r d f o r a woman
o f medium f r a m e :

1) u n d e r w e i g h t (<90% r e f e r e n c e s t a n d a r d ,

i d e a l w e i g h t ( 90-120% r e f e r e n c e ,

BMI 1 9 - 2 2 ) ,

( 121-135% r e f e r e n c e ,

BMI 2 3 - 2 8 ) ,

and 4) v e r y o v e r w e i g h t

reference,

For t h e u n d e r w e i g h t ,

BMI > 2 8 ) .

category,

2 8 . 3 and 1 7 . 8 g,

2)

3) m o d e r a t e l y o v e r w e i g h t
(>135%

nor mal w e i g h t and m o d e r a t e l y

o v e r w e i g h t women, e a c h k i l o g r a m o f m a t e r n a l
w e i g h t by 2 5 . 9 ,

BMI < 1 8 ) ,

weight gain i n cr e as e d b i r t h

respectively.

In t h e v e r y o v e r w e i g h t

h o we v e r , t h e s l o p e o f t h e l i n e d i d n o t d i f f e r from z e r o .

Results indicated t h a t,

w h i l e wei ght g a i n has a s i g n i f i c a n t

b i r t h weight in u n de rw ei gh t,

i n f l u e n c e on

nor mal w e i g h t and m o d e r a t e l y o v e r w e i g h t

women, w e i g h t g a i n d i d n o t i n f l u e n c e b i r t h w e i g h t i n t h e o b e s e women,

a

15

f i n d i n g t h e a u t h o r s s t a t e d c o n t r a d i c t e d o t h e r r e s e a r c h e r s . When m u l t i p l e
r e g r e s s i o n was u s e d t o e v a l u a t e t h e e f f e c t o f p r e p r e g n a n c y body mass and
w e i g h t g a i n on b i r t h w e i g h t , w h i l e h o l d i n g c o n s t a n t t h e e f f e c t s o f
maternal

age,

gestational

race,

age,

socioeconomic s t a t u s ,

c i g a r e t t e s moki ng,

p a r i t y and

24% o f t h e v a r i a n c e i n b i r t h w e i g h t was e x p l a i n e d .

P r e p r e g n a n c y body mass and m a t e r n a l w e i g h t g a i n a c c o u n t e d f o r 1.5% and
4. 6% o f t h e v a r i a n c e ,
Ros s o ( 1 9 8 5 ) ,

respectively.

b a s e d on r e s u l t s o f 262 h e a l t h y ,

non-smoking,

low-

i ncome b l a c k and H i s p a n i c women, r e p o r t e d women who g a i n e d t o 120% o f
t h e i r r e f e r e n c e w e i g h t ( 1959 M e t r o p o l i t a n R e f e r e n c e ; Ap p e n d i x 3 ) ,

or a

minimum w e i g h t g a i n o f 7 kg i f p r e p r e g n a n c y w e i g h t was g r e a t e r t h a n 120%
reference,

delivered

i n f a n t s with s i g n i f i c a n t l y higher b i r t h weights

t h a n d i d m o t h e r s who do n o t meet t h i s g o a l . A w e i g h t g a i n i n e x c e s s o f
120% o f r e f e r e n c e d i d n o t i n c r e a s e b i r t h w e i g h t f u r t h e r .
Th e s e d a t a s u g g e s t u n d e r w e i g h t women ca n r e d u c e t h e i r r i s k o f
d e l i v e r i n g a l ow b i r t h w e i g h t i n f a n t by e s t a b l i s h i n g a h i g h e r
p r e p r e g n a n c y w e i g h t a n d / o r by g a i n i n g e x t r a w e i g h t d u r i n g t h e p r e n a t a l
period.

Th e s e s t u d i e s u n d e r s c o r e t h e i m p o r t a n c e o f d e t e r m i n i n g a woman' s

prepregnant weight s t a t u s

so a more a p p r o p r i a t e ,

r e c o m me n d a t i o n ca n be made.

individual

weight gain

16

Me di c a l

R i s k F a c t o r s Du r i n g P r e g n a n c y

A l a r g e number o f m e d i c a l

and o b s t e t r i c r i s k f a c t o r s t h a t a r i s e

d u r i n g p r e g n a n c y h a ve be e n l i n k e d t o low b i r t h w e i g h t .
1) m u l t i p l e p r e g n a n c y ,
interval,

2) p o o r w e i g h t g a i n ,

4) h y p o t e n s i o n ,

6) s e l e c t e d

infections

s uc h as s y m p t o m a t i c b a c t e r i u r i a and r u b e l l a ,

9) h y p e r e m e s i s ,

8) p l a c e n t a p r e v i a o r a b r u p t i o

10) i n c o m p e t e n t c e r v i x ,

p r e m a t u r e r u p t u r e o f membr anes and 12) f e t a l
Medi ci ne,

3) s h o r t i n t e r p r e g n a n c y

5) h y p e r t e n s i o n / p r e e c l a m p s i a / t o x e m i a ,

7) f i r s t o r s e c o n d t r i m e s t e r b l e e d i n g ,
placenta,

These i n c l u d e :

11) s p o n t a n e o u s

anomalies

( I n s t i t u t e of

1985). This s e c t i o n o f t h e l i t e r a t u r e r evi ew w i l l

s e l e c t e d me d i c a l

f o c u s on t h e

r i s k f a c t o r s o f m a t e r n a l w e i g h t g a i n and t h e c l i n i c a l

indices of iron s t a t u s

(hemoglobin/hematocrit values)

and d i a s t o l i c

blood p r e s s u r e .

We i ght Gai n

The r e l a t i o n s h i p b e t we e n m a t e r n a l w e i g h t g a i n d u r i n g p r e g n a n c y and
p r e g n a n c y out come h a s be e n e x p l o r e d i n s e v e r a l

studies.

Wei ght g a i n has

been shown t o a c c o u n t f o r t h e l a r g e s t p r o p o r t i o n o f v a r i a t i o n
b i r t h weight of term i n f a n t s
Jackson,

( An d e r s o n e t a l , 1984; Ni s w a n d e r and

1974; Brown e t a l , 1 9 8 6 ) , w i t h b i r t h w e i g h t i n c r e a s i n g l i n e a r l y

w i t h i n c r e a s i n g p r e n a t a l w e i g h t g a i n ( M i t c h e r and L e r n e r ,
general,

in t he

each ki logr am i n c r e a s e in mat ernal

1989).

In

body w e i g h t d u r i n g p r e g n a n c y

h a s been a s s o c i a t e d w i t h a 2 0 - 2 5 g i n c r e m e n t a bove t h e u n a d j u s t e d mean
b i r t h w e i g h t ( Ea s t ma n and J a c k s o n ,

1968; Ni s wa n d e r e t a l , 1969; Si mpson

17

e t a l , 1974; Thomson and B i l l e w i c z ,

1957; Abrams and L a r o s ,

1986).

The

c o r r e l a t i o n b e t we e n b i r t h w e i g h t and w e i g h t g a i n i n most s u r v e y s was
u s u a l l y around 0 . 2 0 t o 0 . 3 0 ,

accounting f o r only fou r t o nine p e rc e n t of

t h e v a r i a n c e i n i n f a n t b i r t h w e i g h t ( M e t c o f f e t a l , 19 8 1 b ) .
M e t c o f f e t al

(1981b),

uncomplicated pregna nc ie s,

i n a s a mpl e o f 527 m o t h e r / b a b y p a i r s h a v i n g

found a s t a t i s t i c a l l y

significant correlation

(p < 0 . 0 5 ) b e t we e n b i r t h w e i g h t and m a t e r n a l w e i g h t g a i n .
adjusting for duration of g e sta tio n ,

maternal

age, h e i g h t ,

After
prepregnancy

w e i g h t and s moki ng, t h e c o r r e l a t i o n b e t we e n b i r t h w e i g h t and w e i g h t g a i n
was r = 0 . 2 3 ,

a c c o u n t i n g f o r l e s s t h a n 5% o f t h e v a r i a n c e i n a d j u s t e d

b i r t h weight.
Brown e t a l

( 1986) me a s u r e d t h e i mp a c t o f w e i g h t g a i n on t h e b i r t h

w e i g h t o f 384 h e a l t h y - s i z e d
women i n C l e v e l a n d

( 3 , 0 0 0 t o 4 , 5 0 0 g) i n f a n t s

(54% b l a c k ,

32% w h i t e and 14% " o t h e r " ) .

w e i g h t was s i g n i f i c a n t l y c o r r e l a t e d w i t h p r e n a t a l
p < 0.001).

Mean p r e n a t a l

o f l ow- i nc ome
Infant birth

weight gain

(r-0.20,

we i gh t g a i n a s s o c i a t e d wi t h t h e b i r t h of term

i n f a n t s w e i g h i n g 3 , 0 0 0 t o 4 , 5 0 0 g was s i g n i f i c a n t l y

h ig h er than t h a t

a s s o c i a t e d w i t h t e r m i n f a n t s w e i g h i n g 2 , 0 0 0 t o 3 , 0 0 0 g ( 3 0 + 0 . 9 l b vs
25+0.7 l b ,
gestational

p < 0.001).
length

Multiple regression analysis

( e x p l a i n i n g 7.3% o f t h e v a r i a n c e

w e i g h t g a i n d u r i n g p r e g n a n c y ( 2 . 8 %) ,
c i g a r e t t e s moki ng ( 3. 6%)
with b i r t h weight.
b i r t h weight,

and p a r i t y

indicated
in b i r t h w e i g h t ) ,

prepregnancy weight s t a t u s

( 4 . 9 %) ,

( 1. 9%) we r e i n d e p e n d e n t l y a s s o c i a t e d

The c o n t r i b u t i o n o f e a c h f a c t o r t o t h e v a r i a b i l i t y

in

h o we v e r , d i f f e r e d a c c o r d i n g t o p r e p r e g n a n c y w e i g h t s t a t u s .

The i n f l u e n c e o f g e s t a t i o n a l

l e n g t h on b i r t h w e i g h t weakened as

prepregnancy weight s t a t u s i n c r e a s e d .

Gestational

length,

weight gain

18

and c i g a r e t t e s moki ng we r e n o t s i g n i f i c a n t l y r e l a t e d t o b i r t h w e i g h t
among v e r y o b e s e women ( g r e a t e r t h a n 150%,
Wei ght g a i n s a s s o c i a t e d w i t h o p t i m a l
4 , 5 0 0 g w e r e 3 3 , 32,

1959 M e t r o p o l i t a n R e f e r e n c e ) .

b i r t h w e i g h t s b e t we e n 3 , 0 0 0 and

29 and 19 l b s f o r u n d e r w e i g h t ,

normal w e i g h t ,

o v e r w e i g h t and v e r y o b e s e women, r e s p e c t i v e l y .
The N a t i o n a l

N a t a l i t y S u r v e y (NNS) and t h e N a t i o n a l

M o r t a l i t y S u r v e y (NFMS) ha ve p r o v i d e d n a t i o n a l
gain with f e t a l
all

livebirths

out come

Fetal

d a ta c o r r e l a t i n g weight

(NCHS, 1 9 8 0 ) . The NNS, a p r o b a b i l i t y s a mpl e o f

t h a t o cc u rre d in the United S t a t e s

a p r o b a b i l i t y sampl e o f f e t a l

i n 1980,

and t h e NFMS,

d e a t h s a f t e r 28 weeks g e s t a t i o n ,

or

d e l i v e r y w e i g h t o f 1 , 0 0 0 g o r mor e, e xa mi ne d 3581 women ( 2917 w h i t e ,

554

black).

The a v e r a g e w e i g h t g a i n o f w h i t e m o t h e r s i n t h i s s t u d y was 29. 1

pounds,

2 . 3 pounds h i g h e r t h a n t h e b l a c k m o t h e r s .

w e i g h t was more t h a n t w i c e as h i g h among b l a c k s
w h i t e s ( 5 . 5 %) .

The r a t e o f low b i r t h

( 12. 5%) t h a n among

R e s u l t s i n d i c a t e d one o u t o f e v e r y f i v e w h i t e m o t h e r s ,

and one o u t o f f o u r b l a c k m o t h e r s , whose p r e g n a n c y e x t e n d e d t o a t l e a s t
40 we e k s , g a i n e d l e s s t h a n 21 pou n d s . O v e r a l l ,

23% o f women g i v i n g b i r t h

i n 1980 g a i n e d l e s s t h a n 21 pou n d s , w i t h 12% g a i n i n g l e s s t h a n 16
p o u n d s . As w e i g h t g a i n i n c r e a s e d ,

t h e LBW r a t e and f e t a l

mortality rates

d e c r e a s e d . A w e i g h t g a i n o f 26 t o 35 pounds was a s s o c i a t e d w i t h t h e
l o w e s t LBW and i n f a n t m o r t a l i t y r a t e s .

Bl a c k m o t h e r s we r e t w i c e as

l i k e l y a s w h i t e m o t h e r s t o g a i n l e s s t h a n e i t h e r 21 pounds (33% vs 22%)
o r 16 pounds (20% vs 11%). A f t e r c o n t r o l l i n g f o r m o t h e r ' s p r e p r e g n a n t
weight,
infant's

age, e d u c at io n ,

period of g e s ta t io n ,

l i v e b i r t h o r d e r and

s e x , m o t h e r s who g a i n e d l e s s t h a n 21 pounds wer e 2 . 3 t i m e s more

l i k e l y t o b e a r a LBW i n f a n t as m o t h e r s who g a i n e d 21 pounds o r more.

19

Mitchell

and L e r n e r ( 1989) s t u d i e d t h e r e l a t i o n s h i p b e t we e n

a n t e n a t a l w e i g h t g a i n and p r e g n a n c y out come i n 362 p a i r s o f u n d e r w e i g h t
(<90% 1983 M e t r o p o l i t a n R e f e r e n c e We i ght ) and nor mal w e i g h t
110%) women who we r e m a t c h e d f o r a g e , o c c u p a t i o n ,
and s moki ng h a b i t s .

height,

(90% t o

parity,

race

B i r t h w e i g h t was p o s i t i v e l y c o r r e l a t e d w i t h m a t e r n a l

w e i g h t g a i n (p < 0 . 0 0 1 ) .

Each k i l o g r a m i n c r e a s e i n m a t e r n a l w e i g h t was

a s s o c i a t e d w i t h a 1 2 . 8 5 g i n c r e a s e i n b i r t h w e i g h t o f i n f a n t s b or n t o
u n d e r w e i g h t women, and a 8 . 5 9 g i n c r e a s e i n b i r t h w e i g h t o f i n f a n t s bor n
t o nor mal w e i g h t women. Bot h u n d e r w e i g h t and normal w e i g h t women who
g a i n e d l e s s t h a n 9 kg d e l i v e r e d i n f a n t s w i t h mean b i r t h w e i g h t s o f 367 g
and 251 g l e s s ,

respectively,

t h a n 9 kg (p < 0 . 0 0 1 ) .

t h a n i n f a n t s o f m o t h e r s who g a i n e d more

We i ght g a i n s o f l e s s t h a n 9 kg i n b o t h g r o u p s o f

women we r e a s s o c i a t e d w i t h s i g n i f i c a n t l y l o w e r b i r t h w e i g h t s
T h i s s t u d y c o n f i r m e d r e s u l t s o f numer ous i n v e s t i g a t o r s
1982; Gor mi can e t a l , 1980; Love and Ki n c h ,
i n whi c h a n t e n a t a l

(p < 0 . 0 5 ) .

(Kennedy e t a l ,

1965; P i c o n e e t a l , 1 9 8 2 a , b )

w e i g h t g a i n and p r e p r e g n a n c y w e i g h t s t a t u s wer e

s i g n i f i c a n t d e t e r m i n a n t s o f b i r t h w e i g h t i n nor mal

and u n d e r w e i g h t

women.

Wei ght Gai n Re c omme nda t i ons
The c u r r e n t p r e g n a n c y w e i g h t g a i n r e c o mme n d a t i o n o f t h e Commi t t ee
on M a t e r n a l

Nutrition

( 1970)

on d a t a f r om a l o n g i t u d i n a l
1950's.

Since then,

i s 24 p o u n d s . T h i s r e c o mme n d a t i o n i s ba s e d
s t u d y o f 60 p r e g n a n t women i n t h e mid-

new d a t a ha ve i n d i c a t e d t h e o p t i m a l w e i g h t g a i n i s

h i g h e r t h a n 24 p o u n d s . Da t a f rom t h e P e r i n a t a l
( Na e ye ,

C o l l a b o r a t i v e St u d y

1979) o f 5 0 , 0 0 0 women b e t we e n 1959 and 1965, c l e a r l y doc ume nt ed

20

t h a t i n c r e a s e d m a t e r n a l w e i g h t g a i n was r e l a t e d t o l a r g e r b i r t h w e i g h t s
and a d e c r e a s e d i n c i d e n c e o f LBW and n e o n a t a l m o r t a l i t y .

LBW o c c u r r e d

f o u r t i m e s more f r e q u e n t l y among women who g a i n e d l e s s t h a n 14 p o u n d s ,
t h a n among t h o s e who g a i n e d 3 0 - 3 5 p o u n d s . R e s u l t s i n d i c a t e d t h e b e s t
obstetrical

out come o c c u r r e d among normal w e i g h t women who g a i n e d 27

( r a n g e 2 2 - 3 3 ) pounds ( Ni s w a n d e r and Gor don,
results,

1972).

Based on t h e s e

t h e Ame r i c a n C o l l e g e o f O b s t e t r i c i a n s and G y n e c o l o g i s t s have

recommended a p r e g n a n c y w e i g h t g a i n o f 22- 27 pounds (ACOG,

1982).

A l t h o u g h t h e Commi t t e e on Ma t e r n a l N u t r i t i o n ' s 2 4 - p o u n d w e i g h t
gain curve is s t i l l

us e d i n p r e n a t a l

care f a c i l i t i e s

( Ap p e n d i x 1 ) ,

Rosso

( 1 9 8 5 ; Ap p e n d i x 2) and Brown ( 1983) have d e v e l o p e d new w e i g h t g a i n
c h a r t s whi c h a c c o u n t f o r p r e p r e g n a n c y w e i g h t - f o r - h e i g h t .
e x p e r t s a p p o i n t e d by t h e N a t i o n a l
weight gain d a ta wi ll

R e s e a r c h Co u n c i l

A committee of

t o e v a l u a t e new

mos t l i k e l y recommend a s i m i l a r p r e g n a n c y w e i g h t

g a i n c h a r t whi ch a c c o u n t s f o r p r e p r e g n a n t w e i g h t s t a t u s
f u t u r e ( Ki n g , p e r s o n a l c o m m u n i c a t i o n ,

in t h e near

1 9 8 9 ) . Wei ght g a i n r e c o m m e n d a t i o n s

during pregnancy according to prepregnancy weight s t a t u s

are b r ie f ly

reviewed.
Brown ( 1983) and Rosso ( 1985) b o t h recommended e m p h a s i z i n g r a n g e s
o f nor mal w e i g h t g a i n when c o u n s e l i n g p r e g n a n t women, r a t h e r t h a n
s p e c i f y i n g one p a r t i c u l a r t a r g e t number . Rosso ( 1985) r ecommended a
w e i g h t g a i n t o 120% o f o n e ' s 1959 M e t r o p o l i t a n r e f e r e n c e w e i g h t
( Ap p e n d i x 3 ) .

For t h e nor mal w e i g h t a d u l t woman whose s t a t u r e

5 ' 0 " and 5 ' 1 0 " ,
Similarly,
weight,

this

i s b e t we e n

i s e q u i v a l e n t t o a w e i g h t g a i n o f 22 t o 30 p o u n d s .

Brown ( 1983) recommended a w e i g h t g a i n r a n g e f o r n o r m a l -

a d u l t women o f f r om 24 t o 32 pounds a t t e r m .

21

Women who a r e u n d e r w e i g h t a t c o n c e p t i o n n e e d t o g a i n more w e i g h t
t o accommodat e b o t h " c a t c h up" g r o wt h and a d e q u a t e g r o wt h t o s u p p o r t t h e
pregnancy.

Naeye ( 1 9 7 9 ) ,

using the p e r i n a t a l

o f p r e g n a n c y o u t c ome , n o t e d o p t i m a l

m o r t a l i t y r a t e a s an i n d e x

out come was a s s o c i a t e d w i t h a w e i g h t

g a i n o f 30 pounds ( 1 3 . 6 kg) f o r u n d e r w e i g h t women. Brown e t al

( 1986)

r e p o r t e d a w e i g h t g a i n o f 33 pounds o r 15 kg ( r a n g e 2 8 - 3 6 p o unds ) was
a s s o c i a t e d w i t h an o p t i m a l

b i r t h w e i g h t o f 3 , 0 0 0 t o 4 , 5 0 0 g i f t h e woman

was u n d e r w e i g h t p r i o r t o p r e g n a n c y ( l e s s t h a n 95% o f o n e ' s
Metropolitan reference weight).

1959

Ros s o ( 1985) recommended a w e i g h t g a i n

t o 120% o f o n e ' s 1959 M e t r o p o l i t a n r e f e r e n c e s t a n d a r d .

Although a gain

t o 120% r e f e r e n c e i s e q u i v a l e n t t o a 2 2 - 3 0 pound w e i g h t g a i n f o r t h e
woman a t h e r r e f e r e n c e w e i g h t ,
will

a woman who e n t e r s p r e g n a n c y u n d e r w e i g h t

ha ve t o g a i n more t h a n 2 2 - 3 0 pounds t o a t t a i n

120% o f r e f e r e n c e ,

w i t h t h e e x a c t amount d e p e n d e n t upon h e r d e g r e e o f u n d e r w e i g h t .
E x c e s s i v e w e i g h t g a i n and o b e s i t y i n p r e g n a n c y a r e a s s o c i a t e d w i t h
health risks

( G a r b a c i a k e t a l , 1985; Abrams and P a r k e r ,

the Collaborative Perinatal

Project

( Na e ye ,

1979)

r e g a r d l e s s of p r e - c o n c e p t io n a l weight s t a t u s ,

1987).

Dat a from

indicated that,

women who g a i n e d o v e r 32

pounds ( 1 4 . 5 kg) d u r i n g p r e g n a n c y had h i g h e r r a t e s o f p e r i n a t a l
m o r t a l i t y t h an mothers wi th wei ght g a i n s
recommended 27 pounds ( i . e . ,

i n t h e 80-120% r a n g e o f t h e

22- 32 p o u n d s ) . Mo t h e r s who we r e o b e s e p r i o r

t o p r e g n a n c y had t h e b e s t out c ome s w i t h a 15- 16 pound (7 kg) w e i g h t
gain.

Brown e t al

overweight

( 1986) n o t e d w e i g h t g a i n s o f 29 pounds

( 115-150%,

1959 M e t r o p o l i t a n R e f e r e n c e )

kg) f o r o b e s e women ( g r e a t e r t h a n 150%,
we r e a s s o c i a t e d w i t h o p t i m a l

(13 kg) f o r

and 19 pounds ( 8 . 5

1959 M e t r o p o l i t a n R e f e r e n c e )

i n f a n t b i r t h w e i g h t s o f b e t we e n 3 , 0 0 0 and

22

4 , 5 0 0 g . Rosso ( 1985) recommended o b e s e women g a i n a minimum o f 7 kg,

an

amount e q u i v a l e n t t o t h e w e i g h t o f t h e c o n c e p t u s .

H e m o g l o b i n / H e m a t o c r i t Va l u e s

Du r i n g p r e g n a n c y ,
in both maternal
necessary,

i r o n i s ne e de d f o r t h e m a n u f a c t u r e o f h e mo g l o b i n

and f e t a l

red blood c e l l s

( Va nde r e t a l , 1 9 8 5 ) .

t h e f e t u s a c t s as a t r u e p a r a s i t e ,

assuring

If

i t s own

p r o d u c t i o n o f h e mo g l o b i n by d r a w i n g i r o n f rom t h e m o t h e r ( W o r t h i n g t o n Roberts,

1 9 8 7 ) . Al t h o u g h r e d b l o o d c e l l

production is stim ulated during

p r e g n a n c y , t h e i n c r e a s e i s n o t as l a r g e as t h e 50% i n c r e a s e i n pl a s ma
vol ume t h a t a c c o m p a n i e s p r e g n a n c y . Thus , t h e h e m a t o c r i t ,

whi c h i s

n o r m a l l y a r o u n d 35% i n women, can d r o p as low as 29% t o 31% d u r i n g
p r e g n a n c y . The amount o f h e mo g l o b i n i n e a c h r e d b l o o d c e l l
change,

but because t h e r e a r e fewer red blood c e l l s

hemodilution occurs.

does not

p e r 100 ml b l o o d ,

N o n p r e g n a n t h e mo g l o b i n v a l u e s o f 13 t o 14 g / 100 ml

ca n d r o p as low a s 10 o r 11 g / 100 ml i n t h e e a r l y mont hs o f p r e g n a n c y ,
b u t as l o n g a s t h e r e d c e l l s a r e nor moc hr omi c and n o r m o c y t i c ,

t h e women

a r e n o t a ne mi c ( V a r n e r e t a l , 1 9 8 5 ) .
E s t i m a t e s o f t h e f r e q u e n c y o f i r o n d e f i c i e n c y a ne mi a d u r i n g
p r e g n a n c y v a r y , w i t h an e s t i m a t e d r a n g e o f f rom 5% t o 15% i n t h e U n i t e d
States

(Worthington-Roberts,

Perinatal

Project

1 9 8 7 ) . Da t a f r om t h e N a t i o n a l

Collaborative

( Garn e t a l , 1981) i n d i c a t e d a 15% i n c r e a s e i n t h e

i n c i d e n c e o f low b i r t h w e i g h t when m o t h e r s had h e mo g l o b i n l e v e l s o f 8 . 0
g/dl

as c ompa r ed t o m o t h e r s who had he mo g l o b i n v a l u e s o f 1 0 . 0 g / d l

higher.

or

23

Whi l e l ow h e mo g l o b i n l e v e l s a r e o f t e n as sume d t o be c o r r e l a t e d
w i t h l ow b i r t h w e i g h t , t h i s a s s o c i a t i o n h a s n e v e r be e n d e f i n i t i v e l y
established

( K o l l e r e t a l , 1979).

In c o n t r a s t ,

high maternal

h e mogl obi n

v a l u e s a r e g e n e r a l l y b e l i e v e d t o be a s s o c i a t e d w i t h f a v o r a b l e p e r i n a t a l
out come ( W o r t h i n g t o n - R o b e r t s ,

1989).

R e c e n t l y , h o we v e r , t h r e e s t u d i e s

ha ve n o t e d an a s s o c i a t i o n b e t we e n h i g h m a t e r n a l
increased fetal

h e mo g l o b i n v a l u e s and

risk.

K o l l e r e t al

( 1979) h y p o t h e s i z e d t h e r e woul d be an i n v e r s e

r e l a t i o n s h i p b e t we e n b i r t h w e i g h t o f t h e baby and t h e m o t h e r ' s
h e mo g l o b i n l e v e l
hemodilution,

b a s e d on t h e f o l l o w i n g l i n e o f r e a s o n i n g :

First,

c a u s e d by a d i s p r o p o r t i o n a t e i n c r e a s e i n p l a s ma vol ume

compa r ed t o i n c r e a s e d r e d b l o o d c e l l s ,

i s common d u r i n g p r e g n a n c y .

The

l i n e a r r e l a t i o n s h i p b e t we e n i n c r e a s e d p l a s ma vol ume and i n f a n t b i r t h
w e i g h t ha s be e n d e m o n s t r a t e d ( D u f f u s e t a l , 1971; H y t t e n and P a i n t i n ,
1963; P i r a n i

e t a l , 1973).

Conversely,

a d e c r e a s e d p l a s ma vol ume i s

a s s o c i a t e d w i t h an i n c r e a s e d r i s k o f i n t r a u t e r i n e g r o wt h r e t a r d a t i o n
(IUGR) and f e t a l

d e a t h b e f o r e l a b o r i n a p p a r e n t l y nor mal

( Dunl op e t a l , 1978; L i l e y ,
h e mo g l o b i n l e v e l
1972; L i l e y ,

1970).

Lastly,

pregnancies

i n n o n - p r e g n a n t women,

a low

i n d i c a t e d a r e l a t i v e l y h i g h p l a s ma vol ume ( C h e l s e y ,

1970).

To t e s t t h e h y p o t h e s i s t h a t t h e r e woul d be an i n v e r s e r e l a t i o n s h i p
be t we e n i n f a n t b i r t h w e i g h t and m a t e r n a l

h e mo g l o b i n l e v e l ,

K o l l e r e t al

( 1979) m o n i t o r e d t h e h e mo g l o b i n l e v e l s o f 120 n o n - a n e mi c women w i t h
uncomplicated pregnancie s.

Seven women d e l i v e r e d i n f a n t s w i t h b i r t h

weights l e s s than the 2.5 th p e r c e n t i l e .

The h e mo g l o b i n v a l u e o f t h e s e

women a t a p p r o x i m a t e l y week 32 o f g e s t a t i o n was s i g n i f i c a n t l y h i g h e r

24

(14.12 vs 12.18 g / d l ,

p < 0 . 0 0 1 ) t h a n t h a t o f women who d e l i v e r e d

in fa n ts with higher b i rt h weights.

The a u t h o r s s u g g e s t e d " i t seems

r e a s o n a b l e t o a s s o c i a t e t h i s phenomenon w i t h an i n a d e q u a t e i n c r e a s e i n
t h e p l a s ma vol ume" ( K o l l e r e t a l , 1979, p.
vol ume a h a l l m a r k o f a s u c c e s s f u l

1 2 ) , w i t h an a d e q u a t e pl a s ma

pregnancy (Hytten,

1976).

T h i s h y p o t h e s i s was t e s t e d a g a i n by Sagan e t al

( 1984)

i n a g r oup

o f 577 a p p a r e n t l y nor mal p r e g n a n c i e s i n B e r g e n , Norway. Ma t e r n a l
h e mo g l o b i n l e v e l s wer e n o t i n f l u e n c e d by m a t e r n a l
habits.

Ma t e r n a l

levels increased.

age o r by smoki ng

w e i g h t g a i n was r e d u c e d s i g n i f i c a n t l y a s t h e h e mogl obi n
We i ght s and l e n g t h s o f t h e n e wb o r n s ,

a s we l l

as t he

p l a c e n t a l w e i g h ts , d e c l i n e d in r e l a t i o n t o i n c r e a s i n g maternal
h e mo g l o b i n l e v e l s . The a v e r a g e b i r t h w e i g h t o f i n f a n t s bor n t o mo t h e r s
w i t h a h e mo g l o b i n v a l u e e x c e e d i n g 1 3 . 0 g / d l was 580 g l i g h t e r
than

(15. 5%)

i n f a n t s b o r n t o m o t h e r s w i t h h e mo g l o b i n v a l u e s be l ow 1 2 . 0 g / d l .

placental
indicating

index ( p l a c e n t a l
both f e t a l

w e i g h t / b i r t h weight)

and p l a c e n t a l

The

r e ma i n e d u n c h a n g e d ,

gr owt h d e c r e a s e d i n i n v e r s e

p r o p o r t i o n t o i n c r e a s i n g m a t e r n a l h e mo g l o b i n l e v e l s .
A third

study

(Murphy e t a l , 1986) t e s t e d t h e h y p o t h e s i s t h a t a

h i g h h e mo g l o b i n v a l u e i s a s s o c i a t e d w i t h a r e d u c t i o n i n i n f a n t b i r t h
weight.

A f t e r r e v i e w o f d a t a f rom 5 4 , 3 8 2 s i n g l e t o n p r e g n a n c i e s ,

investigators
than

f ound b o t h h i g h ( g r e a t e r t h a n 1 3 . 2 g / d l )

these

and low ( l e s s

1 0 . 4 g / d l ) h e mo g l o b i n l e v e l s we r e a s s o c i a t e d w i t h a d v e r s e p r e g n a n c y

o u t c ome . A h i g h h e mo g l o b i n l e v e l

be t we en weeks 13 t o 19 o f g e s t a t i o n ,

c ompa r ed t o an i n t e r m e d i a t e he mo g l o b i n l e v e l
a s s o c i a t e d with in c r e a s e d

(10.4-13.2 g / d l) ,

incidence of p e rin a ta l

w e i g h t and p r e t e r m d e l i v e r y .

mortality,

as

was

low b i r t h

A s t r i k i n g r e l a t i o n s h i p was n o t e d be t we en a

25

woman' s i n i t i a l
hypertension

h e mo g l o b i n v a l u e and s u b s e q u e n t f r e q u e n c y o f

(p < 0 . 0 0 1 ) .

The f r e q u e n c y o f h y p e r t e n s i o n i n p r i m i p a r a s

r a n g e d f r om 7% a t h e mo g l o b i n l e v e l s u n d e r 1 0 . 5 g / d l
c o n c e n t r a t i o n s over 14.5 g / d l .

t o 45% a t he mo g l o b i n

The a u t h o r s p o s t u l a t e d t h e h i g h e r

h e mo g l o b i n c o n c e n t r a t i o n r e f l e c t e d some f a i l u r e

i n t h e p l a s ma vol ume t o

e x p a n d , r e s u l t i n g i n a d e l e t e r i o u s e f f e c t on t h e u t e r o p l a c e n t a l
circulation.

Murphy e t al

( 1986) c o n c l u d e d t h a t t h e o p t i m a l

range a t the f i r s t p r e n a t a l
th a t a level

visit

higher than t h i s

he mo g l o b i n

i s b e t we e n 1 0 . 4 and 1 3 . 2 g / d l ,

and

should a l e r t the c l i n i c i a n t o the

p o s s i b i l i t y o f a r e d u c e d p l a s ma vol ume and an a d v e r s e p r e g n a n c y out c ome .

D i a s t o l i c Bl ood P r e s s u r e

Ad e q u a t e b l o o d s u p p l y t o t h e u t e r o p l a c e n t a l
t r a n s m i t e n e r g y and n u t r i e n t s t o t h e f e t u s .

unit

is necessary to

I mp a i r me n t o f t h i s

function

can r e s u l t i n g r o wt h r e t a r d a t i o n and an i n c r e a s e d r a t e o f p r e m a t u r e
births

( Ka u p p i n e n ,

1967; IRaiha and Ka u p p i n e n ,

1979). U t e r o p l a c e n t a l

f l o w d e p e n d s p r i m a r i l y on t h e m a t e r n a l

o u t p u t which, d u r i n g preg n a n c y ,
week 32 o f g e s t a t i o n .
800 ml r i s e

1963; G r u n b e r g e r e t a l ,

i n c r e a s e s a p p r o x i m a t e l y 30% t o 50% by

The i n c r e a s e d c a r d i a c o u t p u t ,

i n p l a s ma vol ume ,

cardiac

c a u s e d by a 500 t o

i n c r e a s e s t h e s t r o k e vol ume ( c a r d i a c

o u t p u t = h e a r t r a t e x s t r o k e vol ume ; Va nde r e t a l , 1 9 8 5 ) .
Other i m po r ta n t f a c t o r s
maternal

influencing uteroplacental

h e a r t r a t e and mean a r t e r i a l

t h e mean a r t e r i a l
1 9 7 9 ) . Ma t e r n a l

pressure.

p r e s s u r e near term is

flow are

Under normal

conditions,

105 mm Hg ( G r u n b e r g e r e t a l ,

hypotension reduces the p l ac e n ta l

perfusion pressure,

26

whi c h c o n c o m i t a n t l y r e d u c e s t h e u t e r o p l a c e n t a l
al,

flow r a t e

(Bech-Jansen et

1972).
Although mat ern al h y p e r t e n s i o n i s monit ored c l o s e l y t h r o u g h o u t

pregnancy, maternal

hypotension receives l i t t l e

attention

(Grunberger et

a l , 1 9 7 9 ) . G r u n b e r g e r h y p o t h e s i z e d a d r o p i n mean m a t e r n a l
pressure,

e ve n i f t h e b l o o d vol ume and h e a r t r a t e r e m a i n c o n s t a n t ,

t o an e x c e s s i v e r e d u c t i o n o f t h e u t e r o p l a c e n t a l
q u antity of the m aternal-fetal
placental

arterial

flow r a t e ,

flow.

Be c a u s e t h e

g a s e o u s e x c h a n g e d e p e n d s p r i m a r i l y on t h e

G r u n b e r g e r e t al p o s t u l a t e d m a t e r n a l

hypotension

c o u l d l e a d t o a d e f i c i e n c y i n t h e s u p p l y o f oxygen t o t h e u t e r u s .
woul d be m a n i f e s t e d by a s i g n i f i c a n t d r o p i n t h e p a r t i a l
oxygen i n t h e f e t a l

blood,

leads

and m i g h t r e s u l t

Th i s

pres s u re of

in dec rea sed f e t a l

g r o wt h

and l ow b i r t h w e i g h t .
To t e s t t h i s

hypothesis,

G r u n b e r g e r e t al

( 1979) c o n d u c t e d a t h r e e

y e a r p r o s p e c t i v e s t u d y on 70 p r e g n a n t women w i t h d i a g n o s e d h y p o t e n s i o n
( b l o o d p r e s s u r e r e a d i n g s l e s s t h a n 1 1 0/ 65 mm Hg). P l a c e n t a l
me a s u r e d u s i n g r a d i o i s o t o p i c m e t h o d s .

Results

f l o w was

indicated th at,

e n d o c r i n e p a r a m e t e r s r e v e a l e d no a b n o r m a l i t i e s .

Placental

s i g n i f i c a n t l y r e d u c e d i n more t h a n 80% o f t h e s e s u b j e c t s .

although

f l o w was
Forty of the

70 s u b j e c t s we r e s u b s e q u e n t l y g i v e n an i n j e c t i o n o f d e o x y c o r t i c o s t e r o n e
t r i m e t h y l a c e t a t e t o i n c r e a s e t h e i r blood p r e s s u r e p h a r m a c o l o g i c a l l y .
s i g n i f i c a n t i mpr ove me nt i n t h e p l a c e n t a l
treated subjects.

p e r f u s i o n r a t e was n o t e d i n t h e

Bot h t h e a v e r a g e t e r m b i r t h w e i g h t s and p l a c e n t a l

w e i g h t s we r e h i g h e r i n t h e t r e a t e d g r o u p as c ompar ed t o c o n t r o l s
weight,

A

3308 vs 2860 g ; p l a c e n t a l w e i g h t ,

527 vs 512 g,

(birth

respectively).

27

Naeye ( 1981) a n a l y z e d d a t a c o l l e c t e d i n t h e U n i t e d S t a t e s
Collaborative Perinatal

P r o j e c t and n o t e d t h a t ,

as peak d i a s t o l i c blood

p r e s s u r e s during pregnancy i n cre as e d ,

b o t h p r e g r a v i d body w e i g h t s and

net pregnancy weight g a in s i n c r e a s e d .

The l ow i n f a n t b i r t h w e i g h t

a s s o c i a t e d w i t h low p r e p r e g n a n c y body w e i g h t s p r o g r e s s i v e l y d i s a p p e a r e d
as m a t e r n a l

peak d i a s t o l i c blood p r e s s u r e s i n c r e a s e d .

Birth weights

became i n d e p e n d e n t o f d i a s t o l i c b l o o d p r e s s u r e a t r e a d i n g s b e t we e n 90 t o
99 mm Hg i n u n d e r w e i g h t women; b i r t h w e i g h t s d e c r e a s e d ,

h o we v e r , when

pe a k d i a s t o l i c p r e s s u r e e x c e e d e d 99 mm Hg.

b i r t h weight

In c o n t r a s t ,

became i n d e p e n d e n t o f b l o o d p r e s s u r e a s t h e m o t h e r s '
weight

increased.

p r e g r a v i d body

Naeye c o n c u r r e d w i t h G r u n b e r g e r ( 1979)

th a t the fetal

g r o wt h e f f e c t s o f t e n a t t r i b u t e d t o n u t r i t i o n a r e mos t l i k e l y m e d i a t e d
through maternal

b l o o d p r e s s u r e and u t e r o p l a c e n t a l

Behavioral

Many b e h a v i o r a l

and E n v i r o n m e n t a l

and e n v i r o n m e n t a l

a s s o c i a t e d w i t h low b i r t h w e i g h t .
nutritional

status,

3) a l c o h o l

caffein e intake
( P o me r a n c e ,

maternal

1) s moki ng,

including occupational
1985). A d d i t i o n a l

2) p o o r

4) DES
hazards,

and

behavioral

f a c t o r s h y p o t h e s i z e d t o i mp a c t b i r t h w e i g h t i n c l u d e

( M a r t i n and B r a c k e n ,

1980). This r evi ew w i l l

s moki ng, a l c o h o l

r i s k f a c t o r s h a ve been

and o t h e r s u b s t a n c e a b u s e ,

( I n s t i t u t e of Medicine,

and e n v i r o n m e n t a l

Risk F a c t o r s

The s e i n c l u d e :

e x p o s u r e and o t h e r t o x i c e x p o s u r e s ,
5) h i g h a l t i t u d e

perfusion.

1987) and m a t e r n a l

f o c u s on t h e LBW r i s k f a c t o r s o f

and c a f f e i n e i n t a k e ,

attitudes.

attitude

d i e t q u a l i t y during pregnancy,

and

28

C i g a r e t t e Cons umpt i on

Ad v e r s e e f f e c t s o f s moki ng d u r i n g p r e g n a n c y on i n f a n t b i r t h w e i g h t
we r e f i r s t doc u me n t e d by Si mpson ( 1 9 5 7 ) .
body o f e p i d e m i o l o g i c a l ,

clinical

Since t h a t time a c o n s i d e r a b l e

and l a b o r a t o r y e v i d e n c e ha s r e p o r t e d a

r e d u c t i o n i n b i r t h w e i g h t , g e n e r a l l y r a n g i n g b e t we e n 150 t o 250 g r a ms ,
among o f f s p r i n g o f women who smoked d u r i n g p r e g n a n c y , w i t h t h e d e c r e m e n t
in b i r t h weight p r o p o rt io n a l

t o t h e number o f c i g a r e t t e s

1980; H a s s e l m e y e r e t a l , 1980;

Longo,

smoked ( Ab e l ,

1 9 8 2 ) . T h i s c o n s i s t e n c y ha s

p e r s i s t e d i n s p i t e o f t h e r e p o r t e d r e d u c t i o n i n t h e a v e r a g e t a r and
n i c o t i n e y i e l d s o f c i g a r e t t e s m a r k e t e d ( S t e i n and K l i n e ,
Additionally,

t h e a s s o c i a t i o n b e t we e n c i g a r e t t e

smoki ng and r e d u c e d

i n t r a u t e r i n e g r o wt h r e m a i n s f i r m and s t a b l e o v e r t i m e ,
social

classes,

Kline,

1983),

s yndr ome "

1983).

o v e r age g r o u p s and g e o g r a p h i c a l

through the

locations

l ead in g to the coining of the term " f e t a l

( S t e i n and

tobacco

(Nieburg e t a l , 1985).

E f f e c t o f Smoking on B i r t h Wei ght
The p r e v a l e n c e o f d e l i v e r i n g a LBW i n f a n t h a s been e s t i m a t e d t o be
54% h i g h e r i n l i g h t s mo k e r s ( l e s s t h a n one pa c k a d a y ) ,
i n h e a vy s moke r s ( one p a c k o r more p e r d a y ) ,

as c ompar ed w i t h no n s mo k e r s

(Meyer e t a l , 1 9 7 6 ) . A n a l y s i s o f t h e 1980 N a t i o n a l
indicated th at,
sex o f c h i l d ,

a f t e r c o n t r o l l i n g f o r maternal

education,

h e i g h t and w e i g h t ,

i n c r e a s e d by 26% f o r e v e r y 5 a d d i t i o n a l

and 130% h i g h e r

age,

N a t a l i t y Survey
live birth order,

t h e odds o f low b i r t h w e i g h t

cigarettes

smoked p e r da y d u r i n g

29

p r e g n a n c y ( t i m i n g o f s moki ng d u r i n g t r i m e s t e r s o f p r e g n a n c y was n o t
recorded)

( Kl e i n ma n and Madans,

1985).

A review o f f i v e s t u d i e s ,
United S t a t e s ,

c o mpr i si ng n e a r l y 113,000 b i r t h s in t he

Ca nada and Wa l e s ,

LBW was a t t r i b u t e d t o m a t e r n a l

s moki ng (Meyer e t a l , 1976; T a b l e 2 . 2 ) .

Of t h e f a c t o r s s t u d i e d , m a t e r n a l
hospital

status

f ound 21% t o 39% o f t h e i n c i d e n c e o f

smoki ng a f f e c t e d b i r t h w e i g h t more t h a n

(private or public), mother's b irth p la c e ,

h eight, mother's prepregnant weight,
pregnancy h i s t o r y ,

sex o f t h e c h i l d ,

p a r i t y or maternal

mother's

previous

age.

C i g a r e t t e s moki ng h a s c o n s i s t e n t l y be e n a s s o c i a t e d w i t h a 150 t o
250 g d e c r e a s e i n b i r t h w e i g h t ( A b e l ,
literature
1976),

1980).

Va l u e s r e p o r t e d i n t h e

i n c l u d e d e c r e a s e s o f 130 g ( H i g g i n s ,

184 g ( P i c o n e e t a l , 1 9 8 2 b ) ,

(Davies e t a l , 1976),

186 g ( S i l v e r m a n ,

209 g ( Ye r u s h a l my ,

241 g ( Br ooke e t a l , 1989)

1976),

1971),

180 g ( S p i r a ,
1 9 7 7 ) , 200 g

234 g ( Rus h,

1974) and

i n women who smoked d u r i n g p r e g n a n c y . Thes e

v a l u e s we r e d e t e r m i n e d a f t e r c o n t r o l l i n g f o r a v a r i e t y o f c o n f o u n d i n g
factors

s uch as a l c o h o l

consumption,

height,

p r e p r e g n a n c y w e i g h t and a g e . Not a l l

c o n t r o l l e d f o r in each s t u d y ,
r e d u c t i o n in b i r t h weight

social

and s e v e r a l

(i.e.,

class,

education level,

factors,

howe ve r ,

wer e

f a c t o r s a s s o c i a t e d with a

d i e t q u a l i t y and p r e p r e g n a n c y w e i g h t -

f o r - h e i g h t ) we r e n o t c o n t r o l l e d f o r i n any o f t h e s e s t u d i e s .

30

TABLE 2 . 2

R e l a t i v e and a t t r i b u t a b l e r i s k s o f low b i r t h w e i g h t by
m a t e r n a l s moki ng h a b i t s ( a d a p t e d f r om Meyer e t a l , 1 9 7 6 ) .

Study

Nonsmokers
N

Smokers
N

# LBW per 1000 Iive bi rths
Nonsmokers
Smokers

Relative
Risk (%)

Attributable
Risk (%)

7,176

6,238

4.1

8.1

1.98

31

US Collaborative (2)
8,466
Wh ite
11,252
Black

9,781
7,777

4.3
10.7

9.5
17.5

2.21
1.64

39
21

Kaiser Permanente (3)
White
3,189
Black
934

2,145
479

3.5
6.4

6.4
13.4

1.83
2.09

25
27

Cardiff (1)

Montreal (4)
Ontario (5)

3,954

3,004

5.2

11.4

2.19

34

27,316

21,062

4.5

9.1

2.02

31

(1) Andrews and McGarry, 1972; (2) Niswander and Gordon, 1972; (3) Yerushalmy, 1971; (A) Fabia,
1973; (5) Ontario Department of Health, 1967.

E f f e c t o f Smoking and D i e t on B i r t h Wei ght
Few s t u d i e s ha ve d e t e r m i n e d t h e e f f e c t s o f b o t h smoki ng and d i e t
with b i r t h weight.

Luke e t al

( 1981) o b s e r v e d i n f a n t s

(n=91) bor n t o

n o n s mo k e r s who o n l y g a i n e d 0 - 1 5 pounds d u r i n g p r e g n a n c y we i ghe d 243 g
more t h a n i n f a n t s
weight

( n=33) bor n t o s moker s g a i n i n g t h e same amount o f

(p < . 0 0 9 ) ; c o n v e r s e l y ,

o n l y a 94 g d i f f e r e n c e

in b i r t h weight

was n o t e d when b o t h s moke r s ( n=24) and nons moke r s ( n=160) g a i n e d 36 o r
more pounds d u r i n g p r e g n a n c y ( NS) .

Luke c o n c l u d e d e n c o u r a g e m e n t o f a

w e i g h t g a i n h i g h e r t h a n n o r m a l l y recommended i n 1980 may h e l p t o c o r r e c t
t h e g r o wt h r e t a r d a t i o n o b s e r v e d i n i n f a n t s bor n t o women who smoke.
P i c o n e e t al

(1982a,

s moki ng and p s y c h o l o g i c a l

1982b) s t u d i e d t h e r o l e s o f d i e t ,
s t r e s s on p r e g n a n c y w e i g h t g a i n

l b s and g r e a t e r t h a n 15 l b s )

cigarette

( l e s s t h a n 15

i n 60 low s o c i o e c o n o m i c p a t i e n t s who

31

registered for prenatal

c a r e a t an u r b a n C o n n e c t i c u t h o s p i t a l

average o f f i v e 24-hour

r e c a l l s we r e o b t a i n e d f r om e a c h s u b j e c t by

experienced d i e t i t i a n .

( n=32) and nons moke r s ( n=28) was c o mp a r e d ,
s i g n i f i c a n t l y more c a l o r i e s

s moke r s consumed

( 2119 vs 1810 k c a l / d a y ;

p < .01),

In a d d i t i o n ,

fat

e ve n t h o u g h s moke r s consumed a p p r o x i m a t e l y 300

i n f a n t s o f s moke r s we i g h e d s i g n i f i c a n t l y l e s s t h a n t h o s e
g vs 3059+511 g ; p < . 0 4 ) . For n o n s mo k e r s ,

d i f f e r e n c e s b e t we e n t h e

i n t a k e s o f low w e i g h t g a i n s u b j e c t s

and a d e q u a t e w e i g h t g a i n s u b j e c t s

significant
(r=0.55,

(1617

( 1905 k c a l / d a y ) wer e

(p < . 0 2 ) , w i t h c a l o r i e i n t a k e c o r r e l a t e d w i t h w e i g h t g a i n

p < .02).

P i c o n e c o n c l u d e d t h a t a low w e i g h t g a i n among

nons moke r s (< 15 p o u n d s )
contrast,

(94 g

than

o f nons moke r s ( 2875+522

kcal/day)

an

i n t a k e o f s moke r s

vs 74 g; p < . 01) and c a l c i u m (1241 mg vs 721 mg, p < . 0 1 )

kcal mor e/ day,

An

Food i n t a k e d a t a we r e c ode d and a n a l y z e d f o r 14

n u t r i e n t s by c o m p u t e r a n a l y s i s . When t h e n u t r i e n t

n o n s mo k e r s .

clinic.

i s a s s o c i a t e d w i t h l o w e r f ood i n t a k e .

In

t h e y h y p o t h e s i z e d smoki ng may c a u s e low w e i g h t g a i n by

reducing the u t i l i z a t i o n of c a l o r i e s f o r weight g a in .

The a u t h o r s

p r o p o s e d n i c o t i n e c a u s e d b o t h an i n c r e a s e d m e t a b o l i c r a t e and an
i n c r e a s e d h e a t l o s s f rom t h e body,
o f d i e t a r y ener gy and, t h u s ,

resulting

i n an i m p a i r e d e f f i c i e n c y

an i n c r e a s e d e n e r g y r e q u i r e m e n t

i n s mo k e r s .

H i g g i n s ( 1976) a s s e s s e d t h e d a i l y i n t a k e o f c a l o r i e s and p r o t e i n
i n 230 s moke r s and 309 n o n s mo k e r s . She r e p o r t e d s moke r s consumed
a p p r o x i m a t e l y 300 more k c a l
n o n s mo k e r s .

Smoke r s ,

and 9 gr ams more p r o t e i n p e r da y t h a n

h o we v e r , ga ve b i r t h t o i n f a n t s w e i g h i n g 130 g l e s s

t h a n i n f a n t s bor n t o n o n s mo k e r s . The me t hods u s e d t o c o l l e c t and a n a l y z e
t h e d a t a we r e n o t r e p o r t e d .

32

Haywort h e t al
fetal

( 1980) a l s o a t t e m p t e d t o d e t e r m i n e w h e t h e r t h e

g r o w t h - r e t a r d i n g e f f e c t o f maternal

c i g a r e t t e s moki ng was due t o a

l o w e r d i e t a r y i n t a k e i n a g r o u p o f s moke r s ( n=208) and n o n s mo k e r s
( n = l 7 5 ) . D i e t a r y i n t a k e was a s s e s s e d by c a l c u l a t i n g t h e a v e r a g e d a i l y
n u t r i e n t i n t a k e f rom b o t h a d i e t a r y h i s t o r y and a 2 4 - h o u r r e c a l l .
mo d e l s we r e u s e d t o h e l p a s s e s s s e r v i n g s i z e s .

The two e s t i m a t e s o f

d a i l y n u t r i e n t i n t a k e we r e a v e r a g e d f o r e a c h s u b j e c t .
P i c o n e ( 1982b) and H i g g i n s ( 1 9 7 6 ) ,

like

p < .025),

fat

( 118 vs

(26 vs 24 mg/ da y; p < . 0 4 ) t h a n n o n s mo k e r s .

D e s p i t e cons umi ng a g r e a t e r number o f c a l o r i e s ,

t h e i n f a n t s o f s moke r s

we i g h e d 224 gr ams l e s s t h a n i n f a n t s o f n o n s mo k e r s .
concluded t h a t ,

Ha y wo r t h ,

r e p o r t e d s moke r s consumed

s i g n i f i c a n t l y more e n e r g y ( 2587 vs 2421 k c a l / d a y ;
104 g ; p < . 0 0 1 ) and n i a c i n

Food

in t h e i r o p i n i o n ,

fetal

Ha ywor t h e t al

g r o wt h r e t a r d a t i o n

i n s moke r s i s

c a u s e d by f a c t o r s o t h e r t h a n t h e m o t h e r ' s d i m i n i s h e d i n t a k e o f f o o d .
S m i t h e l l s e t al

( 1977) a s s e s s e d t h e d a i l y n u t r i e n t

i n t a k e o f 195

women i n t h e f i r s t t r i m e s t e r o f p r e g n a n c y . A f i v e - d a y w e i g h e d d i e t a r y
r e c o r d was o b t a i n e d f rom e a c h s u b j e c t . A minimum o f two s u p e r v i s o r y
v i s i t s we r e made t o e a c h m o t h e r a f t e r i n i t i a l
i n s t r u c t i o n s we r e g i v e n .

d ie t recording

In c o n t r a s t t o p r e v i o u s r e s e a r c h c i t e d ,

S m i t h e l l s f ound no d i f f e r e n c e be t we e n t h e e n e r g y and n u t r i e n t
s moke r s (n=77) and nons moke r s ( n=118) d u r i n g t h e f i r s t
s moke r s cons umi ng an a v e r a g e o f 1933 kcal p e r d a y ,
kc a l

p e r da y consumed by n o n s mo k e r s .

Likewise,

in ta k e of

trimester,

as c ompa r e d w i t h

kc a l

1971

no d i f f e r e n c e was

o b s e r v e d when d a t a was a n a l y z e d a c c o r d i n g t o number o f c i g a r e t t e s
p e r d a y , w i t h mean i n t a k e s o f 2043 ( n = 2 5 ) ,

with

smoked

1851 ( n=38) and 1904 (n=14)

consumed by t h o s e who smoked b e t we e n one t o n i n e ,

ten to nineteen

33

and g r e a t e r t h a n t w e n t y c i g a r e t t e s p e r d a y ,
al d i d ,

h o we v e r ,

respectively.

find s ig n ific a n t differences

i n b o t h e n e r g y and

n u t r i e n t c o n s u m p t i o n b e t we e n m o t h e r s f r om s o c i a l
(upper-class)
kcal,

a s c ompa r e d w i t h c l a s s e s

p < .001; p r o t e i n

III,

Smithells et

classes

I and II

IV and V ( 2183 kc a l

i n t a k e 7 6 . 4 g vs 6 5 . 2 g,

p < .001).

vs 1892

The n u t r i e n t

i n t a k e o f s mo k e r s vs n o n s mo k e r s was n o t s t a t i s t i c a l l y c o r r e c t e d f o r
social

class

(Hoi 1 i n g s h e a d c l a s s i f i c a t i o n ) .

Pr o p o s e d Me chani s ms o f A c t i o n
The me c ha ni s m o f a c t i o n r e s p o n s i b l e f o r t h e e f f e c t s o f smoki ng on
b i r t h weight is not c l e a r .

Proposed h y p o th es e s i n c l u d e a s uboptimal

i n t a k e d u r i n g p r e g n a n c y ( Ru s h ,
smoke ( Ga r n e t a l , 1 9 7 8 ) ,

1974), reduced f a t s t o r e s

Forss,

i n women who

carboxyhemoglobin-induced f e t a l

(Astrup e t a l , 1972), d e c r e a s e d u t e r o p l a c e n t a l

perfusion

f ood

hypoxia
( L e h t o v i r t a and

1978) o r t h e e f f e c t o f one o r more o f t h e e s t i m a t e d 3000 c h e mi c a l

compounds f o u n d i n c i g a r e t t e s / s m o k e on t h e b a s a l

metabolic r a te

t h e woman and t h e t r a n s p o r t o f n u t r i e n t s t o t h e f e t u s
Authors o f se v er a l

carefully controlled

( Longo,

(BMR) o f

1982).

s t u d i e s ha ve c o n c l u d e d t h e

e f f e c t s o f c i g a r e t t e smoke on b i r t h w e i g h t a p p e a r n o t t o be m e d i a t e d
through a decreased maternal

a p p e t i t e o r w e i g h t g a i n as c i t e d e a r l i e r .

The i mp a c t o f s moki ng on g r o w t h a p p e a r s mos t l i k e l y t o be m e d i a t e d
t h r o u g h t h e e f f e c t s o f e i t h e r c a r b o n mo n o x i d e , n i c o t i n e ,
cadmium on p l a c e n t a l
e t a l , 1982a ,

1982b).

cyanide and/or

p e r f u s i o n and oxygen t r a n s p o r t t o t h e f e t u s

(Picone

Ca r bon monoxi de d i s p l a c e s oxygen i n h e mo g l o b i n t o

form c a r b o x y h e m o g l o b i n whi c h i n c r e a s e i n c o n c e n t r a t i o n by f o u r t o f i v e
percent,

a level

a s s o c i a t e d with p h y s io l o g i c a l

alterations

in a d u l t s

34

( Longo,

1 9 7 7 ) . The a c c u m u l a t e d c a r b o x y h e m o g l o b i n can r e d u c e oxygen

release,

o x y h e mo g l o b i n d i s p l a c e m e n t and f e t a l

much a s 25% (Hammer e t a l , 1981; Longo,
vasoconstrictor,
22% r e d u c t i o n
Thiocyanide,

b l o o d oxygen t e n s i o n by as

1976). N i c o t i n e ,

d e c r e a s e s u t e r i n e blood f low,

in p l a c e n t a l

resulting

a known
i n as much a s a

p e r f u s i o n ( L e h t o v i r t a and F o r s s ,

1978).

a h y p o t e n s i v e a g e n t whi ch r e d u c e s t h e c e l l s a b i l i t y t o u s e

o x y g e n , h a s been f ound i n c o n c e n t r a t i o n s two t o f o u r t i m e s g r e a t e r i n
t h e b l o o d and u r i n e o f s m o k e r s '
infants

(Pettigrew,

i n f a n t s a s c ompa r ed t o n o n s m o k e r s '

1 9 7 7 ) . Meberg ( 1979) r e p o r t e d t h i o c y a n a t e

c o n c e n t r a t i o n s we r e p o s i t i v e l y c o r r e l a t e d w i t h c i g a r e t t e c o n s u m p t i o n and
i n v e r s e l y c o r r e l a t e d with b i r t h weight.
interaction,
production,

resulting

Recently,

a c a d mi u m- z i n c

in a reduced zinc a v a i l a b i l i t y

f o r DNA and RNA

h a s been p r o p o s e d a s a p o s s i b l e mec hani s m f o r t h e r e d u c e d

b i r t h w e i g h t s e e n i n i n f a n t s o f s moke r s ( K u h n e r t e t a l , 1 9 8 7 ) .
As c i t e d a b o v e , n i c o t i n e may a c t i n d i r e c t l y t o r e d u c e t h e
e ffic ie n c y of c a lo rie s
( P i c o n e e t a l , 1982a ,

i n women who smoke by i n c r e a s i n g t h e i r BMR
1982b).

N i c o t i n e ha s been shown t o i n c r e a s e t h e

BMR by i n c r e a s i n g t h e s y m p a t h e t i c s t i m u l a t i o n o f e p i n e p h r i n e , whi ch
c a u s e s an i n c r e a s e d h e a r t r a t e ,

blood p r e s s u r e ,

( W i n t e r n i t z and Q u i l l e n ,

and a d e c r e a s e i n p l a c e n t a l

transport

( Rowel l

substantial

1977),

and S a s t r y ,

rate of l ip o l y s is

1 9 7 7 ) . The i n c r e a s e d BMR may have a

e f f e c t on e n e r g y r e q u i r e m e n t s

( H i e s t a d e t a l , 1940).

s t u d i e s have s u g g e s t e d a g r e a t e r f ood i n t a k e i n s mo k e r s ,
a concomitant g r e a t e r p r e n a t a l weight g a in , will
i n f a n t b i r t h weight

ami no a c i d

result

Several

a c c o mp a n i e d by
in a h i g h e r

(Gormicari e t a l , 1980; Luke e t a l , 1981; Papoz e t

a l , 1982), p a r t i c u l a r l y

i n a WIC p o p u l a t i o n

( Met cof f e t a l , 1985).

35

Others,

h o we v e r , h a ve d i s p u t e d t h i s t h e o r y b a s e d on t h e o b s e r v a t i o n t h a t

s moke r s who g a i n e d s i g n i f i c a n t l y more w e i g h t t h a n no n s mo k e r s have
d e l i v e r e d i n f a n t s o f l o w e r b i r t h w e i g h t t h a n nons moke r s ( Ou n s t e d and
Scott,

1982).
A l t h o u g h t h e e x a c t mec ha ni s m o f a c t i o n o f c i g a r e t t e smoke on b i r t h

weight is a t p resen t un c le a r,

the r e d u c t io n in b i r t h weight appears to

be a d i r e c t e f f e c t o f s moki ng on f e t a l

g r o wt h (DHHS, 1 9 8 3 ) . Al t h o u g h

m o t h e r s who smoke h a ve h i g h e r r a t e s o f p r e m a t u r e d e l i v e r i e s ,

their

ne wbor ns a r e s m a l l e r t h a n t h o s e b o r n t o n o n - s m o k e r s a t e v e r y g e s t a t i o n a l
age, d i s p l a y i n g symmetrical

fetal

g r o wt h r e t a r d a t i o n i n c r o w n - h e e l

l e n g t h and c h e s t and head c i r c u m f e r e n c e as we l l

as b i r t h w e i g h t (DHHS,

1983; M i l l e r e t a l , 1 9 7 6 ) .

P r e v a l e n c e o f Smoking Du r i n g P r e g n a n c y
Da t a f r om t h e 1980 N a t i o n a l

N a t a l i t y Su r v e y f o r m a r r i e d m o t h e r s

age 20 and o v e r i n d i c a t e 25% o f w h i t e and 23% o f b l a c k p r e g n a n t women
a r e s moke r s

( Kl ei nman and K o p s t e i n ,

1987).

t h e p e r c e n t o f s moke r s by e d u c a t i o n a l

Striking differences exist

level,

in

with the p r o p o rt io n of

m o t h e r s who smoke d u r i n g p r e g n a n c y r a n g i n g f rom 43% f o r t h o s e w i t h l e s s
t h a n 12 y e a r s o f e d u c a t i o n t o 11% f o r t h o s e w i t h 16 o r more y e a r s o f
education.

I t ha s been e s t i m a t e d t h a t ,

o f t h o s e who e n t e r p r e g n a n c y as

s mo k e r s , o n l y an e s t i m a t e d 17% q u i t smoki ng and 40% c u t down on t h e
number o f c i g a r e t t e s smoked ( Kl e i nma n and K o p s t e i n ,
Campbel l

1987).

Sadly,

( 1985) r e p o r t e d o n l y 16% o f p r e g n a n t women had been i n f o r me d by

t h e i r p h y s i c i a n t h a t s moki ng d u r i n g p r e g n a n c y i s h a z a r d o u s .

36

C o n c l u s i o n : E f f e c t o f C i g a r e t t e Smoke on B i r t h Wei ght
The p r e s e n t body o f l i t e r a t u r e s u p p o r t s t h e c o n c l u s i o n t h a t women
who smoke d u r i n g p r e g n a n c y a r e p u t t i n g t h e i r i n f a n t a t an i n c r e a s e d r i s k
o f LBW. A l t h o u g h s e v e r a l
weight,

factors

have been d e m o n s t r a t e d t o a f f e c t b i r t h

s moki ng a p p e a r s t o have one o f t h e g r e a t e s t m e a s u r a b l e e f f e c t s

( Kl e i nma n and Madans,

1 9 8 7 ) . The e x a c t mec hani s m f o r t h i s a f f e c t

i s as

y e t unknown.

Al c ohol Cons umpt i on

The c l a s s i c r e p o r t by J o n e s e t al
p attern of fetal

( 1973)

i n whi ch a c h a r a c t e r i s t i c

m a l f o r m a t i o n s was c o i n e d " f e t a l

alcohol

s y n d r o me " ,

s e r v e d a s a m a j o r s t i m u l u s f o r r e s e a r c h on t h e a d v e r s e e f f e c t s o f
alcohol

i n ta k e during pregnancy.

In 1981, t h e U. S. Su r g e o n Ge n e r a l

i s s u e d an a d v i s o r y t h a t p r e g n a n t women, o r women p l a n n i n g a p r e g n a n c y ,
should not d r in k alcohol

(Surgeon Ge ne ral ,

1981). N e v e r t h e l e s s ,

s t u d i e s h a v e y i e l d e d i n c o n s i s t e n t and c o n t r a d i c t o r y r e s u l t s ,
s e r i o u s q u e s t i o n s about t h e r e l a t i v e
poor n e o n at al
alcohol

out come ( S t e i n and K l i n e ,

raising

inta ke to

1 9 8 3 ) . Harmful e f f e c t s o f

d u r i n g p r e g n a n c y have been i m p l i c a t e d i n t h r e e s p e c i f i c a r e a s :

1) t h e f e t a l
neonatal

importance of alcohol

human

alcohol

s y ndr ome , 2) i n t r a u t e r i n e g r owt h r e t a r d a t i o n and 3)

n e u r o b e h a v i o r a l d y s f u n c t i o n . Onl y t h e e f f e c t s o f a l c o h o l

i n t r a u t e r i n e g r o wt h r e t a r d a t i o n w i l l

be p r e s e n t e d .

on

37

D e f i n i t i o n and C l a s s i f i c a t i o n o f Al c o h o l
The amount o f a b s o l u t e a l c o h o l
r e v i e w e d h e r e was s e l f - r e p o r t e d .
beer,

Intake

consumed by s u b j e c t s i n a l l

A "drink"

studies

i s d e f i n e d as a 12 - o z can o f

a 4 - o z g l a s s o f wi ne o r one mi xed d r i n k .

I t was assumed e a c h

" d r i n k " c o n t a i n s a p p r o x i m a t e l y 1 / 2 o z , o r 10 g, o f a b s o l u t e a l c o h o l .
The c l a s s i f i c a t i o n o f s u b j e c t s a s " r a r e " ,

"light",

" m o d e r a t e " and

" he a vy" d r i n k e r s v a r i e s f r om s t u d y t o s t u d y , maki ng c o m p a r i s o n o f
results d ifficu lt.

In g e n e r a l ,

i n d i v i d u a l s who consume f i v e o r more

d r i n k s on one o c c a s i o n , w i t h a t l e a s t 45 d r i n k s p e r mont h,
week, a r e c l a s s i f i e d as " h e a v y d r i n k e r s " .
t h a n one d r i n k p e r mont h,

I n d i v i d u a l s who consume more

b u t l e s s t h a n t h e he a vy d r i n k e r ,

c l a s s i f i e d a s " mo d e r a t e d r i n k e r s " .

o r 10 p e r

are

Thos e who consume one a l c o h o l i c

b e v e r a g e p e r month o r l e s s and ha ve n e v e r consumed more t h a n f i v e d r i n k s
on one o c c a s i o n a r e c l a s s i f i e d as " r a r e d r i n k e r s "
R o s e t t e e t a l , 1983; M u l l i n s and Gazaway,
studies

(O ullette et

a l , 1977;

1985). A n a l y s i s o f p u b l i s h e d

i n d i c a t e he a vy d r i n k e r s c o m p r i s e an e s t i m a t e d two t o 13% o f

p r e g n a n t women, m o d e r a t e d r i n k e r s c o m p r i s e a p p r o x i m a t e l y 35-40%, and
r a r e d r i n k e r s c o m p r i s e a p p r o x i m a t e l y 47-63% o f p r e g n a n t women ( M u l l i n s
and Gazaway,

1985) .

J o h n s o n e t al

( 1987) r e p o r t e d u s e o f c i g a r e t t e s

and r e c r e a t i o n a l

d r u g s d u r i n g p r e g n a n c y was a s s o c i a t e d w i t h a l o w e r s o c i o e c o n o m i c s t a t u s ,
while alcohol

c o n s u mp t i o n was a s s o c i a t e d w i t h h i g h e r s o c i a l

Al t h o u g h c e s s a t i o n o f c i g a r e t t e s and r e c r e a t i o n a l

d r u g u s e was more

common among p r o f e s s i o n a l s and t h e c o l l e g e - e d u c a t e d ,
characteristics,

a l o n g w i t h a h i g h e r i ncome l e v e l ,

f a i l u r e to q u i t drin k in g during pregnancy.

status.

t h e s e same two

we r e a s s o c i a t e d w i t h

38

A s s o c i a t i o n Bet ween Al c o h o l
R o s e t t e t al

and B i r t h Wei ght

( 1983) e xa mi ne d t h e e f f e c t s o f h e a v y ( n = 4 3 ) , m o d e r a t e

( n=164) and r a r e a l c o h o l

c o n s u m p t i o n ( n=262) on f e t a l

p ro sp e c tiv e study of m o th er-in fan t p a i r s .

development in a

E f f e c t s o f h e a vy d r i n k i n g i n

e a r l y and l a t e g e s t a t i o n we r e e v a l u a t e d by s e p a r a t e a n a l y s i s o f n e o n a t e s
b o r n t o women who r e d u c e d c o n s u mp t i o n b e f o r e t h e t h i r d t r i m e s t e r .
differences

in f e t a l

No

d e v e l o p m e n t we r e o b s e r v e d b e t we e n o f f s p r i n g o f r a r e

and m o d e r a t e d r i n k e r s .

I n f a n t s b or n t o women who r e d u c e d t h e i r h e a vy

d r i n k i n g d u r i n g p r e g n a n c y d i d n o t d i f f e r i n g r o wt h f r om o f f s p r i n g o f
r a r e and m o d e r a t e d r i n k e r s ,

but di d d e mo n s t r a t e a h i g h e r f re q ue n cy of

abnormalities.

women who we r e s u s t a i n e d ,

In c o n t r a s t ,

heavy d r i n k e r s

t h r o u g h o u t p r e g n a n c y ( n=25) d e l i v e r e d i n f a n t s w i t h s i g n i f i c a n t l y l o w e r
b irth weights,

l e n g t h s and head c i r c u m f e r e n c e s be l ow t h e t e n t h

percentile for gestational

age (p < 0 . 0 0 1 ) . Th e s e f i n d i n g s we r e

independent of g e s t a t i o n a l

age, p r e - p r e g n a n t we i g h t ,

number o f c i g a r e t t e s smoked, e d u c a t i o n l e v e l
autho rs concluded s u s t a i n e d ,

baby's sex,

a t t a i n e d and p a r i t y .

race,
The

heavy d r i n k i n g d u r i n g p r e g n a n c y r e p r e s e n t e d

a major r i s k .
Br ooke e t al

(1989),

i n a p r o s p e c t i v e s t u d y o f 1433 women,

r e p o r t e d a t r e n d t o wa r d r e d u c e d b i r t h w e i g h t s w i t h i n c r e a s e d c o n s u mp t i o n
of alcohol.

Women who had consumed 100 g o r more o f a b s o l u t e a l c o h o l

t h e week p r i o r t o t h e i r f i r s t p r e n a t a l
drinks),
drinkers.

visit

in

( a p p r o x i m a t e l y 9 o r more

d e l i v e r e d i n f a n t s who wer e 137 g l i g h t e r t h a n i n f a n t s o f n o n ­
T h e r e wer e no d i f f e r e n c e s i n b i r t h w e i g h t b e t we e n n o n - s m o k i n g ,

h e a vy d r i n k e r s and n o n - s mo k i n g r a r e - d r i n k e r s . For s m o k e r s ,
s t r o n g a l c o h o l - e f f e c t r e m a i n e d . A s e ven p e r c e n t r e d u c t i o n

h o we v e r ,

a

(p < 0 . 0 0 3 )

in

39

b i r t h w e i g h t was o b s e r v e d b e t we e n i n f a n t s b o r n t o n o n - d r i n k i n g s moke r s
and s mo k e r s who r e p o r t e d d r i n k i n g 100 g o f a l c o h o l
the i n i t i a l

o r more p e r week a t

interview.

Wr i g h t e t a l
w e i g h t and a l c o h o l

( 19 8 3 ) e xa mi ne d t h e r e l a t i o n s h i p b e t w e e n i n f a n t b i r t h
consumption immedi atel y p r i o r t o t h e r e c o g n i t i o n of

p r e g n a n c y i n 900 w h i t e women. A f t e r a d j u s t m e n t f o r s o c i a l
c i g a r e t t e s mo k i n g , m o d e r a t e d r i n k i n g
not r e s u l t

in a s i g n i f i c a n t l y

(RR=1. 2 4 ( 0 . 8 - 1 . 5 8 ) ) .

10 o r more d r i n k s )

asso ciated with a s i g n i f i c a n t

Heavy d r i n k i n g

(100

p r i o r t o r e c o g n i t i o n o f p r e g n a n c y was

i n c r e a s e i n t h e number o f i n f a n t s w i t h

w e i g h t s be l ow t h e t e n t h p e r c e n t i l e
among s mo k e r s ( RR=3. 4 3 ( 1 . 5 2 - 7 . 5 4 ) ) .
t h e i r consumption o f a lc o ho l

5 - 10 d r i n k s ) d i d

i n cr e as e d r e l a t i v e r i s k f o r b i r t h weight

l e s s than th e t e n t h p e r c e n t i l e
g alcohol/week;

(50-100 g/week;

c l a s s and

( RR=2. 2 7 ( 1 . 3 6 - 3 . 8 6 ) ) ,

especially

Of t h e h e a vy d r i n k e r s who r e d u c e d

t o l e s s t h a n 100 g / we e k d u r i n g p r e g n a n c y

( 62%) , 30% d e l i v e r e d a l i g h t ba b y .

The a u t h o r s c o n c l u d e d a l c o h o l

c o n s u m p t i o n o f more t h a n 100 g a week (10 d r i n k s o r mor e) a r o u n d t h e
t i m e o f c o n c e p t i o n c a r r i e d an i n c r e a s e d r i s k o f l ow b i r t h w e i g h t and
t h a t t h e r e d u c t i o n o f heavy d r i n k i n g o nl y in t h e l a t e r s t a g e of
pregnancy,

i n b o t h s mo k e r s and n o n - s m o k e r s ,

did not b e n e f i t the i n f a n t s '

g r o wt h s t a t u s .
L i t t l e e t al

( 1977) e xa mi ne d t h e r e l a t i o n o f m o d e r a t e a l c o h o l

consumption t o i n f a n t b i r t h wei ght

in a p r o s p e c t i v e s t u d y o f 262 p a y i n g

members o f a h e a l t h m a i n t e n a n c e o r g a n i z a t i o n .
to,

in e a r l y ,

Al c o h o l

and i n l a t e p r e g n a n c y was e s t i m a t e d .

consumption p r i o r

A multiple regression

e q u a t i o n was c omput e d f o r e a c h o f t h e t h e s e t h r e e t i m e p e r i o d s .
c o n t r o l l i n g f o r maternal

age,

height,

parity,

daily cigarette

After

40

consumption,

gestational

age and s e x o f t h e c h i l d ,

i n g e s t i o n o f one

o unc e o f a l c o h o l d a i l y b e f o r e p r e g n a n c y ( t wo d r i n k s ) was a s s o c i a t e d w i t h
an a v e r a g e d e c r e a s e i n b i r t h w e i g h t o f 91 g (p < 0 . 0 1 ) .

I n g e s t i o n o f one

o unc e o f a l c o h o l d a i l y i n l a t e p r e g n a n c y ( mont hs f i v e t o e i g h t ) was
a s s o c i a t e d w i t h a 160 g d e c r e a s e i n b i r t h w e i g h t (p < 0 . 0 1 ) .

Ma t e r n a l

w e i g h t g a i n was n o t r e p o r t e d i n t h i s s t u d y .
M i l l s e t al

( 1984)

analyzed d a ta o f 32,870 s u b j e c t s

in t h e K ai s e r -

Permanente s t u d y . A f t e r c o n t r o l l i n g f o r c onfoundi ng v a r i a b l e s ,

these

r e s e a r c h e r s d e m o n s t r a t e d t h a t t h e c o n s u mp t i o n o f one t o two d r i n k s p e r
da y d u r i n g p r e g n a n c y r e d u c e d i n f a n t b i r t h w e i g h t by 83 g (p < 0 . 0 1 ) ,
O u l l e t t e e t al

( 1977) e v a l u a t e d t h e e f f e c t s o f h e a vy d r i n k i n g on

t h e o f f s p r i n g o f 633 women. N u t r i t i o n a l

status

(24-hour r e c a l l ) ,

s moki ng and a l c o h o l h a b i t s we r e a s s e s s e d a t t h e f i r s t
Women we r e c l a s s i f i e d

as h e a v y , m o d e r a t e o r r a r e d r i n k e r s .

i n t a k e d i d n o t d i f f e r among t h e women i n a l l
t o h e a vy d r i n k e r s

than rare drinkers
t h e i r alcohol
In c o n t r a s t ,

t h r e e groups.

(n=58) had t w i c e t h e a b n o r m a l i t i e s

shorter b irth lengths

prenatal

(p < 0 . 0 5 )

(n=326).

drug,

visit.

Nutritional
I n f a n t s bor n

(p < 0 . 0 0 1 ) ,

and l o w e r b i r t h w e i g h t s

(p < 0 . 0 0 1 )

F i f t e e n he a vy d r i n k e r s s i g n i f i c a n t l y r e d u c e d

i n ta k e du rin g pregnancy;

10 o f t h e 15 had nor mal

babies.

o n l y two o f t h e 27 women who d r a n k h e a v i l y t h r o u g h o u t

p r e g n a n c y had i n f a n t s t h a t wer e a s s e s s e d as nor mal

at delivery.

The e f f e c t o f a b s t i n e n c e d u r i n g p r e g n a n c y by women who had a
p r e v i o u s h i s t o r y o f heavy a lc ohol
by L i t t l e e t al

(1980).

i n t a k e was e xa mi ne d i n a s e c o n d s t u d y

T h r e e g r o u p s o f f i f t y women we r e r e c r u i t e d

( l = h i s t o r y o f a l c o h o l i s m p r i o r t o c o n c e p t i o n who r e p o r t e d a b s t i n e n c e
d u r i n g t h e e n t i r e p r e g n a n c y , 2 = h i s t o r y o f he a vy a l c o h o l

ingestion prior

41

to,

a s we l l

as d u r i n g ,

alcoholism).

t h e e n t i r e p r e g n a n c y and 3=no h i s t o r y o f

The mean b i r t h w e i g h t o f i n f a n t s bor n t o a b s t i n e n t

a l c o h o l i c s was 258 g l e s s t h a n t h e mean b i r t h w e i g h t o f t h e c o n t r o l
infants

(p < 0 . 0 5 ) .

than co n tro l
education,

infants

I n f a n t s o f d r i n k i n g a l c o h o l i c s we i g h e d 493 g l e s s
(p < 0 . 0 0 1 ) . A f t e r c o n t r o l l i n g f o r r a c e ,

s moki ng, m a t e r n a l h e i g h t ,

the adjusted b i r t h weights
respectively),

we r e s t i l l

suggest maternal
g r o wt h f a i l u r e ,

parity,

( 3137+466,

s e x and g e s t a t i o n a l

age,

2786+485 and 3520+419,

significantly different

(p < 0 . 0 5 ) .

Results

a l c o h o l i s m c o n t i n u e s t o be a r i s k f a c t o r f o r f e t a l
independent of alcohol

No A s s o c i a t i o n Bet ween Al c ohol

use d ur in g pregnancy.

and B i r t h Wei ght

Da t a f r om t h e Bos t on C i t y H o s p i t a l
pairs

age,

( Hi ngs on e t a l , 1982)

S t u d y o f 1690 m o t h e r - i n f a n t

i n d i c a t e d i n f a n t s whose m o t h e r s d r a n k two o r

more d r i n k s p e r da y we i g h e d 228 g l e s s t h a n i n f a n t s o f n o n - d r i n k e r s .
However, a f t e r c o n t r o l l i n g f o r more t h a n 40 p o t e n t i a l
variables,

confounding

t h i s d i f f e r e n c e was r e d u c e d t o 51 g (NS). M a t e r n a l d r i n k i n g

p r i o r t o p r e g n a n c y was s i g n i f i c a n t l y r e l a t e d t o a s h o r t e n e d g e s t a t i o n .
Mar bur y e t al

( 1983) a s s e s s e d p a t t e r n s o f a l c o h o l

1 2 , 4 4 0 p r e g n a n t women i n t e r v i e w e d a t d e l i v e r y .

c o n s u m p t i o n in

N i n e t y - t w o women ( 0. 7%)

r e p o r t e d d r i n k i n g 14 o r more d r i n k s p e r week, w i t h most o f t h e s e
cons umi ng l e s s t h a n 21 p e r week. Cr ude d a t a a n a l y s i s
consumption o f a t l e a s t

ind icated the

14 o r more d r i n k s p e r week d u r i n g t h e f i r s t

t r i m e s t e r was a s s o c i a t e d w i t h a v a r i e t y o f a d v e r s e o u t c o m e s ,

including

low b i r t h w e i g h t . When c o n f o u n d i n g v a r i a b l e s wer e c o n t r o l l e d by l o g i s t i c
regression analysis,

s moki ng,

and n o t a l c o h o l

c o n s u m p t i o n , was f ound t o

42

be r e s p o n s i b l e f o r t h e i n c r e a s e d l i k e l i h o o d o f d e l i v e r i n g a l ow b i r t h
weight i n f a n t .

However, w i t h i n e a c h g r o u p o f a l c o h o l u s e

( 0,

1-13,

14 o r

more d r i n k s p e r w e e k ) , women who c o n c o m i t a n t l y smoked more t h a n 10
c i g a r e t t e s p e r d a y d e l i v e r e d b a b i e s who we i g h e d 250 g l e s s t h a n b a b i e s
o f non-smokers ( a b s t a i n e r s :
moderate d r i n k e r s :
drinkers:

3495 g , n o n - s m o k e r s vs 3158 g , s m o k e r s ; he a vy

3373 g , n o n - s m o k e r s vs 2919 g,

K l i n e and S t e i n
and a l c o h o l
studies

3353 g , n o n - s m o k e r s vs 3119 g s mo k e r s ;

smokers).

( 1987) e xa mi ne d t h e r e l a t i o n

o f c i g a r e t t e smoki ng

i n t a k e d u r i n g p r e g n a n c y t o b i r t h w e i g h t i n two p r o s p e c t i v e

( P h a s e I and Pha s e I I )

o f 2815 p r e g n a n t women in New York C i t y .

Whi l e c i g a r e t t e smoki ng d u r i n g t h e l a s t h a l f o f p r e g n a n c y was a s s o c i a t e d
w i t h s i g n i f i c a n t d e c r e a s e s i n mean b i r t h w e i g h t o f 159 g ( P h a s e I ) and
202 g ( P h a s e I I )

(p < 0 . 0 0 1 ) ,

o n l y b e e r d r i n k i n g i n P h a s e I I was

a s s o c i a t e d with a s i g n i f i c a n t decrement of 8 .4 g in b i r t h weight per
o unc e o f a b s o l u t e a l c o h o l

consumed (2 s t a n d a r d d r i n k s ;

N e i t h e r wi ne o r l i q u o r d r i n k i n g i n P h a s e I I ,

p < 0.01).

n o r any o f t h e t h r e e

b e v e r a g e s i n Pha s e I , was a s s o c i a t e d w i t h a d e c r e a s e i n b i r t h w e i g h t .
Te nne s and B l a c k a r d ( 1980) r e c o r d e d d r i n k i n g

h i s t o r i e s o f 278

C o l o r a d o women b e f o r e t h e t w e n t i e t h week o f g e s t a t i o n .

Thr ee p e r c e n t of

t h e women i n t h e s t u d y a v e r a g e d more t h a n one and o n e - h a l f d r i n k s p e r
day d u r i n g t h e f i r s t t r i m e s t e r .
a s s o c i a t i o n be t we e n a l c o h o l

Although a s t a t i s t i c a l l y

and d e c r e a s e d g e s t a t i o n a l

( e x p l a i n i n g two p e r c e n t o f t h e v a r i a n c e ) ,
c o n s u mp t i o n and b i r t h w e i g h t was o b s e r v e d .
p r o s p e c t i v e s t u d y whe r e a l c o h o l

age was o b s e r v e d

no a s s o c i a t i o n
Similarly,

significant

be t we e n a l c o h o l

Mau ( 1 9 8 0 ) ,

i n t a k e was me a s u r e q u a l i t a t i v e l y ,

in a
f ound

43

no r e l a t i o n s h i p b e t we e n a l c o h o l

i n t a k e and i n f a n t

b irth weight,

length

o r he a d c i r c u m f e r e n c e .

Summary: Al c o h o l

I n t a k e and B i r t h Wei ght

I n c o n s i s t e n c i e s i n t h e l i t e r a t u r e h a v e been a t t r i b u t e d t o
incomplete c ontrol
bias

of the following confounding v a r i a b l e s :

( Ma r bur y e t a l , 1 9 8 3 ) , 2) u n d e r - r e p o r t i n g

t h e mos t ( F i t z g e r a l d and M u l f o r d ,
consumed (Kuzma and S o k o l ,
e x p o s u r e h a s be e n d e f i n e d

1978),

1) r e c a l l

by i n d i v i d u a l s who d r i n k

3) t y p e o f a l c o h o l i c b e v e r a g e s

1 9 8 2 ) , 4) d i f f e r e n c e s i n t h e way a l c o h o l
( S t e i n and K l i n e ,

1983) ,

5) t h e v a r y i n g

p e r c e n t a g e o f h e a vy and m o d e r a t e d r i n k e r s i n d i f f e r e n t s t u d i e s ,
6) l a c k o f a t t e n t i o n t o t i m i n g o f a l c o h o l
( Zucker man and H i n g s o n ,
Results

and

exposure during pregnancy

1986).

i n d i c a t e women whose a l c o h o l c o n s u m p t i o n i s h i g h d u r i n g

p r e g n a n c y (14 o r more d r i n k s p e r w e e k ) , a r e a t

i n c r e a s e d r i s k of having

an i n f a n t w i t h i n t r a u t e r i n e g r o wt h r e t a r d a t i o n .

Evidence of t h e e f f e c t s

o f m o d e r a t e o r r a r e d r i n k i n g i s l e s s c o n v i n c i n g . Two r e v i e w s o f more
t h a n 900 r e s e a r c h r e p o r t s on a l c o h o l and p r e g n a n c y c o n c u r r e d t h a t ,
instance,

in e i t h e r c l i n i c a l

or experimental

e f f e c t s o f t h e c o n s u m p t i o n o f l ow l e v e l s
( R o s e t t and We i n e r ,

1984; Ab e l ,

1984).

reports,

i n no

have p e r s i s t e n t

of a lc ohol been observed

In c o n t r a s t ,

several

studies

i n d i c a t e an i n c r e a s e d r i s k o f g r o wt h r e t a r d a t i o n f o l l o w i n g e x p o s u r e t o
high blood alcohol c o n c e n t r a t i o n s a t a l l
absence of o t h e r r i s k f a c t o r s
t h e Ame r i c a n J o u r n a l

s t a g e s o f g e s t a t i o n and i n t h e

( We i ne r and R o s e t t ,

o f P u b l i c H e a l t h has s t a t e d ,

1985) . An e d i t o r i a l
it

in

is " u n l i k e l y t h a t

r e g u l a r d r i n k i n g o f f e w e r t h a n two d r i n k s d a i l y , e i t h e r

befo re or during

44

pregnancy,

i s an i m p o r t a n t d e t e r m i n a n t o f i n t r a u t e r i n e g r o wt h

retardation"

( S t e i n and K l i n e ,

1983, p . 1 1 5 6 ) . T h e s e i n c o n s i s t e n t

f i n d i n g s s u g g e s t t h e ne e d f o r f u r t h e r s t u d i e s ,

e s p e c ia lly regarding the

i n t e r - r e l a t i o n s h i p of alcohol with o t h e r f a c t o r s .

C a f f e i n e Cons umpt i on

D e s p i t e w i d e s p r e a d u s e i n b e v e r a g e s and f o o d s ,

the e ff e c ts of

c a f f e i n e on t h e d e v e l o p i n g f e t u s a r e n o t c o m p l e t e l y known ( M a r t i n and
Bracken,

1987).

nervous system.

Pharmacologically,
Physiologically,

i n r e p r o d u c t i v e and f e t a l

caffeine stim ulates the central

c a f f e i n e i n g e s t i o n h a s be e n i m p l i c a t e d

effects

c l e f t p a l a t e and d i g i t d e f o r m i t i e s

in a n im a ls ,

including embryolethality,

( C o l l i n s e t a l , 1982).

Human d a t a a r e

l i m i t e d and c o n t r a d i c t o r y . C a f f e i n e i s known t o c r o s s t h e p l a c e n t a and
en ter the fetal

circulation

(Goldstein,

1 9 6 2 ) , whe r e i t

is metabolized

a t a r a t e t h r e e t i m e s s l o w e r t h a n i n n o n p r e g n a n t women ( K n i t t i

et a l ,

1 9 8 2 ) . The f e t u s d o e s n o t ha ve t h e enzymes n e c e s s a r y t o m e t a b o l i z e
caffeine until

s e v er a l days a f t e r b i r t h

B e c a u s e t h e c h e mi c a l

( M a r t i n and B r a c k e n ,

1987).

s tru c tu re of caffeine is sim ila r to th at of purine

m o l e c u l e s i n DNA, i t ha s be e n h y p o t h e s i z e d t h a t c a f f e i n e c o u l d i n t e r f e r e
with c e l l

division,

g r o wt h and m e t a b o l i s m ( M a r t i n and B r a c k e n ,

1987).

45

Ani mal

S t u d i e s and C a f f e i n e
The p o t e n t i a l

t o x i c i t y o f c a f f e i n e t o t h e d e v e l o p i n g f e t u s was

f i r s t r e p o r t e d by Knoche and Koni g ( 1 9 6 4 ) .

C l e f t p a l a t e s we r e o b s e r v e d

i n m i c e a f t e r d a i l y a d m i n i s t r a t i o n o f 50 mg/kg o f c a f f e i n e
Ko n i g ,

1964) and d i g i t a l

deformities

(ectrodactyly)

( Knoche and

h a v e be e n o b s e r v e d

i n m i c e , W i s t a r r a t s and r a b b i t s a f t e r d a i l y c a f f e i n e a d m i n i s t r a t i o n a t
50,

100 and 125 mg/ kg, r e s p e c t i v e l y ( B e r t r a n d e t a l , 1 9 6 5 ) .
Grossier,

Rosso and Wi nni c k ( 1982) r e p o r t e d o f f s p r i n g o f r a t s who

w e r e f e d c o f f e e d u r i n g p r e g n a n c y had r e d u c e d t o t a l
w e i g h t s a t b i r t h as c ompar ed t o c o n t r o l s .
had r e c o v e r e d i n s i z e ;

body,

By 39 d a y s ,

l i v e r and b r a i n

these offspring

howe ve r t h e y d e m o n s t r a t e d i n c r e a s e d l o c o m o t i o n ,

d e c r e a s e d gr oomi ng t i m e and d e c r e a s e d t i m e s p e n t w i t h a no v e l

object.

Dunl op and C o u r t ( 1981) a l s o f ound m o d e r a t e a mount s o f c a f f e i n e ,
i n t r o d u c e d i n t o t h e d i e t o f r a t s t h r o u g h o u t p r e g n a n c y and l a c t a t i o n ,
resulted

in g r o w t h - r e ta r d e d o f f s p r i n g .

C o l l i n s e t al

( 1982)

i n t u b a t e d r a t s w i t h 0, 6,

mg c a f f e i n e / k g body w e i g h t d u r i n g t h e f i r s t
and f e m a l e r a t s ,

12, 40, 80 and 125

19 d a y s o f g e s t a t i o n .

Male

i n t u b a t e d w i t h 80 and 125 mg/ kg, we i g h e d s i g n i f i c a n t l y

l e s s and we r e s h o r t e r ;

f e m a l e s i n t u b a t e d w i t h 40 mg/ kg we i g h e d

s i g n i f i c a n t l y l e s s and had a s h o r t e r cr own- r ump l e n g t h .

E c t r o d a c t y l y was

o b s e r v e d i n f e t u s e s o f a n i m a l s d o s e d w i t h 80 and 125 mg/kg c a f f e i n e .
H y p o p l a s t i c n a i l s and m i s s i n g d i g i t s we r e o b s e r v e d i n b o t h g r o u p s ,
significant

i n c r e a s e i n t h e number o f m i s s i n g d i g i t s

but a

i n t h e 125 mg/kg

g r o u p was n o t e d . The a b s e n c e o f t h e t h i r d d i g i t on t h e l e f t b a c k paw was
mo s t commonly o b s e r v e d .

Reduced and d e l a y e d o s s i f i c a t i o n

i n c r e a s i n g c a f f e i n e dosage; the incide nce of misshaped,

i n c r e a s e d with
poorly o s s if ie d ,

46

f u s e d and a b s e n t b o n e s i n c r e a s e d s i g n i f i c a n t l y i n r a t s f e d t h e t h r e e
h i g h e s t dose l e v e l s .
Drug A d m i n i s t r a t i o n
sparingly,

T h e s e r e s u l t s p r o mp t e d t h e U n i t e d S t a t e s Food and
(FDA) t o a d v i s e p r e g n a n t women t o a v o i d ,

c a ff e i n e - c o n t a i n i n g foods,

b e v e r a g e s and d r u g s

o r use

( Goyan,

1980).

Human S t u d i e s and C a f f e i n e
I m p l i c a t i o n s o f f i n d i n g s f r om a ni ma l
unclear,

p r i m a r i l y due t o d i f f e r e n c e s

consumed and m e t a b o l i s m ( Goyan,

1980).

have e xa mi ned t h e r e l a t i o n o f c a f f e i n e
weight; all

studies

f o r humans a r e

i n t h e mode o f e x p o s u r e ,
Several

amount

epidemiologic studies

i n t a k e d u r i n g pregnancy to b i r t h

b u t one h a ve i n d i c a t e d a n e g a t i v e a s s o c i a t i o n .

K i r k i n e n e t al

( 1983) r e p o r t e d a d m i n i s t r a t i o n o f 200 mg c a f f e i n e

t o p r e g n a n t women, an amount e q u i v a l e n t t o t h a t
c ups o f c o f f e e ,

f ound i n two t o t h r e e

s i g n i f i c a n t l y reduced blood flow t o t h e p l a c e n t a l

and i n c r e a s e d m a t e r n a l

epinephrine lev e ls.

villi

The r e s e a r c h e r s h y p o t h e s i z e d

t h i s d e c re a s e d blood flow reduced t h e n u t r i e n t supply t o t h e f e t u s ,
r e s u l t i n g i n i n t r a u t e r i n e g r o wt h r e t a r d a t i o n .
B e a u l a c - B a i 1 1a r g e o n and D e s r o s i e r s

( 1987)

o f c a f f e i n e and c i g a r e t t e c o n s u m p t i o n on f e t a l
s t u d y o f 913 n e wb o r n s .

investigated the e ffe c t
g r o wt h i n a r e t r o s p e c t i v e

R e s u l t s showed c a f f e i n e c o n s u m p t i o n d u r i n g

p r e g n a n c y had a n e g a t i v e e f f e c t on t h e b i r t h w e i g h t o f b a b i e s b o r n t o
s moker s o f 15 o r more c i g a r e t t e s

per day.

Doses o f 300 mg o r more of

c a f f e i n e p e r da y a c c e n t u a t e d t h e d e c r e a s e s i n b i r t h w e i g h t c a u s e d by
s moki ng. A f t e r a d j u s t i n g f o r l e n g t h o f g e s t a t i o n and s e x ,
caffeine-cigarette
placental weight.

a significant

i n t e r a c t i o n was o b s e r v e d f o r b o t h b i r t h w e i g h t and
B i r t h w e i g h t was 206 g l i g h t e r f o r b a b i e s whose

47

m o t h e r s consumed 300 mg o r more c a f f e i n e and smoked 15 c i g a r e t t e s o r
more p e r d a y . Among women who consumed l e s s t h a n 300 mg c a f f e i n e d a i l y ,
placental

w e i g h t i n c r e a s e d w i t h i n c r e a s i n g c i g a r e t t e c o n s u m p t i o n due t o

an a p p a r e n t c o m p e n s a t o r y p l a c e n t a l
w e i g h t was s i g n i f i c a n t l y

hypertrophy.

In c o n t r a s t ,

placental

r e d u c e d among women who smoked 15 c i g a r e t t e s o r

more p e r da y i f t h e y c o n c o m i t a n t l y i n g e s t e d 300 mg o r more c a f f e i n e as
compa r ed t o women who consumed t h e same number o f c i g a r e t t e s b u t l e s s
caffeine.

The s e r e s u l t s

i n d i c a t e d t h e c o nc omi ta nt consumption o f

c a f f e i n e and c i g a r e t t e s c o n s t i t u t e d a h i g h r i s k f o r t h e f e t u s .
M a r t i n and Br a c ke n

( 1987) o b s e r v e d a d o s e - d e p e n d e n t ,

increased

r i s k o f d e l i v e r i n g a low b i r t h w e i g h t s i n g l e t o n a f t e r 36 weeks g e s t a t i o n
i n m o t h e r s who consumed one o f f o u r l e v e l s o f c a f f e i n e d u r i n g t h e i r
pregnancy.
study,
coffee,

S e v e n t y - s e v e n p e r c e n t o f t h e 3, 8 9 1 women i n t h i s p r o s p e c t i v e

c o n d u c t e d a t Yal e-New Haven H o s p i t a l ,
tea,

c o l a s and d r u g s ;

i n g e s t e d c a f f e i n e from

o v e r one q u a r t e r o f t h e women consumed

more t h a n 150 mg d a i l y . Av e r a g e d a i l y c a f f e i n e e x p o s u r e ( mg/ da y) was
d e t e r m i n e d f r om c o n s u m p t i o n o f n o n - d e c a f f e i n a t e d c o f f e e and t e a and
c a f f e i n e - c o n t a i n i n g c o l a s most f r e q u e n t l y cons ume d.

C a f f e i n e c o n t e n t was

e s t i m a t e d a t 107, 34 and 47 m g / s e r v i n g f o r c o f f e e ,

t e a and c o l a s ,

respectively.

0 mg,

Four l e v e l s o f c a f f e i n e c o n s u m p t i o n ,

1- 150 mg,

300 mg and g r e a t e r t h a n 300 mg / da y, whi c h e s t i m a t e d 0, < 1 . 5 ,

151-

1 . 5 - 3 and

>3 c u p s p e r d a y , we r e c o mp a r e d . A f t e r a d j u s t i n g f o r t h e c o n f o u n d i n g
f a c t o r s o f age, m a r i t a l
consumption,
mass i n d e x ,
0.87-3.0)

alcohol

status,

intake,

the r e l a ti v e

ethnicity,

marijuana use,

education,
parity,

daily cigarette

w e i g h t g a i n and body

r i s k s o f low b i r t h w e i g h t we r e 1 . 4 (95% Cl

f o r 1- 150 mg c a f f e i n e / d a y ,

2.3 (1 . 1 -5 . 2 )

f o r 1 51- 300 mg/ day

48

and 4 . 6

(2.0-10.5)

f o r o v e r 300 mg c a f f e i n e / d a y .

D e c r e a s e s i n mean b i r t h

w e i g h t b e t we e n c a s e s and c o n t r o l s we r e 6, 31 and 105 g r a ms ,
respectively,

c ompa r ed w i t h a 137 g d e c r e a s e f o r c i g a r e t t e s moki ng. The

auth ors concluded maternal

c a f f e i n e r e s u l t e d in a t w o - f o l d r i s k o f

d e l i v e r i n g a low b i r t h w e i g h t i n f a n t i f t h e e q u i v a l e n t o f 2- 3 c ups o f
c o f f e e we r e consumed p e r da y d u r i n g p r e g n a n c y ; women who consume t h e
c a f f e i n e e q u i v a l e n t o f more t h a n t h r e e c u p s p e r

day had a f o u r - f o l d

risk

o f d e l i v e r i n g a l ow b i r t h w e i g h t ba by.
I n a r e t r o s p e c t i v e s t u d y o f 12, 205 n o n - d i a b e t i c ,
women,

Li nn e t al

( 1982)

non-asthmatic

f oun d no a s s o c i a t i o n b e t we e n low b i r t h w e i g h t ,

p r e t e r m d e l i v e r y o r c o n g e n i t a l m a l f o r m a t i o n s and he a vy c o f f e e
c o n s u m p t i o n ( f o u r o r more c ups p e r day) a f t e r c o n t r o l l i n g f o r smoki ng,
d e m o g r a p h i c c h a r a c t e r i s t i c s and me d i c a l
and s t a t i s t i c a l

history.

However, t h e met hods

a n a l y s i s r e p o r t e d by Li nn ( 1982) dr ew much c r i t i c i s m

( B r a c k e n e t a l , 1982; S t e i n m a n n ,

1982; Luke,

c o n s u m p t i o n f r om s o u r c e s o t h e r t h a n c o f f e e ,
c o l l e c t i o n to only the f i r s t

trimester,

1982) . The l a c k o f c a f f e i n e
the

lim ita tio n of data

and f a i l u r e t o a c c o u n t f o r p r e ­

p r e g n a n c y w e i g h t and g e s t a t i o n a l w e i g h t g a i n wer e t h e m a j o r o b j e c t i o n s .

Summary: C a f f e i n e I n t a k e and B i r t h Wei ght
Present studies

indicate a potential

b i r t h w e i g h t i n f a n t when as l i t t l e
c ons ume d. The i n t e r a c t i o n

r i s k f o r d e l i v e r i n g a reduced

as 151- 300 mg c a f f e i n e / d a y i s

b e t we e n c i g a r e t t e smoki ng and c a f f e i n e

i n g e s t i o n g r e a t e r t h a n 300 mg/ day has been shown t o r e d u c e b o t h i n f a n t
b i r t h w e i g h t and p l a c e n t a l

weight.

Present research fin dings appear to

49

s u p p o r t c o n t i n u a t i o n o f t h e FDA's w a r n i n g a b o u t p o s s i b l e r i s k s o f
c a f f e i n e consumption d u r i n g pregnancy.

Nutrition

Due t o t h e compl ex i n t e r a c t i o n s o f p h y s i o l o g i c ,
environmental,
of n u t ritio n

behavioral,

s o c i o d e m o g r a p h i c and m e t h o d o l o g i c f a c t o r s ,

the exact role

i n p r e g n a n c y out come i s d i f f i c u l t t o d e t e r m i n e .

s e c t i o n o f t h e l i t e r a t u r e review will
whi c h i n t e r f e r e

f o c u s on:

This

1) c o n f o u n d i n g f a c t o r s

in t h e e s t a b l i s h m e n t o f t h e e x a c t r o l e o f n u t r i t i o n

p r e g n a n c y out c ome , 2) e s t a b l i s h e d r e l a t i o n s h i p s b e t we e n n u t r i t i o n
pregnancy, h i g h l i g h t i n g the r o l e of energy,
d e t e r m i n e d by a n i m a l ,
3) c u r r e n t e n e r g y ,

human, h i s t o r i c a l

p r o t e i n and z i n c ,

in

and

as

and p r o s p e c t i v e s t u d i e s ,

p r o t e i n and z i n c n u t r i e n t r e c o m m e n d a t i o n s f o r

p r e g n a n t women, 4) me t hods t o e v a l u a t e u s u a l d i e t a r y
re tro sp e c tiv e study,

i n t a k e in a

and 5) met hods t o a s s e s s t h e i mp a c t o f t o t a l

diet

q u a l i t y on p r e g n a n c y out come .

Co n f o u n d i n g F a c t o r s
Ma t e r n a l d i e t and n u t r i t i o n a l
important f a c to rs influencing f e ta l
c ompl e x p h y s i o l o g i c a l
and f e t u s ,

s t a t u s ha ve l o n g be e n c o n s i d e r e d
g r o wt h and p r e g n a n c y o u t c o me . The

r e l a t i o n s h i p s be t we e n t h e p r e g n a n t woman, p l a c e n t a

h o we ve r , makes t h e q u a n t i t a t i v e d e f i n i t i o n o f n u t r i e n t n e e d s

d u r i n g pr egnancy d i f f i c u l t t o d et er mi n e ( Met cof f e t a l , 1981).
Compoundi ng t h e p h y s i o l o g i c c o m p l e x i t i e s a r e t h r e e i m p o r t a n t
m e t h o d o l o g i c p r o b l e ms t h a t ,

a c c o r d i n g t o H e b e r t and M i l l e r

(1988),

could

50

p r e v e n t t h e o b s e r v a t i o n o f a t r u e a s s o c i a t i o n b e t we e n d i e t a r y f a c t o r s
and t h e out come v a r i a b l e i n q u e s t i o n

(i.e.

b irth weight).

First,

a v a i l a b l e d i e t a s s e s s m e n t me t hods a r e i n a d e q u a t e t o e s t i m a t e t r u e
e x p o s u r e w i t h s u f f i c i e n t a c c u r a c y and p r e c i s i o n ,
p e r i o d s o f t i m e , due t o d i f f i c u l t i e s
Se c o n d ,

e s p e c i a l l y o v e r l ong

in r e c a l l i n g t r u e d i e t a r y

intake.

u s e o f r e t r o s p e c t i v e d i e t a s s e s s m e n t me t hods i n c a s e - c o n t r o l

s t u d y d e s i g n s c a n o f t e n i n t r o d u c e an i m p o r t a n t b i a s ,
b e t we e n c a s e s

(i.e.,

particularly

m o t h e r s who d e l i v e r a LBW ba by) and c o n t r o l s

m o t h e r s who d e l i v e r a 3 5 0 0 - 4 0 0 0 g i n f a n t ) .
study group c o n t r a s t s are o f te n la c ki ng

Third,

(i.e.,

(i.e.,

s u f f i c i e n t within-

t h e t r u e range of in tak e

o f any n u t r i e n t may n o t be s u f f i c i e n t l y l a r g e t o s t a t i s t i c a l l y d e t e c t a
difference).
Many c o n f o u n d i n g f a c t o r s ,

i n a d d i t i o n t o a woman' s n u t r i t i o n a l

s t a t u s p r i o r t o and d u r i n g p r e g n a n c y ,

influence fetal

f a c t o r s o f te n co-vary with d i e t a r y behavior,
researchers'
intake,

and f e t a l

For t h e s e r e a s o n s ,

out c ome .
remarkably l i t t l e

s p e c i f i c r e l a t i o n b e t we e n n u t r i e n t
Indeed, Me tc of f (1981a,
t h a t human f e t a l

in formation e x i s t s about the

i n t a k e and human f e t a l

p. 656) s t a t e d

o u t c o me .

" a l t h o u g h i t may seem o b v i o u s

m a l n u t r i t i o n is the r e s u l t of i n a p p r o p r i a t e d e l i v e r y of

or u t i l i z a t i o n

by, t h e g r o wi n g f e t u s ,

rela tio n s h ip to the n u tritio n a l
identified".

fu rth e r complicating

a b i l i t y t o d i s c e r n t h e t r u e r e l a t i o n s h i p b e t we e n n u t r i e n t

per se,

nutrients to,

o u t c o me . The s e

a specific

s t a t e o f t h e m o t h e r h a s NOT been

N o n e t h e l e s s , d a t a f r om e p i d e m i o l o g i c s t u d i e s ,

supplementation t r i a l s ,

historical

o b s e r v a t i o n s and ani ma l

f ood

51

i n v e s t i g a t i o n s provide s up po rt f o r t h e premise t h a t maternal
i n f l u e n c e s human f e t a l

nutrition

growth.

D e s p i t e t h e c o m p l e x i t i e s i n d e t e r m i n i n g a r e l a t i o n s h i p b e t we e n
n u t r i e n t i n t a k e and human f e t a l

o u t c o me ,

research

in t h i s

a re a should

n o t be a b a n d o n e d . New d i e t a s s e s s m e n t t o o l s and s t a t i s t i c a l

me t h o d s can

be u s e d t o c l a r i f y t h e i n t e r - r e l a t i o n s h i p s whi c h i n f l u e n c e f e t a l
o u t c o me . By f o c u s i n g on t h i s
individual
factors

factors

" s e a m l e s s web" o f f a c t o r s ,

in i s o l a t i o n ,

r a t h e r t h a n on

an e n h a n c e d u n d e r s t a n d i n g o f m o d i f i a b l e

i n f l u e n c i n g b i r t h weight wi ll

be a t t a i n e d

(Jacobson,

1986).

Research St ud ies Ver y l i t t l e

specific

i n f o r m a t i o n was a v a i l a b l e a b o u t d i e t and

pregnancy before the 1 9 30 's .

Four t y p e s o f r e s e a r c h ha ve be e n us e d t o

e xa mi ne t h e e f f e c t o f n u t r i t i o n d u r i n g p r e g n a n c y on b i r t h o ut c ome :
a ni ma l

studies,

human wa r and f a m i n e s t u d i e s ,

out come c o r r e l a t i o n a l
studies.

In g e n e r a l ,

s t u d i e s and e x p e r i m e n t a l
all

n u t r i t i o n ha s a p o s i t i v e
the e f f e c t

nutritional
nutrition

intake/fetal
intervention

s t u d i e s p o i n t t o a common c o n c l u s i o n :
i n f l u e n c e on b i r t h w e i g h t ,

is u n c le a r ( I n s t i t u t e o f Medicine,

good

but t h e magnitude of

1985).

Animal S t u d i e s .
Controlled r a t studie s

i n d i c a t e extreme n u t r i t i o n a l

(50% r e d u c t i o n i n e n e r g y i n t a k e )
b i r t h weight

(Chow and Le e ,

results

1964; Be r g ,

deprivation

i n a 25-30% d e c r e a s e i n l i t t e r
1 9 6 5 ) . The o b s e r v e d r e d u c t i o n

in

b i r t h w e i g h t was c o n s i s t e n t l y l e s s t h a n t h e m a g n i t u d e o f t h e d i e t a r y
reduction.

Metabolic,

t i s s u e and c e l l u l a r d e f i c i t s

i n r a t pups have been

52

a s s o c i a t e d with d i e t a r y r e s t r i c t i o n o f t h e mother d u r i n g pregnancy
( Wi n i c k and No b l e ,

1965; Wi ni c k and No b l e ,

Caloric r e s t r i c t i o n during the final

1966; Wi n i c k e t a l , 1973) .

s t a g e o f p r e g n a n c y h a s been

a s s o c i a t e d with the l a r g e s t b i r t h weight d e f i c i t s

in r a t s

(Wal l ace,

1945).
Growt h f a i l u r e

i n r o d e n t s can be a t t r i b u t e d t o e i t h e r " i n t r i n s i c "

or " e x trin s ic " causes.

I n t r i n s i c i n t r a u t e r i n e g r o wt h f a i l u r e

(i.e.,

g r o wt h r e t a r d a t i o n c a u s e d by f a c t o r s o t h e r t h a n i n a d e q u a t e m a t e r n a l fetal

transport,

infection),

s uc h a s chromosomal a b n o r m a l i t i e s ,

typically results

i n t r a u t e r i n e g r o wt h f a i l u r e ,

dr ug s, maternal

in n o rm al -si zed p l a c e n t a s .
howe ve r ,

Extrinsic

i s u s u a l l y m a n i f e s t e d by p l a c e n t a s

t h a t a r e r e d u c e d i n s i z e and i n c a p a b l e o f s u p p l y i n g t h e f e t u s w i t h
adequate n u t r i t i o n

f o r o p t i m a l g r o wt h ( Wi n i c k e t a l , 1 9 7 3 ) .

Extrinsic

i n t r a u t e r i n e g r o wt h f a i l u r e has been p r o d u c e d e x p e r i m e n t a l l y i n r a t s by
ligating a uterine artery

( Wi ni c k e t a l , 1 9 7 3 ) . T h i s p r o c e d u r e ,

usually

done a t 17 d a ys g e s t a t i o n a f t e r h y p e r p l a s t i c g r o wt h o f t h e p l a c e n t a i s
complete,

c u t s o f f t h e b l o o d s u p p l y t o one o f t h e u t e r i n e h o r n s .

Severe p r o t e i n r e s t r i c t i o n o f r a t s d u r i n g pr egnancy produces
e x t r i n s i c g r o wt h r e t a r d a t i o n
sy n th e s i s of plac e n ta l

by r e d u c i n g t h e s u p p l y o f n u t r i e n t s

and f e t a l

cells.

for the

Bot h v a s c u l a r and n u t r i t i o n a l

e x t r i n s i c g r o wt h f a i l u r e p r o d u c e d p l a c e n t a s whi ch wer e r e d u c e d i n s i z e
in p r o p o r t i o n t o f e t a l
malnutrition

weight.

(reduced t o t a l

In b o t h l i g a t e d a n i m a l s and l a t e m a t e r n a l

dietary intake),

the reduction

in p l a c e n t a l

s i z e was a t t r i b u t e d t o a d e c r e a s e i n t h e a v e r a g e s i z e o f t h e c e l l s .
In c o n t r a s t ,

maternal

d e c r e a s e d both t h e p l a c e n t a l

protein r e s t r i c t i o n throughout gestation
s i z e and c e l l

number ( Wi ni c k e t a l , 1973) .

53

In a d d i t i o n t o p l a c e n t a l

changes, maternal

p ro te in r e s t r i c t i o n during

t h e l a s t d a y s o f g e s t a t i o n r e s u l t e d i n a g r o wt h r e t a r d a t i o n p a t t e r n
s i m i l a r t o t h a t p r o d u c e d by v a s c u l a r i n s u f f i c i e n c y ,

resulting

w i t h p r o p o r t i o n a l l y b i g g e r h e a d s and s m a l l e r b o d i e s .
r e s t r i c t i o n was m a i n t a i n e d t h r o u g h o u t g e s t a t i o n ,
cell

s i z e and number o f a l l

organs,

in r a t s

When p r o t e i n

a 15-25% d e c r e a s e i n

i n c l u d i n g t h e b r a i n , was n o t e d .

R e s u l t s s u g g e s t f e t u s e s a r e n o t p e r f e c t p a r a s i t e s t h a t can s u r v i v e
intrauterine

i n s u l t s wi thout adverse consequences

( Wi n i c k e t a l , 1 9 7 3 ) .

Human Famine S t u d i e s .
Famine c a u s e d by war ha s p r o v i d e d an o p p o r t u n i t y t o e xa mi n e t h e
i mp a c t o f d i e t a r y r e s t r i c t i o n on human b i r t h o u t c o me .

Studies of the

e f f e c t s o f f a mi n e on p r e g n a n c y out come d u r i n g Worl d War I I
( An t o n o v ,

1947) and H o l l a n d ( S mi t h ,

nutritional

1947)

in Leningrad

i n d i c a t e extreme,

sustained

d e p r i v a t i o n can compr omi s e p r e g n a n c y o ut c ome and i n c r e a s e

t h e i n c i d e n c e o f l ow b i r t h w e i g h t .
Ext r eme h a r d s h i p s we r e e n d u r e d by t h e p e o p l e o f L e n i n g r a d ,

during

t h e s i e g e by t h e N a z i s f r om 1941 t o 1943. C o n d i t i o n s we r e e s p e c i a l l y
s e v e r e b e t we e n S e p t e m b e r ,

1941, t o F e b r u a r y ,

1942 ( An t o n o v ,

was i n s u f f i c i e n t i n q u a n t i t y and i n f e r i o r i n q u a l i t y .
o n e - h a l f r y e f l o u r and t h e r e s t c e l l u l o s e ,
principal

1947).

Food

B r e a d , made from

malt or bran,

was t h e

f o o d . Br ead r a t i o n s f o r manual w o r k e r s d u r i n g December o f 1941

we r e 2 5 0 - 3 0 0 g; r a t i o n s f o r me nt a l w o r k e r s we r e o n l y 1 25- 200 g. Which o f
t h e s e two r a t i o n s was made a v a i l a b l e t o p r e g n a n t women was n o t
specified.

Under t h e s e e x t r e m e c o n d i t i o n s ,

b i r t h weight,

a 50% LBW r a t e ,

a 500 g r e d u c t i o n

in a verage

a 41. 2% p r e m a t u r i t y r a t e and a 32.2%

54

overall

i n f a n t m o r t a l i t y r a t e o c c u r r e d . Onl y 4% o f t h e i n f a n t s b o r n i n

the f i r s t

s i x mont hs o f 1942 we i ghe d more t h a n 3500 g.

Ant onov ( 1 9 4 7 ,

p. 259) c o n c l u d e d "we can s a y on t h e b a s i s o f o u r m a t e r i a l
condition of the host,
fetus,

t h e m o t h e r ' s body,

th a t the

is of g r e a t consequence to the

and t h a t s e v e r e q u a n t i t a t i v e and q u a l i t a t i v e h u n g e r o f t h e m o t h e r

d e c i d e d l y a f f e c t s t h e d e v e l o p m e n t o f t h e f e t u s and t h e v i a b i l i t y o f t h e
newbor n c h i l d " .
The H o l l a n d f a mi n e ( S mi t h ,
f a mi n e i n t h a t
time,

1947) d i f f e r e d f r om t h e L e n i n g r a d

i t was o f s h a r p o n s e t ,

l i m i t e d t o a s i x month p e r i o d o f

and was n o t a c c o mp a n i e d by d e p r i v a t i o n s a s s e v e r e as t h o s e

experienced during the sie ge of Leningrad.

In a d d i t i o n ,

t h e women o f

H o l l a n d we r e c o n s i d e r e d t o have had f a i r l y good d i e t s b e f o r e t h e f ood
shortage.

Du r i n g t h e f a m i n e , d i e t a r y i n t a k e was r e d u c e d t o l e s s t h a n

1000 k c a l / d a y ,

and p r o t e i n was l i m i t e d t o 3 0 - 4 0 g.

B e c a u s e t h e f a mi n e

o n l y l a s t e d s i x mo n t h s , b a b i e s c o n c e i v e d b e f o r e and d u r i n g

i t wer e

e x p o s e d f o r v a r y i n g l e n g t h s o f t i m e , w i t h none e x p o s e d f o r t h e e n t i r e
course of g e s ta t io n .

Th u s ,

i t was p o s s i b l e t o c o n s i d e r how t h e t i m i n g o f

maternal d i e t a r y r e s t r i c t i o n s a f f e c t e d f e t a l
On a v e r a g e ,

growth.

b i r t h w e i g h t s o f i n f a n t s e x p o s e d t o t h e H o l l a n d f a mi n e

we r e r e d u c e d by 200 g.
t h e famine d u r i n g t h e

B i r t h w e i g h t s wer e l o w e s t f o r b a b i e s

e n t i r e l a s t h a l f o f p r e g n a n c y . Added e x p o s u r e t o

t h e f a mi n e b e f o r e t h e l a s t h a l f o f p r e g n a n c y d i d
any f u r t h e r ;
first
ended,

in f a c t ,

exposed to

not r educe

b a b i e s who wer e e x p o s e d t o t h e f a mi n e

27 weeks o f g e s t a t i o n ,

b i r t h weight
during the

b u t f i n i s h e d t h e i r t e r m s a f t e r t h e f a mi n e

had h i g h e r a v e r a g e b i r t h w e i g h t s t h a n t h o s e who we r e o n l y e x p o s e d

d u r i n g t h e l a s t t h r e e weeks o f g e s t a t i o n .

Da t a f o r s t i l l b i r t h s

and

55

co ng en ital malformations followed a d i f f e r e n t p a t t e r n ,
f o r i n f a n t s conceived b e f o r e ,
t h e f a m i n e . The s e r e s u l t s
pregnancy a f f e c t e d f e t a l

with r a t e s lowest

and h i g h e s t f o r t h o s e c o n c e i v e d d u r i n g ,

i n d i c a t e d poor n u t r i t i o n

in t he l a t t e r p a r t of

growth, whereas poor n u t r i t i o n

in the e a r l y

mont hs a f f e c t e d d e v e l o p m e n t o f t h e embr yo and i t s c a p a c i t y t o s u r v i v e .
S t e i n e t al

( 1975) r e - e x a m i n e d e f f e c t s o f t h e H o l l a n d f a m i n e on

human d e v e l o p m e n t by c o mp a r i n g t h e me n t a l

and p h y s i c a l

h e a lth s t a t u s of

t h o s e e x p o s e d t o t h e f a m i n e d u r i n g g e s t a t i o n and e a r l y i n f a n c y t o t h e
s t a t u s o f t h o s e who e s c a p e d e x p o s u r e . The a u t h o r s c o n c l u d e d :
1)

be l ow a t h r e s h o l d v a l u e o f f ood r a t i o n s ,

the f e r t i l i t y

rate declined

p a r a l l e l w i t h t h e a v a i l a b i l i t y o f f o o d (NOTE: a l t h o u g h " t h r e s h o l d
l e v e l " was n o t s t a t e d ,
2)

a level

l e s s t h a n 1 , 5 0 0 c a l o r i e s was i m p l i e d ;

a bove a t h r e s h o l d v a l u e o f f ood i n t a k e ,

the mother appeared to

a f f o r d t h e f e t u s p r o t e c t i o n f r om n u t r i t i o n a l
3)

be l ow t h e n u t r i t i o n a l
e x t e n t in t he f i r s t
of the central
weight,

4)

threshold,

the fetus

trim e s te r of g e sta tio n

nervous system,

and p e r i n a t a l

deprivation;

was v u l n e r a b l e t o some
t o a bnor mal d e v e l o p m e n t

p r e m a t u r e b i r t h and v e r y low b i r t h

death;

be l ow t h e n u t r i t i o n a l

threshold,

the fetus

was most v u l n e r a b l e i n

t h e t h i r d t r i m e s t e r o f g e s t a t i o n t o i n t r a u t e r i n e g r o wt h and e a r l y
postnatal m ortality,
effects,
5)

w i t h w e i g h t b e i n g most s e n s i t i v e t o n u t r i t i o n a l

and l e n g t h and head s i z e t h e l e a s t s e n s i t i v e ;

i f prenatal

brain cell

d e p l e t i o n o c c u r r e d in f e t u s e s exposed t o the

f a mi n e d u r i n g t h e t h i r d t r i m e s t e r ,
quite r e s ilie n t;
in d y s f u n c t io n ;

t h e s u r v i v i n g f e t u s e s wer e

any o r g a n i c i m p a i r m e n t d i d n o t m a n i f e s t i t s e l f
and

56

6)

among a d u l t s u r v i v o r s
to indicate prenatal
postnatal

( 25 y e a r s p o s t - f a m i n e ) ,

t h e r e was no e v i d e n c e

n u t r i t i o n had i m p a i r e d me n t a l c o m p e t e n c e ;

if

l e a r n i n g compensated f o r t h e a d v e r s e e f f e c t s o f p r e n a t a l

nutrition deprivation,
across the social

Correlational

classes.

Studies.

Early c o r r e l a t i o n a l
b e t we e n m a t e r n a l

t h e a u t h o r s c o n c l u d e d i t d i d so e q u a l l y

s t u d i e s whi c h e xa mi ne d t h e r e l a t i o n s h i p

nutritional

inconsistent results

i n t a k e and i n f a n t b i r t h w e i g h t p r o v i d e d

(Deckman e t a l , 1951; Wood h i l l

e t a l , 1955; K a s i u s

e t a l , 1958; Mc Ga r i t y e t a l , 1 9 5 4 ) . The s e i n c o n s i s t e n c i e s mos t l i k e l y
r e s u l t e d f r om i n a d e q u a c i e s i n t h e d i e t a s s e s s m e n t t e c h n i q u e s and t h e
incompleteness of t h e n u t r i e n t d a ta base,
s o c i o e c o n o m i c and c u l t u r a l

differences.

c o n f o u n d e d by m e t h o d o l o g i c ,

Unfortunately,

these co n flicting

r e s u l t s c r e a t e d a p e r i o d o f d i s i l l u s i o n m e n t and d i s i n t e r e s t
me d i c a l communi t y a b o u t t h e r e l a t i o n s h i p b e t we e n n u t r i e n t
fetal

o u t c o me .

i n normal c i r c u m s t a n c e s , m a t e r n a l

is not a l i m i t i n g f a c t o r to f o e t a l

decreased feta l

i n t a k e and

Even as l a t e a s 1968 a p o p u l a r o b s t e t r i c s t e x t s t a t e d " I t

seems f a i r t o c o n c l u d e t h a t ,

Recently,

in t he

several

g r o wt h "

(Dawes,

1968,

nutrition

p. 2 5 8 ) .

s t u d i e s ha ve e xa mi ne d t h e r e l a t i o n b e t we e n

w e i g h t and t h e n u t r i t i o n - r e l a t e d f a c t o r s o f m a t e r n a l

w e i g h t g a i n and p r e - p r e g n a n t body s i z e and hemodynamic f a c t o r s o f
d i a s t o l i c b l o o d p r e s s u r e and h e mo g l o b i n m e a s u r e s . The s e s t u d i e s we r e
r e v i e w e d i n t h e "Me di c al

R i s k F a c t o r s Du r i n g P r e g n a n c y " s e c t i o n

l i t e r a t u r e review o f t h i s d i s s e r t a t i o n .

In a d d i t i o n ,

several

in t he

nutrition

s u p p l e m e n t a t i o n s t u d i e s h a ve be e n c o n d u c t e d i n t h e l a s t d e c a d e .

57

Experimental

N u t r i t i o n Su p p l e me n t S t u d i e s .

S u p p l e m e n t a t i o n s t u d i e s have be e n c o n d u c t e d t o d e t e r m i n e w h e t h e r
nutritional

i n t a k e d u r i n g p r e g n a n c y i mp r o v e s b i r t h o u t c o me . The mos t

r e c e n t l y p u b l i s h e d s t u d y an a l y z e d t h e i mpact o f t h e Hi gg i ns N u t r i t i o n
I n t e r v e n t i o n Pr ogr a m

( Mo n t r e a l D i e t D i s p e n s a r y S t u d y ;

b i r t h weights of

552 s i b l i n g p a i r s whose m o t h e r s '

the pregnancy of

the second-born,

pair

a l , 1989).

( Higgins e t

19 6 3 - 1 9 7 9 ) on t h e

p a r t i c i p a t e d during

but not t he f i r s t

b o r n , member o f h e r

The H i g g i n s p r o g r a m, d e v e l o p e d a s an a d j u n c t t o r o u t i n e p r e n a t a l
care,

a t t e m p t e d t o c o mp e n s a t e f o r t h e n e g a t i v e i mp a c t o f h i g h - r i s k

f a c t o r s a s s o c i a t e d w i t h l ow- i n c o me women on b i r t h out come t h r o u g h
in d iv id u alize d n u t r i t i o n assessment,

e d u c a t i o n and s u p p l e m e n t a t i o n .

Women who c o u l d n o t a f f o r d t h e d i e t p r e s c r i b e d by c l i n i c d i e t i t i a n s

were

p r o v i d e d s u p p l e m e n t a l m i l k , e ggs and o r a n g e s i n amount s r e l e v a n t t o
t h e i r needs.

Each woman was s e e n by t h e same d i e t i t i a n

weeks t h r o u g h o u t p r e g n a n c y .

Be c a us e o f t h e m a t c h i n g s y s t e m e mp l o y e d , t h e

i n t e r v e n t i o n i n f a n t s we r e a l l
infants.

of l a t e r p a r i t y than the n o n -in te rv e n tio n

To c o r r e c t f o r t h i s b i a s ,

S t u d y ( Ni s wa n d e r and Gor don,

e v e r y two t o f o u r

d a t a f r om t h e C o l l a b o r a t i v e P e r i n a t a l

1972) we r e u s e d t o d e c r e a s e i n d i v i d u a l

s i b l i n g p a i r d i f f e r e n c e s by v a l u e s c o r r e s p o n d i n g t o t h e mean i n c r e a s e
b i r t h wei ght a s s o c i a t e d wi t h t h e g i ven change in p a r i t y .

Analysis of

c o v a r i a n c e was u s e d t o a d j u s t f o r t h e e f f e c t o f i n f a n t s e x .

Intervention

i n f a n t s we i g h e d 107 g more t h a n t h e i r m a t c h e d s i b l i n g s a t b i r t h
vs 3 , 2 3 3 ,

p < 0.01).

in

(3,340

I n t e r v e n t i o n had a g r e a t e r i mp a c t on t h e b i r t h

w e i g h t o f i n f a n t s b or n t o u n d e r n o u r i s h e d (+275 g) and s t r e s s e d

( +319 g)

58

women. The LBW r a t e was 50% l o w e r among t h e i n t e r v e n t i o n
among t h e i r s i b l i n g s

( 4. 9% vs 8. 9%; p < 0 . 0 1 ) .

s i g n i f i c a n t due t o t h e s ma l l n u mb e r s , p e r i n a t a l
among t h e i n t e r v e n t i o n g r o u p a s we l l
births;

NS).

interview,
nutrition

i n f a n t s than

Whi l e n o t s t a t i s t i c a l l y
m o r t a l i t y was l o w e r

( 9 . 1 vs 16. 3 d e a t h s / 1 0 0 0 l i v e

These f i n d i n g s s u p p o r t t h e i n d i v i d u a l i z e d

n e e d s a s s e s s m e n t and i n s t r u c t i o n )

(personal

approach to p r e n a t a l

i n t e r v e n t i o n and s u p p l e m e n t a t i o n .

Ten c l a s s i c s u p p l e m e n t s t u d i e s ,
t h e Supplemental

Pr ogr a m f o r Women,

reviewed in Table 2. 3.

including three studies analyzing

I n f a n t s and C h i l d r e n

are

When c o n s i d e r e d t o g e t h e r , t h e y i n d i c a t e t h a t

d i e t a r y s u p p l e m e n t a t i o n ca n have a s m a l l ,
benefit to the fetus

(WIC),

but g e n e r a l l y p o s i t i v e ,

( I n s t i t u t e o f Medicine,

1985).

Table 2 . 3 .

Supplementation s t u d i e s involving pregnant women and t h e i r e f f e c t s on maternal weight g ain and in f a n t b i r t h w eight.

Population/
Treatment Group

Supplement

Results

Poor black, previous LBW;
protein intake < 50 g/day;
< 110 lb; low weight
gain in pregnancy; control
plus 2 treatments

Ftavored drink to 2
groups, medical attention
to all; 1) 40 g protein,
470 kcals, 2) 6 g protein,
322 kcals, 3) no kcal/pro;
all received vit/minerals

Mother: increased weiqht gain
in suppl mothers (p <-05);
greater if early enrolled.
Birth Weiqht: Hiqh orotein
decreased by 32 g, tow protein
group increased by 41 g (NS).

2426

Low SES; inadequate diet;
supplement group plus
control group

Eggs, milk and oranges

Mother: higher weight in
suppl mothers (0.3 lbs, NS).
Birth Weiqht: increased 40 q
(3251 vs 3291 g, p < 0.05).

Not random;
suppl given
to Asian women
in first preg.

142

Supplement given independent
of nutritional status;
3 supplemented groups

1) 30 mg vit C + 30 mg Fe;
2) #1 plus 273 kcals;
3) #2 plus 26 g protein

Mother: increased weight gain
in second trimester (fat);
higher gain in lighter women.
Birth Weiqht: no difference
between any groups.

Supplement
given to
women in 4
communities;
voluntary

405

Rural Guatemala;
2 supplemented groups,
no control group

1) Atole: 163 kcal
and 11 g protein;
2) Fresco: 59 kcal
and 0 g protein;
adli biturn

Mother: increased calories
correlated with increased
weight gain (r=0.21; p<0.05).
Birth Weiqht: intake > 20.000
kcals 3105 g; intake < 20,000
kcals 2994 g (p < 0.01);
8% LBW among high vs 17%
among low-supplemented group.

Author &
Location

Study
Type

Sample
Size

Rush et a I
(1980)
New York

Random,
double
blind

768

Rush (1981)
Montreal

Foods
given at
dispensary

Viegas et a I
(1982a,
1982b)
Bi rmingham

Lechtig et a I
(1975)
Guatemala

Table 2 .3 , c o n t.

Author &
Location

Study
Type

Sample
Size

Mora et a I
(1979)
Bogota

Random
assignment

385

McDonald et al
(1981)
Taiwan:
Bacon Chow
Study

Random,
double-blind

506

Prentice et
(1987)
Gambia

al

All pregnant
women of the
community

379

Population/
Treatment Group

Supplement

Results

Poor; women with at least
50% of children with < 85%
wt/age; diet before suppl
1600 kcal/35 g protein;
1 suppl and 1 control group

Dry skim milk, enriched
breads, vegetable oils for
whole family; net increase
of 155 kcal and 20 g pro;
controls had no suppl foods

Mother: increased weight gain
only in women bearing males.
Birth Weight: 2978 vs 2972 g (NS);
95 g increase observed in males
(suppl vs control; p < 0.05);
No effect on females; no effect
on LBW rate.

Poor women with at least
one son; previous diet
1200 kcal and 40 g protein;
2 suppl groups, no control

1) 800 kcal/40 g protein
2) 80 kcal/ 0 g protein

Mother: no difference in weight
gain between groups.
Birth Weight: 52 g increase in
males (3135 vs 3083) and a 63 g
increase in females (3042 vs
2980) in the high suppl group
(NS); % LBW was NS.

Rural population; previous
diet 1480 & 1300 kcals during
wet & dry season; all received
suppl; compared to baseline

Groundnuts, biscuits, tea
with vitamins added; approx
1000 kcal and 40 g protein
added.

Mother: increased weight gain
over baseline was noted;
Birth Weiqht: supplementation
ineffective during dry harvest
season; nigniy ertective in
wet season (+225 g, p<0.001);
LBW dec from 23.7% to 7.5% (wet)
12.5% to 8.6% (dry;p < 0.002).

cn

O

Table 2 .3 , c o n t.

Author &
Location

Study
Type

Sample
Size

Stockbauer
(1987)
Missouri

casecontrol

9411 cases
9411 controls

Missouri WIC participants
who delivered in 1982;
controls matched by
mother's age, education,
number born this pregnancy
and race

Kennedy et at
0 984)
Massachusetts

casecontrol

418 cases
418 controls

Massachusetts WIC clients
who delivered 1973-1978;
controls selected from
WIC waiting-Iist; controls
matched for racial/ethnic
group, age, parity, marital
status and income

Same as above

Mothers: not reported.
Birth Weight: partic in WIC
associated with 107 g increase
in birth weight (p < 0.012)
and 4% decrease LBW (p < 0.06);
teens, blacks & Hispanic women
showed greater benefits.

Metcoff et al
(1985)
Oklahoma

randomized
controlled
nutrition
intervention

Oklahoma mothers who were
predicted to have small (n=226)
or normal birth weight infants
(n=184)

Same as above

Mothers: WIC mother heavier
at entry; maternal wt held
constant,-g no significant
difference in wt gain noted.
Birth Weiqht: WIC smokers had
168 g heavier babies than non-WIC
smokers (> 10 cigs/day; p<0.017).

238 WIC
172 no-WIC

Population/
Treatment Group

Supplement

Results

Nutrition education and
vouchers for supplemental
foods high in protein,
iron and vitamins A, C
and D

Mother: not reported.
Birth Weight: WIC assoc with
19 g decrease in whites (NS)
and 36 g increase in blacks
(p < 0.05); sig decreases
seen in LBW (7.8% vs 9.2%),
prematurity (9.7% vs 12.0%),
inadeq prenatal care (30.5%
vs 31.7%) and increase gest.
age (39.9 wks vs 31.7 wks);
Seven months participation
needed before improvements in
birth weight outcome noted.

62

C u r r e n t Recommended N u t r i e n t A l l o w a n c e s
Be c a u s e p r e g n a n c y i s a t i m e o f g r o w t h ,
increased.

t h e ne e d f o r n u t r i e n t s

is

C u r r e n t Recommended D i e t a r y A l l o w a n c e s (RDAs) a r e i n t e n d e d t o

be i n t e r p r e t e d a s s a f e and a d e q u a t e l e v e l s - - n o t m i n i m a l ,

optimal

or

a b s o l u t e l e v e l s - - w h i c h i n c o r p o r a t e a ma r g i n o f s a f e t y i n t e n d e d t o
a c c o u n t f o r t h e pr es ume d v a r i a b i l i t y among p e o p l e (NRC-RDA,
t he sake of b r e v i t y ,

1989).

For

o n l y t h o s e n u t r i e n t s whi c h ha ve be e n d i r e c t l y

i m p l i c a t e d w i t h low b i r t h w e i g h t

(energy,

p r o t e i n and z i n c ) w i l l

be

reviewed h er e.

Ener gy
Two f a c t o r s t h a t d e t e r m i n e e n e r g y r e q u i r e m e n t s d u r i n g p r e g n a n c y
are:

1) c h a n g e s i n u s u a l

physical

a c t i v i t y and 2) t h e i n c r e a s e i n b a s a l

m e t a b o l i s m f o r t h e g r o wt h o f m a t e r n a l

tissues,

t h e f e t u s and p l a c e n t a .

The c u m u l a t i v e e n e r g y c o s t o f t h i s e x t r a wor k,

a s s u mi n g d e l i v e r y o f a

3 . 3 kg i n f a n t and a w e i g h t g a i n o f 1 2 . 5 kg, ha s been e s t i m a t e d t o be
80,000-85,000 c a l o r i e s

( H y t t e n and L e i t c h ,

1 9 7 1 ) . T h i s f i g u r e was us e d

t o d e t e r m i n e e n e r g y a l l o w a n c e s by b o t h t h e World H e a l t h O r g a n i z a t i o n
(WHO, 1985) and t h e Food and N u t r i t i o n Boar d o f t h e N a t i o n a l
Co u n c i l

(NRC-RDA,

Several
(Durnin,

Research

1989) .

recent studies,

h o we ve r ,

ha ve c h a l l e n g e d t h i s

figure

1 9 8 7 a , b ; Dur ni n e t a l , 1987; Forsum e t a l , 1988; van R a a i j e t

a l , 1990). A l t e r n a t i v e a ssumpt ions c o n c e r n in g t h e c om p o s i ti o n o f t i s s u e
gained,

o b s e r v a t i o n s o f e n e r g y i n t a k e by p r e g n a n t women and m e a s u r e m e n t s

o f r e s t i n g m e t a b o l i s m and e n e r g y e x p e n d i t u r e d u r i n g p h y s i c a l

activity,

ha ve l e d t o c a l o r i c e s t i m a t e s o f t h e c o s t o f p r e g n a n c y f r om as low as

63

1 8 , 6 4 2 kc a l
kc a l

i n women o f t h e Gambia ( D u r n i n ,

1987) t o a s h i g h as 1 1 0 , 0 0 0

i n h e a l t h y Swedi s h women ( For s um e t a l , 1 9 8 8 ) .
In l i g h t o f t h e s u b s t a n t i a l

c o n tr o v e rs y about th e energy

r e q u i r e m e n t s o f p r e g n a n c y and t h e d e g r e e t o whi c h t h e s e n e e d s a r e met by
e x t r a food,

a s e r i e s o f s t u d i e s was c a r r i e d o u t i n f i v e c o u n t r i e s a r o u n d

t h e w o r l d ( Du r n i n e t a l , 1987; Lawr ence e t a l , 1987; T h o n g p r a s e r t e t a l ,
1987; Tuazon e t a l , 1997; and van R a a i j e t a l , 1 9 8 7 ) . T h i s i n t e g r a t e d
u n d e r t a k i n g t o o k p l a c e i n two d e v e l o p e d c o u n t r i e s ,
Netherlands,

and t h r e e d e v e l o p i n g c o u n t r i e s ,

the Philippines.

S c o t l a n d and t h e

t h e Gambi a, T h a i l a n d and

Met hods we r e s t a n d a r d i z e d i n t h e f i v e c e n t e r s

and a l l

women we r e r e c r u i t e d f o r p a r t i c i p a t i o n e a r l y i n p r e g n a n c y o r i n t h e
preconception period.
body w e i g h t ,

E f f o r t was made t h r o u g h o u t p r e g n a n c y t o e v a l u a t e

body f a t ,

energy inta ke,

basal m et ab oli c r a t e

(BMR) and

d a i l y energy expe nditure.
Longitudinal

s t u d i e s o f Du r n i n and c o l l e a g u e s d e m o n s t r a t e d t h a t

the re s tin g metabolic rate

(RMR) d r o p p e d i n e a r l y g e s t a t i o n ,

be l ow p r e g r a v i d l e v e l s u n t i l
increased.

The s e r e s u l t s

remained

t h e 3 0 t h week o f g e s t a t i o n and t h e n

i n d i c a t e d any r e s e a r c h e r who a s s e s s e d t h e RMR

o n l y i n t h e l a t e r s t a g e s o f p r e g n a n c y may have g r o s s l y o v e r e s t i m a t e d t h e
total

r e s t i n g energy needs f o r pregnancy.
O b s e r v a t i o n s made i n t h e Gambia ( La wr enc e e t a l , 1987)

maternal

nutritional

status

i n f l u e n c e s t h e RMR d u r i n g g e s t a t i o n .

Un s u p p l e me n t e d women who consumed o n l y 1500 kcal
re s tin g metabolic rate s

suggested

p e r da y had l o w e r

i n t h e s e c o n d and t h i r d t r i m e s t e r s t h a n women

who r e c e i v e d s u p p l e m e n t s and consumed a b o u t 1950 kc a l

p e r day.

C a l c u l a t i o n s e s t i m a t e d s u p p l e m e n t e d women r e q u i r e d 1 3 , 0 0 0 a d d i t i o n a l

64

kc a l

f o r RMR, w h i l e u n s u p p l e m e n t e d women o n l y r e q u i r e d

kcal.

1,000 a d d i t i o n a l

I t woul d a p p e a r t h a t a s m a l l e r r i s e i n RMR may e n a b l e u n d e r f e d

p r e g n a n t women t o s u s t a i n a d e q u a t e f e t a l

g r o wt h and d e v e l o p m e n t ,

even

with l i m i t e d energy s t o r e s .
Analysis of the r e s u l t s of the f iv e - c o u n t r y study in d ic a te d
several
1)

important findings

(Durnin,

1987b):

Al t h o u g h w e i g h t g a i n d i f f e r e d s u b s t a n t i a l l y among t h e p o p u l a t i o n s

( 7 . 3 kg, t h e Gambia; 8 . 5 kg, P h i l i p p i n e s ; 8 . 9 kg, T h a i l a n d ;
Netherlands;

1 1 . 7 kg, S c o t l a n d ) , when w e i g h t g a i n was e x p r e s s e d as a

percent of the i n i t i a l
(14%, t h e Gambi a;
Netherlands;
2)

1 0 . 5 kg, t h e

w e i g h t o f t h e m o t h e r , more s i m i l a r i t y

19%, P h i l i p p i n e s ;

19%, T h a i l a n d ;

17% kg,

i s s e en

the

20%, S c o t l a n d ) ;

The Dut ch women, a l t h o u g h b i g g e r ( 6 2 . 5 kg vs 5 7 . 3 kg p r e - p r e g n a n t

w e i g h t ) and s l i g h t l y f a t t e r t h a n t h e S c o t t i s h women (28% vs 26% body
fat),

d e p o s i t e d o n l y a b o u t t w o - t h i r d s t h e amount o f f a t a s t h e S c o t t i s h

women, d e s p i t e a h i g h e r e n e r g y i n t a k e and s i m i l a r e n e r g y e x p e n d i t u r e ;
3)

No g r o u p came c l o s e t o g a i n i n g t h e 3 . 5 kg f a t p r o p o s e d by H y t t e n and

C h a m b e r l a i n ( 1 9 8 0 ) ; mean f a t g a i n s
Philippines;
4)

The t o t a l

1.4, Thailand;

2.0,

( kg) we r e 0 . 6 ,

the Netherlands;

t h e Gambi a;
2.3,

1.3,

the

Scotland);

i n c r e a s e i n BMR o v e r t h e whol e p r e g n a n c y d i f f e r e d by a t

l e a s t a f a c t o r o f 10 b e t we e n t h e Gambian women and t h o s e f r om t h e o t h e r
c e n t e r s , demonstrating a remarkable physio l o g i ca l
of severe n u t r i t i o n a l
5)

I f the d i f f e r e n c e s

adaptation

in t h e f a c e

stress;
i n t h e e n e r g y c o s t o f p r e g n a n c y f r om t h e f i v e

c e n t e r s we r e s t a n d a r d i z e d f o r body w e i g h t
c o s t s we r e a b o u t 5 9 , 7 5 0 k c a l

for all

(Table 2 . 4 ) ,

total

energy

g r o u p s e x c e p t t h e Gambian women;

65

t h e s ma l l d i f f e r e n c e s b e t w e e n g r o u p s we r e a t t r i b u t e d t o t h e v a r i a b l e
amount o f m a t e r n a l f a t s t o r e d d u r i n g p r e g n a n c y ;
it

is estimated th is to tal

100 e x t r a kc a l
6)

in developed c o u n t r i e s ,

energy cost t r a n s l a t e s

p e r da y d u r i n g p r e g n a n c y ;

i n t o an i n t a k e o f o n l y

and

Ene r gy i n t a k e s d i d n o t c o n f o r m t o t h e t h e o r e t i c a l l y e x p e c t e d

quantities
general

(i.e.,

80,000 t o 85,000 k c a l ) ,

r a i s i n g q u e s ti o n s about the

r e c o mme n d a t i o n f o r e n e r g y d u r i n g p r e g n a n c y .

Table 2.4.

Ene r gy c o s t

Scotland

(kcal)

of pr egnancy in t h e f i v e - c o u n t r y study*.

The
The
N e t h e r ! a n d s Gambia

Thai 1 and

Philippines

ENERGY COST (KCAL)
8,126

8,222

7,146

7,146

6,907

PIacenta

729

741

559

600

600

Ma t e r n a l
Ti s s ue

2, 891

2,940

2,486

2,486

2,414

Ma t e r n a l
Fa t

25,334

21,998

6,296

15, 391

14, 292

BMR

30,114

34,416

1,888

23,900

18, 881

TOTAL:

67,159

68,345

18, 642

49,712

43,259

Fetus

Based on d a t a from Du r n i n ( 1987b)

D e s p i t e a v a i l a b i l i t y o f t h e a bove d a t a ,
Food and N u t r i t i o n Boar d o f t h e N a t i o n a l

t he subcommittee o f t he

R e s e a r c h Co u n c i l

(NRC-RDA,

1989) b a s e d t h e c u r r e n t e n e r g y a l l o w a n c e f o r p r e g n a n t women i n t h e
U n i t e d S t a t e s on t h e WHO ( 1985) r e c o mme n d a t i o n whi ch was b a s e d on t h e

66

8 0 , 0 0 0 - 8 5 , 0 0 0 kc a l

f i g u r e o f H y t t e n and L e i t c h ( 1 9 7 2 ) . D i v i d i n g t h i s

v a l u e by t h e 280 d a y s o f p r e g n a n c y y i e l d s an a v e r a g e i n c r e a s e o f 300
k c a l / d a y f o r t h e e n t i r e p r e g n a n c y . The NRC-RDA s u b c o m m i t t e e c a u t i o n e d
any r e d u c t i o n i n a c t i v i t y w i t h a d v a n c i n g p r e g n a n c y may r e d u c e t h e e n e r g y
r eq ui rem en t. Also,
reserves,

u n l e s s a woman b e g i n s p r e g n a n c y w i t h d e p l e t e d body

additional

f ir s t trimester.

energy i n ta k e i s probably not r eq u ir ed during the

Th u s , t h e 1989 recommended e n e r g y i n t a k e d u r i n g

p r e g n a n c y i n t h e U. S.

i s an a d d i t i o n a l

300 k c a l / d a y d u r i n g t h e s e c o n d

and t h i r d t r i m e s t e r s o f p r e g n a n c y (NRC-RDA, 1 9 8 9 ) .

Protei n
P r o t e i n r e q u i r e m e n t s d u r i n g p r e g n a n c y a r e b a s e d on t h e n e e d s o f
t h e n o n - p r e g n a n t r e f e r e n c e woman p l u s t h e e x t r a amount n e e de d f o r
g r o w t h . An e s t i m a t e d 925 gr ams o f a d d i t i o n a l
nor mal w e i g h t f e t u s and i n m a t e r n a l
( H y t t e n and L e i t c h ,
pregnancy r e s u l t s
nitrogen)
h o we ve r ,

p r o t e i n a r e d e p o s i t e d in a

ac ce ss o ry t i s s u e s during pregnancy

1 9 7 1 ) . D i v i d i n g t h i s v a l u e by t h e 280 d a y s o f

i n an a v e r a g e o f 3 . 3 g a d d i t i o n a l

n e e d e d e a c h day t h r o u g h o u t p r e g n a n c y .

protein

(0.53 g

Nitrogen r e t e n t i o n ,

i s n o t c o n s t a n t t h r o u g h o u t p r e g n a n c y . N i t r o g e n d e p o s i t i o n has

been e s t i m a t e d t o be 0 . 1 1 ,

0 . 5 2 and 0 . 9 2 g r a m s / d a y d u r i n g t h e f i r s t ,

s e c o n d and t h i r d t r i m e s t e r s o f p r e g n a n c y ,

respectively

(WHO, 1 9 8 5 ) .

E v i d e n c e i n humans i n d i c a t e s p r o t e i n t u r n o v e r i n c r e a s e s by t h e t w e l f t h
week o f p r e g n a n c y ( de B e n o i s t e t a l , 1 9 8 5 ) ,
second t r i m e s t e r ,
Ki ng,

1987)

and t h e same ( J a c k s o n ,

in t h e t h i r d t r i m e s t e r .

remains high t h r o u g h o u t t he

1 9 8 7 ) , o r l o w e r ( F i t c h and

67

The Food and N u t r i t i o n Su b c o mmi t t e e o f t h e N a t i o n a l
Council

(NRC-RDA,

Research

1989) c o n c u r r e d w i t h t h e WHO ( 1985) t h a t p r o t e i n

e s t i m a t e s d u r i n g p r e g n a n c y s h o u l d be b a s e d on t h e f a c t o r i a l
Therefore,

a s s u mi n g a 15% c o e f f i c i e n t o f v a r i a t i o n

70% e f f i c i e n c y
and m a t e r n a l
children),

me t h o d .

i n b i r t h w e i g h t and a

in t h e c o n v e rs i o n o f d i e t a r y p r o t e i n t o f e t a l ,

tissue

placental

( t h e e f f i c i e n c y o f p r o t e i n f o r g r o wt h i n i n f a n t s and

an e s t i m a t e d 1 . 3 , 6 . 1 and 10. 7 gr ams o f a d d i t i o n a l

a r e n e e d e d p e r day d u r i n g t h e f i r s t ,

protein

s e c o n d and t h i r d t r i m e s t e r s ,

r e s p e c t i v e l y (NRC-RDA, 1 9 8 9 ) . Al l o wi n g f o r a m a i n t e n a n c e r e q u i r e m e n t o f
the lean t i s s u e ,

and a c c o u n t i n g f o r t h e u n c e r t a i n t y a b o u t t h e r a t e o f

tissue deposition,
additional

t h e 1989 NRC-RDA s u b c o mm i t t e e recommended an

10 g o f p r o t e i n p e r day t h r o u g h o u t p r e g n a n c y .

This is a

d e c r e a s e o f 20 g p e r day f rom t h e 1980 Recommended D i e t a r y Al l o wa n c e
(NRC-RDA, 1 9 8 0 ) , when t h e s u b c o mm i t t e e assumed a c o n s e r v a t i v e 25%,
r a t h e r t h a n a 70%, e f f i c i e n c y i n t h e c o n v e r s i o n o f d i e t a r y p r o t e i n .
Adverse cons eq u e n c e s o f p r o t e i n d e f i c i e n c y d u r i n g pregnancy a r e
d i f f i c u l t t o s e p a r a t e f r om t h e c a l o r i c c o n t r i b u t i o n o f t h e r e s t o f t h e
diet.

Al mos t a l l

limitations

cases of limited protein

in c a l o r i e s ,

i n t a k e a r e a c c o mp a n i e d by

due t o i t s c a l o r i c c o n t r i b u t i o n o f 4 k c a l / g r a m .

As p r e v i o u s l y i n d i c a t e d i n T a b l e 2 . 3 ,

p r o v is i o n of supplemental

calories

t o women w i t h d e f i c i e n t l e v e l s o f d i e t a r y p r o t e i n was as e f f e c t i v e

in

i n c r e a s i n g i n f a n t b i r t h w e i g h t as s u p p l e m e n t a t i o n w i t h b o t h c a l o r i e s and
p r o t e i n ( L e c h t i g e t a l , 1 9 7 5 ) . Ca l l o wa y ( 1974) e s t i m a t e d an e x t r a

100

calories

had

f rom c a r b o h y d r a t e o r f a t ,

in a p r o t e i n - s p a r i n g c a p a c i t y ,

t h e same e f f e c t on n i t r o g e n r e t e n t i o n as an a d d i t i o n a l
n i t r o g e n p e r da y ( 1 . 7 5 g p r o t e i n ) .

0.28 g of

I t has been e s t i m a t e d t h a t e n e r g y

68

inta ke should never f a l l

bel ow 36 k c a l / k g body w e i g h t / d a y t o m a i n t a i n

nor mal p r o t e i n m e t a b o l i s m d u r i n g p r e g n a n c y ( P i t k i n ,

1981).

Ad v e r s e e f f e c t s o f e x c e s s i v e p r o t e i n d u r i n g p r e g n a n c y a r e p o o r l y
u n d e r s t o o d a t t h e p r e s e n t t i m e . The New York s u p p l e m e n t a t i o n s t u d y (Rush
e t a l , 1980; T a b l e 2 . 3 ) p r o v o k e d much d i s c u s s i o n o f t h i s
results

i s s u e when

i n d i c a t e d t h e h i g h - p r o t e i n s u p p l e m e n t was a s s o c i a t e d w i t h an

i n c r e a s e d number o f p r e m a t u r e i n f a n t s and e x c e s s i v e n e o n a t a l

deaths.

Mo t h e r s who d e l i v e r e d a p r e m a t u r e i n f a n t and consumed t h e h i g h p r o t e i n
supplement (n=51), d e l i v e r e d i n f a n t s weighing s i g n i f i c a n t l y l e s s than
t h e p r e m a t u r e i n f a n t s o f m o t h e r s who consumed e i t h e r t h e low
p r o t e i n / h i g h c a l o r i e s u p p l e m e n t o r no s u p p l e m e n t
2587 g ,

respectively;

p < 0.01).

me a s u r e me n t o f p h y s i c a l

( 2 , 2 5 4 g,

2577 g,

No d i f f e r e n c e s we r e n o t e d i n any

s t a t u r e b e t we e n any o f t h e s u p p l e m e n t a l

a t one y e a r o f a g e . However,

groups

i n f a n t s bor n t o m o t h e r s who had consumed

t h e h i g h p r o t e i n s u p p l e m e n t t h r o u g h o u t p r e g n a n c y had s i g n i f i c a n t l y l o we r
s c o r e s on t h r e e p s y c h o l o g i c a l

measures ( v i s u a l

habitation,

d i s h a b i t a t i o n and mean l e n g t h o f f r e e p l a y e p i s o d e s )
M e t a - a n a l y s i s o f human s u p p l e m e n t a t i o n s t u d i e s
Susser,

visual

a t one y e a r o f a ge .
( Rus h,

S t e i n and

1980) ha s s u g g e s t e d p r o v i d i n g a s u p p l e m e n t w i t h more t h a n 20% o f

t h e c a l o r i e s f r om p r o t e i n was a s s o c i a t e d w i t h r e t a r d e d f e t a l

growth.

S u p p l e me n t s p r o v i d i n g l e s s t h a n 20% o f t h e c a l o r i e s f r om p r o t e i n y i e l d e d
p o s i t i v e i n c r e a s e s in i n f a n t b i r t h weight.

P i c o n e and A l l e n

r e p o r t e d women cons umi ng a h i g h - p r o t e i n d i e t
shorter gestations,
ponderal

less placental

( 1986) r e p o r t e d a hi g h p r o t e i n d i e t

(17.5-25% o f energy)

DNA and p r o t e i n ,

i n d i c e s and s m a l l e r n e o n a t a l

( 1984) have
had

lower neona ta l

head c i r c u m f e r e n c e s .

(60% e n e r g y p r o t e i n ;

Gr eco e t al

40% c a s e i n ,

20%

69

lactalbumin)

f e d t o r a t s f r om t h e f i r s t da y o f p r e g n a n c y ,

inducing morphological
kidney,

a l t e r a t io n s of l iv e r ,

caused sm alle r l i t t e r s

to controls

adrenal

in a d d i t i o n to

cortex,

h e a r t and

and a h i g h e r m o r t a l i t y r a t e when c ompa r ed

(23% p r o t e i n ) .

A l t h o u g h t h e s e d a t a s u g g e s t t o o much p r o t e i n may h a ve a d v e r s e
e f f e c t s on p r e g n a n c y c o u r s e and o u t c o me , d a t a a r e l i m i t e d .
reasonable to conclude,

h o we v e r , t h a t a h i g h - p r o t e i n d i e t

o f e n e r g y f r om p r o t e i n ) ,
adequate,
fetus

I t seems
(20% o r more

o r a h i g h - p r o t e i n s u p p l e m e n t when p r o t e i n

is

p r o mo t e s no r e c o g n i z a b l e b e n e f i t t o t h e p r e g n a n t woman o r h e r

(Worthington-Roberts,

1985).

Zi nc
Bot h ani ma l

and human s t u d i e s ha ve r e l a t e d m a t e r n a l

d e f i c i e n c y t o poor f e t a l
abortion,
congenital

out c ome ,

including increased spontaneous

i n t r a u t e r i n e g r o wt h r e t a r d a t i o n ,
abnormalities

( H u r l e y and Mut ch,

e t a l , 1981; S o l t a n and J e n k i n s ,

zinc

stillbirth

and a v a r i e t y o f

1973; J a me s o n ,

1976; Meadows

1982; Baumah e t a l , 1 9 8 4 ) . D i e t a r y

i n t a k e o f p r e g n a n t women i n t h e U n i t e d S t a t e s a v e r a g e s c o n s i d e r a b l y l e s s
t h a n t h e c u r r e n t Recommended D i e t a r y Al l o wa n c e (NRC-RDA,
addition,

r e c e n t evidence i n d ic a te s

b o t h common d u r i n g p r e g n a n c y ,
( So l o mo n s ,

1989).

In

i r o n and f o l a t e s u p p l e m e n t a t i o n ,

i n t e r f e r e w i t h z i n c a b s o r p t i o n and us e

1986; Ha mbr i dge e t a l , 1987; Simmer e t a l , 1 9 8 7 ) .

Finally,

t h e r e i s i n c r e a s i n g e v i d e n c e t h a t p r e g n a n t women who smoke a r e a t r i s k
f o r low s er um z i n c l e v e l s

( Ku h n e r t e t a l , 1 9 8 8 a ) .

For t h e s e r e a s o n s ,

comprehensive review of c u r r e n t l i t e r a t u r e r e l a t i n g zinc s t a t u s to
p r e g n a n c y out come i s p r e s e n t e d .

a

70

Zi n c S t a t u s Du r i n g P r e g n a n c y
In r a p i d l y g r o wi n g t i s s u e s ,

s uc h a s t h e f e t u s ,

r e t a r d s t h e s y n t h e s i s o f DNA, RNA and p r o t e i n ,
d i v i s i o n , g r o wt h and r e p a i r ( So l o mo n s ,

1988).

zinc deficiency

impairing c e l l u l a r
Progressive decreases

in

p l a s ma z i n c a r e commonly o b s e r v e d d u r i n g p r e g n a n c y b e g i n n i n g i n t h e
t e n t h week; t h i s d e c r e a s e i s n o t r e v e r s e d w i t h z i n c s u p p l e m e n t a t i o n
( B e l i z a n and F i t c h ,

1988). D e t e r m i n a t i o n o f t h e t r u e r o l e o f z i n c in

human r e p r o d u c t i o n i s ha mper ed by l a c k o f a s e n s i t i v e
status

( Apga r ,

i n d i c a t o r of zinc

1985; L a z e b n i k e t a l , 1 9 8 8 ) . C u r r e n t l y ,

plasma z i n c i s

t h e mos t w i d e l y us e d p a r a m e t e r f o r a s s e s s m e n t o f human z i n c s t a t u s .
mild z i n c d e f i c i e n c y ,

In

h o we v e r , p l a s ma z i n c may r e m a i n nor mal w i t h o u t any

overt evidence of d e fi c ie n c y

(Prasad,

1988).

Recently,

several

r e s e a r c h e r s ha ve f ound l e u k o c y t e z i n c t o be a more s e n s i t i v e met hod o f
determining zinc sta tus

(Prasad,

1988; K u h n e r t e t a l , 1988a ,

S a n d s t e a d ( 1973) e s t i m a t e d t h e a d d i t i o n a l
p r e g n a n c y was l e s s t h a n 0 . 1 ,

1988b).

ne e d f o r z i n c d u r i n g

0 . 4 and 0 . 7 5 mg/ da y d u r i n g t h e f i r s t

s e c o n d 10 and l a s t 20 weeks o f g e s t a t i o n ,

respectively.

10,

More r e c e n t l y ,

Swanson and King ( 1987) e s t i m a t e d t h e d a i l y z i n c n e e d d u r i n g p r e g n a n c y
t o be 0 . 1 ,

0 . 2 and 0 . 6 mg/ day f o r t h e s e same t i m e p e r i o d s .

Re c e n t

e vi de nc e i n d i c a t e s z i n c a b s o r p t i o n does not i n c r e a s e d u r i n g pregnancy
( Swanson e t a l , 1 9 8 3 ) . T h e r e f o r e ,

t h e 1989 RDA f o r z i n c o f 15 mg/ day (3

mg/ day h i g h e r t h a n t h e n o n - p r e g n a n t s t a t e ) was b a s e d on t h e same 20%
a b s o r p t i o n e f f i c i e n c y as in t h e n o n - p r e g n a n t s t a t e

(NRC-RDA,

1989).

Th i s

v a l u e r e p r e s e n t s a r e d u c t i o n f r om t h e 20 mg/ da y r ecommended i n b o t h t h e
1974 (NRC-RDA, 1974) and 1980 (NRC-RDA,

1980) RDA' s .

71

Ha mbr i dge e t a l

( 19 8 3 ) r e p o r t e d a mean z i n c i n t a k e o f 11 mg/ day in

36 p r e g n a n t , m i d d l e - i n c o m e women. Hunt e t al

( 1979) r e p o r t e d a mean z i n c

i n t a k e o f 9 mg/ da y (47% o f t h e RDA) i n 213 l o w- i n c o me H i s p a n i c p r e g n a n t
women; 85% o f t h e women i n t h i s s t u d y had i n t a k e s be l ow 33% o f t h e RDA.
The n u t r i e n t d a t a b a s e f o r z i n c ,

howe ve r ,

is incomplete at the present

t i m e , maki ng i t d i f f i c u l t t o a c c u r a t e l y e s t i m a t e z i n c i n t a k e .

Z i n c S t a t u s and B i r t h We i qht
The r e l a t i o n s h i p b e t we e n c i r c u l a t i n g z i n c l e v e l s and b i r t h w e i g h t
ha s been a f o c u s o f i n v e s t i g a t i o n s i n c e H u r l e y and S w e n e r t o n ( 1966)
d e m o n s t r a t e d t h e a v e r a g e w e i g h t o f z i n c - d e p r i v e d pups was l e s s t h a n t h a t
of controls.

Since t h a t time,

several

s t u d i e s have r e p o r t e d a s i m i l a r

r e l a t i o n s h i p i n humans.
M e t c o f f e t al
zinc level

( 1981b) o b s e r v e d a h i g h m i d - p r e g n a n c y c i r c u l a t i n g

i n m o t h e r s who d e l i v e r e d s ma l l

b a b i e s and,

conversely,

a

l o w e r m i d - p r e g n a n c y z i n c s er um c o n c e n t r a t i o n i n m o t h e r s d e l i v e r i n g
normal-weight i n f a n t s .

The a u t h o r s s u g g e s t t h i s phenomenon i s e x p l a i n e d

by t h e m a t e r n a l - t o - f e t a l

t r a n s f e r of c irc u la tin g zinc.

The e x a c t

mec ha ni s m i s a s y e t unknown, b u t b o t h t h e " pus h" and " p u l l " t h e o r i e s
have be e n s u g g e s t e d .

The " pus h" t h e o r y s u g g e s t s t h o s e m o t h e r s c a p a b l e o f

mobilizing t h e i r zinc reserves to benefit t h e i r fetuses will
babies;

in t h i s e x p l a n a t i o n the lowering of maternal

influence birth

ha ve l a r g e r

z i n c i s seen to

s i z e . The " p u l l " t h e o r y s u g g e s t s f e t u s e s t h a t a r e

g r o wi n g more v i g o r o u s l y i n u t e r o w i l l
t o s u s t a i n t h i s nor mal g r o w t h ;

demand more o f t h e m a t e r n a l

in t h i s e x p l a n a t i o n ,

zinc

the lowering of

72

maternal

z i n c s e e n i n t h e m o t h e r s who d e l i v e r e d o p t i m a l

infants,

is a consequence of f e t a l

Several
maternal

health

( Sol omons e t a l , 1 9 8 6 b ) .

s t u d i e s ha ve s u g g e s t e d b i r t h w e i g h t may be r e l a t e d t o

z i n c s t a t u s when l e u k o c y t e z i n c ,

used as t h e index o f z i n c s t a t u s .

r a t h e r t h a n s e r um z i n c ,

Meadows e t al

s a mp l e s f r om 17 m o t h e r s o f p r e t e r m i n f a n t s ,
gestational

age i n f a n t s

The w h i t e c e l l

( 1981) t o o k l e u k o c y t e

44 m o t h e r s o f s m a l l - f o r -

z i n c c o n t e n t o f m o t h e r s o f SGA i n f a n t s

i n f a n t s had a mean l e v e l

( 4 3 . 0 ng/ mg) was

( 5 2 . 3 n g / mg ) . Mo t h e r s o f p r e t e r m

o f 49 ng/ mg,

i n d i s t i n g u i s h a b l e f r om c o n t r o l s .

In a s u b s e q u e n t s t u d y , Meadows e t al

( 1983) c o l l e c t e d c o r d b l o o d

f r om ne wbor ns o f 110 m o t h e r s t o d e t e r m i n e f e t a l
L e u k o c y t e z i n c l e v e l s o f normal w e i g h t i n f a n t s
In c o n t r a s t ,

is

(SGA) and 150 m o t h e r s o f nor mal t e r m i n f a n t s .

s i g n i f i c a n t l y lower t han c o n t r o l s

ng/ mg.

b i r t h weight

leukocyte zinc le v e ls .
( n=63) a v e r a g e d 5 4 . 2

a mean l e u k o c y t e z i n c c o n t e n t o f 5 0 . 7 ng/mg (p <

0 . 0 5 ) was o b s e r v e d i n 19 c h i l d r e n who we r e bo r n s m a l 1 - f o r - g e s t a t i o n a l
age w i t h t h e g r o wt h f a i l u r e o f r e c e n t o r i g i n
ng/mg (P < 0 . 0 1 )

("acute"

in e i g h t i n f a n t s with " c h r o n i c "

l e u k o c y t e l e v e l s showed a s i m i l a r and p a r a l l e l

IUGR), and 4 2 . 4

IUGR. The m a t e r n a l

association,

wi th mothers

f r om b o t h g r o u p s o f IUGR b a b i e s h a v i n g s i g n i f i c a n t l y l o w e r l e u k o c y t e
zinc levels

in t h e i r p e r i p h e r a l whi te c e l l s .

Simmer e t al
plasma,

red c e l l ,

zinc levels

( 1985) o b t a i n e d s i m i l a r r e s u l t s when t h e y me a s u r e d
p o l y m o r p h o n u c l e a r l e u k o c y t e and m o n o n u c l e a r l e u k o c y t e

i n 79 m o t h e r s w i t h i n 24 t o 48 h o u r s p o s t p a r t u m .

Forty-three

o f t h e women d e l i v e r e d normal

b i r t h weight i n f a n t s ;

36 had SGA n e wb o r n s .

L e v e l s o f p l a s ma and r e d c e l l

zinc did not c o r r e l a t e with b i r t h weight,

73

b u t t h e l e v e l s f o r b o t h t y p e s o f w h i t e c e l l s we r e s i g n i f i c a n t l y l o w e r
(p < . 0 0 1 )

f o r the mothers

Ky n a s t and S a l i n g

w i t h SGA i n f a n t s .

( 1986) e v a l u a t e d t h e e f f e c t o f z i n c

s u p p l e m e n t a t i o n d u r i n g p r e g n a n c y on b i r t h w e i g h t . Women s u p p l e m e n t e d
w i t h 20 mg o f z i n c p e r d a y ( n=179) d e l i v e r e d

i n f a n t s w i t h a mean b i r t h

w e i g h t o f 3318 g as c ompa r e d t o 3236 g i n u n s u p p l e m e n t e d c o n t r o l s
( n = 3 4 5 ) . Though n o t s t a t i s t i c a l l y s i g n i f i c a n t ,

t h e a u t h o r s b e l i e v e d an

84 g d i f f e r e n c e was c l i n i c a l l y s i g n i f i c a n t .
In c o n t r a s t ,

several

b e t we e n i n d i c a t o r s o f z i n c

i n v e s t i g a t o r s h a ve n o t f o u n d a c l e a r r e l a t i o n
s t a t u s and b i r t h w e i g h t .

Ca mpbe l 1 -Brown e t al

( 1985) f ou n d no a s s o c i a t i o n b e t we e n c r u d e o r a d j u s t e d b i r t h w e i g h t and
hair zinc,

s er um z i n c o r u r i n a r y z i n c o u t p u t .

T u t t l e e t al

(1985),

in a

s t u d y o f 33 h e a l t h y p r i m i g r a v i d women and 31 p r i m i g r a v i d a s w i t h a h i g h
r i s k o f d e l i v e r i n g a low b i r t h w e i g h t i n f a n t ,

f o u n d no d i f f e r e n c e s

p l a s ma z i n c c o n c e n t r a t i o n s a t 30 and 35 weeks g e s t a t i o n .

in

Bl ood vol ume s ,

h o we ve r , we r e 600 ml l o w e r on a v e r a g e i n t h e h i g h - r i s k g r o u p o f mo t h e r s
(p < 0 . 0 0 1 ) .

When t h e mass o f z i n c i n t h e i n t r a v a s c u l a r c o mp a r t me n t was

comput ed f o r t h e two g r o u p s , t h e r e was 12% t o 20% l e s s c i r c u l a t i n g z i n c
i n t h e h i g h - r i s k women (p < 0 . 0 0 1 ) .

Lastly,

a cross-sectional

s u r v e y of

p r e g n a n t women i n Hong Kong (Ghosh e t a l , 1985) f ound a p o s i t i v e
c o r r e l a t i o n o f i n f a n t b i r t h w e i g h t w i t h s er um z i n c and a n e g a t i v e
c o r r e l a t i o n with h a i r zinc l e v e l s .
as a p o t e n t i a l

This poi nte d to zinc r e d i s t r i b u t i o n

f a c t o r i n f l u e n c i n g p r e g n a n c y o u t c o me , and r e - e m p h a s i z e d

the f a c t th a t a s e n s itiv e ,

accurate in dicator of zinc s ta tu s is lacking.

74

E f f e c t o f Z i n c S t a t u s and Smoking on B i r t h Wei qht
It

i s we l l

e s t a b l i s h e d t h a t smoki ng d u r i n g p r e g n a n c y r e s u l t s

in

i n f a n t s w i t h l o w e r e d b i r t h w e i g h t s ( Kl ei nman e t a l , 1 9 8 5 ) . T h i s
phenomena h a s be e n a t t r i b u t e d most o f t e n t o h y p o x i a f rom c a r b o n monoxi de
and c o n s t r i c t i o n o f t h e u t e r i n e b l o o d v e s s e l s f r om n i c o t i n e
1 9 8 0 ) . K u h n e r t e t al
hypothesis.

(1987),

h o we v e r , ha ve p r o p o s e d an a l t e r n a t e

I t i s known t h a t cadmium, o b t a i n e d f r om c i g a r e t t e smoke,

increases the production of m etallothionein,
metals.

( Ab e l ,

a s t o r a g e p r o t e i n f o r heavy

Each c i g a r e t t e consumed i s e s t i m a t e d t o c o n t r i b u t e

cadmium t o t h e b o d y ' s cadmium pool

( S ol omons ,

1988).

1 ug o f

In a d d i t i o n t o

t r a p p i n g cadmi um, t h e a u t h o r s h y p o t h e s i z e d t h e i n c r e a s e d m e t a l l o t h i o n e i n
also tra p s zinc,
fetus.

t h u s d e c r e a s i n g t h e amount o f z i n c a v a i l a b l e t o t h e

T h e i r r e s e a r c h i n d i c a t e d a " t r a p p i n g " o f z i n c in t h e p l a c e n t a

whi ch was d i r e c t l y r e l a t e d t o l e v e l s o f c i r c u l a t i n g cadmi um. The l e v e l
o f c i r c u l a t i n g cadmi um,
cigarettes

in t u r n ,

smoked. K u h n e r t e t al

was d i r e c t l y r e l a t e d t o t h e number o f
( 1987)

suggested t h i s trapped zinc

r e d u c e d t h e t r a n s f e r o f z i n c t o t h e f e t u s and c o u l d be r e s p o n s i b l e ,
part,

in

f o r t h e l o w e r e d b i r t h w e i g h t o f i n f a n t s b or n t o s mo k e r s .
K u h n e r t e t al

(1988a,

1988b) r e a n a l y z e d t h e i r

1987 d a t a t o f u r t h e r

i n v e s t i g a t e t h e e f f e c t o f smoki ng on z i n c s t a t u s and b i r t h w e i g h t . A
s i g n i f i c a n t r e l a t i o n s h i p be t we e n mean c o r d v e i n r e d b l o o d c e l l
z i n c and b i r t h w e i g h t
maternal
contrast,
RBC z i n c

and f e t a l

(p < 0 . 0 0 1 ) was f o u n d . No r e l a t i o n s h i p be t we e n

i n d i c e s o f z i n c s t a t u s was o b s e r v e d i n n o n s mo k e r s .

a n e g a t i v e c o r r e l a t i o n b e t we e n m a t e r n a l
(i.e.,

(RBC)

high mat ernal

c o r r e l a t i o n b e t we e n m a t e r n a l

zinc=low f e t a l
and f e t a l

pl a s ma z i n c and f e t a l

RBC z i n c ) ,

and a p o s i t i v e

a l k a l i n e p h o s p h a t a s e and pl a s ma

In

75

z i n c , was o b s e r v e d i n s m o k e r s . The a u t h o r s h y p o t h e s i z e d t h i s h i g h
maternal

p l a s ma z i n c l e v e l ,

and c o n c o m i t a n t l o w e r f e t a l

RBC z i n c ,

i s due

t o an i n a b i l i t y o f t h e z i n c t o c r o s s t h e p l a c e n t a i n s mo k e r s . K u h n e r t
suggested f e t a l

zinc,

not maternal

zinc,

is related to fetal

w e i g h t . T h i s i n v e r s e r e l a t i o n s h i p b e t we e n h i g h m a t e r n a l

birth

p l a s ma z i n c and

low b i r t h w e i g h t i n s moke r s p r o v i d e s f u r t h e r s u p p o r t f o r t h e h y p o t h e s i s
t h a t t h e i n a b i l i t y o f z i n c t o r e a c h t h e i n f a n t o f s mo k e r s i s due t o t h e
" t r a p p i n g " o f cadmium and z i n c i n t h e p l a c e n t a .

This " tr a p p in g " r e s u l t e d

i n an i n c r e a s e d p l a c e n t a l

a d e c r e a s e d c o r d RBC

zinc level

(9%),

zinc level

( 10%) , and

i n s moke r s as c ompar ed t o n o n s mo k e r s .

C o n c l u s i o n : Zi n c and P r e g n a n c y Outcome
Several

scientific

and p r e g n a n c y ou t c o me .

studies

i n d i c a t e a r e l a t i o n s h i p b e t we e n z i n c

R e s e a r c h i s h a mp e r e d ,

h o we v e r ,

by b o t h t h e l a c k

o f a s e n s i t i v e b i o l o g i c i n d i c a t o r o f z i n c s t a t u s and a d e f i c i e n t
n u t r i e n t d a ta base.

Nonetheless,

present studies

a v a i l a b i l i t y of zinc to the fetus,

as me a s u r e d by c o r d RBC z i n c ,

e x e r t a r o l e in i n f a n t b i r t h w ei g ht .
with increased p lacen tal
we l l

a s t h e t o x i c me t a l

i n d ic a te the

Evidence l i n k s mat er na l

may

s moki ng

m e t a l l o t h i o n e i n , whi c h a p p e a r s t o t r a p z i n c as
cadmi um. T h i s t r a p p i n g a p p e a r s t o p r e v e n t t h e

t r a n s f e r of zinc to the f e tu s ,

t h u s c o n t r i b u t i n g t o a l o we r b i r t h w e i g h t

by t h e c o n c o m i t a n t r e d u c t i o n i n s y n t h e s i s o f DNA, RDA and c e l l u l a r
proteins.

76

E v a l u a t i o n of D i e t a r y I n t a k e in a R e t r o s p e c t i v e Study

To d e t e r m i n e t h e i mp a c t o f m a t e r n a l

n u t r i t i o n on b i r t h w e i g h t ,

a

v a l i d and r e l i a b l e e s t i m a t e o f u s u a l d i e t a r y i n t a k e must be u s e d .
Although s e v e r a l
research

(i.e.,

food r e c o r d s ,

24-hour r e c a l l ,

data c o lle c tio n ,

e a s e o f a d m i n i s t r a t i o n and met hod o f

t h e f ood f r e q u e n c y q u e s t i o n n a i r e

(FFQ) i s t h e o n l y

d i e t a s s e s s m e n t t o o l whi c h can be u s e d i n a l a r g e - s c a l e ,

r e t r o s p e c t i v e epidem iolo gic study without a personal
e t a l , 1984; Sampson,
a p p r o p r i a t e tool

1 9 8 5 ) . Most i m p o r t a n t l y ,

t o a s s e s s usual

p e r i o d o f time (Block,

i s a l s o t h e most

1985).

(FFQ)

T y p i c a l l y in e pi de m iol og ica l
relatively

it

i n t e r v i e w ( Mu l l e n s

f ood i n t a k e o r f ood p a t t e r n s o v e r a

1986; Sampson,

The Food F r e q u e n c y Q u e s t i o n n a i r e

items),

we i ghe d

none i s w i t h o u t i t s own u n i q u e b i a s e s and s u b s e q u e n t

Be c a u s e o f i t s l ow c o s t ,

practical

d iet records, diet h isto rie s ,

o b s e r v a t i o n o f d i e t i n t a k e and f ood f r e q u e n c y

questionnaires),
error.

d i e t a s s e s s m e n t me t hods a r e commonly u s e d i n n u t r i t i o n

inexpensive tool

studies,

t h e FFQ i s a s h o r t

(60-120

t h a t can be m a i l e d and s e l f ­

a d m i n i s t e r e d . The w i l l i n g n e s s o f s u b j e c t s t o c o m p l e t e t h e FFQ ha s been
shown by h i g h r e t u r n r a t e s o f 75% ( Mu l l e n s e t a l , 1984) t o 93. 5% (Browe
e t a l , 1 9 6 6 ) . The FFQ can be u s e d t o d e f i n e c u r r e n t o r p a s t i n t a k e f o r
i n d i v i d u a l s o r g r o u p s ( Samps on,

1 9 8 5 ) . The aim o f t h e FFQ i s t o

c h a r a c t e r i z e f ood i n t a k e o v e r an e x t e n d e d p e r i o d ,
d e t a i l s o f an i n d i v i d u a l ' s

even t h o u g h s p e c i f i c

f ood c o n s u m p t i o n may be s a c r i f i c e d .

77

The FFQ ha s been u s e d t o r a n k i n d i v i d u a l s a c c o r d i n g t o f ood o r
nutrient

intakes.

The e x t r e m e s ( t y p i c a l l y h i g h i n t a k e vs low i n t a k e ,

tertiles

or q u a r t i l e s of the d i s t r i b u t i o n )

c ompa r e d w i t h an out come v a r i a b l e ( i . e . ,
disease).

a r e t h e n i d e n t i f i e d and

b i r t h weight,

cancer,

heart

E p i d e m i o l o g i s t have u s e d t h i s c l a s s i f i c a t i o n o r r a n k i n g o f

i n d i v i d u a l s i n b r o a d c a t e g o r i e s o f l ow, medium and h i g h i n t a k e b e c a u s e
a c c u r a t e q u a n t i t a t i v e m e a s u r e s o f n u t r i e n t i n t a k e c a n n o t be o b t a i n e d
r e t r o s p e c t i v e l y (Block,

1982).

S e m i - Q u a n t i t a t i v e Food F r e q u e n c y Q u e s t i o n n a i r e (SQFFQ)
Recently,

two s e m i - q u a n t i t a t i v e f ood f r e q u e n c y q u e s t i o n n a i r e s

(SQFFQ), whe r e s u b j e c t s s e l e c t t h e f r e q u e n c y o f a s p e c i f i c q u a n t i t y o f
f ood consumed as we l l

as i n d i c a t e t h e f r e q u e n c y o f c o n s u m p t i o n ,

have

be e n d e v e l o p e d . The SQFFQ a l l o w s f o r t h e c a l c u l a t i o n o f r e a s o n a b l y
a c c u r a t e q u a n t i t a t i v e measures o f n u t r i e n t i n t a k e ( i . e . ,
(W illett,

1988).

12 mg i r o n )

I n c r e a s e d c o n f i d e n c e i n t h e v a l i d i t y o f t h e SQFFQ, and

t h e o b s e r v a t i o n t h a t p e o p l e w i t h i n t h e u p p e r and l o w e r e nds o f t h e
r a n k i n g s c a l e a r e o f t e n " u n u s u a l " o r " o u t l y e r s " who had o v e r - o r
u n d e r e s t i m a t e d t h e i r f r e q u e n c y o f f ood i n t a k e ( C o l d i t z ,
communication,

1989; Sower , p e r s o n a l

c o mm u n i c a t i o n ,

in r e s e a r c h e r s using e s t i m a t e s o f t h e a c tu a l

personal

1989),

daily nutrient

p r e f e r e n c e t o r a nki ng o f i n d i v i d u a l s in d a t a a n a l y s i s .

has r e s u l t e d
intakes

in

The two most

w i d e l y us e d SQFFQ a t p r e s e n t have been d e v e l o p e d by Gl a dys Bl oc k ( B l o c k ,
1986) f o r t h e N a t i o n a l

Ca n c e r I n s t i t u t e and W a l t e r W i l l e t t e t al o f t h e

H a r v a r d Me di c a l

( W i l l e t t e t a l , 1985) f o r t h e Nu r s e s H e a l t h

Study.

School

Bot h t o o l s we r e d e v e l o p e d f o r e p i d e m i o l o g i c and c l i n i c a l

use,

78

with special

e mp h a s i s on n u t r i e n t s p r e v i o u s l y a s s o c i a t e d w i t h c a n c e r ,

s uc h a s v i t a m i n s A, C and l i p i d f r a c t i o n s .

B l o c k ' s SQFFQ.
Block's

( 1986) 9 9 - i t e m SQFFQ was d e v e l o p e d u s i n g d i e t a r y d a t a f rom

1 1 , 6 5 8 a d u l t r e s p o n d e n t s t o t h e Second N a t i o n a l
S u r v e y (NHANES I I ) .

H e a l t h and E x a m i n a t i o n

Food i t e m s we r e s e l e c t e d on t h e b a s i s o f t h e i r

contrib ution to the to ta l

populations

i n t a k e o f e n e r g y and e a c h o f 17

nutrients

i n t h e NHANES I I d a t a .

The f ood i t e m s r e p r e s e n t o v e r 90% o f

the to ta l

i n t a k e f o r each o f t h o s e n u t r i e n t s .

Associated n u trie n t

c o m p o s i t i o n v a l u e s wer e d e t e r m i n e d f r om t h e NHANES I I d a t a b a s e u s i n g
f r e q u e n c y o f consumption d a t a in t h a t s u r v ey . A uni que f e a t u r e o f
B l o c k ' s SQFFQ i s t h a t p o r t i o n s i z e s a s s o c i a t e d w i t h e a c h f ood i t e m
( s m a l l , medium and l a r g e ) ,
distributions

d e r i v e d f r om o b s e r v e d p o r t i o n s i z e

i n NHANES I I u s i n g t h r e e - d i m e n s i o n a l

s e l e c t e d by t h e s u b j e c t f i l l i n g

f ood m o d e l s , must be

o u t t h e f or m. C o r r e l a t i o n s b e t we e n

n u t r i e n t s e s t i m a t e d by o n e - d a y d i e t r e c o r d s o f 50 h e a l t h y 25- 77 y e a r o l d
subjects

(17 ma l e , 33 f e m a l e )

and n u t r i e n t s e s t i m a t e d by t h e Block-SQFFQ

r a n g e d f r om 0 . 7 3 f o r f a t

t o 0 . 9 4 f o r v i t a m i n A. At l e a s t 80% o f

n u t r i e n t s we r e p l a c e d i n

t h e same o r an a d j a c e n t q u a r t i l e o f

distribution.

No n u t r i e n t was g r o s s l y m i s c l a s s i f i e d ,

da y d i e t r e c o r d s and t h e
Bl oc k b e l i e v e d t h e

the

b a s e d on t h e one-

SQFFQ.
f o l l o w i n g d e v e l o p m e n t a l and d e s i g n f e a t u r e s o f

h e r SQFFQ we r e n o t a b l e ( 1 9 8 6 ) .
a s s e s s m e n t o f t h e whol e d i e t ,

1) The SQFFQ i s t a r g e t e d t o w a r d
n o t one o r a few s i m i l a r n u t r i e n t s ,

maki ng

i t p o s s i b l e t o r e a n a l y z e d a t a s e t s i f new n u t r i e n t s become o f r e s e a r c h

79

i n t e r e s t in the f u t u r e .

2) The f o o d l i s t

i s b a s e d on m a j o r n u t r i e n t

c o n t r i b u t o r s a s d e t e r m i n e d by p o p u l a t i o n d a t a (NHANES I I ) whi c h r e s u l t s
i n t h e i n c l u s i o n o f a f ew,

s ome t i me s o v e r l o o k e d ,

foods.

3) The i n c l u s i o n

o f s t a n d a r d p o r t i o n s i z e s b a s e d on p o p u l a t i o n d a t a and i d e n t i f i e d by t h e
r e s p o n d e n t a dds p e r s o n a l

v a r i a b i l i t y i n f ood p r e f e r e n c e s and q u a n t i t y t o

t h e a g e - s e x c o mp o n e n t . 4) The SQFFQ i s c a p a b l e o f b e i n g s e l f ­
administered,

thus c o n s id e r a b l y advancing e p i d e m i o l o g i s t '

a b i l i t y to

u n d e r s t a n d t h e r e l a t i o n s h i p o f d i e t and d i s e a s e .

W i l l e t t SQFFQ.
W i l l e t t and c o l l e a g u e s
refinement of t h e i r o r ig i n a l

( 1988) d e v e l o p e d a 1 1 6 - i t e m SQFFQ f r om
6 1 - i t e m SQFFQ ( W i l l e t t e t a l , 1 9 8 5 ) .

The

W i l l e t t q u e s t i o n n a i r e was d e s i g n e d t o c a t e g o r i z e i n d i v i d u a l s by i n t a k e
o f s e l e c t n u t r i e n t s h y p o t h e s i z e d t o a f f e c t t h e o c c u r r e n c e o f c a n c e r and
heart disease.
fat,

Target n u t r i e n t s

saturated fat,

included p r o te i n ,

o l e i c and l i n o l e i c a c i d ,

s u c r o s e , d i e t a r y and c r u d e f i b e r ,
thiamin,

riboflavin,

ani ma l

cholesterol,

fat,

vegetable

carbohydrate,

p r o v i t a m i n A, p r e f o r m e d v i t a m i n A,

v i t a m i n B- 6, v i t a m i n E, c a l c i u m and i r o n .

The 116 f o o d s on t h e W i l l e t t SQFFQ we r e s e l e c t e d i n t h r e e ways
( W i l l e t t e t a l , 1987).

Initially,

p o t e n t i a l l y important sources of the

s p e c i f i e d n u t r i e n t s we r e i d e n t i f i e d by an e x p e r i e n c e d d i e t i t i a n .
f o o d s i n f r e q u e n t l y consumed wer e e l i m i n a t e d .

Those

Stepwise r e g r e s s i o n of

f o o d s consumed by 1742 f e m a l e n u r s e s i n a p i l o t s t u d y ( W i l l e t t e t a l ,
1981) was u s e d t o i d e n t i f y f o o d s t h a t d i d n o t add a p p r e c i a b l y t o t h e
between-person v a r i a t i o n
d ie t records,

in n u t r i e n t i nt a ke .

Ne x t , n e a r l y 5400 d a y s o f

c o ll e c t e d during a v a li d a ti o n study of the o r ig i n a l

61-

80

i t e m SQFFQ ( W i l l e t t ,

1 9 8 5 ) , we r e u s e d t o i d e n t i f y any a d d i t i o n a l

t h a t might c o n t r i b u t e a p p r e c i a b l y t o a b s o l u t e n u t r i e n t
some f o o d s o f s p e c i a l

intake.

foods

Finally,

i n t e r e s t wi th r e s p e c t t o c a n c e r e t i o l o g y but not

important c o n tr ib u to r s to n u t r i e n t intake ( i . e . ,

mushr ooms) we r e a d d e d .

T h i s p r o c e d u r e r a i s e d t h e number o f f o o d s f r om 61 t o 116 i t e m s . A
p o r t i o n s i z e f o r e a c h f ood i t e m was s p e c i f i e d ,
wh e n e v e r p o s s i b l e ( i . e . ,
foods without a n a tu r a l

s l i c e of bread,
portion size

w i t h common u n i t s u s e d

e i g h t ounce g l a s s o f m i l k ) .

(i.e.,

For

i c e cream or s t r i n g b e a n s ) ,

p r e v i o u s l y c o l l e c t e d d i e t r e c o r d s f r om an i n d e p e n d e n t p o p u l a t i o n o f
U n i t e d S t a t e s women was u s e d t o i d e n t i f y t h e p o r t i o n s i z e most commonly
used ( W i l l e t t ,

1985) ,

S u b j e c t s c o m p l e t i n g t h e W i l l e t t q u e s t i o n n a i r e we r e a s k e d how
often,

on t h e a v e r a g e , t h e y consumed f o o d d u r i n g t h e p r e v i o u s y e a r

any s p e c i f i e d t i m e p e r i o d t h e r e s e a r c h e r c h o o s e s ) .

(or

The s u b j e c t s s e l e c t e d

f r om n i n e p o s s i b l e r e s p o n s e s r a n g i n g f r om " n e v e r " t o " s i x o r more t i m e s
a d a y " . The r e s p o n s e s we r e d e s i g n e d t o l i m i t t h e r a n g e o f i n t a k e w i t h i n
e a c h f r e q u e n c y c a t e g o r y t o a f a c t o r o f two o r l e s s .

Additional

i tems not

p r e s e n t e d in t he f r e qu en cy format i n c l u d e t h e t y p e s o f f a t used f o r
f r y i n g and c o o k i n g , t y p e o f m a r g a r i n e u s e d ,
food, usual t ype o f cold b r e a k f a s t c e r e a l

a mount s o f s u g a r added t o

c ons ume d,

o f m u l t i p l e v i t a m i n s u p p l e m e n t s u s e d and t h e d o s e ,
d u r a t i o n o f i n t a k e o f v i t a m i n and m i n e r a l

f r e q u e n c y and b r a n d
f r e q u e n c y and

supplements.

An o p e n - e n d e d

s e c t i o n i n c l u d e d a t t h e end o f t h e q u e s t i o n n a i r e a l l o w e d s u b j e c t s t o
n o t e any f o o d s e a t e n once p e r week b u t we r e n o t i n c l u d e d i n t h e SQFFQ.
The W i l l e t t 1 1 6 - i t e m SQFFQ was i n i t i a l l y v a l i d a t e d

in a group of

29 men and women aged 20 t o 54 who had p r e v i o u s l y k e p t a d a i l y we i ghe d

81

d i e t r e c o r d f o r one f u l l
Agriculture

y e a r as p a r t o f a U n i t e d S t a t e s D e p a r t m e n t o f

(USDA) e x p e r i m e n t

(Willett,

1 9 8 7 ) . The SQFFQ was m a i l e d t o

t h e s u b j e c t s a p p r o x i m a t e l y 18 mont hs a f t e r t h e d i e t r e c o r d e x p e r i m e n t
had been c o m p l e t e d . T w e n t y - s e v e n (93%) s u b j e c t s ,

i n c l u d i n g 12 men and 15

women, r e t u r n e d c o m p l e t e d f o o d f r e q u e n c y f o r m s . O v e r a l l ,
the d ie t records,
intake.
record

compa r ed w i t h

t h e SQFFQ t e n d e d t o s l i g h t l y u n d e r e s t i m a t e t o t a l

However , t h e n u t r i e n t e s t i m a t e s we r e w i t h i n 10% o f t h e mean d i e t

measuremen ts for 11 o f t h e 18 n u t r i e n t s e v a l u a t e d ( T a b l e 2 . 5 ) ,

and t h e d i f f e r e n c e was l e s s t h a n 25% f o r a l l

b u t one n u t r i e n t

(total

v i t a m i n A) . C o r r e l a t i o n c o e f f i c i e n t s c o mp a r i n g u n a d j u s t e d n u t r i e n t
i n t a k e s me a s u r e d by t h e two me t hods r a n g e d f r om 0 . 3 8 ( v i t a m i n C) t o 0 . 7 6
(total

f a t ) with c o r r e l a t i o n s of 0.67,

calories,

Table 2 .5 .

p r o t e i n and c a l c i u m ,

0 . 6 0 and 0 . 6 3 o b t a i n e d f o r

respectively.

P e r c e n t d e v i a t i o n b e t we e n mean n u t r i e n t i n t a k e s as
d e t e r m i n e d by o n e - y e a r we i g h e d f ood r e c o r d s and t h e W i l l e t t
SQFFQ (n=29) ( a d a p t e d f rom W i l l e t t e t a l , 1 9 8 7 ) .

Nutrient

D i e t Recor d

SQFFQ

T o t a l e n e r g y , kcal
Protein, g
Total f a t , g
Total carb o h y d r a te ,
C h o l e s t e r o l , mg
Vi t a m i n A, IU
T h i a m i n , mg
V i t a m i n C, mg
C a l c i u m , mg
I r o n , mg

2229+707#
82+25
90+30
258+96
362+122
6434+2676
1.5+0.6
125+87
894+446
15+6

2114+1012
87+40
82+46
263+116
332+151
8511+6194
1.3+0.6
146+88
917+586
14+6

g

# Mean + s t a n d a r d d e v i a t i o n

% Deviation

-5
+6
-9
+2
-8
+32
- 13
+ 17
+3
-7

82

A s e c o n d v a l i d a t i o n s t u d y o f t h e 1 1 6 - i t e m SQFFQ was c o n d u c t e d by
c o mp a r i n g r e s p o n s e s o f 150 B o s t o n - a r e a n u r s e s t o t h e SQFFQ and t h e mean
i n t a k e o f f o u r - o n e week we i g h e d d i e t r e c o r d s ,

s p a c e d a t 3- mont h

i n t e r v a l s , whi c h had been c o m p l e t e d f o u r y e a r s p r i o r ( W i l l e t t e t a l ,
1988). O v e r a l l ,
the d ie t records

t h e SQFFQ t e n d e d t o p r o v i d e h i g h e r t o t a l
(Table 2 . 6 ) .

r a n g e d f r om 0 . 4 4 f o r t o t a l
W i l l e t t e t al

(1987,

in ta k e s than

Calorie-adjusted correlation coefficients

v i t a mi n A t o 0.61 f o r t o t a l

carbohydrate.

1988) c o n c l u d e d t h e s e d a t a p r o v i d e f u r t h e r e v i d e n c e

t h a t a s i m p l e and r e l a t i v e l y i n e x p e n s i v e q u e s t i o n n a i r e ca n p r o v i d e
useful

i n f o r m a t i o n on d i e t a r y i n t a k e o v e r an e x t e n d e d p e r i o d o f t i m e .

Table 2.6 .

P e r c e n t d e v i a t i o n b e t we e n mean d a i l y n u t r i e n t i n t a k e s as
d e t e r m i n e d by mean i n t a k e o f f o u r o n e - we e k we i g h e d f ood
r e c o r d s and t h e W i l l e t t SQFFQ ( n=150) ( a d a p t e d f r om W i l l e t t
e t a l , 1987).

Nutrient

D i e t Re c o r d s

Total c a l o r i e s
Protein, g
Total f a t , g
C h o l e s t e r o l , mg
Total c a rb o h yd r a te , g
T o t a l v i t a m i n A, IU
V i t a mi n C, mg
T h i a mi n , mg
C a l c i u m, mg
I r o n , mg

1621+326#
68+12
69+17
307+78
171+45
6875+4055
242+444
4.4+13
640+246
17+14

SQFFQ

% Deviation

1844+559
76+22
76+25
312+119
206+79
10217+5082
292+290
2.4+3.5
832+419
15+12

+ 14
+ 11
+ 11
+ 2
+20
+49
+21
- 55
+30
-9

# Mean + s t a n d a r d d e v i a t i o n

Summary: Food F r e q u e n c y Q u e s t i o n n a i r e s
Sampson ( 1985) ha s s umma r i z ed t h e u s e o f t h e FFQ/SQFFQ as a
research instrument,

i n c l u d i n g v a l i d a t i o n and r e l i a b i l i t y

studies.

In

83

general,

reliability

studies

( r e p e a t e d m e a s u r e s o f t h e same i n s t r u m e n t )

i n d i c a t e g r e a t e r t h a n 60% e x a c t a g r e e m e n t when t h e s e l e c t e d f r e q u e n c y o f
c o n s u mp t i o n i s c ompa r e d ( i . e . ,

1 / 2 cup o f c a r r o t s cons umed 2 - 4 t i m e s p e r

we e k ) ; 90% a g r e e m e n t h a s be e n o b s e r v e d i f " a g r e e m e n t " i s r e l a x e d t o
w i t h i n one ( p l u s o r mi n u s ) f r e q u e n c y c a t e g o r y ( i . e . ,

i f the frequency of

c o n s u mp t i o n s e l e c t e d on t h e f i r s t SQFFQ i s 1/ 2 cup c a r r o t s 2 - 4 t i m e s p e r
week,

a c c e p t a b l e a n s we r s on t h e s e c o n d SQFFQ ca n r a n g e f r om "1 p e r week"

t o " 5 - 6 p e r week" f o r " a g r e e m e n t " )

( Samps on,

1985). V a l i d i t y s t u d i e s

have been c o n d u c t e d by c o mp a r i n g r e s p o n s e s t o FFQs w i t h d a t a f rom d i e t
histories,

f ood d i a r i e s ,

biochemical d a t a .

w e i g h t e d f ood r e c o r d s ,

In g e n e r a l ,

typical

recalls

and

c o r r e l a t i o n s b e t we e n 0 . 5 and 0 . 8 a r e

c o n s i d e r e d r e a s o n a b l e ( Samps on,
lower t han t h i s ,

24-hour d i e t

1985).

N u t r i e n t s with c o r r e l a t i o n values

o f v i t a m i n A (Beaton,

1979; W i l l e t t ,

1988),

s h o u l d be u s e d w i t h c a u t i o n i n h y p o t h e s i s t e s t i n g .

Diet Quality

For t h e many r e a s o n s c i t e d a b o v e , one o f t h e mos t p r e s s i n g ,
unresolved i s s u e s in the f i e l d of n u t r i t i o n

is the q u a n t i f i c a t i o n of the

i mp a c t o f t h e q u a l i t y o f d i e t consumed p r i o r t o and d u r i n g p r e g n a n c y on
i n f a n t b i r t h weight

( Brown,

1 9 8 9 ) . A l t h o u g h many s t u d i e s ha ve

i n v e s t i g a t e d t h e r e l a t i o n s h i p b e t we e n s i n g l e n u t r i e n t
protein,

calories)

and p r e g n a n c y o u t c o me ,

r e l a t i o n s h i p b e t we e n t h e o v e r a l l

intakes

(i.e.,

few s t u d i e s ha ve l o o k e d a t t h e

q u a lity of d ieta ry intake,

w e i g h t g a i n and i n f a n t b i r t h w e i g h t . Two r e a s o n s f o r t h i s

antenatal

include:

84

1) t h e l a c k o f a commonly a c c e p t e d , q u a n t i f i a b l e d e f i n i t i o n o f " d i e t
quality"
per se,

and 2) t h e d i f f i c u l t y

in i s o l a t i n g t h e e f f e c t o f d i e t q u a l i t y ,

f r om t h e e f f e c t o f numer ous c o n f o u n d i n g v a r i a b l e s known t o

i n f l u e n c e b i r t h w e i g h t . Thus , t h e e f f e c t o f d i e t q u a l i t y on a n t e n a t a l
w e i g h t g a i n and i n f a n t b i r t h wei gh r e m a i n s p o o r l y u n d e r s t p o d .
The p u r p o s e o f t h i s
"diet quality",

s e c t i o n of the l i t e r a t u r e review is to de fi n e

t o r e v i e w f o u r me t hods t o q u a n t i f y d i e t q u a l i t y ,

and t o

s umma r i z e r e s u l t s o f t h e few s t u d i e s i n whi c h d i e t q u a l i t y h a s been
a s s o c i a t e d w i t h p r e g n a n c y out c ome .

Diet Quality: A D efin itio n
A diet

i s comprised o f i n d i v i d u a l

whi c h f u l f i l l

foods t h a t provide n u t r i e n t s

three generalized functions:

1) p r o v i d e e n e r g y ,

and m a i n t a i n body t i s s u e and 3) r e g u l a t e body p r o c e s s e s
I f a d i e t i s t o be r a t e d " n u t r i t i o u s " ,
recommended l e v e l s ,
established

all

(Guthrie,

2) b u i l d

(Guthrie,

i t should pr o v id e,

1977) .

at c lo s e to

n u t r i e n t s f o r whi c h s t a n d a r d s ha ve been

1977). A "high q u a l i t y d i e t "

implies n u tritio n a l

a d e q u a c y ( K r e b s - S m i t h e t a l , 1 9 8 7 ) , b u t few r e s e a r c h e r s ha ve e x p l i c i t l y
d e fi n e d the term.
will

For p u r p o s e s o f t h i s p a p e r t h e t e r m " d i e t q u a l i t y "

be d e f i n e d as t h e n u t r i t i o n a l

c ompar ed t o t h e N a t i o n a l
A l l o w a n c e s (NRC-RDA,

a d e q u a c y o f t h e d i e t consumed as

R e s e a r c h C o u n c i l ' s Recommended D i e t a r y

1989).

"Diet q u a l i t y " w i l l

d i f f e r e n t "Diet Qu a lit y Scores",

be me a s u r e d by f o u r

e a ch b e i n g a n u me r i c d e s c r i p t i o n o f t h e

q u a n t i t y o f s e l e c t n u t r i e n t s consumed c ompar ed t o t h e e s t a b l i s h e d
sta nd a rd at the time t h i s

s t u d y was p u b l i s h e d . A summary o f t h e s e s c o r e s

85

ca n be f o u n d a t t h e c o n c l u s i o n o f t h e d i e t q u a l i t y s e c t i o n o f t h i s
l i t e r a t u r e review (Table 2 . 7 ) .

Met hods t o A s s e s s D i e t Q u a l i t y
S e v e r a l me t h o d s h a v e be e n u s e d t o m e a s u r e d i e t q u a l i t y .
considered ideal
q u a lity will

( Ts e ng e t a l , 1 9 8 6 ) .

be p r e s e n t e d :

None i s

Fi v e me t hods o f q u a n t i f y i n g d i e t

1) t h e D i e t S c o r e R a t i n g ,

2) t h e N u t r i e n t

Adequacy R a t i o (NAR) and Mean Adequacy R a t i o (MAR) S c o r e , 3) t h e I ndex
o f D i e t Q u a l i t y ( I DQ) , a l s o known as t h e N u t r i e n t Sum S c o r e ( NSS), 4)
t h e Index o f N u t r i t i o n a l

Q u a l i t y (INQ) ,

a l s o known as t h e I n d e x o f Food

Q u a l i t y ( IFQ) and 5) t h e c o n c e p t o f i n d i c a t o r

nutrients.

B u r k e ' s D ie t Score Ra ting.
One o f t h e e a r l i e s t me t hods u s e d t o q u a n t i f y d i e t q u a l i t y was t h e
D i e t S c o r e R a t i n g d e v e l o p e d by Bur ke e t al
Rating c a t e g o r i z e d d i e t s

(1943a).

B u r k e ' s Di et Score

f r om " v e r y p o o r " t o " e x c e l l e n t "

b a s e d on t h e

p e r c e n t a g e o f t h e Recommended D i e t a r y Al l o wa n c e (RDAs) consumed (NRCRDA, 1 9 4 1 ) .

I f 100% o r more o f t h e RDA f o r a n u t r i e n t was cons ume d,

s c o r e o f 4 ( e x c e l l e n t ) was g i v e n ;
s c o r e o f 3 ( good) was g i v e n ;
o f 2 ( f a i r ) was g i v e n ;

a

i f 80-99% o f t h e RDA was cons ume d,

i f 60-79% o f t h e RDA was c ons ume d,

a

a score

i f 50-59% o f t h e RDA was c ons ume d, a s c o r e o f 1

( p o o r ) was g i v e n ; l a s t l y ,

if less

was consumed o v e r t h e t i m e p e r i o d

t h a n 50% o f t h e RDA f o r any n u t r i e n t
measured,

a s c o r e o f 0( v e r y

p o o r ) was

recorded.

Then, t h e mean o f t h e s c o r e s f o r e i g h t s p e c i f i e d n u t r i e n t s

(protein,

calcium,

iron,

v i t a m i n s C, A, t h i a m i n ,

r i b o f l a v i n and n i a c i n )

86

was d e t e r m i n e d . The r e s u l t i n g number was u s e d t o r a t e t h e d i e t as " v e r y
poor"

( 0) t o " e x c e l l e n t "

(4) and was c a l l e d t h e " D i e t S c o r e R a t i n g " .

Bur ke u s e d t h e D i e t S c o r e R a t i n g t o s t u d y t h e r e l a t i o n s h i p be t we e n
d i e t and b i r t h out come i n 216 women c h o s e n f r om t h e p r e n a t a l
t h e Bo s t o n L y i n g - i n H o s p i t a l

( Bur ke e t a l , 1 9 4 3 a ) .

c l i n i c of

Food r e c o r d s we r e

c o l l e c t e d f o r t h r e e c o n s e c u t i v e d a ys d u r i n g e a c h t r i m e s t e r t h r o u g h o u t
t h e womens' p r e g n a n c y .

The d i e t s we r e a n a l y z e d ,

c ompa r ed t o t h e 1941

RDAs (NRC-RDA, 1 9 4 1 ) , and t h e D i e t S c o r e R a t i n g d e t e r m i n e d .
reported th at,
(n=31),

Bur ke

o f t h o s e women w i t h " good" o r " e x c e l l e n t " p r e n a t a l

68% ( n = 2 1 / 3 1 ) had a normal p r e n a t a l

course; the incidence of

p r e - e c l a m p s i a in

t h i s g r o u p was z e r o .

Conversely,

c on s u mi n g " p o o r "

to

( n = 3 6 ) , o n l y 42% ( n = 1 5 / 3 6 )

nor mal p r e n a t a l

" v e r y poor " d i e t s

diets

o f t h o s e women
had a

c o u r s e , w h i l e 58% ( n = 2 1 / 3 6 ) had c o m p l i c a t i o n s such as

s e v e r e n a u s e a and v o m i t i n g ,

edema,

s e v e r e a ne mi a and s t a i n i n g .

f o u r p e r c e n t o f t h e women cons umi ng " p o o r " o r " v e r y p o o r '
( n = 1 6 / 3 6 ) we r e d i a g n o s e d w i t h p r e - e c l a m p s i a .

Forty-

diets

Mean b i r t h w e i g h t and

l e n g t h both i n c r e a s e d c o n c o m i t a n t l y wi th t he Di et Score Ra ti ng ( "v e ry
p o o r " = 2637 g ,

"fair"

= 3374 g ,

physicians rated the babies'

" e x c e l l e n t " = 3856 g ) .

physical

condition

L a s t l y , when

(fair-good-superior)

w i t h o u t p r i o r k nowl e dge o f t h e m o t h e r s ' d i e t q u a l i t y s c o r e ,

56% o f

b a b i e s r a t e d " s u p e r i o r " we r e bor n t o m o t h e r s cons umi ng " good" o r
"excellent" d iets,

w i t h o n l y 9% o f t h e b a b i e s r a t e d " s u p e r i o r "

m o t h e r s c ons umi ng " p o o r " o r " v e r y p o o r " d i e t s .
whose p h y s i c a l

c o n d i t i o n was r a t e d " f a i r " ,

Conversely,

bor n t o

of the babies

o n l y 1% wer e b o r n t o m o t h e r s

c on s u mi n g "good"

or

" e x c e l l e n t " d i e t s w h i l e 87% we r e b or n t o m o t h e r s

c on s u mi n g " p o o r "

or

" v e r y poor " d i e t s .

Bur ke c o n c l u d e d t h a t t h e D i e t

87

S c o r e R a t i n g a p p e a r e d t o be p o s i t i v e l y ,

l i n e a r l y r e l a t e d to pregnancy

o u t c o me .
M a r g a r e t Moore e t al

( 1947) u s e d t h e Bur ke " D i e t S c o r e R a t i n g " t o

a n a l y z e t h e r e l a t i o n s h i p b e t we e n d i e t q u a l i t y and s t i l l b i r t h / i n f a n t
m o r t a l i t y r a t e i n 69 b l a c k and 90 w h i t e women a t t h e T u l a n e U n i v e r s i t y
Sc hool o f M e d i c i n e . Moore e t al c o l l e c t e d d i e t r e c o r d s f o r s e v e n
c o n s e c u t i v e d a y s f r om e a c h s u b j e c t onc e d u r i n g e i t h e r t h e s e c o n d o r
t h i r d t r i m e s t e r o f pregnancy. Three t o f i v e v i s i t s t o each s u b j e c t ' s
home we r e made d u r i n g t h e r e c o r d i n g p e r i o d i n an a t t e m p t t o i n c r e a s e t h e
v a l i d i t y o f t h e food r e c o r d s .

The r e c o r d s we r e s u b s e q u e n t l y a n a l y z e d ,

c ompa r ed t o t h e 1945 RDAs (NRC-RDA, 1945) and c a t e g o r i z e d a c c o r d i n g t o
t h e met hod o f Bur ke e t al

( 1 9 4 3 a ) . Moore f ound o n l y 4% o f t h e w h i t e ,

and

none o f t h e b l a c k , women met o r e x c e e d e d t h e RDA f o r t h e e i g h t n u t r i e n t s
analyzed.

Forty perc ent of the white,

d i e t s we r e r a t e d

b u t o n l y 13% o f t h e b l a c k , womens'

" e x c e l l e n t " o r " g o o d " ; 49% o f t h e b l a c k ,

w h i t e , womens' d i e t s we r e r a t e d " p o o r " o r " v e r y p o o r " .
stillbirth

and 21% o f t h e

The i n c i d e n c e o f

and i n f a n t d e a t h d i d n o t d i f f e r s i g n i f i c a n t l y among g r o u p s .

Moore d i d n o t compa r e t h e d i e t r a t i n g s t o b i r t h w e i g h t ,
weight gain or i n fa n t/m ate rn a l

gestational

morbidity.

N u t r i e n t Adequacy R a t i o (NAR) and Mean Adequacy R a t i o
Maddens and Yoder ( 1972 ) we r e t h e f i r s t
Adequacy R a t i o (NAR) and Mean Adequacy R a t i o

(MAR) S c o r e .

to develop the N utrient
(MAR) S c o r e a s an o v e r a l l

i n d e x o f d i e t a r y a d e q u a c y . A NAR i s c a l c u l a t e d by d i v i d i n g t h e a c t u a l
i n t a k e o f a n u t r i e n t by t h a t n u t r i e n t ' s RDA and m u l t i p l y i n g by 100.
example,

i f a woman consumed 2 . 3 mg o f v i t a m i n B- 6,

For

h e r NAR-B6 woul d be

88

( 2 . 3 mg B-6 i n t a k e / 2 . 6 mg B-6 RDA) x 100 = 88%.
more t h a n 100% o f t h e RDA f o r any n u t r i e n t ,

I f a p e r s o n consumed

t h a t NAR woul d be t r u n c a t e d

a t 100%. T h i s p r e v e n t s t h e s c o r e f r om b e i n g w e i g h t e d by a n u t r i e n t ( s )
consumed i n e x c e s s i v e q u a n t i t i e s .

The NARs f o r s e l e c t n u t r i e n t s a r e

summed and t h e i r a v e r a g e d e t e r m i n e d . T h i s a v e r a g e o f s e v e r a l

s e l e c t NARS

i s c a l l e d t h e Mean Adequacy R a t i o (MAR). Th u s , t h e MAR i s an i n d e x o f
t h e p e r c e n t o f recommended i n t a k e consumed f o r s e v e r a l

select nutrients.

P h i l l i p s and J o h n s o n ( 1977) u s e d t h e NAR and MAR c o n c e p t t o
e xa mi ne t h e r e l a t i o n s h i p b e t we e n a m o t h e r ' s d i e t q u a l i t y d u r i n g t h e
s e c o n d h a l f o f p r e g n a n c y and h e r b a b y ' s b i r t h w e i g h t .

Forty-seven rural

Wi s c o n s i n women we r e i n s t r u c t e d t o c o m p l e t e a d a i l y f ood r e c o r d s h e e t
e v e r y e i g h t h da y u n t i l
592 f o o d r e c o r d s

delivery to estimate d ie ta ry intake.

of

( r a n g e = 3 t o 30 p e r p e r s o n ; me di a n=13) we r e c o l l e c t e d .

An a v e r a g e o f a l l

f ood r e c o r d s r e t u r n e d was u s e d t o e s t i m a t e e a c h

i n d i v i d u a l ' s mean d a i l y n u t r i e n t
(protein,

A total

calcium,

n i a c i n , magne s i um,

iron,

i n t a k e and a NAR i n d e x f o r 12 n u t r i e n t s

v i t a m i n A, v i t a m i n C, t h i a m i n ,

pantothenic acid,

v a l u e s we r e t r u n c a t e d a t 100.

riboflavin,

p y r i d o x i n e and c o b a l a m i n ) . Al l

Each i n d i v i d u a l ' s

12 t r u n c a t e d n u t r i e n t s

we r e t h e n summed and a v e r a g e d t o c r e a t e a MAR-12 d i e t q u a l i t y

score.

C a l o r i e s we r e n o t i n c l u d e d i n t h e a n a l y s i s .
The mean g r o u p MAR among t h e 47 s u b j e c t s was 75+13 (44 t o 9 5 ) .
Results indicated a s ig n i f ic a n t,

positive correlation

be t we e n b i r t h w e i g h t o f t h e i n f a n t and o v e r a l l
diet

(r=0.30,

p < 0.05)

q u a lity of the mother's

(MAR-12). A weak c o r r e l a t i o n b e t we e n b i r t h w e i g h t and c a l c i u m

intake (r=0.25,

p < 0 . 1 0 ) and b i r t h w e i g h t and magnesi um i n t a k e ( r = 0 . 2 6 ,

p < 0 . 1 0 ) was n o t e d .

Interestingly,

w h i l e t h e MAR-12 i n d e x c o r r e l a t e d

89

p o s i t i v e l y w i t h b i r t h w e i g h t , t e n o f t h e 12 i n d i v i d u a l
not.

n u t r i e n t s did

B i r t h w e i g h t s o f t h e 47 i n f a n t s r a n g e d f r om 2240 t o 4578 g , w i t h a

mean b i r t h w e i g h t o f 3451+491 g . Mean w e i g h t g a i n d u r i n g p r e n a t a l

care

was 25+9 pounds and r a n g e d f r om 2 . 5 t o 4 3 . 5 p o u n d s . The c o r r e l a t i o n
b e t we e n MAR-12 and w e i g h t g a i n d u r i n g p r e g n a n c y was n o t s i g n i f i c a n t
(r=0.27,

p > 0.10).

The c o r r e l a t i o n b e t we e n c a l o r i c i n t a k e and w e i g h t

g a i n was n o t d e t e r m i n e d .

No d e t e c t a b l e c h a n g e s i n d i e t a r y i n t a k e

n o t e d f r om t h e 22nd week

t o t h e end o f p r e g n a n c y . Smoking was n e g a t i v e l y

r e l a t e d t o both weight gain during p re n a t a l
b i r t h weight

(r=-0.42,

care

(r=-0.44,

wer e

p < 0.01)

and

p < 0 . 0 1 ) . Thos e who r e p o r t e d s moki ng n i n e t o 40

c i g a r e t t e s p e r d a y had a

MAR-12 i n d e x o f 69+13 ( n=8) c ompa r ed t o

76+11

(n=32) f o r n o n s mo k e r s

< 0 . 1 0 ) , w i t h t h e l o w e r MAR-12 i n d e x o f

s moker s

(p

a t t r i b u t a b l e t o lower i n t a k e s o f a l l
not r e p o r t e d .
g,

12 n u t r i e n t s .

C a l o r i c i n t a k e was

The mean i n f a n t b i r t h w e i g h t o f t h e 8 s moke r s was 3009+457

s i g n i f i c a n t l y l e s s t h a n t h e 3540+468 g (p < 0 . 0 1 )

in non-smokers.

We i ght g a i n d u r i n g p r e g n a n c y was p o s i t i v e l y r e l a t e d t o a v e r a g e d a i l y
protein

intake (r=0.31,

p < 0.05).

Four m u l t i p l e r e g r e s s i o n e q u a t i o n s

whi c h i n c l u d e d f r om n i n e t o t w e l v e i n d e p e n d e n t v a r i a b l e s r e l a t e d t o
b i r t h weight

(i.e.,

MAR-12, s moki ng, w e i g h t g a i n ) we r e c a l c u l a t e d .

The

p e r c e n t v a r i a t i o n i n b i r t h w e i g h t e x p l a i n e d by t h e r e g r e s s i o n e q u a t i o n
r a n g e d f r om 76-86%.

I n c l u s i o n o f t h e MAR-12 i n e a c h e q u a t i o n r e s u l t e d

a 6-7% i n c r e a s e i n t h e c o e f f i c i e n t o f d e t e r m i n a t i o n .
s umma r i z ed t h a t u s e o f an i n d e x o f d i e t a r y q u a l i t y ,

in

The a u t h o r s
s uc h as t h e MAR-12,

p r o v i d e s a way t o e xa mi n e t h e e f f e c t o f n u t r i e n t s on b i r t h w e i g h t .
Worthington-Roberts

( 1989) u s e d t h e MAR c o n c e p t t o d e t e r m i n e i f a

r e l a t i o n s h i p e x i s t e d b e t we e n o v e r a l l

d i e t q u a l i t y and c r a v i n g s

in a

90

g r o u p o f 173 l a c t a t o r s and 195 n o n - 1 a c t a t o r s . W o r t h i n g t o n - R o b e r t s
c a l c u l a t e d a MAR-16 whi c h i n c l u d e d NARs f o r c a l o r i e s ,
A, v i t a m i n D, v i t a m i n E, v i t a m i n C, t h i a m i n ,
12, c a l c i u m ,

riboflavin,

i r o n , magne s i um, z i n c and f o l i c a c i d .

included in the r e g r e s s i o n a n a l y s i s ,

protein,

vitamin

niacin,

B- 6,

B-

When t h e MAR-16 was

i t f a i l e d t o e x p l a i n any

s i g n i f i c a n t p o r t i o n o f t h e v a r i a n c e in t o t a l

cravings.

K r e b s - S m i t h ( 1989) u s e d b o t h a MAR-11 and a MAR-4 s c o r e as t h e
s t a n d a r d a g a i n s t whi c h a s i m p l i f i e d f ood f r e q u e n c y s c o r e was v a l i d a t e d .
The MAR-11 f o r m u l a i n c l u d e d p r o t e i n ,
phosphorus,

v i t a m i n A, t h i a m i n ,

riboflavin,

and v i t a m i n C. The MAR-4 f o r m u l a ,
and l a c t a t i n g women,

calcium,

iron,

magne s i um,

v i t a m i n B- 6,

v i t a m i n B-12

used t o a n a l y z e t h e d i e t s o f p r eg n a nt

i n c l u d e d c a l c i u m , magnes i um and v i t a m i n s A and C.

The s e n u t r i e n t s we r e i d e n t i f i e d as " p r o b l e m n u t r i e n t s " ,

or n u t r i e n t s

w i t h an a v e r a g e NAR be l ow 80 f o r p r e g n a n t and l a c t a t i n g women i n 274
participants

i n t h e USDA's 1977- 78 N a t i o n w i d e Food Co n s umpt i on S u r v e y .

I ndex o f D i e t Q u a l i t y (IDQ) o r N u t r i e n t Sum S c o r e (NSS).
The t e r m s " I n d e x o f D i e t Q u a l i t y "
and " N u t r i e n t Sum S c o r e "

(IDQ; W o r t h i n g t o n - R o b e r t s ,

(NSS; Ab d e l - Gh a n z ,

1974) a r e i d e n t i c a l

o f d i e t q u a l i t y . The NSS and IDQ b o t h i n d i c a t e t h e t o t a l

1989)

me a s u r e s

number o f

n u t r i e n t s f o r whi ch t h e i n t a k e me e t s o r e x c e e d s 67% o f t h e RDA s e l e c t e d .
A r b i t r a r y c u t - o f f p o i n t s ca n t h e n be s e l e c t e d t o c a t e g o r i z e t h e q u a l i t y
o f t h e d i e t o r t h e number can be e n t e r e d i n t o a r e g r e s s i o n e q u a t i o n t o
d e t e r m i n e t h e r e l a t i o n s h i p be t we e n IDQ and some out come v a r i a b l e .
Worthington-Roberts

(1989),

i n a d d i t i o n t o c a l c u l a t i n g t h e MAR-16,

c a l c u l a t e d an IDQ-16 t o d e t e r m i n e i f a r e l a t i o n s h i p e x i s t e d be t we en

91

overall

d i e t q u a l i t y and c r a v i n g s i n a g r o u p o f l a c t a t o r s and non-

lactators.

The IDQ-16 was c a l c u l a t e d by c o u n t i n g t h e number n u t r i e n t s

consumed i n amount s g r e a t e r t h a n 67% o f t h e RDA (NRC-RDA,
16 c o mp o n e n t s we r e c o n s i d e r e d ,

1980).

Be c a us e

t h e maximum IDQ was 16. Al t h o u g h b ot h

l a c t a t o r s and n o n - 1 a c t a t o r s consumed r e l a t i v e l y p o o r q u a l i t y d i e t s ,

the

IDQ-16 o f t h e l a c t a t o r s was s i g n i f i c a n t l y g r e a t e r t h a n n o n - 1 a c t a t o r s
( 9 . 8 4 vs 8 . 5 ,

p < 0.001).

No c o r r e l a t i o n was f o u n d b e t we e n t o t a l

c r a v i n g s and t h e IDQ- 16 s c o r e .

Index o f N u t r i t i o n a l

Quality

( INQ).

The c o n c e p t o f n u t r i e n t d e n s i t y ,

a comparison o f a f o o d ' s n u t r i e n t

c o n t e n t i n r e l a t i o n t o i t s e n e r g y v a l u e , was t h e b a s i s f o r t h e I ndex o f
Food Q u a l i t y ( IFQ) ,

l a t e r r enamed t h e I nde x o f N u t r i t i o n a l

(I NQ) . The INQ was f i r s t
( S o r e n s o n and Ha ns e n,

Quality

p r e s e n t e d by Hansen ( 1973) and S o r e n s o n

1 9 7 5 ) . The INQ i s a n u m e r i c a l

s c o r e b a s e d on t h e

n u t r i t i v e c o n t e n t o f a f ood and t h e human a l l o w a n c e f o r n u t r i e n t s

( Tseng

e t a l , 1 9 8 6 ) . The U n i t e d S t a t e s Recommended D a i l y Al l o wa n c e (USRDA)
(FDA,

1973),

a standard established for n u tritio n a l

f ood s e l e c t i o n o f t h e p o p u l a t i o n ,
whi c h a f o o d ' s n u t r i t i o n a l
USRDA f o r e n e r g y ,

content

2300 c a l o r i e s

l a b e l i n g to guide

i s o f t e n u s e d as t h e s t a n d a r d a g a i n s t
i s c o mp a r e d .

Be c a u s e t h e r e i s no

i s u s u a l l y c h o s e n as t h e e n e r g y s t a n d a r d

( S o r e n s o n e t a l , 1 9 7 6 ) . An INQ ca n be c a l c u l a t e d as f o l l o w s
al,

( Ts eng e t

1986):

INQ = Amount o f n u t r i e n t i n a f ood samole/US-RDA f o r t h a t n u t r i e n t
Number o f c a l o r i e s i n a f ood s a m p l e / E n e r g y R e q u i r e m e n t

92

When a s p e c i f i c n u t r i e n t i n a f ood h a s an INQ g r e a t e r t h a n o n e ,

it

d en ot es a r e l a t i v e l y hi g h e r n u t r i e n t - t o - c a l o r i e c o n t r i b u t i o n than the
US-RDA. C o n v e r s e l y ,

INQ v a l u e s l e s s t h a n one woul d i d e n t i f y n u t r i e n t s

in

f o o d s o f whi c h an e x c e s s o f c a l o r i e s must be consumed i n o r d e r t o meet
t h e US-RDA f o r t h e s e n u t r i e n t s

( Ha n s e n ,

1973; Wyse e t a l , 1 9 7 6 ) . G u t h r i e

( 1977) s u g g e s t e d c l a s s i f y i n g a f ood a s n u t r i t i o u s

i f t h e INQ f o r e a c h o f

f o u r o f t h e e i g h t n u t r i e n t s r e q u i r e d f o r n u t r i t i o n l a b e l i n g was a t l e a s t
o n e , o r i f t h e INQ f o r two o f t h e e i g h t n u t r i e n t s was a t l e a s t t wo.
Hansen and Wyse ( 1980) d e m o n s t r a t e d t h a t ,
Di eta ry allowances

(RDAs) we r e r e c a l c u l a t e d p e r 1000 c a l o r i e s

t h e RDAs woul d be c o n s t a n t a c r o s s a l l
nutrients.
of all

i f t h e Recommended
(RDA-1000,

age and s e x c a t e g o r i e s f o r most

N u t r i e n t d e n s i t y s c o r e s b a s e d on t h e RDA-lOOOs a l l o w s d i e t s

energy l e v e l s ,

consumed by i n d i v i d u a l s o f a l l

a g e s and s e x e s ,

to

be c ompa r ed due t o t h e common d e n o m i n a t o r . T h i s met hod a l s o a l l o w s d i e t s
o f i n d i v i d u a l s who o v e r e s t i m a t e o r u n d e r e s t i m a t e t o t a l
be c o mp a r e d .
as f o l l o w s

d i e t a r y in take to

I n d e x v a l u e s ba s e d on 1000 c a l o r i e s o f f ood a r e c a l c u l a t e d

( Hans en and Wyse,

1980) :

INQ-1000 = Amount o f n u t r i e n t i n 1000 c a l o r i e s o f f ood
Human a l l o w a n c e o f t h e n u t r i e n t p e r 1000 c a l o r i e s

N u t r i e n t d e n s i t y p r o f i l e s can be d e v e l o p e d u s i n g e i t h e r f o r m u l a
(INQ o r I NQ- 1000) . To d a t e no r e s e a r c h e r h a s summed and a v e r a g e d INQs o r
INQ- 1 0 00s f o r s e v e r a l
nutrient density.

n u t r i e n t s to c r e a t e a s i n g l e index of d i e t a r y

93

Indicator Nutrients.
P e n n i n g t o n ( 1976) a t t e m p t e d t o i d e n t i f y " i n d i c a t o r n u t r i e n t s "
that,

i f su p p lie d at adequate l e v e l s in a d i e t ,

woul d i n d i c a t e t h e

probable presence of adequate l e v e l s of o t h e r n u t r i e n t s

in t h e d i e t .

A

c o r r e l a t i o n m a t r i x was d e v e l o p e d among 45 n u t r i e n t s and t h e n " e y e b a l l e d " t o s e l e c t t h o s e n u t r i e n t s whi c h we r e h i g h l y c o r r e l a t e d .
Penni ngton u l t i m a t e l y s e l e c t e d seven i n d i c a t o r n u t r i e n t s :
v i t a m i n A, c a l c i u m ,

iron,

T h i s work was c r i t i c i z e d

f o lic acid,

pyridoxine,

magnes i um and p a n t o t h e n i c a c i d .

( J e n k i n s and G u t h r i e ,

o n l y 202 f o o d s consumed i n 100 g p o r t i o n s ,

1984) f o r b e i n g b a s e d on

and f o r u s i n g a d a t a b a s e f o r

whi c h t h r e e o f t h e s e v e n s e l e c t e d n u t r i e n t s we r e i n c o m p l e t e .
S u b s e q u e n t l y , J e n k i n s and G u t h r i e ( 1984) a n a l y z e d 3318 t h r e e - d a y r e c o r d s
from t h e 1 977- 1978 N a t i o n w i d e Food Cons umpt i on S u r v e y f o r 13 v i t a m i n s
and m i n e r a l s ,

c a r b o h y d r a t e and p r o t e i n . A c o r r e l a t i o n m a t r i x b e t we e n t h e

15 n u t r i e n t s was c o n s t r u c t e d and s u b m i t t e d t o a f a c t o r a n a l y s i s w i t h an
orthogonal

varimax r o t a t i o n .

nutrients,

we r e i d e n t i f i e d .

iron,

pyridoxine,

Four f a c t o r s ,

or groupings of alike

From t h e g r o u p i n g ,

fo u r index n u t r i e n t s ,

c a l c i u m and v i t a m i n A, we r e s e l e c t e d .

ho we v e r , no s t u d y ha s be e n i d e n t i f i e d

To d a t e ,

i n whi c h t h e s e f o u r i n d i c a t o r

n u t r i e n t s we r e u s e d i n a MAR i n d e x .
In sum,

" D i e t q u a l i t y " was d e f i n e d as " t h e n u t r i t i o n a l

t h e d i e t consumed as c ompar ed t o some s t a n d a r d " ,
RDA, 1989) o r t h e USRDAs (FDA,

1973).

adequacy of

u s u a l l y t h e RDAs (NRC-

F i v e me t h o d s o f q u a n t i f y i n g d i e t

q u a l i t y we r e p r e s e n t e d . A l t h o u g h s e v e r a l m e a s u r e s o f d i e t q u a l i t y e x i s t ,
none i s c o n s i d e r e d i d e a l

( Ts eng e t a l ,

1986).

94

C o n c l u s i o n : D i e t Q u a l i t y and P r e g n a n c y Outcome
The m a g n i t u d e o f n u t r i t i o n a l

e f f e c t s on low b i r t h w e i g h t a r e n o t

e a s i l y assessed because n u t r i t i o n a l

s t a t u s i s d i f f i c u l t t o i s o l a t e from

o t h e r s o c i o e c o n o m i c c h a r a c t e r i s t i c s and b e c a u s e t h e c o m p l i c a t e d r e l a t i o n
be t we e n p r e p r e g n a n t w e i g h t and w e i g h t g a i n d u r i n g p r e g n a n c y . Whi l e
r e s e a r c h e r s ha ve f o u n d p o s i t i v e c o r r e l a t i o n s b e t we e n b i r t h w e i g h t and
nutritional

status,

associations.
studies,

i s wi de v a r i a b i l i t y i n t h e d e g r e e o f t h e s e

A reasonable conclusion,

i s t h a t poor n u t r i t i o n a l

nutritional

b a s e d on b o t h ani mal

status

and human

b e f o r e p r e g n a n c y and i n a d e q u a t e

c o n s u m p t i o n d u r i n g p r e g n a n c y a p p e a r t o ha ve a n e g a t i v e

i mp a c t on f e t a l
weight.

there

weight g a in ,

t h e r e b y i n c r e a s i n g t h e r i s k o f l ow b i r t h

95

Table 2.7.

Comparison of nutrients used to calculate various diet quality scores.

Author:

Worthington-Roberts

Krebs-Smith

Jenkins/Guthrie

Phi 11ips/Johnson

Year:

1989

1989

1984

1977

Formula:

MAR-16
and
IDQ-16

MAR-11
and
MAR-4

Indicator Nutrients

MAR-12

Nutrients:

calories
protein
vitamin A
vitamin D
vitamin E
vitamin C
thi amin
riboflavin
niacin
B-6
B-12
calcium
iron
magnesium
zinc
folic acid

vitamin A

protein
vi tamin A

A

protein w
vitamin A
*
vitamin C
th iami n
riboflavin
B-6
B-12
calcium
iron
magnes iurn

B-6
calci urn
iron

vitamin C
thiamin
riboflavin
niacin
B-6
B-12
calcium
iron
magnesium

phosphorus
pantothenic acid
Did not use in a
diet quality score;
were identified in
factor analysis as
nutrients which
represented total
nutrient intake.

Purpose:

Relation between
diet quality and
cravings in a group
of lactators and
nonlactators.

Validate a
simplified
food frequency
form.

Results:

No relation between
diet quality/craviings
were observed with
either MAR-4 or MAR-16
in multiple regression
analysis.

MAR-4 & MAR-11
were used as the
"gold standard"
in sensitivity and
specificity formulas.

Examine relation
between diet
quality & birth
weight in
regression
analysis.

Explained 6-7%
of the variance
in birth weight.

96

Maternal A t t i t u d e

In a d d i t i o n t o m e d i c a l ,
factors,

several

s o c i o d e m o g r a p h i c and b e h a v i o r a l

risk

r e s e a r c h e r s have t r i e d , w i t h v a r i a b l e s u c c e s s ,

c o r r e l a t e psychosocial conditio n s

(i.e.,

stress,

social

to

s u p p o r t system,

b e l i e f s and s u p e r s t i t i o n s ) w i t h p r e g n a n c y out come ( Mamel l e e t a l , 1989;
Newton and Hunt ,

1984; N u c k o l l s e t a l , 1972; P a s c o e e t a l , 1 9 8 4 ) . Th i s

section of the l i t e r a t u r e

review wi ll

f o c u s on t h o s e few s t u d i e s whi ch

ha ve a t t e m p t e d t o d e t e r m i n e wha t r e l a t i o n s h i p ,

i f any, e x i s t s be t we e n

a t t i t u d e s d u r i n g p r e g n a n c y and p r e g n a n c y o u t c ome .

A t t i t u d e Toward Wei ght Gai n Du r i n g P r e g n a n c y
Pa l me r e t al

( 1985) d e v e l o p e d a q u e s t i o n n a i r e w i t h 18 s t a t e m e n t s

e x p r e s s i n g a t t i t u d e s o f p r e g n a n t women t o w a r d t h e i r own p r e g n a n c y w e i g h t
gain. A ttitudinal

d a t a was o b t a i n e d p r o s p e c t i v e l y f r om 29 w h i t e , m i d d l e -

c l a s s women e n r o l l e d i n c h i l d b i r t h c l a s s e s

i n P u l l m a n , Wa s h i n g t o n .

A c t u a l w e i g h t g a i n i n f o r m a t i o n and i n f a n t b i r t h w e i g h t we r e o b t a i n e d
f r om t h e p a r t i c i p a n t ' s p h y s i c i a n .

R e l ia b i li ty of the Likert-format

a t t i t u d e q u e s t i o n n a i r e was d e t e r m i n e d by t h e Spearman Brown Pr o p h e c y
s p l i t - h a l f formula ( r = 0 . 6 7 ) .

S c o r e s o f t h e 18 w e i g h t g a i n a t t i t u d e

s t a t e m e n t s we r e summed and a v e r a g e d t o y i e l d a c o m p o s i t e a t t i t u d e s c o r e
f o r each p a r t i c i p a n t .

P o s s i b l e s c o r e s r a n g e d f rom 1 . 0 0 (a v e r y n e g a t i v e

a t t i t u d e t o w a r d w e i g h t g a i n ) t o 5 . 0 0 (a v e r y p o s i t i v e a t t i t u d e t o wa r d
weight gain during pregnancy).

97

Q u e s t i o n n a i r e s c o r e s o f t h e 29 s u b j e c t s r a n g e d f r om 2 . 1 1 t o 4 . 3 3
( m e d i a n = 3 . 0 6 ; mean s c o r e = 3 . 1 2 ) .

The i n v e s t i g a t o r s c h o s e t o d i c h o t o m i z e

t h e d a t a and a n a l y z e r e s u l t s u s i n g t h e n o n p a r a m e t r i c Chi s q u a r e t e s t .
Any a t t i t u d e s c o r e g r e a t e r t h a n o r e q u a l

t o 3 . 0 0 was c l a s s i f i e d a s a

positive attitude

( n = 1 7 ) ; any s c o r e l e s s t h a n 3 . 0 0 was c l a s s i f i e d as a

negative a ttitu d e

( n = 1 2 ) . Mean s c o r e s we r e 3 . 4 2 and 2 . 7 2 f o r t h e

p o s i t i v e and n e g a t i v e a t t i t u d e g r o u p s ,

respectively.

No s i g n i f i c a n t

r e l a t i o n s h i p was o b s e r v e d be t we e n a t t i t u d e c l a s s i f i c a t i o n

and a g e ,

number o f p r e v i o u s p r e g n a n c i e s o r knowl edge o f a p p r o p r i a t e w e i g h t g a i n .
T h e r e was ,

h o we ve r ,

a s i g n i f i c a n t r e l a t i o n s h i p b e t we e n t h e womens'

w e i g h t g a i n a t t i t u d e s c o r e and a c t u a l w e i g h t g a i n
p < 0.025),

(Chi s q u a r e = 5 . 6 2 ,

and be t we e n w e i g h t g a i n a t t i t u d e s c o r e and t h e p h y s i c i a n ' s

w e i g h t g a i n r e c o mme n d a t i o n (Chi

square=4.99.

p < 0.05).

Significant

r e l a t i o n s h i p s we r e a l s o i n d i c a t e d be t we e n a c t u a l w e i g h t g a i n e d and o n e ' s
knowl e dge o f a p p r o p r i a t e w e i g h t g a i n (Chi s q u a r e = 3 . 9 3 .
actual

p < 0.05),

and

w e i g h t g a i n e d and d o c t o r ' s w e i g h t g a i n r e c o mme n d a t i o n (Chi

square=4.55,

p < 0.05).

Lastly,

t h e r e was a s i g n i f i c a n t r e l a t i o n s h i p

b e t we e n b i r t h w e i g h t and a c t u a l w e i g h t g a i n (Chi s q u a r e = 9 . 3 5 ,

p < 0.01).

The r e l a t i o n s h i p b e t we e n w e i g h t g a i n a t t i t u d e s c o r e and i n f a n t b i r t h
w e i g h t was n o t d e t e r m i n e d i n t h i s s ma l l
Pome r ance e t al

study.

( 1980) s u r v e y e d 195 p r e g n a n t women t o d e t e r m i n e

t h e i r a t t i t u d e s t o w a r d d i e t i n g and w e i g h t g a i n d u r i n g p r e g n a n c y .

The

r e s e a r c h e r s a s k e d how much w e i g h t t h e s u b j e c t s t h o u g h t t h e y s h o u l d g a i n
dur ing pregnancy, whether the s u b je c t ever d i e t e d immediately before
going t o the d o c t o r ' s o f f i c e ,
woul d be u p s e t by " t o o l i t t l e "

and w h e t h e r t h e s u b j e c t f e l t h e r d o c t o r
o r " t o o much" w e i g h t g a i n .

98

T h i r t y - s e v e n p e r c e n t o f p a t i e n t s b e l i e v e d t h e y s h o u l d g a i n 20
pounds o r l e s s d u r i n g p r e g n a n c y ,

52% r e s p o n d e d 2 1 - 3 0 p o u n d s ,

p e r c e n t t h o u g h t t h e y s h o u l d g a i n more t h a n 30 p o u n d s .
a d m i t t e d t o d i e t i n g b e f o r e a t l e a s t one a n t e n a t a l

and f o u r

Eight perc e nt

visit.

Although t h e

t e r m s " t o o l i t t l e w e i g h t g a i n " and " t o o much w e i g h t g a i n " we r e n o t
d e f i n e d , more p a t i e n t s t h o u g h t t h e i r d o c t o r s woul d be more c o n c e r n e d
w i t h " t o o much" ( 88%), t h a n " t o o l i t t l e

(39%), w e i g h t g a i n .

No a t t e m p t

was made i n t h i s s t u d y t o c o r r e l a t e a t t i t u d e t o w a r d w e i g h t g a i n w i t h
a c t u a l w e i g h t g a i n o r w i t h i n f a n t b i r t h w e i g h t . The a u t h o r s c o n c l u d e d
that,

in t h i s

deficiencies

s e l e c t group o f pregnant p a t i e n t s ,
in t h e u n d e r s t a n d i n g o f n u t r i t i o n a l

ga in in pregnancy,

t h e r e we r e s u b s t a n t i a l
g u i d e l i n e s and w e i g h t

and t h a t o b s t e t r i c i a n s p l a y a key r o l e i n d e t e r m i n i n g

dietary practices.

A t t i t u d e Toward N u t r i t i o n Dur i ng P r e g n a n c y
S c h w a r t z and B a r r ( 1977)

s u r v e y e d 150 m o t h e r s o f ne wbor ns i n

Va n c o u v e r t o d e t e r m i n e t h e i r a t t i t u d e s and p r a c t i c e s r e g a r d i n g m a t e r n a l
and i n f a n t n u t r i t i o n .

The o b j e c t i v e o f t h e s t u d y was t o p r o v i d e

b a c k g r o u n d i n f o r m a t i o n and d i r e c t i o n t o h e a l t h p r o f e s s i o n a l s
with the planning of prenatal
whi c h s ound n u t r i t i o n

involved

p r o g r a ms and t o i d e n t i f y means t h r o u g h

i n f o r m a t i o n c o u l d be c ommuni c a t e d t o t h e m a t e r n a l

p o p u l a t i o n . The s u b j e c t s a n s we r e d 23 s t a t e m e n t s r e f l e c t i n g t h e i r
a t t i t u d e t o w a r d v a r i o u s a s p e c t s o f n u t r i t i o n d u r i n g p r e g n a n c y and
infancy.

Each o f t h e 23 a t t i t u d e s t a t e m e n t was s c o r e d f r om z e r o

(negative a t t i t u d e ,
correct belief).

incorrect belief)

t o seven ( p o s i t i v e a t t i t u d e ,

The s c o r e s we r e t o t a l e d and a p e r c e n t - c o r r e c t s c o r e

99

determined ( i . e . ,

"X" p o i n t s / 1 6 1 p o s s i b l e p o i n t s x 1 0 0 ) . T h i s s c o r e was

c o n s i d e r e d t h e " a t t i t u d e t o w a r d n u t r i t i o n d u r i n g p r e g n a n c y and i n f a n c y "
construct.

De mogr a phi c d a t a we r e o b t a i n e d f r om t h e p a t i e n t s '

me d i c a l

charts.
R e s u l t s i n d i c a t e d t h e p h y s i c i a n was t h e m a j o r s o u r c e o f n u t r i t i o n
i n f o r m a t i o n f o r t h e p r e g n a n t women ( 6 2 . 2 %) . The h i g h e s t mean s c o r e o f
6 . 8 (maximum=7) was o b t a i n e d f o r t h e a t t i t u d e s t a t e m e n t "Good e a t i n g
h a b i t s dur ing pregnancy are very important to the baby's h e a l t h " .
t h e l o w e s t mean s c o r e s

One o f

( 4 . 4 ) was o b t a i n e d f o r t h e a t t i t u d e s t a t e m e n t

" Wei ght g a i n d u r i n g p r e g n a n c y s h o u l d be k e p t down t o 20 pounds t o make
delivery easier".
statement

(i.e.,

T h i s s c o r e i n d i c a t e d many women a g r e e d w i t h t h i s
t h e " c o r r e c t " a n s we r o f 7 . 0 woul d have been o b t a i n e d by

d i s a g r e e i n g with t h i s

statement).

Variables p o s itiv e ly related to t h is 23-question n u t r i ti o n
a t t i t u d e score included a n u cle ar family s t r u c t u r e
socioeconomic s t a t u s

(p < 0 . 0 0 0 0 1 ) ,

(p < 0 . 0 1 ) ,

having completed a high school

e d u c a t i o n o r more (p < 0 . 0 0 1 )

and a t t e n d a n c e a t p r e n a t a l

(p < 0 . 0 0 1 ) .

prenatal

Women who l i s t e d

source of prenatal
or other source,
a tt i t u d e scores

nutrition

as a s o u r c e o f n u t r i t i o n
a tt i t u d e scores.

class

information,

classes

i n s t r u c t o r s as t h e i r m a j o r

as opposed t o t h e i r p h y s i c i a n

had s i g n i f i c a n t l y h i g h e r (more p o s i t i v e )
(p < 0 . 0 1 ) .

higher

nutrition

In c o n t r a s t , women who named t h e i r p h y s i c i a n

i n f o r m a t i o n had s i g n i f i c a n t l y l o w e r n u t r i t i o n

No i n f o r m a t i o n was p r e s e n t e d c o r r e l a t i n g n u t r i t i o n

a t t i t u d e s c o r e s t o e i t h e r t h e amount o f w e i g h t g a i n e d d u r i n g p r e g n a n c y ,
b i r t h weight of t he i n f a n t ,
pregnancy.

or the q u a li ty of the mother's d i e t s during

100

R o s a n d e r and Sims ( 1981) d e v e l o p e d and t e s t e d an a f f e c t i v e - b a s e d
n u t r i t i o n e d u c a t i o n pr o g r a m t h a t pr o mo t e d i mpr ove me nt o f a t t i t u d e s

about

n u t r i t i o n and h e a l t h as a way t o i mpr ove d i e t a r y b e h a v i o r d u r i n g
pregnancy.

The s t u d y was d e s i g n e d t o t e s t t h e h y p o t h e s i s t h a n b e h a v i o r

c h a n g e i s d e p e n d e n t upon a t t i t u d e c h a n g e ,

and t h a t a t t i t u d e c h a n g e

p r e c e d e s b o t h knowl e dge a c q u i s i t i o n and b e h a v i o r c h a n g e . The p r o g r a m was
t e s t e d on a g r o u p o f 23 WIC p a r t i c i p a n t s who a t t e n d e d t h r e e a f f e c t i v e ba s e d n u t r i t i o n e d u c a t i o n l e s s o n s .

R e s u l t s we r e c ompa r e d t o a g r o u p o f

22 WIC p a r t i c i p a n t s who c o m p l e t e d a p r e - and p o s t - t e s t b u t d i d n o t
attend the n u t r i t i o n c la s s e s .
nutrition

knowl edge t e s t ,

Evaluation instruments included a

two a t t i t u d e q u e s t i o n n a i r e s and a f ood

f r e q u e n c y f o r m. The 1 4 - i t e m a t t i t u d e q u e s t i o n n a i r e ,

c onsisting of a

f i v e - p o i n t L i k e r t s c a l e r a n g i n g f r om " s t r o n g l y a g r e e "
disagree"

(5),

( 1) t o " s t r o n g l y

c o n t a i n e d f o u r o r f i v e i tems f o r each o f t h r e e a p r i o r i

a t t i t u d e c o n s t r u c t s as s u g g e s t e d by Sims ( 1 9 8 1 ) .

F a c t o r a n a l y s i s was

used t o determine the u n i d im e n s i o n a li ty of the a t t i t u d e q u e s t i o n n a i r e
and t o v a l i d a t e t h e a p r i o r i
analysis resulted

in the o r i g i n a l

r e d u c e d t o two c o n s t r u c t s :
items)

attitude constructs.

Results of fac to r

t h r e e c o n s t r u c t s and 14 i t e m s b e i n g

"Personal

Control over Eating Habits"

and " F o o d ' s E f f e c t on H e a l t h and F e e l i n g s "

(5 i t e m s ) .

(4

The

Cr onba c h a l p h a c o e f f i c i e n t o f r e l i a b i l i t y f o r t h e two s c a l e s we r e 0 . 6 3
and 0 . 6 4 ,

respectively.

An a d a p t a t i o n o f t h e D i e t a r y A s s e s s me n t S c r e e n i n g T o o l , d e v e l o p e d
by t h e C a l i f o r n i a D e p a r t m e n t o f H e a l t h S e r v i c e s
19 7 9 ) ,

( F o r e s t e r and R e y n o l d s ,

was u s e d by R o s a n d e r and Sims t o a s s e s s d i e t a r y b e h a v i o r .

Th i s

t o o l gave p o i n t v a l u e s f o r fre qu en cy o f consumption o f each o f t he

101

f o l l o w i n g seven food gr o up s: d a i r y p r o d u c t s ,
protein,

f r u i t or ju ic e ,

a ni ma l p r o t e i n ,

folacin-rich vegetables,

v e g e t a b l e s and b r e a d s and c e r e a l s .
f o o d g r o u p and f o r t h e t o t a l

vegetable

other fru its

and

A d i e t a r y s c o r e was comput e d f o r e a c h

diet.

Results indicated a s i g n i f ic a n t,

p o s i t i v e i n c r e a s e in n u t r i t i o n

knowl e dge (p < 0 . 0 0 1 ) among t h o s e s u b j e c t s who p a r t i c i p a t e d
affective-based n u t ritio n education in te rv en tio n s.

in the t h r e e

No d i f f e r e n c e s wer e

f ound b e t we e n t h e u n i n s t r u c t e d and i n s t r u c t e d g r o u p s ' mean p r e t e s t
a t t i t u d e s c o r e s on e i t h e r o f t h e two s c a l e s .

Upon p o s t - t e s t i n g ,

i n s t r u c t e d g r o u p had s i g n i f i c a n t l y g r e a t e r mean a t t i t u d e
t h e i r own p r e t e s t s c o r e s

the

sc ore s than

(P < 0 . 0 1 ) and t h e p o s t - t e s t s c o r e s o f t h e

u n i n s t r u c t e d g r o u p (p < 0 . 0 0 1 ) .

After n u tritio n

intervention,

in

a d d i t i o n t o d e v e l o p i n g a more p o s i t i v e a t t i t u d e t o w a r d n u t r i t i o n ,
i n s t r u c t e d g r o u p p r e s e n t e d i mpr ove d d i e t a r y s c o r e s f o r a l l
S ta tistica lly significant

f ood g r o u p s .

i mp r o v e me n t s i n n u t r i t i o n b e h a v i o r ( d i e t a r y

i n t a k e ) we r e n o t e d f o r t h e t h r e e t a r g e t e d f ood g r o u p s
v e g e t a b l e and b r e a d s and c e r e a l s ) ,
The a u t h o r s c o n c l u d e d t h a t ,
three sessions,

the

as we l l

(dairy,

as i n t h e t o t a l

green

diet

score.

among t h e WIC c l i e n t s who a t t e n d e d

the a f f e c t i v e - b a s e d approach to n u t r i t i o n educatio n

i mpr ove d n u t r i t i o n

k n o wl e d g e , a t t i t u d e s

c o r r e l a t i o n be t we e n t o t a l

and b e h a v i o r s .

d i e t a r y s c o r e and n u t r i t i o n

Neither the
k n o wl e d g e ,

a t t i t u d e s c o r e o r i n f a n t b i r t h w e i g h t we r e p r e s e n t e d .
Ande r s on and S h e p h e r d ( 1989) d e v e l o p e d a q u e s t i o n n a i r e t o i d e n t i f y
t h e b e l i e f s and a t t i t u d e s t h a t s u r r o u n d h e a l t h f u l

f ood c h o i c e s d u r i n g

p r e g n a n c y . The aim o f t h e i r s t u d y was t o e v a l u a t e t h e r o l e o f F i s h b e i n
and A z j e n ' s

( 1975)

" e x p e c t a n c y v a l u e model " i n p r e d i c t i n g

i n t e n t i o n to

102

try "healthful

e a ti n g " during pregnancy in o r d e r to i d e n t i f y s p e c i f i c

v a r i a b l e s t o t a r g e t in a n t e - n a t a l
F i s h b e i n and Az j e n model
constructs,
pressure),

attitude

s t a t e s t h a t t h e two t h e o r e t i c a l l y - l i n k e d

(personal

are c e n tral

n u t r i t i o n e d u c a t i o n p r o g r a m s . The

feelings)

and s u b j e c t i v e norm ( s o c i a l

to the p r e d i c t i o n of the i n t e n t to perform a

s p e c ific behavior. A ttitude,

in t u r n ,

i s p r e d i c t e d by i n d i v i d u a l ' s

b e l i e f s a b o u t t h e out come o f t h e b e h a v i o r ( i . e . ,
beneficial
(i.e.,

to the baby),

breastfeeding is

and m o d i f i e d by t h e e v a l u a t i o n o f t h e out come

w h e t h e r o r n o t you a r e c o n c e r n e d a b o u t t h e b e n e f i t s b r e a s t f e e d i n g

o f f e r s t h e b a b y ) . The s u b j e c t i v e norm i s p r e d i c t e d by t h e n o r m a t i v e
b e l i e f s about whether the i nd ivi dua l

thinks specific

r e f e r e n t s p r e f e r t hem t o a c t a c e r t a i n way ( i . e . ,
mother-in-law think breastfeeding is

i n d iv id u a ls or

the doctor,

husband or

i m p o r t a n t t o t h e b a b y ) , m o d i f i e d by

t h e i n d i v i d u a l ' s m o t i v a t i o n t o compl y w i t h t h e w i s h e s o f t h e s e
influential

individuals.

The q u e s t i o n n a i r e ,

c o m p r i s e d o f 25 s t a t e m e n t s w i t h a s e v e n -

c a t e g o r y L i k e r t r e s p o n s e , was c o m p l e t e d by 95 women a t t h e Abe r de e n
Maternity Hospital.
determined.

Content,

Five c o n s t r u c t s

f a c e and c o n s t r u c t v a l i d i t y we r e
(behavioral

intention,

direct attitude,

d i r e c t s u b j e c t i v e norm, e s t i m a t e d a t t i t u d e and e s t i m a t e d s u b j e c t i v e
norm) we r e d e s i g n e d .

R e l i a b i l i t y was a s s e s s e d by C r o n b a c h ' s a l p h a .

More

t h a n h a l f o f t h e women i n d i c a t e d a p o s i t i v e i n t e n t i o n t o t r y e a t i n g
h e a l t h i e r while pregnant.

Scores f o r behavioral

c o r r e l a t e d with sc ores f o r d i r e c t a t t i t u d e s
in t u r n ,

i n t e n t i o n we r e s t r o n g l y

(r=0.50,

c o r r e l a t e d we l l w i t h e s t i m a t e d a t t i t u d e s

p < 0.001),

(r=0.30,

wh i c h ,

p < 0.002).

The a u t h o r s d i d n o t c o r r e l a t e d any a t t i t u d e c o n s t r u c t w i t h i n f a n t b i r t h

103

w e i g h t o r w i t h any m e a s u r e o f a c t u a l
more b e n e f i c i a l

educational

dietary intake.

Results

suggested a

t e c h n i q u e t o change d i e t a r y h a b i t s d ur in g

p r e g n a n c y woul d be t o f o c u s on u n d e r l y i n g b e l i e f s and a t t i t u d e s
n u t r i t i o n d u r i n g p r e g n a n c y and i n f a n c y ,

about

r a t h e r than simply c o n c e n t r a t i n g

on i n f o r m a t i o n t r a n s f e r .

A t t i t u d e Toward Bei ng P r e g n a n t and P r e g n a n c y Out come
Al t h o u g h a c a u s a l r e l a t i o n s h i p b e t we e n a m o t h e r ' s a t t i t u d e t o wa r d
b e i n g p r e g n a n t and n e g a t i v e c o n s e q u e n c e s i s p l a u s i b l e

( Pohl ma n,

few d a t a have been p u b l i s h e d t o s u p p o r t o r r e f u t e t h i s
La u k a r a n and van den Ber g ( 1980)
maternal

1969),

hypothesis.

i n v e s t ig a t e d the r e l a t i o n s h i p of

a t t i t u d e t o wa r d b e i n g p r e g n a n t t o p r e g n a n c y out come and

obstetrical

complications

in a p r o s p e c t i v e study of 8,000 gr avi da s

e n r o l l e d i n t h e C h i l d H e a l t h and De ve l opme nt S t u d y o f t h e K a i s e r
F o u n d a t i o n H e a l t h Pl a n i n San F r a n c i s c o .

I n t e r v i e w s we r e c o n d u c t e d e a r l y

i n p r e g n a n c y . The m o t h e r ' s a t t i t u d e was d e t e r m i n e d t h r o u g h a s i n g l e ,
open-ended q u e s ti o n ,

"How do you f e e l

a b o u t h a v i n g a baby now?". The

r e s p o n s e s we r e c a t e g o r i z e d as s t r o n g l y f a v o r a b l e
favorable

( 1 5 . 0 %) ,

ambivalent

( 22. 4%) and n e g a t i v e

p r e g n a n c y o u t c ome , d u r a t i o n o f l a b o r ,
c o m p l i c a t i o n s and p r e n a t a l
me d i c a l

( 5 6 . 4 %) ,

moderately

( 6 . 2 % ) . Da t a on

a n a lg e s ic use,

pregnancy

a c c i d e n t s we r e a b s t r a c t e d f rom t h e womens'

records.

After controlling for parity,

h u s b a n d ' s o c c u p a t i o n and age o f t h e

m o t h e r , C o c h r a n ' s C h i - s q u a r e and t h e M a n t e l - H a e n z e l

adjusted

relative

r i s k (RR) we r e u s e d t o c ompa r e t h e r i s k s b e t we e n t h e " d e f i n i t e l y wa nt e d"
and t h e " d e f i n i t e l y unwa nt e d" p r e g n a n c i e s .

Women w i t h m o d e r a t e l y

104

p o s i t i v e and a m b i v a l e n t a t t i t u d e s we r e d i s r e g a r d e d i n t h e a n a l y s i s . A
negative maternal

a t t i t u d e t o w a r d b e i n g p r e g n a n t was r e l a t e d t o an

increased incidence of p e r i n a ta l death

(fetal

d e a t h a t 120+ d a y s and

n e o n a t a l d e a t h w i t h i n 28 d a y s f o l l o w i n g b i r t h ;
congenital

a n o m a l i e s (p < 0 . 0 4 ,

h e mo r r h a g e (p < 0 . 0 0 4 ,

RR=1. 4 5 ) ,

for psychological

(p < 0 . 0 0 0 1 ,

i n j u r y d u r i n g p r e g n a n c y (p < 0 . 0 0 0 0 1 ,
a n a l g e s i c s d u r i n g l a b o r (p < 0 . 0 0 0 1 ,

RR= 2 . 6 6 ) ,

length of labor,

pre-eclampsia,

prenatal

accidental

RR=1.45) and t h e n e e d f o r
RR=1. 40) . M a t e r n a l

t h e p r e g n a n c y was n o t r e l a t e d t o i n f a n t b i r t h w e i g h t ,
gestation,

RR=1. 80) ,

p o s t p a r t u m i n f e c t i o n or

RR= 1 . 6 6 ) , c l i n i c v i s i t s

complaints rela te d to anxiety s t a t e

p < 0.003,

complications

placenta previa prior to labor,

a t t i t u d e t o wa r d

d u r a t i o n of

(i.e.,

eclampsia,

i ncompet ent c e r v i x or

p r e m a t u r e r u p t u r e o f t h e membrane) o r i n t r a p a r t u m o b s t e t r i c a l
complications

(i.e.,

hemorrhage, p l a c e n t a l

abnormalities,

c o r d , meconi um s t a i n i n g o r i n t r a p a r t u m t r a n s f u s i o n ) .
i n t e r v a l s f o r t h e r e l a t i v e r i s k s we r e n o t r e p o r t e d .
justification

f o r c o n s i d e r i n g maternal

r is k fa c to r regarding fe ta l

attitude

prolapsed

Confidence
Th e s e r e s u l t s o f f e r

a c l i n i c a l l y meaningful

o u t c ome .

C o n c l u s i o n : A t t i t u d e and P r e g n a n c y Outcome
Few s t u d i e s ha ve a d d r e s s e d t h e r e l a t i o n s h i p b e t we e n m a t e r n a l
a t t i t u d e s d u r i n g p r e g n a n c y and m a t e r n a l w e i g h t g a i n ,
p r e g n a n c y o u t c o me .
universal

d i e t q u a l i t y or

R e s e a r c h e r s i n t h i s a r e a h a v e n o t a g r e e d on e i t h e r a

d efin itio n of "attitude"

and/or analyze a t t i t u d e c o n s tr u c ts

o r a p p r o p r i a t e t e c h n i q u e s t o me a s u r e
( Si ms ,

1981).

Furthermore,

no s t u d y

t o d a t e a p p e a r s t o ha ve i n v e s t i g a t e d t h e r e l a t i o n s h i p b e t we e n a t t i t u d e s

105

t o w a r d s p e c i f i c c o n s t r u c t s and s u b s e q u e n t i n f a n t b i r t h w e i g h t .
Additional

r e s e a r c h i s n e e d e d b e f o r e i t can be d e t e r m i n e d i f o n e ' s

a t t i t u d e toward weight g a i n d u r i n g pregnancy, o r toward being pr eg n an t
in g e n e r a l ,

i n f l u e n c e s ac tu a l weight gain a n d /o r subsequent i n f a n t b i r t h

w e i g h t , o r i f o n e ' s a t t i t u d e t o wa r d n u t r i t i o n d u r i n g p r e g n a n c y
influences actual d i e t a r y intake and/or in fa n t b i r t h weight.

H e a l t h Ca r e R i s k s
Two h e a l t h c a r e r i s k s have been a s s o c i a t e d w i t h an i n c r e a s e d
i n c i d e n c e o f LBW: 1) a b s e n t / i n a d e q u a t e p r e n a t a l
prematurity,

i.e.,

p r e m a t u r e d e l i v e r y due t o some me d i c a l

( I n s t i t u t e o f Medicine,
will

c a r e and 2) i a t r o g e n i c

1985). This s e c t i o n o f t h e l i t e r a t u r e

f o c u s o n l y on t h e r e l a t i o n o f p r e n a t a l

Prenatal

In t h i s c e n t u r y ,

review

care to b i r t h weight.

Ca r e

t h e h e a l t h c a r e s e r v i c e mos t r e l i e d upon t o

a s s u r e p o s i t i v e p r e g n a n c y out come ha s been p r e n a t a l
In g e n e r a l ,

intervention

women who r e c e i v e p r e n a t a l

care

(DHHS,

1989b).

care during the f i r s t trim e s te r

ha ve b e t t e r p r e g n a n c y o u t c o me s t h a n women who ha ve l i t t l e

o r no p r e n a t a l

c a r e (NCHS, 1 9 8 8 ) .
The r e c e n t r e p o r t C a r i n g f o r Our F u t u r e : The C o n t e n t o f P r e n a t a l
Ca r e (DHHS, 1989b, p. 5) s t a t e d t h e o b j e c t i v e s o f p r e n a t a l
p r e g n a n t woman a r e :
a f t e r pregnancy,

1) t o i n c r e a s e h e r w e l l - b e i n g b e f o r e ,

care for the
d u r i n g and

and t o i mpr ove h e r s e l f - i m a g e and s e l f - c a r e ,

2) t o

106

r e d u c e m a t e r n a l m o r t a l i t y and m o r b i d i t y ,
pregnancy i n t e r v e n t i o n s ,

fetal

l o s s and u n n e c e s s a r y

3) t o r e d u c e t h e r i s k s t o h e r h e a l t h p r i o r t o

s u b s e q u e n t p r e g n a n c i e s and beyond c h i l d b e a r i n g y e a r s and 4) t o p r o mo t e
t h e development o f p a r e n t i n g s k i l l s .
infants are:

1) t o i n c r e a s e w e l l - b e i n g ,

i n t r a u t e r i n e growth r e t a r d a t i o n ,
thrive,

O b j e c t i v e s f o r t h e f e t u s and t h e
2) t o r e d u c e p r e t e r m b i r t h ,

congenital

a n o m a l i e s and f a i l u r e t o

3) t o p r o mo t e h e a l t h y g r o wt h and d e v e l o p m e n t ,

health supervision,

i m m u n i z a t i o n and

4) t o r e d u c e n e u r o l o g i c , d e v e l o p m e n t a l

m o r b i d i t i e s and 5) t o r e d u c e c h i l d a b u s e and n e g l e c t ,
p r e v e n t a b l e a c u t e and c h r o n i c i l l n e s s

and o t h e r

injuries,

and t h e n e e d f o r e x t e n d e d

hospitalization after birth.
Despite these w ell-intentioned objectives,

r e s u l t s o f an

i n v e s t i g a t i o n by t h e Al an G u t t m a c h e r I n s t i t u t e

(AGI,

o f p r e g n a n t women,

a r e g e t t i n g what i s

some 1 . 3 m i l l i o n e a c h y e a r ,

generally considered i n s u f f ic i e n t prenatal
not begin care u n t i l
s ta r t until

care.

1986) e s t i m a t e d 34%

An e s t i m a t e d 6 6 2 , 0 0 0 do

t h e second t r i m e s t e r o f p r egna nc y;

t h e t h i r d t r i m e s t e r o r g e t no c a r e a t a l l .

393,000 i n i t i a t e c a r e in t h e f i r s t
The p e r c e n t a g e o f women g e t t i n g
u n m a r r i e d ( 58%), t e e n a g e r s
( 51%) , H i s p a n i c s

trimester,

i n s u f f ic i e n t care

b u t more t h a n t h e n i n e and s e v e n v i s i t s
Ca r e (NCHS,

( 53%) , b l a c k s

1 9 8 6 ) . Women make an

somewhat f e w e r t h a n t h e 13 recommended

by t h e Ame r i c a n C o l l e g e o f O b s t e t r i c i a n s

Content of P re na ta l

i s h i g h e s t among t h e

( 56%) , t h e l e a s t - e d u c a t e d

visits,

An a d d i t i o n a l

b u t make v e r y few v i s i t s .

(47%) and t h e p o o r (47%) (AGI,

ave ra ge o f 10.5 p r e n a t a l

2 0 7 , 0 0 0 do no t

and G y n e c o l o g i s t s

recommended by t h e Panel

1989) f o r t h e l o w - r i s k ,

l o w - r i s k p a r o u s women, r e s p e c t i v e l y .

(AC0G,

1982) ,
on t h e

nulliparous,

and

107

Be c a u s e o f t h e w i d e l y - r e c o g n i z e d i m p o r t a n c e o f e a r l y p r e n a t a l
on t h e h e a l t h o f t h e m o t h e r and t h e ba b y , t h e U. S.
goal o f e a r l y

( f ir s t trimester)

prenatal

Su r g e o n Ge n e r a l

c a r e f o r 90% o f a l l

care
set a

expectant

m o t h e r s by t h e y e a r 1990 (DHHS, 1 9 7 9 ) . A m i d - c o u r s e r e v i e w o f t h i s
o b j e c t i v e d e t e r m i n e d i n 1984,
mothers,

20.4% o f w h i t e m o t h e r s , 37. 8% o f b l a c k

40% o f Ame r i c a n I n d i a n m o t h e r s and 43% o f H i s p a n i c m o t h e r s

r e c e i v e d no p r e n a t a l

c a r e d u r i n g t h e f i r s t t r i m e s t e r (DHHS,

1986).

In a d d i t i o n t o a t w o - f o l d i n c r e a s e d r i s k f o r d e l i v e r i n g a low
b i r t h w e i g h t baby (10% vs 5%), women who do n o t o b t a i n s u f f i c i e n t
prenatal

c a r e a r e more l i k e l y t o d e l i v e r p r e m a t u r e l y (13% vs 8%),

g a i n t o o l i t t l e w e i g h t d u r i n g p r e g n a n c y (28% vs 21%)

(AGI,

1986) .

T w e n t y - e i g h t p e r c e n t o f women who do n o t s e e a p h y s i c i a n u n t i l
in l a b o r ,
care,

and t o

they are

a s c ompa r e d t o 10% o f women who g e t a t l e a s t some p r e n a t a l

d e liv e r prematurely;

27% o f t h o s e who d i d n o t s e e k p r e n a t a l

d e l i v e r e d a l ow b i r t h w e i g h t i n f a n t ,
o b t a i n e d some p r e n a t a l

c a r e (AGI,

care

c ompar ed t o 7% o f women who

1 9 8 6 ) . Da t a f rom t h e N a t i o n a l

Infant

M o r t a l i t y S u r v e i l l a n c e (NIMS) p r o j e c t i n d i c a t e d t h e i n f a n t m o r t a l i t y
r a t e among ne wbor ns whose m o t h e r s '
first

obtained prenatal

t r i m e s t e r was 9 . 7 p e r 1000 l i v e b i r t h s .

care during the

The IMR r o s e t o 1 2 . 5

d e a t h s when c a r e was i n i t i a t e d l a t e r i n p r e g n a n c y ,

and j umped t o 4 8 . 7

d e a t h s p e r 1000 c a s e s when t h e m o t h e r o b t a i n e d no p r e n a t a l
( an e s t i m a t e d 2% o f p r e g n a n t women)
In M i c h i g a n ,

( Hogue,

care at all

1987).

i n 1987, 82. 7% o f w h i t e i n f a n t s ,

c ompar ed t o 68. 4% o f

b l a c k i n f a n t s , we r e b o r n t o m o t h e r s who be gan t h e i r p r e n a t a l
first

c a r e in t he

t r i m e s t e r , w i t h 41. 3% o f t h e s e women i n i t i a t i n g c a r e d u r i n g t h e

s e c o n d month o f p r e g n a n c y (MDPH,

1 9 8 9 ) . The medi an number o f p r e n a t a l

108

v i s i t s was 12,

11.8 f o r mothers of white i n f a n t s ,

m o t h e r s o f b l a c k i n f a n t s . Al mos t t w o - t h i r d s
we r e t o women r e c e i v i n g 10- 14 p r e n a t a l
births

and 1 1 . 3 v i s i t s

(61. 9%) o f a l l

visits.

In 1987,

( 9 . 3 p e r 1 , 0 0 0 ) we r e t o women w i t h no p r e n a t a l

on t h e b i r t h c e r t i f i c a t e ) .

The l a c k o f p r e n a t a l

for

live births

1,303 r e s i d e n t

care

(as recorded

c a r e was

d i s p r o p o r t i o n a t e among y o u n g e r m o t h e r s and among m o t h e r s o f b l a c k
infants.

The r a t i o o f l i v e b i r t h s i n whi c h t h e m o t h e r r e c e i v e d no

prenatal

care,

to the to ta l

number o f l i v e b i r t h s ,

a s l a r g e f o r b l a c k i n f a n t s as f o r w h i t e i n f a n t s
respectively)

was a l m o s t f i v e t i m e s

( 2 6 . 5 / 1 0 0 0 vs 5 . 4 / 1 0 0 0 ,

(MDPH, 1 9 8 9 ) .

The K e s s n e r I n d e x i s a me a s u r e o f t h e q u a l i t y o f p r e n a t a l
obtained during pregnancy.
c a r e began, t h e g e s t a t i o n a l
visits.

I t c ombi ne s i n f o r m a t i o n on t h e month p r e n a t a l
age a t b i r t h and t h e number o f p r e n a t a l

Three l e v e l s o f p r e n a t a l

1) Ad e q u a t e P r e n a t a l

care

care are defined

(MDPH,

1989) :

Ca r e i s d e f i n e d as c a r e whi c h be ga n w i t h i n t h e

f i r s t t r i m e s t e r and whi ch i n c l u d e d an a v e r a g e o f a t l e a s t one o r two
additional

prenatal

length of ge sta tio n ;

v i s i t s p e r month o f g e s t a t i o n ,
2) I n t e r m e d i a t e P r e n a t a l

whi c h began d u r i n g t h e s e c o n d t r i m e s t e r ,
visits,

d e p e n d i n g on t h e

Ca r e i s d e f i n e d as c a r e

wi t h c o r r e s p o n d i n g fewer

o r whi ch began d u r i n g t h e f i r s t t r i m e s t e r b u t w i t h f e w e r v i s i t s

t h a n woul d be a p p r o p r i a t e f o r t h e l e n g t h o f g e s t a t i o n ;
Prenatal

3)

Inadequate

Ca r e i s d e f i n e d as c a r e b e g i n n i n g i n t h e t h i r d t r i m e s t e r ,

h a v i n g had no p r e n a t a l

c a r e o r b e g i n n i n g c a r e d u r i n g t h e f i r s t o r s e c ond

t r i m e s t e r b u t l e s s t h a n f i v e v i s i t s o c c u r r e d , when t h e l e n g t h o f
g e s t a t i o n was 34 weeks o r mor e. When t h e l e n g t h o f g e s t a t i o n was l e s s
t h a n 34 we e k s , c a r e i s d e f i n e d as i n a d e q u a t e when c a r e be ga n d u r i n g t h e

109

f i r s t o r second t r i m e s t e r ,

but even fewer t han f i v e v i s i t s o c c u r r e d .

In

M i c h i g a n , t h e K e s s n e r I n d e x ca n be c a l c u l a t e d f r om d a t a a v a i l a b l e on t h e
birth certificate.
I n Mi c h i g a n i n 1987,

adequate prenatal

o f m o t h e r s who d e l i v e r e d l i v e b i r t h s

c a r e was o b t a i n e d by 73.1%

(75. 5% w h i t e , 61. 8% b l a c k ) .

The

i n c i d e n c e o f l ow b i r t h w e i g h t among i n f a n t s o f m o t h e r s who o b t a i n e d
a d e q u a t e c a r e a c c o r d i n g t o t h e K e s s n e r I n d e x was 5 9 . 5 p e r 1 , 0 0 0 l i v e
births

(47.3/1,000 white,

124.0/1,000 black).

I n a d e q u a t e c a r e was

r e c e i v e d by 6. 1% o f Mi c h i g a n m o t h e r s ( 5. 2% w h i t e ,

10.1% b l a c k ) .

The

i n c i d e n c e o f low b i r t h w e i g h t among i n f a n t s bor n t o m o t h e r s w i t h
i n a d e q u a t e c a r e r o s e s i g n i f i c a n t l y from 5 9 . 5 / 1 , 0 0 0 t o 1 3 7 . 6 / 1 , 0 0 0
(97.3/1000 white,

230.0/1,000 black).

The i n c i d e n c e o f LBW among i n f a n t s

whose m o t h e r s o b t a i n e d i n t e r m e d i a t e c a r e was 9 2 . 7 / 1 , 0 0 0
white,

149.9/1,000 black)
Clearly,

(72.9/1,000

(MDPH, 1 9 8 9 ) .

adequate prena tal

c a r e was a s s o c i a t e d w i t h a r e d u c e d

i n c i d e n c e o f l ow b i r t h w e i g h t i n M i c h i g a n . Re duc i ng b a r r i e r s t o p r e n a t a l
care will
services

r e q u i r e c h a n g e s i n p u b l i c p o l i c y and d e l i v e r y o f h e a l t h c a r e
(DHHS, 1 9 8 9 ) . U n t i l

t h a t time,

the a b i l i t y of t h i s nation to

me e t t h e g o a l o f i n c r e a s i n g t h e p r o p o r t i o n o f a l l
receive prenatal
by t h e U. S.

p r e g n a n t women who

c a r e i n t h e f i r s t t r i m e s t e r t o 90%,

Su r g e o n G e n e r a l

f i r s t established

i n t h e Year 1990 H e a l t h O b j e c t i v e s f o r t h e

N a t i o n (DHHS, 1 9 7 9 ) , and r e p e a t e d i n t h e d r a f t copy o f t h e Ye a r 2000
H e a l t h O b . i e c t i v e s f o r t h e N a t i o n (DHHS, 1 9 8 9 a ) ,

appears u n r e a l i s t i c .

110

Summary

This review o f the l i t e r a t u r e i d e n t i f i e s f i v e major c a t e g o r i e s of
r i s k f a c t o r s a s s o c i a t e d w i t h low b i r t h w e i g h t :
2)

1) d e m o g r a p h i c f a c t o r s ,

me d i c a l f a c t o r s p r e d a t i n g p r e g n a n c y , 3) me d i c a l

p r e g n a n c y , 4) b e h a v i o r a l
factors.

and e n v i r o n m e n t a l

f a c t o r s during

f a c t o r s and 5) h e a l t h c a r e

The f o l l o w i n g c o n c l u s i o n s r e p r e s e n t t h e p r i n c i p a l

findings

r e l e v a n t to the c u r r e n t study.
1.

Low b i r t h w e i g h t i s m u l t i f a c t o r i a l ; i d e n t i f i c a t i o n o f r i s k f a c t o r s
a s s o c i a t e d w i t h l ow b i r t h w e i g h t must e nc ompa s s t h e " s e a m l e s s web"
( J a c o b s o n , 1986) o f f a c t o r s a s s o c i a t e d w i t h t h i s c o n d i t i o n ,
i n c l u d i n g s o c i o d e m o g r a p h i c , b e h a v i o r a l , me d i c a l and a t t i t u d i n a l
factors.

2.

A b i r t h w e i g h t o f 3 , 5 0 0 t o 4 , 0 0 0 g a p p e a r s t o be a s s o c i a t e d w i t h
t h e l o w e s t r i s k o f i n f a n t m o r t a l i t y and m o r b i d i t y and c o u l d be
considered "optimal".

3.

P r e p r e g n a n t w e i g h t s t a t u s i s an i m p o r t a n t d e t e r m i n a n t o f f e t a l
o u t c o me , i n d e p e n d e n t o f a n t e n a t a l w e i g h t g a i n . P e r c e n t o f r e f e r e n c e
w e i g h t a t t a i n e d a t t e r m (120%) a p p e a r s t o p r e d i c t o p t i m a l o u t c ome ,
a l t h o u g h t h i s h y p o t h e s i s must be v a l i d a t e d i n a r e p r e s e n t a t i v e
population.

4.

The i mp a c t o f t h e m o t h e r ' s b i r t h w e i g h t on h e r c o n c e p t u s ' b i r t h
w e i g h t h a s a p u b l i c h e a l t h pr ogr ammi ng i m p l i c a t i o n and w a r r a n t s
further research.

5.

R e s e a r c h i s n e e d e d t o e xa mi ne t h e e f f e c t o f t o t a l d i e t q u a l i t y on
f e t a l o u t c ome . Use o f a v a l i d a t e d f ood f r e q u e n c y t o o l t o d e t e r m i n e
n u t r i e n t i n t a k e and a d i e t q u a l i t y s c o r e d u r i n g p r e g n a n c y ha s n o t
been r e p o r t e d i n t h e l i t e r a t u r e t o d a t e .

6.

Few s t u d i e s have i n v e s t i g a t e d t h e r e l a t i o n s h i p b e t we e n m a t e r n a l
a t t i t u d e s and p r e g n a n c y out come . S p e c i f i c i n f o r m a t i o n r e g a r d i n g
r e l a t i o n s h i p b e t we e n a t t i t u d e t o wa r d w e i g h t g a i n and a c t u a l w e i g h t
g a i n , a t t i t u d e toward t h e importance o f n u t r i t i o n d u r i n g pregnancy
and a c t u a l q u a l i t y o f t h e d i e t and how t h e s e b e h a v i o r s , i n t u r n ,
i mp a c t on b i r t h w e i g h t ne e d t o be d e t e r m i n e d .

Ill

7.

T h r e e s t u d i e s ha ve i n d i c a t e d an i n v e r s e r e l a t i o n s h i p b e t we e n
m a t e r n a l h e mo g l o b i n l e v e l s and i n f a n t b i r t h w e i g h t . T h i s
issue warrants f u rth e r investigation.

8.

R e s e a r c h i n d i c a t e s a p o s s i b l e r e l a t i o n s h i p b e t we e n a l ow m a t e r n a l
d i a s t o l i c b l o o d p r e s s u r e and i n c r e a s e d r i s k f o r l ow b i r t h w e i g h t .
This o b s e r v a t i o n w a r r a n t s f u r t h e r i n v e s t i g a t i o n .

9.

L a s t l y , t h e i n t e r a c t i o n o f a l l t h e a bove f a c t o r s s h o u l d be a s s e s s e d
t o g e t h e r t o d e t e r m i n e t h e c a u s a l p a t h wa y s t h a t i n f l u e n c e i n f a n t
b i r t h weight.

Based on t h e s e o b s e r v a t i o n s ,

the following conceptual

f r a me wor k

was d e v e l o p e d t o i d e n t i f y f a c t o r s a s s o c i a t e d w i t h b i r t h w e i g h t i n
M i c h i g a n . T h i s model p r o v i d e d t h e t h e o r e t i c a l
design,

b a s i s by whi c h t h e s t u d y

q u e s t i o n n a i r e i t e m s and d a t a a n a l y t i c t e c h n i q u e s we r e c h o s e n .

112

CONCEPTUAL FRAMEWORK:
A MODEL TO PR E D IC T B IR T H WEIGHT

MOTHER'S
BIRTH WEIGHT

BEHAVIORAL
RISK FACTORS
--caffeine
--cigarettes
--alcohol

QUALITY
OF DIET
ATTITUDE
--weight gain
--nutri tion
--pregnancy
WEIGHT
GAIN

REFERENCE
WEIGHT AT

WEIGHT
TERM

CLINICAL
PARAMETERS
--DBP
--Hct/Hb

PRENATAL
CARE

SOCIAL SERVICE
PARTICIPATION

SOCIODEMOGRAPHIC
RISK FACTORS

BIRTH

CHAPTER I I I

OPERATIONAL DEFINITIONS

The f o l l o w i n g l i s t o f d e f i n i t i o n s we r e u s e d t o d r i v e t h e d a t a c o l l e c t i o n
and a n a l y s i s , b o t h c o n c e p t u a l l y and o p e r a t i o n a l l y .

OUTCOME VARIABLES
B i r t h We i g h t :

Wei ght o f i n f a n t a t t i m e o f d e l i v e r y i n gr ams ,

Low B i r t h
We i ght (LBW):

B i r t h w e i g h t l e s s t h a n 2 , 5 0 0 g r a ms .

Opt i ma l B i r t h
We i ght (OBW):

B i r t h w e i g h t be t we e n 3 , 5 0 0 and 4 , 0 0 0 g ( Br own,

1988)

PREDICTOR VARIABLES
R e f e r e n c e We i ght f o r - H e i g h t (RW):
C a l c u l a t i o n o f e a c h woman' s r e f e r e n c e w e i g h t - f o r h e i g h t b a s e d on: 1) t h e 1959 M e t r o p o l i t a n
L i f e I n s u r a n c e Company' s r e f e r e n c e s t a n d a r d f o r women
w i t h o u t s h o e s o r c l o t h e s ( Appe ndi x 3) and 2) t h e
r e v i s e d 1983 M e t r o p o l i t a n L i f e I n s u r a n c e Compa ny' s
r e f e r e n c e s t a n d a r d w e i g h t - f o r - h e i g h t t a b l e ( Appe ndi x
4).

Percent Pre-Pregnant
R e f e r e n c e We i g h t ,
(PP-RW):
Each woman' s s e l f - r e p o r t e d p r e - p r e g n a n t w e i g h t
(PPW) w i l l be d i v i d e d by h e r 1959 and 1983 RW and
m u l t i p l i e d by 100 t o c a l c u l a t e a p r e - p r e g n a n t
r e f e r e n c e w e i g h t - f o r - h e i g h t (PP-RW).

113

114

Classification
o f PP-RW:

Each woman' s PP-RW w i l l be u s e d t o c l a s s i f y h e r
according to the following c a te g o ri e s :
1. U n d e r w e i g h t = <90% PP-RW
2. Normal = 90-119% PP-RW
3. O v e r w e i g h t = 120-149% PP-RW
4. Ver y O v e r w e i g h t = >150% PP-RW

P e r c e n t Term
R e f e r e n c e We i ght : C a l c u l a t e d by d i v i d i n g e a c h woman' s t e r m w e i g h t by
h e r 1959 and 1983 r e f e r e n c e w e i g h t - f o r - h e i g h t and
m u l t i p l y i n g by 100.

P r e - P r e g n a n t Body
Mass I n d e x (BMI): Each woman' s p r e - p r e g n a n t body mass i n d e x (BMI) was
d e t e r m i n e d f r om h e r s e l f - r e p o r t e d p r e - p r e g n a n t
w e i g h t and h e i g h t a c c o r d i n g t o t h e f o r m u l a :
BMI = w e i g h t , k g / h e i g h t , m 2

Mother's
B i r t h We i ght :

Smoking:

S e l f - r e p o r t e d b i r t h w e i g h t o f t h e m o t h e r who d e l i v e r e d
t h e i n f a n t s e l e c t e d f o r t h i s s u r v e y . Al l b i r t h w e i g h t s
r e p o r t e d i n pounds and o u n c e s we r e c o n v e r t e d t o gr ams
by u s e o f a s t a n d a r d c o n v e r s i o n c h a r t ( Appe ndi x 5 ) .

1. Smoked p r i o r t o p r e g n a n c y .
S e l f - r e p o r t e d mean number o f c i g a r e t t e s
da y p r i o r t o p r e g n a n c y .

smoked p e r

2. Smoked d u r i n g p r e g n a n c y .
S e l f - r e p o r t e d mean number o f c i g a r e t t e s
da y d u r i n g p r e g n a n c y .

smoked p e r

3. Change i n smoki ng h a b i t s .
The d i f f e r e n c e ( p o s i t i v e , n e g a t i v e , none ) i n number
o f c i g a r e t t e s smoked p r i o r t o and d u r i n g p r e g n a n c y ;
v a l i d a t e d by q u e s t i o n 13.

Classification
o f Smoking:

1.
2.
3.
4.

A b s t a i n e r s = d i d n o t smoke.
L i g h t s moker = 1- 9 c i g a r e t t e s p e r d a y .
Mo d e r a t e smoker = 10- 19 c i g a r e t t e s p e r d a y .
Heavy s moker = 20 o r more c i g a r e t t e s d a i l y .

115

Al c ohol
Co n s u mp t i o n :

1. Al c ohol c o n s u mp t i o n b e f o r e c o n c e p t i o n .
S e l f - r e p o r t e d a v e r a g e number o f a l c o h o l i c b e v e r a g e s
consumed p e r week o r month d u r i n g t h e t h r e e mont hs
p r i o r t o c o n c e p t i o n . A d r i n k was d e f i n e d a s 12 oz
b e e r (1 c a n ) , 4 oz wi n e o r 1 . 5 oz h a r d l i q u o r .
2. Al c o h o l c o n s u mp t i o n d u r i n g p r e g n a n c y .
S e l f - r e p o r t e d a v e r a g e number o f a l c o h o l i c b e v e r a g e s
consumed p e r week o r month d u r i n g t h e s u b j e c t ' s
p r e g n a n c y . A d r i n k was d e f i n e d as 12 oz b e e r
1 c a n ) , 4 oz wi ne ( 1 / 2 c up) o r 1 . 5 oz h a r d l i q u o r .
3. Change i n a l c o h o l c o n s u m p t i o n .
The d i f f e r e n c e ( p o s i t i v e , n e g a t i v e , n one ) i n number
o f a l c o h o l i c b e v e r a g e s consumed p r i o r t o and d u r i n g
p r e g n a n c y ; v a l i d a t e d by q u e s t i o n 12.

Cl a s s i f i c a t i o n
o f Al c ohol
Cons ump t i on:

Caffeine

Intake:

Classification o
Caffeine Intake:

Caloric
Restriction:

Vi t a m i n
Supplementation:

1. A b s t a i n e r / R a r e D r i n k e r = l e s s t h a n one d r i n k p e r
month.
2. L i g h t / M o d e r a t e D r i n k e r = a t l e a s t one d r i n k p e r
mont h, b u t l e s s t h a n 5 p e r
week (< 50 g / w e e k ) .
3. Mo d e r a t e D r i n k e r = f i v e t o n i n e d r i n k s ( 5 0 - 9 9 g)
p e r week.
4. Heavy D r i n k e r = 10 o r more d r i n k s ( 100 g) p e r week.

O b t a i n e d f rom t h e W i l l e t t SQFFQ.

1. A b s t a i n e r / L o w Ex p o s u r e = < 150 mg c a f f e i n e p e r d a y .
2. Mo d e r a t e Expos ur e = 151- 300 mg c a f f e i n e / d a y .
3. High Ex p o s u r e = g r e a t e r t h a n 300 mg c a f f e i n e / d a y .

S e l f - r e p o r t e d r e s p o n s e t o Q. 10 "Di d you r e s t r i c t
y o u r c a l o r i e i n t a k e d u r i n g y o u r p r e g n a n c y " and "on
whose a d v i c e " .

S e l f - r e p o r t e d r e s p o n s e t o Q. 14 "Di d you t a k e a v i t a m i n
s u p p l e m e n t d u r i n g y o u r p r e g n a n c y " and "on whose
advice".

116

Diet Quality
Score:

Numer i c r e p r e s e n t a t i o n o f t h e s e l f - r e p o r t e d q u a n t i t y
o f f o o d s and n u t r i e n t s consumed by t h e s u b j e c t , on
average, during her pregnancy. Analysis of the W i l le t t
SQFFQ was u s e d t o c a l c u l a t e t h r e e d i e t q u a l i t y s c o r e s :
1) a MAR-12 s c o r e c o n t a i n i n g t h e n u t r i e n t s c a l c i u m ,
i r o n , z i n c , v i t a m i n A, t h i a m i n , r i b o f l a v i n ,
p y r i d o x i n e , v i t a m i n D, v i t a m i n B12, v i t a m i n E, f o l a c i n
and v i t a m i n C, 2) a MAR-4 u s i n g v i t a m i n A, B- 6,
c a l c i u m and i r o n , a s p e r t h e met hod o f J e n k i n s and
G u t h r i e ( 1984) and 3) INQ-12 s c o r e u s i n g t h e s e same
n u t r i e n t s , b a s e d on t h e me t hods o f Hansen and Wyse,
1 9 8 0 ) . Al l s c o r e s we r e b a s e d on n u t r i e n t i n t a k e
w i t h o u t v i t a m i n / m i n e r a l supplements as t h e v a r i a b l e of
i n t e r e s t was " d i e t q u a l i t y " . The RDA/1000 c a l o r i e s was
d e v e l o p e d u s i n g t h e 1989 RDA's f o r p r e g n a n t women
(Table 3 - 1 ) . :

INQ-1000 = Amount o f n u t r i e n t i n 1000 c a l o r i e s o f f ood
Human a l l o w a n c e o f t h e n u t r i e n t p e r 1000 c a l o r i e s

Table 3 .1 .

Recommended D i e t a r y A l l o w a n c e s (RDA) and RDA/1000 c a l o r i e s
f o r p r e g n a n t , a d u l t women (NRC-RDA, 1 9 8 9 ) .

Nutrient

Recommended A l l o w a n c e

RDA/1000 C a l o r i e s

V i t a mi n A, IU
V i t a mi n D, IU
V i t a mi n E, mg TE
V i t a mi n C, mg
T h i a mi n , mg
R i b o f l a v i n , mg
P y r i d o x i n e , mg
F o l a c i n , meg
B- 12, meg
C a l c i u m, mg
I r o n , mg
Z i n c , mg

4000
400
10
70
1.5
1.6
2.2
400
2.2
1200
30
15

1600
160
4
28
0.6
0.64
0.88
160
0.88
480
12
6

Protein, g
Calories

60
2500

24
1000

117

Attitude:

1. Toward t h i s p r e g n a n c y .
Va l u e r e c o r d e d by m o t h e r ( Q. 40) r a n g i n g f r om
"I wa n t e d t h i s p r e g n a n c y " , t o "I d i d n o t wa nt t o
become p r e g n a n t t h e n o r a t any t i m e i n t h e f u t u r e " .
2. Towar d w e i g h t g a i n d u r i n g p r e g n a n c y .
Mean s c o r e o f a n s w e r s g i v e n by r e s p o n d e n t ( Q . 18- 31)
which, in f a c t o r a n a l y s i s , " load" t o t h i s c on c ep t .
3. Toward n u t r i t i o n d u r i n g p r e g n a n c y .
Mean s c o r e o f a n s w e r s g i v e n by r e s p o n d e n t ( Q . 18- 31)
which, in f a c t o r a n a l y s i s , "load" t o t h i s concept.

Prenatal
Care:

Kessner
Index:

Education:

Socioeconomic
Status:

Month p r e n a t a l c a r e be ga n and number o f p r e n a t a l
v i s i t s a s r e c o r d e d on t h e s u b j e c t ' s b i r t h c e r t i f i c a t e
and t h e K e s s n e r I nde x S c o r e as c a l c u l a t e d f r om d a t a
p r o v i d e d on t h e b i r t h c e r t i f i c a t e .

C l a s s i f i c a t i o n o f p r e n a t a l c a r e b a s e d on t h e month
o f p r e g n a n c y i n whi ch p r e n a t a l c a r e b e g a n , t h e number
o f p r e n a t a l v i s i t s and t h e l e n g t h o f g e s t a t i o n .
1. A d e q u a t e Ca r e
2. I n t e r m e d i a t e Car e
3. I n a d e q u a t e Car e

T h a t v a l u e r e p o r t e d on t h e b i r t h c e r t i f i c a t e , g i v e n i n
y e a r s o f e l e m e n t a r y , high school o r c o l l e g e a t t e n d e d .

S u b j e c t s w i l l be c l a s s i f i e d a c c o r d i n g t o t h e 1988- 1989
F e d e r a l P o v e r t y T h r e s h o l d Level ( e f f e c t i v e O c t o b e r
1988) b a s e d on f a m i l y s i z e and n e t f a m i l y i ncome.
S u b j e c t s w i l l be c l a s s i f i e d i n t o t h r e e c a t e g o r i e s :
1) n e t i ncome l e s s t h a n 100%, 2) n e t i ncome g r e a t e r
t h a n 100% b u t l e s s t h a n 155% and 3) n e t i ncome g r e a t e r
t h a n 155%. The s e a r e t h e n e t i ncome c u t - o f f s u s e d f o r
Food St amps (100%) and WIC (155%) e l i g i b i l i t y .
F a mi l y
Size

1
2
3
4
5
6
7

100% ( Net Income
Food Stamp Cap)

481
645
808
971
1135
1298
1461

155% ( Net Income
WIC E l i g i b i l i t y )

746
1000
1253
1505
1760
2012
2265

118

Public
Assistance:

Anemia o f
Pregnancy:

Classification
o f Anemia o f
Pregnancy:

D i a s t o l i c Bl ood
P r e s s u r e (DBP):

Classification
of Subjects
by DBP:

S e l f - r e p o r t e d r e s p o n s e t o Q. 37 i n whi c h r e s p o n d e n t s
we r e a s k e d i f t h e y r e c e i v e d any a s s i s t a n c e f r om p u b l i c
s e r v i c e s o r s u p p o r t programs d u r i n g t h e i r p r egnancy.

H e m a t o c r i t ( Hc t ) and h e mo g l o b i n (Hb) v a l u e s r e p o r t e d
by t h e s u b j e c t ' s p h y s i c i a n and c l a s s i f i e d a c c o r d i n g t o
Murphy e t a l ( 1 9 8 6 ) .

1) D e f i c i e n t = Hb < 1 0 . 4 g / d l .
2) M o d e r a t e = Hb 1 0 . 4 - 1 3 . 2 g / d l .
3) Hi gh = Hb > 1 3 . 2 g / d l .

Va l u e r e p o r t e d by t h e s u b j e c t s '

1) Low DBP = < 65 mm/Hg.
2) M o d e r a t e DBP = 6 5 - 9 0 mm/Hg.
3) I d e a l DBP = 9 0 - 9 9 mm/Hg.
4) High DBP = >99 mm/Hg.

p h y s i c i a n i n mm/Hg.

CHAPTER IV

METHODS

The p u r p o s e o f t h i s r e s e a r c h was t o d e t e r m i n e f a c t o r s whi ch
d i f f e r e n t i a t e d optimal
l ow b i r t h w e i g h t

b i r t h weight

( l e s s t h a n 2500 g)

describes the subject selection,
and s t a t i s t i c a l

( 3500 t o 4000 g)

i n Mi c h i g a n i n f a n t s .

study design,

This c h a p t e r i s di vid ed i n t o t h r e e s e c t i o n s :

"Prenatal

Ca r e S u r v e y " ,

procedures

case-control

study.

1) t h e p i l o t s t u d y ,

a s u r v e y o f 600 r a n d o ml y s e l e c t e d

w h i t e Mi c h i g a n i n f a n t s ' m o t h e r s and t h e i r p r e n a t a l
3)

1988) f rom

This c h a p t e r

instruments,

a n a l y s i s used in t h i s r e t r o s p e c t i v e ,

2) t h e " Mi c h i g a n Mo t h e r s S u r v e y " ,

(Brown,

c a r e p r o v i d e r s and

a survey o f t h e p h y s i c i a n in a t t e n d a n c e ,

r e c o r d e d on t h e b i r t h c e r t i f i c a t e ,

as

o f 825 r a n d o ml y s e l e c t e d b l a c k

Mi c h i g a n i n f a n t s .

S t u d y Appr ova l
Appr ova l
University's

t o c o n d u c t t h i s s t u d y was o b t a i n e d f r om Mi c h i g a n S t a t e

(MSU) U n i v e r s i t y Commi t t e e f o r t h e Revi ew and I n v e s t i g a t i o n

o f Human S u b j e c t s

(UCRIHS)

( 1 0 / 1 1 / 8 8 ; Appe ndi x 6) and t h e Mi c h i g a n

D e p a r t m e n t o f P u b l i c H e a l t h ' s Commi t t e e f o r t h e E v a l u a t i o n o f S t u d i e s

119

120

I n v o l v i n g Human S u b j e c t s

( 1 2 / 1 3 / 8 8 ; Appe ndi x 7 ) .

In a d d i t i o n ,

t h i s study

was d e s i g n a t e d a s a me d i c a l r e s e a r c h p r o j e c t u n d e r t h e p r o v i s i o n s o f t h e
Mi c h i g a n P u b l i c H e a l t h Code,

P. A. 368 o f 1978 a s amended, MCL 3 3 3 . 2 6 3 1 -

3 3 3 . 2 6 3 5 ( 1 1 / 2 3 / 8 8 ; Appe ndi x 8 ) .

P i l o t Study

Subjects
Sixty infants

(42 b l a c k and 18 w h i t e ) we r e r a n d o m l y s e l e c t e d by

c o m p u t e r s e a r c h o f t h e S t a t e o f Mi c h i g a n b i r t h c e r t i f i c a t e s d a t e d Augus t
1987 t o A p r i l

1988. S u b j e c t s we r e i n c l u d e d i n t h e s a m p l i n g f r a me i f t h e

i n f a n t ' s m o t h e r was:

1) a b l a c k o r w h i t e Mi c h i g a n r e s i d e n t 2) be t we e n

2 0 - 3 4 y e a r s o f age and 3) d e l i v e r e d a s i n g l e t o n , who was 4) e i t h e r h e r
f i r s t o r second c h i l d ,

5) a s s i s t e d by e i t h e r an MD o r a DO, 6) a f t e r a

g e s t a t i o n p e r i o d e s t i m a t e d t o be b e t we e n 37 and 42 we e k s . The b l a c k
i n f a n t s a mpl e f r a me was s u b d i v i d e d i n t o t h r e e b i r t h w e i g h t c a t e g o r i e s :
1)

l e s s t h a n 2500 g ( n = 2 5 ) , 2) 2500 t o 4000 g (n=10) and 3) 4001 t o 4500

g ( n = 7 ) . The w h i t e i n f a n t s a mp l e f r a me was s u b d i v i d e d i n t o two b i r t h
weight c a t e g o r i e s :

1) 1500 t o 4000 g ( n = l l )

and 2) 4001 t o 4500 g ( n = 7 ) .

De s i g n
The p i l o t s t u d y was a r e t r o s p e c t i v e ,

follow-back study c o n s is t in g

o f two s u r v e y s m a i l e d t o t h e m o t h e r and t o t h e p r e n a t a l
( p h y s i c i a n o r c l i n i c ) o f t h e 60 r a n d o ml y s e l e c t e d
followed Dillman's

( 1978) T o t a l

care provider

infants.

De s i g n Method (TDM).

Protocol

121

Instruments
The " P r e g n a n c y L i f e s t y l e Q u e s t i o n n a i r e "

( Appe ndi x 9) and a

m o d i f i e d v e r s i o n o f t h e W i l l e t t S e m i - Q u a n t i t a t i v e Food F r e q u e n c y
Questionnaire
"Prenatal

(SQFFQ) ( Appe ndi x 10) we r e s e n t t o e a c h s u b j e c t .

Ca r e Q u e s t i o n n a i r e "

The

( Appe ndi x 11) was s e n t t o t h e p h y s i c i a n

f r om whom t h e m o t h e r o b t a i n e d p r e n a t a l c a r e . Al l q u e s t i o n n a i r e s we r e
e v a l u a t e d f o r c l a r i t y and a c c u r a c y by s e v e r a l
education s p e c i a l i s t ,
and s e v e r a l

me d i c a l

an e p i d e m i o l o g i s t ,

graduate students,

a social

an

survey methodologist

and n u t r i t i o n e x p e r t s .

Procedures
The p i l o t p r o j e c t commenced J a n u a r y o f 1989. Names and a d d r e s s e s
o f t h e 60 r a n d o m l y s e l e c t e d i n f a n t s ' m o t h e r s we r e a b s t r a c t e d f r om t h e
infants'

birth

certificate.

Each mo t h e r was s e n t an i n d i v i d u a l i z e d

l e t t e r requesting her p a r t i c i p a t i o n

( Appe ndi x 1 2 ) .

Included with the

l e t t e r was a c opy o f t h e " P r e g n a n c y L i f e s t y l e Q u e s t i o n n a i r e "
9 ) , t h e W i l l e t t SQFFQ ( Appe ndi x 1 0 ) ,

a number two p e n c i l ,

( Appe ndi x

a s t a mp e d ,

p r e - a d d r e s s e d r e t u r n e n v e l o p e , and a p l a s t i c b i b f o r t h e baby as a t o k e n
of a p p re c ia t io n f o r completing the survey instruments.
c a r d was s e n t one week f o l l o w i n g t h e i n i t i a l
T h r e e weeks from t h e

initial

mailing,

A reminder note

m a i l i n g ( Appe ndi x 1 3 ) .

a second l e t t e r

( Appe ndi x 14) and

c o m p l e t e s u r v e y p a c k e t we r e m a i l e d t o e a c h n o n - r e s p o n d e r . Al l

surveys

r e t u r n e d w i t h i n s u f f i c i e n t o r i n c o r r e c t a d d r e s s e s we r e f o l l o w e d - u p by a
search of c ity

and t e l e p h o n e d i r e c t o r i e s .

black subjects

(15%) wer e n o t l o c a t e d .

Current a ddr es se s f o r nine

122

Each woman was a s k e d t o p r o v i d e t h e name and a d d r e s s o f h e r
primary prenatal care provider (physician or c l i n i c )
c o n s e n t f or m a l l o w i n g t h e r e l e a s e o f me d i c a l
page 7 ) .

Th i s i n d i v i d u a l

participation

and t o s i g n a

information

( Ap p e n d i x 9,

o r c l i n i c was c o n t a c t e d r e q u e s t i n g t h e i r

( Appe ndi x 1 5 ) . A copy o f t h e m o t h e r ' s s i g n e d c o n s e n t f or m,

a s t a m p e d , p r e - a d d r e s s e d r e t u r n e n v e l o p e and a c opy o f t h e " P r e n a t a l
Ca r e Q u e s t i o n n a i r e "

( Appe ndi x 11) we r e s e n t . A r e m i n d e r n o t e c a r d

( Ap p e n d i x 16) was m a i l e d a p p r o x i m a t e l y one week l a t e r .
low r e s p o n s e r a t e f rom b l a c k m o t h e r s (14%),
Ca r e Q u e s t i o n n a i r e

(Table 3 . 1 ) ,

the Prenatal

( Appe ndi x 11) was s e n t d i r e c t l y t o t h e p h y s i c i a n o f

r e c o r d n o t e d on t h e s u b j e c t ' s b i r t h c e r t i f i c a t e .
physicians'

Be c a u s e o f t h e

response r a t e fo r black su b jects

e n t i r e s a mpl e p o p u l a t i o n

(n=42).

In c o n t r a s t ,

Therefore,

the

(33%) i s b a s e d on t h e
the Prenatal

Q u e s t i o n n a i r e was o n l y s e n t t o t h e w h i t e s u b j e c t s '

physician

c o n s e n t was o b t a i n e d ( n = 1 3 ) . Seven c o m p l e t e d s u r v e y s
( T a b l e 4 . 1 ) . Any s u r v e y r e c e i v e d a f t e r March 25,

Ca r e
i f signed

(54%) we r e r e t u r n e d

1989 was n o t i n c l u d e d

in t h e a n a l y s i s .

Table 4 .1 .

Re s pons e r a t e s o b t a i n e d d u r i n g t h e p i l o t t e s t .

Population

Su r v e y s S e n t

Mi c h i g a n Mot he r s
B1 ack
Whi t e
TOTAL

42
18
60

Mi c h i g a n P h y s i c i a n s
Bl a c k I n f a n t s
Whi t e I n f a n t s
TOTAL

42
13
56

Re s p o n s e (%)

6
13
19

14
7
21

(14.3)
(72.2)
(31.7)

(33.3)
(53.8)
(38.2)

123

Analvsi s
Da t a we r e a n a l y z e d u s i n g SPSS-PC+ 2 . 0 (SPSS,
microcomputer.

1988) on a Z e n i t h

Bot h p a r a m e t r i c and n o n - p a r a m e t r i c s t a t i s t i c s we r e u s e d

as a p p r o p r i a t e .

F r e q u e n c y c o u n t s and d e s c r i p t i v e s t a t i s t i c s we r e u s e d t o

e l i m i n a t e n o n d i s c r i m i n a t i n g q u e s t i o n s f r om t h e P r e g n a n c y L i f e s t y l e
Q u e s t i o n n a i r e and t h e P r e n a t a l
indicated additional
"nutrition"

Ca r e Q u e s t i o n n a i r e .

Factor analysis

a t t i t u d e q u e s t i o n s whi c h l o a d e d t o t h e f a c t o r s o f

and " w e i g h t g a i n " we r e n e e d e d .

Whi t e Mi c h i g a n M o t h e r ' s Sur ve y

Sub.iects
S i x h u n d r e d w h i t e i n f a n t s w i t h b i r t h w e i g h t s r a n g i n g b e t we e n 1000
and 4000 g we r e r a n d o ml y s e l e c t e d by c o m p u t e r s e a r c h o f t h e S t a t e o f
Mi c h i g a n b i r t h c e r t i f i c a t e s .

In a d d i t i o n t o t h e same s e l e c t i o n c r i t e r i a

used in t h e p i l o t s t u d y ,

an i n f a n t was e x c l u d e d f rom t h e s a m p l i n g f r ame

i f the b irth c e r t i f i c a t e

i n d i c a t e d t h e m o t h e r e x p e r i e n c e d any o f t h e

f o l l o w i n g me d i c a l c o m p l i c a t i o n s o f p r e g n a n c y o r c o n c u r r e n t i l l n e s s e s o r
c o n d i t i o n s a f f e c t i n g pregnancy:

1) p r e g n a n c y i n d u c e d h y p e r t e n s i o n ,

c h r o n i c h y p e r t e n s i o n o r r e na l d i s e a s e wi th superimposed t oxemia,
2) e c l a m p s i a ,
congenital

3) d i a b e t e s

anomalies,

(gestational

or m e llitu s ) ,

5) m a t e r n a l d e a t h ,

4) b a b i e s w i t h

6) c i r c u l a t o r y d i s e a s e ,

7) renal d i s e a s e , 8) gonorrhea and o th er venereal d i s e a s e s and 9) AIDS.

124

The mean s t a n d a r d d e v i a t i o n o f b i r t h w e i g h t f o r a l l

white infants

w e i g h i n g b e t we e n 1000 and 4000 g b o r n i n Mi c h i g a n b e t we e n 1985 and 1987
was 523 g . Us i ng t h i s number , and t h e met hod o f Kr a e me r and Thi emann
(1988),

an e s t i m a t e d 170 l ow b i r t h w e i g h t c a s e s

optimal

b i r t h weight c o n tr o l s

( 1 0 0 0 - 2 4 9 9 g) and 170

( 3 5 0 0 - 4 0 0 0 g) we r e n e e d e d t o d e t e c t a 100

gram d i f f e r e n c e i n b i r t h w e i g h t w i t h 80% power and 95% c o n f i d e n c e
4.2).

Us i ng t h e met hod o f S n e d e c o r ( 1 9 8 4 ) ,

o n l y 109 c a s e s and 109

c o n t r o l s we r e n e c e s s a r y t o d e t e c t t h e same s t a t i s t i c a l

Table 4 .2 .

difference.

E s t i m a t e d s a mp l e s i z e o f w h i t e i n f a n t s n e e d e d t o d e t e c t a
d i f f e r e n c e w i t h 80% powe r , 95% c o n f i d e n c e and a 523 g SD.

Method

Kr aemer and
Thi eman ( 1988)

S n e d e c o r ( 1984)

D e t e c t i o n Level

Ca s e s

100 g d i f f e r e n c e
125 g d i f f e r e n c e

170
115

170
115

100 g d i f f e r e n c e
125 g d i f f e r e n c e

109
70

109
70

Based on r e s u l t s o f t h e p i l o t s t u d y ,

respectively.

and 250 c o n t r o l s

Controls

LBW c a s e s and OBW c o n t r o l s

we r e o v e r - s a m p l e d by a p p r o x i m a t e l y 70% (120 s u b j e c t s )
subjects),

(Table

and 47% (80

Thus , t h e s a m p l i n g f r a me c o n s i s t e d o f 290 c a s e s

( T a b l e 4 . 3 ) . A 59% r e s p o n s e r a t e f r om c a s e s

and 68% f r om c o n t r o l s

(170/290),

( 1 7 0 / 2 5 0 ) , was n e e d e d t o d e t e c t a 100 g d i f f e r e n c e

w i t h 80% power and 95% c o n f i d e n c e .

S i x t y i n f a n t s w e i g h i n g b e t we e n 2500

and 3499 g (medium b i r t h w e i g h t ) we r e i n c l u d e d i n t h e s a m p l i n g f r a me t o

125

fill

i n t h e r e g r e s s i o n l i n e when a n a l y z i n g t h e r e l a t i o n b e t we e n p e r c e n t

r e f e r e n c e w e i g h t a t t a i n e d a t t e r m and b i r t h w e i g h t .
To e n s u r e an e ve n d i s t r i b u t i o n o f s u b j e c t s w i t h i n e a c h b i r t h
weight c ategory,
4 . 3 ) . Al l

e a c h o f t h e c a t e g o r i e s was f u r t h e r s u b d i v i d e d ( T a b l e

s u b j e c t s we r e b o r n b e t we e n J u l y 1,

1988 and November 30,

e x c e p t f o r i n f a n t s w e i g h i n g 1000 t o 1999 g . Due t o t h e s ma l l
surviving infants
all

in t h i s weight c a te g o ry ,

Table 4 .3 .

introducing unavoidable r e c a l l

Subject se le c tio n c r i t e r i a
Survey.

Number
Needed*

B i r t h Wei ght
Category

Low B i r t h We i ght ( C a s e s )
100 0 - 1 9 9 9 g
2000-2499 g
Sub-Total:
Mo d e r a t e B i r t h Wei ght
2500-2999 g
3000-3499 g
Sub-Total:
Opt i ma l B i r t h We i ght
3500-3600 g
3601-3700 g
3701-3800 g
3801-3900 g
3901-4000 g
Sub-Total:
GRAND TOTAL:

number o f

i t was n e c e s s a r y t o s e l e c t

i n f a n t s b o r n b e t we e n J a n u a r y 1 and November 30,

in t h i s stud y,

bias

1988 f o r i n c l u s i o n
in t h i s

subgroup.

i n t h e Whi t e Mi c h i g a n Mo t h e r s

T o t a l MI
Population

% o f Total
Population

Time P e r i o d
Surveyed

88
202
290

88
350
438

100.0
57.7
66.2

1-11/88
7-11/88

30
30
60

2291
7380
9671

1.3
0.4
0.6

7-11/88
7-11/88

1819
1325
1493
1018
1026
6681

2.7
3.8
3.3
4.9
4.9
3.7

7-11/88
7-11/88
7-11/88
7-11/88
7-11/88

16,790

3.6

(Controls)
50
50
50
50
50
250
600

1988,

* f o r 80% power and 95% c o n f i d e n c e t o d e t e c t a 100 gr am d i f f e r e n c e i n
b i r t h w e i g h t e s t i m a t i n g a 59-68% r e s p o n s e r a t e .

126

De s i g n
The Whi t e Mi c h i g a n Mo t h e r s Su r v e y was a r e t r o s p e c t i v e ,

case-

c o n t r o l , s t u d y c o n s i s t i n g o f a mai l s u r v e y s e n t t o m o t h e r s o f 600
r a n d o ml y s e l e c t e d w h i t e i n f a n t s . A f o l l o w - u p q u e s t i o n n a i r e was s e n t t o
the prenatal
consent.

h e a l t h c a r e p r o v i d e r o f m o t h e r s who p r o v i d e d s i g n e d

Protocol

Dillman's

f o r t h i s survey followed a modified ve rs ion of

( 1 9 7 8 ) T o t a l De s i g n Method (TDM). Ad h e r e n c e t o p r o c e d u r e s

d e s c r i b e d i n t h i s met hod h a s been shown t o ma xi mi z e r e s p o n s e r a t e s
mai l

in

surveys.

Instruments
T h r e e i n s t r u m e n t s we r e u s e d t o c o l l e c t d a t a :
Pregnancy L i f e s t y l e Q u e s t io n n a i r e ,

1) t h e M o t h e r s '

2) t h e W i l l e t t S e m i - Q u a n t i t a t i v e Food

F r e q u e n c y Q u e s t i o n n a i r e (SQFFQ) and 3) t h e P h y s i c i a n s '
Questionnaire.
p i l o t study;

Prenatal

Ca r e

Th e s e i n s t r u m e n t s we r e r e v i s e d b a s e d on r e s u l t s o f t h e

all

we r e r e - e v a l u a t e d by t h e same e x p e r t s .

M o t h e r ' s Survey Q u e s t i o n n a i r e .
The " P r e g n a n c y L i f e s t y l e Q u e s t i o n n a i r e "

( Appe ndi x 17) c o n t a i n e d 44

q u e s t i o n s d e s i g n e d t o g a t h e r i n f o r m a t i o n a b o u t t h e womens' h e i g h t ,
p r e g n a n c y and d e l i v e r y w e i g h t , m a t e r n a l
wei ght g a i n ,

n u t r i t i o n and p r e g n a n c y ,

behavior r is k fac to rs
aversions,

social

(i.e.,

b i r t h weight,

a t t i t u d e s t o wa r d

e n g a g e me n t i n o r a v o i d a n c e o f

s moki ng, d r i n k i n g ) ,

pre­

f ood c r a v i n g s and

s e r v i c e a s s i s t a n c e and s o c i o e c o n o m i c s t a t u s .

q u e s t i o n s we r e a d a p t e d f r om t h r e e p r e v i o u s l y v a l i d a t e d n a t i o n a l

The

127

questionnaires:
questionnaire,

t h e 1988 P r e g n a n c y N u t r i t i o n S u r v e i l l a n c e Sys t e m (PNSS)
t h e 1980 N a t i o n a l N a t a l i t y S u r v e y (DHHS, 1985) and t h e

1988 N a t i o n a l M a t e r n a l
Q u e s t i o n n a i r e (DHHS,

and I n f a n t H e a l t h S u r v e y ' s M o t h e r s ' s

1 9 8 8 ) . The a t t i t u d e q u e s t i o n s we r e a d a p t e d from

t h o s e p u b l i s h e d by Pa l me r e t al

(1985),

S c h w a r t z and B a r r ( 1977) and

R o s a n d e r and Sims ( 1981) and we r e v a l i d a t e d d u r i n g t h e p i l o t s u r v e y .

S e m i - Q u a n t i t a t i v e Food F r e q u e n c y Q u e s t i o n n a i r e

(SQFFQ1.

A m o d i f i e d v e r s i o n o f t h e r e v i s e d W i l l e t t SQFFQ ( Appe ndi x 18) was
selected to estimate the su b je c ts'

usual n u t r i e n t i n t a k e during

p r e g n a n c y ( W i l l e t t e t a l , 1 9 8 8 ) . The r e v i s e d SQFFQ f o r m a t d i d n o t
c o n t a i n an e xa mpl e d e m o n s t r a t i n g how t o c o r r e c t l y f i l l
r e s p o n s e s . Thus , an i n s t r u c t i o n s h e e t ,

i n t h e SQFFQ

p r e p a r e d by t h e r e s e a r c h e r

( Appe ndi x 1 9 ) , was i n c l u d e d w i t h e a c h SQFFQ. Two m o d i f i c a t i o n s we r e made
i n t h e SQFFQ i n s t r u c t i o n s :
two q u e s t i o n s a b o u t u s u a l

1) s u b j e c t s we r e a s k e d t o b y p a s s t h e f i r s t
v i t a m i n and m i n e r a l

u s e and 2) t h e r e s p o n d e n t s

we r e a s k e d t o f i l l

i n t h e f r e q u e n c y o f c o n s u m p t i o n whi ch i n d i c a t e d how

often,

t h e y consumed t h e amount o f f ood s p e c i f i e d

on a v e r a g e ,

t h e i r pregnancy",

r a t h e r than "during the p a s t y e a r " .

"during

Th e s e d i r e c t i o n s

we r e r u b b e r - s t a m p e d on e a c h SQFFQ.
The SQFFQ p r o v i d e d f r e q u e n c y o f c o n s u m p t i o n o f f o o d s / f o o d g r o u p s
as we l l

a s an e s t i m a t e o f n u t r i e n t ,

Individual

nutrient

c a f f e i n e and a l c o h o l

intake.

i n t a k e s we r e c omput ed by m u l t i p l y i n g t h e r e l a t i v e

f r e q u e n c y o f c o n s u m p t i o n o f e a c h f ood i t e m by t h e n u t r i e n t c o n t e n t o f
the specified portion size.

The p r i m a r y s o u r c e o f t h e n u t r i e n t d a t a b a s e

was t h e U n i t e d S t a t e s D e p a r t m e n t o f A g r i c u l t u r e

(USDA) f ood c o m p o s i t i o n

128

tables

(Adams,

Ma t t h e ws ,

1975; USDA, 1976 t o 1983; O r r ,

1984),

published data

1969; H a y t o w i t z and

supplemented with m a n u f a c t u r e r s '

i n f o r m a t i o n and o t h e r

( F e e l e y e t a l , 1972; Mc La ughl i n and W e i l h r a u c h ,

The c a f f e i n e d a t a b a s e was c o m p r e h e n s i v e ,
decaffeinated tea,

1979).

i n c l u d i n g c a f f e i n a t e d and

c o f f e e and d i e t and r e g u l a r s o d a ,

brownies,

i c e cr eam

s u n d a e s and c h o c o l a t e c a n d y b a r s .
The W i l l e t t SQFFQ was s e l e c t e d f o r s e v e r a l

reasons:

1) i t was

d e v e l o p e d t o a n a l y z e more t a r g e t n u t r i e n t s t h a n any o t h e r SQFFQ, 2) t h e
q u e s t i o n n a i r e was i n e x p e n s i v e ( $ 0 . 2 5 e a c h ) ,

c o u l d be s e l f - a d m i n i s t e r e d

and c o u l d be a d a p t e d t o r e q u e s t i n f o r m a t i o n a b o u t u s u a l
d u r i n g p r e g n a n c y and 3)

f ood i n t a k e

i t c o u l d be c o m p u t e r s c o r e d a t a r e a s o n a b l e c o s t

( $ 1 . 2 5 e a c h p l u s $ 5 0 . 0 0 t o downl oa d t h e d a t a t o d i s k e t t e ) .

Physicians'

Prenatal

The " P r e n a t a l

Ca r e Q u e s t i o n n a i r e .

Ca r e Q u e s t i o n n a i r e "

q u e s t i o n s a b o u t t h e womens' h e i g h t ,

( Appe ndi x 20) c o n s i s t e d o f 11

p r e - p r e g n a n c y and d e l i v e r y w e i g h t s ,

r a t e o f w e i g h t g a i n t h r o u g h o u t p r e g n a n c y and t h e h i g h e s t and l o w e s t
hemoglobin,

h e m a t o c r i t and d i a s t o l i c b l o o d p r e s s u r e r e a d i n g s r e c o r d e d

during pregnancy.

The s u r v e y q u e s t i o n s we r e d e r i v e d f r om an a b b r e v i a t e d

version of the p ilo t questionnaire,

t h e PNSS q u e s t i o n n a i r e and t h e

p r o p o s e d ( 1989) r e v i s i o n o f t h e S t a t e o f Mi c h i g a n b i r t h

certificate,

f r om whi c h t h e l i s t o f m e d i c a l c o m p l i c a t i o n s was c o m p i l e d .

Procedures
The names o f t h e 600 w h i t e i n f a n t s r a n d o ml y s e l e c t e d f o r t h e
s a m p l i n g f r a me we r e c h e c k e d a g a i n s t c o m p u t e r i z e d d e a t h c e r t i f i c a t e s .

Any

129

s u b j e c t who had d i e d was removed f r om t h e s a m p l i n g f r a me and r e p l a c e d by
a n o t h e r r a n d o ml y s e l e c t e d

i n f a n t who met t h e e l i g i b i l i t y r e q u i r e m e n t s .

Each i n f a n t was a s s i g n e d a c ode number .
birth date,

Each i n f a n t ' s name and

and t h e name and a d d r e s s o f e a c h i n f a n t ' s m o t h e r , we r e

a b s t r a c t e d f r om t h e b i r t h c e r t i f i c a t e .

An i n d i v i d u a l i z e d l e t t e r

( Ap p e n d i x 21) d e s c r i b i n g t h e s t u d y and r e q u e s t i n g p a r t i c i p a t i o n was s e n t
t o e a c h m o t h e r . The l e t t e r ,
H e a l t h (MDPH) s t a t i o n e r y ,

p r i n t e d on Mi c h i g a n D e p a r t m e n t o f P u b l i c

i n c l u d e d t h e b a b y ' s name t o a s s u r e t h e m o t h e r

a n s we r e d t h e q u e s t i o n n a i r e a b o u t t h e a p p r o p r i a t e i n f a n t .

The l e t t e r was

s i g n e d by Ge or ge H. Van Amburg, MS, MPH, S t a t e R e g i s t r a r and C h i e f ,
O f f i c e o f t h e S t a t e R e g i s t r a r and C e n t e r f o r H e a l t h S t a t i s t i c s
Ge or ge H. B a k e r , J r . ,

MD, C h i e f , O f f i c e o f M a t e r n a l

In a d d i t i o n t o t h e l e t t e r ,
L ife sty le Questionnaire

and C h i l d H e a l t h .

e a c h m o t h e r was s e n t a P r e g n a n c y

( Appe ndi x 1 7 ) ,

a copy o f t h e r e v i s e d W i l l e t t

SQFFQ ( Appe ndi x 18) and i n s t r u c t i o n s f o r i t s c o m p l e t i o n
number 2 p e n c i l ,

and t h e N a t i o n a l

Each s u b j e c t r e c e i v e d a

L i v e s t o c k and Meat Bo a r d ,

p l a s t i c b i b d o n a t e d by G e r b e r ,

return the questionnaire,
mailed in a wh it e,

and a

as i n c e n t i v e s t o c o m p l e t e and

s i g n e d c o n s e n t f orm and SQFFQ. The p a c k e t was

6 . 5 x 9 . 5 i n c h e n v e l o p e c l e a r l y s t a mp e d " F i r s t C l a s s "

in r ed ink.
One week a f t e r t h e i n i t i a l
note card,

a

" N u t r i t i o n Du r i n g t h e F i r s t F i v e Y e a r s " , d o n a t e d by t h e

Mi c h i g a n Be e f Co u n c i l
colorful,

( Appe ndi x 1 9 ) ,

and a s t a m p e d , r e t u r n e n v e l o p e a d d r e s s e d t o Van Amburg

a t t h e Mi c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h .
booklet e n t i t l e d

and

s u r v e y p a c k e t was m a i l e d ,

e n c l o s e d i n a w h i t e MDPH b u s i n e s s e n v e l o p e ,

s u b j e c t by f i r s t c l a s s mai l

a reminder

was s e n t t o e a c h

( Appe ndi x 1 3 ) . The s u b j e c t was t h a n k e d f o r

130

h e r pr ompt r e s p o n s e a n d ,

i f s h e had n o t a l r e a d y done s o, was e n c o u r a g e d

to r e t u r n the survey a t her e a r l i e s t convenience.

The p r i m a r y

r e s e a r c h e r ' s name and t e l e p h o n e number wer e p r o v i d e d ,
was e n c o u r a g e d t o c a l l

c o l l e c t i f t h e s u r v e y had b e e n m i s p l a c e d o r n o t

r e c e i v e d . T h r e e weeks f r om t h e i n i t i a l
22) and c o m p l e t e p a c k e t ,
responders.

m a i li n g a second l e t t e r

mi nus t h e i n c e n t i v e s ,

F i v e weeks a f t e r t h e i n i t i a l

increase the response r a t e ,
infants

(cases)

and t h e s u b j e c t

all

was m a i l e d t o a l l

mailing,

non-responders

non­

in an a t t e m p t t o

o f low b i r t h w e i g h t

f o r whom a wo r k i n g t e l e p h o n e number c o u l d be o b t a i n e d

we r e c a l l e d t o e n c o u r a g e t h e c o m p l e t i o n o f t h e q u e s t i o n n a i r e .
controls

( Appe ndi x

(optimal

Mot he r s o f

b i r t h w e i g h t i n f a n t s ) w e r e n o t t e l e p h o n e d as

s u f f i c i e n t s u r v e y s had b e e n r e c e i v e d f r o m t h i s

group.

Any s u r v e y r e t u r n e d by t h e p o s t o f f i c e f o r an i n s u f f i c i e n t o r
i n c o r r e c t a d d r e s s was f o l l o w e d - u p by s e a r c h e s o f c i t y and t e l e p h o n e
directories,

Mi c h i g a n Be l l

o r d e r had e x p i r e d ,

D i r e c t o r y A s s i s t a n c e and,

personal

i f the forwarding

r e q u e s t s t o t h e p o s t m a s t e r o f t h e c i t y wher e

t h e p e r s o n had p r e v i o u s l y r e s i d e d ( $ 1 . 0 0 p e r r e q u e s t ) . The names o f a l l
s u b j e c t s w i t h unknown a d d r e s s e s we r e s e n t t o t h e Mi c h i g a n D e p a r t m e n t o f
Mot or V e h i c l e s Commer ci al

Look-Up U n i t .

R e s p o n d e n t s m a i l e d t h e c o m p l e t e d s u r v e y s t o t h e MDPH whe r e t h e y
we r e d a t e d ,
mailing,

r e c o r d e d and i n s p e c t e d .

The c o d e number and wave ( f i r s t

second m a i l i n g o r p o s t - t e l e p h o n e c a l l )

o f th e r etu rn ed surveys

we r e r e c o r d e d d a i l y u s i n g a c o m p u t e r d a t a b a s e p r o g r a m . The b i r t h d a t e and
b i r t h w e i g h t o f e a c h i n f a n t we r e t r a n s c r i b e d from t h e b i r t h c e r t i f i c a t e
t o t h e s u r v e y . Al l

b i r t h w e i g h t s r e p o r t e d i n pounds and o u n c e s wer e

c o n v e r t e d t o gr ams w i t h a s t a n d a r d c h a r t

( Appe ndi x 5 ) .

131

Any i n c o m p l e t e s u r v e y o r SQFFQ was r e m a i l e d w i t h a l e t t e r
( Ap p e n d i x 23) a s k i n g t h e s u b j e c t t o c o m p l e t e and r e t u r n i t
e n c l o s e d s t a mp e d ,
signed

pre-addressed envelope.

in t he

I f t h e c o n s e n t f or m was n o t

( n o n - c o n s e n t e r s ) , t h e m o t h e r was s e n t a l e t t e r

( Appe ndi x 24)

r e q u e s t i n g h e r r e c o n s i d e r a t i o n . A copy o f t h e P h y s i c i a n s '

Prenatal

Car e

Q u e s t i o n n a i r e ( Appe ndi x 20) was s e n t so t h e m o t h e r knew e x a c t l y what
i n f o r m a t i o n was b e i n g r e q u e s t e d .
Subsequently, the Prenatal
sent to the prenatal
release

Ca r e Q u e s t i o n n a i r e

( Appe ndi x 20) was

c a r e p r o v i d e r o f a l l women who p r o v i d e d s i g n e d

( c o n s e n t e r s ) . The name and a d d r e s s o f t h e p h y s i c i a n ,

the consenter,

was c r o s s - c h e c k e d w i t h t h e b i r t h c e r t i f i c a t e

and c o m p l e t e n e s s . Any m i s s i n g i n f o r m a t i o n
initials,

(i.e.,

p r o v i d e d by
f o r accuracy

d o c t o r ' s f i r s t name o r

s t r e e t name, z i p c o d e ) n o t a v a i l a b l e on t h e b i r t h c e r t i f i c a t e

was o b t a i n e d f r om t h e Ame r i c a n H o s p i t a l A s s o c i a t i o n Gui de t o t h e H e a l t h
C a r e F i e l d (AHA, 1 9 8 6 ) , t e l e p h o n e d i r e c t o r i e s ,

d i r e c t o r y a s s i s t a n c e or

by c a l l i n g t h e r e s p o n d e n t .
I n d i v i d u a l i z e d l e t t e r s d e s c r i b i n g t h e s t u d y and r e q u e s t i n g t h e
physicians'
mothers'

p a r t i c i p a t i o n we r e c r e a t e d u s i n g d a t a a b s t r a c t e d f rom t h e

q u e s t i o n n a i r e and t h e i n f a n t s '

Each l e t t e r ,

birth ce rtific a te

s i g n e d by Van Amburg and B a k e r ,

( Appe ndi x 2 5 ) .

i n c l u d e d t h e m o t h e r ' s and

b a b y ' s name t o a s s u r e q u e s t i o n s we r e a n s we r e d a b o u t t h e a p p r o p r i a t e
infant.
infant's

The " P r e n a t a l
birthdate,

Ca r e Q u e s t i o n n a i r e " ,

l a b e l e d w i t h t h e c ode number ,

and name o f b o t h t h e i n f a n t and t h e m o t h e r ,

o f t h e s i g n e d c o n s e n t f o r m,

a number two p e n c i l

and a s t a m p e d ,

a copy
return

e n v e l o p e a d d r e s s e d t o Van Amburg a t t h e MDPH we r e s e n t t o e a c h p h y s i c i a n
in a wh i t e,

6 . 5 x 9 . 5 i n c h e n v e l o p e c l e a r l y s t a mpe d " F i r s t C l a s s " .

132

F o l l o w - u p p r o t o c o l was i d e n t i c a l

to th a t described for the p i lo t

s t u d y , w i t h a r e m i n d e r n o t e c a r d ( Appe ndi x 16) m a i l e d a p p r o x i m a t e l y t e n
days a f t e r t he i n i t i a l

s u r v e y p a c k e t and a s e c o n d p a c k e t m a i l e d t o n o n ­

r e s p o n d e r s one month f r om t h e i n i t i a l

m a i l i n g ( Appe ndi x 2 6 ) . Any

q u e s t i o n n a i r e r e t u r n e d f o r an i n s u f f i c i e n t o r i n c o r r e c t a d d r e s s was
f o l l o w e d - u p by s e a r c h e s o f c i t y and t e l e p h o n e d i r e c t o r i e s ,

me d i c a l

d i r e c t o r i e s and Mi c h i g a n Be l l D i r e c t o r y A s s i s t a n c e .

S e l e c t i o n of the Reference Weight-For-Height Standards
Ma j or s t u d i e s on i n s u r e d p o p u l a t i o n s c o n d u c t e d i n t h e U n i t e d
S t a t e s and Canada i n 1959 and 1979 by t h e S o c i e t y o f A c t u a r i e s and t h e
A s s o c i a t i o n o f L i f e I n s u r a n c e Medi cal D i r e c t o r s o f Ame r i c a ( S o c i e t y o f
Actuaries,

1959,

1983) we r e us e d t o d e v e l o p t h e M e t r o p o l i t a n L i f e

Insurance Reference Weight-for-H eight t a b l e s

( Appe ndi x 3 and 4 ) .

The

w i d e l y u s e d 1959 r e f e r e n c e t a b l e was r e p l a c e d by t h e 1983 M e t r o p o l i t a n
R e f e r e n c e T a b l e when, b a s e d on f i n d i n g s f r om t h e 1979 B u i l d and Bl ood
P r e s s u r e S t u d y o f a p p r o x i m a t e l y 4 . 2 m i l l i o n i n s u r e d men and women,

it

was d e t e r m i n e d t h a t t h e w e i g h t a s s o c i a t e d w i t h t h e g r e a t e s t l o n g e v i t y
was s l i g h t l y h i g h e r t h a n p r e v i o u s l y e s t i m a t e d , maki ng t h e 1983
M e tr op ol ita n sta nd a rd the p r e f e r r e d "gold s ta n d a r d " .
H e i g h t and w e i g h t d a t a o f 2 0 , 3 2 2 i n d i v i d u a l s b e t we e n t h e a g e s o f
s i x mont hs and 72 y e a r s we r e c o l l e c t e d as p a r t o f t h e N a t i o n a l

Health

and N u t r i t i o n E x a m i n a t i o n I I s u r v e y (DHHS, 1 9 8 9 c ) . An u n p u b l i s h e d s u b s e t
of t h i s d a ta base,

the w e i g h t - f o r - h e i g h t t a b l e f o r non-pregnant females

be t we e n t h e a g e s o f 2 0 - 3 4 , was r e q u e s t e d f r om t h e N a t i o n a l
Health S t a t i s t i c s

Center for

( Appe ndi x 3 1 a ) . When t h e medi a n w e i g h t - f o r - h e i g h t was

133

p l o t t e d a g a i n s t t h e 1959 and t h e 1983 M e t r o p o l i t a n r e f e r e n c e s w e i g h t for-height,

a s t r i k i n g s i m i l a r i t y b e t we e n t h e NHANES I I 5 0 t h p e r c e n t i l e

and t h e 1983 M e t r o p o l i t a n s t a n d a r d was n o t e d ( Appe ndi x 3 1 b ) .
reason,

For t h a t

o n l y t h e 1959 and t h e 1983 M e t r o p o l i t a n r e f e r e n c e s t a n d a r d s w i l l

be u s e d i n t h i s d i s s e r t a t i o n .
B e c a u s e Rosso ( 1 9 8 5 ) p r e s e n t e d h i s r e s u l t s b a s e d on t h e 1959
Metropolitan Reference,

t h e f i r s t h y p o t h e s i s w i l l be a n a l y z e d u s i n g bo t h

t h e 1959 and t h e 1983 M e t r o p o l i t a n R e f e r e n c e s t a n d a r d s . T h r o u g h o u t t h e
r e s t of t h is d i s s e r t a t i o n ,
will

howe ve r , o n l y t h e 1983 M e t r o p o l i t a n R e f e r e n c e

be u s e d i n d a t a a n a l y s i s .

The s p e c i f i c v a l u e c h o s e n t o r e p r e s e n t a

s u b j e c t ' s d e s i r a b l e w e i g h t - f o r - h e i g h t was t h e mean v a l u e o f t h e medi um­
framed,

u n c l o t h e d woman w i t h o u t s h o e s i n 1/ 2 i n c h h e i g h t i n c r e m e n t s .

Analvsi s
Separate data f i l e s

c o n t a i n i n g i n f o r m a t i o n c o l l e c t e d f r om t h e

P r e g n a n c y L i f e s t y l e Q u e s t i o n n a i r e and t h e P r e n a t a l

Ca r e Q u e s t i o n n a i r e

we r e c r e a t e d i n ASCII u s i n g W o r d s t a r 4 . 0 non- d o c u me n t mode. B i r t h
c e r t i f i c a t e d a t a o f t h e 600 r a n d o ml y s e l e c t e d s u b j e c t s was downl oa de d
onto floppy d i s k .
certificate,

The s c r a m b l e d s i x d i g i t c o d e ,

unique t o each b i r t h

was t r a n s c r i b e d f r om t h e b i r t h c e r t i f i c a t e s ,

unscrambled,

and ma t c h e d w i t h t h e s u b j e c t c ode number . B i r t h w e i g h t c a t e g o r y (LBW,
MBW o r OBW) and r e s p o n s e s t a t u s

( r e s p o n d e r vs n o n - r e s p o n d e r ) we r e coded

on t h e d a t a t a p e t o i n c r e a s e e f f i c i e n c y o f d a t a management .

The coded

SQFFQs we r e a n a l y z e d by t h e Cha nni ng L a b o r a t o r y i n Bos t on and downl oa de d
t o a f l o p p y d i s k i n ASCI I . The f o u r d a t a s e t s c o l l e c t e d i n t h i s s t u d y
( t h e Pregnancy L i f e s t y l e Q u e s t i o n n a i r e ,

t h e SQFFQ, t h e b i r t h c e r t i f i c a t e

134

data,

and t h e P r e n a t a l C a r e Q u e s t i o n n a i r e ) we r e ma t c h e d by s u b j e c t code

number and c o m p i l e d i n t o one d a t a s e t .
The p e r c e n t s t a n d a r d body w e i g h t a t t a i n e d a t t e r m we r e d e t e r m i n e d
by c o mp a r i n g t h e women' s p r e - p r e g n a n t and t e r m w e i g h t t o b o t h t h e 1959
and t h e 1983 M e t r o p o l i t a n L i f e I n s u r a n c e Company' s R e f e r e n c e W e i g h t - f o r - H e i g h t ( Appe ndi x 3 and 4 ) . A c o m p a r i s o n o f t h e u n p u b l i s h e d NHANES I I
w e i g h t - f o r - h e i g h t d a t a f o r w h i t e Amer i can women be t we e n t h e a g e s o f 2034 ( Appe ndi x 31 )

i n d i c a t e d a c l o s e a g r e e m e n t b e t we e n t h e NHANES I I d a t a

and t h e 1983 M e t r o p o l i t a n r e f e r e n c e d a t a .

Thus , t h e p e r c e n t o f o n e ' s

NHANES I I r e f e r e n c e a t t a i n e d a t t e r m was n o t c o mput e d.
A MAR-12 d i e t q u a l i t y s c o r e and an INQ- 1000 n u t r i e n t d e n s i t y
p r o f i l e w e r e c a l c u l a t e d f o r e a c h s u b j e c t a c c o r d i n g t o t h e me t hods o f
Worthington-Roberts

( 1 9 8 9 ) , J e n k i n s and G u t h r i e ( 1984) and Hansen and

Wyse ( 1 9 8 0 ) . B e c a u s e 98% o f t h e r e s p o n d e n t s r e p o r t e d t a k i n g a s u p p l e m e n t
at lea st

f i v e t i m e s p e r week, a l l

d i e t a r y d a t a we r e a n a l y z e d w i t h o u t

nutrient

s u p p l e m e n t s . C a f f e i n e and a l c o h o l

i n t a k e d a t a we r e o b t a i n e d

f r om t h e SQFFQ. Da t a from any s u b j e c t who r e p o r t e d cons umi ng l e s s t h a n
600 o r g r e a t e r t h a n 4 , 0 0 0 c a l o r i e s we r e e x c l u d e d f r om a n a l y s i s as
recommended by t h e W i l l e t t r e s e a r c h g r o u p a t t h e Cha nni ng L a b o r a t o r y i n
Bo s t o n ( Samps on, p e r s o n a l

communication,

s t e m l e a f and nor mal p l o t s i n d i c a t e d a l l

1990).

Examination o f t h e

e x t r e m e o u t l i e r s we r e removed

when t h e s e c a l o r i c r e s t r i c t i o n s we r e f o l l o w e d ( Appe ndi x 2 9 - 2 a , b , c ) .
Al l d a t a we r e a n a l y z e d u s i n g SPSS-PC 3 . 1
CompuAdd 2 8 6 / 1 2 m i c r o c o m p u t e r .
when t h e p r o b a b i l i t y l e v e l

Statistical

(SPSS,

1988) on a

s i g n i f i c a n c e was r e p o r t e d

a t t a i n e d a value o f 0.05 or l e s s with the

135

f o l l o w i n g e x c e p t i o n - - v a r i a b l e s we r e m a i n t a i n e d i n m u l t i p l e r e g r e s s i o n
equations i f they a t t a i n e d a s ig n i f ic a n c e level

of 0.10.

S p e c i f i c c o n t r a s t s o f i n t e r e s t t o i d e n t i f y d i f f e r e n c e s among
g r o u p s ( c a s e s vs c o n t r o l s and r e s p o n d e r s vs n o n - r e s p o n d e r s by b i r t h
w e i g h t c a t e g o r y and p r e - p r e g n a n c y w e i g h t s t a t u s ) we r e a n a l y z e d v i a
oneway a n a l y s i s o f v a r i a n c e and C h i - s q u a r e a s a p p r o p r i a t e .

Crosstabs

we r e u s e d t o c a l c u l a t e t h e c r u d e odds r a t i o and t h e M a n t e l - H a e n s z e l
summary o dds r a t i o

( t h e a d j u s t e d odds r a t i o whi c h " c o r r e c t s " f o r t h e

e f f e c t s of several

r i s k f a c t o r s a t one t i m e ) t o d e t e r m i n e t h e r e l a t i v e

r i s k o f l ow b i r t h r a t e f o r v a r i o u s f a c t o r s me a s u r e d i n t h i s

survey

( K e l s e y e t a l , 1 9 8 6 ) . Bot h t h e c r u d e odds r a t i o s and t h e M a n t e l - H a e n s z e l
summary odds r a t i o we r e h a n d - c a l c u l a t e d a c c o r d i n g t o s t a n d a r d me t hods
( K e l s e y e t a l , 1986) due t o t h e i n a c c e s s i b i l i t y o f an a f f o r d a b l e
c o mp u t e r p r o g r a m t h a t c o u l d c a l c u l a t e t h e s e v a l u e s .
C o r r e l a t i o n s , ANOVA and m u l t i p l e r e g r e s s i o n a n a l y s i s we r e u s e d t o
d e t e r m i n e t h e s t r e n g t h o f r e l a t i o n s h i p be t we e n t h e i n d e p e n d e n t and
dependent v a r i a b l e s ,

t o d e t e r m i n e any i n t e r a c t i o n e f f e c t s ,

to develop

p r e d i c t i o n e q u a t i o n s and t o d e t e r m i n e whi c h f a c t o r s a c c o u n t f o r t h e
l a r g e s t p o r t i o n o f v a r i a n c e i n b i r t h w e i g h t b e t we e n c a s e s and c o n t r o l s .
A correlational

m u l t i p l e r e g r e s s i o n model t o p r e d i c t t h e r e l a t i o n s h i p

b e t we e n v a r i a b l e s o f i n t e r e s t and b i r t h w e i g h t was u s e d t h r o u g h o u t t h i s
study.

Bot h s t e p w i s e r e g r e s s i o n

(forward i n c l u s i o n )

and " e n t e r "

r e g r e s s i o n p r o c e d u r e s we r e u s e d t o d e t e r m i n e t h e m u l t i p l e r e g r e s s i o n
mode l s r e p o r t e d i n t h i s

s t u d y (SPSS,

1989).

The f o l l o w i n g v a r i a b l e s we r e r e c o d e d f o r t h e f i n a l
prediction equation:

b i r t h weight

1) i ncome l e v e l was r e c o d e d as "0" ( l e s s t h a n 185%

136

of poverty)

and "1" ( g r e a t e r t h a n o r e q u a l t o 185% o f p o v e r t y ) ,

2) s e x

was r e c o d e d as "0" f e m a l e and "1" ma l e and 3) t h e K e s s n e r I n d e x was
r e c o d e d a s "0"

( n o t a d e q u a t e ) and "1" ( a d e q u a t e ) .

F a c t o r a n a l y s i s ( v a r i m a x r o t a t i o n ) was u s e d t o d e t e r m i n e t h e
c o n s t r u c t v a l i d i t y o f t h e q u e s t i o n n a i r e and t h e number o f " a t t i t u d i n a l
c o n s t r u c t s " me a s ur e d by t h e q u e s t i o n n a i r e .

Specific a ttitu d in a l

s t a t e m e n t s whi c h c o m p r i s e d t h e a t t i t u d e s c a l e s
weight gain,
if,

(i.e.,

a t t i t u d e toward

a t t i t u d e t o wa r d n u t r i t i o n d u r i n g p r e g n a n c y ) we r e s e l e c t e d

w i t h in each c o n s t r u c t ,

fac to r analysis indicated the c o rr e la tio n

c o e f f i c i e n t o f t h e a t t i t u d e s t a t e m e n t was g r e a t e r t h a n 0 . 5 0 ( Ap p e n d i x
29-7).

The Spear man- Br own s p l i t - h a l f r e l i a b i l i t y me a s u r e was u s e d t o

determine the r e l i a b i l i t y of the e n t i r e a t t i t u d e q u e s tio n n a ir e .
C r o n b a c h ' s a l p h a - r e l i a b i l i t y c o e f f i c i e n t was u s e d t o d e t e r m i n e t h e
r e l i a b i l i t y o f e a c h o f t h e a t t i t u d e c o n s t r u c t s c a l e s ( S i ms ,

1981).

In

t h e f i e l d o f a t t i t u d e m e a s u r e me n t , r e l i a b i l i t y c o e f f i c i e n t s o f 0 . 7 0 o r
a bove a r e c o n s i d e r e d " d e s i r a b l e " ,
tolerated

( He n e r s o n e t a l , 1 9 7 8 ) .

a l t h o u g h lower c o e f f i c i e n t s a r e

137

Physician's Prenatal

Ca r e S u r v e y o f B l a c k Mi c h i g a n Mo t h e r s

Su b . i e c t s
Results of the p i l o t study suggested i n s u f f i c i e n t information
woul d be o b t a i n e d f r om a random s a mpl e o f b l a c k i n f a n t s '

m o t h e r s . The

only v i a b l e option f o r o b t a i n in g useabl e d a ta about the black po pul atio n
w i t h i n t h e c o n s t r a i n t s o f t h i s s t u d y was t o c o n t a c t t h e p h y s i c i a n i n
attendance at b irth ,

as n o t e d on t h e b i r t h c e r t i f i c a t e ,

a b s t r a c t i o n o f i n f o r m a t i o n f r om t h e s u b j e c t s '
approval

medical

o f t h e Mi c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h ,

and r e q u e s t t h e

records.

Upon

the Prenatal

Ca r e

Q u e s t i o n n a i r e was s e n t t o t h e p h y s i c i a n o f r e c o r d o f 825 r a n d o m l y
s e l e c t e d b l a c k Mi c h i g a n i n f a n t s .

Th e s e b l a c k i n f a n t s ,

with b i r t h weights

r a n g i n g b e t we e n 1000 and 4000 g, we r e r a n d o ml y s e l e c t e d by a c o m p u t e r
s e a r c h o f t h e S t a t e o f Mi c h i g a n b i r t h c e r t i f i c a t e s ,

u s i n g t h e same

s e l e c t i o n and e x c l u s i o n c r i t e r i o n as t h e Whi t e M i c h i g a n Mo t h e r s S u r v e y .
The mean s t a n d a r d d e v i a t i o n o f b i r t h w e i g h t f o r a l l

b l a c k Mi c h i g a n

i n f a n t s bor n be t we e n 1985 and 1987, w e i g h i n g b e t we e n 1000 and 4000 g,
was 577 g. Us i ng t h i s v a l u e ,
(1988),

212 c a s e s

and t h e met hod o f Kr a e me r and Thi eman

( 1 0 0 0 - 2 4 9 9 g) and 212 c o n t r o l s

n e c e s s a r y t o d e t e c t a 100 gram d i f f e r e n c e
and 95% c o n f i d e n c e ( T a b l e 4 . 4 ) .

( 3 5 0 0 - 4 0 0 0 g) wer e

i n b i r t h w e i g h t w i t h 80% power

Us i ng t h e met hod o f S n e d e c o r ( 1 9 8 4 ) ,

o n l y 133 c a s e s and 133 c o n t r o l s we r e n e e d e d t o d e t e c t t h e same
difference.

Increasing the difference necessary to de te c t significance

f rom 100 t o 125 g r e d u c e d t h e s a mp l e s i z e t o 140 and 85 f o r e a c h met hod,
respectively.

138

Table 4 .4

E s t i m a t e d s a mp l e s i z e o f b l a c k i n f a n t s n e e d e d t o d e t e c t a
d i f f e r e n c e w i t h 80% powe r , 95% c o n f i d e n c e and a 577 g SD.

Method

Kr a e me r and
Thi eman ( 1988)

S n e d e c o r ( 1984)

D e t e c t i o n Level

Ca s e s

100 g d i f f e r e n c e
125 g d i f f e r e n c e

212
140

212
140

100 g d i f f e r e n c e
125 g d i f f e r e n c e

133
85

133
85

Based on r e s u l t s o f t h e p i l o t s t u d y ,

cases

(OBW) we r e o v e r - s a m p l e d by 267 and 192 s u b j e c t s ,

Controls

(LBW) and c o n t r o l s
respectively.

s a m p l i n g f r a me c o n s i s t e d o f 400 c a s e s and 325 c o n t r o l s
Us i ng t h e met hod o f Kr a e me r and Thi eman ( 1 9 8 8 ) ,
r a t e o f 53% f o r c a s e s

(212/400)

The f i n a l

(Table 4 . 5 ) .

an e s t i m a t e d r e s p o n s e

and 52% f o r c o n t r o l s

( 2 1 2 / 3 2 5 ) was

n e e d e d t o d e t e c t a 100 g d i f f e r e n c e w i t h 80% power and 95% c o n f i d e n c e .
Us i ng t h e met hod o f S n e d e c o r ( 1 9 8 4 ) ,
f o r c a s e s and 41% ( 1 3 3 / 3 2 5 )
d iffe re n c e at the level

a r e s p o n s e r a t e o f 33% ( 1 3 3 / 4 0 0 )

f o r c o n t r o l s was n e c e s s a r y t o d e t e c t a 100 g

selected.

One h u n d r e d b l a c k i n f a n t s w e i g h i n g

be t we e n 2500 and 3499 g (medium b i r t h w e i g h t ) we r e i n c l u d e d i n t h e
s u r v e y f o r a n a l y s i s o f t h e r e l a t i o n b e t we e n p e r c e n t r e f e r e n c e w e i g h t f o r - h e i g h t a t t a i n e d a t t e r m and i n f a n t b i r t h w e i g h t .

139

Table 4 .5 .

Subject se le c tio n c r i t e r i a for black subjects
P h y s i c i a n ' s P r e n a t a l Ca r e S u r v e y .

B i r t h Wei ght
Category

Number
Needed®

Low B i r t h We i ght ( C a s e s )
1000- 1999 g
200 0 - 2 4 9 9 g
Sub-Total:
Mo d e r a t e B i r t h Wei ght
2 500- 2999 g
3000-3499 g
Sub-Total:

% o f Total
Population

T o t a l MI
Population

Time P e r i o d
Surveyed

33
45
218
104
400

33
55
218
179
485

100
82
100
58
82

1-11/88
1-12/87
1-11/88
7-12/87

50
50
100

452
844
1296

11
6
7

7-11/88
7-11/88

150
103
105
167
152
677

43
63
62
39
43
48

7-11/88
7-11/88
7-11/88
7-11/88
7-11/88

2458

34

Opt i ma l B i r t h Wei ght ( C o n t r o l s )
350 0 - 3 6 0 0 g
65
3601-3700 g
65
370 1 - 3 8 0 0 g
65
3 80 1 - 3 9 0 0 g
65
390 1 - 4 0 0 0 g
65
Sub-Total:
325
GRAND TOTAL:

in the

825

af o r 80% power and 95% c o n f i d e n c e t o d e t e c t a 125 gram d i f f e r e n c e
b i r t h w e i g h t e s t i m a t i n g a 34-43% r e s p o n s e r a t e .

Al l

s u b j e c t s we r e b o r n b e t we e n J u l y 1,

1988 and November 30,

e x c e p t f o r 149 c a s e s (37%) who we r e bo r n b e t we e n J a n u a r y 1,
November 30,

in

1988,

1987 and

1988. A t w o - y e a r s e l e c t i o n p e r i o d f o r t h i s c a t e g o r y was

n e c e s s a r y due t o t h e s ma l l

population size.

Because t h e i n f o r m a t i o n

r e q u e s t e d n e e d e d t o be a b s t r a c t e d f r om me d i c a l
upon memory, r e c a l l

records,

b i a s was n o t c o n s i d e r e d a f a c t o r .

and d i d n o t r e l y

Locating the

140

medical

r e c o r d s and t h e a p p r o p r i a t e p h y s i c i a n ,

h o we v e r , was a m a j o r

concern.

Design.

I n s t r u m e n t s and P r o c e d u r e s

The d e s i g n ,
Prenatal

i n s t r u m e n t s , me t h o d s and p r o t o c o l

Ca r e S u r v e y we r e i d e n t i c a l

of the Physicians'

t o t h o s e d e s c r i b e d i n t h e Whi t e

Mi c h i g a n Mo t h e r s S u r v e y w i t h few e x c e p t i o n s .

The i n d i v i d u a l i z e d l e t t e r

sent to the a tte nding physician of the black su b je c ts
differed

s l i g h t l y f r om t h e l e t t e r s e n t t o t h e w h i t e c o n s e n t e r s '

care provider.
well

( Ap p e n d i x 27)

The l e t t e r

prenatal

i n c l u d e d b o t h t h e m o t h e r ' s and b a b y ' s name, as

as t h e b a b y ' s b i r t h d a t e , t o a s s u r e t h e p h y s i c i a n answered t h e

q u e s t i o n n a i r e about t h e a p p r o p r i a t e i n f a n t .

The s e c o n d l e t t e r

( Appe ndi x

28) and s u r v e y we r e m a i l e d t o a l l n o n - r e s p o n d e r s a p p r o x i m a t e l y one month
a f t e r the i n i t i a l

mailing.

Analvsis
A d a t a f i l e c o n t a i n i n g r e s p o n s e s f r om t h e P r e n a t a l
Q u e s t i o n n a i r e f o r b l a c k Mi c h i g a n s u b j e c t s was c r e a t e d
u s i n g SPSS- Da t a E n t r y . The d a t a f r om t h e p r e n a t a l

Ca r e

i n ASCII code

c a r e p r o v i d e r s was

ma t c h e d and mer ged w i t h e a c h s u b j e c t ' s b i r t h c e r t i f i c a t e d a t a .
data analytical

p r o c e d u r e s and l e v e l s o f s t a t i s t i c a l

The same

s i g n i f i c a n c e as

p r e v i o u s l y r e p o r t e d i n t h e Whi t e Mi c h i g a n M o t h e r ' s S u r v e y we r e a p p l i e d
t o t h i s d a t a s e t as a p p r o p r i a t e .

CHAPTER V

RESULTS AND DISCUSSION

The p u r p o s e o f t h i s s t u d y was t o d e t e r m i n e f a c t o r s wh i c h d i f f e r
b e t we e n m o t h e r s who d e l i v e r o p t i m a l

and low b i r t h w e i g h t i n f a n t s .

The

r e s u l t s o f b o t h t h e Whi t e Mi c h i g a n M o t h e r ' s S t u d y and t h e P h y s i c i a n ' s
Su r v e y o f Bl a c k Mi c h i g a n Mo t h e r s a r e r e p o r t e d and d i s c u s s e d i n t h i s
chapter.

F o l l o w i n g t h e p r e s e n t a t i o n o f r e s p o n s e r a t e s and d e s c r i p t i v e

statistics,

r e s u l t s and d i s c u s s i o n a r e p r e s e n t e d f o r e a c h h y p o t h e s i s .

Whi t e Mi c h i g a n M o t h e r ' s S t u d y

Re s p o n s e Ra t e
Four h u n d r e d o f t h e 600 m o t h e r s who we r e s e n t a P r e g n a n c y
L i f e s t y l e Q u e s t i o n n a i r e (67%) r e s p o n d e d ( T a b l e 5 . 1 ) ,
(LBW) and 184 c o n t r o l s

i n c l u d i n g 171 c a s e s

(OBW). Two LBW c a s e s we r e d r o p p e d f r om s u b s e q u e n t

a n a l y s i s due t o e x t r e m e w e i g h t l o s s e s o f 64 and 60 pounds f o l l o w i n g
m a j o r s u r g e r y f o r a g a s t r i c e x c l u s i o n and a j e j u n o i l i a l
respectively.
controls,

Thus d a t a f r om 398 s u b j e c t s ,

bypass,

i n c l u d i n g 169 c a s e s and 184

we r e a n a l y z e d .

E i g h t y - o n e p e r c e n t o f t h e s u r v e y s we r e r e t u r n e d a f t e r t h e f i r s t
mailing

(n=323),

18% a f t e r t h e s e c ond m a i l i n g ( n=72) and l e s s t h a n one

141

142

percent

( n=3) a f t e r t e l e p h o n e c a l l s t o a l l

w o r k i n g t e l e p h o n e number c o u l d be o b t a i n e d

LBW n o n - r e s p o n d e r s f o r whom a
(n=28)

( Ap p e n d i x 2 9 - 1 ) .

C u r r e n t a d d r e s s e s c o u l d n o t be l o c a t e d by s t a n d a r d me t hods f o r 5% o f t h e
s a m p l i n g f r a me ( n = 3 2 ) , 30 o f whom w e r e m o t h e r s o f LBW c a s e s .
o f Mi c h i g a n Mot or V e h i c l e Commer ci al

The S t a t e

Look-Up U n i t was a b l e t o p r o v i d e

c u r r e n t a d d r e s s e s f o r 11 o f t h e s e 32 s u b j e c t s

( 34%). Th u s ,

579 o f t h e

s u b j e c t s s e l e c t e d f o r t h i s s t u d y ( 96. 5%) we r e c o n t a c t e d .
S e v e n t y - o n e o f t h e 400 s u r v e y s

(18%) we r e r e t u r n e d w i t h o u t a

s i g n e d c o n s e n t f or m whi ch a l l o w e d t h e s u b j e c t ' s p h y s i c i a n t o r e l e a s e
me d i c a l

informatio n to the r e s e a r c h e r (Table 5 . 1 ) .

request,

34 o f t h e 71 n o n - c o n s e n t e r s

resulting

in a t o t a l

Table 5 .1 .

A f t e r a second

(47%) r e t u r n e d a s i g n e d f or m,

o f 363 c o n s e n t e r s (91%).

R e s p o n s e and c o n s e n t r a t e t o t h e w h i t e m o t h e r ' s P r e g n a n c y
L ifestyle Questionnaire.

Included
in Study

Group

Se n t

R e t u r n e d (%)

C o n s e n t e r s 3 (%)

Low B i r t h
We i ght (LBW)

290

171 ( 60)

169

151 ( 88)

Mo d e r a t e B i r t h
We i ght (MBW)

60

45 ( 75)

45

41 ( 91)

Opt i ma l B i r t h
We i ght (OBW)

250

184 ( 74)

184

171 ( 93)

TOTAL:

600

400 ( 67)

398

363 ( 91)

a Number o f r e s p o n d e r s who s i g n e d a c o n s e n t f or m a l l o w i n g t h e i r
p h y s i c i a n t o r e l e a s e medical i n f o r m a t i o n .

143

Of t h e 400 r e s p o n d e r s ,
Food F r e q u e n c y Q u e s t i o n n a i r e
Of t h e s e ,

380 r e t u r n e d t h e W i l l e t t S e m i - Q u a n t i t a t i v e
(SQFFQ) w i t h a l l

116 i t e m s c o m p l e t e d (95%).

21 ( 5. 5%) we r e e x c l u d e d f r om f u r t h e r a n a l y s i s b e c a u s e t h e

s u b j e c t s ' c a l o r i c i n t a k e e x c e e d e d t h e g u i d e l i n e s f o r v a l i d i t y and
r e l i a b i l i t y e s t a b l i s h e d by t h e Cha nni ng L a b o r a t o r y (600 c a l o r i e s t o
3,500 c a l o r i e s ) ,

i n d i c a t i n g t h e r e s u l t s we r e u n r e l i a b l e and i n v a l i d

( Samps on, p e r s o n a l c o m m u n i c a t i o n ,

1 9 9 0 ) . Be c a u s e t h e SQFFQ had n o t

p r e v i o u s l y be e n u s e d w i t h a p r e g n a n t p o p u l a t i o n ,
additional

an a r b i t r a r y ,

500 c a l o r i e s we r e added t o t h e u p p e r l i m i t t o accommodat e t h e

e x t r a c a l o r i c n e e d s o f p r e g n a n c y . To r e i n f o r c e t h i s d e c i s i o n ,

three

s t e m l e a f p l o t s wer e c r e a t e d t o d e t e r m i n e t h e n o r m a l i t y o f t h e
d i s t r i b u t i o n o f c a l o r i c i n t a k e d e p e n d e n t upon whi c h c u t - o f f p o i n t f o r
e x c l u s i o n was s e l e c t e d
o u t l i e r s when a l l

( Appe ndi x 2 9 : 2 a - c ) .

Results indicated

t h e s u b j e c t s ' d a t a we r e e xa mi ne d ( n = 3 8 0 ) ,

when t h e a r b i t r a r y c u t - o f f was s e t a t 4 , 5 0 0 c a l o r i e s
o u t l i e r s when t h e c u t - o f f was s e t a t 4 , 0 0 0 c a l o r i e s

12 e x t r e m e
two o u t l i e r s

( n=368) and no
( n = 3 5 9 ) . Th u s ,

a

s u b j e c t ' s SQFFQ was a r b i t r a r i l y e x c l u d e d f r om t h e s t u d y i f more t h a n
4 , 0 0 0 c a l o r i e s wer e consumed p e r d a y . A t o t a l

o f 359 SQFFQs we r e

analyzed.
The p r e n a t a l c a r e p r o v i d e r o f e a c h c o n s e n t e r was c o n t a c t e d and
asked to complete t h e Pr e na t a l

Ca r e Q u e s t i o n n a i r e .

physicians of the white su b je c ts

Of t h e s e ,

281

(77%) r e t u r n e d c o m p l e t e d s u r v e y s ,

a f t e r t h e f i r s t m a i l i n g and 28% a f t e r t h e s e c o n d m a i l i n g

72%

(Table 5 . 2 ) .

144

Table 5 .2 .

Re s pons e r a t e t o t h e P h y s i c i a n s '
white su b je c ts.

Prenatal

Ca r e Su r v e y f o r

Group

Number
Sent

Re s p o n s e
n (%)

LBW
MBW
OBW

151
41
171

113 ( 75)
32 ( 78)
136 ( 80)

TOTAL:

363

281 ( 7 7 . 4 )

Few p r o b l e m s we r e e n c o u n t e r e d i n l o c a t i n g t h e w h i t e s u b j e c t s '
prenatal

care providers.

F i f t e e n p h y s ic i a n s could not prov ide the

r e q u e s t e d i n f o r m a t i o n due t o t h e i r i n a b i l i t y t o l o c a t e r e c o r d s
stated refusal

to p a r t i c i p a te

l o c a t i o n o r having r e t i r e d

(n=4),

( n=3) and no l o n g e r b e i n g empl oye d a t t h a t

( n=8)

( Appe ndi x 2 9 - 3 ) .

Thus ,

of the physicians provided the requested info rmatio n,

a l t h o u g h 77.4%

81. 5% o f t h e

conta cte d physic ians corresponded with the r e s e a r c h e r .

G e n e r a l i z a b i l i t v of Results to the Population
S o c i o d e m o g r a p h i c i n f o r m a t i o n f r om t h e b i r t h c e r t i f i c a t e o f
responders'

and n o n - r e s p o n d e r s '

i n f a n t s was c ompar ed t o d e t e r m i n e t h e

c o n f i d e n c e w i t h whi c h r e s u l t s o b t a i n e d f r om t h i s

s a mpl e c o u l d be

g e n e r a l i z e d t o t h e p o p u l a t i o n . A comparison o f t h e r e s p o n s e r a t e of
r e s p o n d e r s by g e o g r a p h i c l o c a t i o n t h r o u g h o u t t h e s t a t e
b irth occurred)

( c o u n t y wher e t h e

i n d i c a t e d a 69% r e s p o n s e r a t e by women who d e l i v e r e d i n

145

a primarily rural

c o u n t y and a 65% r e s p o n s e r a t e by women who d e l i v e r e d

i n a p r i m a r i l y u r b a n c o u n t y ( Appe ndi x 3 2 a ) .
T h e r e we r e no s i g n i f i c a n t d i f f e r e n c e s
m o t h e r ' s a g e , number o f p r e n a t a l

visits,

p a r e n t s named on t h e b i r t h c e r t i f i c a t e ,
of prenatal

care,

in i n f a n t b i r t h we i g h t ,

weeks g e s t a t i o n ,

number o f

sex o f t h e i n f a n t ,

K e s s n e r I nde x

and o n e - m i n u t e and f i v e - m i n u t e Apga r s c o r e s , when

r e s p o n d e r s (R) and n o n - r e s p o n d e r s

(NR) who d e l i v e r e d an o p t i m a l

w e i g h t i n f a n t we r e compar ed ( Appe ndi x 2 9 - 4 ) .

Statistically

significant

d i f f e r e n c e s we r e n o t e d b e t we e n t h e m o t h e r ' s y e a r s o f e d u c a t i o n
vs 1 2 . 2 NR; p < . 0001) and month p r e n a t a l
< 0.05),

although the p r a c t i c a l

questionable.

birth

(13.5 R

c a r e be ga n ( 2 . 4 R vs 2 . 7 NR; p

significance of these d iffe re n c es

is

R e s u l t s s u g g e s t a r e p r e s e n t a t i v e s a mp l e o f w h i t e m o t h e r s

who d e l i v e r OBW i n f a n t s i n Mi c h i g a n was o b t a i n e d .
No s i g n i f i c a n t d i f f e r e n c e s we r e n o t e d b e t we e n r e s p o n d e r s and n o n ­
r e s p o n d e r s who d e l i v e r e d a low b i r t h w e i g h t i n f a n t i n t h e f o l l o w i n g
characteristics:

i n f a n t b i r t h w e i g h t , m o t h e r ' s a g e , number o f p r e v i o u s

c h i l d r e n , weeks g e s t a t i o n o r o n e - m i n u t e and f i v e - m i n u t e Apga r s c o r e s
( Appe ndi x 2 9 - 5 ) .
education

However,

LBW-NR had s i g n i f i c a n t l y f e w e r y e a r s o f

( 1 2 . 1 NR vs 1 2 . 7 R; p < 0 . 0 4 9 ) ,

vs 1 1 . 7 R; p < 0 . 0 0 1 7 ) , e n t e r e d p r e n a t a l
mont hs NR vs 2 . 4 mont hs R; p < 0 . 0 0 1 ) ,
care,

fewer p r e n a t a l

visits

( 1 0 . 3 NR

c a re l a t e r in pregnancy (3.2

had a l o w e r q u a l i t y o f p r e n a t a l

a s i n d i c a t e d by a h i g h e r K e s s n e r I nde x s c o r e ( 1 . 5 NR vs 1 . 2 R ) ;

p < .0005),
parents

and had o n l y one p a r e n t (12% NR vs 7% R) ,

as opposed t o both

(29% NR vs 52% R) , named on t h e b i r t h c e r t i f i c a t e

(p < . 0 0 0 8 ) .

The s e d i f f e r e n c e s s u g g e s t any a s s o c i a t i o n o b s e r v e d b e t we e n t h e v a r i a b l e s
o f i n t e r e s t i n t h i s s t u d y and low b i r t h w e i g h t w i l l mos t l i k e l y u n d e r -

146

represent the true association,

resulting

i n an a t t e n u a t i o n t o w a r d t h e

mean a t t h e r i s k o f a t y p e I I e r r o r ( S n e d e c o r and C o c h r a n ,

1980).

C h a r a c t e r i s t i c s o f t h e Re s p o n d i n g Sampl e P o p u l a t i o n
The mean r e s p o n d e r i n t h e Whi t e Mi c h i g a n M o t h e r ' s S t u d y was 2 6 . 5
y e a r s o l d and had c o m p l e t e d one y e a r o f p o s t - h i g h s c h o o l

education

( T a b l e 5 . 3 ) . An e s t i m a t e d 40% o f t h e r e s p o n d e r s had h o u s e h o l d i ncomes
l e s s t h a n 185% o f t h e 1988 p o v e r t y i n d e x ( s e e O p e r a t i o n a l
Chapter 3).

Definitions,

Twent y p e r c e n t o f t h e s a mp l e r e p o r t e d m o n t h l y i ncomes l e s s

t h a n 100% o f t h e p o v e r t y l e v e l .
(10%) r e c e i v e d f o o d
Self-reported

T h i r t y - s i x women (9%) r e c e i v e d AFDC, 39

s t a mp s and 69 (17%) we r e e n r o l l e d i n

WIC.

d a t a i n d i c a t e d t h e a v e r a g e r e s p o n d e r was 5 ' 4 1 / 2"

and we i g h e d 131 l b s p r i o r t o p r e g n a n c y ( r a n g e 8 5 - 2 5 5 l b s ) .
w e i g h t g a i n d u r i n g p r e g n a n c y was 2 9 . 5 l b s ,
t o a g a i n o f 71 l b s .
their

Overall,

The a v e r a g e

r a n g i n g f r om a l o s s o f 12 l b s

t h e s u b j e c t s e n t e r e d p r e g n a n c y a t 99% o f

1983 M e t r o p o l i t a n r e f e r e n c e w e i g h t - f o r - h e i g h t

(range 68-190),

and

g a i n e d t o 122% o f t h e i r R e f e r e n c e Wei ght a t t e r m ( r a n g e 6 9 - 2 1 0 ) . Ni ne
mont hs a f t e r d e l i v e r y ,
t h r e e pounds h i g h e r

t h e s u b j e c t s ' mean w e i g h t was , on a v e r a g e ,

only

t h a n a t c o n c e p t i o n ( 134 l b v s 131 l b ) .

S i x t y - s e v e n p e r c e n t o f t h e s u b j e c t s r e p o r t e d c on s u mi n g no a l c o h o l
d u r i n g p r e g n a n c y ; 62% r e p o r t e d t h e y d i d n o t smoke. Al l

but e ig h t

s u b j e c t s r e p o r t e d t a k i n g a v i t a m i n s u p p l e m e n t w h i l e p r e g n a n t . As a
group,

the mothers i n i t i a t e d p r ena tal

p r e g n a n c y and saw a p r e n a t a l

c a r e d u r i n g t h e s e c o n d month o f

c a r e p r o v i d e r 12 t i m e s . Of t h e 398 i n f a n t s ,

206 we r e ma l e (52%) and 192 we r e f e m a l e (48%).

147

Table 5.3.

C h a r a c t e r i s t i c s o f t h e s a mpl e r e s p o n d e r s

Characteristic

(n=398).

Mean + SDa

Range

26.5 + 3.8
13.2 + 2. 0
40b
20
9
17

(21-34)
( 7-17)

64.4
131
29.5
134
99
122

(57-72)
(85-255)
(-12-71)
(80-273)
(68-190)
(69-210)

SOCIODEMOGRAPHIC
Age, y r s
Education, yrs
Income < 185% p o v e r t y , %
Income < 100% p o v e r t y , %
AFDC, %
WIC, %
ANTHROPOMETRIC
He ight , in
Pre-pregnant weight, lbs
Pregnancy we ight g a i n , l b s
Current weight, lbs
% 1983 RW, p r e - p r e g n a n t
% 1983 RW, a t t e r m

+
+
+
+
+
±

2.6
27
12
29
19
21

BEHAVIORAL
Month p r e n a t a l c a r e began
Number o f p r e n a t a l v i s i t s
Took v i t a m i n s u p p l e m e n t , %
Consumed no a l c o h o l , %
Did n o t smoke c i g a r e t t e s , %

2 . 4 + 1. 2
12 + 3
95
67
62

(1-8)
(1-24)

a e x c e p t whe r e p e r c e n t a g e o f t o t a l , as n o t e d .
b n=352.

Co mp a r i s o n o f Ca s e s and C o n t r o l s bv S e l e c t D e s c r i p t i v e V a r i a b l e s
A c o m p a r i s o n o f c a s e s ( m o t h e r s o f LBW i n f a n t s ;
controls

( m o t h e r o f OBW i n f a n t s )

anthropometric variables
5.4).

< 2500 g) and

f o r s e l e c t e d s o c i o d e m o g r a p h i c and

i n d i c a t e s many s i g n i f i c a n t d i f f e r e n c e s

The i mp a c t o f t h e s e d i f f e r e n c e s on b i r t h w e i g h t w i l l

f o r each h y p o t h e s i s .

(Table

be p r e s e n t e d

148

Table 5.4.

Co mp a r i s o n o f w h i t e c a s e s and c o n t r o l s f o r s e l e c t
d e s c r i p t i v e v a r i a b l e s (Means+SD, u n l e s s n o t e d ) .

Variable

OBW
( n = 184)

LBW
(n=169)

t or
X2

P

SOCIODEMOGRAPHIC
26.9+3.7
13.5+2.0
18b
3
7

2.59
3.85
5 . 9C
7.3°
2.9C

. 0100
. 0001
. 0529
. 0069
. 0900

He ight , in
64 + 3
P r e - p r e g n a n t wt , l b s
122 + 25
Term w e i g h t , l b s
148 + 28
P r e g n a n c y wt g a i n , l b s
26 + 12
% 1983 RW, p r e - p r e g n a n t
94 + 18
% 1983 RW, a t t e r m
114 + 20
% < 90% RW83, p r e - p r e g n a n t
24

65
134
173
33
104
129

5.36
6.32
8.34
5.70
5.20
4.97
1 5 . 4C

. 0000
. 0000
. 0000
. 0000
. 0000
. 0000
. 0000

Birth weight, g
Femal e i n f a n t s , %

3761+143
40

62.1
3.33

. 0000
. 0009

Age, y r s
Education, y r s
Income < 185% p o v e r t y , %
AFDC, %
WIC, %

25.8+3.8
12.7+2.0
21a
7
10

ANTHROPOMETRIC

a . _

1 A n

____L. - ! _____J . -

—

2187+309
58

+
+
+
+
+
+
12

2
7
27
11
19
19

-

a n=148 s u b j e c t s r e s p o n d e d .
b n=169 s u b j e c t s r e s p o n d e d .
c X2

Compa r i s on o f S e l f - R e p o r t e d and Me di c a l
Ma t e r n a l
strongly,

se lf-reported height,

Re c or d Da t a

p r e - p r e g n a n c y and t e r m w e i g h t s wer e

p o s i t i v e l y c o r r e l a t e d with the p h y s ic ia n -rec o rd e d data

5 . 5 ) . The P e a r s o n c o r r e l a t i o n c o e f f i c i e n t s ,
used t o r e p o r t v a l i d i t y
0.95 (p=0.0000).

It

t h e mos t common p r o c e d u r e

( Mehr ens and Lehmann,

is s ig n if ic a n t to note,

(Table

1984),

h o we v e r ,

r a n g e d f r om 0 . 9 4 t o
t h a t o f t h e 281

149

p h y s i c i a n s who r e s p o n d e d t o t h e Mi c h i g a n M o t h e r ' s S u r v e y ,
we r e u n a b l e t o p r o v i d e a r e c o r d o f t h e p a t i e n t ' s h e i g h t .

20% (n=55)
Be c a u s e o f t h e

h i g h c o r r e l a t i o n s o b t a i n e d b e t we e n t h e m o t h e r ' s s e l f - r e p o r t e d and t h e
p h y s i c i a n ' s medical
f r om t h e i n a b i l i t y

r e c o r d d a t a , and b e c a u s e t h e l o s s o f d a t a r e s u l t i n g
to c a l c u l a t e a s u b j e c t ' s r e f e r e n c e w e i g h t - f o r - h e i g h t

f r om t h e p h y s i c i a n ' s d a t a woul d r e s u l t i n a s i g n i f i c a n t l o s s o f power ,
t h e m o t h e r ' s s e l f - r e p o r t e d a n t h r o p o m e t r i c d a t a we r e u s e d t h r o u g h o u t t h e
Wh i t e M i c h i g a n M o t h e r ' s S t u d y .

Table 5.5

Co mp a r i s o n o f m o t h e r ' s s e l f - r e p o r t e d and p h y s i c i a n - r e p o r t e d
a n t h r o p o m e t r i c m e a s u r e m e n t s i n t h e Whi t e Mi c h i g a n M o t h e r ' s
Study.

Subject

Mean

Heiqht,
Mot he r
Medi cal

Re c or d

SD

inches

64.54
64.50

Mot he r
Me di c a l

Re c or d

131.5
132.9

Term We i q h t ,
Mot he r
Me di c a l

Re c or d

Self-reports

160.8
162.7

lbs

28.0
29.2

. 94

.001

. 94

.001

. 95

. 000

(n=272)

25.9
26.4

lbs

P

(n=226)

2.6
2.6

P r e - P r e q n a n c v We i q h t ,

r

(n=279)

o f h e i g h t and w e i g h t may be s u b j e c t t o d i s t o r t i o n and

i n a c c u r a c y , w i t h t h e v a l i d i t y o f s uc h d a t a a c a u s e f o r c o n c e r n ( P i r i e e t

150

a l , 1 9 8 1 ) . No r e p o r t i n d i c a t i n g t h e v a l i d i t y o f s e l f - r e p o r t e d h e i g h t s
and w e i g h t s i n p r e g n a n t women was f ound i n t h e l i t e r a t u r e .
the non-pregnant population, o v e r- r e p o r t in g of h e ig h t,

However ,

as we l l

in

as

m i s r e p o r t i n g o f w e i g h t ( u n d e r e s t i m a t i o n o f o v e r w e i g h t and e x t r e m e
o v e r w e i g h t and o v e r e s t i m a t i o n o f u n d e r w e i g h t ) a r e common ( Rowl a nd,
S t e w a r t e t a l , 1987). S i g n i f i c a n t l i f e e v e n t s ,

h o we v e r ,

c l e a r l y c ode d and r emember ed (Hewson and B e n n e t t ,
pregnancy i s a s i g n i f i c a n t l i f e ev ent,

are often

1987). Because

and b e c a u s e p r e g n a n c y i s a t i m e

when w e i g h t g a i n i s a c c e p t a b l e and e n c o u r a g e d ,
c a s e t h e m o t h e r s had good r e c a l l

1989;

i t appeared t h a t

in t h i s

a b o u t t h e i r p r e - p r e g n a n c y and t e r m

p r e g n a n c y w e i g h t and p r o v i d e d a c c u r a t e ,

re lia b le data.

RESEARCH HYPOTHESES

H0. , - l a:

A w e i g h t g a i n t o 120% o r more o f o n e ' s r e f e r e n c e w e i g h t - f o r h e ig h t a t term is not a s s o c i a t e d with a reduced in ci d e n ce of
d e l i v e r i n g a LBW i n f a n t i n h e a l t h y , w h i t e women b e t we e n t h e
a g e s o f 20 t o 34.

H01- l b :

Whi t e women be t we e n t h e a g e s o f 20- 3 4 who g a i n t o 120% o r
more o f t h e i r r e f e r e n c e w e i g h t - f o r - h e i g h t a t t e r m do n o t
d e l i v e r i n f a n t s w i t h s i g n i f i c a n t l y h i g h e r mean b i r t h w e i g h t s
t h a n t h o s e f r om m o t h e r s who do n o t mee t t h i s g o a l .

HO^lc:

A w e i g h t g a i n t o 120% o r more o f o n e ' s r e f e r e n c e w e i g h t - f o r h e i g h t a t t e r m i s n o t a s s o c i a t e d w i t h an o p t i m a l b i r t h
w e i g h t b e t we e n 3500 and 4000 g , i n h e a l t h y , w h i t e women
b e t we e n t h e a g e s o f 20 t o 34.

HO,- I d :

A minimum g a i n o f s e v e n k i l o g r a m s i f a woman' s p r e - p r e g n a n c y
w e i g h t i s g r e a t e r t h a n 120% o f r e f e r e n c e d o e s n o t r e d u c e t h e
i n c i d e n c e o f LBW i n h e a l t h y w h i t e women b e t we e n t h e a g e s o f
20 t o 34.

R e s u l t s i n d i c a t e d women who d i d n o t g a i n t o 120% o f t h e i r 1959
M e t r o p o l i t a n r e f e r e n c e w e i g h t - f o r - h e i g h t had a l m o s t a f o u r - f o l d

151

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t t h a n i f t h e y had g a i n e d t o
120% o r more o f r e f e r e n c e
Metropolitan standard,

( T a b l e 5 . 6 ) . When c ompa r ed w i t h t h e 1983

the estimated r e l a t i v e r i s k of not gaining to

120% o f r e f e r e n c e was a s s o c i a t e d w i t h a l m o s t a f i v e t i m e s g r e a t e r c h a n c e
o f d e l i v e r i n g a LBW i n f a n t [ R R = 4 . 6 3 ( 3 . 0 - 7 . 3 ) ] .

Table 5.6.

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t i f
120% o f o n e ' s r e f e r e n c e w e i g h t was n o t a t t a i n e d a t t e r m .

Variable

Ca s e s
N

Controls
N

RR (95% Cl )

- - 1 9 5 9 M e t r o p o l i t a n R e f e r e n c e We i ght a t Te r m- R i s k o f LBW ( n = 3 5 1 ) :
Not g a i n i n g t o 120%
Ga i n e d t o 120% o r more

96
72

48
135

3.75 ( 2 .3 -5 .9 )
1.0a

- - 1 9 8 3 M e t r o p o l i t a n R e f e r e n c e We i ght a t Te r m- R i s k o f LBW ( n = 3 5 1 ) :
Not g a i n i n g t o 120%
Ga i n e d t o 120% o r more

119
49

4.63 (3 . 0 -7 . 3 )
1.0a

63
120

a.. r . ' ■'i
l
-i - ;:" . . - i ...
ar e f e r e n t - - b a s e l i n e v a l u e a s s o c i a t e d w i t h no r i s k .

The c o r r e l a t i o n b e t we e n p e r c e n t 1959 M e t r o p o l i t a n r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m by s u b j e c t s who g a i n e d t o l e s s t h a n 120% o f r e f e r e n c e
was s t r o n g l y and p o s i t i v e l y r e l a t e d t o i n f a n t b i r t h w e i g h t ( T a b l e 5 . 7 ) .
The c o r r e l a t i o n
( 1985)

( r = 0 . 3 3 ) was a l m o s t i d e n t i c a l

in a group o f r a c i a l l y - m i x e d ,

t o t h a t o b s e r v e d by Rosso

l ow i ncome women i n New York

152

(r=0.30).

R e g r e s s i o n a n a l y s i s i n d i c a t e d e a c h one p e r c e n t i n c r e a s e i n

p e r c e n t o f r e f e r e n c e w e i g h t g a i n e d i n t h i s g r o u p was a s s o c i a t e d w i t h a
30 g i n c r e a s e i n b i r t h w e i g h t . Once s u b j e c t s a t t a i n e d t o 120% o r more o f
reference,

howe ve r ,

t h e c o r r e l a t i o n b e t we e n i n f a n t b i r t h w e i g h t and

p e r c e n t r e f e r e n c e a t t a i n e d became n o n - s i g n i f i c a n t

(r=0.12,

p=0.07).

A g a i n , t h e s e r e s u l t s c o n c u r w i t h t h o s e o b t a i n e d by Ros s o ( 1 9 8 5 ) , who
c o n c l u d e d maximal f e t a l
attained a "critical"

g r o wt h o c c u r r e d o n l y i n t h e women who had

body mass e q u i v a l e n t t o 120% o f t h e i r n o n - p r e g n a n t

standard weight.

Table 5 .7 .

C o r r e l a t i o n be t we e n p e r c e n t 1959 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and i n f a n t b i r t h w e i g h t .

< 120% RW a t Term

Subjects

> 120% RW a t Term

--1959 R e f e r e n c e - Al l R e s p o n d e r s

(n=398):

R
adjusted R
Be t a
Standard Error-Beta
F
P
n

.33
. 10
30. 1
6.9
19.0
.0000
160

. 12
.01
4.8
2.6
3.4
. 07
238

The r e l a t i o n s h i p b e t we e n p e r c e n t o f t h e 1959 M e t r o p o l i t a n
r e f e r e n c e a t t a i n e d a t t e r m and i n f a n t b i r t h w e i g h t ca n be s e e n i n t h e
g r a p h i n F i g u r e 5 . 1 . The 30 g i n c r e a s e i n b i r t h w e i g h t p e r e a c h

153

incremental

i n c r e a s e i n p e r c e n t s t a n d a r d body w e i g h t u n t i l

120-130% o f

s t a n d a r d i s d e m o n s t r a t e d by t h e r i s i n g s l o p e .

4500

Birth W eight, g

4000
3500
3000

II

PI

2500

2000
1500

1000
500
n=396
0
80

100

120

140

160

180

200

% R e feren ce W eight A ttaine d at Term

Figure 5.1.

R e l a t i o n s h i p b e t we e n p e r c e n t o f 1959 r e f e r e n c e w e i g h t
a t t a i n e d a t term with b i r t h weight.

When t h e 1983 M e t r o p o l i t a n r e f e r e n c e was u s e d as t h e s t a n d a r d f o r
" r e f e r e n c e weight"

(Table 5 . 8 ) ,

t h e c o r r e l a t i o n b e t we e n i n f a n t b i r t h

w e i g h t and p e r c e n t r e f e r e n c e w e i g h t a t t a i n e d a t t e r m i n women who g a i n e d
t o l e s s t h a n 120% o f r e f e r e n c e was s l i g h t l y h i g h e r ( r = 0 . 3 5 ) ,

explaining

12% o f t h e v a r i a n c e i n b i r t h w e i g h t . Once a g a i n t o 120% o r more o f t h e
1983 r e f e r e n c e was a t t a i n e d ,
significant

(r=0.06,

i n f a n t b i r t h weight

p=0.41),

h o we v e r , t h e r e g r e s s i o n s l o p e became n o n ­
i n d i c a t i n g o n l y a mi ni mal

(2.5 g f o r each p e r c e n t i n c r e a s e ) .

i n c r e a s e in
These r e s u l t s

154

s u g g e s t a t t a i n i n g t o 120% o f t h e 1983 r e f e r e n c e ,
reference,

r a t h e r t h a n t h e 1959

c o r r e l a t e s more s t r o n g l y w i t h b i r t h w e i g h t and i s a b e t t e r

p red ic to r of the c r i t i c a l

Table 5.8.

body mass a woman s h o u l d a t t a i n n e a r t e r m .

C o r r e l a t i o n b e t we e n p e r c e n t 1983 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t .

Subjects

< 120% RW a t Term

> 120% RW a t Term

--1983 R e f e r e n c e - Al l

Re s Donde r s ( n = 3 9 8 ) :
R
a d j u s t e d R2
Beta
SE- Be t a
F
P
n

. 35
. 12
30.4
5.8
27.7
. 0000
206

. 06
-.002
2.5
3.0
0.68
.41
192

The r e l a t i o n s h i p b e t we e n p e r c e n t o f t h e 1983 M e t r o p o l i t a n
r e f e r e n c e s t a n d a r d w e i g h t a t t a i n e d a t t e r m and i n f a n t b i r t h w e i g h t can
be s e e n g r a p h i c a l l y i n F i g u r e 5 . 2 . The 3 0 . 4 g i n c r e a s e i n b i r t h w e i g h t
a s s o c i a t e d wi th each i n cr eme nt al

i n c r e a s e in p e r c e n t r e f e r e n c e a t t a i n e d

i s d e n o t e d by t h e i n c l i n e i n t h e s l o p e up t o 120-130% o f r e f e r e n c e .
t h i s weight l ev e l

is a t t a i n e d during pregnancy, t h e a d d i t i o n a l

t o i n f a n t b i r t h weight i s minimal,
in th e r e g r e s s i o n slope.

Once

benefit

a s d e m o n s t r a t e d by t h e p l a t e a u e f f e c t

155

B ir th W e ig h t, g

4500
4000
3500
3000
2500

2000
1500
000

n=396
100

120

140

160

% 1983 Reference Attained at Term

Figure 5.2 .

R e l a t i o n s h i p betw een p e r c e n t o f 1983 r e f e r e n c e w e i g h t
a t t a i n e d a t term w ith b i r t h weight

B e c a us e Rosso (1 9 85 ) t e s t e d h i s h y p o t h e s i s on a g r o u p o f n o n ­
smoking " h e a l t h y " women, a s u b s e t o f n o n - s m o k i n g women who we ig h e d l e s s
t h a n 120% p r i o r t o c o n c e p t i o n was f o rm e d . D e s p i t e t h e r e d u c t i o n
from t h e s m a l l e r s am p le s i z e ,

in power

th e r e l a t i v e r i s k o f g a in in g to l e s s than

120% o f r e f e r e n c e a t t e r m and s u b s e q u e n t l y d e l i v e r i n g a low b i r t h w e i g h t
i n f a n t i n d i c a t e d an e s t i m a t e d 4 . 5 - f o l d
increased,

increased,

and a 3 . 5 - f o l d

r i s k b a s e d on t h e 1959 and t h e 1983 r e f e r e n c e s t a n d a r d s ,

respectively.

156

Table 5 .9 .

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t i f 120%
o f r e f e r e n c e w e i g h t was n o t a t t a i n e d a t t e r m : smok ers and
overweight s u b je c ts excluded.

V ariable

Case s
N

Controls
N

RR (95% Cl)

--1959 M e tro p o lita n R eferen ce-R i s k o f LBW ( n = 1 5 4 ) :
Not g a i n i n g t o 120%
Gained t o 120%

34
14

37
69

4.53 ( 2 .1 6 - 9 .4 9 )
1.0a

--1983 M e tro p o lita n R e f e re n c e - R i s k o f LBW (n=1611b:
Not g a i n i n g t o 120%
G ai ne d t o 120%

37
13

50
61

3.47 ( 1 .9 - 6 .4 )
1.0a

a . . - j ? _____ x .................................................................................. ................ .......
ar e f e r e n t
bn d i f f e r s due t o h i g h e r w e i g h t c u t - o f f f o r 1983 r e f e r e n c e

The removal o f smok ers and o v e r w e i g h t women i n c r e a s e d t h e
c o r r e l a t i o n betw een p e r c e n t 1959 r e f e r e n c e and b i r t h w e i g h t in women who
g a i n e d t o l e s s t h a n 120% o f r e f e r e n c e a t t e r m from r = 0 . 3 3 t o r = 0 . 3 9 ,
d e s p i t e t h e r e d u c t i o n i n s a m pl e s i z e from 160 t o 81 ( T a b l e 5 . 1 0 ) .

Each

i n c r e a s e in p e r c e n t s t a n d a r d w e i g h t a t t a i n e d was a s s o c i a t e d w i t h a 38 g
i n c r e a s e in b i r t h w e i g h t . G a i n i n g t o more t h a n 120% o f r e f e r e n c e ,
ho wev er , was n o t a s s o c i a t e d w i t h a s i g n i f i c a n t l y h i g h e r i n f a n t b i r t h
weight,
r=0.04.

as t h e c o r r e l a t i o n b e tw een t h e two v a r i a b l e s was r e d u c e d t o

157

Table 5 .1 0 .

C o r r e l a t i o n b e tw een p e r c e n t 1959 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t w i t h smoke rs and
o v e r w e i g h t women ( p r e - p r e g n a n t wt > 120%) e x c l u d e d .

Subjects

< 120% RW a t Term

> 120% RW a t Term

--1959 R e fe re n c e-PPW < 120% RW-59 and Non-Smoker ( n = 1 7 7 1 :
R
a d j u s t e d R2
Be ta
Standard E rro r-B e ta
F
P
n

.39
.14
38.4
1 0 .2
14.1
.0003
81

When co mpared t o t h e 1983 r e f e r e n c e s t a n d a r d ,

.04
-.009
-2.3
6.6
0.12
.729
96

an even l a r g e r

i n c r e a s e i n b i r t h w e i g h t (44 g i n c r e a s e vs a 3 0 . 4 g i n c r e a s e in t h e
e n t i r e sa m p l e ) was o b s e r v e d i n t h e same s u b s e t o f u n d e r w e i g h t and normal
weight ( p r e - p r e g n a n t) ,

n o n - sm o k i n g women ( T a b l e 5 . 1 1 ) .

h i g h e r t h a n 120% o f s t a n d a r d ,

A weight gain to

ho wev er , d i d n o t i n c r e a s e , o r d e c r e a s e ,

in fa n t b i r t h weight s i g n i f i c a n t l y .

158

Table 5.11.

C o r r e l a t i o n between p e r c e n t 1983 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t w i t h smokers and
o v e r w e i g h t women (> 120% p r e - p r e g n a n t wt) e x c l u d e d .

Subjects

< 120% RW a t Term

> 120% RW a t Term

--1983 R eferen ce-PPW < 120% RW-83 and Non-Smoker ( n =1 87 ) :
R
a d j u s t e d R2
Beta
SE-Beta
F
P
n

.49
.23
43.9
7.8
31.7
.0000
102

.004
-.012
-.302
7.8
.002
.969
85

The mean b i r t h w e i g h t o f i n f a n t s bo rn t o women who a t t a i n e d t o
120% o f t h e i r

1959 r e f e r e n c e a t t e r m was 3 , 2 0 6 g ( T a b l e 5 . 1 2 ) . Women who

d i d n o t g a i n t o 120% o f t h e 1959 r e f e r e n c e d e l i v e r e d i n f a n t s who
weighed,

on a v e r a g e ,

486 g l o w e r ( t = 6 . 3 2 ; p = 0 . 0 0 0 0 ) . When t h e 1983

M e t r o p o l i t a n r e f e r e n c e was used as t h e s t a n d a r d , t h e mean b i r t h w e i g h t
o f i n f a n t s b o r n t o women who a t t a i n e d t o 120% o f t h e i r r e f e r e n c e a t te r m
was 3 , 2 8 9 g . Women who d i d n o t g a i n t o 120% o f t h e i r r e f e r e n c e d e l i v e r e d
i n f a n t s who w e i g h e d , on a v e r a g e ,

537 g l o w e r ( t = 7 . 2 3 ; p = 0 . 0 0 0 0 ) .

159

T a b l e 5 . 1 2 . Mean b i r t h w e i g h t o f i n f a n t s b o r n t o women who d i d and d i d
n o t a t t a i n t o 120% o f t h e i r M e t r o p o l i t a n r e f e r e n c e w e i g h t a t
term.

V ariable

1959 M e t r o p o l i t a n
R e f e r e n c e Weight

1983 M e t r o p o l i t a n
R e f e r e n c e Weight

Gained t o < 120%
a t Term
■ (N)

G ai ne d t o 120%
o r More a t Term
(N)

t

P

2720 ± 746
(159)

3206 ± 750
(237)

6.32

.0000

2752 ± 754
(205)

3289 ± 721
(191)

7.23

.0000

Th es e r e s u l t s s u p p o r t t h e o b s e r v a t i o n o f Rosso (1985) t h a t women
who a t t a i n e d t o 120% o f t h e i r 1959 M e t r o p o l i t a n r e f e r e n c e s t a n d a r d
weight d e liv e r e d

i n f a n t s w i t h s i g n i f i c a n t l y h i g h e r mean b i r t h w e i g h t s

t h a n t h o s e from m o t h e r s who d i d n o t meet t h i s g o a l .

However, even th ou gh

a w e i g h t g a i n t o 120 p e r c e n t o f e i t h e r t h e 1959 o r t h e 1983 M e t r o p o l i t a n
r e f e r e n c e w e i g h t was a s s o c i a t e d w i t h a d e c r e a s e d i n c i d e n c e o f LBW, and
h i g h e r mean b i r t h w e i g h t s ,

t h i s g a i n d i d n o t c o r r e s p o n d t o Br ow n' s

(1988) d e f i n i t i o n o f an " o p t i m a l " b i r t h w e i g h t o f 3 , 5 0 0 g t o 4 , 0 0 0 g in
t h i s s t u d y . The mean b i r t h w e i g h t o f i n f a n t s bor n t o women who g a i n e d t o
120% o r more o f t h e 1983 s t a n d a r d

( 3 , 2 8 9 ± 721 g) was 173 g l o w e r t h a n

t h e 3 , 4 6 2 ± 482 o b s e r v e d by Rosso (1985)

in t h e g r o u p o f 262 n o n ­

smoking, r a c i a l l y mixed lo w - in c o m e women, and 126 g l o w e r t h a n t h e mean
b i r t h w e i g h t o f w h i t e M ic hi ga n i n f a n t s in 1987 o f 3 , 4 1 5 g (MDPH, 1 9 89 ) .
I t must be n o t e d ,

ho we v e r, t h a t t h e p r e s e n t s am p le i s n o t a homogeneous

sample r e p r e s e n t a t i v e o f a l l

p o ssib le b ir th w eights,

as was t r u e f o r

160

b o t h R o s s o ' s samp le and t h e M ic h ig a n f i g u r e s .
c o n s i s t e d p r i m a r i l y o f LBW and OBW i n f a n t s .

Rather, t h i s

s a m pl e

The e f f e c t o f t h i s

sampling

d e c i s i o n i s i n d i c a t e d by t h e l a r g e s t a n d a r d d e v i a t i o n i n b i r t h w e i g h t .
W h eth er o r n o t a g a i n t o 120% o f r e f e r e n c e i n a homogeneous p o p u l a t i o n
rep resen tativ e of all

b i r t h w e i g h t s would be a s s o c i a t e d w i t h an o p t i m a l

b i r t h w e i g h t c a n n o t be a n s w e re d w i t h t h e p r e s e n t s t u d y d e s i g n .
Of t h e 56 women who we ighed more t h a n 120% o f t h e i r 1959 r e f e r e n c e
a t conception,
these,

o n l y 10 g a i n e d l e s s t h a n 7 kg a t t e r m ( T a b l e 5 . 1 3 ) .

Of

f i v e d e l i v e r e d a LBW i n f a n t and f i v e d e l i v e r e d an OBW i n f a n t .

Of

t h e 40 women who we ig h e d more t h a n 120% o f t h e i r 1983 r e f e r e n c e p r i o r t o
p r e g n a n c y , o n l y e i g h t g a i n e d l e s s t h a n 7 kg a t t e r m . Of t h e s e ,
d e l i v e r e d a LBW i n f a n t and f i v e d e l i v e r e d an OBW i n f a n t .

three

The e s t i m a t e d

r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t when p r e - p r e g n a n c y w e i g h t was
120% o r more o f r e f e r e n c e and l e s s t h a n 7 kg were g a i n e d was n o t
s i g n i f i c a n t l y d i f f e r e n t when u s i n g e i t h e r t h e 1959 o r t h e 1983
M etropoli tan r e f e r e n c e .

Table 5.13.

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t i f a
woman e n t e r s p r e g n a n c y a t o r above 120% o f r e f e r e n c e and
g a i n s l e s s t h a n s e v en kg.

V ariable

I f > 120% 1959 P r e - P r e a n a n t ( n = 5 6 ) :
G a in e d l e s s t h a n 7 kg
Ga in e d 7 kg o r more

RR (95% Cl)

Cases

Controls

N

N

5
13

5
33

2.54 ( 0 .6 3 -1 2 .2 6 )
r

3
9

5
23

1 .5 3
la

I f > 120% 1983 P r e - P r e q n a n t ( n = 4 0 ) :
Gaine d l e s s t h a n 7 kg
G a in e d 7 kg o r more
a.__ r ___ _ J.
ar e f e r e n t

.........................

(0.30-7.78)

161

O v e r w e i g h t (120% o r more o f r e f e r e n c e ) women o f t e n d e l i v e r l a r g e r t h a n - a v e r a g e i n f a n t s even when t h e i r g e s t a t i o n a l w e i g h t g a i n i s l e s s
t h a n t h e recommended 24 l b s o r 11 kg (E astman and J a c k s o n ,
N is w a n d e r e t a l , 1969; Simpson e t a l , 1 9 7 5 ) .

1968;

For t h a t r e a s o n ,

a minimal

w e i g h t g a i n o f 15 l b s (7 k g ) , e q u i v a l e n t t o t h e w e i g h t o f t h e p r o d u c t s
o f c o n c e p t i o n , has been recommended f o r o v e r w e i g h t women ( N i s w a n d e r e t
a l , 1969; Eastman and J a c k s o n ,

1968).

R e s u l t s o f t h e M ic h i g a n M o t h e r ' s

S t u d y , ho we ve r, d i d n o t e q u a t e a w e i g h t g a i n o f l e s s t h a n 7 kg w i t h an
i n c r e a s e d i n c i d e n c e o f LBW among women who wer e o v e r w e i g h t o r o b e s e
p r i o r t o p r e g n a n c y . The s a m pl e s i z e ,
Based on t h e s e r e s u l t s ,

ho we ve r, was q u i t e s m a l l .

the null

h y p o t h e s e s H O ^ l a and HC^-lb a r e

r e f u t e d . A w e i g h t g a i n t o 120% o f r e f e r e n c e , w h e t h e r t h e 1959 o r t h e
1983 r e f e r e n c e ,

i s a s s o c i a t e d w i t h a r e d u c t i o n in t h e i n c i d e n c e o f LBW,

and h i g h e r mean b i r t h w e i g h t s . A w e i g h t g a i n t o 120% o f t h e 1983
R e f e r e n c e was a s s o c i a t e d w i t h a h i g h e r mean b i r t h w e i g h t t h a n a g a i n t o
120% o f t h e 1959 r e f e r e n c e . T h e s e d a t a v a l i d a t e t h e h y p o t h e s i s o f Rosso
(1985)

in w h i t e women, and i n d i c a t e t h e 1983 M e t r o p o l i t a n r e f e r e n c e

s t a n d a r d s h o u l d be t h e r e f e r e n c e t o o l
The n u l l

of choice.

h y p o t h e s i s H O ^ l c c a n n o t be r e f u t e d .

A w eight g a in to

120% o f r e f e r e n c e was n o t a s s o c i a t e d w i t h t h e d e l i v e r y o f an " o p t i m a l "
b i r t h weight o f 3 ,5 00-4,000 g.

Rather,

a g a i n t o 120% o r more o f

r e f e r e n c e was a s s o c i a t e d w i t h a mean b i r t h w e i g h t o f 3 , 2 0 6 ± 7 5 0 g (n=237)
when t h e 1959 r e f e r e n c e s t a n d a r d was u s e d ,

and 3289+721 g (n=191) when

t h e 1983 M e t r o p o l i t a n r e f e r e n c e s t a n d a r d was u s e d . Th e se b i r t h w e i g h t s
a r e l o w e r t h a n t h e 3 , 4 6 2 ± 4 82 r e p o r t e d by Rosso (1985)

in a g r o u p o f 262

b l a c k and H i s p a n i c n o n - s m o k i n g , n o n - d r i n k i n g p r e g n a n t women.

162

Although not c o n s id e re d

" o p t i m a l " by Br o w n 's (198 8) d e f i n i t i o n ,

t h e s e w e i g h t s hav e bee n a s s o c i a t e d i n M ic h i g a n w i t h an i n f a n t m o r t a l i t y
r a t e of approxim ately 3 .6 deaths/1000 l i v e b i r t h s w ith in the f i r s t year
of l i f e

(A ppendix 3 0 a ) , w e l l

below t h e 9 / 1 0 0 0 d e a t h s s e t as a Year 2000

H e a l t h O b j e c t i v e f o r t h e N a t i o n (DHHS, 1 9 8 9 a ) . T h u s ,
" o p t i m a l " by Br o w n 's d e f i n i t i o n ,

although not

t h e b i r t h w e i g h t o f i n f a n t s bor n t o

m o t h e r s who g a i n e d t o 120% o r more o f r e f e r e n c e can be c o n s i d e r e d a
"healthy" b i r t h w eight,

i f t h e c o r r e s p o n d i n g M ic h i g a n i n f a n t m o r t a l i t y

r a t e s and t h e Year 2000 O b j e c t i v e a r e u s e d as t h e s t a n d a r d .
Based on r e s u l t s p r e s e n t e d h e r e , t h e n u l l
be r e t a i n e d .

h y p o t h e s i s H O ^ l d must

T h e r e was no s i g n i f i c a n t d i f f e r e n c e in t h e e s t i m a t e d r i s k

o f d e l i v e r i n g a LBW i n f a n t in women who g a i n e d l e s s t h a n 7 kg ( 1 5 . 5 l b s )
a t t e r m i f o v e r w e i g h t p r i o r t o p r e g n a n c y . The s m a ll

samp le s i z e

(only

t e n women o b e s e p r i o r t o p r e g n a n c y g a i n e d l e s s t h a n 7 kg a t t e r m )
resulted

in a r e d u c t i o n

to w a r d i t s n u l l

H02- l a :

i n power and an a t t e n u a t i o n o f t h e m ea s u r e

v a l u e ( K e l s e y e t a l , 19 86 ) .

M a t e r n a l b i r t h w e i g h t (MBW) d o e s n o t d i f f e r b e tw e en m o t h e r s
who d e l i v e r o p t i m a l and low b i r t h w e i g h t i n f a n t s and c a n n o t
be u se d t o p r e d i c t b i r t h w e i g h t .

E i g h t y - s e v e n p e r c e n t o f t h e r e s p o n d e r s t o t h e White M ic hi ga n
M o t h e r ' s S u r v e y (n=348) p r o v i d e d an e s t i m a t e o f t h e i r own b i r t h w e i g h t ,
144 o f whom s u b s e q u e n t l y d e l i v e r e d a LBW i n f a n t and 166 o f whom
d e l i v e r e d an OBW i n f a n t . On a v e r a g e , t h e m a t e r n a l

b i r t h w e i g h t (MBW) o f

women who d e l i v e r e d a LBW i n f a n t was 381 g l e s s t h a n t h e MBW o f women
who d e l i v e r e d an OBW i n f a n t

(Table 5 .1 4 ).

163

T a b l e 5 . 1 4 . Mean s e l f - r e p o r t e d m a t e r n a l b i r t h w e i g h t o f women who
d e l i v e r e d a LBW o r an OBW i n f a n t .

M a t e r n a l B i r t h Weight

Delivered
LBW Baby

D elivered
OBW Baby

t

3009±603

3390±543

5.87

N

.0000

166

144

The c r u d e odds r a t i o

p

i n d i c a t e d a woman whose own b i r t h w e i g h t was

l e s s t h a n 2 , 5 0 0 g had a t h r e e - f o l d

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW

i n f a n t as compared t o a woman whose MBW was g r e a t e r t h a n 2 , 5 0 0 g ( T a b le
5.15 ).

Low b i r t h w e i g h t women had a n i n e - t i m e s g r e a t e r r i s k o f

d e l i v e r i n g a LBW i n f a n t t h a n d i d women whose b i r t h w e i g h t was " o p t i m a l "
(3,500 to 4,000 g ) .

Table 5.15

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t
by s e l f - r e p o r t e d m a t e r n a l b i r t h w e i g h t (MBW) c a t e g o r i e s .

V ariable

M a t e r n a l B i r t h Weight
Optimal ( 3 , 5 0 0 - 4 , 0 0 0 g)
LBW (< 2 , 5 0 0 g)
M a t e r n a l B i r t h Weight
> 2,500 g
< 2 ,5 0 0 g
a r e f e r e n c e group

RR

(95% Cl)

LBW
Infant

OBW
Infant

N
20
27

N
75
11

1.0a
9.2 (3 .9 -2 1 .7 )

117
27

155
11

1.0a
3.3 ( 1 .6 -6 .8 )

164

The o v e r a l l

c o r r e l a t i o n b e tw e e n m a t e r n a l

i n f a n t b i r t h weight

b i r t h w e i g h t (MBW) and

(IBW) was h i g h l y s i g n i f i c a n t

(r= 0.32, p < 0.0000),

e x p l a i n i n g 10% o f t h e v a r i a n c e in b i r t h w e i g h t . When s u b j e c t s were
c a t e g o r i z e d by p r e - p r e g n a n t r e f e r e n c e w e i g h t ( T a b l e 5 . 1 6 ) ,
indicated the c o rre la tio n

between MBW and IBW was h i g h e s t f o r s u b j e c t s

who e n t e r e d p r e g n a n c y u n d e r w e i g h t
r e f e r e n c e w eight;

r=0.37)

( w e i g h i n g l e s s t h a n 90% o f t h e i r 1983

or a t t h e i r d e s i r a b l e w e i g h t ( b et w e e n 90 and

119% o f t h e i r 1983 r e f e r e n c e w e i g h t ;
of the variance in in fa n t

results

r=0.28),

b i r t h weight,

a c c o u n t i n g f o r 14% and 8%

respectively.

The c o r r e l a t i o n

b e tw e en MBW and IBW was n o t s i g n i f i c a n t f o r s u b j e c t s who e n t e r e d
p r e g n a n c y w e i g h i n g 120% o r more o f t h e i r 1983 r e f e r e n c e s t a n d a r d .
was l i k e l y due t o t h e s m a l l

Table 5.16

This

numbers and t h e l a r g e v a r i a n c e o b s e r v e d .

C o r r e l a t i o n b e tw een i n f a n t b i r t h w e i g h t (IBW) and m a t e r n a l
b i r t h w e i g h t (MBW) by p r e - p r e g n a n t 1983 M e t r o p o l i t a n
refe re n c e w eight.

Pre-Pregnant
Weight

N

R

R2

B

SE-B

All M oth er s

348

.32

.10

.42

.07

< 90% RW

118

.37

.13

.46

90-119% RW

187

.2 8

.08

120-149% RW

33

.26

> 150% RW

10

.31

Constant

F

P

1696

38.3

.0000

.11

1253

18.0

.0000

.37

.09

1992

15.8

.0001

.07

.29

.20

2314

2.2

.1449

.01

.39

.42

2106

0.8

.3584

165

As i n d i c a t e d i n T a b l e 5 . 1 7 , t h e r e w er e no s t a t i s t i c a l l y
s i g n i f i c a n t d i f f e r e n c e s in maternal

b i r t h w e i g h t b e tw e en any o f t h e f o u r

p r e - p r e g n a n t w eight c a t e g o r i e s w ith in th e i n f a n t b i r t h w eight groups
(LBW, p = 0 . 9 6 ; OBW, p = 0 . 4 8 ) . However, m o t h e r s who w e i g h e d l e s s t h a n 90%
o f t h e i r 1983 R e f e r e n c e Weigh t a t c o n c e p t i o n ,
d e l i v e r e d a LBW i n f a n t ,

and who s u b s e q u e n t l y

had l o w e r m a t e r n a l b i r t h w e i g h t s t h a n

u n d e r w e i g h t m o t h e r s who d e l i v e r e d an OBW i n f a n t

(MBW=2,958 vs 3 , 5 0 1 ,

p = 0 . 0 0 0 ) . S i m i l a r l y , m o t h e r s who we ig he d b e tw een 90-119% o f t h e i r
R e f e r e n c e Weight a t c o n c e p t i o n ,
lower maternal
an OBW i n f a n t
differences

and who d e l i v e r e d a LBW i n f a n t ,

1983

had

b i r t h w e i g h t s t h a n d e s i r a b l e - w e i g h t m o t h e r s who d e l i v e r e d
(MBW=3,034 g vs 3 ,3 4 7 g,

p = 0 . 0 0 9 ) . T h e r e were no

in MBW be tw een women who d e l i v e r e d LBW o r OBW i n f a n t s

if

s u b j e c t s we ighed g r e a t e r t h a n 120% o f r e f e r e n c e p r i o r t o c o n c e p t i o n .

T a b l e 5 .1 7

M a te r n a l b i r t h w e i g h t o f women who d e l i v e r e d a LBW o r OBW
i n f a n t by t h e i r p r e - p r e g n a n t 1983 M e t r o p o l i t a n r e f e r e n c e
weight c a te g o ry .

Pre-Pregnant
W eight C a t e g o r y

Delivered
LBW Baby

N

Maternal

Delivered
OBW Baby

N

t

P

B i r t h W eig ht s

< 90% RW

2985+583

75

3 5 0 1±491

36

4.58

.000

90-119% RW

3034±626

57

3347±520

103

3.38

.001

120-149% RW

3018±765

9

3 3 9 1±644

20

1.38

.184

> 150% RW

3100+603

3

3276+666

7

0.45

.675

F-prob,
w ith in group

0.96

0.48

166

Be c a us e a woman's p r e - p r e g n a n c y w e i g h t s t a t u s and t h e amount o f
w e i g h t g a i n e d d u r i n g p r e g n a n c y h a s been shown t o a c c o u n t f o r t h e l a r g e s t
p e r c e n t o f v a r i a n c e i n t e r m i n f a n t ' s b i r t h w e i g h t (Brown,
1984),

s u b je c t s in t h i s

1986; T a f f e l ,

s t u d y were c a t e g o r i z e d by p e r c e n t o f p r e ­

pregnant r e f e r e n c e w eight a t t a i n e d a t term to account f o r t h e s e f a c t o r s
( T a b l e 5 . 1 8 ) . R e s u l t s i n d i c a t e m o t h e r s who d e l i v e r e d LBW i n f a n t s had
lower maternal

b i r t h w e i g h t s t h a n m o t h e r s who d e l i v e r e d OBW i n f a n t s ,

d e s p i t e g a i n i n g t o t h e same r e f e r e n c e w e i g h t a t t e r m . T h e s e r e s u l t s
s u g g e s t m a te rn a l b i r t h w eight impacts i n f a n t b i r t h w eight in d ep e n d e n t of
p r e - p r e g n a n t w e i g h t s t a t u s and amount o f w e i g h t g a i n e d d u r i n g p r e g n a n c y .

Table 5.18

M a te r n a l b i r t h w e i g h t o f women who d e l i v e r e d a LBW o r OBW
i n f a n t by t h e p e r c e n t 1983 M e t r o p o l i t a n r e f e r e n c e w e i g h t
a t t a i n e d at term.

R e f e r e n c e Weight
A t t a i n e d a t Term

D elivered
LBW Baby

N

M a te r n a l

Delivered
OBW Baby

N

t

P

B i r t h Weiqhts

< 90% RW

2782+579

7

90-119% RW

2990+555

95

3408+576

56

4.42

.000

120-149% RW

3072+716

36

3378±457

88

2.85

.005

> 150% RW

3199+682

6

3336+726

21

0.45

.683

MEAN:

3009+603

144

3390+543

166

5.87

.000

F-prob
w ith in groups

.56

-

-

.86

-

-

167

N o n e t h e l e s s , f o r t h e 38 women who r e p o r t e d w e i g h i n g l e s s t h a n
2,500 g a t b i r t h ,

t h e c r u d e odds r a t i o

(Table 5.19)

indicated a

p r o t e c t i v e e f f e c t a g a i n s t t h e d e l i v e r y o f a LBW i n f a n t i f t h e women
g a i n e d t o 120% o r more o f t h e 1983 r e f e r e n c e w e i g h t a t t e r m [RR=0.19,
(0.04-0.88)].

Thes e r e s u l t s s u g g e s t p r e n a t a l c a r e p r o v i d e r s s h o u l d be

e n c o u r a g e d t o d e t e r m i n e a p a t i e n t ' s own b i r t h w e i g h t ,

and i f LBW, t h e

p r o v i d e r s h o u l d e n c o u r a g e t h e woman t o g a i n t o a minimum o f 120% o f
s t a n d a r d a t t e r m a s a s a f e g u a r d a g a i n s t t h e d e l i v e r y o f a low b i r t h
weight i n f a n t .

Table 5 .1 9 .

E s t i m a t e d r e l a t i v e r i s k (RR) o f a LBW m o t h e r d e l i v e r i n g a
LBW i n f a n t i f t h e m o t h e r d i d n o t g a i n t o 120% o f h e r
r e f e re n c e weight a t term.

LBW
(N)

OBW
(N)

RR (95% Cl)

Gained t o > 120% RW a t te r m

9

8

0.19 (0 .0 4 -0 ,8 8 )

Gained t o < 120% RW a t t e r m

18

3

la

R i s k o f LBW

I f MBW < 2 , 5 0 0 q and:

a r e f e r e n c e group

Based upon t h e s e r e s u l t s ,

the null

h y p o t h e s i s H02- l a

is rejected .

In women who were n o t o v e r w e i g h t o r o b e s e a t c o n c e p t i o n , m a t e r n a l b i r t h
w e i g h t c l e a r l y i m p a c te d i n f a n t b i r t h w e i g h t ,

independent of p r e ­

p r e g n a n c y w e i g h t s t a t u s and p e r c e n t s t a n d a r d w e i g h t a t t a i n e d

at term.

168

Although b i r t h w eight undoubtedly i s t h e r e s u l t o f th e i n t e r a c t i o n
b e tw e en many f a c t o r s ,

these r e s u lts in d icate a possible genetic

i n f l u e n c e on b i r t h w e i g h t which a c c o u n t e d f o r a p p r o x i m a t e l y 10% o f t h e
v a r i a n c e i n b i r t h w e i g h t among women who were n o t o b e s e p r i o r t o
p r e g n a n c y . Th e se r e s u l t s s u g g e s t a s t r o n g e r r e l a t i o n s h i p t h a n o b s e r v e d
by Hackman e t al
m aternal

(1983) who r e p o r t e d t h e s i m p l e c o r r e l a t i o n be tw een

b i r t h w e i g h t and i n f a n t b i r t h w e i g h t was r = 0 . 1 1 ,

accounting fo r

a p p r o x i m a t e l y 1% o f t h e v a r i a n c e in b i r t h w e i g h t . The p r e s e n t s a m p l e ,
ho we ve r,

i s n o t homogenous i n b i r t h w e i g h t and i s " l o a d e d " w i t h low

b i r t h weight i n f a n t s ,

t h e g r o u p in which Hackman e t al

s t r o n g e s t r e l a t i o n s h i p between MBW and IBW e x i s t e d .

suggested the

Results are also

s l i g h t l y h i g h e r t h a n t h o s e o b s e r v e d by K l e b a n o f f and Yip (198 7) who
r e p o r t e d an a s s o c i a t i o n o f r = 0 . 2 0 f o r w h i t e s and r = 0 . 1 8 f o r b l a c k s ,
e x p l a i n i n g 4% and 3.2% o f t h e v a r i a n c e i n b i r t h w e i g h t ,
In l i g h t o f t h e p o t e n t i a l

respectively.

i m p a c t LBW c o u l d have on t h e b i r t h

weight of the next g e n e ra tio n of b a b ie s,

and in view o f t h e i n c r e a s i n g

number o f LBW and v e r y low b i r t h w e i g h t i n f a n t s who a r e s u r v i v i n g t o d a y ,
t h e s e r e s u l t s p r o v i d e added i m p e tu s t o s t r e n g t h e n r e s e a r c h e f f o r t s t o
i d e n t i f y m ed ic al, environmental
poor f e t a l

and b e h a v i o r a l

outcome and t o d e v e l o p e d u c a t i o n a l

f a c t o r s a s s o c i a t e d with
and p u b l i c a s s i s t a n c e

pr o g ra m s t o h e l p women m o d u l a t e t h o s e r i s k b e h a v i o r s .
women s h o u l d be i d e n t i f i e d e a r l y in p r e n a t a l
monitored c l o s e l y ,

as,

in t h i s s t u d y ,

In a d d i t i o n ,

LBW

c a r e and t h e i r w e i g h t g a i n

u n d e r w e i g h t and normal w e i g h t

women who t h e m s e l v e s were LBW r e d u c e d t h e i r r i s k o f d e l i v e r i n g a LBW
i n f a n t by g a i n i n g t o a t l e a s t 120% o f r e f e r e n c e w e i g h t a t t e r m .

169

H02- l b :

M a t e r n a l p e r c e n t p r e p r e g n a n t w e i g h t - f o r - h e i g h t (1983
M e t r o p o l i t a n R e f e r e n c e ) d o e s n o t d i f f e r b e tw een m o t h e r s who
d e l i v e r OBW and LBW i n f a n t s and c a n n o t be u s e d t o p r e d i c t
b i r t h w eight.

On a v e r a g e , m o t h e r s who s u b s e q u e n t l y d e l i v e r e d a LBW i n f a n t
e n t e r e d p r e g n a n c y a t 94% o f t h e i r 1983 M e t r o p o l i t a n r e f e r e n c e w e i g h t f o r - h e i g h t ( T a b l e 5 . 2 0 ) . M o t h e r s o f c o n t r o l s w e i g h e d , on a v e r a g e ,

104%

of reference.

Table 5.20

Mean p e r c e n t p r e p r e g n a n t w e i g h t - f o r - h e i g h t
m o t h e r s o f LBW and OBW i n f a n t s .

Variable

LBW

% 1983 PPW

OBW

93 .5 ± 17.8

Range, %
n

1 0 3 . 9 ± 19 .4

(68-190)

(71-187)

168

184

T h irty -fiv e percent

(n=140) o f a l l

(PPW) f o r

t

P

5.19

responders to t h i s

.0000

survey

r e p o r t e d e n t e r i n g p r e g n a n c y a t a w e i g h t l e s s t h a n 90% o f t h e i r 1983
r e f e r e n c e w e i g h t . Of t h e s e , 85 s u b s e q u e n t l y d e l i v e r e d a LBW i n f a n t and
41 d e l i v e r e d an OBW i n f a n t .

The c r u d e odd s r a t i o

i n d i c a t e d women who

e n t e r e d p r e g n a n c y a t l e s s t h a n 90% o f r e f e r e n c e had a 333% i n c r e a s e d
r i s k o f d e l i v e r i n g a LBW i n f a n t t h a n a m o t h e r who e n t e r e d p r e g n a n c y a t
90-119% o f r e f e r e n c e ( T a b l e 5 . 2 1 ) .
reference
increased,

(i.e .,

E n t e r i n g p r e g n a n c y abov e 119% o f

o v e r w e i g h t o r o b e s e ) was n o t a s s o c i a t e d w i t h e i t h e r an

or a decreased,

r i s k o f d e l i v e r i n g a LBW i n f a n t .

170

Table 5.21

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l p r e p r e g n a n t r e f e r e n c e w e i g h t for-height.

V ariable

Cases
N

Controls
N

RR (95% Cl

P r e D r e q n a n t R e f e r e n c e We igh t:
< 90%

85

41

90-119%

71

114

120-149%

9

21

0.69 ( 0 .3 0 -1 .5 9 )

150% o r more

3

7

0.69 ( 0 .1 7 -2 .7 6 )

3.33 ( 2 .0 7 -5 .3 6 )
1.0a

aa r. .e-fre_____
r e n it

When p e r c e n t p r e p r e g n a n t r e f e r e n c e w e i g h t was r e g r e s s e d a g a i n s t
b ir th w eight, the c o r r e la tio n
sig n ifican t,
subjects'

(r=0.266;

F= 30.0) was s t a t i s t i c a l l y

e x p l a i n i n g 7% o f t h e v a r i a n c e i n b i r t h w e i g h t . When

p e r c e n t p r e p r e g n a n t r e f e r e n c e w e i g h t and p r e g n a n c y w e i g h t g a i n

wer e b o t h r e g r e s s e d a g a i n s t b i r t h w e i g h t ,

t h e amount o f e x p l a i n e d

v a r i a n c e i n b i r t h w e i g h t i n c r e a s e d t o 16% ( r = 0 . 4 0 ) . The p a r t i a l
regression c o e ffic ie n ts
weight s t a t u s "
b ir th w eight,

indicated

"weight g ain"

and " p r e p r e g n a n t

a c c o u n t e d f o r 52% and 48% o f t h e e x p l a i n e d v a r i a n c e in
respectively

(Table 5 .2 2 ) .

171

Table 5.22

M u ltip le r e g r e s s io n a n a ly s i s o f p rep re g n a n t weight
s t a t u s (% PPW) and w e i g h t g a i n on b i r t h w e i g h t .

V ariable

B

SE-B

P artial

Weight g a i n
% PPW
Constant

20.16
11 .4 7
1277

3.10
1. 8 7
215

0.301
0.284

M ultiple R
R2
F
DF
P

0.40
0.16
37.8
(2,393)
.000

r

t

Sig t

6.51
6.14
5.95

.0000
.0000
.0 000

When s u b j e c t s were c l a s s i f i e d by p e r c e n t p r e p r e g n a n t r e f e r e n c e
w e i g h t as u n d e r w e i g h t (< 90% RW), normal w e i g h t (90-119% RW), o v e r w e i g h t
(120-149% RW) o r v e r y o v e r w e i g h t (150% RW o r m o r e ) , t h e c o r r e s p o n d i n g
p e r c e n t r e f e r e n c e w e i g h t a t t a i n e d a t t e r m and i n f a n t b i r t h w e i g h t were
highly c o rre la te d

(Table 5 .2 3 ) .

For t h e u n d e r w e i g h t , normal w e i g h t and

m o d e r a t e l y o v e r w e i g h t women, e a ch p e r c e n t i n c r e a s e i n r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m was a s s o c i a t e d w i t h a 3 3 . 7 g ( p = 0 . 0 0 0 ) ,
( p = 0 . 0 0 9 ) and 2 6 . 8 g ( p = 0 . 0 1 0 6 )
In t h e v e r y o v e r w e i g h t c a t e g o r y ,

i n c r e a s e in b i r t h w e ig h t,

14.6 g
respectively.

th e slope of th e r e g r e s s io n l i n e did

n o t d i f f e r from z e r o and was t h e r e f o r e n o t s t a t i s t i c a l l y

significant.

172

Table 5.23.

R e g r e s s i o n o f p e r c e n t 1983 r e f e r e n c e w e i g h t a t t a i n e d
a t t e r m on i n f a n t b i r t h w e i g h t by p r e - p r e g n a n t
weight c l a s s i f i c a t i o n .

P r e - P r e q n a n t Weiaht C l a s s i f i c a t i o n
U n d e r w e i g ht
(< 90%)

r
adj r 2
B
SE-B
F
n
P

0.43
0.18
33.7
6.0
31.2
140

0.0000

This r e l a t i o n s h i p

Normal Weight
(90-119%)

Overweight
(120-149%)

0 .2 3
0.05
1 4 .6
4.3
11.3
212
0.0009

0.43
0.16
26.8
9.9
7.3
36
0.0106

Obese
(>150%)

-0.49
-0.16
-20.5
1 2 .0
2.9
12
0.1224

o f i n c r e a s i n g i n f a n t b i r t h w e i g h t by an

i n c r e a s e d w e i g h t g a i n i n women who e n t e r e d p r e g n a n c y u n d e r w e i g h t women
i s s e e n g r a p h i c a l l y i n F i g u r e 5 . 3 . These r e s u l t s r e i n f o r c e t h e
i m p o r t a n c e o f a w e i g h t g a i n t o 120-130% o f o n e ' s s t a n d a r d w e i g h t a t t e r m
f o r optimal

b i r t h w e i g h t . The

d e c r e a s e o b s e r v e d in i n f a n t b i r t h

weight

as women in t h i s s t u d y g a i n e d

t o more t h a n 150% o f r e f e r e n c e a t

term is

n o t u n l i k e t h a t which h as been p r e v i o u s l y r e p o r t e d in t h e l i t e r a t u r e
(Abrams and L a r o s ,
this

study,

1 9 8 6 ) . The

ho weve r,

is q u ite

sample s i z e o f v e r y o v e r w e i g h t women in
small

(n=12).

173

Birth Weight
5000

4000

3000

Pre-Pregnant Weight

2000

——

< 90% PP-RW

- t it -

90-119% P P - R W

-B-

120-149% P P -R W

1000
150+% P P - R W
85

10 5

125

14 5

165

18 5

20 5 +

% 1 98 3 R e f e r e n c e W e i g h t at Term

Figure 5 .3 .

B i r t h w e i g h t by p e r c e n t r e f e r e n c e w e i g h t a t t e r m a c c o r d i n g
to a s u b j e c t 's prepregnancy weight c l a s s i f i c a t i o n .

Responders' h e ig h t,

i n d e p e n d e n t o f w e i g h t , was a s s o c i a t e d w i t h

b i r t h w e i g h t ( r = 0 . 2 4 ; F = 2 4 . 5 9 ) , a c c o u n t i n g f o r 6% o f t h e v a r i a n c e i n
b i r t h w e i g h t (Appendix 2 9 - 5 a ) . When s u b j e c t s were c a t e g o r i z e d by
m aternal
66"),

s t a t u r e as b e i n g s h o r t (< 6 2 " ) , medium ( 6 2 . 5 - 6 5 . 6 " )

t h e c o r r e s p o n d i n g i n f a n t b i r t h w e i g h t s w er e 2729 g ,

3191 g,
maternal

respectively

or t a l l

3017 g and

( F=1 0 . 4 9 ; p = 0 . 0 0 0 0 ) . The i m p a c t o f i n c r e a s i n g

h e i g h t on i n f a n t b i r t h w e i g h t , w i t h i n e a ch o f t h e f o u r

c a t e g o r i e s of p e rc e n t r e f e r e n c e weight a t t a i n e d a t term ,
g r a p h i c a l l y in F igure 5 .4 .

i s seen

(>

174

Birth Weight
4000
3500
3000
250D

2000
1500
Height

1000

m

52" o r l e s s
62.5-65.5-

500

6 6 “ or m o r e

0
(90%

90-1119%

120-149%

1 5 0 % or m o r e

% 1 9 83 R e f e r e n c e W e i g h t at Ter m

Figure 5.4.

E f f e c t o f i n c r e a s i n g m a t e r n a l h e i g h t on i n f a n t b i r t h w e i g h t
by p e r c e n t 1983 M e t r o p o l i t a n R e f e r e n c e w e i g h t a t t e r m .

R e s u l t s p r e s e n t e d h e r e c o n t r i b u t e t o t h e body o f l i t e r a t u r e which
i n d i c a t e d women who e n t e r p r e g n a n c y below t h e i r r e f e r e n c e w e i g h t - f o r h e i g h t a r e a t i n c r e a s e d r i s k f o r d e l i v e r i n g a low b i r t h w e i g h t i n f a n t
(Na ey e,

1979; NCHS, 1980; Simpson e t a l , 1975; Brown e t a l , 1 9 81 ) .

M e t c o f f e t al

(198 1) s u g g e s t e d t h a t ,

a fte r gestational

age,

pregravid

w e i g h t s t a t u s and a n t e n a t a l w e i g h t g a i n have t h e g r e a t e s t im p a c t on
b i r t h w e i g h t , e a ch a c c o u n t i n g f o r a p p r o x i m a t e l y e i g h t and s i x p e r c e n t o f
th e v a r i a n c e in b i r t h w e ig h t, r e s p e c t i v e l y .
c o n s i s t e n t with t h i s o b s e rv a tio n .

R esu lts of t h i s study are

In t h i s g r o u p o f t e r m i n f a n t s ,

175

p r e p r e g n a n t w e i g h t s t a t u s a c c o u n t e d f o r s e v e n p e r c e n t o f t h e v a r i a n c e in
b i r t h w e i g h t . When b o t h w e i g h t g a i n and p e r c e n t p r e p r e g n a n t w e i g h t
s t a t u s were r e g r e s s e d a g a i n s t b i r t h w e i g h t ,

16% o f t h e v a r i a n c e was

e x p l a i n e d , w i t h w e i g h t g a i n e x p l a i n i n g s l i g h t l y more t h a n h a l f .
Abrams and L a r o s (198 6) s t r a t i f i e d 2946 women who d e l i v e r e d l i v e ,
term i n f a n t s in to fo u r prepregnancy w e i g h t - f o r - h e i g h t c a t e g o r i e s based
on t h e 1959 M e t r o p o l i t a n r e f e r e n c e . T he se r e s e a r c h e r s o b s e r v e d t h a t ,

for

t h e u n d e r w e i g h t (< 90%), normal w e i g h t (90-120%) and m o d e r a t e l y
o v e r w e i g h t (121-135%) s u b j e c t s ,

e a ch k i l o g r a m o f m a t e r n a l w e i g h t g a i n

i n c r e a s e d b i r t h w e i g h t by 2 5 . 9 ,

2 8 . 3 and 1 7 . 8 g ,

respectively.

t h e r e f e r e n c e s t a n d a r d and c a t e g o r y c u t - o f f s d i f f e r e d
r e s u l t s p rese n ted here i n d i c a t e a s i m i l a r t r e n d .

A lt h o u g h

in t h i s s t u d y ,

The b i r t h w e i g h t o f

i n f a n t s bo rn t o women who e n t e r e d p r e g n a n c y u n d e r w e i g h t i n c r e a s e d a l m o s t
34 g f o r e ach one p e r c e n t i n c r e a s e i n r e f e r e n c e w e i g h t a t t e r m .
Corresponding in c r e a s e s

i n b i r t h w e i g h t o f i n f a n t s b o r n t o women

e n t e r i n g p r e g n a n c y a t a normal w e i g h t o r o v e r w e i g h t were 1 4 . 6 g and 2 6 . 8
g f o r e a ch one p e r c e n t i n c r e a s e i n p e r c e n t r e f e r e n c e w e i g h t a t t a i n e d a t
term. R e su lts o f t h i s

s t u d y c o n c u r w i t h t h e o b s e r v a t i o n o f Abrams and

La r os (1986) t h a t v e r y o v e r w e i g h t women d i d n o t b e n e f i t t h e i r i n f a n t by
high weight g a in s .

The p r e s e n t samp le s i z e o f v e r y o v e r w e i g h t women,

ho wev er , was q u i t e s m a l l .
Luke e t al

(1984) r e p o r t e d mean i n f a n t b i r t h w e i g h t p a r a l l e l e d

i n c r e a s i n g m aternal d e l i v e r y weight in s h o r t ,

medium and t a l l

women.

The se r e s e a r c h e r s r e p o r t e d a 10% i n c r e a s e i n w e i g h t a s s o c i a t e d w i t h
i n c r e a s e s o f 127 g , 74 g and 87 g in mean b i r t h w e i g h t f o r s h o r t ,
and t a l l women, r e s p e c t i v e l y .

R esults of t h i s

medium

study i n d ic a te d s h o rt

176

women d e l i v e r e d i n f a n t s w e i g h i n g , o n a v e r a g e , 462 g l e s s t h a n i n f a n t s
born t o t a l l
on a v e r a g e ,

women. Women o f medium h e i g h t d e l i v e r e d
174 g l e s s t h a n t a l l

women. W it h in e a c h c a t e g o r y o f p e r c e n t

r e f e r e n c e w eight a t t a i n e d a t term th e o b s e r v a t io n
general,

i n f a n t s weighing,

i s more s t r i k i n g .

In

a s p e r c e n t r e f e r e n c e w e i g h t a t t e r m i n c r e a s e d up t o 150% o f

reference,

i n f a n t b i r t h w e i g h t i n c r e a s e d . As s t a t u r e

increased w ithin

e a c h o f t h e t e r m r e f e r e n c e w e i g h t c a t e g o r i e s up t o 150% o f r e f e r e n c e ,
i n f a n t b i r t h weight in c re a s e d .
R e s u l t s p r e s e n t e d h e r e s u p p o r t t h e h y p o t h e s i s o f Rosso (1985) t h a t
a w e i g h t g a i n t o 120% o f o n e ' s r e f e r e n c e w e i g h t a t t e r m i s a s s o c i a t e d
w i t h i n c r e a s e d i n f a n t b i r t h w e i g h t . R e s u l t s p r e s e n t e d in F i g u r e 5 . 3 and
F i g u r e 5 . 4 d e m o n s t r a t e d t h e l e v e l i n g - o f f e f f e c t on b i r t h w e i g h t as
s u b j e c t s g a i n e d t o be tw e e n 120-130% o f t h e i r 1983 r e f e r e n c e w e i g h t .
R e s u l t s a l s o p r o v i d e m od es t s u p p o r t f o r R o s s o ' s o b s e r v a t i o n t h a t v e r y
o v e r w e i g h t women may n o t n e e d t o g a i n t h e same amount o f w e i g h t as
women who e n t e r p r e g n a n c y w e i g h i n g l e s s t h a n 120% o f r e f e r e n c e .
presented

Results

in T a b l e 5 . 2 3 i n d i c a t e d no s i g n i f i c a n t i n c r e a s e in b i r t h

w e i g h t w i t h i n c r e a s i n g w e i g h t g a i n in v e r y o v e r w e i g h t women.
Based on t h e s e r e s u l t s t h e n u l l
p re -p re g n a n t weight

hypotheses are r e f u te d .

M a te r n a l

( p e r c e n t o f 1983 M e t r o p o l i t a n r e f e r e n c e w e i g h t - f o r -

h e i g h t ) c l e a r l y d i f f e r e d be tw e e n m o t h e r s who d e l i v e r e d LBW and 0BW
infants.

Women who e n t e r e d p r e g n a n c y u n d e r w e i g h t had a t h r e e - f o l d

increased ris k of d eliv erin g

a LBW i n f a n t .

Maternal

stature,

i n d e p e n d e n t o f p r e p r e g n a n c y w e i g h t , was p r e d i c t i v e o f i n f a n t b i r t h
w eight.
a t term,

Even w i t h i n e ach c a t e g o r y o f p e r c e n t r e f e r e n c e w e i g h t a t t a i n e d
t a l l e r women d e l i v e r e d h e a v i e r i n f a n t s .

177

R e s u l t s i n d i c a t e d m a t e r n a l p e r c e n t p r e p r e g n a n t w e i g h t can be used
as a p r e d i c t o r o f b i r t h w e ig h t.

By i t s e l f ,

a s u b je c t's prepregnant

w e i g h t s t a t u s a c c o u n t e d f o r 7% o f t h e v a r i a n c e i n b i r t h w e i g h t . When
p r e p r e g n a n t w e i g h t s t a t u s was combined w i t h w e i g h t g a i n ,

both v a r i a b l e s

t o g e t h e r e x p l a i n e d 16% o f t h e v a r i a n c e i n i n f a n t b i r t h w e i g h t .
Taken t o g e t h e r ,

t h e s e d a t a s u g g e s t u n d e r w e i g h t women ca n r e d u c e

t h e i r r i s k o f d e l i v e r i n g a LBW i n f a n t by e s t a b l i s h i n g a h i g h e r
p r e p r e g n a n c y w e i g h t a n d / o r by g a i n i n g e x t r a w e i g h t d u r i n g t h e p r e n a t a l
p e r i o d . Th e se r e s u l t s u n d e r s c o r e t h e i m p o r t a n c e o f d e t e r m i n i n g a woman's
p r e p r e g n a n t w e i g h t s t a t u s so an a p p r o p r i a t e ,
re c om m e n d a tio n can be made.

In t h i s s t u d y ,

in d iv id u a l weight gain

how ev er , 20% o f t h e p r e n a t a l

c a r e p r o v i d e r s were u n a b l e t o p r o v i d e t h e i r p a t i e n t ' s h e i g h t .

Prenatal

c a r e p r o v i d e r s s h o u l d be u r g e d t o d e t e r m i n e a p a t i e n t ' s p r e - p r e g n a n t
w e i g h t - f o r - h e i g h t s t a t u s and make w e i g h t g a i n r e c o m m e n d a ti o n s
a c c o r d i n g l y . The p r e s e n t samp le s i z e o f v e r y o v e r w e i g h t women was t o o
smal l t o p r o v i d e s t a b l e e v i d e n c e o f a d e l e t e r i o u s e f f e c t on b i r t h w e i g h t
w i t h i n c r e a s i n g w e i g h t g a i n in o b e s e women. F u r t h e r r e s e a r c h ,

how ev er ,

is warranted.

H02- 2 a :

M a t e r n a l w e i g h t g a i n d oe s n o t d i f f e r b e tw een m o t h e r s who
d e l i v e r OBW and LBW i n f a n t s and c a n n o t be us ed t o p r e d i c t
b i r t h w eight.

As a g r o u p ,

r e s p o n d e r s t o t h e White M ic hi ga n M o t h e r ' s S ur ve y

g a i n e d 2 9 . 5 pounds ( n = 3 9 6 ) . Women who d e l i v e r e d LBW i n f a n t s g a i n e d , on
average,
5.24).

s e v e n pounds l e s s t h a n m o t h e r s who d e l i v e r e d OBW i n f a n t s

(Table

178

Table 5.24.

Mean w e i g h t g a i n o f w h i t e m o t h e r s who d e l i v e r e d LBW
and OBW i n f a n t s .

V ariable

OBW

LBW

Weight g a i n ,

lbs

26.4 ± 11.6

3 3 . 2 ± 1 0 .7

F

P

5.70

0.0000

Seventy f o u r p e rc e n t o f th e resp o n d e rs i n d ic a te d t h e i r p r e n a ta l
c a r e p r o v i d e r had made a s p e c i f i c w e i g h t g a i n r e c o m m e n d a ti o n . On
average,

t h e w e i g h t g a i n o f LBW s u b j e c t s was a l m o s t i d e n t i c a l

recommended by t h e s e s u b j e c t s '

prenatal

c a r e p r o v i d e r (27 l b s ) .

who d e l i v e r e d OBW i n f a n t s g a i n e d , on a v e r a g e ,
prenatal

to th at
Women

s i x pounds more t h a n t h e i r

c a r e p r o v i d e r had recommended (28 l b s ) .

The c r u d e odds r a t i o

i n d i c a t e d women who g a i n e d l e s s t h a n 22

pound s we re n o t a t an i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t compared
t o m o t h e r s who g a i n e d t h e c u r r e n t l y recommended 22-27 pounds ( T a b l e
5 . 2 5 ) . However, women who g a i n e d l e s s t h a n 22 pounds had a 540%
i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t t h a n m o t h e r s who g a i n e d 28
pounds o r more.

179

Table 5.25.

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t d e p e n d e n t
on amount o f p r e g n a n c y w e i g h t g a i n ( n = 3 5 1 ) .

LBW

V ariable

OBW

RR (95% Cl)

N

N

< 22 l b s

59

22

1.83 ( 0 .9 3 - 3 .5 9 )

2 2 -2 7 l b s

44

30

la

> 27 l b s

65

131

Weioht q a i n ,

lbs:

0.34

5.40 (3 .0 5 -9 .5 8 )

< 22 vs > 27 l b s
n...
r —.....
ar e f e r e n t

(0.19-0.59)

' .......

When s u b j e c t s were c a t e g o r i z e d a c c o r d i n g t o t h e i r p r e - p r e g n a n t
p e r c e n t r e f e r e n c e w e i g h t (<90%, 90-119%,

120-149% 150% o r m o r e ) ,

u n d e r w e i g h t and normal w e i g h t women who s u b s e q u e n t l y d e l i v e r e d OBW
i n f a n t s g a i n e d s i g n i f i c a n t l y more w e i g h t t h a n women who d e l i v e r e d LBW
infants

(Table 5 .2 6 ) .

S i m i l a r l y , o v e r w e i g h t women who d e l i v e r e d OBW

i n f a n t s g a i n e d more t h a n o v e r w e i g h t women who d e l i v e r e d LBW i n f a n t s ,
however t h e d i f f e r e n c e was n o t s t a t i s t i c a l l y

significant

(31+14 vs

20±14; t = l . 9 0 ) . Very o v e r w e i g h t women who d e l i v e r e d OBW i n f a n t s g a i n e d
l e s s w e i g h t t h a n v e r y o v e r w e i g h t m o t h e r s o f LBW i n f a n t s ,
d i f f e r e n c e was n o t s t a t i s t i c a l l y

but again the

s i g n i f i c a n t due t o t h e s a m pl e s i z e and

t h e v a r i a n c e o b s e r v e d i n t h e m e a s u r e ( 1 9 . 5±15 vs 31±8; t = 1 . 3 0 ) .

180

T a b l e 5 . 2 6 . Amount o f w e i g h t g a i n e d d u r i n g p r e g n a n c y by m o t h e r s o f
OBW and LBW i n f a n t s when s u b j e c t s were c a t e g o r i z e d a c c o r d i n g
t o t h e i r 1983 M e t r o p o l i t a n p r e - p r e g n a n c y r e f e r e n c e w e i g h t .

P r e - P r e g n a n t Weight
C lassification

LBW

OBW

( n)

( n)

t

P

< 90%

25 ± 10
(85)

34 ± 8
(41)

4.82

.0000

90- 119%

29 ± 13
(71)

34 ± 10
(114)

3.29

.0012

120-149%

20 ± 14
(9)

31 ± 14
(21)

1.90

.0667

150% o r more

3 1 + 8
( 3)

19 ± 15
( 7)

1.30

.2336

Regression a n a ly s is

i n d i c a t e d w e i g h t g a i n was h i g h l y c o r r e l a t e d

with b i r t h w eight (Table 5 .2 7 ) ,

e x p l a i n i n g 8% o f t h e v a r i a n c e . The

c o r r e l a t i o n b e tw e en b i r t h w e i g h t and w e i g h t g a i n was h i g h e r among women
who we ig h e d l e s s t h a n 120% o f t h e i r 1983 M e t r o p o l i t a n r e f e r e n c e p r i o r t o
pregnancy ( r = 0 .31; F=35.1).

Each pound o f w e i g h t g a i n e d by u n d e r w e i g h t

and normal w e i g h t women was a s s o c i a t e d w i t h a 4 8 . 8 g i n c r e a s e i n b i r t h
w e i g h t . A s m a l l e r g a i n i n b i r t h w e i g h t ( 3 2 . 3 g / p o u n d w e i g h t g a i n ) was
n o t e d among women who e n t e r e d p r e g n a n c y o v e r w e i g h t o r o b e s e .

181

T a b l e 5 . 2 7 . R e g r e s s i o n o f w e i g h t g a i n on b i r t h w e i g h t by w h i t e s u b j e c t ' s
pre-p reg n an t percen t of re fe re n c e w eight.

S tatistic

< 120%
Pre-Pregnant

120% o r more
Pre-Pregnant

A ll S u b j e c t s

r
r2
B
SE-B
F
P
n

0 .3 1
0.10
48.8
8.2
3 5 .1
0.00
330

0.28
0.08
32.3
13.6
5.7
0.02
66

0.284
0.08
41.9
7.1
34.6
0.00
396

R e s u l t s o f t h e M ic h i g a n M o t h e r ' s S t u d y p r e s e n t e d h e r e r e i n f o r c e
t h e p o s i t i o n o f Brown ( 1 983 ) and Rosso (198 5) t h a t w e i g h t g a i n
r e c o m m e n d a ti o n s s h o u l d be i n d i v i d u a l i z e d .

R esults of th is

study

i n d i c a t e d women who e n t e r e d p r e g n a n c y u n d e r w e i g h t n e e d ed t o g a i n more
t h a n t h e 22-27 pounds c u r r e n t l y recommended by t h e Ame rican C o l l e g e o f
O b s t e t r i c i a n s and G y n e c o l o g i s t s (ACOG, 1 9 8 2 ) ,
subjects'

prenatal

as w e l l

a s by t h e s e

care providers.

P r e v i o u s r e s e a r c h h a s i n d i c a t e d e a ch pound o f w e i g h t g a i n e d d u r i n g
p r e g n a n c y was a s s o c i a t e d w i t h a 44 -5 0 g i n c r e a s e in b i r t h w e i g h t
(Eastman and J a c k s o n ,
Abrams and L a r o s ,
observation,

1968; N i s w a n d e r e t a l , 1969; Simpson e t a l , 1974;

1986).

R esults of th is

study concur with t h i s

as e ach pound o f w e i g h t g a i n among u n d e r w e i g h t and normal

w e i g h t women was a s s o c i a t e d w i t h a 4 8 . 8 g i n c r e a s e i n b i r t h w e i g h t . A
s m a l l e r i n c r e a s e was s e e n among women who e n t e r e d p r e g n a n c y o v e r w e i g h t
o r v e r y o v e r w e i g h t . M e t c o f f e t al

(1 981b) i n d i c a t e d t h e c o r r e l a t i o n

182

c o e f f i c i e n t s betw een w e i g h t g a i n and b i r t h w e i g h t i n most s u r v e y s a r e
u s u a l l y around 0.20 t o 0 .3 0 . Again,
th is observation,

r e s u l t s o f th e p re s e n t study support

as t h e c o r r e l a t i o n c o e f f i c i e n t betw een w e i g h t g a i n and

b i r t h w e i g h t among a l l

s u b j e c t s was 0 . 2 8 . When o v e r w e i g h t and v e r y

o v e r w e i g h t s u b j e c t s w er e removed from t h e sample p o p u l a t i o n ,

the

c o r r e l a t i o n b e tw e en w e i g h t g a i n and b i r t h w e i g h t i n c r e a s e d t o 0 . 3 1 ,
e x p l a i n i n g 10% o f t h e v a r i a n c e in b i r t h w e i g h t .
Naeye (197 9) n o t e d o p t i m a l

i n f a n t outcome was a s s o c i a t e d w i t h a

w e i g h t g a i n o f 30 pounds f o r u n d e r w e i g h t women. Brown (198 6) r e p o r t e d a
w e i g h t g a i n o f 33 pounds was a s s o c i a t e d w i t h an o p t i m a l

b i r t h weight of

3 , 0 0 0 t o 4 , 0 0 0 g i f t h e m o t h e r was u n d e r w e i g h t p r i o r t o p r e g n a n c y .
R esults o f t h is

s t u d y i n d i c a t e d a w e i g h t g a i n o f 34 pounds by

u n d e r w e i g h t women was a s s o c i a t e d w i t h an o p t i m a l

b i r t h w e i g h t o f 3 ,5 0 0

t o 4 , 0 0 0 g. T h i s same w e i g h t g a i n was a s s o c i a t e d w i t h o p t i m a l

birth

w e i g h t among women who e n t e r e d p r e g n a n c y a t o r n e a r t h e i r d e s i r a b l e
r e f e re n c e w eight.

No s p e c i f i c w e i g h t g a i n re c o m m e n d a tio n can be made f o r

women who e n t e r e d p r e g n a n c y o v e r w e i g h t from t h i s

s t u d y due t o t h e small

s am pl e s i z e and h i g h v a r i a n c e o b s e r v e d .
Based on r e s u l t s p r e s e n t e d h e r e ,

th e null

hypotheses are r e fu te d .

T h e r e was a s i g n i f i c a n t d i f f e r e n c e i n amount o f w e i g h t g a i n e d by m o th e r s
o f LBW and OBW i n f a n t s .

I t must be n o t e d t h a t t h e amount o f w e i g h t

g a i n e d by m o t h e r s o f LBW i n f a n t s was n o t ,

on a v e r a g e ,

h i g h e s t w e i g h t g a i n recommended by t h e s u b j e c t s '

le s s than the

prenatal

care

p r o v i d e r s . Th u s , a 27 pound w e i g h t g a i n r e c o m m e n d a tio n was c l e a r l y n o t
h i g h enough f o r t h e s e s u b j e c t s . The e s t i m a t e d r e l a t i v e r i s k o f
d e l i v e r i n g a LBW i n f a n t a l s o s u p p o r t s t h e f a c t t h a t a 22- 27 pound w e i g h t

183

g a i n was i n s u f f i c i e n t .

In f a c t ,

t h e r e l a t i v e r i s k o f d e l i v e r i n g a LBW

i n f a n t was n o t s i g n i f i c a n t l y d i f f e r e n t betw een women who g a i n e d e i t h e r
22-27 pounds o r l e s s t h a n 22 p o u n d s . A w e i g h t g a i n g r e a t e r t h a n 27
pounds,

in c o n t r a s t ,

H02- 2 b :

s i g n i f i c a n t l y r e d u c e d t h e i n c i d e n c e o f LBW.

M a t e r n a l he m o gl o b in v a l u e s d u r i n g p r e g n a n c y do n o t d i f f e r
b e tw een m o t h e r s who d e l i v e r o p t i m a l and low b i r t h w e i g h t
i n f a n t s and c a n n o t be u se d t o p r e d i c t b i r t h w e i g h t .

The h i g h e s t and l o w e s t h e m og lo bi n l e v e l s r e c o r d e d d u r i n g p r e g n a n c y
were p r o v i d e d by t h e p r e n a t a l

c a r e p r o v i d e r o f 230 c a s e s and c o n t r o l s .

I f o n l y one v a l u e was r e c o r d e d d u r i n g p r e g n a n c y ( n = 6 8 ) ,
the "highest" value.
observed

No s t a t i s t i c a l l y

i t was code d as

s i g n i f i c a n t d i f f e r e n c e s wer e

in e i t h e r t h e h i g h e s t o r t h e l o w e s t h e m og lo bi n v a l u e s r e c o r d e d

d u r i n g p r e g n a n c y betw een m o t h e r s who d e l i v e r e d o p t i m a l
weight i n f a n ts

o r low b i r t h

(Table 5 .2 8 ).

Table 5.28.

V ariable

Mean h i g h and low he mo g lo b in v a l u e s r e c o r d e d d u r i n g
p r e g n a n c y b e tw een c a s e s and c o n t r o l s .

LBW

(n)

OBW

(n)

t

p

H i g h e s t Hb, g / d l

13 .2 ± 1.1

(108)

13.1 ± 0 . 8

(122)

0.91

.37

Lowest Hb, g / d l

1 2 . 0 ± 1.1

(69)

1 1 . 8 + 1. 0

(93)

0.64

.52

The c o r r e l a t i o n betw een t h e l o w e s t he mo gl obi n v a l u e r e c o r d e d
d u r i n g p r e g n a n c y and b i r t h w e i g h t was n o t s i g n i f i c a n t

( r = 0 .07;

Fp=0.36).

184

Likewise,

t h e c o r r e l a t i o n betw een t h e h i g h e s t h e m og lo bi n v a l u e and b i r t h

w e i g h t was n o t s i g n i f i c a n t ( r = 0 . 0 6 ; F p = 0 . 3 2 ) . When t h e h em o g l o b in v a l u e s
we re c a t e g o r i z e d a c c o r d i n g t o t h e l e v e l s recommended by Murphy e t al
( 1 9 8 6 ) , t h e odd s r a t i o d i d n o t i n d i c a t e a s t a t i s t i c a l l y

significant

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t i f t h e h i g h e s t h e m og lo bi n
v a l u e r e c o r d e d d u r i n g p r e g n a n c y was g r e a t e r t h a n 1 3 .2 g / d l

Table 5.29

(Table 5 .2 9 ) .

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l he mo g lo b in l e v e l s r e c o r d e d
du rin g pregnancy.

V ariable

Cases
N

Controls
N

RR (95% Cl)

H i g h e s t Hb r e c o r d e d (n=230)
< 10.4 g /d l

2

0

-

10.4-13.2 g/dl

53

76

1.0a

> 1 3 . 2 g/dl

53

46

1.65 ( 0 .9 8 - 2 .8 0 )

a referent

T h i s o b s e r v a t i o n d o e s n o t s u p p o r t t h a t o f Murphy e t al
r e p o r t e d h em o g l o b in l e v e l s g r e a t e r t h a n 1 3 .2 g / d l

(1986) who

i n p r e g n a n t women were

a s s o c i a t e d w i t h an i n c r e a s e d i n c i d e n c e o f p e r i n a t a l

m ortality,

preterm

d e l i v e r y and low b i r t h w e i g h t a s compared t o i n f a n t s o f women w i t h
i n t e r m e d i a t e he mo g lo b in l e v e l s

(10.4-13.2 g / d l) .

Thes e r e s e a r c h e r s had

s u g g e s t e d t h e h i g h he mo g lo b in l e v e l s r e f l e c t e d some f a i l u r e
volume e x p a n s i o n ,

resulting

in d e c r e a s e d u t e r o p l a c e n t a l

i n p las m a

circulation

a c o n c o m i t a n t d e c r e a s e d b i r t h w e i g h t due t o a r e d u c e d s u p p l y o f
n u tr ie n ts to the fe tu s .

Naeye (1977) had a l s o h y p o t h e s i z e d h i g h

and

185

h e mo g l o b i n v a l u e s c o n t r i b u t e d t o t h e f o r m a t i o n o f p l a c e n t a l
again r e s u l t i n g in decreased u t e r o p l a c e n ta l

infarcts,

flow, d ecre ased n u t r i e n t

t r a n s f e r and d e c r e a s e d i n f a n t s i z e .
Based upon t h e s e r e s u l t s ,

the null

hypothesis is retained.

There

we r e no s i g n i f i c a n t d i f f e r e n c e s i n t h e mean h e m a t o l o g i c v a l u e s b e t we e n
g r o u p s , n o r was t h e r e a s i g n i f i c a n t c o r r e l a t i o n b e t we e n b i r t h w e i g h t and
e i t h e r t h e h i g h e s t o r l o w e s t h e mo g l o b i n v a l u e s r e c o r d e d d u r i n g
pregnancy.

In a d d i t i o n ,

t h e c r u d e odds r a t i o d i d n o t i n d i c a t e an

e l e v a t e d r i s k o f d e l i v e r i n g a LBW i n f a n t i f t h e m a t e r n a l
v a l u e was h i g h e r t h a n 1 3 . 2 g / d l

H02- 2 c :

h e mo g l o b i n

a t some p o i n t d u r i n g p r e g n a n c y .

H i g h e s t and l o w e s t m a t e r n a l d i a s t o l i c b l o o d p r e s s u r e v a l u e s
r e c o r d e d d u r i n g p r e g n a n c y do n o t d i f f e r b e t w e e n m o t h e r s who
d e l i v e r o p t i m a l and l ow b i r t h w e i g h t i n f a n t s and c a n n o t be
used t o p r e d i c t b i r t h we i g h t.

H i g h e s t and l o w e s t d i a s t o l i c b l o o d p r e s s u r e r e a d i n g s we r e p r o v i d e d
by t h e p r e n a t a l

c a r e p r o v i d e r o f 229 c a s e s and c o n t r o l s .

i n d i c a t e d no s t a t i s t i c a l l y

Results

s i g n i f i c a n t d i f f e r e n c e i n e i t h e r t h e mean

h i g h o r l ow d i a s t o l i c b l o o d p r e s s u r e r e a d i n g s b e t we e n m o t h e r s who
d e l i v e r e d o p t i ma l

o r low b i r t h w e i g h t i n f a n t s

(Table 5 .3 0 ) .

186

Table 5.30.

Mean h i g h and low d i a s t o l i c b l o o d p r e s s u r e (DBP)
r e a d i n g s d u r i n g p r e g n a n c y b e t we e n c a s e s and c o n t r o l s .

Variable

LBW
( n=105)

OBW
( n=124)

t

H i g h e s t DBP, mm HG

79 ± 13

77 ± 9

1. 9 2

.057

Lowest DBP, mm HG

59 + 9

5 9 + 8

0. 0 1

.351

The c o r r e l a t i o n b e t we e n t h e l o w e s t r e c o r d e d di a s t o l i c

P

blood

p r e s s u r e r e a d i n g d u r i n g p r e g n a n c y and b i r t h w e i g h t was n o t s i g n i f i c a n t
(Table 5 .3 1 ) .

However, t h e c o r r e l a t i o n b e t we e n t h e h i g h e s t r e c o r d e d

b l o o d p r e s s u r e r e a d i n g d u r i n g p r e g n a n c y and b i r t h w e i g h t was
statistically

significant,

wi th each i nc r e me nt a l

i n c r e a s e in d i a s t o l i c

blood p r e s s u r e a s s o c i a t e d wi th a 10.5 g d e c r e a s e in i n f a n t b i r t h we ight.

Table 5.31.

C o r r e l a t i o n b e t we e n h i g h e s t and l o w e s t d i a s t o l i c b l ood
p r e s s u r e r e a d i n g s r e c o r d e d d u r i n g p r e g n a n c y and i n f a n t
b i r t h weight.

Variable

R
adjusted
Be t a
Standard
Constant
F
p
n

R2
Error-Beta

Lowest DBP

H i g h e s t DBP

-.03
. 00
-2.9
5.7
3207
. 2516
. 6164
256

-.15
.02
-10.5
4.3
3854
5.9
. 0158
256

187

H i g h e s t and l o w e s t d i a s t o l i c b l o o d p r e s s u r e v a l u e s we r e
c a t e g o r i z e d b a s e d on t h e o b s e r v a t i o n s o f G r u n b e r g e r e t al

( 1979) and

Naeye ( 1 9 7 9 ) , who i n d e p e n d e n t l y o b s e r v e d t h a t d i a s t o l i c b l o o d p r e s s u r e
r e a d i n g s o f l e s s t h a n 65 mm Hg o r g r e a t e r t h a n 99 mm Hg we r e a s s o c i a t e d
w i t h a d e c r e a s e d i n f a n t b i r t h w e i g h t . The c r u d e odds r a t i o s
that,

indicated

a l t h o u g h t h e r e was no a s s o c i a t i o n b e t we e n a d i a s t o l i c b l o o d

p r e s s u r e o f l e s s t h a n 65 mm Hg and l ow b i r t h w e i g h t ,
statistically

significant

t h e r e was a

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t i f

t h e h i g h e s t d i a s t o l i c b l o o d p r e s s u r e r e a d i n g d u r i n g p r e g n a n c y was
g r e a t e r t h a n 99 mm Hg ( T a b l e 5 . 3 2 ) .

Table 5.32.

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon h i g h e s t and l o w e s t m a t e r n a l d i a s t o l i c
blood p r e s s u r e r e a d i n g s d u r i n g pregnancy.

Variable

Ca s e s
N

Controls
N

RR (95% Cl )

H i q h e s t DBP r e c o r d e d ( n = 2 1 3 ) :
< 65 mmHg
6 5 - 8 9 mmHg
9 0 - 9 9 mmHg
> 99 mmHg

0
77
6
13

0
107
9
1

la
0 . 9 2 ( 0 . 3 1 - 2 . 69)
1 8 . 0 ( 2 . 3 - 1 4 1 . 0)

81
24

102
22

0.73
la

Lowes t DBP r e c o r d e d ( n = 2 2 9 ) :
< 65 mmHg
6 5 - 8 9 mmHg
9 0 - 9 9 mmHg
> 99 mmHg

vr
... r ____.................... . ■■
a referent

-

-

( 0 . 3 8 - 1 . 39)
-

188

Th e s e r e s u l t s do n o t s u p p o r t t h e o b s e r v a t i o n o f G r u n b e r g e r e t al
( 1979) t h a t a d i a s t o l i c b l o o d p r e s s u r e l o w e r t h a n 65 mmHg r e d u c e s
uteroplacental
and r e s u l t i n g

perfusion,

decreasing t r a n s f e r of n u trie n ts to the fetus

i n a s m a l l e r i n f a n t . Th e s e r e s u l t s a r e ,

howe ve r ,

c o n s i s t e n t w i t h t h e o b s e r v a t i o n o f Naeye ( 1979) t h a t a p e a k d i a s t o l i c
b l o o d p r e s s u r e g r e a t e r t h a n 99 mm Hg d u r i n g p r e g n a n c y i s a s s o c i a t e d w i t h
a r e d u c e d i n f a n t b i r t h w e i g h t . Naeye s u g g e s t e d t h i s h i g h d i a s t o l i c bl o o d
p r e s s u r e r e p r e s e n t s an o v e r s h o o t o f t h e n o r m a l ,
me c h a n i s ms ,

homeostatic,

hemodynamic

r e d u c i n g t h e s u p p l y o f n u t r i e n t s t o t h e f e t u s and r e s u l t i n g

in a s m a l le r than expected i n f a n t .
Results presented herein suggest th a t,

w h i l e l ow m a t e r n a l

d i a s t o l i c b l o o d p r e s s u r e v a l u e s do n o t d i f f e r b e t we e n m o t h e r s who
d e l i v e r optimal

and low b i r t h w e i g h t i n f a n t s ,

high d i a s t o l i c

p r e s s u r e s do d i f f e r b e t we e n m o t h e r s o f c a s e s and c o n t r o l s ,
used t o p r e d i c t i n f a n t b i r t h w ei g h t . A high d i a s t o l i c

blood

and can be

bl o o d p r e s s u r e

g r e a t e r t h a n 99 mmHg a t some t i m e d u r i n g p r e g n a n c y was a s s o c i a t e d w i t h
an 1 8 - f o l d i n c r e a s e d r i s k f o r d e l i v e r i n g a LBW i n f a n t .
results,

the null

Based upon t h e s e

h y p o t h e s i s t h a t low d i a s t o l i c b l o o d p r e s s u r e r e a d i n g s

do n o t d i f f e r b e t we e n m o t h e r s o f LBW and OBW m o t h e r s i s r e t a i n e d .
However , t h e n u l l

hypothesis t h a t highest recorded d i a s t o l i c

blood

p r e s s u r e s do n o t d i f f e r b e t we e n m o t h e r s o f LBW and OBW i n f a n t s

is

c a u t i o u s l y r e f u t e d , w i t h a d i a s t o l i c b l o o d p r e s s u r e g r e a t e r t h a n 99 mmHg
a s s o c i a t e d w i t h an i n c r e a s e d r i s k f o r d e l i v e r i n g a LBW i n f a n t .
Caut ion i s w a r r a n t e d in i n t e r p r e t i n g t h e s e r e s u l t s .

Peak d i a s t o l i c

b l o o d p r e s s u r e v a l u e s f o r 16 s u b j e c t s we r e d i s c a r d e d d u r i n g d a t a e n t r y

189

d ue t o wha t a p p e a r e d t o be an a p p a r e n t m i s i n t e r p r e t a t i o n o f t h e q u e s t i o n
by r e s p o n d e n t s . Da t a we r e d i s c a r d e d i f t h e p e a k d i a s t o l i c r e a d i n g was
r e p o r t e d t o be 120 mm Hg o r g r e a t e r w i t h no me n t i o n made o f a d i a g n o s i s
o f hypertensio n or toxemia.
s a m p l i n g f r a me i f ,

(REMINDER: S u b j e c t s we r e e x c l u d e d f r om t h e

according to the b i r t h c e r t i f i c a t e ,

diagnosed the p a t i e n t as having hy p e rt e n s io n ,
during pregnancy).

t h e p h y s i c i a n had

p r e - e c l a m p s i a or toxemia

I t appeared t o t h i s r e s e a r c h e r t h a t

some r e s p o n d e n t s

had p r o v i d e d t h e s u b j e c t ' s s y s t o l i c and d i a s t o l i c b l o o d p r e s s u r e s ,
r a t h e r t h a n t h e h i g h and l ow d i a s t o l i c p r e s s u r e s . T h i s o b s e r v a t i o n was
e s p e c i a l l y n o t i c e a b l e when a m e d i c a l r e c o r d s a s s i s t a n t had c o m p l e t e d t h e
survey.

Thus ,

H02- 3 a :

it

a p p e a r s b i a s ha s be e n i n t r o d u c e d i n t o t h i s q u e s t i o n .

The mean number o f c i g a r e t t e s consumed p e r da y d oe s n o t
d i f f e r b e t we e n m o t h e r s who d e l i v e r o p t i m a l and l ow b i r t h
w e i g h t i n f a n t s and c a n n o t be u s e d t o p r e d i c t b i r t h w e i g h t ,
r e g a r d l e s s o f p e r c e n t 1983 r e f e r e n c e w e i g h t a t t e r m o r
number o f c a l o r i e s cons umed.

S e l f - r e p o r t e d s moki ng b e h a v i o r p r i o r t o and d u r i n g p r e g n a n c y was
p r o v i d e d by 395 r e s p o n d e n t s t o t h e Mi c h i g a n M o t h e r ' s S u r v e y .
p e r c e n t o f t h e women ( n = 2 14)
pregnancy.

Fifty-four

i n d i c a t e d t h e y d i d n o t smoke p r i o r t o

An e s t i m a t e d e i g h t p e r c e n t q u i t smoki ng w h i l e p r e g n a n t ,

b r i n g i n g t h e number o f n o n - s m o k e r s t o 62% o f t h e s a mpl e ( n = 2 4 5 ) .
percent

Thirty

( n=54) o f t h e women who smoked b e f o r e p r e g n a n c y r e p o r t e d t h e y

d i d not r educe t h e i r consumption o f c i g a r e t t e s d u r i n g pregnancy.
In t h i s

study,

m o t h e r s who d e l i v e r e d LBW i n f a n t s consumed

s i g n i f i c a n t l y more c i g a r e t t e s ,

b o t h p r i o r t o and d u r i n g p r e g n a n c y ,

as

190

c ompa r e d t o women who d e l i v e r e d OBW i n f a n t s

(Table 5 .3 3 ) .

On a v e r a g e ,

b o t h g r o u p s r e d u c e d t h e i r c i g a r e t t e c o n s u m p t i o n d u r i n g p r e g n a n c y by
half.

Table 5.33.

Mean number o f c i g a r e t t e s consumed p e r da y p r i o r t o
and d u r i n g p r e g n a n c y a s r e p o r t e d by m o t h e r s o f c a s e s
and c o n t r o l s .

Variable

LBW
( n=167)

OBW
( n=184)

t

P

# Ciqarettes/dav
Before pregnancy

13.4 ± 12.2

5.4 ± 9.9

6.75

. 0000

Du r i n g p r e g n a n c y

7 . 8 ± 10.2

2.7 ± 6.6

5.71

. 0000

The c r u d e odds r a t i o

i n d i c a t e d women who r e p o r t e d s moki ng d u r i n g

p r e g n a n c y had a l m o s t a 5 - f o l d i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t
a s c ompa r ed t o n o n - s m o k e r s ( T a b l e 5 . 3 4 ) .

Women who r e p o r t e d cons umi ng 20

o r more c i g a r e t t e s p e r d a y d u r i n g p r e g n a n c y wer e a t h i g h e s t r i s k f o r
d e l i v e r y o f a LBW i n f a n t

[RR=5. 6 ( 2 . 6 - 1 1 . 8 ) ] . A f t e r a d j u s t i n g f o r t h e

c o n f o u n d i n g r i s k f a c t o r o f n o t g a i n i n g t o 120% o f 1983 M e t r o p o l i t a n
r e f e r e n c e weight a t term,

t h e Mant el Ha e n s z e l

a d j u s t e d odds r a t i o

i n d i c a t e d s moki ng more t h a n one c i g a r e t t e p e r da y d u r i n g p r e g n a n c y was
still

a s s o c i a t e d w i t h an i n c r e a s e d r i s k f o r d e l i v e r y o f a LBW i n f a n t

[ RR=4. 73 ( 3 . 4 7 - 6 . 4 6 ) ] .

191

Table 5.34.

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
a s s o c i a t e d w i t h number o f c i g a r e t t e s consumed p e r da y
du rin g pregnancy.

Variable

Ca s e s
N

Controls
N

RR (95% Cl )

# Cioarettes/dav:
Non- s moke r

70

143

la

Smoker
1- 9
10- 19
20 o r more

97
29
38
30

41
17
13
11

4.8
3.5
6.0
5.6

(3.0-7.7)
(1.8-6.8)
(3.0-11.9)
(2.6-11.8)

a
a r e f e___
r e n jt.

Si mp l e r e g r e s s i o n i n d i c a t e d t h e number o f c i g a r e t t e s consumed p e r
da y d u r i n g p r e g n a n c y was n e g a t i v e l y a s s o c i a t e d w i t h i n f a n t b i r t h w e i g h t
(r= - 0 . 2 5 ) .

Each c i g a r e t t e consumed p e r d a y was a s s o c i a t e d w i t h a 2 2 . 3 g

de c re a s e in i n f a n t b i r t h weight (Table 5 .3 5 ) .

Table 5.35.

Si mp l e r e g r e s s i o n o f number o f c i g a r e t t e s consumed p e r
d a y d u r i n g p r e g n a n c y on b i r t h w e i g h t ( n = 3 9 5 ) .

Stati sties

R
a d j u s t e d R2
Be t a
Standard Error-Beta
Constant
F
DF
P

Val ue

-0.25
0.06
-22.3
4.3
3127
26.7
(1,394)
. 0000

192

When b o t h t h e p e r c e n t o f 1983 r e f e r e n c e w e i g h t a t t a i n e d a t t e r m
and number o f c i g a r e t t e s consumed p e r day d u r i n g p r e g n a n c y we r e
regressed against infant b irth weight,
entered the equation

both f a c t o r s

independently

( T a b l e 5 . 3 6 ) . T o g e t h e r t h e s e two v a r i a b l e s

e x p l a i n e d 17% o f t h e v a r i a n c e i n b i r t h w e i g h t

(r=0.41).

f o r p e r c e n t 1983 r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ,

After correcting

each c i g a r e t t e

consumed p e r da y was a s s o c i a t e d w i t h an 1 8 . 3 g d e c r e a s e i n i n f a n t b i r t h
w e i g h t . Th u s ,

s moki ng o n e - h a l f p a c k o f c i g a r e t t e s p e r da y was a s s o c i a t e d

w i t h a 183 g d e c r e a s e i n i n f a n t b i r t h w e i g h t .

Smoking a p a c k o r more p e r

da y d u r i n g p r e g n a n c y was a s s o c i a t e d w i t h a 363 g d e c r e a s e i n b i r t h
weight in t h i s study.

Table 5.36.

Regression a n a ly s i s i n d i c a t i n g the r e l a t i o n s h i p
b e t we e n number o f c i g a r e t t e s cons umed p e r d a y , p e r c e n t
1983 r e f e r e n c e w e i g h t a t t a i n e d a t t e r m and b i r t h
weight.

Variable

B

SE-B

Regression
Coefficient

T

Si g T

% 1983 R e f e r e n c e
We i ght a t Term

12.36

1.75

0.328

7.05

. 0000

# Cigarettes/day

-18.28

4.11

-0.207

-4.45

. 0000

Constant, g

1603

7.29

. 0000

Multiple R
R2
F
DF
p

. 410
. 168
39.55
(2,391)
. 0000

220

193

The d e c r e a s e i n b i r t h w e i g h t w i t h i n c r e a s i n g number o f c i g a r e t t e s
consumed p e r d a y ca n be s e e n g r a p h i c a l l y i n F i g u r e 5 . 5 .

The s l i g h t

i n c r e a s e i n b i r t h w e i g h t a s s o c i a t e d w i t h t h e c o n s u m p t i o n o f 20 o r more
c i g a r e t t e s per day,

a s c ompa r ed t o t h e c o n s u m p t i o n o f 10- 19 c i g a r e t t e s

p e r d a y , was u n e x p e c t e d .

Possible explanations include:

r e p o r t e d c on s u mi n g 10- 19 c i g a r e t t e s u n d e r - r e p o r t e d ,

thus t h e i r i n f a n t 's

b i r t h w e i g h t s a r e l o w e r t h a n one woul d ha ve e x p e c t e d ,
who d e l i v e r e d o p t i m a l

b i r t h weight i n f a n t s ,

1) m o t h e r s who

in f a c t ,

2) s e v e r a l

women

smoked 20 o r more

c i g a r e t t e s p e r day c a u s i n g a r e g r e s s i o n o f b i r t h w e i g h t t o w a r d t h e mean
o r 3) t h i s c o u l d be a s t a t i s t i c a l

artifact.

Bi r t h w e i g h t
4000
3500

3247
2783

3000
2500
2000

1000
500

0

1- 9

10-19

20 *

Number of C i g a re t t e s / d a y

Figure 5.5.

E f f e c t o f i n c r e a s i n g c i g a r e t t e c o n s u m p t i o n on b i r t h w e i g h t .

194

When t h e s u b j e c t s w e r e c l a s s i f i e d a s e i t h e r b e i n g a s moker ( smoked
one o r more c i g a r e t t e s p e r da y ) o r a n o n - s m o k e r ( a b s t a i n e d f r om smoki ng
throughout pregnancy),
average,

s mo k e r s d e l i v e r e d i n f a n t s who w e i g h e d , on

556 g l e s s t h a n i n f a n t s b o r n t o women who i n d i c a t e d t h e y d i d

n o t smoke ( 2670+752 vs 3226±728; t = 7 . 2 8 ) .

Interestingly,

w e i g h t g a i n o f s moke r s was n o t s i g n i f i c a n t l y d i f f e r e n t
s mo k e r s , n o r was t h e r e a s i g n i f i c a n t d i f f e r e n c e
o f c a l o r i e s consumed p e r d a y ( T a b l e 5 . 3 7 ) .

the average

from t h a t o f non-

i n t h e e s t i m a t e d number

No n - s moke r s wer e

s i g n i f i c a n t l y o l d e r t h a n s moke r s by one y e a r ( t = 3 . 7 1 ; p = . 0 0 0 2 ) .

Table 5.37.

Compa r i s on o f i n f a n t b i r t h w e i g h t , w e i g h t g a i n and
c a l o r i e s consumed p e r da y b e t we e n s moke r s vs nons moke r s ( n = 3 9 5 ) .

Variable

Non- Smoker s
( n=244)

Birth weight, g

3226 ± 728

We i ght g a i n ,

lbs

Calories/day
Age, y e a r s

30 + 12

Smokers
( n=244)

2670 ± 753
29 ± 12

t

P

7.28

. 0000

1.25

.2111

2312 ± 669

2317 ± 727

0.08

. 9399

27 ± 4

26 ± 4

3.71

. 0002

Da t a f rom t h e N a t i o n a l N a t a l i t y S u r v e y i n d i c a t e d an e s t i m a t e d 25%
o f m a r r i e d w h i t e women o v e r t h e a ge o f 20 smoke ( Kl e i nma n and K o p s t e i n
( 1 9 8 7 ) . Of t h e s e ,

an e s t i m a t e d 17% o f women q u i t s moki ng,

and 40% c u t

down on t h e number o f c i g a r e t t e s consumed p e r da y d u r i n g p r e g n a n c y .

195

R e s u l t s o f t h e Wh i t e Mi c h i g a n M o t h e r ' s S t u d y i n d i c a t e d a much h i g h e r
i n c i d e n c e o f s moki ng (46%) among t h e w h i t e r e s p o n d e n t s b e t we e n 20- 34
y e a r s o f a ge a t d e l i v e r y and a much l o w e r number o f r e s p o n d e n t s who q u i t
s moki ng d u r i n g p r e g n a n c y (8%). Onl y t h e p e r c e n t a g e o f s u b j e c t s who c u t
down on c i g a r e t t e u s a g e d u r i n g p r e g n a n c y i n t h i s s t u d y was c o m p a t i b l e
with the n atio n al

s u r v e y d a t a (37% vs 40%).

A review o f the l i t e r a t u r e

indicated cig arette

s moki ng ha s

c o n s i s t e n t l y b e e n a s s o c i a t e d w i t h a 150 t o 250 g d e c r e a s e i n b i r t h
weight

(Abel,

1980).

R e s u l t s o f t h e Whi t e Mi c h i g a n M o t h e r ' s St udy

i n d i c a t e d s mo k e r s d e l i v e r e d
than i n f a n t s of non-smokers.

i n f a n t s who w e i g h e d , on a v e r a g e ,

556 g l e s s

T h i s l a r g e d i f f e r e n c e f ou n d must be

r e g a r d e d i n c o n t e x t w i t h t h e s a mp l e d e s i g n c h o s e n f o r t h i s s t u d y .
B e c a u s e 43% o f t h e s u b j e c t s i n t h i s s t u d y we i g h e d l e s s t h a n 2 , 5 0 0 g a t
birth

(cases),

and 46% w e i g h e d 3 , 5 0 0 t o 4 , 0 0 0 g a t b i r t h

(controls),

the

m a g n i t u d e o f t h e d i f f e r e n c e i n b i r t h w e i g h t woul d be e x p e c t e d t o be
l a r g e i f t h e p r e v a l e n c e o f s moki ng was h i g h e r i n one g r o u p t h a n t h e
other.

Be c a u s e more c a s e s t h a n c o n t r o l s smoked, t h i s

large d i f f e r e n c e is

not s u r p r i s i n g .
M e t c o f f e t al

( 19 8 1 b ) r e p o r t e d c i g a r e t t e

s moki ng t y p i c a l l y

a c c o u n t s f o r 3-6% o f t h e v a r i a n c e i n b i r t h w e i g h t .
here concur with t h i s s t a t e m e n t ,

Results presented

as r e g r e s s i o n a n a l y s i s

indicated

c i g a r e t t e s moki ng a c c o u n t e d f o r 4-6% o f t h e v a r i a n c e i n b i r t h w e i g h t .
The e s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t i f a mo t h e r
smoked d u r i n g p r e g n a n c y was h i g h e r t h a n any v a l u e p r e v i o u s l y r e p o r t e d i n
the l i t e r a t u r e .

Again, t h e p r e s e n t s t ud y d e s i g n c o n t r i b u t e s to t he

magnitude o f th e d i f f e r e n c e .

LBW i n f a n t s a r e c ompa r ed t o o p t i m a l

birth

196

weight i n f a n t s ,

r a t h e r t h a n t o i n f a n t s who we i gh 2 , 5 0 0 g o r mor e .

Few s t u d i e s ha ve r e p o r t e d t h e e f f e c t o f b o t h s moki ng and d i e t on b i r t h
weight.

Pi cone e t al

(1982a,

1 9 8 2 b ) , b a s e d on r e s u l t s o f f i v e 2 4 - h o u r

d i e t r e c a l l s obtained throughout pregnancy,

r e p o r t e d s mo k e r s consumed

s i g n i f i c a n t l y more c a l o r i e s t h a n n o n - s m o k e r s .
Higgins

Ha ywor t h e t al

( 1980)

and

( 1976) a l s o r e p o r t e d s moke r s consumed s i g n i f i c a n t l y more

c a l o r i e s p e r da y t h a n n o n - s m o k e r s . The e s t i m a t e d d a i l y c a l o r i c
du rin g pregnancy in t h i s

study,

intake

a s d e t e r m i n e d by t h e W i l l e t t SQFFQ, was

n o t s i g n i f i c a n t l y d i f f e r e n t b e t we e n s moke r s and n o n - s m o k e r s .
Based on t h e s e r e s u l t s ,

the null

h y p o t h e s i s o f no d i f f e r e n c e

in

t h e number o f c i g a r e t t e s consumed p e r day b e t we e n m o t h e r s who d e l i v e r
optimal

and low b i r t h w e i g h t i n f a n t s

is refuted.

Results

indicate

m o t h e r s o f LBW i n f a n t s consumed s i g n i f i c a n t l y more c i g a r e t t e s
In a d d i t i o n ,

m o t h e r s who smoked a t a l l

p e r day.

d u r i n g p r e g n a n c y had a f i v e - f o l d

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t .
Regression a n a ly s is

i n d i c a t e d t h a t t h e number o f c i g a r e t t e s

p e r da y d u r i n g p r e g n a n c y was h i g h l y ,
b i r t h weight.

smoked

n e g a t i v e l y a s s o c i a t e d with i n fa n t

Each c i g a r e t t e smoked p e r da y was a s s o c i a t e d w i t h an

e s t i m a t e d 18 gr am d e c r e a s e i n b i r t h w e i g h t ,
st a n d a r d weight a t t a i n e d at term.

a f t e r accounting for percent

S i mp l e r e g r e s s i o n

a c c o u n t e d f o r 6% o f t h e v a r i a n c e i n b i r t h w e i g h t ,
with t h a t r e p o r t e d in th e l i t e r a t u r e .
clause of the null

indicated

a value co n sisten t

Based on t h e s e r e s u l t s ,

hypothesis is refuted.

smoki ng

t h e second

Results presented herein

i n d i c a t e t h e number o f c i g a r e t t e s consumed p e r d a y c a n be u s e d t o
p r e d i c t i n fa n t b i r t h weight.

197

H02- 3 b :

Mean d a i l y a l c o h o l i n t a k e d oe s n o t d i f f e r b e t we e n m o t h e r s
who d e l i v e r o p t i m a l and l ow b i r t h w e i g h t i n f a n t s and c a n n o t
be u s e d t o p r e d i c t b i r t h w e i g h t .

R e s u l t s o f t h e P r e g n a n c y L i f e s t y l e Q u e s t i o n n a i r e i n d i c a t e d 92% o f
r e s p o n d e n t s e i t h e r r ed u c ed o r e l i m i n a t e d t h e i r consumption o f alcohol
du rin g pregnancy.

E i g h t y - n i n e p e r c e n t o f t h e women ( n=355) r e p o r t e d

c o n s u mi n g l e s s t h a n one d r i n k p e r mont h. Onl y s i x r e s p o n d e n t s r e p o r t e d
c o n s u mi n g t h r e e t o f i v e d r i n k s o r more p e r week.

When t h e W i l l e t t s emi -

q u a n t i t a t i v e f ood f r e q u e n c y q u e s t i o n n a i r e (SQFFQ) was u s e d t o e s t i m a t e
alcohol

intake,

17 s u b j e c t s r e p o r t e d c ons umi ng f i v e o r more d r i n k s p e r

week. Which f i g u r e i s mos t a c c u r a t e c a n n o t be d e t e r m i n e d i n t h i s
r e t r o s p e c t i v e s t u d y . Da t a o b t a i n e d from t h e SQFFQ was a n a l y z e d t o
determine the r e l a t i o n of s e l f - r e p o r t e d
An e s t i m a t e o f t h e mean a l c o h o l

alcohol

in ta ke to b i r t h weight.

i n t a k e ( g /d ay ) d u ri ng pregnancy

was o b t a i n e d f o r 359 r e s p o n d e r s t o t h e Wh i t e Mi c h i g a n M o t h e r ' s S u r v e y .
R e s u l t s i n d i c a t e d m o t h e r s o f c a s e s c ons ume d, on a v e r a g e ,
alcohol

p e r da y a s m o t h e r s o f c o n t r o l s ( T a b l e 5 . 3 8 ) .

each group,

t w i c e a s much

The v a r i a n c e w i t h i n

h o we v e r , was q u i t e l a r g e .

Table 5.38.

Variable

Daily alcohol
intake, g

Mean d a i l y a l c o h o l i n t a k e a s r e p o r t e d by m o t h e r s o f
c a s e s and c o n t r o l s on t h e SQFFQ i n s t r u m e n t .

LBW
( n=144)

1.4 + 3.3

OBW
(n=166)

0.7 ± 2.2

t

2.26

p

. 0245

198

S u b j e c t s we r e c a t e g o r i z e d by mean d a i l y a l c o h o l

intake into the

f o l l o w i n g f o u r g r o u p s a c c o r d i n g t o t h e met hod o f Wr i g h t e t al
abstainer

( no a l c o h o l

during pregnancy), l i g h t d rin k e rs

(1983):

( 1-49 g/week o r

a t l e a s t one d r i n k p e r mont h b u t l e s s t h a n f i v e p e r w e e k ) , m o d e r a t e
drinkers

( 5 0 - 9 9 g / we e k o r f i v e o r mor e, b u t l e s s t h a n 10, p e r week) and

h e a vy d r i n k e r s

(100 o r more g / we e k o r 10 o r more d r i n k s p e r w e e k ) . The

c r u d e odds r a t i o i n d i c a t e d a s i g n i f i c a n t i n c r e a s e i n t h e r i s k o f
d e l i v e r i n g a LBW i n f a n t o n l y when s u b j e c t s consumed more t h a n 100 g o f
alcohol

p e r week ( T a b l e 5 . 3 9 ) .

Table 5.39.

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
a s s o c i a t e d wi t h mat ernal consumption o f a l c oh o l d u r i n g
p r e g n a n c y as r e p o r t e d on t h e W i l l e t t SQFFQ ( n = 3 1 0 ) .

Variable

Al c o h o l

Cas es
N

Cons umer s vs a b s t a i n e r s
Consumed > 50 g / we e k
vs a b s t a i n e r s
..

r

_

RR (95% Cl )

Co n s u mp t i o n , q / we e k :

Abstainer
< 50 g
50-99 g
100+ g

a

Controls
N

102
31
10
1

136
34
5
1

1.0a
1.22 ( 0 . 7 0 - 2 . 1 2 )
2.67 ( 0 . 8 8 -8 . 0 4 )
1.33 ( 1 . 0 3 - 1 . 7 2 )

42
11

40
6

1.4 ( 0 . 8 5 - 2 . 3 2 )
2.34 (0 . 8 4 -2 . 3 2 )

J.

a referent

Si mp l e r e g r e s s i o n b e t we e n mean d a i l y a l c o h o l

i n t a k e and i n f a n t

b i r t h w e i g h t was s i g n i f i c a n t l y and n e g a t i v e l y c o r r e l a t e d
F=9.86).

Each gram o f a l c o h o l

(r= - 0 . 1 3 ;

consumed p e r da y d u r i n g p r e g n a n c y was

199

a s s o c i a t e d w i t h a 38 g d e c r e a s e i n b i r t h w e i g h t . The c o r r e l a t i o n be t we e n
the alcohol

c o n s u m p t i o n and number o f c i g a r e t t e s

significant

(r=0.23; Fp=19.6),

effect.

When a l c o h o l ,

smoked p e r da y was

indicating a potential

confounding

number o f c i g a r e t t e s and an a l c o h o l

i n t e r a c t i o n t e r m we r e r e g r e s s e d a g a i n s t b i r t h w e i g h t

x cigarette

(Table 5 . 4 0 ) ,

the

i n t e r a c t i o n t e r m p r o v i d e d o n l y mode s t e v i d e n c e o f an i mp a c t o f a l c o h o l
d e p e n d e n t on t h e number o f c i g a r e t t e s smoked p e r da y ( t = 1 . 4 8 ,
Analysis of the p a rtia l

regression coefficients

i n t a k e and t h e number o f c i g a r e t t e s

i n d i c a t e d both alcohol

i n d e p e n d e n t l y i mpacted b i r t h w e i g h t.

T o g e t h e r t h e y e x p l a i n e d 6. 6% o f t h e v a r i a n c e i n b i r t h w e i g h t
F = 8 . 3 5 ) . Of t h e 6. 6% o f v a r i a n c e e x p l a i n e d ,
coefficients

in d ic a te d alcohol

p=0.14).

the p a rtia l

(r=0.257;

regression

i n t a k e e x p l a i n e d a p p r o x i m a t e l y 28%,

smoki ng 50% and t h e i n t e r a c t i o n b e t we e n t h e two a p p r o x i m a t e l y 23% o f t h e
v a r i a n c e in b i r t h weight.

Table 5.40.

R e g r e s s i o n a n a l y s i s o f a lcohol consumption p e r day,
number o f c i g a r e t t e s smoked and t h e i n t e r a c t i o n
b e t we e n t h e s e v a r i a b l e s on b i r t h w e i g h t .

Variables

B

Alcohol/day, g
Cigarettes/day
Al c o h o l x c i g a r e t t e s
Constant

-43.5
-23.3
2.0
3195

Multiple R
R2
F
DF
P

-0.257
0.066
8.35
(3,353)

0.0000

SE-B

20.7
5.5
1.4
48.66

Regression
Coefficient

-0.15
-0.26
0.12

t

-2.43
-4.25
1.48
65.66

Si g t

.0362
.0000
. 1386
. 0000

200

Re s u l ts p r es e n t ed here are c o n s i s t e n t with t h e o b s e r v a t i o n of
Br ooke e t al

( 1989) who r e p o r t e d a t r e n d t o w a r d r e d u c e d b i r t h w e i g h t

wi t h i n c r e a s i n g consumption o f a l c o h o l . A f t e r c o n t r o l l i n g f o r e f f e c t s o f
s mo k i n g , h o we v e r , no a d d i t i o n a l

a l c o h o l - e f f e c t on b i r t h w e i g h t was n o t e d

e x c e p t among s moke r s who d r a n k h e a v i l y .

Be c a u s e o n l y two s u b j e c t s

t h i s s t u d y r e p o r t e d cons umi ng more t h a n 100 g a l c o h o l

in

p e r week ( B r o o k e ' s

d e f i n i t i o n of "heavy"), m u l t i p l e r e g r e s s i o n a n a l y s i s could not t e s t

this

h y p o t h e s i s i n t h e Whi t e Mi c h i g a n M o t h e r ' s S t u d y .
Al t h o u g h o n l y two women r e p o r t e d c ons umi ng 100 g o r more a l c o h o l
p e r week i n t h i s s t u d y ,

t h e c r u d e odds r a t i o d i d i n d i c a t e an i n c r e a s e d

r i s k o f d e l i v e r i n g a LBW i n f a n t when 100 g o r more a l c o h o l
p e r day [RR=1.33 ( 1 . 0 3 - 1 . 7 2 ) ] .
Wr i g h t e t al

we r e consumed

T h i s same o b s e r v a t i o n was r e p o r t e d by

( 1983) who, a f t e r a d j u s t i n g f o r s mo k i n g , d e t e c t e d an

i n c r e a s e d r i s k o f low b i r t h w e i g h t among women who d r a n k more t h a n 100
g/ we e k d u r i n g p r e g n a n c y [ RR=2. 2 7 ( 1 . 3 6 - 3 . 8 6 ) ] .
Based on t h e s e r e s u l t s ,
a statistically
alcohol

the null

hypotheses are r e f u t e d .

T h e r e was

s i g n i f i c a n t d i f f e r e n c e i n t h e amount o f s e l f - r e p o r t e d

consumed p e r day be t we e n m o t h e r s who d e l i v e r e d o p t i m a l

b i r t h weight i n f a n t s .

The c r u d e odds r a t i o i n d i c a t e d an a l c o h o l

and low
intake

o f 100 g o r more p e r week was a s s o c i a t e d w i t h an i n c r e a s e d r i s k o f
d e l i v e r i n g a LBW i n f a n t .

Al t h o u g h s t a t i s t i c a l l y

significant,

t h e s ampl e

s i z e was q u i t e s m a l l , w i t h t h e mo t h e r o f o n l y one c a s e and one c o n t r o l
r e p o r t e d cons umi ng more t h a n 100 g a l c o h o l

( 10 o r more d r i n k s )

Si mp l e r e g r e s s i o n i n d i c a t e d a s i g n i f i c a n t ,
be t we e n a l c o h o l

p e r week.

negative relationship

and b i r t h w e i g h t . A f t e r c o n t r o l l i n g f o r t h e e f f e c t o f

201

c i g a r e t t e consumption, t h e p a r t i a l
indicated a s ig n ific a n t,

regression coefficient s t i l l

negative e f f e c t o f alcohol

Holding c i g a r e t t e consumpt ion c o n s t a n t ,

on b i r t h w e i g h t .

e a c h gr am o f a l c o h o l

consumed

p e r da y was a s s o c i a t e d w i t h a 4 3 . 5 g d e c r e a s e i n i n f a n t b i r t h w e i g h t .
C o n s i d e r i n g t h e mean d a i l y i n t a k e o f a l c o h o l was o n l y 1 . 4 and 0 . 7 g / d a y
f o r m o t h e r s o f LBW and OBW i n f a n t s ,
e f f e c t of alcohol
was m a r g i n a l

H02- 3 c :

r e s p e c t i v e l y , one ca n s e e t h a t t h e

a s a r i s k f a c t o r f o r l ow b i r t h w e i g h t i n t h i s

study

at best.

S e l f - r e p o r t e d in ta k e of c a f f e i n e during pregnancy does
n o t d i f f e r b e t we e n m o t h e r s who d e l i v e r o p t i m a l and low b i r t h
w e i g h t i n f a n t s and c a n n o t be u s e d t o p r e d i c t b i r t h w e i g h t .

Da t a f r om t h e W i l l e t t s e m i - q u a n t i t a t i v e f ood f r e q u e n c y
questionnaire

(SQFFQ) p r o v i d e d an e s t i m a t e d mean d a i l y i n t a k e o f

c a f f e i n e d u r i n g p r e g n a n c y f o r 359 s u b j e c t s . Oneway ANOVA i n d i c a t e d a
s i g n i f i c a n t d i f f e r e n c e i n e s t i m a t e d mean d a i l y i n t a k e o f c a f f e i n e
be t we e n m o t h e r s o f c a s e s and c o n t r o l s

Table 5 .41.

Variable

C a f f e i n e , mg
N

(Table 5.41 ).

S e lf-re p o rte d estimated daily intake of caffeine
b e t we e n m o t h e r s o f c a s e s and c o n t r o l s .

LBW

OBW

168 ± 209

97 ± 152

( 144)

( 176)

t

3.52

P
. 0005

202

When c a f f e i n e i n t a k e was c l a s s i f i e d a c c o r d i n g t o t h e met hod o f
M a r t i n and Br a c k e n ( 1 9 8 7 ) , t h e odds r a t i o i n d i c a t e d a t h r e e - f o l d
i n c r e a s e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t when more t h a n 300 mg
of caffeine,

t h e amount i n t wo c u p s o f c o f f e e , was cons umed p e r day

d u r i n g p r e g n a n c y ( T a b l e 5 . 4 2 ) . T h e r e was no i n c r e a s e d r i s k o f LBW
a s s o c i a t e d w i t h t h e c o n s u m p t i o n o f l e s s t h a n 300 mg c a f f e i n e p e r d a y .

Table 5.42.

E s t i m a t e d r e l a t i v e r i s k (RR) o f l ow b i r t h w e i g h t by
s e lf-re p o rte d caffeine intake during pregnancy.3

Variable

Ca s e s
N

Controls
N

RR (95% Cl )

C a f f e i n e consumption:
< 50 mg/ day

53

90

1.0b

5 0 - 1 4 9 mg/ day

31

37

1.42

(0.76-2.56)

1 50- 299 mg/ day

20

17

2.00

(0.96-4.15)

300+ mg/ day

33

18

3.11

(1.60-6.07)

3 d a t a f r om t h e W i l l e t t SQFFQ
b referent

The i mp a c t o f c a f f e i n e

i n t a k e on b i r t h w e i g h t c a n be s e e n

g r a p h i c a l l y i n F i g u r e 5 . 6 . R e s u l t s i n d i c a t e d women who e s t i m a t e d t h e i r
d a i l y c a f f e i n e i n t a k e t o be b e t we e n 0 - 1 4 9 mg c a f f e i n e
d e l i v e r e d o f i n f a n t s who we i g h e d , on a v e r a g e ,

( n=232) we r e

3173 ± 755 g .

In c o n t r a s t ,

women who e s t i m a t e d t h e i r c a f f e i n e i n t a k e t o be 300 mg/ da y o r more
(n=58) d e l i v e r e d i n f a n t s who w e i g h e d , on a v e r a g e ,

2782 ± 933 g.

d i f f e r e n c e was s t a t i s t i c a l l y

p=0.0033).

significant

( t = 2 .41,

Th i s

203

Birin w e ig t t t
3500

-------------- 3+ ^
2921
2782

3000

2500

2000
1500

1000

500

0 - 1 4 9 mg

1 5 0 - 2 9 9 mg

3 0 0 ♦ mg

Ca ffeine/day

Figure 5.6.

I mpa c t o f c a f f e i n e i n t a k e on b i r t h w e i g h t .

Multiple regression analysis
statistically

significant,

(Table 5.43)

indicated a

n e g a t i v e r e l a t i o n s h i p b e t we e n c a f f e i n e i n t a k e

and i n f a n t b i r t h w e i g h t ( r = - 0 . 1 6 ) . The c o r r e l a t i o n b e t we e n number o f
cigarettes
significant

smoked and c a f f e i n e i n t a k e p e r day was s t a t i s t i c a l l y
(r=0.45).

an a d d i t i o n a l

Each c i g a r e t t e smoked p e r day was a s s o c i a t e d w i t h

10 mg i n c r e a s e i n c a f f e i n e c o n s u m p t i o n .

204

Table 5.43.

Si mp l e r e g r e s s i o n o f c a f f e i n e i n t a k e on b i r t h w e i g h t
and c a f f e i n e i n t a k e on number o f c i g a r e t t e s smoked
p e r da y d u r i n g p r e g n a n c y .

r
adjusted r 2
Beta
S E- Be t a
Constant
F
P
n

Caffeine &
B i r t h Wei ght

Caffeine &
Cigarettes

-0.16
0.03
-0.67
0.21
3147
9.86
. 0018
358

0.45
0.20
9.56
1. 01
84
89.10
. 0000
358

The i n t e r a c t i v e e f f e c t o f number o f c i g a r e t t e s

smoked p e r day and

mean d a i l y c a f f e i n e i n t a k e on b i r t h w e i g h t was d e t e r m i n e d and r e g r e s s e d
against b i r t h weight. A c a ff e in e x c i g a r e t t e
l i n e a r smoki ng t e r m we r e b o t h s t a t i s t i c a l l y

Table 5.44.

significant

(Table 5 .4 4 ) .

M u l t i p l e r e g r e s s i o n a n a l y s i s o f c a f f e i n e and
c i g a r e t t e s on b i r t h w e i g h t .

Variable

B

Caffeine
-0.68
# Cigarettes
-44.94
Smoking x smoki ng
0.52
Caffeine x Cigarettes
0.04
Constant
3257
Multiple R
R2
F
DF
Fp

i n t e r a c t i o n t e r m and a n o n ­

0.30
0.09
8.68
(4,352)
0.000

SE-B

0.34
9.69
0.23
0.02
54.83

Partial

-0.166
-0.509
0.225
0.217

r

t

-2.00
-4.64
2.24
2.00
59.4

Sig t

. 0465
. 0000
. 0254
. 0458
. 0000

205

These r e s u l t s

indicate four variables contributed s ig n i f ic a n tl y to

the v a r i a n c e in b i r t h wei ght,

s u g g e s t i n g b o t h an i n d e p e n d e n t and an

i n t e r a c t i v e e f f e c t o f c a f f e i n e and smoki ng on b i r t h w e i g h t .
regression coefficients
cigarettes

The p a r t i a l

i n d i c a t e d d a i l y c a f f e i n e i n t a k e and number o f

smoked p e r day d u r i n g p r e g n a n c y i n d e p e n d e n t l y r e d u c e d b i r t h

w e i g h t . Whi l e h o l d i n g c i g a r e t t e smoki ng c o n s t a n t ,

e a c h 100 mg o f

c a f f e i n e was a s s o c i a t e d w i t h a 68 g d e c r e a s e i n b i r t h w e i g h t .
The c a f f e i n e - c i g a r e t t e
Figure 5.7.

i n t e r a c t i o n c a n be s e e n g r a p h i c a l l y

For s a k e o f c l a r i t y ,

in

c a f f e i n e c o n s u m p t i o n was c a t e g o r i z e d as

l e s s t h a n 300 mg/ da y o r 300+ mg/ da y and s u b j e c t s we r e c l a s s i f i e d

as

e i t h e r b e i n g s moke r s o r n o n - s m o k e r s . The mean b i r t h w e i g h t o f i n f a n t s
b or n t o s moke r s who consumed l e s s t h a n 300 mg c a f f e i n e p e r day ( n = 8 6 ) ,
a p p e a r e d n o t t o be d e p r e s s e d any f u r t h e r by t h e c o n s u m p t i o n o f 300 mg o r
more c a f f e i n e / d a y

( n=46) t h a n t h e y a l r e a d y we r e d e p r e s s e d f r om s moki ng.

However, t h e c o n s u m p t i o n o f 300 mg o r more c a f f e i n e / d a y among nons moke r s ( n = 12) was a s s o c i a t e d w i t h a 551 g d e c r e a s e i n b i r t h w e i g h t as
c ompa r ed t o i n f a n t s b or n t o women who d i d n o t smoke and a l s o consumed
l e s s t h a n 300 mg c a f f e i n e / d a y

( n = 2 1 3 ) . Al t h o u g h t h i s a p p a r e n t c a f f e i n e -

e f f e c t on t h e b i r t h w e i g h t o f i n f a n t s bor n t o n o n - s m o k e r s i s s t r i k i n g ,
t h e r e a d e r i s c a u t i o n e d t h a t t h e number o f s u b j e c t s w i t h i n t h i s c a t e g o r y
was q u i t e s ma l l

(n=12).

206

Bi r t h We i g h t
4000

3500

3000
2696

2500
Di d n o t s m o k e
t

Smoked

2000
< 3 0 0 mg

3 0 0 + mg

Estimated Daily Caffeine Intake, mg

Figure 5.7.

In te r a c tiv e e ff e c t of caffeine
in fa n t b i r t h weight.

Based on t h e s e o b s e r v a t i o n s ,

i n t a k e and smoki ng on

the f i r s t c o n d it io n of the null

hy p o th es is i s r e f u t e d . There i s a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e
i n t h e e s t i m a t e d d a i l y i n t a k e o f c a f f e i n e b e t we e n m o t h e r s o f c a s e s and
controls.

The c o n s u m p t i o n o f 300 mg o r more c a f f e i n e p e r day was

a s so c ia te d with a t h r e e - f o l d

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t .

R e g r e s s i o n a n a l y s i s i n d i c a t e d b o t h an i n d e p e n d e n t and an i n t e r a c t i v e
e f f e c t o f c a f f e i n e on b i r t h w e i g h t . T h e r e d i d n o t a p p e a r t o be an
additional
s mo k e r s .

c a f f e i n e - e f f e c t on t h e b i r t h w e i g h t o f i n f a n t s bo r n t o

In c o n t r a s t ,

n o n - s m o k e r who consumed more t h a n 300 mg/ day

d e l i v e r e d i n f a n t s who had s i g n i f i c a n t l y r e d u c e d b i r t h w e i g h t s as

207

c ompa r e d t o i n f a n t s o f n o n - s m o k e r s who consumed l e s s t h a n 300 mg
caffeine/day.
B e a u l a c - B a i l l a r g e o n and D e s r o s i e r s

( 1987)

i n d i c a t e d consumption of

300 mg o r more c a f f e i n e p e r da y was a s s o c i a t e d w i t h d e c r e a s e d b i r t h
w e i g h t . They n o t e d 206 g d e c r e a s e i n b i r t h w e i g h t i n i n f a n t s b or n t o
m o t h e r s who b o t h smoked 15 o r more c i g a r e t t e s p e r da y and consumed 300
mg o r more c a f f e i n e ,

a s o p p o s e d t o m o t h e r s who o n l y smoked. The s e

r e s e a r c h e r s als o observed a reduced p la c e n ta l

w e i g h t i n women who b o t h

smoked and consumed 300 mg o r more c a f f e i n e a s c ompar ed t o women who
o n l y smoked. The a u t h o r s c o n c l u d e d t h e c o n c o m i t a n t c o n s u mp t i o n o f
c a f f e i n e and c i g a r e t t e s c o n s t i t u t e d a h i g h r i s k f o r t h e d e v e l o p i n g
fetus.
R e s u l t s o f t h i s s t u d y , do n o t s u p p o r t t h i s c o n c l u s i o n o f B e a u l a c B a i l l a r g e o n and D e s r o s i e r s

( 1 9 8 7 ) . T h e r e was no a d d i t i o n a l

decrement in

t h e b i r t h w e i g h t o f i n f a n t s b or n t o s moke r s t h a t c o u l d be a t t r i b u t e d
caffeine.

Rather,

to

r e s u l t s o f t h i s s t u d y s u g g e s t a c a f f e i n e e f f e c t among

n o n - s m o k e r s who consumed more t h a n 300 mg c a f f e i n e / d a y .
M a r t i n and Br a c k e n ( 1987) o b s e r v e d an i n c r e a s e d r e l a t i v e r i s k o f
low b i r t h w e i g h t among m o t h e r s who consumed 151- 300 mg [ 2 . 3 ( 1 . 1 - 5 . 2 ) ] ,
and 300 mg o r more c a f f e i n e p e r da y [ 4 . 6 ( 2 . 0 - 1 0 . 5 ) ] .

Results presented

h e r e o n l y i n d i c a t e d an i n c r e a s e d r e l a t i v e r i s k o f LBW among women who
consumed 300 mg c a f f e i n e o r more p e r da y [RR=3.1 ( 1 . 6 - 6 . 0 ) ] .

M a r t i n and

Br a c k e n ( 1987) d e t e c t e d a d e c r e a s e i n b i r t h w e i g h t o f 31 g and 105 g
among women who consumed 151- 300 mg and more t h a n 300 mg c a f f e i n e p e r
day,

respectively,

a s c ompa r e d t o women who d i d n o t consume c a f f e i n e .

C i g a r e t t e smoki ng was o n l y a s s o c i a t e d w i t h a 137 g d e c r e a s e i n b i r t h

208

weight.

R e s u l t s o f t h e Mi c h i g a n M o t h e r ' s S t u d y p r e s e n t e d h e r e i n d i c a t e d

a much h i g h e r d e c r e a s e i n i n f a n t b i r t h w e i g h t among women who consumed
150- 299 g and 300 g o r more c a f f e i n e p e r da y (216 g and 355 g,
respectively).

In a d d i t i o n ,

a much h i g h e r r e d u c t i o n i n b i r t h w e i g h t

( 464 g) was o b s e r v e d i n t h e p r e s e n t s t u d y when t h e b i r t h w e i g h t o f
i n f a n t s whose m o t h e r d i d n o t smoke a t a l l we r e c ompa r e d t o i n f a n t s bor n
t o m o t h e r s who r e p o r t e d s moki ng 20 o r more c i g a r e t t e s p e r d a y . The s e
l a r g e d i f f e r e n c e s a r e mos t l i k e l y due t o t h e b i r t h w e i g h t d i s t r i b u t i o n
o f t h e s a m p l i n g f r a me i n t h e Whi t e Mi c h i g a n M o t h e r ' s S u r v e y .
Li nn e t al

( 1982) r e p o r t e d l ow b i r t h w e i g h t o c c u r r e d more

f r e q u e n t l y among 12, 2 0 5 n o n - d i a b e t i c women who d r a n k f o u r o r more cups
o f c o f f e e p e r day ( a p p r o x i m a t e l y 500 mg c a f f e i n e ) .

The LBW r a t e o f women

who consumed no t e a o r c o f f e e d u r i n g p r e g n a n c y was 7 . 4 / 1 0 0 .

The LBW r a t e

r o s e t o 1 0 . 4 / 1 0 0 among women who consumed more t h a n f o u r c ups o f c o f f e e
o r t e a p e r d a y . Upon f u r t h e r a n a l y s i s ,

these researchers stated that,

i n d e p e n d e n t o f s moki ng, t h e r e was no i n c r e a s e LBW i n f a n t s bo r n t o women
who we r e he a vy c o f f e e d r i n k e r s .
R e s u l t s p r e s e n t e d h e r e do n o t s u p p o r t t h i s c o n c l u s i o n .
study,

partial

regression coefficients

In t h i s

i n d i c a t e d b o t h an i n d e p e n d e n t and

an i n t e r a c t i v e e f f e c t o f c a f f e i n e and c i g a r e t t e s on b i r t h w e i g h t .
Differences

in t h e c a f f e i n e d a t a b a s e could p o s s i b l y account f o r t h e l a c k

o f c o n g r u i t y b e t we e n t h e s e two s t u d i e s .

Li nn e t al

c o f f e e and t e a t o q u a n t i f y t h e e x p o s u r e v a r i a b l e .

onl y used i n t a k e of
The c a f f e i n e d a t a b a s e

i n t h e Whi t e Mi c h i g a n M o t h e r ' s S t u d y was much more c o m p r e h e n s i v e .
i n c l u d e d n o t o n l y c a f f e i n a t e d and d e c a f f e i n a t e d c o f f e e ,
and r e g u l a r s o d a pop, b u t a l s o c o c o a ,

brownies,

tea,

It

and d i e t

i c e c r e a m s u n d a e s and

209

c h o c o l a t e candy, r e s u l t i n g

i n a more a c c u r a t e a c c o u n t o f t h e t r u e

exposure v a r i a b l e .
Based on t h e s e r e s u l t s ,

the null

hypotheses are r e f u t e d .

A

s i g n i f i c a n t d i f f e r e n c e was o b s e r v e d i n t h e mean i n t a k e o f c a f f e i n e
b e t we e n m o t h e r s o f c a s e s and m o t h e r s o f c o n t r o l s . An i n t a k e o f 300 mg
c a f f e i n e o r more p e r d a y i n t h i s s t u d y was a s s o c i a t e d w i t h an i n c r e a s e d
r i s k o f d e l i v e r i n g a LBW i n f a n t .
i n d i c a t e d b o t h an i n d e p e n d e n t ,

Lastly, multiple regression analysis

and an i n t e r a c t i v e ,

e f f e c t o f c a f f e i n e on

b i r t h weight.
Th e s e d a t a p r o v i d e a d d i t i o n a l

support for the in c l u s io n of

estimated daily caffeine intake to the l i s t of r is k fac to rs associated
with a reduced b i r t h we ight.

Prenatal

c a r e p r o v i d e r s s h o u l d be

encouraged to determine t h e c a f f e i n e i n ta k e of t h e i r p a t i e n t s
d i s c u s s w i t h t hem i t s p o t e n t i a l

H02- 3 d :

d e l e t e r i o u s e f f e c t s on b i r t h w e i g h t .

Q u a l i t y o f t h e d i e t d u r i n g p r e g n a n c y d o e s n o t d i f f e r be t we e n
m o t h e r s who d e l i v e r o p t i m a l and l ow b i r t h w e i g h t i n f a n t s and
c a n n o t be u s e d t o p r e d i c t b i r t h w e i g h t .

Overall,

t h e 398 r e s p o n d e r s t o t h e Whi t e Mi c h i g a n M o t h e r ' s S u r v e y

r a t e d the q u a l i t y of t h e i r d i e t during pregnancy (l=poor,
higher than the q u a l i t y of t h e i r d i e t before pregnancy.
percent
diet,

and

1 0 = e x c e l 1e n t )

Seventy-nine

(n=315) o f t h e s u b j e c t s i n d i c a t e d t h e y consumed a h i g h e r q u a l i t y

18% (n=71) consumed t h e same q u a l i t y and o n l y 3% ( n=12) r e p o r t e d

c ons umi ng a p o o r e r q u a l i t y d i e t d u r i n g p r e g n a n c y .

The Ma nn- Whi t e ne y t e s t

i n d i c a t e d no d i f f e r e n c e i n e i t h e r o f t h e two d i e t q u a l i t y r a t i n g s when
r e s p o n s e s o f m o t h e r s who d e l i v e r e d LBW and OBW i n f a n t s we r e c ompa r ed

210

(mean r a n k b e f o r e = 1 7 4 vs 180, p = 0 . 5 3 8 2 ; mean r a n k a f t e r = 1 7 3 vs 181;
p = 0 . 4 2 1 4 ) . Bot h g r o u p s r e p o r t e d s i g n i f i c a n t i n c r e a s e s

in t he q u a l i t y of

t h e i r d i e t du rin g pregnancy (Table 5 .4 5 ) .

Table 5.45.

S e l f - r e p o r t e d r a t i n g of d i e t q u a l i t y (l=poor,
1 0 = e x c e l l e n t ) p r i o r t o and d u r i n g p r e g n a n c y by m o t h e r s
o f c a s e s and c o n t r o l s .

LBW
( n=169)

OBW
( n=184)

Before Pregnancy

5.2 ± 1.8

Du r i n g P r e g n a n c y

7 .5 ± 1.8

Diet Quality
Rating

Mean r a n k s w i t h i n g r o u p s

Z

Si g Z

5.3 ± 1.8

-0.62

. 5382

7. 7 ± 1.6

-0.80

. 4214

58.3

Z, w i t h i n g r o u p s
Si g Z

71. 1
-10.6
. 000

-9.4
. 000

D i e t a r y d a t a f o r 144 c a s e s and 176 c o n t r o l s we r e a n a l y z e d .
Overall,
all

m o t h e r s o f OBW i n f a n t s consumed a s l i g h t l y h i g h e r q u a n t i t y o f

n u t r i e n t s t h a n m o t h e r s o f LBW i n f a n t s .

d i f f e r e n c e b e t we e n g r o u p s ,

The m a g n i t u d e o f t h e

h o we v e r , was q u i t e s ma l l

(Table 5 .4 6 ) .

The

e s t i m a t e d e n e r g y i n t a k e b e t w e e n c a s e s and c o n t r o l s d i f f e r e d by o n l y 83
calories.

The d i f f e r e n c e

although s t a t i s t i c a l l y

in p r o t e i n

significant

Analysis of the individual

i n t a k e b e t we e n c a s e s and c o n t r o l s ,
(t=5.67;

was o n l y 9 g / d a y .

m icronutrient content of the d i e t

c o n t r o l s consumed s i g n i f i c a n t l y more i r o n ,
f o l a c i n than did c o n t r o l s

p=0.0178),

( Appe ndi x 2 9 - 6 a ) .

zinc,

thiamin,

indicated

p y r i d o x i n e and

211

Table 5.46.

D a i l y m a c r o n u t r i e n t i n t a k e b e t we e n c a s e s and c o n t r o l s
a s e s t i m a t e d by t h e W i l l e t t SQFFQ.

Nutrient

LBW

Calories
Protein, g
Carbohydrate, g
Saturated f a t ,

g

t

OBW

Si g t

2258 ± 718

2341 ± 648

1.08

. 2810

96 + 32

105 ± 32

2.38

. 0178

284 ± 104

294 ± 95

0.98

. 3738

35 ± 15

35 ± 12

0.00

. 9970

Mo n o u n s a t .

fat,

g

30 + 11

31 ± 11

0.77

. 4418

Polyunsat.

fat,

g

13 ± 6

14 ± 5

1. 2 2

. 2247

357 + 154

361 ± 128

0.24

. 8093

Cholesterol,

mg

In g e n e r a l , when n u t r i e n t i n t a k e s we r e c ompa r ed t o t h e 1989
Recommended D i e t a r y A l l o wa n c e s f o r p r e g n a n t a d u l t women (NRC-RDA,

1989) ,

m o t h e r s o f b o t h c a s e s and c o n t r o l s a p p e a r e d t o consume a d e q u a t e d i e t s .
The m o t h e r s o f OBW i n f a n t s c o n s i s t e n t l y r e p o r t e d c ons umi ng a h i g h e r
p e r c e n t o f t h e RDA f o r e v e r y n u t r i e n t ,

d e s p i t e c ons umi ng o n l y a

e s t i m a t e d 87 c a l o r i e s p e r da y more t h a n m o t h e r s o f c a s e s
Statistically

s i g n i f i c a n t d i f f e r e n c e s we r e n o t e d i n t h e p e r c e n t o f t h e

RDA consumed f o r t h i a m i n ,
protein.

(Table 5 .4 7) .

pyridoxine,

f o li c acid,

iron,

z i n c and

I r o n was t h e o n l y n u t r i e n t f o r whi ch b o t h g r o u p s consumed l e s s

t h a n t w o - t h i r d s o f t h e RDA.

212

Table 5.47.

Nutrient

E s t i m a t e d p e r c e n t o f t h e 1989 Recommended D i e t a r y
A l l o w a n c e (RDA) consumed p e r da y d u r i n g p r e g n a n c y
b e t we e n m o t h e r s o f c a s e s and c o n t r o l s , w i t h o u t
supplements.

LBW
( n=144)

OBW
( n=176)

t

Si g t

% 1989 RDA
Calories

90 ± 29

94 + 26

1.08

.281

Protein

150 + 53

174 + 53

2.38

. 018

V i t a mi n A

67 + 61

72 ± 66

0.67

. 500

V i t a mi n D

88 + 49

98 + 48

1.94

.053

V i t a mi n E

81 + 54

92 + 57

1.69

. 090

A s c o r b i c Aci d

255 + 175

275 + 166

0.95

. 340

Thi a mi n

104 + 39

116 + 38

2.74

. 006

Riboflavin

154

± 63

166 + 60

1. 77

. 080

Pyridoxine

99

± 38

111 + 43

2.52

. 012

Folacin

76

± 35

84 + 35

2.04

. 042

b,2

442

± 350

464 + 348

0.57

. 566

Ca l c i u m

107

± 50

116 + 46

1.58

. 115

Iron

47

± 21

53 ± 22

2.28

.023

Zi n c

96

± 35

105 ± 37

2.35

. 020

A c o m p a r i s o n o f t h e mean MAR-12 s c o r e s f o r m o t h e r s o f c a s e s and
c o n t r o l s i n d i c a t e d m o t h e r s who d e l i v e r e d OBW i n f a n t s consumed d i e t s o f

213

s ig n i f ic a n tl y higher n u tritio n a l
infants

q u a l i t y t h a n m o t h e r s who d e l i v e r e d LBW

( T a b l e 5 . 4 8 ) . T h i s f i n d i n g means t h a t ,

a f t e r r e mo v i n g t h e

w e i g h t i n g e f f e c t c o n t r i b u t e d by s u b j e c t s who consumed more t h a n 100% o f
t h e RDA f o r any o r a l l

nutrients,

t h e m o t h e r s o f OBW i n f a n t s consumed a

h i g h e r p e r c e n t o f t h e RDA t h a n d i d m o t h e r s o f LBW i n f a n t s .

Table 5.48.

Mean d i e t q u a l i t y s c o r e s (MAR-12) b e t w e e n m o t h e r s o f
c a s e s and c o n t r o l s , w i t h o u t s u p p l e m e n t s .

Variable

LBW

OBW

MAR-12

73 ± 13

77 ± 11

t

P

2.75

. 0063

The same o b s e r v a t i o n was n o t e d when s u b j e c t s we r e c a t e g o r i z e d as
b e i n g s moker s o r n o n - s m o k e r s . The MAR-12 o f n o n - s m o k e r s was
s i g n i f i c a n t l y h i g h e r t h a n t h e MAR-12 o f n o n - s m o k e r s ( 7 6 . 9 ± 11 vs 7 3 . 6 ±
13; t = 2 . 6 4 ; p = 0 . 0 0 8 6 ) , d e s p i t e cons umi ng t h e same number o f c a l o r i e s
( 2303 ± 674 vs 2327 ± 711; t = 0 . 3 2 ; p = 0 . 7 4 7 4 ) .
be t we e n m o t h e r s o f c a s e s and c o n t r o l s ,
s mo k e r s , was n o t d i f f e r e n t ,

Because t h e c a l o r i c

intake

and b e t we e n s moke r s and non-

t h e h i g h e r MAR-12 s c o r e s

i n d i c a t e s mothers

o f OBW i n f a n t s and non - s mo k i n g m o t h e r s s e l e c t e d more n u t r i e n t - d e n s e
d i e t s f o r t h e number o f c a l o r i e s consumed.
A c o m p a r i s o n o f t h e I ndex o f N u t r i t i o n a l
o f a n u t r i e n t consumed p e r 1000 c a l o r i e s ,

Quality

( I NQ) ,

t h e amount

i n d i c a t e d m o t h e r s o f OBW

i n f a n t s consumed t e n n u t r i e n t s w i t h an INQ s c o r e o f 1 . 0 o r mor e . Mo t h e r s
o f LBW i n f a n t s ,

i n c o m p a r i s o n , consumed e i g h t n u t r i e n t s w i t h an INQ o f

214

1 . 0 o r more ( Appe ndi x 2 9 - 6 b ) . The INQ-12 s c o r e d i d n o t d i f f e r b e t we e n
c a s e s and c o n t r o l s

(LBW=1.62 ± 0 . 6 vs OBW=1.70 ± 0 . 6 ;

no d i f f e r e n c e was n o t e d when t h e INQ-4 s c o r e ,
Guthrie's

( 1984) f o u r i n d i c a t o r n u t r i e n t s

t=0.96).

Likewise,

b a s e d on J e n k i n s and

(A, B- 6,

i r o n and c a l c i u m ) ,

we r e c ompar ed ( 0 . 9 0 ± 0 . 2 8 vs 0 . 9 4 ± 0 . 3 0 ; t = 0 . 4 5 ) .
R e g r e s s i o n a n a l y s i s i n d i c a t e d t h e o n l y n u t r i t i o n i n d i c a t o r s whi ch
c o r r e l a t e d s i g n i f i c a n t l y with b i r t h weight in t h i s

s t u d y we r e p r o t e i n

i n t a k e and t h e MAR-12 s c o r e ( T a b l e 5 . 4 9 ) . A l t h o u g h b o t h we r e
statistically

significant,

n e i t h e r o f t h e s e two v a r i a b l e s e x p l a i n e d more

t h a n one t o two p e r c e n t o f t h e v a r i a n c e i n i n f a n t b i r t h w e i g h t .

Table 5.49.

S i mp l e r e g r e s s i o n o f c a l o r i e s , p r o t e i n and d i e t
q u a l i t y s c o r e s wi th b i r t h we ight (n=359).

Statistic

Calories

Protein

MAR-12

INQ-12

INQ-4

R
R2
Be t a
SE- Be t a
Constant
F
P

0.04
0.001
0.04
0.06
2964
0.48
0.49

0.11
0.01
2.7
1.3
2791
2.07
0.04

0.13
0.02
8.6
3.4
2406
6.41
0.01

0.06
0.004
142
74
2914
1.40
0.24

0.09
0.007
229
142
2847
2.62
0. 11

A p r o t e i n i n t a k e e q u i v a l e n t t o 20% o r more o f o n e ' s c a l o r i c

intake

h a s been a s s o c i a t e d w i t h d e c r e a s e d b i r t h w e i g h t (Rush e t a l , 1980;
P i c o n e and A l l e n ,

1984).

Results of t h i s

s t u d y i n d i c a t e d t h e r e was no

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t i f t h e d i e t c o n t a i n e d more

215

t h a n 20% o f i t s c a l o r i e s f r om p r o t e i n

(Table 5 .5 0 ) .

Likewise, t he

c o n s u m p t i o n o f l e s s t h a n 10% o f o n e ' s c a l o r i e s f r om p r o t e i n was n o t
a s s o c i a t e d w i t h an i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t .

Table 5.50.

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon p e r c e n t o f c a l o r i e s f r om d i e t a r y
protein.

Variable

Ca s e s
N

Controls
N

RR (95% Cl )

% C a l o r i e s f r om P r o t e i n :
10% o r l e s s
11-19%
20% o r more
aa .r. e fre r..e n. . tJ.

3

2

1.71

121

138

1.0a

20

36

0.63

(0.3-10.4)

(0.35-1.15)

...........................................

The l i m i t e d a s s o c i a t i o n s f ou n d b e t we e n d i e t a r y
w e i g h t we r e n o t e n t i r e l y u n e x p e c t e d .

Be c a u s e o f t h e c o m p l e x i t y o f t h e

p h y s io lo g ic r e l a t i o n s h i p s during pregnancy,
and u s e o f d i e t a r y d a t a ,

i n t a k e and b i r t h

t h e problems with c o l l e c t i o n

and t h e c o n f o u n d i n g o f t h e d i e t / p r e g n a n c y

r e l a t i o n s h i p by b e h a v i o r a l

and s o c i o d e m o g r a p h i c f a c t o r s ,

r e m a r k a b l y few

s t u d i e s ha ve f ound a s s o c i a t i o n s b e t we e n d i e t a r y i n t a k e and p r e g n a n c y
o u t c o me , p a r t i c u l a r l y when t h e p o p u l a t i o n was n o t s p e c i f i c a l l y s e l e c t e d
a priori

as b e i n g " h i g h r i s k " .

In a d d i t i o n ,

t h e s e r e s u l t s mus t be

t e m p e r e d by t h e r e a l i z a t i o n t h a t t h e W i l l e t t SQFFQ h a s n o t p r e v i o u s l y
been u s e d w i t h a p r e g n a n t p o p u l a t i o n . T h e r e f o r e ,

t h e v a l i d i t y and

r e l i a b i l i t y o f t h e s e d a t a must be c o n s i d e r e d c o n d i t i o n a l .

216

Animal

and human s t u d i e s h a v e b o t h i n d i c a t e d a d e c r e a s e i n b i r t h

weight with severe c a l o r i c r e s t r i c t i o n
1964; S m i t h ,

1947)

1965; A n t o n o v ,

( Wal lace,

and s e v e r e p r o t e i n r e s t r i c t i o n

1 9 4 7 ) . On a v e r a g e ,

1945; Chow and Lee,
( Wi n i c k and No b l e ,

s u b j e c t s i n t h i s s t u d y consumed 92% o f

t h e RDA f o r c a l o r i e s d u r i n g p r e g n a n c y .

If the recently published data,

i n d i c a t i n g o n l y 100 a d d i t i o n a l c a l o r i e s a r e n e e d e d p e r da y t o meet t h e
energy c o s t of pregnancy,

are validated

(Durnin,

1 9 8 7 a , b) , mothers o f

OBW and LBW i n f a n t s i n t h i s s t u d y woul d ha ve consumed a p p r o x i m a t e l y 100%
o f t h e r ecommended 2300 c a l o r i e s .

Thus ,

it

is not s u r p r i s i n g t h a t

caloric

i n t a k e i n t h i s s t u d y was n o t a s s o c i a t e d w i t h a d e c r e a s e d b i r t h

weight.

Even i f a s u b j e c t consumed f e w e r c a l o r i e s t h a n recommended, d a t a

f r om t h e 5 - c o u n t r y s t u d y ( D u r n i n ,

1987a,b)

i n d i c a t e d t h e human body has

a tremendous c a p a c i t y t o a d a p t p h y s i o l o g i c a l l y t o a reduced energy
i n t a k e by r e d u c i n g t h e r e s t i n g m e t a b o l i c r a t e .
p r e g n a n t woman t o s u s t a i n a d e q u a t e f e t a l

T h i s e n a b l e s an u n d e r f e d

g r o wt h and d e v e l o p m e n t , even in

the face of l i m i t e d energy s t o r e s .
The o n l y a d d i t i o n a l m a c r o n u t r i e n t a s s o c i a t e d w i t h b i r t h w e i g h t f o r
whi c h e ve n a mo d e s t body o f l i t e r a t u r e e x i s t s
L e c ht ig e t a l , 1975).

is protein

( Rus h,

1981;

S u b j e c t s i n t h i s s t u d y cons ume d, on a v e r a g e ,

t o 174% o f t h e RDA f o r p r o t e i n .

160

Be c a u s e b o t h p r o t e i n and c a l o r i e s wer e

cons umed i n more t h a n a d e q u a t e amount s by r e s p o n d e r s t o t h e Mi c hi ga n
M o t h e r ' s Study,

any r e d u c t i o n

in b i r t h we i gh t a s s o c i a t e d wi t h a reduced

p r o t e i n a n d / o r c a l o r i e i n t a k e woul d n o t be e x p e c t e d i n t h i s p o p u l a t i o n .
Meta-analysis of several
c o n t a i n i n g more t h a n 20% o f i t s
wi t h r e t a r d e d f e t a l growth

human s t u d i e s had s u g g e s t e d a d i e t
c a l o r i e s f r om p r o t e i n was a s s o c i a t e d

( Rus h, S t e i n and S u s s e r ,

1980).

Results of

217

t h e p r e s e n t s t u d y do n o t s u p p o r t t h i s c o n c l u s i o n .
i n d i c a t e d no s i g n i f i c a n t i n c r e a s e , o r d e c r e a s e ,

The o dds r a t i o

i n b i r t h w e i g h t when 20%

o r more o f a s u b j e c t ' s c a l o r i e s we r e f rom p r o t e i n .
D i e t a r y z i n c and f o l i c a c i d i n t a k e s we r e s i g n i f i c a n t l y h i g h e r i n
m o t h e r s o f OBW i n f a n t s .

Z i n c and f o l i c a c i d b o t h p l a y a c r i t i c a l

r a p i d l y g r o wi n g t i s s u e s ,

with a d e f i c i e n c y o f both a s s o c i a t e d with a

r e d u c e d s y n t h e s i s o f DNA, RNA and c e l l u l a r p r o t e i n s
ha s be e n w e l l e s t a b l i s h e d ,

( S o l o mo n s ,

( Apga r ,

1985;

1988).

It

howe ve r , t h a t d i e t a r y i n t a k e d o e s n o t s e r v e

a s a v a l i d i n d i c a t o r o f t h e amount o f a n u t r i e n t t h a t
functioning

r o l e in

is physiologically

L a z e b n i k e t a l , 1 9 8 8 ) . Wi t h o u t any b i o c h e m i c a l

i n d i c e s o f t h e z i n c o r f o l a c i n s t a t u s o f t h e mother o r f e t u s ,

no

r e l a t i o n s h i p be t we e n t h e s e n u t r i e n t i n t a k e l e v e l s and b i r t h w e i g h t can
be , o r s h o u l d b e ,
Brown ( 1989)

suggested.
i n d i c a t e d one o f t h e mos t p r e s s i n g ,

in the f i e l d o f n u t r i t i o n

unresolved issues

i s q u a n t i f i c a t i o n o f t h e i mp a c t o f t o t a l

diet

q u a l i t y on i n f a n t b i r t h w e i g h t . To t h a t e n d , t h e c o r r e l a t i o n b e t we e n t h e
MAR-12 s c o r e and b i r t h w e i g h t o b s e r v e d i n t h i s

study is encouraging.

Onl y two s t u d i e s whi ch e xa mi ned t h e e f f e c t o f a t o t a l
and b i r t h w e i g h t ,

as o p p o s e d t o t h e r e l a t i o n s h i p b e t we e n i n d i v i d u a l

n u t r i e n t i n t a k e s and b i r t h w e i g h t , we r e i d e n t i f i e d
Bur ke e t al

d i e t q u a l i t y score

in th e l i t e r a t u r e .

( 1943a) r e p o r t e d an " e x c e l l e n t " d i e t ,

one whi ch

c o n t a i n e d 100% o r more o f t h e 1941 RDA f o r e i g h t n u t r i e n t s ,
a s s o c i a t e d w i t h a b i r t h w e i g h t o f 3 , 8 5 6 g.
diet",

In c o n t r a s t ,

was

a " ver y poor

one whi c h c o n t a i n e d l e s s t h a n 50% o f t h e RDA f o r t h e same e i g h t

nutrients,

was a s s o c i a t e d w i t h a b i r t h w e i g h t o f 2 , 6 3 7 g.

P h i l l i p s and

J o h n s o n ( 1977) r e p o r t e d a MAR-12 s c o r e was p o s i t i v e l y c o r r e l a t e d w i t h

218

b i r t h weight (r=0.30;

p < 0 . 0 5 ) . When i n c l u d e d i n a s e r i e s o f m u l t i p l e

regression equations,

t h e MAR-12 s c o r e r e ma i n e d s i g n i f i c a n t l y a s s o c i a t e d

with b i r t h weight,

a c c o u n t i n g f o r a p p r o x i m a t e l y 6-7% o f t h e v a r i a n c e .

A l t h o u g h n o t c o r r e l a t e d a s h i g h l y a s t h a t o b s e r v e d by P h i l l i p s and
J o h n s o n ( 1 9 7 7 ) , t h e MAR-12 s c o r e was p o s i t i v e l y a s s o c i a t e d w i t h b i r t h
weight

(r=0.13).

The amount o f v a r i a n c e i n b i r t h w e i g h t e x p l a i n e d by t h e

d i e t q u a lity score,

h o we v e r , was mi ni mal

(CV=1%). The MAR-12 s c o r e was

s i g n i f i c a n t l y h i g h e r i n m o t h e r s o f OBW i n f a n t s t h a n m o t h e r s o f LBW
infants,

and m o t h e r s who d i d n o t smoke. T h i s was t r u e d e s p i t e no

differences

i n c a l o r i c i n t a k e be t we e n t h e s e g r o u p s .

T h e s e r e s u l t s p r o v i d e mode s t s u p p o r t f o r t h e p r e m i s e t h a t d i e t
q u a l i t y i s a s s o c i a t e d w i t h i n c r e a s e d b i r t h w e i g h t . T h e r e we r e no
statistically

s i g n i f i c a n t a s s o c i a t i o n s b e t we e n c a l o r i e

intake,

t h e INQ-

12 o r t h e INQ-4 d i e t q u a l i t y s c o r e and b i r t h w e i g h t . No d i f f e r e n c e s wer e
n o t e d b e t we e n m o t h e r s o f OBW and LBW i n t h e mean i n t a k e o f c a l o r i e s o r
t h e INQ-12 and INQ-4 s c o r e s .

However, p r o t e i n i n t a k e and t h e MAR-12

s c o r e d i f f e r e d b e t we e n m o t h e r s o f c a s e s and c o n t r o l s ,
s moke r s and n o n - s m o k e r s ,
weight.

and be t we e n

and we r e s t a t i s t i c a l l y c o r r e l a t e d w i t h b i r t h

For t h e s e r e a s o n s ,

the null

hypothesis is cautiously refuted.

P r o t e i n i n t a k e and a MAR-12 s c o r e a p p e a r t o be m o d e s t l y a s s o c i a t e d w i t h
b i r t h w e i g h t . Whe t he r t h e s e v a r i a b l e s a c t e d as a p r o x y f o r s o c i o e c o n o m i c
status,

or whether t h e s e r e s u l t s are s puri ous , will

investigation.
woul d do we l l

require additional

Nonetheless, these r e s u l t s suggest prenatal

care advisors

t o recommend n u t r i t i o n c o u n s e l i n g f o r s moke r s t o h e l p

i n c r e a s e t h e n u t r i e n t d e n s i t y o f t h e i r f ood c h o i c e s d u r i n g p r e g n a n c y .

219

H02- 3 e :

Ma t e r n a l a t t i t u d e t o w a r d w e i g h t g a i n , n u t r i t i o n , and b e i n g
p r e g n a n t do n o t d i f f e r b e t we e n m o t h e r s who d e l i v e r o p t i m a l
and l ow b i r t h w e i g h t i n f a n t s and c a n n o t be u s e d t o p r e d i c t
b i r t h weight.

Factor analysis

i n d i c a t e d 11 a t t i t u d e q u e s t i o n s f r om t h e P r e g n a n c y

L i f e s t y l e Questio nnaire loaded to t h r e e d i s t i n c t a t t i t u d e c o n s t r u c t s :
a t t i t u d e toward we i ght g a i n d u r i n g p r eg n a n c y ,

1)

2) a t t i t u d e t o w a r d t h e

i m p o r t a n c e o f good n u t r i t i o n d u r i n g p r e g n a n c y and 3) a t t i t u d e t o w a r d
b e i n g p r e g n a n t a t t h a t t i m e ( Appe ndi x 2 9 - 7 ) . The Spe ar man- Br own s p l i t h a l f r e l i a b i l i t y o f t h e e n t i r e q u e s t i o n n a i r e was r = 0 . 7 3 .
alpha r e l i a b i l i t y c o e f f i c i e n t for the t h re e indiv idual
c o n s t r u c t s we r e 0 . 7 3 ,

attitude

0 . 6 7 and 0 . 2 8 f o r t h e w e i g h t f a c t o r ,

f a c t o r and p r e g n a n c y f a c t o r s c o r e s ,
results,

Cronbach's

respectively.

nutrition

Based on t h e s e

t h e " a t t i t u d e t o w a r d b e i n g p r e g n a n t " f a c t o r was d r o p p e d from

f u r t h e r a n a l y s i s due t o i t s

a p p a r e n t poor r e l i a b i l i t y .

s c o r e and t h e n u t r i t i o n f a c t o r s c o r e ,

The w e i g h t f a c t o r

h o we v e r , we r e q u i t e a c c e p t a b l e .

Each o f t h e s e two a t t i t u d e c o n s t r u c t s w i l l

be d i s c u s s e d s e p a r a t e l y .

A t t i t u d e Toward N u t r i t i o n
Oneway ANOVA i n d i c a t e d t h e n u t r i t i o n a t t i t u d e s c o r e ( l = n e g a t i v e ,
5 = p o s i t i v e ) was n o t s i g n i f i c a n t l y d i f f e r e n t b e t we e n m o t h e r s who
d e l i v e r e d LBW and OBW i n f a n t s
correlation

( 4 . 4 5 ± 0 . 5 vs 4 . 5 1 ± 0 . 5 ;

t= -1.38).

Pearson's

i n d i c a t e d a n o n s i g n i f i c a n t r e l a t i o n s h i p b e t we e n s u b j e c t ' s

n u t r i t i o n a t t i t u d e s c o r e and i n f a n t b i r t h w e i g h t
these re s u lts ,

the null

hypothesis

is retained.

(r=0.04;

N S ) . Bas ed on

A subject's nutrition

a t t i t u d e s c o r e i s n o t d i f f e r e n t b e t we e n m o t h e r s o f c a s e s and c o n t r o l s ,
and t h e n u t r i t i o n f a c t o r s c o r e i s n o t p r e d i c t i v e o f b i r t h w e i g h t .

220

Further analysis indicated the n u tritio n fac to r score,

although

n o t a s s o c i a t e d w i t h b i r t h w e i g h t , was p o s i t i v e l y c o r r e l a t e d w i t h a
subject's

s e l f - r e p o r t e d d i e t q u a l i t y during pregnancy.

Regression

a n a l y s i s i n d i c a t e d a p o s i t i v e r e l a t i o n s h i p b e t we e n n u t r i t i o n a t t i t u d e
s c o r e and MAR-12 d i e t q u a l i t y s c o r e ( r = 0 . 2 3 ; F = 1 9 . 8 ) ,
( r = 0 . 1 4 ; F= 6 . 6 3 ) and INQ-12 s c o r e ( r = 0 . 1 4 ;
a t t i t u d e score,

F = 6 . 6 4 ) . The n u t r i t i o n

howe ve r , was n o t a s s o c i a t e d w i t h e i t h e r c a l o r i c

( r = 0 . 0 7 ; F=1.82) o r pr egnancy weight g a i n ( r = 0 . 0 3 ;
results

protein intake

suggest t h a t ,

pregnancy weight g a i n ,

intake

F = 0 . 2 8 ) . The s e

although not p r e d i c t i v e of b i r t h weight or
t h e n u t r i t i o n a t t i t u d e s c o r e was p r e d i c t i v e o f

s e lf -r e p o rte d n u t r i ti o n behavior.

S u b j e c t s i n t h i s s t u d y who r e p o r t e d a

p o s i t i v e a t t i t u d e toward n u t r i t i o n d u r i n g pregnancy a l s o r e p o r t e d e a t i n g
a more n u t r i e n t d e n s e d i e t .

A t t i t u d e Toward Wei ght Gai n
R e s u l t s i n d i c a t e d a s i g n i f i c a n t d i f f e r e n c e i n t h e mean " a t t i t u d e
t o w a r d w e i g h t g a i n " s c o r e b e t we e n m o t h e r s o f c a s e s and c o n t r o l s
5.51).

(Table

Women who d e l i v e r e d LBW i n f a n t s r e p o r t e d a more p o s i t i v e a t t i t u d e

t o w a r d w e i g h t g a i n d u r i n g p r e g n a n c y t h a n women who d e l i v e r e d OBW
i n f a n t s , d e s p i t e having gained l e s s weight.

Table 5.51.

We i ght g a i n a t t i t u d e s c o r e s and a c t u a l w e i g h t g a i n e d
b e t we e n m o t h e r s o f c a s e s and c o n t r o l s ( l = n e g a t i v e ,
5=positive).

Variable

We i ght a t t i t u d e s c o r e
We i ght g a i n , l b s

LBW
( 169)
3.75 + 0.68
26 ± 11

OBW
(184)
3.45 + 0.73
33 ± 11

t

1.98
5.70

P

. 0000
. 0000

221

When s u b j e c t s we r e c a t e g o r i z e d a c c o r d i n g t o t h e i r p r e - p r e g n a n t
1983 r e f e r e n c e w e i g h t , t wo o b s e r v a t i o n s we r e s t r i k i n g .

When s c o r e s wer e

c ompa r ed by w e i g h t c a t e g o r i e s , women who e n t e r e d p r e g n a n c y u n d e r w e i g h t
had s i g n i f i c a n t l y more p o s i t i v e a t t i d u e s a b o u t w e i g h t g a i n t h a n d i d
women who e n t e r e d p r e g n a n c y a t o r n e a r t h e i r d e s i r a b l e w e i g h t
5.52).

(Table

No d i f f e r e n c e i n a t t i t u d e was d e t e c t e d b e t we e n u n d e r w e i g h t and

o v e r w e i g h t women.

In f a c t ,

b o t h u n d e r w e i g h t and o v e r w e i g h t women

e x p r e s s e d a more p o s i t i v e a t t i t u d e t o w a r d w e i g h t g a i n t h a n d i d normal
w e i g h t women.

Table 5.52.

We i ght g a i n a t t i t u d e s c o r e o f women who e n t e r e d
p r e g n a n c y u n d e r w e i g h t , nor mal w e i g h t and o v e r w e i g h t .

We i ght C a t e g o r y

N

Mean

SD

< 90%

139

3.82a

0.70

90-119%

211

3 . 46a

0.74

3.66

0.61

120% o r more

46

S i g n i f i c a n t l y d i f f e r e n t f r om e a c h o t h e r ,

t=4.74,

P

11.38

. 0000

p=0.0000

The s e c o n d o b s e r v a t i o n was e ve n more s t r i k i n g .
pregnant weight c a te g o ry ,

F

Wi t hi n each p r e ­

u n d e r w e i g h t and nor mal w e i g h t women who

d e l i v e r e d LBW i n f a n t s r e p o r t e d a more p o s i t i v e a t t i t u d e t o w a r d w e i g h t
g a i n t h a n women who d e l i v e r e d OBW i n f a n t s

(Table 5 .5 3) .

222

Table 5. 53.

Wei ght f a c t o r a t t i t u d e s c o r e o f m o t h e r s o f c a s e s and
c o n t r o l s c a t e g o r i z e d by 1983 p r e - p r e g n a n t w e i g h t
(l=negative, 5=positive).

We i ght
Category

LBW

n

OBW

n

F

p

< 90%

4.04 ± 0.67

85

3.75 ± 0.83

41

4.28

. 0406

90-119%

3.70 ± 0.74

71

3.42 ± 0.78

114

5.83

. 0167

1 2 0 %+

3.63 ± 0.78

12

3.76 ± 0 . 6 1

28

0.33

. 5696

Mean w e i g h t g a i n s d e p e n d e n t upon a s u b j e c t ' s w e i g h t g a i n a t t i t u d e
s c o r e we r e c o mp a r e d . R e s u l t s i n d i c a t e d s u b j e c t s who e x p r e s s e d a more
p o s i t i v e a t t i t u d e ga in ed fewer pounds,

b o t h w i t h i n and b e t w e e n g r o u p s

(Table 5 .5 4 ).

Table 5 .5 4.

Wei ght A t t i t u d e
Score

Wei ght g a i n o f women who d e l i v e r e d LBW and OBW i n f a n t s
c a t e g o r i z e d by t h e i r w e i g h t g a i n a t t i t u d e s c o r e .

LBW

n

Wei ght Ga i n ,
1 (negative)

-

OBW

n

lbs

-

42

(3)

2

31

(21)

38

(35)

3

27

( 59)

32

( 80)

4

24

( 74)

31

( 58)

5 (positive)

26

( 14)

30

( 7)

F, w i t h i n
F prob

2.0
0.115

3.63
0.0071

223

The f a c t t h a t m o t h e r s o f OBW i n f a n t s g a i n e d ,

on a v e r a g e ,

pounds more w e i g h t t h a n was recommended by t h e i r p h y s i c i a n ,
m o t h e r s o f LBW i n f a n t s g a i n e d ,

seven

and t h a t

on a v e r a g e , e x a c t l y wha t t h e i r p h y s i c i a n

had r ecommended, d o e s s u g g e s t a p o s s i b l e l i n k b e t we e n t h e two f a c t o r s .
If true,

the implication of t h i s finding is th a t prenatal

care providers

s h o u l d be e n c o u r a g e d t o f o s t e r i n t h e i r p a t i e n t s a h e a l t h i e r ,
a t t i t u d e toward a r e a s o n a b l e we ight g a in d u r i n g pr egnancy.
al

( 1980)

guilt-free

Pomer ance e t

i n d i c a t e d 88% o f p r e g n a n t women i n d i c a t e d t h e y t h o u g h t t h e i r

p h y s i c i a n woul d be more c o n c e r n e d i f t h e y g a i n e d " t o o much",
to "too l i t t l e " ,

weight.

In t h i s

s t u d y , women who g a i n e d more w e i g h t had

a more n e g a t i v e a t t i t u d e a b o u t t h e w e i g h t g a i n ,
g a i n a p p e a r e d t o be an i n f a n t o f o p t i m a l
Regression a n a ly s i s

a s c ompar ed

but the r e s u l t of t h e i r

b i r t h weight.

i n d i c a t e d the weight gain a t t i t u d e

s c o r e was

s i g n i f i c a n t l y and n e g a t i v e l y r e l a t e d t o b o t h b i r t h w e i g h t

(r= - 0. 2266;

p < 0 . 0 0 1 ) and a c t u a l w e i g h t g a i n e d ( r = - 0 . 2 0 7 ;

Each one u n i t

F=17.66).

i n c r e a s e i n t h e w e i g h t g a i n a t t i t u d e s c o r e was a s s o c i a t e d w i t h a t h r e e
pound d e c r e m e n t i n a c t u a l

weight gain,

on a v e r a g e .

Few r e s e a r c h e r s h a ve e xa mi n e d t h e r e l a t i o n s h i p b e t we e n womens'
a t t i t u d e s d u r i n g p r e g n a n c y and s u b s e q u e n t p r e g n a n c y o u t c o me .
al

( 1985) o b s e r v e d a s i g n i f i c a n t ,

g a i n a t t i t u d e s c o r e and a c t u a l
study,

P a l me r e t

p o s i t i v e r e l a t i o n s h i p b e t we e n a w e i g h t

w e i g h t (p < 0 . 0 2 5 ) .

Da t a a n a l y s i s

in t h i s

h o we v e r , was done w i t h Chi s q u a r e a f t e r c a t e g o r i z i n g t h e s u b j e c t s

as h a v i n g a " p o s i t i v e " a t t i t u d e o r a " n e g a t i v e " a t t i t u d e b a s e d on
whether t he s u b j e c t s sc o re f e l l
s a mp l e .

In a d d i t i o n ,

a bove o r be l ow t h e me di a n s c o r e o f t h e

P a l m e r e t al o n l y e xa mi ne d t h e a t t i t u d e s o f 29

white, m id d le-class s u b je c t s .

224

R e s u l t s p r e s e n t e d h e r e a p p e a r t o be u n i q u e i n t h e a t t i t u d e
literature.

Ba s e d on t h e s e o b s e r v a t i o n s ,

S u b j e c t ' s weight gain a t t i t u d e
and c o n t r o l s ,

the null

hypothesis is refuted.

s c o r e s d i f f e r e d b e t we e n m o t h e r s o f c a s e s

i n an u n e x p e c t e d d i r e c t i o n .

Re s u lts i n d i c a t e d mothers of

LBW i n f a n t s had a more p o s i t i v e a t t i t u d e t o w a r d w e i g h t g a i n t h a n m o t h e r s
o f OBW i n f a n t s who g a i n e d more w e i g h t .

In a d d i t i o n ,

regression analysis

i n d i c a t e d t h e w e i g h t g a i n a t t i t u d e s c o r e was p r e d i c t i v e o f b i r t h w e i g h t ,
as w e l l
study,

as we ight g a i n ,

b u t a g a i n i n an u n e x p e c t e d d i r e c t i o n .

In t h i s

a more p o s i t i v e a t t i t u d e t o wa r d w e i g h t g a i n was a s s o c i a t e d w i t h a

l o w e r b i r t h w e i g h t and a l o we r a c t u a l w e i g h t g a i n .

The s t u d y d e s i g n o n l y

a l l o w s s p e c u l a t i o n as t o t h e c a u s e o f t h i s l e s s p o s i t i v e a t t i t u d e .
F u t u r e r e s e a r c h mus t be d o n e t o v a l i d a t e t h e s e r e s u l t s
p o s s i b l e causal
behavior,

paths.

However,

and t o d e t e r m i n e

i f one's a tt it u d e s or b e lie fs

as i n d i c a t e d i n t h e Whi t e Mi c h i g a n M o t h e r ' s S t u d y ,

i d e n t i f i c a t i o n o f in d iv i d u a l s with in ap p ro p ria te behavioral
or a tt it u d e s

is c r i t i c a l

intervention

strategies.

H02- 4 a :

influence
then

intentions

t o d e s i g n and t a r g e t a p p r o p r i a t e p r e n a t a l

The q u a l i t y o f p r e n a t a l c a r e , a s me a s u r e d by t h e K e s s n e r
I n d e x , d o e s n o t d i f f e r be t we e n m o t h e r s who d e l i v e r o p t i m a l
and low b i r t h w e i g h t i n f a n t s and c a n n o t be u s e d t o p r e d i c t
b i r t h weight.

Results of th is

s t u d y i n d i c a t e d 86% o f t h e m o t h e r s o f LBW i n f a n t s ,

and 90% o f t h e m o t h e r s o f OBW i n f a n t s who r e s p o n d e d t o t h e s u r v e y ,
p r e n a t a l c a r e in the f i r s t t r i m e s t e r .
U. S. a v e r a g e

(76%) a n d ,

began

T h i s p e r c e n t a g e e x c e e d s t h e 1986

i n t h e OBW m o t h e r s , t h e h e a l t h o b j e c t i v e f o r t h e

y e a r 2000, whi c h i s t o i n c r e a s e t o a t l e a s t 90% t h e p r o p o r t i o n o f a l l

225

p r e g n a n t women who r e c e i v e p r e n a t a l

c a r e in t he f i r s t t r i m e s t e r of

p r e g n a n c y (DHHS, 1 9 8 9 ) .
The K e s s n e r I n d e x i n d i c a t e d 78% o f t h e c a s e s and 85% o f c o n t r o l s
who r e s p o n d e d t o t h i s
t h e i r pregnancies.

survey obtained adequate prenatal

care during

The p e r c e n t o f women r e c e i v i n g a d e q u a t e c a r e i n t h i s

s u r v e y was h i g h e r t h a n t h e s t a t e o f Mi c h i g a n as a whol e when,
adequate prena tal
white i n fa n ts

i n 1987,

c a r e was o b t a i n e d by 75. 7% o f t h e m o t h e r s o f l i v e bor n

(MDPH, 1 9 8 9 ) . W i t h i n t h i s s a mp l e , Chi S q u a r e a n a l y s i s

i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e i n t h e K e s s n e r I nde x b e t we e n m o t h e r s
o f c a s e s and c o n t r o l s

Table 5.55.

(Table 5 .5 5) .

Kessner Index c l a s s i f i c a t i o n o f p r e n a t a l
m o t h e r s o f c a s e s and c o n t r o l s .

c a r e o b t a i n e d by

K e s s n e r I nde x
Classification

LBW
(n=169)

OBW
( n = 184)

A d e q u a t e Ca r e

132

156

Intermediate

33

22

4

6

Inadequate

X2

P

3.97

. 1374

When t h e K e s s n e r I n d e x was d i s s e c t e d i n t o i t s c omponent p a r t s
( weeks g e s t a t i o n ,
began),

number o f p r e n a t a l

t h e number o f p r e n a t a l

visits

and t h e e s t i m a t e d weeks o f g e s t a t i o n

v i s i t s and month p r e n a t a l
( 1 1 . 7 ± 3 . 4 vs 1 2 . 3 + 2 . 8 ;

weight,

p= 0 . 0 4 6 9 )

( 3 8 . 6 + 1 . 4 vs 4 0 . O i l . 3 ; p = 0 . 0 0 0 )

we r e s i g n i f i c a n t l y l o w e r among c a s e s t h a n c o n t r o l s .
individual

care

When t h e s e t h r e e

c o mp o n e n t s and t h e K e s s n e r I n d e x we r e r e g r e s s e d a g a i n s t b i r t h

19% o f t h e v a r i a n c e i n i n f a n t b i r t h w e i g h t was e x p l a i n e d

(Table

226

5 . 5 6 ) . Of t h e s e v a r i a b l e s ,
statistically

only

" e s t i m a t e d weeks g e s t a t i o n " was

s i g n i f i c a n t , w i t h e a c h a d d i t i o n a l week o f g e s t a t i o n

a s s o c i a t e d w i t h a 216 g i n c r e a s e i n b i r t h w e i g h t . No o t h e r p r e n a t a l

care

v a r i a b l e c o n t r i b u t e d s i g n i f i c a n t l y t o t h e v a r i a n c e in b i r t h w e i g h t in
t h i s s a mp l e .

Table 5.56

R e g r e s s i o n a n a l y s i s o f t h e K e s s n e r I n d e x , number o f p r e n a t a l
v i s i t s , month p r e n a t a l c a r e be ga n and e s t i m a t e d weeks
g e s ta t io n with b i r t h weight.

Variables

B

SE-B

Regression
Coefficient

T

Si g T

K e s s n e r I ndex

165.8

128

. 082

1.29

. 1964

Weeks g e s t a t i o n

215.6

24

. 419

8.92

. 0000

1. 3

14

. 005

0.093

.9258

-6.6

41

-.009

-0.161

. 8719

- 5598

926

-6.047

. 0000

# Prenatal

visits

Month c a r e began
Constant
R
R2
F
DF
p

0.43
0.187
22.4
(4,389)
. 0000

Early,

high q u a l i t y p r e n a t a l

c a r e h a s be e n c o r r e l a t e d w i t h

h e a l t h i e r p r e g n a n c i e s and t h e p r e v e n t i o n o f p o o r p r e g n a n c y out come
(DHHS, 1 9 8 9 b ) . R e s u l t s o f t h e p r e s e n t s t u d y ,
any s i g n i f i c a n t d i f f e r e n c e s
Kessner Index,

h o we v e r ,

in t h e q u a l i t y o f c a r e ,

do n o t i n d i c a t e

a s d e f i n e d by t h e

be t we en m o t h e r s o f c a s e s and c o n t r o l s .

For t h a t r e a s o n ,

Ill
the null

h y p o t h e s i s must be r e t a i n e d :

the Kessner Index,

i s n o t d i f f e r e n t b e t we e n m o t h e r s o f c a s e s and c o n t r o l s ,

in t h i s

study,

and c a n n o t be

used t o p r e d i c t i n f a n t b i r t h w ei g h t .
However , a l l

infants

t h e y we r e " t e r m i n f a n t s " .

i n t h e p r e s e n t s t u d y we r e s e l e c t e d b e c a u s e
Results obtained herein suggest the selection

c r i t e r i a o f "term i n f a n t s " ,

and t h e b i a s t h a t r e s u l t e d f r om r e s p o n d e r s

o f c a s e s h a v i n g had s i g n i f i c a n t l y h i g h e r K e s s n e r I n d e x s c o r e s t h a n n o n ­
responders,

a p p e a r e d t o f o r c e t h e s a mp l e p o p u l a t i o n i n t o h a v i n g a

K e s s n e r I n d e x whi ch was n o t s i g n i f i c a n t l y d i f f e r e n t b e t we e n g r o u p s .
Th u s ,

in t h i s

s t u d y , t h e K e s s n e r I nde x d o e s n o t f u n c t i o n a s a

d i s c r i m i n a t i n g independent v a r i a b l e to p r e d i c t b i r t h weight.

Conceptual

Fr amewor k: A Model f o r P r e d i c t i n g B i r t h Wei ght

The c o n c e p t u a l model u s e d t o d r i v e t h i s

s t u d y t h e o r e t i c a l l y and

o p e r a t i o n a l l y was p r e s e n t e d a t t h e end o f C h a p t e r I I . A n a l y s i s o f d a t a
i n d i c a t e d t h e f o l l o w i n g model
b irth weight.

( F i g u r e 5 . 8 ) was p r e d i c t i v e o f i n f a n t

The m u l t i p l e r e g r e s s i o n e q u a t i o n s f r om whi c h t h e p a r t i a l

r e g r e s s i o n c o e f f i c i e n t s u s e d i n t h e model we r e d e r i v e d ca n be f ou n d i n
Ap p e n d i x 2 9 - 8 .

Conceptual Framework:
-0.33

EDUCATION

A Model to Pre dict Bir th Wei ght
Cigarettes

MATERNAL
BIRTH WEIGHT

0.24
0.13

ATTITUDE:

0 . 20

NUTRITION

< -0 . 1 2

OIET

-

0.11

%

i

QUALITY

REFERENCE

•AT T E R M

„ nr

0.25

------

BIRTH j 0„ .1 0
WEIGHT *- - - -

A
0.16

AGE

o:o6

0.37

0.33

V
ATTITUDE:
WE IGHT GAIN

F i g u r e 5.8.

-0.15

WEIGHT
GAIN

0.16

WEEKS
GESTATION

Mo d e l i n d i c a t i n g th e c o r r e l a t i o n b e t w e e n s e l e c t e d m a t e r n a l c h a r a c t e r i s t i c s ,
a t t i t u d e s a n d b e h a v i o r s as t h e y i n f l u e n c e b i r t h w e i g h t ( v a l u e s = p a r t i a l r e g r e s s i o n
c o e f f i c i e n t s ( R = 0 . 5 9 4 ; R2 = 3 5 %).

INFANT
SEX

229

T h i s c a u s a l model a c c o u n t e d f o r a p p r o x i m a t e l y 35% o f t h e v a r i a t i o n
in i n f a n t b i r t h weight ( r = 0 . 5 9 ;

F = 3 6 . 9 2 ) . Wh e t h e r o r n o t t h i s p e r c e n t o f

e x p l a i n e d v a r i a t i o n i s i n c o n c o r d a n c e w i t h t h e l i t e r a t u r e c a n n o t be
determined,

b e c a u s e no s i m i l a r s t u d y d e s i g n was i d e n t i f i e d .

The s t r o n g

a s s o c i a t i o n o f m a t e r n a l b i r t h w e i g h t on i n f a n t b i r t h w e i g h t

(r=0.24)

is

p r e s e n t e d h e re in a m u l t i p l e r e g r e s s i o n e q u a t i o n f o r o nl y t h e second
t i m e ( Ande r s on e t a l , 1 9 8 4 ) . The s t r o n g i n f l u e n c e o f p e r c e n t s t a n d a r d
w e i g h t a t t a i n e d a t t e r m on b i r t h w e i g h t ( r = 0 . 2 5 ) ,
i n f l u e n c e d by p r e g n a n c y w e i g h t g a i n

(r=0.37),

whi c h i n t u r n was

i n d i c a t e d th e importance

o f d e t e r m i n i n g a t a r g e t w e i g h t g a i n b a s e d on an i n d i v i d u a l ' s p r e p r e g n a n t
r e f e r e n c e w e i g h t . Ma t e r n a l

age was i n d e p e n d e n t l y a s s o c i a t e d w i t h p e r c e n t

r e f e r e n c e weight a t t a i n e d at term ( r = 0 . 1 6 ) .
with a decreased weight gain

(r=-0.11),

n u t r i t i o n during pregnancy ( r= - 0 .1 2 )
0 . 3 3 ) had a d i r e c t ,
quality,

Maternal

s moki ng,

associated

a l e s s p o s i t i v e a t t i t u d e t o wa r d

and f e w e r y e a r s o f e d u c a t i o n

n e g a t i v e e f f e c t on b i r t h w e i g h t

a s s o c i a t e d with a h i g h e r le v e l

(r=-

(r=-0.15).

Hi gh d i e t

( r = 0 . 13)

and a more

of education

p o s i t i v e a t t i t u d e t o wa r d t h e i m p o r t a n c e o f n u t r i t i o n d u r i n g p r e g n a n c y
(r=0.20),

i mp a c t e d w e i g h t g a i n m i n i m a l l y ( r = 0 . 0 6 ) .

A less positive

a t t i t u d e t o w a r d w e i g h t g a i n d u r i n g p r e g n a n c y was a s s o c i a t e d
s t u d y w i t h women who g a i n e d t h e mos t w e i g h t ( r = - 0 . 1 5 )
optimal

b i r t h weight i n f a n t s .

only term i n f a n t s

Despite designing t h is

(37 t o 40 weeks g e s t a t i o n ) ,

in t h i s

and d e l i v e r e d
study to include

each a d d i t i o n a l

week o f

g e s t a t i o n w i t h i n t h i s f o u r - w e e k s pa n was a s s o c i a t e d w i t h b o t h an
in cr e as e d maternal weight gain
(r=0.33).

( r = 0 . 1 6 ) and i n f a n t b i r t h w e i g h t

In g e n e r a l , ma l e s we i g h e d more t h a n f e m a l e s ( r = 0 . 1 0 ) .

o b s e r v a t i o n i s c o n s i s t e n t w i t h f i g u r e s r e p o r t e d by t h e S t a t e o f

This

230

M i c h i g a n ' s O f f i c e o f t h e R e g i s t r a r where,
i n f a n t s we r e f e m a l e .
infants

In c o m p a r i s o n ,

i n 1988,

55% o f a l l

54% o f a l l

optimal

LBW w h i t e

b i r t h weight

( 3 , 5 0 0 - 4 , 0 0 0 g) we r e m a l e .

M u l t i p l e R e g r e s s i o n A n a l y s i s t o P r e d i c t B i r t h We i ght
Two m u l t i p l e r e g r e s s i o n e q u a t i o n s t o p r e d i c t b i r t h w e i g h t
(one="stepwise",

t w o = " e n t e r " ) , b a s e d on a s a mp l e c o n s i s t i n g p r i m a r i l y o f

LBW and 0BW i n f a n t s ,
(Table 5 . 5 7 ) .

a c c o u n t e d f o r 38% o f t h e v a r i a n c e i n b i r t h w e i g h t

Due t o t h e c a s e - c o n t r o l d e s i g n o f t h i s s t u d y ,

e q u a ti o n s are unique to th e l i t e r a t u r e
In g e n e r a l ,

h o we ve r ,

of the v a ria tio n
gestation,

these

and c a n n o t be d i r e c t l y c ompa r e d.

f o r i n f a n t s bor n a t a l l

gestational

ages,

a b o u t 40%

i n b i r t h w e i g h t ha s been a c c o u n t e d f o r by weeks o f

p r e n a t a l weight ga in,

p r e p r e g n a n c y w e i g h t s t a t u s and smoki ng

d u r i n g p r e g n a n c y ( Ande r s on e t a l , 1984; Bur ke e t a l , 1943; Bur ke e t a l ,
1949; M e t c o f f e t a l , 1 9 8 1 b ) , w i t h weeks g e s t a t i o n a c c o u n t i n g f o r t h e
l a r g e s t p r o p o r t i o n o f v a r i a n c e i n e a c h s t u d y . Th u s , t h e m u l t i p l e R and
t h e p e r c e n t o f v a r i a n c e e x p l a i n e d by t h e two e q u a t i o n s p r e s e n t e d h e r e
a p p e a r t o be i n t h e r e a l m o f v a l u e s r e p o r t e d i n t h e l i t e r a t u r e .

231

Tabl e 5.57

Two m u l t i p l e r e g r e s s i o n e q u a t i o n s t o p r e d i c t b i r t h w e i g h t .

Variable

Equation #1: Method=Stepwise
B
b
t
Sigt

Equation #2: Method=Enter
B
b
t
Sigt

Weeks gestation

173

0.34

7.21

.0000

170

0.33

7.46

.0000

Maternal birth weight

0.31

0.24

5.25

.0000

0.31

0.238

5.45

.0000

% 1983 reference
weight at term

7.69

0.20

4.29

.0000

8.50

0.226

5.043

.0000

Number cigarettes/day

-12.3

-0.14

-3.02

.0028

-11.5

-0.13

-2.917

.0038

Weight gain
attitude score

-123

-0.12

-2.61

.0095

-106

-0.10

-2.35

.0193

Mother's age

21.9

0.11

2.32

.0211

Mate infant

143

0.09

1.99

.0476

Received Public
Asst (AFDC.Food Stamps)

NS

Kessner Index
Mother's education
Weight gain
Nutrition attitude score
Diet Quality MAR-12 score
Calories/day
Protein/day, g
Caffeine/day, mg
Alcohol/day, g

NS
NS
NS
NS
NS
NS
NS
NS
NS

Constant
R
r 2 ,%

SE-B

-5858

-5.73

0.617

.0000

NS
136

0.09

1.99

.0473

-172

-0.09

-2.14

.0038
NS
NS
NS
NS
NS
NS
NS
NS
NS

-5279

.0000

0.615

38

38

624 g

625 g

DF

(7,307)

F

26.89

29.30

P

.0000

.0000

In b o t h e q u a t i o n s ,

-5.65

(7,338)

e s t i m a t e d weeks g e s t a t i o n a c c o u n t e d f o r t h e

l a r g e s t p r o p o r t i o n o f v a r i a n c e e x p l a i n e d i n t h i s s t u d y ( 33- 34%) ,
e x p l a i n i n g 11% o f t h e t o t a l

v a r i a n c e in b i r t h w e i g h t . Maternal

birth

232

weight accounted f o r t he next l a r g e s t p r o p o r t io n of e x p l a i n e d v a r i a n c e
i n b i r t h w e i g h t (24% o f e x p l a i n e d , 6% o f t h e t o t a l
weight).

Each kg o f m a t e r n a l

b i r t h w e i g h t was a s s o c i a t e d w i t h an

i n c r e a s e d 310 g i n c r e a s e i n i n f a n t b i r t h w e i g h t .
i n t h e l i t e r a t u r e whi ch i n c l u d e d m a t e r n a l
e q u a t i o n ( B= 0 . 1 1 8 , r 2= 0 . 0 1 4 )

v a r i a n c e in b i r t h

The o n l y s t u d y l o c a t e d

b i r t h weight in a r e g r e s s i o n

i n d i c a t e d e a c h kg o f m a t e r n a l

b i r t h weight

was a s s o c i a t e d w i t h a 107 gm i n c r e a s e i n i n f a n t b i r t h w e i g h t
et al,

( An d e r s o n

1984).
The p e r c e n t o f r e f e r e n c e w e i g h t a t t e r m a c c o u n t e d f o r b e t we e n 20-

22% o f t h e e x p l a i n e d v a r i a n c e (5% o f t h e t o t a l
weight).

v a r i a n c e in b i r t h

The h i g h c o r r e l a t i o n be t we e n p r e p r e g n a n t w e i g h t s t a t u s and t e r m

r e f e r e n c e weight (r=0.86)

r e q u i r e d t h e e l i m i n a t i o n o f one o f t h e s e two

v a r i a b l e s t o avoid m u l t i c o i l i n e a r i t y

(Snedecor,

1 9 8 1 ) . Addi ng w e i g h t

g a i n d i d n o t i mpr ove t h e amount o f e x p l a i n e d v a r i a n c e .

Th e s e r e s u l t s

s u g g e s t t e r m r e f e r e n c e w e i g h t i s an a d e q u a t e s u b s t i t u t e f o r p r e p r e g n a n t
w e i g h t and w e i g h t g a i n ,

two v a r i a b l e s shown i n p r e v i o u s s t u d i e s t o

e x p l a i n a p p r o x i m a t e l y 6-8% o f t h e v a r i a n c e i n b i r t h w e i g h t
al,

(Metcoff et

19 8 1 b ) .
C i g a r e t t e s c o n s u m p t i o n i n t h i s s t u d y was a s s o c i a t e d w i t h an 1 1 . 5 -

1 2 . 3 g d e c r e a s e i n b i r t h w e i g h t f o r e v e r y c i g a r e t t e smoked p e r d a y ,
e x p l a i n i n g 2% o f t h e v a r i a n c e i n t o t a l

b i r t h weight.

A woman who smoked

a p a c k o f c i g a r e t t e s c o u l d e x p e c t t o d e l i v e r an i n f a n t w e i g h t 2 3 0 - 2 5 0 g
l e s s t h a n i f s h e d i d n o t smoke. The s e r e s u l t s a r e c o n s i s t e n t w i t h t h e
d e c r e a s e o f - 1 2 . 5 g / c i g a r e t t e r e p o r t e d by An d e r s o n e t al

( 1 9 8 4 ) and t h e

- 1 1 . 0 r e p o r t e d by P h i l i p p s and J o h n s o n ( 1 9 7 7 ) . M e t c o f f e t al

( 1981b)

233

r e p o r t e d c i g a r e t t e s moki ng t y p i c a l l y c o n t r i b u t e s t h r e e t o s i x p e r c e n t o f
t he v a r i a n c e in b i r t h we ight.
The i n c l u s i o n o f a " w e i g h t g a i n a t t i t u d e s c o r e "

is r e p o r t e d here

f o r t h e f i r s t t i m e . Women who e x p r e s s e d a more n e u t r a l
a t t i t u d e toward g a i n i n g w e i g ht d u r i n g pregnancy d i d ,

or negative

on a v e r a g e ,

a c t u a l l y g a i n more w e i g h t and d e l i v e r b a b i e s who we i g h e d more t h a n women
who e x p r e s s e d a v e r y p o s i t i v e a t t i t u d e t o w a r d w e i g h t g a i n .
Ma t e r n a l

age and e d u c a t i o n h a ve be e n r e p o r t e d t o a c c o u n t f o r a s

much as e i g h t p e r c e n t o f t h e v a r i a n c e i n b i r t h w e i g h t
1 9 8 1 b ) . Ande r s on e t al

( 1984) r e p o r t e d a 7 . 1 g i n c r e a s e i n b i r t h w e i g h t

f o r each y e a r o f mat ern a l
maternal

(Metcoff et a l ,

age (R2= 0 . 0 0 3 ) .

In t h i s

study,

increasing

age was a s s o c i a t e d w i t h an 11 g i n c r e a s e i n b i r t h w e i g h t f o r

each y e a r in t h e s t e p w i s e e q u a t i o n .

When a l l

v a r i a b l e s we r e e n t e r e d

into

t h e r e g r e s s i o n e q u a t i o n , w h e t h e r o r n o t p u b l i c a s s i s t a n c e was r e c e i v e d
(AFDC, Food St a mp s , WIC) was more s t r o n g l y c o r r e l a t e d w i t h b i r t h w e i g h t
t h a n was a g e . The c o r r e l a t i o n b e t we e n t h e s e two v a r i a b l e s ,

h o we v e r , was

h i g h ( r = - 0 . 2 9 5 ) , w i t h y o u n g e r m o t h e r s r e c e i v i n g more p u b l i c a s s i s t a n c e
t h a n o l d e r m o t h e r s , w i t h i n t h e 2 0 - 3 4 y e a r age r a n g e o f t h e s u b j e c t s

in

t h i s study.
Lastly,

p r e v i o u s r e s e a r c h h a s i n d i c a t e d f e m a l e i n f a n t s we i gh 171 g

( Ande r s on e t a l , 1984) and 118 g ( Do u g h e r t y and J o n e s ,
males.

In t h e p r e s e n t s t u d y ,

1982) l e s s

than

b e i n g f e m a l e was a s s o c i a t e d w i t h a

r e d u c t i o n o f 136- 143 g a s c ompa r e d t o m a l e s .
In summary, t h e s e p r e d i c t i o n e q u a t i o n s ,

in cl u d in g t h e unique

v a r i a b l e s o f " p e r c e n t r e f e r e n c e w e i g h t a t t e r m" a s a s u b s t i t u t e f o r
p r e p r e g n a n c y w e i g h t s t a t u s and w e i g h t g a i n ,

"maternal

b i r t h weight"

and

234

" a t t i t u d e toward wei ght g a i n s c o r e " ,

are not o u t s i d e the realm of

p r e v i o u s l y p u b l i s h e d e q u a t i o n s and make a u n i q u e c o n t r i b u t i o n t o t h e
field.

Summary: Whi t e Mi c h i g a n M o t h e r ' s S t u d y

I n f a n t b i r t h weight is the primary p r e d i c t o r of i n f a n t v i a b i l i t y ,
accounting for the vast majority of v a ria tio n
morbidity

( S ha pi r o e t a l , 1980).

i d e n t i f i e d as t h e c r i t i c a l
rate

i n i n f a n t m o r t a l i t y and

I mp r o v i n g i n f a n t b i r t h w e i g h t h a s been

iss ue i f d e c l i n e s in t he i n f a n t m o r t a l i t y

i n t h e U n i t e d S t a t e s a r e t o o c c u r ( McCormick,

Such i mp r o v e me n t s w i l l ,

in p a r t ,

1985; S h a p i r o ,

1985).

d e pe nd upon i d e n t i f i c a t i o n and

i mp r o v e me n t o f m o d i f i a b l e f a c t o r s t h a t i n f l u e n c e b i r t h w e i g h t .
R e s u l t s o f t h e Whi t e Mi c h i g a n M o t h e r ' s S u r v e y ,

a s t u d y o f 398

Mi c h i g a n r e s i d e n t s b e t we e n t h e a g e s o f 20- 3 4 who wer e d e l i v e r e d o f
e i t h e r t h e i r f i r s t o r s e c o n d c h i l d b e t we e n J u n e 1,
1988,

1988 and November 30,

i d e n t i f i e d several modifiable r i s k f a c t o r s for the d e liv e ry of a

l ow b i r t h w e i g h t i n f a n t .
l ow i ncome l e v e l ,

In a d d i t i o n t o t h e known LBW r i s k f a c t o r s o f

fewer y e a r s o f mat ernal

g e s t a t i o n and i n f a n t s e x ,

results

education,

number o f weeks

indicated the following r is k factors

d i f f e r e d b e t we e n m o t h e r s who d e l i v e r e d LBW and OBW i n f a n t s and c o u l d be
used t o p r e d i c t b i r t h w e i g h t :
1)

A w e i g h t g a i n t o l e s s t h a n 120% o f o n e ' s

1983 M e t r o p o l i t a n

r e f e r e n c e w e i g h t a t t e r m . A g a i n t o l e s s t h a n 120% was a s s o c i a t e d
w i t h a 463% h i g h e r r i s k o f LBW.

Maternal

b i r t h weight. A maternal

b i r t h weight of l e s s than

2 , 5 0 0 g was a s s o c i a t e d w i t h a 9 - f o l d i n c r e a s e d r i s k o f d e l i v e r i n g
a LBW, r a t h e r t h a n an OBW, i n f a n t .
Prep reg na nt w e i g h t - f o r - h e i g h t . A w e i g h t - f o r - h e i g h t l e s s than
90% o f r e f e r e n c e was a s s o c i a t e d w i t h a 333% i n c r e a s e d r i s k o f
d e l i v e r i n g a LBW, r a t h e r t h a n an OBW, i n f a n t .
Pregnancy weight g a i n .

A w e i g h t g a i n l e s s t h a n 22 l b s was

a s s o c i a t e d with a f i v e - f o l d

i n c r e a s e d r i s k o f LBW as c ompar ed t o

a woman who g a i n e d more t h a n 27 l b s .
D i a s t o l i c blood p r e s s u r e .

A d i a s t o l i c blood p r e s s u r e r e a d i n g of

100 mg Hg o r more a t some p o i n t i n p r e g n a n c y a s s o c i a t e d w i t h an
1 8 - f o l d i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t .
C i g a r e t t e consumption.

Each c i g a r e t t e consumed p e r day was

a s s o c i a t e d w i t h a p p r o x i m a t e l y an 11- 12 g d e c r e m e n t i n b i r t h
weight.
Al c o h o l

intake.

The c o n s u m p t i o n o f g r e a t e r t h a n 100 g/ we e k was

a s s o c i a t e d w i t h a 1 . 3 - f o l d r i s k o f LBW i n t h i s s t u d y .
Caffeine intake.

The c o n s u m p t i o n o f more t h a n 300 mg/ day was

a s s o c i a te d with a t h r e e - f o l d

increased r is k of delivering a

LBW i n f a n t .
Diet q u a l i t y .

A more n u t r i e n t - d e n s e d i e t ,

as i n d i c a t e d by a

MAR-12 s c o r e , was a s s o c i a t e d w i t h a d e c r e a s e d r i s k o f d e l i v e r i n g
a LBW i n f a n t .
A t t i t u d e t o w a r d w e i g h t g a i n . The d e l i v e r y o f OBW i n f a n t s was
a s s o c i a t e d w i t h women who r e p o r t e d a l e s s p o s i t i v e a t t i t u d e
t o w a r d t h e i r w e i g h t g a i n t h a n m o t h e r s o f LBW i n f a n t s .

236

Several

f a c t o r s h y p o t h e s i z e d t o be a s s o c i a t e d w i t h LBW we r e n o t

f o u n d t o be a s s o c i a t e d w i t h an i n c r e a s e d r i s k o f LBW i n t h i s
These f a c t o r s

i n c l u d e d a mi ni mal w e i g h t g a i n o f 7 kg i f o n e ' s

p r e p r e g n a n c y w e i g h t was 120% o r more o f r e f e r e n c e ,
maternal

h e mo g l o b i n l e v e l s ,

Hg, c a l o r i c i n t a k e ,

the lo c a l,

e i t h e r l ow o r h i g h

a d i a s t o l i c b l o o d p r e s s u r e l e s s t h a n 60 mm

a t t i t u d e t o wa r d n u t r i t i o n d u r i n g p r e g n a n c y and t h e

Ke s s n e r Index o f p r e n a t a l
Several

study.

care.

r e s u l t s of t h i s

s t u d y can be u s e d i n p r o g r a m p l a n n i n g a t

s t a t e and n a t i o n a l

level to t a r g e t s p e c i f ic sub-populations

a t r i s k f o r low b i r t h w e i g h t .

Prenatal

c a r e p r o v i d e r s mus t be made awar e

o f t h e i n c r e a s i n g body o f l i t e r a t u r e whi c h s u p p o r t s t h e a s s o c i a t i o n
be t we e n a h i g h e r w e i g h t g a i n d u r i n g p r e g n a n c y and a more " o p t i m a l " b i r t h
w e i g h t o f a t l e a s t 3 , 3 0 0 g o r mor e. E v i d e n c e i n d i c a t e s a woman' s t a r g e t
w e i g h t g a i n d u r i n g p r e g n a n c y s h o u l d be b a s e d on h e r p r e p r e g n a n c y
r e f e r e n c e w e i g h t - f o r - h e i g h t s t a t u s , with t he t a r g e t e q u i v a l e n t to a
minimum o f 120% o f o n e ' s
t h i s study c le a rly

1983 M e t r o p o l i t a n r e f e r e n c e w e i g h t .

Results of

i n d i c a t e d a w e i g h t g a i n o f 22- 27 pounds was n o t

a d e q u a t e p r o t e c t i o n a g a i n s t t h e d e l i v e r y o f a LBW i n f a n t ,
i f t h e woman e n t e r e d p r e g n a n c y u n d e r w e i g h t .

Physician's

particularly

s h o u l d be u r g e d

t o r e c o r d b o t h t h e s u b j e c t ' s h e i g h t and w e i g h t d u r i n g t h e f i r s t
visit

in o r d e r t o c a l c u l a t e t h e p erc en t of r e f e r e n c e weight.

prenatal

The b l a n k e t

r e c o m me n d a t i o n o f 2 2 - 2 7 p o u n d s , w h i l e an i mpr ove me nt o v e r e a r l i e r
pregnancy wei ght recommendations,
r i s k f a c t o r s of c i g a r e t t e

s h o u l d be i n d i v i d u a l i z e d .

s moki ng, c a f f e i n e i n t a k e ,

alcohol

Associated
consumption

and a l ow n u t r i e n t - d e n s e d i e t s h o u l d be e m p h a s i z e d . Thr ough i mpr ove d

237

p a tie n t education,

and c o n c o m i t a n t p a t i e n t c o m p l i a n c e ,

t h e mean i n f a n t b i r t h w e i g h t ,

an i n c r e a s e i n

and r e d u c t i o n i n i n f a n t m o r t a l i t y and

m o r b i d i t y a s s o c i a t e d w i t h LBW, s h o u l d o c c u r .

P h y s i c i a n ' s P r e n a t a l Ca r e S u r v e y o f B l a c k Mi c h i g a n Mot he r s

Re s p o n s e Ra t e
T h r e e h u n d r e d and one s u r v e y s ( 36. 5%) s e n t t o t h e p h y s i c i a n o f
r e c o r d o f t h e 825 r a n d o ml y s e l e c t e d b l a c k Mi c h i g a n m o t h e r s we r e r e t u r n e d
(Table 5 .5 8 ) .

Of t h e s e ,

136 (45%) r e f e r r e d t o m o t h e r s o f LBW i n f a n t s and

124 (41%) r e f e r r e d t o m o t h e r s o f OBW i n f a n t s .

F ifty-nine percent

( n = l 77)

o f t h e r e t u r n e d s u r v e y s we r e r e c e i v e d a f t e r t h e f i r s t m a i l i n g and 41%
( n=124) a f t e r t h e s e c o n d m a i l i n g .

Table 5 .58.

Re s pons e r a t e t o t h e P h y s i c i a n ' s P r e n a t a l
b l a c k Mi c h i g a n m o t h e r s .

Ca r e S u r v e y o f

First
Mailing

Second
Mailing

n

n

(%)

n

(%)

n

Low B i r t h
Wei ght (LBW)

400

83

( 61)

53

( 39)

136

(34)

Mo d e r a t e B i r t h
Wei ght (MBW)

100

27

( 66)

14

(34)

41

(41)

Opt i ma l B i r t h
Wei ght (OBW)

325

67

( 55)

57

( 45)

124

(38)

TOTAL:

825

177

(59)

124

( 41)

301

(37)

Group

Number
Sent

Re s pons e
Ra t e
(%)

(%)

238

One h u n d r e d and e i g h t y - o n e (22%) b l a c k s u b j e c t s we r e l o s t t o
follow-up.

Primary r e a s o n s f o r t h i s l o s s i n c l u d e d :

d e l i v e r e d t h e i n f a n t s as r e s i d e n t s o r i n t e r n s ,
out of s t a t e or to a d i f f e r e n t h o s p ita l
record,

1) many p h y s i c i a n s

b u t s u b s e q u e n t l y moved

and d i d n o t ha ve a c c e s s t o t h e

2) many p h y s i c i a n s d e l i v e r e d t h e s u b j e c t ' s baby b u t we r e n o t

involved in t h e i r prenatal
information,

c a r e and t h u s c o u l d n o t p r o v i d e t h e r e q u e s t e d

3) i n a b i l i t y t o l o c a t e t h e p a t i e n t ' s p r e n a t a l

4) p h y s i c i a n r e f u s a l

r e c o r d s and

due t o l a c k o f s i g n e d c o n s e n t by t h e p a t i e n t

(n=3).

G e n e raliz a b ilitv of Results to the Population
S o c i o d e m o g r a p h i c i n f o r m a t i o n f r om t h e b i r t h c e r t i f i c a t e o f
responders'

and n o n - r e s p o n d e r s '

i n f a n t s was c ompa r e d t o d e t e r m i n e t h e

c o n f i d e n c e w i t h whi c h r e s u l t s o b t a i n e d f r om t h i s

s a mp l e c o u l d be

g e n e r a l i z e d t o t h e p o p u l a t i o n o f b l a c k Mi c h i g a n m o t h e r s .
by c o u n t y i n d i c a t e d ,

in g e n e r a l ,

Re s pons e r a t e

a much l o w e r r e s p o n s e f rom l a r g e , u r b a n

c e n t e r s s uc h as Ke n t , O a k l a n d , Wayne and Washt enaw c o u n t i e s
compa r ed t o p r i m a r i l y r u r a l

counties

( 66%),

(33%)

as

indicating response bias

( Appe ndi x 3 2 b ) .
When r e s p o n d e r s (R) and n o n - r e s p o n d e r s
optimal

(NR) who had d e l i v e r e d an

b i r t h w e i g h t i n f a n t wer e c ompar ed ( Ap p e n d i x 2 9 - 9 a , b ) ,

no s i g n i f i c a n t d i f f e r e n c e s i n i n f a n t b i r t h w e i g h t , m a t e r n a l
prenatal

c a r e b e g a n , number o f p r e n a t a l

f a t h e r ' s age,
certificate,

f a t h e r 's education,
sex o f t h e i n f a n t ,

visits,

t h e r e we r e

a g e , month

weeks g e s t a t i o n ,

number o f p a r e n t s named on t h e b i r t h

concurrent i ll n e s s e s or complications,

239

Ke ss ne r Index o f p r e n a t a l

care,

s c o r e s . The o n l y s t a t i s t i c a l l y
maternal ye a rs of education
practical

and o n e - m i n u t e and f i v e - m i n u t e Apgar
s i g n i f i c a n t d i f f e r e n c e was n o t e d be t we e n

( 1 3 . 5 R v s 1 2 . 8 NR; p < . 0 0 0 5 ) , a l t h o u g h t h e

significance of this difference is questionable.

suggest a rep re s en ta tiv e

Results

s a mp l e o f b l a c k m o t h e r s who d e l i v e r OBW i n f a n t s

i n Mi c h i g a n was o b t a i n e d .
No s i g n i f i c a n t d i f f e r e n c e s we r e n o t e d b e t we e n r e s p o n d e r s and n o n ­
r e s p o n d e r s who had d e l i v e r e d l ow b i r t h w e i g h t i n f a n t s

in the following

c h a r a c t e r i s t i e s : i n f a n t b i r t h w e i g h t , m o t h e r ' s a g e , month p r e n a t a l
b e g a n , number o f p r e n a t a l
f a t h e r ' s education,
delivery,

visits,

infant's

sex,

weeks g e s t a t i o n ,

care,

( Ap p e n d i x 2 9 - 9 c , d ) . However ,

years of education

f a t h e r ' s age,

c om pl ic a tio ns or pregnancy or

Kessner Index o f p r e n a t a l

Apga r s c o r e s

care

o r o n e - m i n u t e and f i v e - m i n u t e
LBW-NR had s i g n i f i c a n t l y f e we r

( 1 2 . 3 NR vs 1 2 . 7 R; p < 0 . 0 4 2 ) ,

a h i g h e r frequency of

d r u g a b u s e d u r i n g t h e i r p r e g n a n c y a s r e p o r t e d on t h e b i r t h c e r t i f i c a t e
( 15 vs 0 ) ,
parents

and had o n l y one p a r e n t

( 82 NR vs 56 R) ,

p=0.0339).

true association.

(X2= 4 . 5 0 ;

s u g g e s t a s s o c i a t i o n s o b s e r v e d b e t we e n t h e

i n t h i s s t u d y and LBW c o u l d u n d e r - r e p r e s e n t t h e

If true,

in a type II e r r o r ,
truth,

named on t h e b i r t h c e r t i f i c a t e

Th e s e d i f f e r e n c e s

variables of in te re s t

(184 NR vs 77 R ) , as o p p o s e d t o b o t h

this

a t t e n u a t i o n t o w a r d t h e mean c o u l d r e s u l t

causing the null

i t s h o u l d be r e f u t e d

h y p o t h e s i s t o be r e t a i n e d when,

( S n e d e c o r and C o c h r a n ,

in

1980).

C h a r a c t e r i s t i e s o f t h e Re s p o n d i n g Sampl e P o p u l a t i o n
I n f o r m a t i o n o b t a i n e d f r om t h e b i r t h c e r t i f i c a t e s

ind icated the

a v e r a g e s u b j e c t i n t h i s s t u d y was 2 5 . 1 y e a r s o l d and had c o m p l e t e d one

240

y e a r o f p o s t - h i g h s c h o o l e d u c a t i o n ( T a b l e 5 . 5 9 ) . Al l
b l a c k . A c c o r d i n g t o t h e s u b j e c t ' s me d i c a l

records,

s u b j e c t s we r e

the average responder

was 5 ' 4" and we i g h e d 143 l b s p r i o r t o p r e g n a n c y ( r a n g e 9 0 - 3 7 5 l b s ) .
a v e r a g e w e i g h t g a i n d u r i n g p r e g n a n c y was 31 l b s ,
29 l b s t o a g a i n o f 83 l b s . O v e r a l l ,

r a n g i n g f r om a l o s s o f

t h e s u b j e c t s e n te r e d pregnancy at

109% o f t h e i r 1983 M e t r o p o l i t a n R e f e r e n c e W e i g h t - f o r - H e i g h t
273),

The

( r a n g e 74-

and g a i n e d t o 133% o f t h e i r 1983 R e f e r e n c e Wei ght a t t e r m ( r a n g e

7 8 - 2 9 2 ) . As a g r o u p , t h e m o t h e r s i n i t i a t e d p r e n a t a l

c a r e d u r i n g t h e end

o f t h e s e c o n d month o f p r e g n a n c y and saw a p r e n a t a l

care provider

a p p r o x i m a t e l y 12 t i m e s .

Table 5.59.

C h a r a c t e r i s t i c s o f t h e s a mpl e r e s p o n d e r s

Characteri s t i c

(n=301).

Mean + SD

n

Range

25. 1 + 4 . 1
13. 1 + 1 . 7

301
301

(20-34)
(8-17)

64.3
143
31
109
133

2.8
37
15
27
29

230
263
262
220
220

(59-71)
(90-375)
(-29-83)
(74-273)
(78-292)

2 . 8 + 1.5
12 + 4

301
301

(1-9)
(0-35)

SOCIODEMOGRAPHIC
Age, y r s
Education, yrs

ANTHROPOMETRIC
H e i g h t , in
Pr e-p regnan t weight, lbs
Pregnancy wei ght g a i n , l b s
% 1983 RW, p r e - p r e g n a n t
% 1983 RW, a t t e r m

+
+
+
+
+

BEHAVIORAL
Month p r e n a t a l c a r e began
Number o f p r e n a t a l v i s i t s

241

Co mp a r i s o n o f Ca s e s and C o n t r o l s bv S e l e c t D e s c r i p t i v e V a r i a b l e s
A comparison o f ca se s
controls

( m o t h e r s o f LBW i n f a n t s ;

( m o t h e r o f OBW i n f a n t s ;

< 2500 g) and

3 , 5 0 0 - 4 , 0 0 0 g) f o r s e l e c t e d

s o c i o d e m o g r a p h i c and a n t h r o p o m e t r i c v a r i a b l e s i n d i c a t e d many s i g n i f i c a n t
differences

(Table 5.6 0).

Onl y m a t e r n a l

a g e , p e r c e n t o f 1983 p r e p r e g n a n t

r e f e r e n c e w e i g h t and number o f s u b j e c t s e n t e r i n g p r e g n a n c y a t l e s s t h a n
90% o f t h e i r 1983 M e t r o p o l i t a n r e f e r e n c e w e i g h t we r e n o t s i g n i f i c a n t l y
d i f f e r e n t b e t we e n g r o u p s .

Table 5.60.

Compa r i s on o f c a s e s and c o n t r o l s f o r s e l e c t d e s c r i p t i v e
v a r i a b l e s (Means+SD, u n l e s s n o t e d ) .

Variable

LBW

n

OBW

n

t or

P

x2
S0CI0DEM0GRAPHIC
25.1+4.1
12.7+1.7
88
42

134
134
134
134

25.6+4.2
13.5+1.7
97
57

122
122
122
122

1. 02
3.77
6 . 32a
4. 76a

. 3060
. 0000
. 0120
. 0292

He i gh t, in
P r e - p r e g n a n t wt, l b s
Term w e i g h t , l b s
P r e g . wt g a i n , l b s
% 1983 RW, p r e - p r e g .
% 1983 RW, a t t e r m
% < 90% RW83, PPW

64
139
163
25
108
127

3
39
40
15
28
29

98
112
116
111
94
96
20

65
150
189
39
112
141

3
36
37
14
27
27

101
110
120
110
95
101
15

3.48
2.34
5. 31
7.33
1. 11
3.66
2 . 50a

. 0001
. 0200
. 0000
. 0000
. 2670
. 0000
. 2860

Birth weighi, g
Percent female i n f a n t s

2295+284
58

134
134

3753+137
42

122
122

52.8
6 . 23a

. 0000
.0125

Age, y r s
Education, yrs
Had p r e n a t a l c a r e , %
Two p a r e n t s named, %

ANTHROPOMETRIC

a X2

+
+
+
+
+
+
11

+
+
+
+
+
+
8

242

RESEARCH HYPOTHESES
H03- l a :

A w e i g h t g a i n t o 120% o r more o f o n e ' s r e f e r e n c e w e i g h t - f o r h e ig h t at term is not a s s o c i a t e d wit h a reduced in ci d e n ce of
d e l i v e r i n g a LBW i n f a n t i n h e a l t h y , b l a c k women b e t we e n t h e
a g e s o f 20 t o 34.

H03- l b :

B l a c k women be t we e n t h e a g e s o f 2 0 - 3 4 who g a i n t o 120% o r
more o f t h e i r r e f e r e n c e w e i g h t - f o r - h e i g h t a t t e r m do n o t
d e l i v e r i n f a n t s w i t h s i g n i f i c a n t l y h i g h e r mean b i r t h w e i g h t s
t h a n i n f a n t s o f m o t h e r s who do n o t me e t t h i s g o a l .

H03- 1 c :

A w e i g h t g a i n t o 120% o r more o f o n e ' s r e f e r e n c e w e i g h t - f o r h e i g h t a t t e r m i s n o t a s s o c i a t e d w i t h an o p t i m a l b i r t h
w e i g h t b e t we e n 3500 and 4000 g i n h e a l t h y , b l a c k women
be t we e n t h e a ge s o f 20 t o 34.

H03- l d :

I f a woman' s p r e - p r e g n a n c y w e i g h t i s g r e a t e r t h a n 120% o f
r e f e r e n c e , a minimum g a i n o f s e v e n k i l o g r a m s w i l l n o t r e d u c e
t h e i n c i d e n c e o f LBW i n h e a l t h y b l a c k women b e t we e n t h e a g e s
o f 20 t o 34.

R e s p o n d e r s we r e u n a b l e t o p r o v i d e t h e f o l l o w i n g a n t h r o p o m e t r i c
me a s u r e m e n t s f o r s e v e r a l
( n=38)

and t e r m w e i g h t

subjects:

he igh t (n=71),

p r e p r e g n a n t weight

( n = 3 8 ) . Onl y 220 b l a c k s u b j e c t s had d a t a f o r a l l

t h r e e v a r i a b l e s n e c e s s a r y t o a n s we r h y p o t h e s e s H03- 1 .

Of t h e s e ,

95 wer e

c a s e s and 101 wer e c o n t r o l s .
Results of the P h y sicia n 's Prenatal

Ca r e S u r v e y o f B l a c k Mi c h i g a n

M o t h e r ' s i n d i c a t e d women who d i d n o t g a i n t o 120% o f t h e i r

1959

M e t r o p o l i t a n r e f e r e n c e w e i g h t - f o r - h e i g h t had a 243% i n c r e a s e d r i s k o f
delivering

a LBW i n f a n t t h a n i f t h e y had g a i n e d t o 120% o r more o f

reference

(Table 5 . 6 1 ) .

When compar ed w i t h t h e 1983 M e t r o p o l i t a n

standard,

t h e e s t i m a t e d r e l a t i v e r i s k o f n o t g a i n i n g t o 120% o f

243

r e f e r e n c e was a s s o c i a t e d w i t h a 275% g r e a t e r c h a n c e o f d e l i v e r i n g a LBW
infant

[ RR=2. 7 5 ( 1 . 4 9 - 5 . 0 9 ) ] .

Table 5.61.

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t i f
120% o f o n e ' s r e f e r e n c e w e i g h t was n o t a t t a i n e d a t t e r m
among b l a c k Mi c h i g a n m o t h e r s .

Ca s e s
N

Variable

Controls
N

RR (95% Cl )

- - 1 9 5 9 M e t r o p o l i t a n R e f e r e n c e Wei ght a t Te r m- R i s k o f LBW ( n=197:
Not g a i n i n g t o 120%
Ga i ne d t o 120% o r more

27
69

14
87

2.43 (1 . 1 8 -4 . 9 9 )
1.0a

- - 1 9 8 3 M e t r o p o l i t a n R e f e r e n c e Wei ght a t Ter m- R i s k o f LBW ( n = 1 9 7 ) :
Not g a i n i n g t o 120%
Ga i ne d t o 120% o r more
____ J.

u

43
53

23
78

2.75 (1.49-5.09)
1.0a

n ...

ar e f e r e n t - - b a s e l i n e v a l u e a s s o c i a t e d w i t h no r i s k .

The c o r r e l a t i o n b e t w e e n p e r c e n t 1959 M e t r o p o l i t a n r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m by s u b j e c t s who g a i n e d t o l e s s t h a n 120% o f r e f e r e n c e ,
h o we ve r , was n o t l i n e a r l y r e l a t e d t o i n f a n t b i r t h w e i g h t

(Table 5.62).

The c o r r e l a t i o n b e t we e n i n f a n t b i r t h w e i g h t and p e r c e n t r e f e r e n c e
a t t a i n e d when s u b j e c t s g a i n e d t o 120% o r more o f r e f e r e n c e was,
likewise,

not s i g n i f i c a n t

(r=0.10,

p=0.10).

244

Table 5.62.

C o r r e l a t i o n b e t we e n p e r c e n t 1959 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t among b l a c k
subjects.

< 120% RW a t Term

Subjects

> 120% RW a t Term

--1959 Referen ce- Al l

Re s p o n d e r s

(n=230):

R
a d j u s t e d R2
Be t a
Standard Error-Beta
F
P
n

. 24
. 04
18.6
10. 7
3.04
. 0873
52

.12
.01
3.4
2. 1
2.66
. 1047
178

The r e l a t i o n s h i p b e t we e n p e r c e n t o f t h e 1959 M e t r o p o l i t a n
r e f e r e n c e a t t a i n e d a t t e r m and i n f a n t b i r t h w e i g h t c a n be s e e n i n t h e
g r a p h i n F i g u r e 5 . 9 . The i n c o n s i s t e n t i n c r e a s e i n b i r t h w e i g h t w i t h e a c h
10% i n c r e a s e i n r e f e r e n c e w e i g h t a t t a i n e d a t t e r m i s d e m o n s t r a t e d by t h e
r i s i n g and f a l l i n g s l o p e .

245

Bi r t h W e i g h t , g

4000
3500
30 00
2500
2000
15 00
1000
500
n =2 3 0
BO

100

120

140

160

100

200

% 1959 Reference Wei ght Attained at Term

Figure 5.9.

R e l a t i o n s h i p b e t we e n p e r c e n t o f 1959 r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m w i t h b i r t h w e i g h t among b l a c k s u b j e c t s .

When t h e 1983 M e t r o p o l i t a n r e f e r e n c e was u s e d a s t h e g o l d s t a n d a r d
f o r " r e f e r e n c e weight"

(Table 5 .6 3 ) ,

t h e c o r r e l a t i o n b e t we e n i n f a n t

b i r t h w e i g h t and p e r c e n t r e f e r e n c e w e i g h t a t t a i n e d a t t e r m i n women who
g a i n e d t o l e s s t h a n 120% o f r e f e r e n c e was s t i l l
significant

( r = 0 .20;

p=0.08),

not s t a t i s t i c a l l y

e x p l a i n i n g o n l y 3% o f t h e v a r i a n c e i n

b i r t h w e i g h t . The r e g r e s s i o n s l o p e b e t we e n b i r t h w e i g h t and a w e i g h t
g a i n t o 120% o r more o f o n e ' s

1983 r e f e r e n c e s t a n d a r d was n o t

s i g n i f i c a n t l y d i f f e r e n t than zero (r=0.10,

p=0.21).

246

Table 5.63.

C o r r e l a t i o n b e t we e n p e r c e n t 1983 M e t r o p o l i t a n
r e f e r e n c e w e i g h t a t t a i n e d a t t e r m ( l e s s t h a n 120% o r
g r e a t e r t h a n 120%) and b i r t h w e i g h t among b l a c k women.

Subjects

< 120% RW a t Term

> 120% RW a t Term

--1983 R e f e r e n c e - Al l

Responders (n=230):
R
a d j u s t e d R2
Be t a
S E- Be t a
F
P
n

. 20
.03
14 . 9
8.3
3.2
. 0756
80

. 10
. 004
2.93
2.3
1.57
.2118
154

The r e l a t i o n s h i p b e t we e n p e r c e n t o f t h e 1983 M e t r o p o l i t a n
r e f e r e n c e s t a n d a r d w e i g h t a t t a i n e d a t t e r m and i n f a n t b i r t h w e i g h t can
be s e e n g r a p h i c a l l y i n F i g u r e 5 . 1 0 . The n o n - s i g n i f i c a n t
b i r t h w e ight a s s o c i a t e d wi th each i ncr ement al

i n c r e a s e in p e r c e n t

r e f e r e n c e a t t a i n e d i s d e n o t e d by t h e r i s i n g and f a l l i n g
general,

i n c r e a s e in

a g a i n t o b e t we e n 140-149% o f r e f e r e n c e

slope.

In

( 19 8 3 ) was a s s o c i a t e d

w i t h t h e h e a v i e s t b a b i e s f o r t h e l a r g e s t number o f s u b j e c t s

( 3325 g;

n = 3 2 ) . The pe a k b i r t h w e i g h t o f 3912 o b s e r v e d b e t w e e n 180-189% o f
r e f e r e n c e was a s s o c i a t e d w i t h o n l y one s u b j e c t .

247

Bi rt h W e i g h t , g
4500
4000
3500
3000
2500
2000
1500
1000
500
n =2 3 0

0
BO

100

120

140

160

180

200

% 1983 Reference Wei ght At tai ned at Term

Figure 5.10.

R e l a t i o n s h i p be t we e n p e r c e n t o f 1983 r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m w i t h b i r t h w e i g h t among b l a c k women.

The mean b i r t h w e i g h t o f i n f a n t s bor n t o women who a t t a i n e d t o
120% o f t h e i r 1959 r e f e r e n c e a t t e r m was 3 , 0 6 6 g ( T a b l e 5 . 6 4 ) .
d i d n o t g a i n t o 120% o f t h e 1959 r e f e r e n c e d e l i v e r e d
w e i g h e d , on a v e r a g e ,

Women who

i n f a n t s who

249 g l o w e r ( p = 0 . 0 2 4 ) . When t h e 1983 M e t r o p o l i t a n

r e f e r e n c e was u s e d a s t h e g o l d s t a n d a r d ,

t h e mean b i r t h w e i g h t o f

i n f a n t s b or n t o women who a t t a i n e d t o 120% o f t h e i r r e f e r e n c e a t t e r m
was 3 , 1 0 5 g. Women who d i d n o t g a i n t o 120% o f t h e i r r e f e r e n c e d e l i v e r e d
i n f a n t s who w e i g h e d , on a v e r a g e ,

281 g l o w e r ( p = 0 . 0 0 5 ) .

248

T a b l e 5 . 6 4 . Mean b i r t h w e i g h t o f i n f a n t s b o r n t o b l a c k women who d i d and
d i d n o t a t t a i n t o 120% o f t h e i r M e t r o p o l i t a n r e f e r e n c e
w e i g h t a t t e r m (Mean ± SE) .

Variable

Ga i n e d t o < 120%
a t Term
(N)

Ga i n e d t o 120%
o r More a t Term
(N)

B i r t h We i g h t ,
1959 M e t r o p o l i t a n
R e f e r e n c e Wei ght

1983 M e t r o p o l i t a n
R e f e r e n c e Wei ght

t

p

9

2817 ± 93
(51)

3066 ± 57
(177)

2.30

.024

2824 ± 79
( 205)

3105 ± 61
(191)

2.82

. 005

Even t h o u g h a w e i g h t g a i n t o 120 p e r c e n t o f e i t h e r t h e 1959 o r t h e
1983 M e t r o p o l i t a n r e f e r e n c e w e i g h t was a s s o c i a t e d w i t h a d e c r e a s e d
i n c i d e n c e o f LBW, and h i g h e r mean b i r t h w e i g h t s ,

t h i s ga in d id not

c o r r e s p o n d t o Br o wn ' s ( 1 9 8 8 ) d e f i n i t i o n o f an " o p t i m a l " b i r t h w e i g h t o f
3,500 g t o 4,000 g in t h i s

study.

The mean b i r t h w e i g h t o f i n f a n t s bor n

t o women who g a i n e d t o 120% o r more o f t h e 1983 s t a n d a r d

( 3 , 1 0 5 ± 61 g)

was 357 g l o w e r t h a n t h e 3 , 4 6 2 + 482 o b s e r v e d by Ros s o ( 1985)
g r o u p o f 262 n o n - s m o k i n g ,

in the

r a c i a l l y mi xed l o w- i n c o me women, y e t 28 g

h i g h e r t h a n t h e mean b i r t h w e i g h t o f w h i t e Mi c h i g a n i n f a n t s i n 1987 o f
3 , 0 7 7 g (MDPH, 1 9 8 9 ) .

I t mus t be n o t e d t h a t t h e p r e s e n t s a mpl e i s n o t a

homogeneous s a mpl e o f a l l

possible b irth weights.

c o n s i s t e d p r i m a r i l y o f LBW and OBW i n f a n t s .

Rather,

In a d d i t i o n ,

may o r may n o t be " h e a l t h y " by R o s s o ' s d e f i n i t i o n ,

this

s a mpl e

t h is population

because infor mation

249

a b o u t s moki ng was n o t c o l l e c t e d .

Whe t he r o r n o t a g a i n t o 120% o f

r e f e r e n c e i n a homogeneous n o n - s m o k i n g , b l a c k Mi c h i g a n p o p u l a t i o n
representative of all

b i r t h w e i g h t s woul d be a s s o c i a t e d w i t h an o p t i m a l

b i r t h w e i g h t c a n n o t be a n s we r e d w i t h t h e p r e s e n t s t u d y d e s i g n .
Of t h e 69 women who we i g h e d more t h a n 120% o f t h e i r 1959 r e f e r e n c e
at conception,
5.65).

o n l y 9 g a i n e d l e s s t h a n 7 kg ( 1 5 . 5 l b s )

Of t h e s e ,

infant.

a t term (Table

s e v e n d e l i v e r e d a LBW i n f a n t and two d e l i v e r e d an OBW

The e s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t when p r e ­

p r e g n a n c y w e i g h t was 120% o r more o f r e f e r e n c e and p r e g n a n c y w e i g h t g a i n
was l e s s t h a n 7 kg, was s i x - f o l d h i g h e r t h a n among women who g a i n e d more
t h a n 7 kg [ RR=6. 22 ( 1 . 1 7 - 3 3 . 1 8 ) .

Of t h e 48 women who we i ghe d more t h a n

120% o f t h e i r 1983 r e f e r e n c e p r i o r t o p r e g n a n c y ,
t h a n 7 kg a t t e r m . Of t h e s e ,
d e l i v e r e d an OBW i n f a n t .

only nine gained l e s s

s e v e n d e l i v e r e d a LBW i n f a n t and two

Again, t h e e s t i m a t e d r e l a t i v e r i s k o f

d e l i v e r i n g a LBW i n f a n t when p r e - p r e g n a n c y w e i g h t was 120% o r more o f
one's

1983 r e f e r e n c e and l e s s t h a n 7 kg wer e g a i n e d was s i g n i f i c a n t l y

different,

i n d i c a t i n g an e i g h t - f o l d h i g h e r i n c r e a s e d r i s k o f LBW t h a n

b l a c k women who g a i n e d more t h a t 7 kg.

250

Table 5.65.

E s t i m a t e d r e l a t i v e r i s k (RR) o f d e l i v e r i n g a LBW i n f a n t i f a
woman e n t e r s p r e g n a n c y a t o r a bove 120% o f r e f e r e n c e and
g a i n s l e s s t h a n s e v e n kg a c c o r d i n g t o t h e b l a c k s u b j e c t s
me d i c a l r e c o r d s .

Variable

Ca s e s

Controls

N

N

7
18

2
32

6.22
la

(1.17-33.18)

2
23

8.05
la

(1.42-45.77)

I f > 120% 1959 P r e - P r e q n a n t ( n = 5 9 ) :
Ga i n e d l e s s t h a n 7 kg
Ga i n e d 7 kg o r more

RR (95% Cl )

I f > 120% 1983 P r e - P r e q n a n t ( n = 4 2 ) :
Ga i n e d l e s s t h a n 7 kg
Ga i n e d 7 kg o r more

7
10

ar e f e r e n t

Re s u lts p res en ted here concur,

f o r t h e most p a r t ,

with the

o b s e r v a t i o n s o f Rosso ( 1985) t h a n a w e i g h t g a i n t o 120% o f o n e ' s

1959

M e t r o p o l i t a n r e f e r e n c e was a s s o c i a t e d w i t h i n f a n t s o f s i g n i f i c a n t l y
h i g h e r mean b i r t h w e i g h t s t h a n m o t h e r s who d i d n o t a t t a i n t o t h i s l e v e l .
Regression a n a ly s is in d ic a te d a gain

t o a p p r o x i m a t e l y 140% o f o n e ' s

1959

o r 1983 r e f e r e n c e w e i g h t a p p e a r e d t o

be a s s o c i a t e d w i t h

t h e h i g h e s t mean

s l i g h t l y more t h a n

a two-fold

b i r t h weight in t h i s p o p u l a t io n .
The c r u d e odds r a t i o i n d i c a t e d

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t i f 120% o f r e f e r e n c e was n o t
attained.

The s t u d e n t ' s t - t e s t

i n d i c a t e d women who g a i n e d t o 120% o r

more o f e i t h e r t h e 1983 o r 1959 M e t r o p o l i t a n r e f e r e n c e s d e l i v e r e d
s i g n i f i c a n t l y h e a v i e r b a b i e s who w e i g h e d , on a v e r a g e ,

249- 281 g more

t h a n m o t h e r ' s who d i d n o t a t t a i n t h i s l e v e l . A g a i n t o 120% o f r e f e r e n c e

251

was n o t , h o we v e r ,

a s s o c i a t e d w i t h t h e d e l i v e r y o f an " o p t i m a l

birth

w e i g h t " a s d e f i n e d by Brown ( 1 9 8 8 ) .
The c o r r e l a t i o n be t we e n p e r c e n t r e f e r e n c e w e i g h t a t t a i n e d a t t e r m
and b i r t h w e i g h t was n o t s t a t i s t i c a l l y s i g n i f i c a n t .

Ros s o ( 1985)

r e p o r t e d t h a t t h e c o r r e l a t i o n be t we e n b i r t h w e i g h t and p e r c e n t r e f e r e n c e
w e i g h t a t t a i n e d a t t e r m ( up t o 120% o f r e f e r e n c e )
h e a l t h y , non-smoking,

among a g r o u p o f

l o w- i n c o me b l a c k and H i s p a n i c women was r = 0 . 3 0 .

A f t e r a t t a i n i n g t o 120% o f r e f e r e n c e ,
in cr e ase in i n f a n t b i r t h weight.

Rosso r e p o r t e d no a d d i t i o n a l

In t h e p r e s e n t s t u d y ,

h o we v e r ,

the

c o r r e l a t i o n b e t we e n b i r t h w e i g h t and p e r c e n t s t a n d a r d w e i g h t a t t a i n e d a t
t e r m ( up t o 120%) was l o w e r ( r = 0 . 2 4 ,
s ta tis tic a lly significant.

1959; r = 0 . 2 0 ,

1983) and no t

Be c a us e i n f o r m a t i o n a b o u t t h e s moki ng h a b i t s

o f t h e s e s u b j e c t s was n o t c o l l e c t e d ,

a "healthy"

sub-population,

t o R o s s o ' s , c o u l d n o t be d e r i v e d f rom t h i s p o p u l a t i o n .
f r om t h e M i s s o u r i
1983,

Center for Health S t a t i s t i c s ,

similar

However , d a t a

c o l l e c t e d b e t we e n 1981-

i n d i c a t e d a p p r o x i m a t e l y 35. 5% o f b l a c k women smoked d u r i n g

pregnancy

( Ma l l o y e t a l , 1 9 8 9 ) .

s i g n i f i c a n t e f f e c t o f s moki ng,
weight,

I f t h i s we r e t r u e

in Michi gan,

a s s o c i a t e d with a r e d u c t i o n

a

in b i r t h

c o u l d be e x p e c t e d .

Because o v e rw e ig h t

(120% o r more o f r e f e r e n c e ) women o f t e n d e l i v e r

1a r g e r - t h a n - a v e r a g e i n f a n t s ,

even when t h e i r g e s t a t i o n a l

weight gain is

l e s s t h a n t h e recommended 24 l b s o r 11 kg, a mi ni mal w e i g h t g a i n o f 15
lbs

(7 kg) ha s be e n recommended f o r o v e r w e i g h t women ( N i s w a n d e r e t a l ,

1969; Eas t man and J a c k s o n ,

1968).

Results of the Physician's Prenatal

C a r e S u r v e y o f B l a c k Mi c h i g a n Mo t h e r s s u p p o r t t h i s r e c o m m e n d a t i o n .
t h i s s t u d y , b l a c k women who e n t e r e d p r e g n a n c y o v e r w e i g h t o r o b e s e

In

252

( g r e a t e r t h a n 120% o f r e f e r e n c e )

and who d i d n o t g a i n a minimum 7 kg,

had a s i x - f o l d t o an e i g h t - f o l d i n c r e a s e d r i s k o f d e l i v e r i n g a LBW
infant,

a s c ompar ed t o o v e r w e i g h t and o b e s e m o t h e r s who g a i n e d more t h a n

7 kg. The c o n f i d e n c e i n t e r v a l s we r e wi de d ue t o t h e s ma l l
Based on t h e s e r e s u l t s ,

the null

s a mp l e s i z e .

h y p o t h e s e s H03- l a and H03- l b a r e

r e f u t e d . Al t h o u g h t h e c o r r e l a t i o n s b e t we e n b i r t h w e i g h t and p e r c e n t o f
r e f e r e n c e a t t a i n e d a t t e r m we r e n o t s i g n i f i c a n t ,

a w e i g h t g a i n t o 120%

o f e i t h e r t h e 1959 o r 1983 r e f e r e n c e was a s s o c i a t e d w i t h a r e d u c t i o n i n
t h e i n c i d e n c e o f LBW, and h i g h e r mean b i r t h w e i g h t s . A w e i g h t g a i n t o
120% o f t h e 1983 R e f e r e n c e was a s s o c i a t e d w i t h a 39 g h i g h e r mean b i r t h
w e i g h t t h a n a g a i n t o 120% o f t h e 1959 R e f e r e n c e .

Th e s e d a t a r e p e a t t h e

p r e v i o u s l y r e p o r t e d f i n d i n g s o f Ros s o ( 1985) i n b l a c k women.

Because a

h i g h e r b i r t h w e i g h t was a s s o c i a t e d w i t h a g a i n t o 120% o f t h e 1983
Metropolitan reference,
the r e f e r e n c e tool
The n u l l

t h i s r e s e a r c h e r r ecommends t h e 1983 s t a n d a r d be

of choice.

h y p o t h e s i s H03- l c c a n n o t be r e f u t e d .

A weight gain to

120% o f r e f e r e n c e was n o t a s s o c i a t e d w i t h t h e d e l i v e r y o f an " o p t i m a l "
b i r t h weight o f 3 , 5 0 0 - 4 , 0 0 0 g. R a t h e r ,

a g a i n t o 120% o r more o f t h e

1959 and 1983 r e f e r e n c e was a s s o c i a t e d w i t h a mean b i r t h w e i g h t o f
3 , 0 6 6 + 5 7 g ( n = l 77) and 3, 1 0 5 + 6 1 g ( n = l 5 1 ) ,

respectively.

Th e s e b i r t h

w e i g h t s a r e l o w e r t h a n t h e 3 , 4 6 2 ± 4 8 2 r e p o r t e d by Rosso ( 1985)
o f 262 b l a c k and H i s p a n i c n o n - s m o k i n g ,

in a group

n o n - d r i n k i n g p r e g n a n t women. The

Rosso s t u d y and t h e B l a c k Mi c h i g a n M o t h e r ' s s t u d y c a n n o t be d i r e c t l y
compa r ed f o r two r e a s o n s :
s u b j e c t s was n o t r e p o r t e d ,

1) t h e mean b i r t h w e i g h t among o n l y t h e b l a c k
and 2) h i s t o r i c a l l y ,

H i s p a n i c women d e l i v e r

253

h e a v i e r i n f a n t s t h a n b l a c k women ( S h i o n o e t a l , 1 9 8 6 ) .
reasons,

For t h e s e

t h e mean b i r t h w e i g h t r e p o r t e d by Ros s o may be i n f l a t e d .

A l t h o u g h n o t c o n s i d e r e d " o p t i m a l " by Br o wn ' s ( 1988) d e f i n i t i o n ,
t h e mean b i r t h w e i g h t s f r om t h i s s t u d y h a ve been a s s o c i a t e d w i t h a b l a c k
in f a n t m o r t a l i t y r a t e of approximately 5.8 deaths/1000 l i v e b i r t h s
w i t h i n t h e f i r s t y e a r o f l i f e i n Mi c h i g a n ( Ap p e n d i x 3 0 b ) ,

be l ow t h e

9 / 1 0 0 0 d e a t h s s e t a s a Ye a r 2000 H e a l t h O b j e c t i v e f o r t h e N a t i o n (DHHS,
1989a ) and w e l l
births

(MDPH,

be l ow t h e c u r r e n t Mi c h i g a n b l a c k IMR o f 2 2 . 0 / 1 0 0 0 l i v e

1 9 8 9 ) . T h u s , a l t h o u g h n o t " o p t i m a l " by Br o wn ' s d e f i n i t i o n ,

t h e b i r t h w e i g h t o f i n f a n t s b o r n t o m o t h e r s who g a i n e d t o 120% o r more
o f r e f e r e n c e c a n be c o n s i d e r e d a " h e a l t h y " b i r t h w e i g h t ,

i f the

c o r r e s p o n d i n g Mi c h i g a n IMR and t h e Year 2000 O b j e c t i v e a r e u s e d as t h e
refe re n c e guide.
Based on r e s u l t s p r e s e n t e d h e r e ,
refuted.
this

the null

h y p o t h e s i s H03- l d

is

O v e r w e i g h t and o b e s e women who d i d n o t g a i n a minimum 7 kg i n

s t u d y had b e t we e n a s i x - f o l d t o e i g h t - f o l d

increased r i s k of

d e l i v e r i n g a LBW i n f a n t a s c ompa r e d t o o v e r w e i g h t and o b e s e women who
g a i n e d more t h a n t h i s a mount . Th u s , r e s u l t s o f t h i s
minimum w e i g h t g a i n o f 7 kg ( 1 5 . 5 l b s )

study suggest a

s h o u l d be recommended f o r b l a c k

women who e n t e r p r e g n a n c y o v e r w e i g h t o r o b e s e .

254

H04- 1 : M a t e r n a l p e r c e n t p r e p r e g n a n t w e i g h t - f o r - h e i g h t ( 1983 M e t r o p o l i t a n
R e f e r e n c e ) d o e s n o t d i f f e r b e t we e n b l a c k m o t h e r s who d e l i v e r OBW
and LBW i n f a n t s and c a n n o t be u s e d t o p r e d i c t b i r t h w e i g h t .

On a v e r a g e , m o t h e r s who s u b s e q u e n t l y d e l i v e r e d a LBW i n f a n t
e n t e r e d p r e g n a n c y a t 108% o f t h e i r 1983 M e t r o p o l i t a n R e f e r e n c e w e i g h t for-height

(Table 5 .6 6 ) .

of reference.

Mot he r s o f c o n t r o l s w e i g h e d , on a v e r a g e ,

T h i s d i f f e r e n c e was n o t s t a t i s t i c a l l y

significant.

112%
The

r a n g e w i t h i n b o t h g r o u p s was v e r y l a r g e ( 1 4 2 - 2 0 0 %) .

Table 5.66

Mean p e r c e n t p r e p r e g n a n t w e i g h t - f o r - h e i g h t
b l a c k m o t h e r s o f LBW and OBW i n f a n t s .

Variable

LBW

% 1983 PPW
Range, %

108 ± 28

(74-216)

94

95

Nineteen p ercen t
in t h i s

t

112 ± 27

(74-274)

n

controls

OBW

(PPW) f o r

1.08

P
0.2670

( n=35) o f b a c k m o t h e r s who d e l i v e r e d c a s e s and

s u r v e y e n t e r e d p r e g n a n c y a t l e s s t h a n 90% o f t h e i r 1983

r e f e r e n c e w e i g h t . Of t h e s e ,
d e l i v e r e d OBW i n f a n t s .

20 s u b s e q u e n t l y d e l i v e r e d LBW i n f a n t s and 15

The c r u d e odds r a t i o

p r e g n a n c y a t l e s s t h a n 90% o f r e f e r e n c e ,

i n d i c a t e d women who e n t e r e d

o r 120% o f r e f e r e n c e o r more,

we r e n o t a t an i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t as c ompar ed t o
m o t h e r s who e n t e r e d p r e g n a n c y a t 90-119% o f r e f e r e n c e

(Table 5 .6 7) .

255

Table 5.67

Variable

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l p r e p r e g n a n t r e f e r e n c e w e i g h t f o r - h e i g h t among b l a c k s u b j e c t s .

Ca s es
N

Controls
N

RR (95% Cl )

P r e o r e a n a n t R e f e r e n c e We i a h t ( n =1 8 9 ) :
< 90%

20

15

1.29 ( 0 . 6 0 - 2 . 7 8 )

90-119%

57

55

1.0a

120-149%

9

17

0.51

150% o r more

8

8

(0.21-1.24)

0.96 (0.34-2.74)

a __n ____ J.
a referent

When p e r c e n t p r e p r e g n a n t r e f e r e n c e w e i g h t was r e g r e s s e d a g a i n s t
b i r t h weight,
significant.

the c o rr e la tio n

(r=0.049;

However , when s u b j e c t s '

F=0. 52) was n o t s t a t i s t i c a l l y

percent prepregnant reference

w e i g h t and p r e g n a n c y w e i g h t g a i n we r e b o t h r e g r e s s e d a g a i n s t b i r t h
weight,

t h e amount o f e x p l a i n e d v a r i a n c e i n b i r t h w e i g h t i n c r e a s e d

s i g n i f i c a n t l y t o 16% ( r = 0 . 4 0 ) . The p a r t i a l

regression coefficients

i n d i c a t e d o n l y " w e i g h t g a i n " a c c o u n t e d f o r any o f t h e e x p l a i n e d v a r i a n c e
in b i r t h weight (Table 5 .6 8 ) .

R e s u l t s i n d i c a t e d p r e - p r e g n a n t s t a t u s was

n o t i n d i c a t i v e o f p r e g n a n c y out come among t h i s s a mpl e o f b l a c k Mi c h i g a n
women.

256

Table 5.69

M u lt i p le r e g r e s s i o n a n a l y s i s o f pr ep r e g n a n t weight
s t a t u s (% PPW) and w e i g h t g a i n on b i r t h w e i g h t among
black s u b je c t s .

Variable

B

SE-B

We i ght g a i n
% PPW
Constant

18 . 8 6
1.83
2224

2.97
1.70
216

Multiple R
R2
F
DF
P

0.40
0.16
20.4
(2,216)
. 000

Partial

r

0.40
0.07

t

Sig t

6.34
1.08
10. 31

. 0000
. 2835
. 0000

When s u b j e c t s we r e c l a s s i f i e d by p e r c e n t p r e p r e g n a n t r e f e r e n c e
w e i g h t a s b e i n g u n d e r w e i g h t (< 90% RW), a t t h e i r d e s i r a b l e w e i g h t
119% RW), o v e r w e i g h t ( 120- 149% RW) o r v e r y o v e r w e i g h t

( 90-

(150% RW o r m o r e ) ,

t h e c o r r e s p o n d i n g p e r c e n t r e f e r e n c e w e i g h t a t t a i n e d a t t e r m and b i r t h
w e i g h t was o n l y s t a t i s t i c a l l y c o r r e l a t e d i n t h e d e s i r a b l e w e i g h t g r o u p
(Table 5 .6 9 ) .

In t h i s g r o u p ,

each p e r c e n t i n c r e a s e in r e f e r e n c e wei ght

a t t a i n e d a t t e r m was a s s o c i a t e d w i t h a 2 0 . 3 g ( p = 0 . 0 0 0 )
b i r t h weight.
categories,

i n c r e a s e in

In t h e u n d e r w e i g h t , o v e r w e i g h t and v e r y o v e r w e i g h t

t h e s l o p e o f t h e r e g r e s s i o n l i n e s d i d n o t d i f f e r f rom z e r o

and we r e n o t s t a t i s t i c a l l y

significant.

257

Table 5.68.

R e g r e s s i o n o f p e r c e n t 1983 r e f e r e n c e w e i g h t a t t a i n e d
a t t e r m on i n f a n t b i r t h w e i g h t by p r e - p r e g n a n t
w e i g h t c l a s s i f i c a t i o n among b l a c k Mi c h i g a n m o t h e r s .

P r e - P r e g n a n t Wei ght C l a s s i f i c a t i o n
Statistic

Un d e r we i g h t
(< 90%)

Normal We i ght
( 90-119%)

Overweight
( 120- 149%)

Obese
(>150%)

% Term Reference Weight with Birth Weight
r
adj r 2
B
SE-B
F
n
P

0.28
0.06
17.9
9.4
3.64
45
0.063

0.37
0.13
20.3
4.5
30.37
128

0.000

0.24
0.02
13.9
10.6
1.73
32
0.199

0.20
-0.02
4.30
5.57
0.61
18
0.446

The l a c k o f a r e l a t i o n s h i p b e t we e n i n f a n t b i r t h w e i g h t and p e r c e n t
o f 1983 r e f e r e n c e a t t a i n e d a t t e r m can be s e e n i n F i g u r e 5 . 1 1 .

A

p o s i t i v e a s s o c i a t i o n b e t we e n b i r t h w e i g h t and p e r c e n t r e f e r e n c e w e i g h t
a t t a i n e d a t t e r m was o b s e r v e d o n l y among t h e g r o u p o f women who e n t e r e d
p r e g n a n c y a t o r n e a r t h e i r d e s i r a b l e 1983 r e f e r e n c e w e i g h t .

258

Bi r t h We i g h t

3500

3000

Pre-Pregnant weight

2500

—-

< 90% PP-RW
90-119% P P - R W

2000
-B" +“

120- 119% P P - R W
150*% P P - R W

1500
85

105

125

M 5

165

I 85

205

225

% 1983 Term Reference Weight, Black

Figure 5.11.

B i r t h w e i g h t by p e r c e n t r e f e r e n c e w e i g h t a t t e r m
a c c o r d i n g t o p r e p r e g n a n c y w e i g h t c l a s s i f i c a t i o n among
b l a c k Mi c h i g a n m o t h e r s .

We i ght g a i n d u r i n g p r e g n a n c y and p r e p r e g n a n t w e i g h t ha ve been
shown t o be t h e two s t r o n g e s t d e t e r m i n a n t s o f i n f a n t b i r t h w e i g h t w i t h
the exception of g e sta tio n a l
1988).

Edwards e t al

age ( P h i l i p p s and J o h n s o n ,

1977; Brown,

( 1979) s u g g e s t e d u n d e r w e i g h t s t a t u s p r i o r t o

p r e g n a n c y was a more i m p o r t a n t d e t e r m i n a n t f o r t h e d e l i v e r y o f LBW
i n f a n t s t h a n w e i g ht g a i n in p r egna nc y. These r e s e a r c h e r s ob s er v e d a t wo­
f o l d i n c r e a s e i n t h e d e l i v e r y o f LBW i n f a n t s among u n d e r w e i g h t women
d e s p i t e adequate t o t a l weight gains

(22-27 l b s ) .

and J a c k s o n ( 1974) us e d d a t a f r om t h e P e r i n a t a l

In c o n t r a s t ,

Ni s wa n d e r

C o l l a b o r a t i v e Study t o

259

r a n k 32 c o n d i t i o n s i n h i e r a r c h y o f i m p o r t a n c e a s b i r t h w e i g h t
predictors.

They f o u n d t h a t ,

i n b o t h b l a c k and w h i t e women, w e i g h t g a i n

d u r i n g p r e g n a n c y was t h e s t r o n g e s t p r e d i c t o r o f b i r t h w e i g h t , w i t h
prepregnant weight (not % of referen ce)

ranking second.

Re su lts ob ta in e d in t h e p r e s e n t study suggest maternal weight gain
had t h e g r e a t e s t

i mp a c t on t h e b i r t h w e i g h t o f b l a c k Mi c h i g a n i n f a n t s .

Ne i th e r p r ep re gna nt p e r c e n t of r e f e r e n c e weight nor pe rc e n t of r e f e r e n c e
w e i g h t a t t a i n e d a t t e r m we r e s t a t i s t i c a l l y a s s o c i a t e d w i t h b i r t h w e i g h t
in t h i s s a mp l e . T h i s l a c k o f r e l a t i o n s h i p i s
r e p o r t e d by Rosso ( 1 9 8 5 ) ,
all

in c o n t r a s t t o t h a t

Brown ( 1981) and Abrams and La r o s

( 1985) who

r e p o r t e d a s t r o n g e r a s s o c i a t i o n b e t we e n b i r t h w e i g h t and p e r c e n t

r e f e r e n c e weight at term,

p a r t i c u l a r l y among women who e n t e r e d p r e g n a n c y

u n d e r w e i g h t . The r e a s o n s f o r t h e o b s e r v e d r e s u l t s ca n o n l y be
speculated.
alcohol
factors,

Wi t h o u t i n f o r m a t i o n r e g a r d i n g c i g a r e t t e ,

use, d i e t a r y

i n t a k e and s o c i o e c o n o m i c s t a t u s ,

c a f f e i n e and

t o name b u t a few

a c o n c r e t e e x p l a n a t i o n can n o t be a t t e m p t e d .

Based on t h e s e r e s u l t s t h e n u l l
Ma t e r n a l

drug,

p r e - p r e g n a n t weight

h y p o t h e s e s must be r e t a i n e d .

( p e r c e n t o f 1983 M e t r o p o l i t a n R e f e r e n c e

w e i g h t - f o r - h e i g h t ) d i d n o t d i f f e r b e t we e n b l a c k m o t h e r s who d e l i v e r e d
LBW and OBW i n f a n t s .

Women who e n t e r e d p r e g n a n c y u n d e r w e i g h t we r e n o t a t

an i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t .

Prepregnant percent

r e f e r e n c e w e i g h t was n o t p r e d i c t i v e o f i n f a n t b i r t h w e i g h t .

When

s u b j e c t s wer e c l a s s i f i e d a c c o r d i n g t o t h e i r p r e p r e g n a n t w e i g h t ,

the

c o r r e l a t i o n b e t we e n p e r c e n t o f r e f e r e n c e w e i g h t a t t a i n e d a t t e r m and
b i r t h w e i g h t was s i g n i f i c a n t o n l y among women who e n t e r e d p r e g n a n c y a t
their

ideal weight.

T h e r e was a t r e n d t o w a r d s i g n i f i c a n c e among

260

u n d e r w e i g h t m o t h e r s ( p = 0 . 0 6 3 4 ) . Th e s e r e s u l t s s u g g e s t t h a t ,

among t h i s

s a m p l e , t h e amount o f w e i g h t a woman g a i n e d was more i m p o r t a n t t h a n t h e
percent of reference weight-for-height.

H04- 2 a :

M a t e r n a l w e i g h t g a i n d o e s n o t d i f f e r b e t we e n b l a c k m o t h e r s
who d e l i v e r OBW and LBW i n f a n t s and c a n n o t be u s e d t o
p r e d i c t b i r t h weight.

As a g r o u p ,

s u b j e c t s in the P h y s i c i a n ' s Prenatal

Ca r e S u r v e y o f

B l a c k Mi c h i g a n Mo t h e r s g a i n e d 31 pounds ( n = 2 6 2 ) . The r a n g e o f w e i g h t
g a i n s was q u i t e h i g h . When m o t h e r s o f c a s e s and c o n t r o l s we r e c o mpa r e d,
women who d e l i v e r e d LBW i n f a n t s g a i n e d , on a v e r a g e ,
l e s s t h a n m o t h e r s who d e l i v e r e d OBW i n f a n t s

Table 5.70.

Range
n

(Table 5 .7 0 ) .

Mean w e i g h t g a i n o f b l a c k m o t h e r s who d e l i v e r e d LBW
and OBW i n f a n t s .

Variable

LBW
(n=223)

We i ght g a i n ,

a l m o s t 14 pounds

lbs

OBW
( n = l 10)

2 5 . 0 ± 14 . 9

38.6 ± 14.0

(-29-73)

(8-83)

111

110

Seventy fou r perc e n t of the p r en a t al

t

6.95

0.0000

c a r e p r o v id e r s i n d i c a t e d they

had made a s p e c i f i c w e i g h t g a i n r e c o mme n d a t i o n t o t h e s u b j e c t s
question.

p

The mean r e c o mme n d a t i o n was 27 l b s

in

( r a n g e 1 2 - 4 0 ) . On a v e r a g e ,

261

t h e w e i g h t g a i n o f LBW s u b j e c t s was two p ounds l e s s t h a n t h a t
r ecommended by t h e s e s u b j e c t s '

prenatal

c a r e p r o v i d e r ( 27 l b s ,

Women who d e l i v e r e d OBW i n f a n t s g a i n e d , on a v e r a g e ,
than t h e i r prenatal

n=93).

1 1 . 6 p ounds more

c a r e p r o v i d e r had r ecommended ( 27 l b s ;

n=99).

The c r u d e odds r a t i o i n d i c a t e d women who g a i n e d l e s s t h a n 22
pounds had a t h r e e - f o l d i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t t h a n
m o t h e r s who g a i n e d t h e c u r r e n t l y recommended 2 2 - 2 7 pounds ( T a b l e 5 . 7 1 ) .
G a i n i n g more t h a n t h e recommended 2 2- 27 p ounds p r o t e c t e d a g a i n s t t h e
d e l i v e r y o f a LBW i n f a n t
women i n t h i s

[RR=0.36 ( 0 . 1 7 - 0 . 7 8 0 ] .

S t a t e d a n o t h e r way,

s t u d y who g a i n e d t h e recommended 2 2 - 2 7 p ounds we r e a t a

279% i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t as c ompa r ed t o women who
g a i n e d more t h a n 27 p o u n d s . When women who g a i n e d l e s s t h a n 22 pounds
we r e c ompar ed t o women who g a i n e d 28 pounds o r mo r e ,

a 919% i n c r e a s e d

r i s k o f d e l i v e r i n g a LBW i n f a n t was o b s e r v e d .

Table 5.71.

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t d e p e n d e n t
on amount o f p r e g n a n c y w e i g h t g a i n by b l a c k women ( n = 2 2 1 ) .

Variable

LBW

Wei qht q a i n , l b s :
< 22 l b s
22- 27 l b s
> 27 l b s
22- 27 l b s vs > 27 l b s
< 22 l b s vs > 27 l b s

N
47
20
44

a ; . ___ j.
ar e f e r e n t

OBW

N
10
14
86

RR (95% Cl )

3.29
la
0.36
2.79
9.19

(1.25-8.64)
(0.17-0.78)
(1.29-6.05)
(4.24-19.91)

262

When s u b j e c t s we r e c a t e g o r i z e d a c c o r d i n g t o t h e i r p r e - p r e g n a n t
percent r e f e re n c e weight

(<90%, 90-119%,

each group,

nor mal w e i g h t and o v e r w e i g h t women who

underweight,

120-149% 150% o r m o r e ) , w i t h i n

d e l i v e r e d OBW i n f a n t s g a i n e d s i g n i f i c a n t l y more w e i g h t t h a n women who
d e l i v e r e d LBW i n f a n t s
OBW i n f a n t s ,

(Table 5 .7 2 ) .

Ver y o v e r w e i g h t women who d e l i v e r e d

a s c ompa r ed t o LBW i n f a n t s ,

d i f f e r e n c e was n o t s t a t i s t i c a l l y

g a i n e d more w e i g h t ,

but the

s i g n i f i c a n t due t o t h e s a mp l e s i z e and

t h e v e r y l a r g e v a r i a n c e o b s e r v e d i n t h e me a s u r e (33+17 vs 1 6 ± 2 9 ; t = l . 4 7 ) .

T a b l e 5 . 7 2 . Amount o f w e i g h t g a i n e d d u r i n g p r e g n a n c y by b l a c k m o t h e r s o f
OBW and LBW i n f a n t s when s u b j e c t s we r e c a t e g o r i z e d a c c o r d i n g
t o t h e i r 1983 M e t r o p o l i t a n p r e - p r e g n a n c y r e f e r e n c e w e i g h t .

LBW

OBW

( n)

( n)

< 90%

26 ± 13
( 20)

34 ± 9
( 15)

2.11

.041

90-119%

26 ± 13
( 56)

40 ± 14
(55)

5.75

.000

120-149%

24 ± 18
( 9)

37 ± 14
(17)

2.06

.049

150% o r more

16 ± 29
(8)

33 ± 17
(8)

1. 4 7

. 165

1.13

1.36

P r e - P r e g n a n t We i ght
Classification

F, w i t h i n
F p r ob

0.3408

Regression a n a ly s i s

t

P

0.2601

i n d i c a t e d w e i g h t g a i n was h i g h l y c o r r e l a t e d

with b i r t h weight (Table 5 . 7 3 ) ,

e x p l a i n i n g 16% o f t h e v a r i a n c e .

The

263

c o r r e l a t i o n b e t we e n b i r t h w e i g h t and w e i g h t g a i n was a l m o s t i d e n t i c a l
among women who we i g h e d l e s s t h a n 120% o f t h e i r 1983 M e t r o p o l i t a n
r e f e r e n c e p r i o r to pregnancy (r=0.41;

F=33.1),

g a i n e d t o more t h a n 120% o f r e f e r e n c e ( r = 0 . 3 9 ;

as c ompa r e d t o women who
F=8.30).

Each pound o f

w e i g h t g a i n e d by u n d e r w e i g h t and normal w e i g h t women was a s s o c i a t e d w i t h
a 20.5 g i n c r e a s e in b i r t h weight. A s m a lle r gain in b i r t h weight
( 1 5 . 7 g / l b w e i g h t g a i n ) was n o t e d among women who e n t e r e d p r e g n a n c y
overweight or obese.

Table 5.73.

R e g r e s s i o n o f w e i g h t g a i n on b i r t h w e i g h t by b l a c k s u b j e c t ' s
pre-pregnant percent of reference weight.

Statistic

< 120%
Pre-Pregnant

120% o r more
Pre-Pregnant

Al l S u b j e c t s

r
r2
B
SE-B
F
P
n

0.40
0.16
20.5
3.6
33.1

0.39
0.15
15 . 7
5.5
8.30
0.006
49

0.40
0.16
19.2
2.7
50.3

0.000
172

Results of the P h y s ic ia n 's Prenatal

0.000
260

Car e S u r v e y o f B l a c k Mi c h i g a n

Mo t h e r s p r e s e n t e d h e r e do n o t r e i n f o r c e t h e p o s i t i o n o f Brown ( 1983) and
Ros s o ( 1985) t h a t w e i g h t g a i n r e c o m me n d a t i o n s s h o u l d be i n d i v i d u a l i z e d
d e p e n d e n t upon p r e p r e g n a n t w e i g h t s t a t u s .
s t u d y i n d i c a t e d t h e d e l i v e r y o f an o p t i m a l

In g e n e r a l ,

r e s u l t s of t h is

b i r t h weight i n f a n t :

1) was

i n d e p e n d e n t o f t h e s u b j e c t ' s p r e p r e g n a n t w e i g h t s t a t u s and 2) was
a s s o c i a t e d w i t h a w e i g h t g a i n much h i g h e r t h a n t h e 2 2- 27 pounds

264

c u r r e n t l y recommended by t h e Ame r i c a n C o l l e g e o f O b s t e t r i c i a n s and
Gynecologists

(ACOG, 1982) and t h e s e s u b j e c t s '

prenatal

care providers.

P r e v i o u s r e s e a r c h h a s i n d i c a t e d e a c h pound o f w e i g h t g a i n e d d u r i n g
p r e g n a n c y was a s s o c i a t e d w i t h a 4 4 - 5 0 g i n c r e a s e i n b i r t h w e i g h t
( Ea s t man and J a c k s o n ,
Abrams and L a r o s ,

1968; Ni s w a n d e r e t a l , 1969; Si mpson e t a l , 1974;

1986).

Results of the present study indicated t h a t ,

women who we i g h e d l e s s t h a n 120% o f r e f e r e n c e p r i o r t o p r e g n a n t ,

each

pound o f w e i g h t g a i n was a s s o c i a t e d w i t h a 2 0 . 5 ± 3 . 6 g i n c r e a s e

in

in

b i r t h w ei g ht . This i s l e s s t han h a l f t h e c o r r e s p o n d i n g i n c r e a s e in b i r t h
w e i g h t s e e n i n w h i t e Mi c h i g a n i n f a n t s

( s e e Mi c h i g a n M o t h e r ' s S u r v e y ) .

women who e n t e r e d p r e g n a n c y o v e r w e i g h t o r o b e s e ,

In

e a c h pound o f w e i g h t

g a i n e d d u r i n g p r e g n a n c y was a s s o c i a t e d w i t h a 1 5 . 7 ± 5 . 5 g i n c r e a s e

in

b i r t h weight.
M e t c o f f e t al

( 19 8 1 b )

indicated the c o rr e la tio n c o e f f ic i e n t s

b e t we e n w e i g h t g a i n and b i r t h w e i g h t i n mos t s u r v e y s a r e u s u a l l y a r o u n d
0.20 to 0.30.

Ni s w a n d e r and J a c k s o n

( 1974) n o t e d t h a t t h e s i m p l e

c o r r e l a t i o n b e t we e n b i r t h w e i g h t and w e i g h t g a i n among t h e 6 , 0 1 2 b l a c k
s u b j e c t s in t h e C o l l a b o r a t i v e P e r i n a t a l
study,

S t u d y was r = 0 . 2 2 .

In t h e p r e s e n t

t h e c o r r e l a t i o n b e t we e n t h e s e two v a r i a b l e s was much h i g h e r

(r=0.40),

e ve n t h o u g h t h e c o r r e s p o n d i n g b e t a w e i g h t s

(i.e.,

2 0 . 5 g and

1 5 . 7 g) we r e much l o w e r t h a n t h o s e u s u a l l y s e e n .
Naeye ( 1979) n o t e d o p t i m a l

i n f a n t o ut c ome was a s s o c i a t e d w i t h a

w e i g h t g a i n o f 30 pounds f o r u n d e r w e i g h t women. Brown ( 1986)
w e i g h t g a i n o f 33 pounds was a s s o c i a t e d w i t h an o p t i m a l

reported a

b i r t h weight of

3 , 0 0 0 t o 4 , 0 0 0 g i f t h e m o t h e r was u n d e r w e i g h t p r i o r t o p r e g n a n c y .
R e s u l t s o f t h i s s t u d y i n d i c a t e d a w e i g h t g a i n o f 34+9 pounds by

265

u n d e r w e i g h t women ( n=15) was a s s o c i a t e d w i t h an o p t i m a l

b i r t h weight of

3 , 5 0 0 t o 4 , 0 0 0 g . A much h i g h e r w e i g h t g a i n ( 40±14 l b s ) was a s s o c i a t e d
with optimal

b i r t h w e i g h t among women who e n t e r e d p r e g n a n c y a t o r n e a r

t h e i r d e s i r a b l e r e f e r e n c e w e i g h t ( n = 5 5 ) . The d e l i v e r y o f an OBW i n f a n t
by women who e n t e r e d p r e g n a n c y o v e r w e i g h t

( n=17) o r o b e s e (n=8) was

a s s o c i a t e d w i t h w e i g h t g a i n s o f 37±14 and 33±17 l b s ,
Bas ed on r e s u l t s p r e s e n t e d h e r e , t h e n u l l

respectively.

hypotheses are r e f u t e d .

T h e r e was a s i g n i f i c a n t d i f f e r e n c e i n amount o f w e i g h t g a i n e d by m o t h e r s
o f LBW and OBW i n f a n t s .

The amount o f w e i g h t g a i n e d by m o t h e r s o f LBW

i n f a n t s wa s , on a v e r a g e ,

two pounds l e s s t h a n t h e mean w e i g h t g a i n

r ecommended by t h e s u b j e c t s '

prenatal

care providers.

The e s t i m a t e d

r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t i n d i c a t e d a 2 2- 27 pound w e i g h t
g a i n was i n s u f f i c i e n t t o s u p p o r t t h e d e l i v e r y o f an OBW i n f a n t .
g a i n g r e a t e r t h a n 27 p o u n d s ,
2 2- 27 p o u n d s ,

A weight

as c ompar ed t o t h e g e n e r a l l y recommended

s i g n i f i c a n t l y r e d u c e d t h e i n c i d e n c e o f LBW.

R e s u l t s i n d i c a t e d t h e amount o f w e i g h t a woman g a i n e d c o u l d be
u s e d t o p r e d i c t b i r t h w e i g h t . The c o r r e l a t i o n b e t we e n t h e s e v a r i a b l e s
was s i g n i f i c a n t and h i g h l y p o s i t i v e ,
v a r i a n c e in b i r t h wei ght .

e x p l a i n i n g a p p r o x i m a t e l y 16% o f t h e

Surprisingly,

t h i s r e l a t i o n s h i p did not vary

among women who e n t e r e d p r e g n a n c y e i t h e r u n d e r w e i g h t ,
weight,

at t h e i r desirable

overweight or obese.

In sum, r e s u l t s o f t h i s

s t u d y i n d i c a t e d a 2 2 - 2 7 pound w e i g h t g a i n

d u r i n g p r e g n a n c y was i n s u f f i c i e n t t o s u p p o r t t h e d e v e l o p m e n t o f a f e t u s
who w e i g h s 3 , 0 0 0 t o 4 , 0 0 0 g a t t e r m f o r women i n a l l
categories.

p r e p r e g n a n t weight

I f s i g n i f i c a n t p r o g r e s s i s t o be made i n d e c r e a s i n g t h e LBW

and IMR r a t e s

in t h i s c o u n tr y ,

t h e s e r e s u l t s t h e me d i c a l

communi t y must

266

r e c o n s i d e r t h e p r e s e n t p r e g n a n c y w e i g h t g a i n r e c o m me n d a t i o n o f 22 t o 27
pounds f o r a l l women, r e g a r d l e s s o f p r e - p r e g n a n c y w e i g h t s t a t u s .

H04- 3 a :

Ma t e r n a l h e mo g l o b i n v a l u e s d u r i n g p r e g n a n c y do n o t d i f f e r
be t we e n b l a c k m o t h e r s who d e l i v e r o p t i m a l and l ow b i r t h
w e i g h t i n f a n t s and c a n n o t be u s e d t o p r e d i c t b i r t h w e i g h t .

The h i g h e s t and l o w e s t h e mo g l o b i n l e v e l s r e c o r d e d d u r i n g p r e g n a n c y
we r e p r o v i d e d by t h e p r e n a t a l

c a r e p r o v i d e r o f 216 c a s e s and c o n t r o l s .

I f o n l y one v a l u e was r e c o r d e d d u r i n g p r e g n a n c y ( n = 8 8 ) ,
the "highest" value.

No s t a t i s t i c a l l y

i t was c ode d as

significant difference

in t h e

h i g h e s t h e mo g l o b i n v a l u e s r e c o r d e d d u r i n g p r e g n a n c y was n o t e d be t we e n
m o t h e r s who d e l i v e r e d o p t i m a l o r l ow b i r t h w e i g h t i n f a n t s
A statistically

(Table 5 . 7 4 ) .

s i g n i f i c a n t d i f f e r e n c e b e t we e n t h e l o w e s t h e mo g l o b i n

r e a d i n g was o b s e r v e d . Mo t h e r s o f OBW i n f a n t s had 1ower h e mo g l o b i n l e v e l s
(11.1 g / d l

vs 1 1 . 6 g / d l ) .

Table 5.74.

Variable

Mean h i g h and low h e mo g l o b i n v a l u e s r e c o r d e d d u r i n g
p r e g n a n c y be t we e n b l a c k m o t h e r s o f c a s e s and c o n t r o l s .

LBW
(n)

OBW
(n)

t

p

H i g h e s t Hb, g / d l

1 2 . 3 ± 1. 1
( 110)

1 2 . 2 + 1. 1
( 106)

0.38

. 7037

Lowest Hb, g / d l

11.6 ± 1.2
( 73)

11. 1 ± 1 . 0
( 74)

2.58

. 0109

267

Similarly,

t h e c o r r e l a t i o n b e t we e n t h e l o w e s t h e mo g l o b i n v a l u e

r e c o r d e d d u r i n g p r e g n a n c y and b i r t h w e i g h t was s i g n i f i c a n t
Fp=5.96).

In c o n t r a s t ,

(r=0.18;

t h e c o r r e l a t i o n b e t we e n t h e h i g h e s t h e mogl obi n

v a l u e and b i r t h w e i g h t was n o t s i g n i f i c a n t
h e mo g l o b i n v a l u e s we r e c a t e g o r i z e d

(r= 0 .0 4 ; Fp=0.45).

(Murphy e t a l , 1 9 8 6 ) ,

When t h e

t h e odds r a t i o

did not i n d i c a t e a s t a t i s t i c a l l y s i g n i f i c a n t increased or decreased r i s k
o f d e l i v e r i n g a LBW i n f a n t i f t h e h i g h e s t h e mo g l o b i n v a l u e s r e c o r d e d
we r e g r e a t e r t h a n 1 3 . 2 g / d l

Table 5.75

o r l e s s than 10.4 g / d l

(Table 5.75).

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon m a t e r n a l h e mo g l o b i n l e v e l s r e c o r d e d
d u r i n g p r e g n a n c y among b l a c k s u b j e c t s .

Variable

Ca s e s
N

H i g h e s t Hb r e c o r d e d ( n=216)
< 1 0 . 4 g/dl

Controls
N

RR (95% Cl )

5

3

1.69 ( 0 . 3 9 - 7 . 2 8 )

10.4-13.2 g/dl

85

86

1.0a

> 1 3 . 2 g/dl

20

17

1.19 ( 0 . 5 8 - 2 . 4 3 )

a referent

T h i s o b s e r v a t i o n d o e s n o t s u p p o r t t h a t o f Murphy e t a l
r e p o r t e d h e mo g l o b i n l e v e l s g r e a t e r t h a n 1 3 . 2 g / d l

( 1986) who

i n p r e g n a n t women wer e

a s s o c i a t e d w i t h an i n c r e a s e d i n c i d e n c e o f p e r i n a t a l m o r t a l i t y ,

preterm

d e l i v e r y and l ow b i r t h w e i g h t as compar ed t o i n f a n t s o f women w i t h
i n t e r m e d i a t e h e mo g l o b i n l e v e l s

(10.4-13.2 g / d l ) .

T h e s e r e s e a r c h e r s had

s u g g e s t e d t h e h i g h h e mo g l o b i n l e v e l s r e f l e c t e d some f a i l u r e

i n pl as ma

268

vol ume e x p a n s i o n ,

resulting

in d e c re a s e d u t e r o p l a c e n t a l

c i r c u l a t i o n and

a c o n c o m i t a n t d e c r e a s e d b i r t h w e i g h t d ue t o a r e d u c e d s u p p l y o f
n u trie n ts to the fetus.

Naeye ( 1977) had a l s o h y p o t h e s i z e d h i g h

h e mo g l o b i n v a l u e s c o n t r i b u t e d t o t h e f o r m a t i o n o f p l a c e n t a l
whi c h r e s u l t e d

in d e c r e a s e d u t e r o p l a c e n t a l

infarcts,

flow, dec rea sed n u t r i e n t

t r a n s f e r and d e c r e a s e d i n f a n t s i z e .
Several

s t u d i e s h a ve i n d i c a t e d t h e s i z e o f t h e i n c r e a s e i n pl as ma

vol ume c o r r e l a t e s p o s i t i v e l y w i t h t h e b i r t h w e i g h t
1963;

P i r a n i e t a l , 1973; Du f f u s e t a l , 1 9 7 1 ) .

( H y t t e n and P a i n t i n ,

I t i s p o s s i b l e t h a t in

t h i s g r o u p o f b l a c k Mi c h i g a n m o t h e r s t h e l ow h e mo g l o b i n v a l u e was
a c t u a l l y a r e f l e c t i o n o f a h i g h e r maternal
contributed to the i n f a n t 's

pl a s ma vol ume whi ch

size.

Based upon t h e s e r e s u l t s ,

the null

hypotheses are r e f u t e d .

was a s i g n i f i c a n t d i f f e r e n c e i n t h e mean h e m a t o l o g i c v a l u e s ,

The r e

with

m o t h e r ' s o f OBW i n f a n t s h a v i n g a l o w e r " l o w e s t " h e mo g l o b i n r e a d i n g s .
addition,

In

t h e r e was a s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n be t we en

b i r t h w e i g h t and t h e l o w e s t h e mogl obi n v a l u e s r e c o r d e d d u r i n g p r e g n a n c y .
The p r a c t i c a l

physiological

11. 1 vs 1 1 . 6 g / d l ,

d i f f e r e n c e be t we e n a h e mo g l o b i n v a l u e o f

h o we v e r , must be q u e s t i o n e d .

269

H04- 3 b :

H i g h e s t and l o w e s t m a t e r n a l d i a s t o l i c b l o o d p r e s s u r e v a l u e s
r e c o r d e d d u r i n g p r e g n a n c y do n o t d i f f e r b e t we e n b l a c k
m o t h e r s who d e l i v e r o p t i m a l and l ow b i r t h w e i g h t i n f a n t s and
c a n n o t be u s e d t o p r e d i c t b i r t h w e i g h t .

H i g h e s t and l o w e s t d i a s t o l i c b l o o d p r e s s u r e r e c o r d i n g s we r e
p r o v i d e d by t h e p r e n a t a l

c a r e p r o v i d e r o f 229 c a s e s and c o n t r o l s .

R e s u l t s i n d i c a t e d a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e b e t we e n t h e
mean h i g h e s t ,

but not lowest,

d i a s t o l i c b l o o d p r e s s u r e r e a d i n g s be t we e n

m o t h e r s who d e l i v e r e d o p t i m a l o r low b i r t h w e i g h t i n f a n t s

Table 5.76.

(Table 5 .7 6) .

Mean h i g h and low d i a s t o l i c b l o o d p r e s s u r e (DBP)
r e a d i n g s d u r i n g p r e g n a n c y b e t we e n b l a c k m o t h e r s o f
c a s e s and c o n t r o l s .

Variable

LBW
( n=101)

OBW
( n = l 10)

t

H i g h e s t DBP, mm HG

7 8 . 6 ± 10

7 5 . 5 ± 10

2.32

0. 021

Lowest DBP, mm HG

59.5 ± 9

57 . 1 ± 10

1.85

0.065

P

The c o r r e l a t i o n b e t we e n t h e l o w e s t r e c o r d e d d i a s t o l i c b l o o d
p r e s s u r e r e a d i n g d u r i n g p r e g n a n c y and b i r t h w e i g h t was n o t s i g n i f i c a n t
(Table 5 .7 7 ) .

The c o r r e l a t i o n be t we e n t h e h i g h e s t r e c o r d e d b l o o d

p r e s s u r e r e a d i n g d u r i n g p r e g n a n c y and b i r t h w e i g h t was s t a t i s t i c a l l y
significant,

wi th each i ncr eme nt al

i n c r e a s e in d i a s t o l i c blood p r e s s u r e

a s s o c i a t e d with a 9 . 7 g d e c r e a s e in i n f a n t b i r t h w ei g ht .

270

Table 5.77.

C o r r e l a t i o n b e t we e n h i g h e s t and l o w e s t d i a s t o l i c b l o o d
p r e s s u r e r e a d i n g s r e c o r d e d d u r i n g p r e g n a n c y and i n f a n t
b i r t h w e i g h t among b l a c k Mi c h i g a n m o t h e r s .

Variable

R
a d j u s t e d R2
Be t a
Standard Error-Beta
Constant
F
P
n

Lowes t DBP

H i g h e s t DBP

-.10
.01
-7.8
5.1
3467
2.35
0.126
241

-.13
.01
-9.7
4.7
3767
4.27
0.040
243

H i g h e s t and l o w e s t d i a s t o l i c b l o o d p r e s s u r e v a l u e s wer e
c a t e g o r i z e d b a s e d on t h e o b s e r v a t i o n s o f G r u n b e r g e r e t al
Naeye ( 1 9 7 9 ) .

The c r u d e o dds r a t i o s

( 1979) and

i n d i c a t e d no a s s o c i a t i o n b e t we e n any

c a t e g o r y o f d i a s t o l i c b l o o d p r e s s u r e and l ow b i r t h w e i g h t

(Table 5 .7 8) .

271

Table 5.78.

E s t i m a t e d r e l a t i v e r i s k o f d e l i v e r i n g a LBW i n f a n t
d e p e n d e n t upon h i g h e s t and l o w e s t m a t e r n a l d i a s t o l i c
b l o o d p r e s s u r e r e a d i n g s d u r i n g p r e g n a n c y among b l a c k
subjects.

Variable

Ca s e s
N

Controls
N

RR (95% Cl )

H i q h e s t DBP r e c o r d e d ..( n = 2 1 1 ) :
< 65 mmHg
6 5 - 8 9 mmHg
9 0 - 9 9 mmHg
> 99 mmHg

6
81
11
3

13
86
9
2

0.49 (0.18-1.35)
la
1.30 ( 0 . 5 1 - 3 . 3 0 )
1.59 ( 0 . 2 6 - 9 . 7 6 )

77
24

87
21

0.77 (0 . 4 0 -1 . 4 9 )
la

-

-

Lowest DBP r e c o r d e d ( n = 2 0 9 ) :
< 65 mmHg
6 5 - 8 9 mmHg
9 0 - 9 9 mmHg
> 99 mmHg
a'

r

■

1

a referent

-

..........................................

Th e s e r e s u l t s do n o t s u p p o r t t h e o b s e r v a t i o n o f G r u n b e r g e r e t al
( 1979) and Naeye ( 1979) who i n d e p e n d e n t l y o b s e r v e d d i a s t o l i c b l o o d
p r e s s u r e r e a d i n g s l e s s t h a n 65 mm Hg we r e a s s o c i a t e d w i t h a d e c r e a s e d
i n f a n t b i r t h w e i g h t . G r u n b e r g e r e t al

( 1979) s u g g e s t e d t h a t a d i a s t o l i c

b l o o d p r e s s u r e l o w e r t h a n 65 mmHg r e d u c e d u t e r o p l a c e n t a l

perfusion,

d e c r e a s i n g t r a n s f e r o f n u t r i e n t s t o t h e f e t u s and r e s u l t i n g
infant.

in a sm a l le r

In t h e p r e s e n t s t u d y , t h e d e l i v e r y o f a l a r g e r baby was

a s s o c i a t e d with a lower d i a s t o l i c blood p r e s s u r e .
Results presented herein suggest t h a t ,

whi l e high mat ernal

d i a s t o l i c b l o o d p r e s s u r e v a l u e s d i d n o t d i f f e r be t we e n m o t h e r s who
d e l i v e r e d optimal

and l ow b i r t h w e i g h t i n f a n t s ,

low d i a s t o l i c b l o o d

Ill
pressures did d i f f e r ,
(r= - 0 . 1 3 ) .

and c o u l d be u s e d t o p r e d i c t i n f a n t b i r t h w e i g h t

Ea s e d upon t h e s e r e s u l t s ,

the null

h y p o t h e s e s t h a t h i gh

d i a s t o l i c b l o o d p r e s s u r e r e a d i n g s do n o t d i f f e r b e t we e n m o t h e r s o f LBW
and OBW m o t h e r s i s r e f u t e d . Mo t h e r s o f LBW i n f a n t s had s i g n i f i c a n t l y
h i g h e r "high" d i a s t o l i c blood p r e s s u r e r e a d i n g s , with each u n i t i n c r e a s e
in d i a s t o l i c p r e s s u r e a s s o c i a t e d with a 9.7 g decrement in b i r t h weight.
The n u l l

h y p o t h e s i s t h a t l ow d i a s t o l i c b l o o d p r e s s u r e r e a d i n g s do n o t

d i f f e r b e t we e n m o t h e r s o f c a s e s and c o n t r o l s ,

h o we v e r , mus t be r e t a i n e d .

Caut ion i s w a r r a n t e d in i n t e r p r e t i n g t h e s e r e s u l t s .

Peak d i a s t o l i c

b l o o d p r e s s u r e v a l u e s we r e d i s c a r d e d d u r i n g d a t a e n t r y due i f an
a p p a r e n t m i s i n t e r p r e t a t i o n o f t h e q u e s t i o n by r e s p o n d e n t s was n o t e d .
Da t a we r e d i s c a r d e d i f t h e p e a k d i a s t o l i c r e a d i n g was r e p o r t e d t o be 120
mm Hg o r g r e a t e r w i t h no m e n t i o n made o f a d i a g n o s i s o f h y p e r t e n s i o n o r
toxemia.

(REMINDER: S u b j e c t s we r e e x c l u d e d f r om t h e s a m p l i n g f r a me i f ,

according to the b i r t h c e r t i f i c a t e ,
p a t i e n t as h a v i n g h y p e r t e n s i o n ,
pregnancy).

t h e p h y s i c i a n had d i a g n o s e d t h e

p r e- e c la m p s i a or toxemia during

I t a p p e a r e d t o t h i s r e s e a r c h e r t h a t some r e s p o n d e n t s had

p r o v i d e d t h e s u b j e c t ' s s y s t o l i c and d i a s t o l i c b l o o d p r e s s u r e s ,

rather

t h a n t h e h i g h and l ow d i a s t o l i c p r e s s u r e s . T h i s o b s e r v a t i o n was
e s p e c i a l l y n o t i c e a b l e when a me d i c a l
s u r v e y . Th u s ,

r e c o r d s a s s i s t a n t had c o m p l e t e d t h e

i t a p p e a r s b i a s ha s be e n i n t r o d u c e d i n t o t h i s q u e s t i o n .

T h e r e i s no r e a s o n t o b e l i e v e ,

on t h e o t h e r ha n d ,

lower d i a s t o l i c blood p r e s s u r e r e a d i n g s .

t h e r e i s b i a s in t he

273

HO^-4: The q u a l i t y o f p r e n a t a l c a r e , as me a s u r e d by t h e K e s s n e r I n d e x ,
d o e s n o t d i f f e r b e t we e n m o t h e r s who d e l i v e r o p t i m a l and l ow b i r t h
w e i g h t i n f a n t s and c a n n o t be u s e d t o p r e d i c t b i r t h w e i g h t .

R e s u l t s o f t h e Mi c h i g a n M o t h e r ' s S t u d y i n d i c a t e d 78% o f t h e
m o t h e r s o f b o t h LBW and OBW i n f a n t s began t h e i r p r e n a t a l
f ir s t trimester.

T h i s p e r c e n t a g e e x c e e d s t h e 1986 U. S.

c a r e in t h e

a v e r a g e ( 76%) ,

b u t i s l e s s t h a n t h e h e a l t h o b j e c t i v e f o r t h e y e a r 2000 whi ch recommends
t h a t a t l e a s t 90% o f a l l
the f i r s t

p r e g n a n t women s h o u l d r e c e i v e p r e n a t a l

c a r e in

t r i m e s t e r o f p r e g n a n c y (DHHS, 1 9 8 9 ) .

The K e s s n e r I n d e x i n d i c a t e d 69% o f t h e c a s e s and 74% o f c o n t r o l s
in the P h y sicia n 's

Prenatal

obtained adequate prenatal

Ca r e S u r v e y o f B l a c k Mi c h i g a n Mo t h e r s
care during t h e i r pregnancies.

The p e r c e n t o f

women r e c e i v i n g a d e q u a t e c a r e i n t h i s s u r v e y was h i g h e r t h a n t h e s t a t e
o f Mi c h i g a n i n 1987, when a d e q u a t e p r e n a t a l

c a r e was o b t a i n e d by o n l y

61. 8% o f t h e m o t h e r s o f l i v e bor n b l a c k i n f a n t s
this

s a mp l e ,

(MDPH, 1 9 8 9 ) . Wi t h i n

Chi S q u a r e a n a l y s i s i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e

t h e K e s s n e r I n d e x b e t we e n m o t h e r s o f c a s e s and c o n t r o l s

T a b l e 5 . 7 9 . K e s s n e r I ndex c l a s s i f i c a t i o n o f p r e n a t a l
b l a c k m o t h e r s o f c a s e s and c o n t r o l s .

K essner Index
Classification

LBW
(n=134)

92

90

Intermediate

31

24

Inadequate

11

8

(Table 5 .7 9 ) .

c a r e o b t a i n e d by

OBW
( n= 122)

Adequate Care

in

X2

0.83

p

. 6617

274

When t h e K e s s n e r I n d e x was a n a l y z e d by i t s compone nt p a r t s ,
s i g n i f i c a n t d i f f e r e n c e was n o t e d i n t h e month p r e n a t a l
vs 2 . 8 ;

t=0.237).

12.7 ± 4 . 4 ;

However , t h e number o f p r e n a t a l

no

c a r e be ga n ( 2 . 8

visits

( 1 1 . 4 ± 4 . 0 vs

t = 2 . 5 4 ; p = 0 . 0 1 2 ) and t h e e s t i m a t e d weeks o f g e s t a t i o n

(38.6

± 1 . 5 vs 3 9 . 8 ± 1 . 2 ; t = 7 . 1 2 ; p = 0 . 0 0 0 ) we r e s i g n i f i c a n t l y l o w e r among
c a s e s t h a n c o n t r o l s . When t h e s e t h r e e i n d i v i d u a l

c o mp o n e n t s and t h e

K e s s n e r I ndex we r e r e g r e s s e d a g a i n s t b i r t h w e i g h t ,
i n i n f a n t b i r t h w e i g h t was e x p l a i n e d
variables,

13% o f t h e v a r i a n c e

( T a b l e 5 . 8 0 ) . Of t h e s e f o u r

o n l y t h e v a r i a b l e " e s t i m a t e d weeks g e s t a t i o n " was

s t a t i s t i c a l l y s i g n i f i c a n t , w i t h e a c h week o f g e s t a t i o n a s s o c i a t e d w i t h a
17 4 . 5 g i n c r e a s e i n b i r t h w e i g h t .

No o t h e r v a r i a b l e c o n t r i b u t e d

s i g n i f i c a n t l y t o t h e v a r i a n c e i n b i r t h w e i g h t i n t h i s s a mp l e .

Table 5.80

R e g r e s s i o n a n a l y s i s o f t h e K e s s n e r I n d e x , number o f p r e n a t a l
v i s i t s , month p r e n a t a l c a r e began and e s t i m a t e d weeks
g e s t a t i o n w i t h b i r t h w e i g h t among i n f a n t s o f b l a c k m o t h e r s .

B

Var i a b l e s

SE-B

Regression T
Coefficient

Si g T

- 108

71

-.09

-1.52

. 1299

Weeks g e s t a t i o n

174.5

27

.351

6.40

. 0000

2. 1

3.2

. 038

0.64

. 5237

-0.2

4.6

o
o
1

-0.04

. 9662

- 3766

1069

# Prenatal

visits

Month c a r e began
Constant
R
R2
F
DF
p

0.36
0.13
11. 1
(4,292)
. 0000

CO

K e s s n e r I ndex

-3.51

. 0005

275

Early,

high q u a l i t y p r e n a t a l

c a r e h a s be e n h i g h l y c o r r e l a t e d w i t h

h e a l t h i e r p r e g n a n c i e s and t h e p r e v e n t i o n o f p o o r p r e g n a n c y out come
(DHHS, 1 9 8 9 b ) . R e s u l t s o f t h e p r e s e n t s t u d y ,
any s i g n i f i c a n t d i f f e r e n c e s

h o we ve r , do n o t i n d i c a t e

in t he q u a l i t y of c a r e ,

a s d e f i n e d by t h e

K e s s n e r I n d e x , b e t we e n m o t h e r s o f c a s e s and c o n t r o l s .
the null

h y p o t h e s i s mus t be r e t a i n e d :

For t h a t r e a s o n ,

t h e Kessner Index,

i s n o t d i f f e r e n t b e t we e n m o t h e r s o f c a s e s and c o n t r o l s ,

in t h i s study,
and c a n n o t be

used t o p r e d i c t i n f a n t b i r t h w e i g h t .
Al l

i n f a n t s in t h e p r e s e n t s tu dy ,

t h e y we r e " t e r m i n f a n t s " .

h o we v e r , we r e s e l e c t e d b e c a u s e

Results obtained herein suggest the selection

c r i t e r i a o f "term i n f a n t s " ,

and t h e b i a s t h a t r e s u l t e d f r om r e s p o n d e r s

o f c a s e s h a v i n g had s i g n i f i c a n t l y h i g h e r K e s s n e r I n d e x s c o r e s t h a n n o n ­
responders,

a p p e a r e d t o f o r c e t h e s a mpl e p o p u l a t i o n

i n to having a

K e s s n e r I n d e x whi c h was n o t s i g n i f i c a n t l y d i f f e r e n t b e t we e n g r o u p s .
Thus ,

in t h i s s t u d y ,

t h e Kessner Index does not f u n c t i o n as a

d i s c r i m i n a t i n g independent v a r i a b l e to p r e d i c t b i r t h weight.

M u l t i p l e R e g r e s s i o n A n a l y s i s t o P r e d i c t B i r t h Wei ght
Two m u l t i p l e r e g r e s s i o n e q u a t i o n s
p r e d i c t b i r t h weight,

( s t e p w i s e and " e n t e r " )

to

b a s e d on a s a mpl e c o n s i s t i n g p r i m a r i l y o f b l a c k

LBW and OBW i n f a n t s ,

a c c o u n t e d f o r 34-37% o f t h e v a r i a n c e i n b i r t h

wei ght (Table 5 . 8 1 ) .

Due t o t h e d e s i g n o f t h i s s t u d y ,

these equations

a r e u n i q u e t o t h e l i t e r a t u r e and c a n n o t be d i r e c t l y c o mp a r e d . A

276

r e g r e s s i o n e q u a t i o n b a s e d s o l e l y on b l a c k i n f a n t s was n o t l o c a t e d i n t h e
literature.
ages,

In g e n e r a l ,

h o we ve r ,

a b o u t 40% o f t h e v a r i a t i o n

by weeks o f g e s t a t i o n ,

f o r i n f a n t s born a t a l l

gestational

i n b i r t h w e i g h t h a s be e n a c c o u n t e d f o r

p ren atal weight gain,

prepregnancy weight s t a t u s

and s moki ng d u r i n g p r e g n a n c y ( Ande r s on e t a l , 1984; Bur ke e t a l , 1943;
Bur ke e t a l , 1949; M e t c o f f e t a l , 1 9 8 1 b ) , w i t h weeks g e s t a t i o n
a c c o u n t i n g f o r t h e l a r g e s t p r o p o r t i o n o f v a r i a n c e i n e a c h s t u d y . Thus ,
t h e m u l t i p l e R and t h e p e r c e n t o f v a r i a n c e e x p l a i n e d by t h e two
e q u a t i o n s p r e s e n t e d h e r e a p p e a r t o be i n t h e r e a l m o f v a l u e s r e p o r t e d
the l i t e r a t u r e .

in

277

Tabl e 5.81

Two m u l t i p l e r e g r e s s i o n e q u a t i o n s t o p r e d i c t b i r t h w e i g h t o f
black i n f a n t s .

Equation #1: Stepwise
b
t
Sig t

Variable
B

Weight gain
Weeks gestation
Hemoglobin, g/dl
Height, inches

Equation #2 : Enter
b
t

B

Sig t

18

0.37

5.06

.0000

18.6

0.38

5.17

.0000

138

0.28

3.83

.0002

131

0.26

3.57

.0005

-138

-0.21

2.87

.0048

3.10

.0024

41

0.15

2.09

.0383

2.07

.0408

1.68

.0965

0.13

1.72

.0884

0.10

1.33

.1858

1.34

.1826

-158
41.3

-0.24
0.15

Diastolic BP, mmHG

NS

-10.0

% 1983 prepregnant

NS

3.7

Previous chi Id (n=1)

NS

Kessner Index

NS

-120

Both parents named

NS

53

0.05

0.65

.5170

Mother's age

NS

9.5

0.05

0.67

.5017

Female sex

NS

-30.9

-0.02

0.28

.7812

Mother's education

NS

-3.4

-0.02

0.32

.7472

-1.78

.0790

R
R2 ,%
SE-B
DF
F
p

-2.10

-4095

Constant

.0380

0.563
32
626 g
(4,134)
15.54
.0000

148

-0.13

-0.10

-3592

0.609
37
619 g
(12,126)
6.20
.0000

In b o t h e q u a t i o n s ,

pregnancy weight gain accounted f o r the l a r g e s t

p r o p o r t i o n o f v a r i a n c e e x p l a i n e d i n t h i s s t u d y ( 37- 38%) ,

accounting for

a p p r o x i m a t e l y 14% o f t h e t o t a l

E s t i m a t e d weeks

va ria nc e in b i r t h weight.

g e s t a t i o n accounted f o r the next l a r g e s t p ro p o rtio n of explained
v a r i a n c e i n b i r t h w e i g h t (26-28% o f e x p l a i n e d ,
in b i r t h we ig h t).

8% o f t h e t o t a l

variance

Each pound o f w e i g h t g a i n e d d u r i n g p r e g n a n c y was

a s s o c i a t e d w i t h an i n c r e a s e o f 180- 185 g i n i n f a n t b i r t h w e i g h t .

278

The i n c l u s i o n o f m a t e r n a l

h e mo g l o b i n v a l u e s i n t h e r e g r e s s i o n

e q u a t i o n s i n d i c a t e d t h e h i g h e r t h e h e mo g l o b i n r e a d i n g s ,
b irth weight.

Each i n c r e m e n t a l

i n c r e a s e i n h e mo g l o b i n ( g / d l ) was

a s s o c i a t e d w i t h a 158 g d e c r e m e n t i n b i r t h w e i g h t
t r e n d was t r u e f o r a d i a s t o l i c b l o o d p r e s s u r e .
at p < 0.05,

t h e lower t he

(p=0.0024).

The same

Although not s i g n i f i c a n t

e a c h mm Hg i n c r e a s e i n d i a s t o l i c b l o o d p r e s s u r e was

a s s o c i a t e d w i t h a 10 g d e c r e m e n t i n b i r t h w e i g h t ( p = 0 . 0 9 6 5 ) .
Mat er nal

age and e d u c a t i o n h a ve be e n r e p o r t e d t o a c c o u n t f o r as

much a s e i g h t p e r c e n t o f t h e v a r i a n c e i n b i r t h w e i g h t
1 9 8 1 b ) . An d e r s o n e t al

( 1984) r e p o r t e d a 7 . 1 g i n c r e a s e i n b i r t h w e i g h t

f o r each y e a r o f mat ernal
maternal

(Metcoff e t a l ,

age (R2= 0 . 0 0 3 ) .

In t h i s

study,

increasing

age was a s s o c i a t e d w i t h a n o n - s i g n i f i c a n t 9 . 5 g i n c r e a s e i n

b i r t h we ight f o r each y e a r ( e q u a t i o n #2) . Maternal
a s s o c i a t e d wi t h b i r t h we ight in t h i s s t u d y .

e d u c a t i o n was n o t

Delive ry of a female i n f a n t

was a s s o c i a t e d w i t h a n o n - s i g n i f i c a n t d e c r e m e n t i n b i r t h w e i g h t o f 51 g.
P r e v i o u s r e s e a r c h i n d i c a t e s f e m a l e i n f a n t s we i g h e d 171 g ( An d e r s o n e t
a l , 1984) and 118 g ( D o u g h e r t y e t a l , 1982) l e s s t h a n m a l e s .
In summary, t h e s e p r e d i c t i o n e q u a t i o n s ,
v a r i a b l e s o f " lo wes t d i a s t o l i c blood p r e s s u r e "
value",

i n c l u d in g the unique
and " l o w e s t h e mo g l o b i n

a p p e a r t o make a u n i q u e c o n t r i b u t i o n t o t h e f i e l d .

inclusion of education,
certificate

i n f a n t sex,

The l a c k o f

number o f named p a r e n t s on t h e b i r t h

and t h e K e s s n e r I n d e x s c o r e o f p r e n a t a l

c a r e was u n e x p e c t e d .

279

Summary: P h y s i c i a n ' s P r e n a t a l

Ca r e S u r v e y o f Bl a c k Mi c h i g a n Mot he r s

R e s u l t s o f t h e P h y s i c i a n ' s P r e n a t a l Ca r e S u r v e y o f B l a c k Mi c hi ga n
Mothers,

a s t u d y o f a p p r o x i m a t e l y 301 b l a c k Mi c h i g a n r e s i d e n t s be t we en

t h e a g e s o f 2 0 - 3 4 who we r e d e l i v e r e d o f e i t h e r t h e i r f i r s t
c h i l d b e t we e n J a n u a r y 1,

1987 and November 30,

1988,

or second

identified

several

m o d i f i a b l e r i s k f a c t o r s f o r t h e d e l i v e r y o f a low b i r t h w e i g h t i n f a n t .
I n a d d i t i o n t o t h e known LBW r i s k f a c t o r o f number o f weeks g e s t a t i o n ,
results

i n d i c a t e d t h e f o l l o w i n g r i s k f a c t o r s d i f f e r e d b e t we e n m o t h e r s

who d e l i v e r e d LBW and OBW i n f a n t s and c o u l d be us e d t o p r e d i c t b i r t h
weight:

1)

A w e i g h t g a i n t o l e s s t h a n 120%

of one's

r e f e r e n c e weight a t term. A gain t o l e s s

1983 M e t r o p o l i t a n
than

120% was a s s o c i a t e d

w i t h a 275% h i g h e r r i s k o f LBW.

2)

A w e i g h t g a i n o f l e s s t h a n 7 kg

(15.5 lbs)

i f one's pre-pregnant

w e i g h t was 120% o r more o f t h e 1959 o r 1983 M e t r o p o l i t a n
r e f e r e n c e . A w e i g h t g a i n o f l e s s t h a n 7 kg was a s s o c i a t e d w i t h
an e i g h t - f o l d

3)

i n c r e a s e d r i s k o f d e l i v e r i n g a LBW i n f a n t .

Pregnancy weight g a i n .

A w e i g h t g a i n l e s s t h a n 22 l b s was

a s s o c i a t e d w i t h a n i n e - f o l d i n c r e a s e d r i s k o f LBW as compar ed t o
a woman who g a i n e d more t h a n 27 l b s . A w e i g h t g a i n o f 22- 27
pounds was s t i l l

a s s o c i a t e d w i t h a 279% i n c r e a s e d r i s k o f LBW.

280

4)

Maternal

h e mo g l o b i n l e v e l .

Women who d e l i v e r e d o p t i m a l

birth

w e i g h t i n f a n t s had a s i g n i f i c a n t l y l o w e r h e mo g l o b i n l e v e l s t h a n
m o t h e r s o f LBW i n f a n t s ,

although the physiological

s i g n i f i c a n c e of

the diffe re nc e is questionable.

Several

f a c t o r s h y p o t h e s i z e d t o be a s s o c i a t e d w i t h LBW we r e n o t

a s s o c i a t e d w i t h an i n c r e a s e d r i s k o f LBW i n t h i s s t u d y . Th e s e f a c t o r s
included a s u b j e c t ' s prepregnancy w e i g h t - f o r - h e i g h t ,
underweight,

t h e Kessner Index o f p r e n a t a l

especially

if

c a r e , m o t h e r ' s e d u c a t i o n and

age and t h e number o f p a r e n t s named on t h e b i r t h c e r t i f i c a t e .

The r e a s o n

f o r t h e l a c k o f a s s o c i a t i o n b e t we e n t h e s e v a r i a b l e s and b i r t h w e i g h t
c a n n o t be a s c e r t a i n e d f r om t h e a v a i l a b l e i n f o r m a t i o n .
R e s u l t s o f t h i s p r e s e n t s t u d y can be u s e d i n p r o g r a m p l a n n i n g a t
the lo c a l,

s t a t e and n a t i o n a l

a t r i s k f o r l ow b i r t h w e i g h t .

level

to ta rg e t sp e cific sub-populations

P r e n a t a l c a r e p r o v i d e r s mus t be made awar e

o f t h e i n c r e a s i n g body o f l i t e r a t u r e whi ch s u p p o r t s t h e a s s o c i a t i o n
b e t we e n a h i g h e r w e i g h t g a i n d u r i n g p r e g n a n c y and a more " o p t i m a l " b i r t h
w e i g h t o f a t l e a s t 3 , 3 0 0 g o r mor e.

Evidence p r e s e n t e d i n d i c a t e d a

w e i g h t g a i n o f 22- 27 pounds was n o t a d e q u a t e p r o t e c t i o n a g a i n s t t h e
d e l i v e r y o f a LBW i n f a n t f o r women o f a l l

pre-pregnancy weights.

P h y s i c i a n ' s s h o u l d be u r g e d t o r e c o r d b o t h t h e s u b j e c t ' s h e i g h t and
wei ght d u r i n g t h e f i r s t p r e n a t a l
education,

visit.

Thr ough i mpr ove d p a t i e n t

and c o n c o m i t a n t p a t i e n t c o m p l i a n c e ,

in fa n t b i r t h weight,

an i n c r e a s e i n t h e mean

and r e d u c t i o n i n i n f a n t m o r t a l i t y and m o r b i d i t y

a s s o c i a t e d w i t h LBW, s h o u l d o c c u r .

281

Results of the Physician's Prenatal

Ca r e S u r v e y o f B l a c k Mi c h i g a n

Mo t h e r s mus t be c o n s i d e r e d p r e l i m i n a r y . Wi t h o u t c o m p l e t e i n f o r m a t i o n
r e g a r d i n g s uc h f a c t o r s a s s moki ng, d i e t q u a l i t y ,
socioeconomic s t a t u s ,

d r u g u s e and

the t r u e e f f e c t of t h e f a c t o r s p r e s e n t e d in t h i s

s t u d y on b i r t h w e i g h t c a n n o t be s t a t e d w i t h c o n f i d e n c e .

CHAPTER VI

LIMITATIONS, CONCLUSIONS AND RECOMMENDATIONS

L i m i t a t i o n s o f t h e P r e s e n t Study

The r e a d e r i s e n c o u r a g e d t o b e a r i n mind t h e f o l l o w i n g l i m i t a t i o n s
o f t h i s s tu d y in both t h e i n t e r p r e t a t i o n o f r e s u l t s

and t h e a p p l i c a t i o n

o f i t s recommendations:
1.

Analysis of sociodemographic d a ta i n d i c a t e d a p o t e n t i a l

r e s p o n s e b i a s among LBW i n f a n t s
review of the l i t e r a t u r e
appear to r e s u l t
II e r r o r

2.

( b o t h b l a c k and w h i t e ) .

( I n s t i t u t e of Medicine,

Bas ed on a

1 9 8 5 ) , t h e b i a s woul d

i n an a t t e n u a t i o n t o w a r d t h e mean and a p o t e n t i a l

( r e p o r t i n g "no d i f f e r e n c e " when,

in f a c t ,

Type

a difference exists).

Da t a o b t a i n e d f r om t h e w h i t e m o t h e r s was s e l f - r e p o r t e d .

V a l id a t io n checks o f maternal

h e i g h t and p r e - p r e g n a n t and t e r m w e i g h t s

i n d i c a t e d a h i g h c o r r e l a t i o n b e t we e n t h e p h y s i c i a n - r e c o r d e d
a n t h r o p o m e t r i c d a t a and m a t e r n a l

s e lf-re p o rte d data

However, t h e v a l i d i t y o f t h e p o s t - t e r m w e i g h t ,

and a l l

d i e t a r y and s o c i o d e m o g r a p h i c d a t a o b t a i n e d i n t h i s
t h e m o t h e r s must be c o n s i d e r e d c o n d i t i o n a l .

282

(Table 5 . 5 ) .
other behavioral,

s u r v e y d i r e c t l y from

283

3.

A l t h o u g h t h e v a l i d i t y and r e l i a b i l i t y o f t h e W i l l e t t Semi-

Q u a n t i t a t i v e Food F r e q u e n c y Q u e s t i o n n a i r e i n s t r u m e n t h a s been
e s t a b l i s h e d among a n o n - p r e g n a n t p o p u l a t i o n
review o f the l i t e r a t u r e

( W i l l e t t e t a l , 1987),

a

i n d i c a t e d t h e i n s t r u m e n t had n o t be e n us e d

p r e v i o u s l y i n a p r e g n a n t p o p u l a t i o n i n a r e t r o s p e c t i v e s t u d y . Th u s ,
d i e t a r y i n fo r m a tio n o b t ai n e d in t h i s

the

s t u d y mus t be c o n s i d e r e d

conditional.

4.

I n f o r m a t i o n o b t a i n e d i n t h i s s t u d y f r om t h e p r e n a t a l

care

p r o v i d e r o f t h e r a n d o ml y s e l e c t e d b l a c k s u b j e c t s was i n s u f f i c i e n t t o
a c c u r a t e l y a s s e s s t h e p r o f i l e o f c o n d i t i o n s a s s o c i a t e d w i t h low b i r t h
weight.
32b),

In a d d i t i o n t o a p o s s i b l e g e o g r a p h i c r e s p o n s e b i a s

info rmatio n r ega rdin g substance abuse,

maternal

b irth weight,

a d e q u a c y we r e m i s s i n g .

e c onomi c s t a t u s ,
Th u s ,

behavioral

social

( Appe ndi x

characteristics,

s u p p o r t and d i e t a r y

r e s u l ts of the Prenatal

Ca r e S u r v e y o f

B l a c k Mi c h i g a n Mo t h e r s must be c o n s i d e r e d p r o v i s i o n a l .

5.

I n f o r m a t i o n r e g a r d i n g o v e r - t h e - c o u n t e r and i l l i c i t d r u g us e

was n o t c o l l e c t e d

in t h i s

study.

Re a s ons f o r t h i s

included concerns of

t h e Human S u b j e c t ' s Commi t t e e a t Mi c h i g a n S t a t e U n i v e r s i t y ,

concerns of

t h e r e s e a r c h e r and g u i d a n c e c o mm i t t e e r e g a r d i n g t h e i n f l u e n c e o f such
q u e s t i o n s on t h e r e s p o n s e r a t e ,
r e p o r t e d drug us e,

and l e g a l

concerns of the v a l i d i t y of s e l f -

concerns reg a rd in g the p r o v is i o n of t h i s

i n f o r m a t i o n by t h e s u b j e c t ' s p r e n a t a l
t h a t th e confounding v a r i a b l e ,

care provider.

It

is recognized

" d r u g u s e d u r i n g p r e g n a n c y " may have

i n f l u e n c e d t h e r e s u l t s o f t h i s s t u d y i n an unknown f a s h i o n .

284

6.

R e s u l t s o f t h e s t u d y must be i n t e r p r e t e d w i t h c a r e .

a r e b a s e d on a c a s e - c o n t r o l

s a mp l i n g d e s i g n .

m o t h e r s who d e l i v e r e d LBW and OBW i n f a n t s .

Subjects c o n s is te d of

I t woul d be i n c o r r e c t t o

as sume t h e s t r e n g t h o f t h e a s s o c i a t i o n s f o u n d i n t h i s
r e p e a t e d i n a r andom s e l e c t i o n o f i n f a n t s o f a l l

7.
as " t e r m"

Lastly,

all

Results

i n f a n t s s e l e c t e d in t h i s

s t u d y woul d be

b irth weights.

s t u d y we r e c l a s s i f i e d

i n f a n t s a c c o r d i n g t o t h e c o m p u t e r - c a l c u l a t e d number o f weeks

g e s t a t i o n b a s e d on t h e l a s t m e n s t r u a l

period date.

D i s c r e p a n c i e s we r e

n o t e d b e t we e n t h e p h y s i c i a n - r e p o r t e d l e n g t h o f g e s t a t i o n and t h e
computer-generated length of g e sta tio n .
computer-generated data suggested all

For t h i s r e a s o n ,

although

s u b j e c t s we r e " t e r m " ,

m i g h t n o t have a c t u a l l y be e n t e r m i n f a n t s .

the infants

Which o f t h e s e two m e a s u r e s

o f g e s t a t i o n was most a c c u r a t e i s unknown.

Conclusions

R e s u l t s o f t h i s s t u d y i n d i c a t e d t h e f o l l o w i n g we r e r i s k f a c t o r s
f o r LBW: 1) a w e i g h t g a i n t o l e s s t h a n 120% o f o n e ' s 1983 t e r m
M e t r o p o l i t a n r e f e r e n c e w e i g h t ( w h i t e and b l a c k ) ,
l e s s t h a n 7 kg ( 1 5 . 5 l b s )

2) a w e i g h t g a i n o f

i f t h e m o t h e r was o b e s e p r i o r t o p r e g n a n c y

(black),

3) a p r e - p r e g n a n t w e i g h t - f o r - h e i g h t l e s s t h a n 90% o f r e f e r e n c e

(white),

4) a w e i g h t g a i n o f 27 pounds o r l e s s

addition,

( w h i t e and b l a c k ) .

r e s u l t s o f t h e w h i t e Mi c h i g a n m o t h e r s '

In

survey in d ic a te d the

285

f o l l o w i n g r i s k f a c t o r s w e r e a s s o c i a t e d w i t h t h e d e l i v e r y o f a LBW, as
c ompa r ed t o an OBW, i n f a n t :
2) c i g a r e t t e c o n s u m p t i o n ,

1) m a t e r n a l

b i r t h w e i g h t l e s s t h a n 2 , 5 0 0 g,

3) c o n s u m p t i o n o f 100 g a l c o h o l / w e e k ,

c o n s u m p t i o n o f more t h a n 300 mg c a f f e i n e / d a y ,

4)

5) c o n s u m p t i o n o f a l e s s

n u t r i e n t - d e n s e d i e t and 6) a more p o s i t i v e a t t i t u d e t o w a r d w e i g h t g a i n .
Based on t h e c ombi ne d r e s u l t s o f t h e Whi t e Mi c h i g a n M o t h e r ' s
S u r v e y and t h e P h y s i c i a n ' s
Mothers,

1.

Prenatal

Ca r e S u r v e y o f Bl a c k Mi c hi ga n

t h e f o l l o w i n g r e c o m m e n d a t i o n s f o r p r e g n a n c y a r e made:

Women s h o u l d be e n c o u r a g e d t o g a i n t o 120% o f t h e i r 1983
Metropolitan reference w eight-for-height.
gain to t h i s level

Clearly,

was a s s o c i a t e d w i t h a d e c r e a s e d

a weight
incidence of

LBW and a h i g h e r b i r t h w e i g h t i n b o t h b l a c k and w h i t e s u b j e c t s .

2.

A w e i g h t g a i n o f 2 2 - 2 7 pounds i s c l e a r l y n o t a d e q u a t e t o
t h e development o f a 3,500 g i n f a n t .
was a s s o c i a t e d w i t h o p t i m a l
and nor mal w e i g h t s u b j e c t s

support

A w e i g h t g a i n o f 34 pounds

b i r t h w e i g h t i n f a n t s among u n d e r w e i g h t
in t h i s

s t u d y . Women who wei gh more

t h a n 120% o f t h e i r 1983 r e f e r e n c e p r i o r t o p r e g n a n c y s h o u l d be
e n c o u r a g e d t o g a i n a t l e a s t a minimum o f 15 p o u n d s ,

3.

i f n o t mor e.

P h y s i c i a n ' s s h o u l d be u r g e d t o d e t e r m i n e t h e wome n' s own

birth

weight.

LBW m o t h e r s a r e a t i n c r e a s e d r i s k o f d e l i v e r i n g LBW

babies.

However , w i t h an i n c r e a s e d w e i g h t g a i n ,

to decrease.

the r i s k appears

286

4.

Women s h o u l d be e n c o u r a g e d t o s t o p s moki ng c i g a r e t t e s

and r e d u c e

t h e i r c o n s u m p t i o n o f c a f f e i n e t o l e s s t h a n 300 mg p e r day
( a p p r o x i m a t e l y t h r e e cups o f c o f f e e ) .

5.

Women s h o u l d be e n c o u r a g e d t o c o n s u l t w i t h a d i e t i t i a n

regarding

th e q u a l i t y of t h e i r d i e t during pregnancy, e s p e c i a l l y the
s e l e c t i o n of n u t r i e n t - d e n s e foods.

The d e t e r m i n a n t s o f i n f a n t b i r t h w e i g h t a r e v a r i e d and c o mpl e x.
Results presented here,

although s t a t i s t i c a l l y

significant,

only

e x p l a i n e d 30-40% o f t h e v a r i a n c e i n b i r t h w e i g h t . T h i s amount o f
e x p l a i n e d v a r i a n c e i s s i m i l a r t o t h a t r e p o r t e d by o t h e r r e s e a r c h e r s i n
the f i e l d

(Metcoff,

physiological

1981b, An d e r s o n e t a l , 1 9 8 4 ) .

Perhaps because of the

c o m p l e x i t i e s and a d a p t a t i o n mec ha ni s ms t h a t a p p e a r t o be

a s s o c i a t e d with pregnancy,

researchers will

n e v e r be a b l e t o p r e d i c t

b i r t h weight with g r e a t e r accuracy than t h i s .

Nonetheless,

by

c o n t r a s t i n g low b i r t h w e i g h t i n f a n t s w i t h i n f a n t s o f " o p t i m a l b i r t h
weight",
wh i c h ,

the re s u lts of th is

i f followed,

s t u d y do p r o v i d e s p e c i f i c r e c o m m e n d a t i o n s

s h o u l d h e l p r e d u c e t h e i n c i d e n c e o f LBW, and t h e

concomitant i n f a n t m o r t a l i t y ,

i n t h i s s t a t e and t h i s c o u n t r y .

287

Suggestions f o r Future St udies

The c o l l e c t i o n ,

i n t e r p r e t a t i o n and d i s c u s s i o n o f t h e d a t a f o r t h i s

s t u d y p r o v i d e d an o p p o r t u n i t y t o c o n s i d e r s e v e r a l

ideas for future

r e s e a r c h . An a b b r e v i a t e d l i s t f o l l o w s :
1.

I f a s i m i l a r s t u d y was r e p e a t e d ,

t h is researcher suggests the

f o l l o w i n g d a t a be c o l l e c t e d .
a)

the in fa n ts '

l e n g t h and he a d c i r c u m f e r e n c e

b)

the f a t h e r 's

b i r t h weight

c)

information regarding the mother's social

d)

p a s s i v e s moki ng i n t h e home/ wor k p l a c e

e)

e x e r c i s e h a b i t s o f t h e m o t h e r b e f o r e and d u r i n g p r e g n a n c y

f)

a s p e c i f i c q u e s t i o n o f b o t h t h e m o t h e r and t h e p h y s i c i a n
r e g a r d i n g h e a l t h and b e h a v i o r a l
prenatal

care,

i.e.,

s u p p o r t network

r e c o m m e n d a t i o n s made d u r i n g

" d i d y o u r p h y s i c i a n recommend you

reduce your c a f f e i n e intake?"

( m o t h e r ) and " d i d you

recommend t h a t y o u r p a t i e n t r e d u c e h e r c a f f e i n e i n t a k e ? "
(physician)
2.

Th e s e i n f a n t s ,

or another s i m i l a r subset of i n f a n t s ,

c o u l d be

followed throughout t h e i r infancy and/or childhood to determine
g r o wt h p a t t e r n s o f LBW vs OBW i n f a n t s .
3.

A f o l l o w - b a c k s u r v e y o f i n f a n t s who we r e e i t h e r LBW o r OBW c o u l d
be c o n d u c t e d t o d e t e r m i n e t h e d i f f e r e n c e s
a n t h r o p o m e t r i c and me d i c a l

health risks

in r a t e s o f v a r i o u s

(i.e.,

obesity,

diabetes,

h e a r t d i s e a s e ) t h a t m i g h t have o c c u r r e d b e t we e n t h e s e g r o u p s as

t h e y r e a c h e d a d u l t h o o d and o l d a g e . Th e s e d a t a c o u l d be u s e d t o
d e t e r m i n e w h e t h e r an " o p t i m a l " b i r t h w e i g h t o f 3 , 5 0 0 - 4 , 0 0 0 g ,
shown t o be a s s o c i a t e d w i t h t h e l o w e s t i n c i d e n c e o f i n f a n t
mortality,

i s a s s o c i a t e d w i t h an i n c r e a s e d , d e c r e a s e d ,

or s i m i l a r

r i s k o f h e a l t h - r e l a t e d b e h a v i o r s i n t h e f u t u r e a s c omp a r e d t o
i n f a n t s who we r e LBW.
The c o r r e l a t i o n b e t we e n s e l f - r e p o r t e d m a t e r n a l b i r t h w e i g h t and
actual

maternal

b i r t h w e i g h t c o u l d be d e t e r m i n e d t o v a l i d a t e t h e

self-reported data.

The b i r t h c e r t i f i c a t e s o f m o t h e r s i n t h i s

s t u d y c o u l d be l o c a t e d by c o m p u t e r s e a r c h and ma t c he d w i t h t h e i r
s e l f - r e p o r t e d b i r t h weight.
The r e d u c t i o n i n b i r t h w e i g h t s e e n i n t h i s

s t u d y among n o n - s mo k e r s

who consumed 300 mg o r more c a f f e i n e p e r day s h o u l d be r e p l i c a t e d .
Additional

s t u d i e s a r e n e e d e d whi c h e xa mi n e t h e r e l a t i o n s h i p

be t we e n p r e g n a n c y out come and m a t e r n a l
i n t e n t i o n s and a c t u a l

behavior,

mother's locus of control

attitudes,

behavioral

p a r t i c u l a r l y as r e l a t e d t o t h e

and s o c i a l

support network.

Results of

t h i s s t u d y s u g g e s t t h e a f f e c t i v e domai n may p l a y an i m p o r t a n t r o l e
i n p r e g n a n c y o u t c o me , p a r t i c u l a r l y r e g a r d i n g t h e amount o f w e i g h t
gained during pregnancy.

PHYSICAL CHARACTERISTICS, HEALTH-RELATED BEHAVIORS AND
ATTITUDES OF MOTHERS WHO DELIVERED OPTIMAL AND LOW BIRTH
WEIGHT INFANTS IN MICHIGAN, 1 9 8 7 - 1 9 8 8 : A RETROSPECTIVE STUDY
Volume I I

By

Ca r ol Ann F r i e s e n

A DISSERTATION

Submitted t o
Mi c h i g a n S t a t e U n i v e r s i t y
in p a r t i a l f u l f i l l m e n t o f t h e requ ir em en ts
f o r the degree of

DOCTOR OF PHILOSOPHY

D e p a r t m e n t o f Food S c i e n c e and Human N u t r i t i o n

1990

A ppendix 1

S i n g l e - L i n e C h a r t t o M o n i t o r P r e g n a n c y Wei ght Gai n

28 9

50

50

46

*0

40

38

38

36

36

32
30

30

28

23

26

26
24

22

22

20

20

18

10

10

10

FIG I. Curve for the assessment of weight gain during pregnancy (8).

Appendix 2

R o s s o ' s P r e g n a n c y We i ght Gai n M o n i t o r i n g
C h a r t Based on P r e - P r e g n a n c y W e i g h t - F o r - H e i g h t

29 0

■o

125

(fi

'2 °

TO

HO

± iH

D ) 105

TO 8 5

12 14

16

18

20 22 24 26

i

28

3 0 32 34 36 38 4 0 42

Weeks of Gestation

C han to monitor weight gain during pregnancy considering pre-pregnancy weight and height.

(Rosso, 1985)

Appendix 3

1959 Metropolitan L i f e Insurance Company
W ei ght -f or- H eig h t Reference Standard

291

Weight in Pounds According to Frame (In Indoor Clothing)
S mall
F rame

H eight

M edium
F rame

L arge
F rame

H eight

S mall
F rame

M edium
F rame

L arge
F rame

WOMENf

M en
F eet

Inches

F eet

Inches

5

2

1 1 2 -1 2 0

1 1 8 -1 2 9

126-141

4

10

9 2 - 98

9 6 -1 0 7

1 0 4 -1 1 9

5

3

115-123

1 21-133

129-144

4

11

9 4 -1 0 1

9 8 -1 1 0

1 0 6 -122

5

4

1 18-126

1 2 4 -1 3 6

132-148

5

0

9 6 -1 0 4

1 0 1 -1 1 3

109-125

5

5

121-129

1 2 7 -1 3 9

135-152

5

1

9 9 -1 0 7

1 0 4 -1 1 6

112-128

2

1 0 2 -1 1 0

1 0 7 -1 1 9

115-131

1 1 0 -1 2 2

1 1 8 -134

5

6

124-133

1 30-143

138-156

5

5

7

1 28-137

13 4 -1 4 7

142-161

5

3

1 0 5 -1 1 3

5

8

132-141

13 8 -1 5 2

147-166

5

4

1 0 8 -1 1 6

1 1 3 -1 2 6

1 2 1 -138

5

9

136-145

14 2 -1 5 6

151 -170

5

5

1 1 1 -1 1 9

1 1 6 -1 3 0

1 2 5 -142

5

10

1 4 0 -1 5 0

1 4 6 -1 6 0

155-174

5

6

1 1 4 -1 2 3

1 2 0 -1 3 5

1 2 9 -1 4 6

5

11

1 4 4 -1 5 4

1 50-165

159-179

5

7

1 1 8 -1 2 7

1 2 4 -1 3 9

1 3 3 -1 5 0

6

0

148-158

1 5 4 -1 7 0

164-184

5

8

122-131

1 2 8 -1 4 3

1 3 7 -1 5 4

6

1

1 52-162

158-175

168-189

5

9

1 2 6 -1 3 5

1 3 2 -1 4 7

1 4 1 -1 5 8

6

2

156-167

1 6 2 -1 8 0

1 73 -1 9 4

5

10

1 3 0 -1 4 0

1 3 6 -1 5 1

1 4 5 -1 6 3

6

3

160-171

1 67-185

178 -199

5

11

1 3 4 -1 4 4

1 4 0 -1 5 5

1 4 9 -168

6

4

164-175

1 7 2 -1 9 0

1 82 -2 0 4

6

0

1 3 8 -1 4 8

1 4 4 -1 5 9

1 5 3 -1 7 3

* Metropolitan Life Insurance Company.
t For girls between 18 and 25, subtract 1 pound for each year under 25.

Appendix 4

1983 Metr opo li ta n L i f e Insurance Company
W e ig ht -f o r- H ei gh t Reference Standard

WOMEN
«

Height
(Without Sheas)

1959

19*3

Change
Since
1939

LARGE FRAME

MEDIUM FRAME

SMALL FRAME
Percent
Change

test

1933

Chongs
Since
1939

Percent
Change

1939

1983

Change
Since
1939

Weight In Pounds (Without Clothing)

Incites

4

9

90- 97

99-108

9

11

10 11

94-106

106-118

12 12

13 11

102-118

115-128

13 10

13

8

4

10

92-100

100-110

8

10

9 10

97-109

108-120

11

11

11

10

105-121

117-131

12 10

11

8

4

11

95-103

101-112

6

9

6

9

100-112

110-123

10

11

10 10

108-124

119-134

11

10

10

8

5

0

98-106

103-115

5

9

5

8

103-115

112-126

9 11

9 10

111-127

122-137

11

10

10

8

5

1

101-109

105-118

4

9

4

8

108-118

115-129

9

11

8

9

114-130

125-140

11

10

10

*8

5

2

104-112

108-121

4

9

4

8

109-122

118-132

9

10

8

8

117-134

128-144

11

10

9

7

5

3

107-115

111-124

4

9

4

8

112-126

121-135

9

9

3

7

121-138

131-148

10 10

8

7

5

4

110-119

114-127

4

8

4

7

116-131

124-138

8

7

7

5

125-142

134-152

9 10

7

7

5

5

114-123

117-130

3

7

3

6

120-135

127-141

7

6

6

4

129-148

137-156

8 10

6

7

5

6

118-127

120-133

2

6

2

5

124-139

130-144

6

5

5

4

133-150

140-160

7 10

5

7

5

7

122-131

123-136

I

5

1

4

128-143

133-147

5

4

4

3

137-154

143-164

6 10

4

6

5

8

128-138

128-139

0

3

0

2

132-147

138-150

4

3

3

2

141-159

146-167

5

8

4

5

5

9

130-140

129-142

-1

2

-1

1

136-151

139-153

3

2

2

1

145-164

149-170

4

6

3

4

5

10

134-144

132-145

-2

1

-1

1

140-155

142-156

2

1

1

1

149-169

152-173

3

4

2

2

Note Prepared by Metropolitan tile Insurance Company
Source ol banc data Buna Study 1979. end Buna end Blood

18S®, Society ol Actuaries and Association ol Lila Insurance Medical Directors ol America.

292

Feet

Appendix 5

Conversion Chart to Change Infant's Birth Weight
From Pounds and Ounces to Grams

293

CRAM W£)GKT CONVERSION TAULE

To us e t h i s t a b l e , f i n d t h e n u mb e r o f p o u n d s i n t h e c o T u n n t o t h e
f a r l e f t ( o r r i g h t ) , a n d t h e n umbe r o f o u n c e s i n t h e t o p r o w.
Re a d a c r o s s
f r om t h e n umbe r o f p o unds and down f r o m t h e n i m b e r o f o u n c e s ; t h e g r a m
w e i g h t i s f o u n d w h e r e t h e t wo l i n e s i n t e r s e c t . ( i . e . , 2 p o u n d s , 6 o u n c e s =
1077 g r a ms ) .
For a w e i g h t o f l e s s t h a n a p o u n d , f i n d t h e number o f o u n c e s
in the top l i n e o f t he t a b l e .
The n u mb e r i m m e d i a t e l y b e l o w i t w i l l b e t h e
c o r r e s p o n d i n g w e i g h t i n gr a ms ( i . e . , 8 o u n c e s ■ 227 g r a m s ) .

0
o|

—

13

14 15

16 I

38

57

85

113

162

170

198

227.

255

266

3« 9

397

625

656

5io

539

567

595

626

652

6 bO

709

737

76S

796

622

OSl

079

907 I

2

3

4

5

OUNCES
7 8

11 12
•312 360

1

6

9

10

1°
1

.ll

6 S6

1,62

21

537

535

ssu

993

1021

2069

1077

1106 ■1136

1162

1291

1219

1267

1276

1306

1332

1361

1367

11,16

1666

1676

1S°3

1 S31

1559

1 5 B8

] 6 l6

1666

1673

1701

1729

1758

178 £

3
4 | 1816

1355

} 6 lt

1563

1671

1639

1528

1956

19 S5

2013

2061

2070

2056

2126

2155

2163

2211

2260

2268

5I

22£8

2256

3353

2 3 S1

2610

2636

2666

2695

2523

2552

2560

260S

2637

2££5

7693

2722 1 5

6

3732

27S0 2776

2607

2835

2663

2652

2920

2966

2977

3005

>533

3062

3090

3119

3167

3175

7]

3175

3306

3233

3260

3289

3317

3365

3376

3602

3630

3659

3687

3Si S

3566

3572

3 CDO

3629

8

3S3S 3557

3SB6

3711

3762

3771

3799

3627

3856

3886

3912

3961

3969

3997

6026

6056

6082

till

6135

hi 67

61S6

6226. 62S3

6281

6309

6338

6366

6396

6623

6 6 S1

6679

6508

6536

1593 6621

6669

6678

67CS 6736

6763

6791

6820

6868

6876

6905

6933

6961

6990

lf? >

$028 506 6 S»75

5103

5131

5160 5188

5216

5265

52.73

5301

5330

5350

5387

S615

5663

M 3

5673 5500

55?B

5557

5585

5613

5662

5670

5693

5727

5755

5 /8 3

5012

5860

5868

5697

5BS7

5525

5956

5902

6010

6039

6357

6095

6126

6152

6189

6209

6237

6265

6296

6322

6350

6635

61,61,

6692

6521

6S77

6606

6662

£691

5

6

6082

9
10
11
12
13

6536 6S66

u\
1

6350

6375

0

1

3335

6 L07

2

3

4

6569
7

OUNCES

8

9

6636

10 11

12

£719

6767

67 7 6

£831

13

.14

15

16

12
13
I4
16
7
18
19
|io
111
|12
113
(14
1

Appendix 6

Human S u b j e c t s A p p r o v a l :
UCRIHS - - Mi c h i g a n S t a t e U n i v e r s i t y ' s
Co mmi t t e e f o r t h e Revi ew and I n v e s t i g a t i o n o f Human S u b j e c t s

294

M IC H IG A N STATE U N IV E R S IT Y
U N I V E R S I T Y C 0 H M 1 T T U O N R E S E A R C H I N V O L V IN G

E A S T L A N S IN G •

M IC H IG A N • 4 M 2 4 - I I H

H U M A N S U B JE C T S (U C R IH S )
B M B E JL K FY H A U

0 1 7 ) 553 9738

IR B # 88-340

October 11,1988

Carol A. Fricsen
204 Food Science
MSU
Dear Ms. Friesen:
Subject:

’T H E RELATIONSHIP BETWEEN PERCENT ST A N D A R D BO DY
WEIGHT ATTAINED AT TERM A N D INFAN T BIRTH W EIGHT
IR B # 88-340"

I am pleased to advise that because of the nature of the proposed research, it was eligible
for expedited review. This process has been completed, the rights and welfare o f the
human subjects appear to be adequately protected, and your project is therefore approved.
You are reminded that UCRIHS approval is valid for one calendar year. If you plan to
continue this project beyond one year, please make provisions for obtaining appropriate
UCRIHS approval prior to September 26,1989.
Any changes in procedures involving human subjects must be reviewed by the UCRIHS
prior to initiation of the change. UCRIHS must also be notified promptly o f any problems
(unexpected side effects, complaints, etc.) involving human subjects during the course o f
the work.
Thank you for bringing this project to our attention. If we can be o f any future
do not hesitate to let us know.
Sincere!'

John K. Hudzik, Ph.D.
Chair, UCRIHS
JKH/sar
cc: S. Hoerr

M jU iia a /y/trmafM* A r iie a /E fM l C ^ o f liia it y failitiilieR

help, please

A ppendix 7

Human S u b j e c t s A p p r o v a l :
M i c h i g a n D e p a r t m e n t o f P u b l i c Heal

295

MI CHI GAN DEPARTMENT OF PUBLI C HEALTH
Department

TO:

Co b b I t t e e f o r t h e
I n v o l v i n g Huean

Raj U Wiener
Acting State

Health

Evaluation
Subjects

of

Studies

Director

'«»«’

.C L c u r

P R I NC I P AL

I NVESTI G A T O R ( S ) :

j

C (lot{.

S & v i c v i W o tr r -

0 <£ fc j^ r

DATE PROJ ECT RECEI VED:
FUNDI NG:

STATE

FEDERAL_________

OTHER

COMMITTEE RECOMMENDATIONS:
/

■J

Approved

_ _ _ _

through

expedited

A pp ro v ed by r e v i e w b o a r d
without m odifications

_ A p p r o v e d by r e v i e w
w ith o o d l f Icat Ions

board

review

and

full

Oate:
cobb

Ittee
Oate:

and

full

c o b b

Ittee
Date:

COMMENTS:

DATE:

I
CHAIRPERSON

cc:

Bureau Chief
Principal InvestIgator(s)
O f f i c e of F i n a n c e and Ge ner al
C o m m i t t e e Me mb e r s

Services

Appendix 8
Approval o f the Study
as a Medical Research P ro je ct :
The Michigan Department o f Public Health

296

STATE OF MICHIGAN

JA M E S J BLANCHARD. G o v e rn o r

DEPARTMENT OF PUBLIC HEALTH
3423 N. LOGAN
P.O . BOX 30 1 9 5 . LANSING,,M ICHIGAN 4 8 9 0 9

Raj M W i e n e r , A c t i n g D i r e c t o r

Novem ber

23 , 1988

C a r o l F r i e s e n , M . S . , R. D.
D e p t o f F ood S c i e n c e & Human N u t r i t i o n
M ich iga n S t a t e U n i v e r s i t y
165 A n th o n y D a i r y A n n ex
E a s t L a n s i n g , MI 48824
D e a r Ms. F r i e s e n :
T h i s i s t o d e s i g n a t e y o u r s t u d y "The r e l a t i o n s h i p b e t w e e n p e r c e n t s t a n d a r d body
w e i g h t a t t a i n e d a t t e r m and i n f a n t b i r t h w e i g h t " , d e s c r i b e d i n t h e l e t t e r and
m a t e r i a l s u b m i t t e d N ov em b er 23 , 1988 a s a m e d i c a l r e s e a r c h p r o j e c t .
T h is d e s i g n a t i o n i s p r o v id e d under t h e p r o v i s i o n s o f th e M ich ig a n P u b li c H e a lth
C o d e , P . A . 368 o f 1978 , a s am end ed , b e i n g MCL 333 . 2631 - 333 . 2635 .
T h is a s s u r e s
t h a t i n f o r m a t i o n c o l l e c t e d fr o m p a r t i c i p a t i n g p a r t i e s w i l l b e k e p t c o n f i d e n t i a l .
A copy o f th e r e fe r e n c e d s e c t io n s i s e n c lo s e d .
S in c e r e ly ,

S.
/- ^ R a j M W ie n e r
A ctin g S t a t e H e a lth D ir e c to r

**<■•»*I,' IP*
m t »l u t

►

Appendix 9
PILOT: Michigan Mother's Pregnancy L i f e s t y l e Questi on na ire

297

C O D E N O :______

PREGNANCY LIFESTYLE QUESTIONNAIRE
DIRECTIONS: Please complete the following questions as completely a s possible. Simply
write in the correct information in the space provided or check the box of the answ er you think is
most correct. All the questions refer to your MOST RECENT PREGNANCY.
1.

What is the name, address and phone number of the doctor or clinic you went to
for most of your medical care during your pregnancy?
NAME:____________________________________________
CLINIC or
HOSPITAL NAME:_________________________________
STREET ADDRESS:______________________________
CITY:_____________

STATE:___________ ZIP:_______

PHONE: (_____ )___________________________________
2.
3.

How tall are you, without shoes?

________ fe e t_________ inches

Approximately how much did you weigh BEFORE you becam e pregnant with
your last child?
___________ pounds

4.

Approximately how much did you weigh JUST BEFORE YOU DELIVERED
your baby?
___________ pounds

5.

Do you, or does someone in your family, remember how much YOU weighed when
YOU were bom ? If you know, record the amount below.
pounds ___________ ounces

6.

7.

Did a doctor, nurse or nutrition counselor tell you how much weight you should
gain during this pregnancy?
□

YES (if y es, go to next question)

□

NO

(if no, go to question 8)

How many p o u n d s were you told to gain from the BEGINNING to the
END of this pregnancy?
___________ pounds

29 8

P age 2
During your recent pregnancy, did you do any ot the tollowing on a regular basis? Check only
ONE BOX p er q u e s tio n .
YES, based on
doctor’s or
other medical
source's
suggestion.
8.
9.
10.
11.
12.
13.

YES, based on
my decision
without asking
a doctor or
other medical
source.

NO, Idid
NOT.

Does NOT
apply to me

Take a vitamin
supplem ent?
Restrict your calorie
intake?
Restrict your salt
intake?
Cut down or stop
drinking alcohol?
Cut down or stop
smoking cigarettes?
Stop taking aspirin
the last 3 months?

D IR EC TIO N S:

C ircle the number which most closely represents your opinion
about the following statements. EXAMPLE: 5 = Strongly Agree.
STRONGLY AGREE
NO
AGREE
OPINION

DISAGREE

14.

Nutrition is extremely
important during pregnancy.

5

4

3

2

15.

A poor d e l during pregnancy
will NOT affect the baby's health.

5

4

3

2

16.

Mother's who eat well produce
healthier babies than mother's
who do not eat well.

5

4

3

2

17.

I worried that I might get fat
during my recent pregnancy.

5

4

3

2

18.

I tried to keep my weight down
so I didn't look so pregnant.

5

4

3

2

19.

As long as I ate a well-balanced
diet, I didnl care how much I
gained during my pregnancy.

5

4

3

2

STRONGLY
DISAGREE

299

Page 3

STRONGLY
AGREE

20.

I think a pregnant woman is
beautiful.

21.

I was embarassed by how big I
got during my pregnancy.

22.

I would gain 40 pounds if it meant
my baby would be healthier.

23.

I feel that women have to be
especially careful about getting
fat during pregnancy.

24.

Just before I went to the doctor,
I tried not to eat.

25.

NO
OPINION

DISAGREE

STRONGLY
DISAGREE

How would you rate the QUALITY of your diet during your pregnancy, on a scale
of 1 to 10? Circle your rating.
1
POOR

26.

AGREE

2

3

4

5
6
AVERAGE

7

8

9

10
EXCELLENT

On the average, how many drinks of alcoholic beverages, if any, did you have
the three months BEFORE and then DURING your pregnancy? A drink is 12
ounces of beer (1 can), 4 ounces of wine (1/2 cu p ), or 1 1/2 ounces of liquor. Mark ONE
box for BEFORE and one box for DURING your recent pregnancy.
BEFORE
PREGNANCY

□
□
□
□
□
□
□

□

□
□
□

DURING
PREGNANCY
21 or more drinks a week
14to 20 drinks a week

9to 13 drinks a week
6 to 8 drinks a week
3 to 5 drinks a week
2 drinks a week
1 drink a week
2to 3 drinks a month
1 drink a month
Less than one drink a month
I did NOT drink

□
□
□
□
□
□
□

□

□
□
I— I

300

Page 4
27.

On the average, how many cigarettes, it any, did you smoke A DAY during the
3 months BEFORE you found out you were pregnant and DURING your
pregnancy? Write in "0" it you did NOT smoke.
___________ average number of cigarettes a day BEFORE I found out I w as pregnant
___________ average number of cigarettes a day DURING my pregnancy

28.

Which of the following health problem s or symptoms did you have during this
pregnancy? Check ALL that apply.

□
□
□
□
□
□
29.

nausea
vomiting
stomach cramps
vaginal bleeding
swollen feet

□
□
□
□
□

diarrhea
constipation
hemorrhoids
none of the above
other - specify

severe headaches

Which of the following problem s or feelings did you have about getting
medical care during your pregnancy? Check ALL that apply.

□

□
□
□
□
□

□
□
□

I did not have anyone to take care of my children
I could not miss work or school
I did not have a way to get to the clinic or doctor's office
There were no doctors or cfinics nearby
I did not know where to go to get prenatal care
I did not think it was important to see a doctor
The wait at the doctor's office or clinic was too long
I was afraid of medical tests and examinations
I did not like the doctor's or nurse's attitudes

□

The office hours were not convenient

□

I could not get an appointment

□

None of the above were problems

□

Other - specify

301

Page 5
30.

How did you pay for your medical bills during your pregnancy? Check ALL that
apply.

□

31.

32.

33.

□

Self-pay (include self, family or friends)

□

Health Insurance (like Blue Cross, Prudential)

□

Medicaid

□

Care provided by the military

□

Other - please sp ec ify _________________

HMO (Health Maintenance Organization)

Did you receive assistance from any social services programs during your
pregnancy? If yes, please check ALL that apply.

□

WIC (Supplemental Program for Women, Infants and Children)

□

EFNEP (Expanded Food and Nutrition Education Program)

□

MCH (Maternal and Child Health Program)

□

Food Stamps

□

Food Bank (church, community)

□

AFDC (Welfare)

□

No social service assistance was received

□

Other -- please sp ecify ___________________ _____________

On the average, what w as theTOTAL MONTHLY INCOME (after taxes) of all
household members you lived with (include yourself) during your pregnancy?
P lea se check your BEST ESTIMATE.

□

$0 to $299

□

$300 to $499

□

$500 to $999

□

□

$1000 to $1499

□

$2000 to $2499

□

$2500 or more

□

I do not know or wish to say

$1500 to $1999

How many individuals did this total income sen/e (including you)?

Thinking back to JUST BEFORE you becam e pregnant with your new baby,
did you WANT to become pregnant at that time? Check only ONE BOX.

□
□
□
□

I wanted this pregnancy AT AN EARLIER TIME, as well as at that time.
I wanted to become pregnant AT THAT TIME.
I did NOT want to become pregnant at that time, but rather I wanted a
child sometime IN THE FUTURE.
I did NOT want to become pregnant at that time OR at any time in the
future.

If we have questions about anything you have written down, could w e call you? If so,
please give us a number where you can be reached and when it would be convenient.
PHONE: {_____ ) ___________________________

TIME:___________________

In case we can't reach you, would you give us the name and address of a person
who would likely know where you could be reached?
NAME:

__________________________________________________

ADDRESS:_______________________________________________________
CITY:________________________ STATE:___________ ZIP:_____________
PHONE:

(_____ )__________________

Would you like u s to send you some

of the results of this survey?

□

□

YES

NO

Is there anything else you would like to tell us about yourself, your pregnancy,
your baby or anything else in this questionnaire?

CODE:

It is important for you to read and sign the CONSENT STATEMENT below.
Your doctor can tell us more about the care you and your baby received. What
your doctor can tell us is also very important. All of the information we obtain
will be kept strictly confidential.

CONSENT STATEMENT
I have voluntarily participated in this pregnancy survey. I give my
perm ission for the Michigan Department of Public Health to obtain
additional information about my pregnancy from the medical source
listed in question 1 above. I understand that the Department will
u se th is inform ation ONLY for sta tistica l p u r p o se s in health
research , and no information which identifies either me or the
m edical source will EVER be released or published.

(Signature - in INK)

(Today’s Date)

Thank you for your help and cooperation! Please check to make sure all your
responses to BOTH this QUESTIONNAIRE and the FOOD FREQUENCY
are completed and returned in the enclosed envelope
at your earliest convenience.

A p pe nd ix 10
PILOT: The W i l l e t t S e m i - Q u a n t i t a t i v e Food
F r e q u e n c y Q u e s t i o n n a i r e (SQFFQ)

304

DIET

N C S T r a n s - O p t i c 8 E B 10 - 2 0 1 5 6 : 13

ASSESSM EN T0

CoTftETo,

>xoM o:;oiQ ie?Tojoro: 00®©©©©©©®
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. r t J I s a P H A R D -W R ITIN G W ITHIN

IN S T R U C T IO N S :

P L E A S E U S E A N O R D IN A R Y ( e .g . * 2 ) PEN C IL T O A N S W E R ALL Q U E S T IO N S
BY CO M PLETE LY FILLING IN T H E A P P R O P R IA T E R E S P O N S E CIRC LE, OR BY
W R IT IN G IN T H E R E Q U E S T E D IN FO R M A T IO N W H E N A S P A C E IS PR O V ID E D .

EXAM PLE t :

DO Y O U LIVE IN T H E U N ITED S T A T E S ?

EXA M PLE 2 :

W HERE W ERE YOU BORN?

O

OKEbON

®®()f

^ B O R D E R S OF R ESPO N SE BOX)

BECA USE THIS FORM IS M EA N T TO BE READ BY OPTICAL-SCANNING EQU IPM EN T. IT IS IM PO R TA N T THA T
YOU M AKE NO S TRA Y M A R K S. TO C H A N G E A R E SP O N S E. ER A SE THE INCORRECT M A R K COMPLETELY.

1. D O Y O U R E G U L A R L Y T A K E M U L T IP L E V IT A M IN S ? O NEVER HAVE

ne

®0©©®©®®©®i
x YES, CURRENTLY
TAKE THEM

O PA ST ONLY

b) IF Y O U C U RR EN TL Y TA K E T H E M . H O W M A N Y D O Y O U TA K E P E R W E E K ?
2 OR LE S S

Q

3~5

O 6"9

O

1 0 OR M ORE

2 . N O T C O U N T IN G M U L T IP L E V IT A M IN S , D O Y O U T A K E ANY O F T H E F O L L O W IN G P R E P A R A T IO N S ?
PR EPA R A T IO N

NEVER
TAKEN

TAKEN IN
THE P A ST ONLY

VITAM IN A

o

o

O'

o

o

o

V IT A M IN C

IF YOU TAKE IT CURRENTLY.
W H A T AVERAGE DAILY D O SE?

YES. CURRENTLY
TAKE IT

o

L E S S THAN
8 . 0 0 0 IU

O 8*
00° t0IU.
12.000

O

1 3 .0 0 0 to
2 2 . 0 0 0 IU

O

2 3 . 0 0 0 IU
OR M O R E

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LE S S THAN
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0

4 0 0 to
700 m g.

2 5 0 to
1 ,2 5 0 m g.

0

1 ,3 0 0 m g ,
OR M ORE

S E L E N IU M

IR O N

o
o

o

o
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o

0 L E S S THAN
^ 1 0 0 IU

Q
^

1 0 0 to
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O

3 0 0 to
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0

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O

L E S S THAN
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1 3 0 m eg.

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1 4 0 to
2 5 0 m eg.

0

o

O

L E S S THAN
51 m g .

o

C A L C IU M
OR
D O L O M IT E

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YR .

^

a

O

D O N ’T
KNOW

____

0 5 - 9 Y R S. 0

10Y R S.
OR M ORE

Q

2 - 4 YRS.

0 -1 YR.

0 O -1 Y R .
O

FOODS AND A M O U NTS
D A IR Y F O O D S

SK IM OR L O W FAT MILK (8 o z . G LA SS)
W H O LE MILK {8 oz. G LA SS)
CREAM , e .g . COFFEE. W H Ip ’P ED (TB s T
SO U R CREAM (TBS)
NO N -D A IR Y COFFEE W H ITEN ER (tsp .)
SH ERBET OR" ICE MILK ('/? CUP)

PL E A SE TU R N
TO PA G E 2

ICE CREAM {'.<2 CUP)

0

0 5 - 9 YRS. 0
~

LE S S THAN
2 5 m g.

W KNOW

O
w

D O N 'T
KNOW

200 mg- Ow

D O N 'T
KNOW

2 6 0 m eg.
OR M ORE
51 to

0 2 - 4 Y R S.

0 5 - 9 YRS. Q

1 0 Y R S.
OR M ORE

0 , 1 0 -1 YR.

2 - 4 YRS.

0

0 5 - 9 Y R S.

( 'J 0 -1 YR.

025 to

74 m q.
y

O 101

“ 10 Y R S.
~ OR MORE
0

0 9 0 1 to
1 .3 0 0 m g.

0

O
^

2 - 4 YRS.

0 5 - 9 Y R S. .

10 Y R S.
OR M ORE

Q O - I YR.

2 - 4 Y R S.

0 5 - 9 Y R S. .

10 Y R S.
OR M ORE

v

O
D O N ’T
' - ' KNOW

m g.
OR M ORE

L E S S THAN
4 0 0 m g.

10 Y R S.
OR M ORE

DON'T

4 0 0 to
9 ° ° n ig . Q
1 .3 0 1 m g .
OR M ORE

Q 0 -1 Y R .

0 2 - 4 Y R S.

d o n -t

KN0W 0 5 - 9 Y R S .

A N Y O T H E R V IT A M IN S O R M IN E R A L S ?
(S P E C IF Y T Y P E A N D DAILY D O S E )
3 . F O R E A C H F O O D L IS T E D , FILL IN T H E C IR C L E
IN D IC A T IN G H O W O F T E N , O N A V E R A G E ,
Y O U H A V E U S E D T H E A M O U N T S P E C IF IE D ,
D U R IN G T H E P A S T YEAR.

0 2 - 4 Y R S.

OR M ORE

0 7 5 to
1 0 0 m g.

O

KNOW

O 4 0 0 m g.

0 2 0 1 to
4 0 0 m g.

o
ZIN C

0 0 -1

OOON'T

^

O

V IT A M IN E

HOW LONG HAVE YOU
BEEN TAKING IT?

w

" 1 0 Y R S.
“ OR M ORE
© ® @

© @

®0®©@
A V E R A G E U S E L A S T Y EA R
NEVER,
o n LESS
TH AN ONCE
PER M ONTH

o
o
o
o
o

" o '

o '

1 -3

PER

MO.

o
o'
o

o'
o
o„

o

1
2 -4
5 -6
PER
PER
PER
WEEK W EEK WEEK

©

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@
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iWi

o o
0
o

C TJ

© © o r o*: Dt. o © CTJ

a ) IF Y O U C U R R EN TL Y TA K E T H E M . W H A T B R A N D D O Y O U U S E ? {SPECIFY E X A C T BR A N D )

O

i

~d~

1
PER
DAY

D1

2 -3
PER

4 -5
PER

DAY

DAY

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6+
PER
DAY

o
o
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305

PAGE 2
3 . (C O N T IN U E D ) P L E A S E FILL IN Y O U R A V E R A G E U S E .

A V E R A G E U S E L A S T Y EA R
NEVER.
O R LE SS
TH AN ONCE
PER M ONTH

FOODS AND A M O U N TS
YOGURT (1 CUP)
COTTAGE OR RICOTTA CHEESE (ft CUP)
CREAM CHEESE U oz.)
OTHER CHEESE, o.g. AMERICAN, CHEDDAR, etc.,
PLAIN OR A S PART OF A DISH (1 SLICE
OR 1 oz. SERVING)
MARGARINE (PAT). AOOED TO FOOD OR BREAD;
EXCLUDE USE IN COOKING
BUTTER (PAT). ADDED TO FOOD OR BREAD;
EXCLUDE USE IN COOKING

FRUflTS

RAISINS <1 oz. OR SMALL PACK) OR GRAPES
PRUNES ('A CUP)

PLEASE TRY TO
AVERAGE YOUR
S E A SO N A L USE
OF FO O D S OVER
THE ENTIRE YEAR.
FOR EXAM PLE, IF
A FOOD SU C H A S
CANTALOUPE IS
EATEN 4 TIM ES A
WEEK DURING THE
APPRO XIM ATE 3
M O N T H S TH AT IT IS
IN S E A S O N , THEN
THE AVERAGE U SE
W O ULD BE Oi\)CE
PER WEEK.

BANANAS (1)
PEACHES, APRICOTS OR PLUMS (1 FRESH,
OR ft CUP CANNED)

NEVER

FRESH APPLES OR PEARS (1)
APPLE JUICE OR CIDER (SMALL GLASS)
ORANGES (1)
ORANGE JUICE (SMALL GLASS)
GRAPEFRUIT (ft)
GRAPEFRUIT JUICE (SMALL GLASS)
OTHER FRUIT JUICES (SMALL GLASS)
STRAWBERRIES, FRESH, FROZEN OR CANNED
BLUEBERRIES, FRESH. FROZEN OR CANNED
CANTALOUPE

(ft

(ft

(ft

CUP)

CUP)

MELON)

WATERMELON (1 SLICE)

V EGETABLES

BROCCOLI (ft CUP)
CABBAGE OR COLE SLAW (ft CUP)
CAULIFLOWER (ft CUP)
BRUSSELS SPROUTS (ft CUP)
CARROTS (1 WHOLE OR vs CUP COOKED)
CORN (1 EAR OR vs CUP FROZEN OR CANNED)
PEAS, OR LIMA BEANS (■/* CUP FRESH, FROZEN, CANNED)
MIXED VEGETABLES (vs CUP)
YELLOW (WINTER) SQUASH (vs CUP)
EGGPLANT. ZUCCHINI, OR OTHER SUMMER
SQUASH (vs CUP)
YAMS OR SWEET POTATOES (vs CUP)
SPINACH. COOKED (ft CUP)
SPINACH. RAW AS IN SALAD
KALE. MUSTARD OR CHARD GREENS (vs CUP)
ICEBERG OR HEAD LETTUCE (SERVING)
ROMAINE OR LEAF LETTUCE (SERVING)
TOMATOES (1)
TOMATO JUICE (SMALL GLASS)

RED CHIU SAUCE (1 TBS)
TOFU OR SOYBEANS ( 3 - 4 oz.)

(ft

CUP)

BEANS OR LENTILS, BAKED OR DRIED

M EATS

(ft

CUP)

EGGS (1)
CHICKEN OR TURKEY, WITH SKIN ( 4 - 6 oz.)
CHICKEN OR TURKEY, WITHOUT SKIN ( 4 - 6 02.)
BACON (2 SLICES)
HOT DOGS (1)

PL E A SE G O
T O PA G E 3

PROCESSED MEATS, o .g. SAUSAGE, SALAMI,
BOLOGNA, etc. (PIECE OR SLICE)

PER
MO.

o
o
o
o
o
o
o
o
o
o
o
o
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o
o
o
o
o
o
o
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Q

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2-4

5 -6
PER
PER
PER
WEEK WEEK WEEK
®
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®

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TOMATO SAUCE (ft CUP) e .g . SPAGHETTI SAUCE

STRING BEANS

o
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PAGE 3
3 . (C O N T IN U E D ) P L E A S E FILL IN Y O U R A V E R A G E U S E .
D U R IN G T H E P A S T Y E A R . O F E A C H S P E C IF IE D F O O D .

A V ERA G E U S E L A S T YEAR
NEVER.

FOO D S AND A M O U N TS

OR L E SS
TH AN ONCE
PER M O N TH

PER
MO.

O
o
o
o
o
o
o
o
o

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
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o
o
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o
o
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o
o
o
o
o
o

LIVER ( 3 - 4 or.)
HAMBURGER (1 PATTY)
BEEF. PORK, OR LAMB A S A SANDW ICH OR MIXED
DISH. e.g . STEW . CASSEROLE. LASAGNE, etc.
BEEF. PORK. OR LAMB A S A MAIN DISH. e.g . STEAK.
ROAST. HAM. e tc . ( 4 - 6 oz.)
CANNED TUNA FISH ( 3 - 4 or.)
DARK MEAT FISH. e.g . MACKEREL. SALMON.
SARDINES, BLUEFISH, SW ORDFISH ( 3 - 5 oz.)
OTHER FISH ( 3 - 5 or.)
SHRIMP, LOBSTER, SCALLOPS AS A MAINDISH

SW E E T S AND
BA K E D G O O D S

CAKE. HOME BAKED (SLICE)
CAKE. READY MADE (SLICE)
SW EET ROLL. COFFEE CAKE OR OTHER PASTRY.
HOME BAKED (SERVING)
SW EET ROLL. COFFEE CAKE OR OTHER PASTRY.
READY MADE (SERVING)
PIE, HOMEMADE (SLICE)
PIE. READY MADE (SLICE)
COOKIES. HOME BAKED (1)
COOKIES. READY MADE (1)
BROW NIES (1)
DOUGHNUTS (1)
CHOCOLATE (SMALL BAH OR 1 o r.)
CANDY WITHOUT CHOCOLATE (1 oz.)
JA M S , JELLIES. PRESERVES, SYRUP, OR HONEY (1 TBS)

B R EA D S. C ER EA LS.
STARCHES

COOKED OATMEAL (1 CUP)

0

OTHER COOKED BREAKFAST CEREAL (1 CUP)

O

DARK BREAD (SLICE)
ENGLISH M UFFINS, BAGELS, OR ROLLS (1)
MUFFINS OR BISCUITS (1)
BROW N RICE (1 CUP)
WHITE RICE (1 CUP)
PASTA. e.g . SPAGHETTI, NOODLES, e tc . (1 CUP)
OTHER GRAINS, o.g. BULGER. KASHA,
CO USCOU S, Gtc. (1 CUP)
PANCAKES OR W AFFLES (SERVING)
FRENCH FRIED POTATOES (4oz.)
POTATOES. BAKED. BOILED (1) OR MASHED (1 CUP)
POTATO CHIPS OR CORN CHIPS (SMALL BAG OR 1 oz.)
CRACKERS, TRISKETS, WHEAT THINS (1)
PIZZA (2 SLICES)
LOW CALORIE COLA, o .g. TAB WITH CAFFEINE

CONSIDER THE
SERVING SIZE
AS 1 GLASS.
BOTTLE OR CAN
FOR THESE
CARBONATED
BEVERAGES.

OTHER LOW CALORIE CARBONATED BEVERAGE, o.g.
FRESCA, DIET 7-U P, DIET GINGER ALE

LOW CALORIE CAFFEINE-FREE COLA, e.g. PEPSI FREE

COKE. PEPSI. OR OTHER COLA WITH SUGAR
CAFFEINE FREE COKE. PEPSI, OR OTHER COLA
WITH SUGAR
OTHER CARBONATED BEVERAGE WITH SUGAR,
o.g. 7-UP, GINGER ALE
HAWAIIAN PUNCH, LEMONADE. OR OTHER NON*
CARBONATED FRUIT DRINKS (1 GLASS. BOTTLE, CAN)
DECAFFEINATED COFFEE (1 CUP)

PLEASE TURN
TO PAGE 4

o
o
o
o
o
o
o
o
o
o
p ,

WHITE BREAD (SLICE)

OTHER
BEV ERA G ES

o

0
NEVER 1 - 3 m

COLD BREAKFAST CEREAL (1 CUP)

CARBONATED
BEVERAGES

COFFEE (1 CUP)

1 -3

o
o
o
o
o
o
o
NEVER

O

o
o
o
o
o
o
o
o
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o
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o
o
o

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1 - 3 /M

1

2 -4

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PER
PER
PER
WEEK WEEK WEEK
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© r', p o
© O o o

307

PAGE 4

S =

3 . (C O N T IN U E D ) P L E A S E FILL IN Y O U R A V E R A G E U S E ,
D U R IN G T H E P A S T Y E A R , O F E A C H S P E C IF IE D F O O D .

NEVER.
OR L E SS
TH AN ONCE
PER M ONTH

TEA (1 CUP). NOT HERBAJ. TEAS
BEER (1 GLASS. BOTTLE. CAN)
RED W INE (4 oz. GLASS)
WHITE WINE {4 oz. GLASS)
LIQUOR, o.g. WHISKEY, GIN. e tc . (1 DRINK OR SHOT)
PEANUT BUTTER <1 TBS)

M IS C E L L A N E O U S

POPCORN {1 CUP)
NUTS (SMALL PACKET OR 1 oz.)
WHEAT GERM (1 TBS)
CHOWDER OR CREAM SO U P (1 CUP)
OIL AND VINEGAR DR ES SIN G, e.g. ITALIAN (1 TBS)
MAYONNAISE OR OTHER CREAMY
SALAD DRESSING (1 TBS)

4.
O

O
O
6.

O
O

O

G

s t ic k

O

tub

FORM

NONE. OR LESS THAN 1 T B S/W E E K

©
©

d
o
o'
o

o

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o

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iw)

o
o'

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1 - 2 T B S/W E E K

Q

1 0 OR M ORE

8.

5 - 9 T B S /W K

W H A T D O Y O U D O W IT H T H E V IS IB L E F A T O N Y O U R
M EAT?
e a t M O S T OF THE FAT

O

EAT S O M E OF THE FAT

EAT A S LITTLE A S PO SSIB LE

O

(D O N 'T EAT MEAT)

U SE HAS
DECREASED

USE ABOUT
THE SA M E

o
o

o
o
o

WHOLE MILK
BUTTER
MARGARINE
EGGS
FISH
RED MEAT
FRUITS
VEGETABLES

j) WHOLE GRAINS
k) ALCOHOL
I) SUGAR

o

o

o
o
o

o
o
on

o
o

o

o
o
o

o

o

o

o
o
o
o

o

©

©

o

(

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o

©
.'0

I

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LARD

O

LARD

O

USUALLY
U S E ? •"* ....
9 . W H A T KIND O F CO LD B R E A K F A S T _
C E R EA L D O Y O U USUALLY U S E ?
^

0

0

:t

2

2

2

3

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3 .. 3

4

4

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0

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U SU A L
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A V ER A G E U S E
PE R W E E K

(b)
(c)

<d)
(el

VEGETABLE OIL

M ARGARIN E

16. WHAT IS
YOUR
CURRENT
WEIGHT?.,

(o ) -:T)

O

DAILY

O

4 - 6 TIM ES PER W EEK

O

1 - 3 TIM ES PER W EEK

O

LE S S THAN O N C E A WEEK

1 5 . H O W O F T E N D O Y O U EA T FRIED F O O D A W A Y F R O M
H O M E ? (o .g . F R E N C H F R IE S , C H IC K E N , FR IED F IS H )
O

DAILY

O

4 ~ 6 TIM ES PER W EEK

C

1 - 3 TIM ES PER W EEK

C

LESS THAN ONCE A W EEK

(ij (i : '
a) 0

17. WHAT IS
YOUR
HEIGHT?

1 i ;'2 : - 3 .• ( > : ' e ; >' 6 ‘ ( 7 ) ip) ( 9 )

;i >(2; 3 . lit iis; i e) (7) (s) (9)
© ■
>' © ■ © © © © ©

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0

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® © d © d (i) (!) © tir
j) © ('3) © (i) © @ @ ®
' 1; >.->■3: © ©@ © 0 ®
/d© © © ® ®

18. WHAT WAS
YOUR
WEIGHT
AT AGE 18?>

1 4 . H O W O F T E N D O Y O U EA T F O O D T H A T IS FR IED A T
HOM E?

1 =

0

!' l''. ' f ' T : ' V ) ' T)

t

(a)

Q VEGETABLE OIL

VEGETABLE SH O RTEN IN G

(o' 0 f o

o

ISP.

W H A T T Y PE O F C O O K IN G OIL DO

OTHER FOODS THAT YOU USUALLY
USE AT LEAST ONCE PER WEEK

1 3 . W H A T K IND O F FAT D O Y O U U SU A L L Y U S E FO R
B A K IN G ?
REAL BUTTER

O

S P IC E S A N D DO N O T LIST S O M E T H IN G TH A T H A S BEEN LISTED IN
T H E P R E V IO U S S E C T IO N S . FO R EX A M PLE: B R A IN S . PA TE. C R E A M
S A U C E , C U S T A R D . C A R R O T JU IC E . C O C O N U T , TO RTILLA S. Y E A ST.
A V O C A D O , M A N G O . PA PA Y A . DRIED A P R IC O T S , D A TES, FIG S.

( J M ARGARIN E

O

VEGETABLE SH ORTENING

O

1 1 . A R E T H E R E A N Y O T H E R IM P O R T A N T F O O D S T H A T Y O U
U SU A L L Y EA T A T L E A S T O N C E P E R W E E K ? PLE A SE EXCLUDE

1 2 . W H A T K IND O F FAT D O Y O U U SU A L L Y U S E FO R
FR Y IN G ?
REAL BUTTER

O

0)

.O '

SPECIFY TYPE A N D BRA N D

U SE H A S
IN CREASED

o
o
o
o
o
o
o
o

6+

PER
DAY

O '

©

o

4 -5

PER
DAY

6

" O '

©

2 -3
PER
DAY

i'o;<

o

j©

1

PER
DAY

®
®

SPECIFY TYPE A N D B R A N D

Q

3 - 4 T B S/W E E K

I) WHOLE WHEAT
BREAD

O
O

o
'O
o
o
Q
o
o

o on
o
o
o n

©

m

H O W M ANY TA BLESPO O N S OF BRAN DO YOU A D D
TO Y O U R FOOD EACH W E E K ?

FOOD

O
O

o o
o 'O
o o
o O
o o

vnun m n n Farw
D A Y ? — -----

DIET ILOW
CALORIE) FORM

1 0 . H O W H A S Y O U R U S E O F T H E F O L L O W IN G
FO O D S CHANGED OVER TH E PA S T TEN
Y EA RS?

a)
b)
c)
d)
a)
4)
g)
h)

2 -4
5 -6
1
PER
PER
PER
WEEK W EEK WEEK

W H A T F O R M O F M A R G A R IN E D O Y O U U SU A L L Y U S E ? 7 . H O W M A N Y T E A S P O O N S OF
none

FORM

5.

1 -3
PER
M O.

1

’n 0 @ © ® ® ®
© ® <•>© © ©
f I ! »)'±'©,3 @ @ ® © @ ©
*.> ‘ iol<©"~00© 0 ® ® ® ®
KV KD (&)L?;|U|© © © © © © ® © ® ®

Appe ndi x 11
PILOT:

P h y s i c i a n ' s P r e n a t a l Ca re S u r v e y

308
PATIENT NAME:___________________________
DELIVERY DATE:___________________________
CODE NO:_________________________________

PHYSICIAN PREGNANCY SURVEY
DIRECTIONS: P lease com plete the following questions for the patient listed above. Be a s
thorough as possible. If the information is NOT AVAILABLE, please record "NA” ; do not leave
the sp ace blank.
1.

What is this patient's HEIGHT, without sh o e s?
___________ feet

2.

Did you suggest that this patient limit her total weight gain during her
recent pregnancy?
□
□

3.

inches o r ____________ cm

YES (If YES, go to question 3)
NO (If NO, go to question 4)

What limit in total weight gain did you recom m end?
□
□
□
□
□

less than 16 pounds
16-21 pounds
22-27 pounds
28-34 pounds
35 pounds or more

Did you RECOMMEND any of the following to this wom an during h er m ost recent pregnancy?

"NR" = Not Recorded.
YES
4.

Take a vitamin-mineral supplement?

5.

Restrict her calorie intake?

6.

Restrict her salt intake?

7.

Use diuretics?

8

Cut down or stop drinking alcohol?

9.

Cut down or stop smoking cigarettes?

10.

Restrict her u se of aspirin and ibuprofen-products,
especially during the last trimester?

NO

NR

_____ _______ _______

309

Page 2
11.

According to the medical charts, w as this wom an exposed to any of the following
medical risk factors during her pregnancy? "NR" = Not RECORDED.
YES

NO

NR

a.

Anemia (Hct< 30%; H g< 10 g/dL)

b.

Cardiac disease

c.

Lung disease, acute or chronic

d.

Diabetes, chronic

e.

Diabetes, gestational

f.

Genital herpes

g.

Hypertension, chronic
(less than 20 w eeks gestation)________________ __________________

h.

Hypertension, pregnancy-related
(20 weeks or more gestation)__________________ __________________

i.

Diagnosed Eclampsia________________________ __________________

j.

Incompetent Cervix

__________________

k.

Previous infant 4000+ gram s

__________________

I.

Previous pre-term or small-forgestational age infant (less than
37 w eeks or less than 2500 g)_________________ __________________

m.

Renal disease__________________________________________________

n.

Rh sensitization______________________________ __________________

o.

Short inter-pregnancy period
(less than 1 year)_______________________________________________

p.

Uterine bleeding or threatened
abortion____________________________________ __________________

q.

AIDS__________________________________________________________

r.

C esarean delivery

s.

O th e r-p le a se specify____________________________________________

L _ _

310
P ag e 3
According to the medical charts, w as this woman exposed to any of the following behavioral risk
factors during her pregnancy? "NR" = NOT RECORDED.
YES

15.

12.

Tobacco use during her pregnancy?

13.

Alcohol u se during her pregnancy?

14.

Inadequate weight gain?

NR

NO

P lease record the wom an's INITIAL and FINAL hemoglobin and/or
hemalocrit values you m easured during her recent pregnancy.
WEEK OF GESTATION
(estim ated )

HEMATOCRIT
(%)

HEMOGLOBIN
(g/dL)

F irst Iron V alue
L a st Iron V alue

16.

The following information is CRITICAL to this study.
a.

What w as the woman's
PRE-PREGN ANCY W EIGHT?____________________________
(Please make a good estimate if the actual value is not recorded.)

b.

What is the FIRST pregnant weight
recorded for this wom an?
___________________________
Approximately how far into
the pregnancy w as this?

c.

________________________________

What is the LAST recorded weight
for this wom an during this pregnancy?______________________
Approximately how long after this
weight w as recorded did the w om an deliver?.

311

Page 4
17.

It would be extremely helpful if you could provide ALL of the weights which are charted for
this woman. Though time consuming, the information would significantly enhance the
results of this study.
WEIGHT

18.

EST. WK. GESTATION

WEIGHT

EST. WK. GESTATION

Are there any other observations or comments you would like to m ake about any factor(s)
which, in your opinion, influenced this woman's pregnancy outcom e?

P le ase record the nam e, degree and telephone num ber of the person completing this
questionnaire so that, if clarifications are needed, the appropriate individual m ay b e contacted.
NAME:_______________________________________________________
PHONE:

(_____ )____________________

T h an k y o u fo r y o u r c o o p e ra tio n . P le a s e re tu rn p ro m p tly in th e e n c lo s e d
p o s ta g e - p a id e n v e lo p e a t y o u r e a r lie s t c o n v e n ie n c e .

Appe ndi x 12
PILOT:

F i r s t L e t t e r t o t h e M ic h i g a n Mo the r

312

STATE OF MICHIGAN

JA M E S J. B LA N C H A R D , G o v e rn o r

DEPARTMENT OF PUBLIC HEALTH
3 4 2 3 N. LO G A N
P .O . b o x 3019 5 . l a n s i n g . M i c h i g a n 4 8 9 0 9

January 7

1989

J a n e Doe
2 00 5 S o u t h v i e w B l v d .
E a s t L a n s i n g , MI 4 8 8 2 3

D e a r m o t h e r o f B e a t r i c e Doe:
We a r e i n v i t i n g y o u t o p a r t i c i p a t e i n a s t a t e w i d e r e s e a r c h p r o j e c t . I t s
p u r p o s e i s t o g a i n a b e t t e r u n d e r s t a n d i n g o f t h e h e a l t h c a r e t h a t women
r e c e i v e d u r i n g t h e i r p r e g n a n c y a n d t h e i r a t t i t u d e s a nd a c t i o n s d u r i n g
th is tim e.
The i n f o r m a t i o n y o u p r o v i d e c a n h e l p women a n d b a b i e s i n t h e
future.
You a r e o n e o f a s m a l l nu mb e r o f women s t a t e w i d e y o u h a v e b e e n
s c i e n t i f i c a l l y s e l e c t e d t o be i n t h i s s u r v e y .
Whether o r n o t you a g r e e
t o p a r t i c i p a t e , y o u r e c e i v e a FREE G e r b e r b i b f o r y ou b a b y .
I f you
a g r e e t o p a r t i c i p a t e , a l l yo u h a v e t o do i s c o m p l e t e t h e e n c l o s e d
q u e s t i o n n a i r e a n d f o o d f r e q u e n c y f o r m and r e t u r n t h e m i n t h e p o s t a g e paid, re tu rn envelope provided.
The q u e s t i o n s i n t h i s s u r v e y a s k a b o u t
your r e c e n t pregnancy with B e a tr ic e .
P l e a s e c o m p l e t e t h e q u e s t i o n n a i r e a nd r e t u r n i t i n t h e e n c l o s e d
e n v e l o p e . The M i c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h w i l l u s e t h i s
i n f o r m a t i o n o n l y f o r s t a t i s t i c a l p u r p o s e s ; no i n f o r m a t i o n t h a t
i d e n t i f i e s yo u o r y o u r baby w i l l e v e r be p u b l i s h e d .
Th e q u e s t i o n n a i r e
h a s a n i d e n t i f i c a t i o n n u mb e r f o r m a i l i n g p u r p o s e s o n l y .
T h i s n umber
w i l l a l l o w u s t o c h e c k y o u r name o f f o u r m a i l i n g l i s t when y o u r
questionnaire is returned.
Yo u r p a r t i c i p a t i o n i s v o l u n t a r y a n d y o u r
r e f u s a l t o a n s w e r some o r a l l o f t h e q u e s t i o n s w i l l n o t r e s u l t i n a n y
p e n a l t y o r l o s s o f s e r v i c e s o r b e n e f i t s from t h e Mi c h ig a n D e p ar t m en t o f
Public Health.
I f y o u h a v e a n y f u r t h e r q u e s t i o n s r e g a r d i n g t h i s p r o j e c t , o r i f yo u
would p r e f e r a t e l e p h o n e i n t e r v i e w , p l e a s e c a l l o u r P r o j e c t C o o r d i n a t o r ,
Caro l F r i e s e n , c o l l e c t a t (517) 351-8334.
We h o p e y o u w i l l

a c c e p t o u r r e q u e s t t o be i n t h i s

study.

Sincerely,

G e o r g e H. Van Ambur g, MPH
S t a t e R e g i s t r a r a nd C h i e f
Office of the S tate Registrar
an d C e n t e r f o r H e a l t h S t a t i s t i c s

2 -2 5 4/68

G e o r g e H. B a k e r , MD
C h ie f , O f f i c e of Maternal
Child Health

and

4

Appen dix 13
M ic h i g a n M o t h e r ' s Reminder P o s t c a r d

313

L ast w e ek , a questio n n aire w a s m ailed to you that a s k e d a b o u t your recen t
p re g n a n c y . You w ere scientifically s e le c te d to b e in th is im portant statew id e
r e s e a rc h study.
If you h a v e already co m p le te d a n d retu rn ed it to u s, p le a s e a c c e p t o u r sin cere
th a n k s. If not, p le a se d o s o today. B e c a u se it h a s b e e n s e n t to only a sm all
sa m p le of w om en, it is very im portant that w e receiv e y o u r re s p o n s e . T he
m ore w o m en w e h e a r from , th e b e tte r will b e our inform ation for u s e in
im proving p ro g ram s for p re g n a n t w om en a n d infants in th e future.
If you did not receive th e q u estio n n aire, or if it got m is p la c e d , p le a s e call
C arol F rie se n right now collect at (517) 351-8334, a n d w e will g e t a n o th e r o n e
in th e mail to you today.

eorge Van Alhburg, State Register and Chief
ffice of the State Registrar and Center for Health Statistics
lichigan Department of Pubfic Health

Appendix 14
PILOT: Second L e t t e r t o M ic hi ga n M ot he r s

314

STATE OF M ICHIGAN

JA M E S J B L A N C H A R D . G o v e rn o r

DEPARTMENT OF PUBLIC HEALTH
P .O

3 4 2 3 N. L O G A N
B O X 3 0 1 9 5 . L A N S IN G . M IC H IG A N 4 8 9 0 9

F e b r u a r y 7,

1989

J a n e E. Doe
2005 S o u t h v i e w Bl vd.
E a s t L a n s i n g , MI 4 8 8 2 3

D e a r m o t h e r o f B e a t r i c e Doe:
A b o u t t h r e e we e k s a g o , we i n v i t e d you t o p a r t i c i p a t e i n a s t a t e w i d e
re s e a rc h p r o j e c t . I t s purpose is t o gain a b e t t e r u n d e rs ta n d in g o f the
h e a l t h c a r e t h a t women r e c e i v e d u r i n g t h e i r p r e g n a n c y a n d t h e i r
a t t i t u d e s and a c t i o n s
d u r i n g t h i s t i m e . The i n f o r m a t i o n y o u p r o v i d e c a n
h e l p women and b a b i e s
in t h e f u t u r e .
As m e n t i o n e d i n o u r p r e v i o u s l e t t e r , y o u a r e o n e o f a s m a l l n u m b e r o f
women s t a t e w i d e who h a v e b e e n s c i e n t i f i c a l l y s e l e c t e d t o b e i n t h i s
survey.
I f y o u a g r e e t o p a r t i c i p a t e , a l l y ou h a v e t o d o i s c o m p l e t e t h e
e n c l o s e d q u e s t i o n n a i r e and f o o d f r e q u e n c y f o r m a n d r e t u r n t h e m i n t h e
p o sta g e -p a id , r e tu r n envelope provided.
The q u e s t i o n s i n t h i s s u r v e y
ask about your r e c e n t pregnancy w ith B e a t r i c e .
I f y o u h a v e r e t u r n e d t h e q u e s t i o n n a i r e i n t h e p a s t f e w d a y s , we
a p p r e c i a t e i t v e r y mu ch. I f y o u h a v e n o t , p l e a s e c o m p l e t e t h e
q u e s t i o n n a i r e and r e t u r n i t i n t h e e n c l o s e d e n v e l o p e . T h e M i c h i g a n
Department of P u b lic H ealth w ill use t h i s in fo rm atio n o n ly f o r
s t a t i s t i c a l p u r p o s e s ; no i n f o r m a t i o n t h a t i d e n t i f i e s y o u o r y o u r b a b y
w i l l e v e r be p u b l i s h e d .
Th e q u e s t i o n n a i r e h a s a n i d e n t i f i c a t i o n n u m b e r
fo r m ailing purposes only.
T h i s n u m b e r w i l l a l l o w u s t o c h e c k y o u r name
o f f o u r m a i l i n g l i s t when y o u r q u e s t i o n n a i r e i s r e t u r n e d .
Yo u r p a r t i c i p a t i o n i s v o l u n t a r y a n d y o u r r e f u s a l t o a n s w e r s o m e o r a l l
o f t h e q u e s t i o n s w i l l not r e s u l t i n anyp e n a l t y o r l o s s o f s e r v i c e s o r
b e n e f i t s from t h e Mi c hi ga n D e p ar tm en t o f P u b l i c H e a l t h .

.

I f you have any f u r t h e r q u e s t i o n s r e g a r d i n g t h i s p r o j e c t , o r i f you
would p r e f e r a t e l e p h o n e i n t e r v i e w , p l e a s e c a l l o u r P r o j e c t C o o r d i n a t o r ,
Ca rol F r i e s e n , c o l l e c t a t (517) 35 1 -8 3 3 4 .
We h o p e y o u w i l l

a c c e p t o u r r e q u e s t t o be in t h i s

study.

Sincerely,

G e o r g e H. Van Ambur g, MPH
S t a t e R e g i s t r a r and C h i e f
O ffice of the S ta te R egistrar
and C e n t e r f o r H e a l t h S t a t i s t i c s

Z-25

4 /0 8

G e o r g e H. B a k e r , MD
Chief, O ffice o f Maternal
Child Health

and

4

Ap pendix 15
PILOT:

F i r s t L e tte r to Physicians

315

STATE OF MICHIGAN

JA M E S J . B LA N C H A R D . G o v ern o r

DEPARTMENT OF PUBLIC HEALTH
3 4 2 3 N LOGAN
P .O . B O X 3 0 1 9 5 . L A N S IN G . M IC H IG A N 4 8 9 0 9

F eb ru ary 7,

1989

Thomas Lowe, M.D.
Westview C l in i c
100 S o u t h v i e w B l v d .
E a s t L a n s i n g , MI 4 88 2 3

D e a r Dr .

Lowe:

Yo u r a s s i s t a n c e i s n e e d e d i n a s t a t e w i d e r e s e a r c h p r o j e c t c o n d u c t e d by t h e
Michigan Department o f P u b lic H e alth .
The p u r p o s e s o f t h e s t u d y a r e : 1) t o
d e t e r m i n e i f t h e a t t a i n m e n t o f a s p e c i f i c p e r c e n t a g e o f a woman's d e s i r a b l e
body w e i g h t i s a s s o c i a t e d w i t h s u c c e s s f u l f e t a l o u t c o m e , a nd 2) t o i d e n t i f y
a n d q u a n t i f y f a c t o r s a s s o c i a t e d w i t h l o w b i r t h w e i g h t (LBW) i n M i c h i g a n .
B eca use Mi ch iga n i s t i e d w i t h P e n n s y l v a n i a as t h e s t a t e w i t h t h e h i g h e s t
i n c i d e n c e o f LBW i n B l a c k s i n t h e n a t i o n ( 1 2 . 9 % B l a c k , 5 . 5 % W h i t e , 6. 8%
S t a t e w i d e ) , i d e n t i f i c a t i o n o f f a c t o r s c o n t r i b u t i n g t o , and t h e p r e v e n t i o n
o f , LBW h a s become a p r i o r i t y p u b l i c h e a l t h c o n c e r n o f t h e D e p a r t m e n t .
You w e r e i d e n t i f i e d a s b e i n g t h e p r e n a t a l h e a l t h c a r e p r o v i d e r o f J a n e E.
Doe , who p r o v i d e d u s w i t h y o u r name a n d a d d r e s s . She h a s a u t h o r i z e d y o u t o
p r o v i d e us w i t h i n f o r m a t i o n from h e r medic al r e c o r d s a b o u t h e r p r e gn an c y
w i t h B e a t r i c e Doe .
A l l i n f o r m a t i o n y o u r e p o r t w i l l be k e p t s t r i c t l y
confidential.
No i n f o r m a t i o n w h i c h i d e n t i f i e s e i t h e r y o u o r t h e p a t i e n t
w i l l be r e l e a s e d .
Your p a r t i c i p a t i o n i s v o l u n t a r y . Th e d i r e c t o r o f p u b l i c
h e a l t h has d e c l a r e d t h i s a medical r e s e a r c h p r o j e c t under t h e p r o v i s i o n o f
MCL 3 3 3 . 2 6 3 1 - 3 3 3 . 2 6 3 5 . As s u c h , a n y i n f o r m a t i o n s h a r e d w i t h u s i s n o t
subject to d isclosure.
Th e d a t a c o l l e c t e d w i l l b e u s e d i n p r o g r a m p l a n n i n g
and e p i d e m i o l o g i c a l r e s e a r c h t o be p u b l i s h e d i n p r o f e s s i o n a l j o u r n a l s .
B e c a u s e t h i s s u r v e y i s b a s e d on a s m a l l r a n d o m s a m p l e o f M i c h i g a n women, i t
i s i m p o r t a n t t h a t we o b t a i n a s much i n f o r m a t i o n a s p o s s i b l e o n a l l women i n
t h i s study.
P l e a s e c o m p l e t e t h e q u e s t i o n n a i r e and r e t u r n i t i n t h e e n c l o s e d p r e ­
addressed, posta g e-p a id envelope at your e a r l i e s t convenience.
I f you
s h o u l d ha ve any q u e s t i o n s , p l e a s e c a l l t h e P r o j e c t C o o r d i n a t o r , Ca r o l
F r i e s e n , a t (517) 351-8334.
Your c o o p e r a t i o n i s g r e a t l y a p p r e c i a t e d .

Z 2 5 4 /8 8

Sincerely yours,

Sincerely yours,

G e o r g e Van Ambur g, MPH
S ta te R e g is tra r & Chief
O ffice of the S tate R egistrar
and C e n t e r f o r H e a l t h S t a t i s t i c s

Ge o r g e H. B a k e r , J r . , M.D.
C h i e f , O f f i c e o f M a t e r n a l and
Child Health

4

Appe ndi x 16
P h y s i c i a n ' s Rem inder P o s t c a r d

316

Last w eek, a questionnaire w a s m ailed to you that a sk e d specific information about
a recent pregnancy of o n e of your patients. Vour patient w a s scientifically selected
to be in this im portant statew ide re se a rc h study.
If you have already com pleted a n d returned it to u s, p le a s e ac c e p t o u r sincere
thanks. If not, p le a se d o s o today. B e c a u se it h a s b e e n se n t to only a small sam ple
of w om en an d their physicians, it is very important that w e receive your response.
T he m ore su b jects w e h e a r from, the better will b e our inform ation for u s e in
improving program s for pregnant w om en and infants.
If you did not receive th e questionnaire, o r if it got m isplaced, p le a s e call
C arol F riesen collect at (517) 3 5 1 -B334, an d we will g e t an o th e r o n e in the mail to
you today.

ind Chief
State R egistrar a n d Cpt r for Health S tatistics
Michigan D epartm ent of Public H ealth

A p p e n d i x 17
M ichigan M o th e r's Pregnancy L i f e s t y l e Q u e s t i o n n a i r e

317
CODE NO:

PREGNANCY LIFESTYLE QUESTIONNAIRE
DIRECTIONS: P lease com plete the following questions as completely a s possible. Write the
information in the sp ace provided or check the box of the answ er you think is most correct. All the
q u estio n s refer to your p re g n a n c y w ith y o u r ch ild n a m e d In th e e n c lo s e d le tte r.
1.

What is the nam e, address and phone number of the doctor you saw
for m ost of your medical care during your pregnancy?
PHYSICIAN'S
NAME:

______________________________________________

CLINIC or
HOSPITAL NAME:
STREET ADDRESS:
CITY:________________________ STATE:____________ ZIP:________
PHONE: (_____ )____________________________________
2.
3.

4.

How tall are you, without sh o es?

________ f e e t __________ inches

Approximately how much did you weigh BEFORE
you becam e pregnant ?
Approximately how much did you weigh JU ST BEFORE
YOU DELIVERED your baby?

5.

How much do you weigh to d a y ?

6.

Do you, or d o es som eone in your family, rem em ber
how much YOU weighed when YOU were bom ?

7.

8.

9.

lbs

________________ lbs

_______________ lbs
Date:

/

/

__________ lbs_________ ounces

Did a doctor, nurse or nutrition counselor tell you how much weight you should
gain during this pregnancy?

n

YES (if y e s, go to next question)

□

NO

(if no, go to question 8)

How many p o u n d s w ere you told to gain from the
BEGINNING to the END of this p r e g n a n

c y

? __________________ lbs

Did you breastfeed? If yes, for approximately how long (please specify w eeks or months)?
□

NO

□

Y E S : ____________________________

318

Page 2
During your recent pregnancy, did you do any of the following on a re g u la r b a s is ? Check only ONE
BOX p er question.
YES, based on
doctor’s or
other medical
source's
suggestion.

10.
11.
12.
13.
14.

15.

YES, based on
my decision
without asking
a doctor or
other medical
source.

Restrict your calorie
intake?
Restrict your caffeine
intake (i.e. coffee/tea)?
Cut down or stop
drinking alcohol?
Cut down or stop
sm oking cigarettes?
Take a vitamin/mineral
supplem ent?

NO. I did
NOT.

Does NOT
apply to me.

'

If you took a vitamin/mineral supplement, what w as the brand n am e? .
If you took an iron supplem ent, what w as the brand n a m e ? _________

16.

How often would you say you took the supplement(s) during your pregnancy?
MULTI-VITAMIN

17.

S U PPLEM EN T

IRON

S U P PL E M E N T

□

daily

□

daily

□

5 times per week

□

5 tim es per week

□

3 tim es per week

□

3 tim es per week

□

1-2 times per week

□

1-2 tim es per week

□

irregularly

□

irregularly

On the average, how many CUPS of each of the following beverages did you consum e
PER DAY during the la s t th re e m o n th s of your pregnancy?
LAST 3
M O N TH S

HOW DO YOU LIKE YOUR
COFFEE OR TEA (please check)?

Coffee, regular

Strong

T ea, regular

Medium

S o d a pop, caffeinated

Weak

319

Page 3
D IR E C T IO N S :

C ircle the num ber which m ost closely represents your o p in io n about the
following statem ents. EXAMPLE: 5 = Strongly Agree.
STRONGLY
AGREE

AGREE

NO
OPINION

DISAGREE

18.

Nutrition is important
during pregnancy.

5

3

19.

A poor diet during pregnancy
will NOT affect the baby's health.

5

3

20.

Mothers who eat good diets deliver
healthier babies than m others
who do not eat well.

5

3

21.

I worried that I might get fat
during my recent pregnancy.

5

4

3

2

2 2.

I tried to keep my weight down
so I didn't look so pregnant.

5

4

3

2

23.

I felt that eating a well-balanced
diet w as more important than how
much weight I gained while pregnant.

5

3

2

24.

I think a pregnant woman is
beautiful.

5

4

3

25.

I w as em barassed by how big I
got during my pregnancy

5

4

3

26.

As long a s I took my vitamin pill in
the morning, I didn't worry about
what I ate.

5

27.

I would gain 40 pounds if it meant
my baby would b e healthier.

5

4

3

2

28.

I feel that women have to be
especially careful about getting
fat during pregnancy.

5

4

3

2

29.

The weight I gained during my
pregnancy m ade me feel unattractive.

5

3

2

30.

Good eating habits during pregnancy
are very important to the baby's health.

5

3

2

31.

Just before I went to the doctor,
I tried not to eat, because I w as worried
about my weight gain.

5

3

3

STRONGLY
DISAGREE

32 0

Page 4
32.

How would you rate your diet BEFORE and DURING your pregnancy, on a scale of
1 (poor) to 10 (excellent)? C ircle your rating.

IB E F O R E .

1

2

3

4

DIRECTIONS:

1

6

7

8

9

AVERAGE

POOR
IDU RING:

5

2

3

4

5

10
EXCELLENT

6

7

8

9

10

R esearch suggests many wom en crave unusual foods or have strong food aversions
during pregnancy.

3 3.

During your pregnancy, did you have any, u n u su a l c ra v in g s (a strong desire to e a t o r chew
things like ice, starch, clay, pickles)?

34.

During your pregnancy, did you have any, food a v e rs io n s (a strong dislike for a food you
previously enjoyed like coffee, chocolate, spices)?

35.

On the average, how many drinks of alcoholic beverages, if any, did you have
the three m onths BEFORE and then DURING your pregnancy? A drink is 12
ounces of b eer (1 can), 4 ounces of wine (1/2 c u p ), or 1 1/2 ounces of liquor. Mark ONE
box for BEFORE and o n e box for DURING your recent pregnancy.
BEFORE
PREGNANCY
□

DURIN G
PREGNANCY
21 or more drinks a week

□

□

14 to 20 drinks a week

□

□

9 to 13 drinks a w eek

□

□

6 to 8 drinks a week

□

□

3 to 5 drinks a week

□

□

2 drinks a week

□

□

1 drink a week

□

□

□
□
□

2 to 3 drinks a month
1 drink a month
L ess than one drink a month
I did NOT drink

I

□

□
□
□

I

321

Page 5
36.

On the average, how many cigarettes, if any, did you sm oke A DAY during the
3 m onths BEFORE you found out you w ere pregnant and DURING your
pregnancy? Write in "0" if you did NOT smoke.
average num ber of cigarettes a day BEFORE I w as pregnant
____________ average num ber of cigarettes a day DURING my pregnancy

37.

Did you receive assistance from any public services or support program s during your
pregnancy? If yes, please check ALL that apply.

□
□
□
□

□
□
□
□
□
38

EFNEP (Expanded Food and Nutrition Education Program)
MCH (Maternal and Child Health Programs like MSS and MIC)
Food Stam ps
Food C losets (church, community)
Community kitchen
AFDC (Welfare)
No public service assistance or support w as received
O ther - p lease s p e c ify _________________________________

On the average, what w as theTOTAL MONTHLY INCOME (after taxes) of all
household m em bers you lived with (include yourself) during your pregnancy?
P le ase check your BEST ESTIMATE.

□
□

$0 to $299
$300 to $499

□

$500 to $999

□

$1000 to $1499

□

$1500 to $1999

□

$2000 to $2499

□
□
39.

WIC (Supplemental Program for Women, Infants and Children)

$2500 or more
I do not know or wish to say

How many individuals did this total income serve (including you)?

322

Page 6
40.

Thinking back to JU ST BEFORE you w ere pregnant, how did you feel about becoming
pregnant? C heck only ONE BOX.

□

41.

I w anted to be pregnant s o o n e r.

□
□

I w anted to becom e pregnant later.

□

I did NOT want to be pregnant then, o r at any time in the future.

□

I d o n t know or wish to say.

I w anted to be pregnant th e n .

If we have questions about anything you have written down, could we call you? If so,
please give u s a number w here you can be reached and when it would be convenient.
PHONE: (______) ____________________________

42.

TIME:____________________

In ca se we can't reach you, would you give us the nam e and address of a person
who would likely know where you could be reached?
NAME:____________________________________________________________
ADDRESS:_________________________________________________________
CITY:_________________________ STATE:___________ ZIP:______________
PHONE:

43.

Would you like us to send you results of this
NOTE: Expect results sometime this fall.

D

YES

4 4.

(_____ )__________________

survey?

CD

NO

Is there anything else you would like to tell us about yourself, your pregnancy,
your baby or something in this questionnaire?

323

CODE:

It is important for you to read and sign the CONSENT STATEMENT below. Your
doctor can tell us more about the care you and your baby received. What your doctor
can tell us is also very important. All of the information we obtain will be kept strictly
confidential.

CONSENT STATEMENT
I have voluntarily participated in this pregnancy survey.
I give my
permission for the Michigan Department of Public Health to obtain
additional information about my pregnancy from the medical source
listed in question 1. I understand that the Department will use this
information ONLY for statistical purposes in health research, and no
information which identifies either me or the medical source will EVER
be released or published.

(Signature -- in INK)

(Today's Date)

Thank you for your help and cooperation! Please check to make sure your
responses to BOTH this QUESTIONNAIRE and the FOOD FREQUENCY are
completed and returned in the enclosed postage-paid envelope
at your earliest convenience.

MICHIGAN D E P A R T M E N T O F PUBLIC HEALTH
Office of the State Registrar and Center for Health Statistics
1989

A p p e n d i x 18

Revised W i l l e t t S e m i- Q ua n t it at iv e
Food Frequency Quest ion na ire

324

DIET ASSESSMENT

®©©®©©©©©® ®©©®®©®©©®
®©®®®®®®®@ ®© ©®® ©®© ®® ® © © ® ® ® © Q ® ©
®© ®@© © © © @© © Q ® ® ® ® ® © ® ® ® © © ® @ © © © ® ®
® © © ® © ® © ® ® ©

ID:

1. Do you currently take multiple v itam in s? (Please report individual vitamins under question 2.)
£ 3 No

(3 Y es

♦ If v as.

a) How m any do you take
O 2 or loss
por w e e k ? -------------------------►r~\ n ^
O 3-5

® © @ ® © © © © © ©
® © © © © © © © @ ®

( 3 6-9
r\
( 3 10 or more

®Q®®©©@©®®

b) W h at specific brand do
you usually use? ----------

S p e c ify e x a c t b ra n d a n d ty p e

2. N o t c o u n tin g m u ltip le v ita m in s , d o y o u t a k e a n y o f t h e fo llo w in g p re p a ra tio n s :
a)V ita m in A?
ONo

i

O Yes- seasonal only
Yes. most months

If
Yes,

O

b )V ita m in C ?

O No

i

Q 2 3 .0 0 0 IU
or more

O Don't
know

0 2 - 4 yrs.

o

5-9 yrs.

O 10+ Vrs-

( 3 Don't
know

f “)4 0 0 to
700 mg.

0 7 5 0 to
1250 mg.

C ) 1300 mg.
or more

Q 2-4 '

( 3 Don't
know
Don't
( 3 know
O Don't
know
Don't
( 3 know
( 3 Don't
know
Don't
( 3 know
O Don’t
know
Don't
( 3 know
O Don't
know

O 10+

If y es.

How m any years?
I W h at d o se per day?

> Q 0 -1 yr.
►O L e s s than
w 100 IU

Q 2-4 yrs.
o 100 to
250 IU

Q 5-9 yrs.
O 300 to
500 IU

Q 10+
O BOO IU
or more

( 3 Yes —► If y es.

j How many years?
I W hat d o se per day?

Q O -1 yr.
^ Q l e s s than

Q 2-4 yrs.
Q 8 0 to

Q 5-9 yrs.
O 140 to
9250
^0 m
m
meg.

Q 10+ yrs.
( 3 2 6 0 meg

( 3 Yes —> If y es.

How m any years?
I W h at doso per day?

-frQ p - 1 yr.
^ O L e s s than
51 mg.

Q 2-4 yrs.
0 5 1 to
200 mg.

Q 5-9 yrs.
0 2 0 1 to
400 mg.

Q 10+ yrs.
0 4 0 1 mg.
or more

O Yes —* If ves.

j How many years?
I W hat d o se per day?

Q 2-4 yrs.
0 2 5 to
74 mg.

Q 5-9 yrs.
0 ? 5 to
100 mg.

Q 10+
( 3 101 mg.
or more

O Yes — ► if yes.

i) A re th e r e o th e r s u p p le ­
m e n ts t h a t y o u ta k e o n
a re g u la r b a sis ? P le a s e
m a rk if y es:

> Q 0 -1 yr.

►
OL
ess than
25 mg.

How m any years?
W h at d o se per day?

o

Folic acid
( 3 Vitamin D
O B-Complex
Vitamins

1 TO
m
30 m
meg.

3 0 mCQ.

Q O -1 Vr-

( 3 2 - 4 yrs.

♦O Less than
4 00 mg.

O Cod liver

w 0il

O Omega-3
^ Fatty-acids

3. F o r e a c h fo o d lis te d , fill in th e circle in d ic a tin g
h o w o f te n o n a v e r a g e y o u h a v e u s e d t h e a m o u n t
s p e c ifie d d u rin g th e p a s t y e a r.
DAIRY FOODS
Skim or low fat milk (8 02 . glass)
Whole milk (8 0 2 . glass)
Cream, e.g. coffee, whipped (Tbs)
Sour cream (Tbs)
Non-dairy coffee whitener (tsp.)
Sherbet or ice milk ( : cup)
Ice cream (V2 cup)
Yogurt (1 cup)
Cottage or ricotta cheese {Vi cup)
Cream cheese (1 oz.)

Please turn
to p age 2

O 13.000 to
w 22.000 IU

Q 5 -9 .
O -> 0 to
79 mg.

in Dolomito.)

ONo

0 8 . 0 0 0 to
^ 12.000 IU

O 39
10 mg.
to

( 3 Yes •

O
O
O
w

Q Don't
know

yrs.

> Q 0 -1 y r .
>O Less than
10 mg.

g )Z in c ?
O No

•I

O io+

yrs.

I W h at doso per day?

f) Iron?
ONo

t O l e s s than
^ 8.000 IU

| How many years?

e) S e le n iu m ?
O No

W hat dose
per day?

O 5-9

yrs.

Q Yes —* If y e s,

d) V ita m in E?
O No

02-4

yr.

Yes, §S W h at dose —> f)L e s s than
Yes,
per day?
400 mg.

Yes, most months

c) V itam in B6?
ONo

►
Oo-1

How many - > 0 0 - 1 yr.
years?

O Yes- seasonal only

o

How many
years?

norr more
in n m

900 mg.

know
( 3 Don't
know

— Don’t
Q know
( 3 Don’t
know

10+ Vrs
( 3 1301 mg.
or more

O

( 3 BetaCarotene

-Don't

O

(3 5 - 9 yrs.
0 9 0 1 to
1300 mg.

0^00
Iodine
Copper
Brewer's
Yeast

( 3 80 mg.
or more

O th e r (p lease specify):

( 3 Magnesium

AVERAGE U SE LAST YEAR
Never,
or losa
than onco
por month

TJ
O
o
o
o
o
o
o

1-3
per
m o.

TJO

per
w eek

®

o
o
o
o

®

2-4

5 -6

per
w eek

per
w eek

per
day

TJ TJ
O

O
O

o
o
o
o
o
o
o
o

o
o
o
o
o
o
o

2 -3

4 -5

per
day

per
day

TJ

U

®

O
O
O
O
O
O
O
O
O

o
o
o
o
o
o
o
o
o

®
©
®

®
®

6+
per
day

O
O

o
o
o
o
o
o
o
o

jO
J®
'O

o
4®

Hi

o
o

o
o
o
o

Other cheese, e.g. American, cheddar. etc.,
plain or as part of a dish (1 slice
or 1 oz. serving)

o

o

o

o

®

O

o

o

o

Margarine (pat), added to food or bread;
exclude use in cooking

o

o

o

o

©

O

o

o

c

is I

£L

Butter (pat), added to food or bread;
exclude use in cooking

u

®
©

j£L

D .

®

325

■■
1 in v o u r a v e r a g e u s e ,
o f e a c h s p e c ifie d fo o d .

Please try to
average your
seasonal use
of fo o d s over
th e entire year.
For exam ple, if
a food such as
cantaloupe is
eaten 4 tim es a
w eek during th e
approxim ate 3
m onths th a t it is
in seaso n , then
th e average use
would b e once
per w eek.

■■

Page 2

FRUITS
Raisins (1 oz. or small pack) ex' grapes
Prunes (Vi cup)
Bananas (1)
Cantaloupe (Vi melon)
Watermelon (1 slice)
Fresh apples or poars (1)
Apple juice or cider (small glass)
Oranges (1)
Orange juice (small glass)
Grapefruit (Vi)
Grapefruit juice (small glass)
Other fruit juices (small glass)
Strawberries, fresh, frozen or canned (Vi cup)
Blueberries, fresh, frozen or canned (Vi cup)
Peaches, apricots or plums (1 fresh,
or Vi cup canned)

Never,
or loss
than once
por month
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O

1-3
per
mo.
0
O
O
O
O
O
O
O
O
O
O
O
O
O
O

1
2-4
5-6
per
per
per
week week week
©
©

©
©
©
®

©
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Nover,
o r le s s

VEGETABLES
Tomatoes (1)
Tomato juice (small glass)
Tomato sauce (Vi cup) e.g. spaghetti sauce
chili sauce (1 Tbs)
Tofu or soybeans (3*4 oz.)
String beans (Vi cup)
Broccoli
cup)
Cabbage or cole slaw (V2 cup)
Cauliflower (Vi cup)
Brussels sprouts (V i cup)
Carrots, raw (Vi carrot or 2-4 sticks)
Carrots, cooked (V i cup)
Com (1 ear or Vi cup frozen or canned)
Peas, or lima beans (Vi cup fresh, frozen, canned)
Mixed vegetables (Vi cup)
Beans or lentils, baked or dried (Vi cup)
Yellow (winter) squash (Vi cup)

Hod

(Vi

Eggplant, zucchini, or other summer
squash (Vi cup)
Yams or sw eet potatoes (Vi cup)
Spinach, cooked (Vi cup)
Spinach, raw as in salad
Kale, mustard or chard greens (Vi cup)
Iceberg or head lettuce (serving)
Romaine or leaf lettuce (serving)
Celery (4' stick)
Beets (V i cup)
Alfalfa sprouts (Vi cup)
Garlic, fresh or powdered (1 clove or shake)

then once
per month
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E G G S , M E A T , ETC.

Please go
to page 3

Egss (1)
Chicken or turkey, with skin (4-6 oz.)
Chicken or turkey, without skin (4-6 oz.)
Bacon (2 slices)
Hot dogs (1)

o r lo ss
th e n o n c e
p e r m o n th

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326

Page 3
P le a s e

fill in v o u r a v e r a q e

D ast v e a r, o f e a c h

s p e c ifie d

u se,
fo o d .

M EA TS (CONTINUED)

mm
Never,
or lass
than onco
per month

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Hamburger
patty)

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couscous, etc. (1 •cup)
Pancakes or waffles (serving)
French fried potatoes (4 oz.)
Potatoes, baked, boiled (1) or mashed (1 cup)
Potato chips or com chips (small bag or 1 oz)
Crackers, Tnskets, Wheat Thins (1)
Pizza (2 slices)

Please turn
to page 4

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OTHER

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V ERAGES

6+

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BREA D S, CEREA LS, STA RC H ES
Cold breakfast cereal
cup)
Cooked oatmeal (1 cup)
Other cooked breakfast cereal (1 cup)
White bread (slice), including pita bread
Dark broad (slice)
English muffins, bagels, or rolls (1)
Muffins or biscuits (1)
Brown rice (1 cup)
White rice 1 cup)
Pasta, e.g. spaghetti, noodles, etc. (1 cup)

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per
day

0

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BEVERAGES
Low caione cola, e.g Tab with caffeine
Low calorie caffeine-free cola, e.g Pepsi Free
Other low calorie carbonated beverage, e.g
Fresca. Diet 7-Up, dsat gaiger ale
Coke. Pepsi, or other cola with sugar
Caffeine Free Coke, Pepsi, or other cola
with sugar
Other carbonated beverage with sugar,
e.g. 7-Up, ginger ale
Hawaiian Pinch, lemonade, or other non­
carbonated frut drinks (1 glass, bottle, a n )
Decaffeinated coffee (1 cup)
Coffee (1 cup)
Tea (1 cup), not herbal teas
Beer 11 glass, bottle, can)
Red wine (4 oz. glass)
White wine (4 oz. glass)
Liquor, e.g. whiskey, gin, etc. (1 drink or shot)

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Shrimp, lobster, scallops as a main dish

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per
day

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1
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day

0

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sardines, bluafish, swordfish (3-5 oz.)

Consider the
serving size
as 1 glass,
bottle or can
for these
carbonated
beverages.

2-4
1
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week week week

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roast, ham. etc. (4-6 oz.)

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types

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E P 0 1 - 2 6 4 5 9 .6 5 4

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bologna, etc. (piece or slice)

(1

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A p p e n d i x 19

In stru ctio n s fo r the W ille tt
S e m i - Q u a n t i t a t i v e Food F r e q u e n c y Q u e s t i o n n a i r e

328

This form a s k s ab o u t your usual food intake d u rin g y o u r r e c e n t
p r e g n a n c y . It ta k e s about 20 m inutes to com plete. P le a s e follow
th e se instructions. If you have any q u e stio n s, call Carol F riesen
collect a t (517) 351-8334, and s h e will b e happy to help you.

1.

A nsw er e a c h question a s b e s t you c a n -e s tim a te if you a re n ’t
su re .

2.

U se ONLY th e enclosed pencil or a n y other # 2 pencil.
DO NOT USE INK.

3.

Be certain to com pletely blacken in e a c h of your an sw e rs, a n d
e ra s e com pletely if you m ake any c h a n g e s. K eep any h a n d ­
w ritten w o rd s within the border of th e resp o n d en t box.

4.

Do not m ake a n y other m arks on this form.

5.

If you w ish to m ake com m ents, p le a s e u s e a s e p a ra te p ie c e of
p ap e r.

6.

S ta rt th e q u estio n n aire w h ere you s e e :

START
HERE

You h av e alre ad y provided th e vitam in a n d m ineral inform ation,
so it is not n e c e ssa ry to a n sw e r th e first two q u estio n s.

EXAMPLE:

Do you live in the United S ta te s ?

O

NO

®

YES

( fill circle c o m p le te ly )

Appe ndi x 20
P h y sicia n 's Prenatal

Car e Su rv ey

329
PATIENT NAME:_
DELIVERY DATE:.
CODE NO:______

PHYSICIAN PREGNANCY SURVEY
DIRECTIONS: P lease complete the following questions for the patient listed above. If the
information is NOT AVAILABLE, please record "NA"; do not leave the sp ac e blank.
1.

What is this patient's HEIGHT, without sh o e s?

2.

What weight gain recommendation, if any, did you
suggest to this patient during her pregnancy?

3.

ft

in

lbs

P lease record the w om an's HIGHEST and LOW EST hem oglobin and/or
hematocrit values you m easured during her pregnancy.
WEEK OF GESTATION
(estim ated )

HEMATOCRIT
(%)

HEMOGLOBIN
(g/dL)

H ig h e st Iron V alue
L o w e st Iron V alue

4.

P lease record the w om an's HIGHEST and LOW EST diastolic blood p re ssu res
recorded during her pregnancy. Approximately how long do you estim ate th e se p eak and
trough values last?
WEEK OF GESTATION
(e stim ated )

DIASTOLIC
PRESSURE

ESTIMATED
W EEKS AT
THIS DBP

H ig h e s t D ia sto lic
L o w e st D ia sto lic

5.

What w as the woman’s
PRE-PR EG N A N C Y W EIGHT?
__________________________________ lbs
(Please make a good estimate, if the actual value is not recorded.)

6.

What is the FIRST pregnant weight
recorded for this w om an?
___

lbs

330

7.

Approximately how far into
the pregnancy w as this?

8.

__________________________________________ w eeks

What is the LAST recorded weight
for this woman during this pregnancy?

lbs

9.

Approximately how many days after this
weight w as recorded did the woman d e l i v e r ? ________________________ days

10.

It would be extremely helpful if you could provide ALL of the weights charted for
this woman. This information would significantly enhance the results of this study.
WEIGHT

11.

ESTIMATED
WK. GESTATION

WEIGHT

ESTIMATED
WK. GESTATION

Are there any other observations or com m ents you would like to make about any factor(s)
which, in your opinion, influenced this w om an's pregnancy outcom e?

P lease record the nam e, degree and telephone num ber of the person completing this
questionnaire so that if clarifications are needed, the appropriate individual may be contacted.
NAME:________________________________________________________
PHONE:

(_____ )_____________________

T h a n k y o u for y o u r c o o p e ra tio n . P le a s e re tu rn In th e e n c lo s e d p o s ta g e - p a id
e n v e lo p e a t y o u r e a r lie s t c o n v e n ie n c e .
MICHIGAN DEPARTM ENT O F PULIC HEALTH
O ffice o f th e S ta t e R e g is tr a r a n d C e n te r for H ea lth S ta tis tic s
1989

Appendix 21
F i r s t L e t t e r t o M ic h ig a n M oth er s

331

STATE OF MICHIGAN

J A M E S J. BLANCHARD. G o v ern o r

99 9

DEPARTMENT OF PUBLIC HEALTH

June 9 1989

3 4 2 3 N. L O G A N
p.o.
P.O . BO X 3 0 1 9 5 . LA NSING. M ICHIGAN 4 0 9 0 9

J a n e E. Ooe
2005 Sou th vi ew B lvd.
E a s t L a n s i n g , MI 4 8 82 3

D e a r m o t h e r o f B e a t r i c e Doe:
We a r e i n v i t i n g y o u t o p a r t i c i p a t e i n a s t a t e w i d e r e s e a r c h p r o j e c t . I t s
p u r p o s e i s t o h e l p u s b e t t e r u n d e r s t a n d w o m e n ' s a t t i t u d e s , a c t i o n s and
h e a l t h c a r e d u r i n g p r e g n a n c y . T h i s i n f o r m a t i o n w i l l be u s e d t o i mpr ove
s e r v i c e s t o p r e g n a n t women and i n f a n t s .
You a r e one o f a s m a l l n u mb e r o f women s t a t e w i d e who h a v e b e e n
s c i e n t i f i c a l l y s e l e c t e d t o be i n t h i s s u r v e y .
To p a r t i c i p a t e , j u s t
c o m p l e t e t h e e n c l o s e d q u e s t i o n n a i r e and f o o d f r e q u e n c y f o r m and r e t u r n t hem
in the posta g e-p a id envelope provided.
To t h a n k y o u f o r y o u r h e l p , we h a v e
e n c l o s e d a b i b f o r y o u r b a b y c o u r t e s y o f G e r b e r ' s a n d a c o p y o f "A Food
G u i d e f o r t h e F i r s t F i v e Y e a r s " , c o u r t e s y o f t h e M i c h i g a n B e e f C o u n c i l . We
hope you e n j o y t h e s e g i f t s .
The q u e s t i o n s
If Beatrice is
a n s w e r some o f
m ight p ro v id e
future.

in t h i s survey ask about your r e c e n t pregnancy w ith B e a t r i c e .
n o t a l i v e , we r e a l i z e t h a t i t m i g h t b e p a i n f u l f o r y o u t o
t h e s e q u e s t i o n s . Ho we v e r , we b e l i e v e t h a t by d o i n g s o , yo u
i n f o r m a t i o n t h a t c o u l d h e l p some o t h e r woman o r b a b y i n t h e

P l e a s e c o m p l e t e t h e q u e s t i o n n a i r e and r e t u r n i t i n t h e e n c l o s e d e n v e l o p e .
The M i c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h w i l l u s e t h i s i n f o r m a t i o n o n l y f o r
s t a t i s t i c a l p u r p o s e s ; no i n f o r m a t i o n i d e n t i f y i n g y o u o r y o u r b a b y w i l l e v e r
be p u b lis h e d .
The q u e s t i o n n a i r e h a s a n i d e n t i f i c a t i o n n u m b e r f o r m a i l i n g
purposes only.
T h i s n u m b e r w i l l a l l o w u s t o c h e c k y o u r name o f f o u r
m a i l i n g l i s t when y o u r q u e s t i o n n a i r e i s r e t u r n e d .
Your p a r t i c i p a t i o n i s
v o l u n t a r y and y o u r r e f u s a l t o a n s w e r some o r a l l o f t h e q u e s t i o n s w i l l n o t
r e s u l t i n any p e n a l t y o r l o s s o f s e r v i c e s o r b e n e f i t s f r o m t h e M i c h i g a n
Department o f P u b l i c H e alth .
I f you have a ny f u r t h e r q u e s t i o n s r e g a r d i n g t h i s p r o j e c t , o r i f you woul d
p r e f e r a t e l e p h o n e i n t e r v i e w , p l e a s e c a l l o u r P r o j e c t C o o r d i n a t o r , Carol
F r i e s e n , c o l l e c t a t (517) 351 -8334.
We h o p e you w i l l

a c c e p t o u r r e q u e s t t o be i n

this

study.

Sincerely,

G e o r g e H. Van Ambur g, MPH
S t a t e R e g i s t r a r and C h i e f
O ffice of the S t a te R e g is tr a r
an d C e n t e r f o r H e a l t h S t a t i s t i c s
Z 25 4 08

G e o r g e H. B a k e r ,
Chief, O ffice of
Child H ealth

MD
M a t e r n a l and

t

Appendix 22
Second L e t t e r t o M ic h ig a n M ot he rs

332

STATE OF MICHIGAN

JA M E S J BLANCHARD. G overnor

DEPARTMENT OF PUBLIC HEALTH
9 99

3 4 2 3 N. L O G A N
P.O. B O X 3 0 1 9 5 . L A N SIN G . MICHIGAN 4 8 9 0 9

J u l y 7,

1989

J a n e E. Doe
2005 S o ut hv ie w Blvd.
E a s t L a n s i n g , MI 4 88 2 3

D e a r m o t h e r o f B e a t r i c e Doe:
A b o u t t h r e e we e k s a g o , we i n v i t e d y o u t o
participate
in
research project.
I t s purpose is to gain a b e t t e r u n d erstan d in g
h e a l t h c a r e t h a t women r e c e i v e d u r i n g t h e i r p r e g n a n c y a n d t h e i r
an d a c t i o n s d u r i n g t h i s t i m e .
The i n f o r m a t i o n y o u p r o v i d e c a n
and b a b i e s in t h e f u t u r e .

a statewide
of the
attitudes
h e l p women

As m e n t i o n e d i n o u r p r e v i o u s l e t t e r , you a r e o n e o f a s m a l l n u mb e r o f women
s t a t e w i d e who h a v e b e e n s c i e n t i f i c a l l y s e l e c t e d t o b e i n t h i s s u r v e y .
If
y o u a g r e e t o p a r t i c i p a t e , a l l y o u h a v e t o do i s c o m p l e t e t h e e n c l o s e d
q u e s t i o n n a i r e and f o o d f r e q u e n c y f or m and r e t u r n t h e m i n t h e p o s t a g e - p a i d ,
r e tu r n envelope provided.
The q u e s t i o n s i n t h i s s u r v e y a s k a b o u t y o u r
r e c e n t pregnancy w ith B e a t r i c e .
I f y o u h a v e r e t u r n e d t h e q u e s t i o n n a i r e i n t h e p a s t f e w d a y s , we a p p r e c i a t e
i t v e r y much. I f y o u h a v e n o t , p l e a s e c o m p l e t e t h e q u e s t i o n n a i r e a n d r e t u r n
i t i n t h e e n c l o s e d e n v e l o p e . The M i c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h w i l l
u s e t h i s i n f o r m a t i o n o n l y f o r s t a t i s t i c a l p u r p o s e s ; no i n f o r m a t i o n t h a t
i d e n t i f i e s y o u o r y o u r b a b y w i l l e v e r be
published.
The q u e s t i o n n a i r e h a s
an i d e n t i f i c a t i o n number f o r m a i l i n g p u r p o s e s o n l y . T h i s number w i l l a l l o w
u s t o c h e c k y o u r name o f f o u r m a i l i n g l i s t when y o u r q u e s t i o n n a i r e i s
returned.
Yo u r p a r t i c i p a t i o n i s v o l u n t a r y and y o u r r e f u s a l t o a n s w e r some o r a l l
t h e q u e s t i o n s w i l l n o t r e s u l t i n any p e n a l t y o r l o s s o f s e r v i c e s o r
b e n e f i t s fr om t h e M i c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h .

of

I f y o u h a v e a n y f u r t h e r q u e s t i o n s r e g a r d i n g t h i s p r o j e c t , o r i f y o u wo u l d
p r e f e r a t e l e p h o n e i n t e r v i e w , p l e a s e c a l l ou r P r o j e c t C o o r d i n a t o r , Carol
F r i e s e n , c o l l e c t a t ( 5 1 7 ) 3 5 1 - 8 3 3 4 e v e n i n g s and w e e k e n d s .
We t r u l y h o p e y o u w i l l

a c c e p t o u r r e q u e s t t o be i n t h i s

study.

Sincerely,

G e o r g e H. Van Ambur g, MPH
S t a t e R e g i s t r a r and C h i e f
O ffice of the State R egistrar
and C e n t e r f o r H e a l t h S t a t i s t i c s
Z -2 5 4 'B 8

G e o r g e H. B a k e r ,
Chief, O ffice of
Child Health

MD
M a t e r n a l and

4

A p p e n d i x 23

L e t t e r R e q u e s t i n g t h e S u b j e c t t o Comp let e t h e
Su rv ey o r Food F r e q u e n c y Q u e s t i o n n a i r e

333

STATE O F M IC H IG A N

JA M E S J. BLANCHARD, G o v e rn o r

DEPARTMENT OF PUBLIC HEALTH
3423 N LOGAN
P.O. B O X 3 0 1 9 5 , LA N SIN G . M IC H IG A N 4 8 9 0 9

August 2,

1989

Dear B e a t r i c e :
T h a n k y o u so much f o r f i l l i n g o u t t h e p r e g n a n c y s u r v e y s e n t t o you
r e c e n t l y from t h e Mich igan Department o f P u b l i c H e a l t h . 1 a p p r e c i a t e
your response!
I n o t i c e d you d i d n o t c o m p l e te t h e l a s t page o f t h e food f r e q u e n c y
q u e s t i o n n a i r e . P e r h a p s i t was an o v e r s i g h t ? I know i t g e t s t o b e p r e t t y
l o n g , b u t I s u r e wo u l d a p p r e c i a t e i t i f y o u c o u l d c o m p l e t e t h e l a s t p a g e
an d r e t u r n i t t o me i n t h e e n c l o s e d e n v e l o p e . Th an k y ou s o much.
I h o p e y o u a r e h a v i n g a g o od summer.
Sincerely,

C a r o l A. F r i e s e n , M . S . , R.D.
Pregnancy P r o j e c t C oordinator
Michigan Departm ent o f Public H ealth

P.S.

I f y o u w a n t t o t a l k t o me a b o u t t h i s , c a l l c o l l e c t
d u r i n g t h e e v e n i n g s o r weekends a t (5 1 7) 3 5 1- 83 3 4.

149

2 25 4 88

4

A p p e n d i x 24

L e t te r Requesting S u b j e c t 's R e c o n sid e ratio n
t o S i g n t h e P h y s i c i a n ' s R e l e a s e Form

3 34

STATE O F M IC H IG A N

JA M ES J Bl ANCHARD, G overnor

DEPARTMENT OF PUBLIC HEALTH
3 4 2 3 N. L O G A N
P .O . B O X 3 0 1 9 5 . L A N S I N G . M I C H I G A N 4 8 9 0 9

A ugus t 21,

1989

Dear B e a t r i c e :
T h a n k y o u so much f o r f i l l i n g o u t t h e p r e g n a n c y s u r v e y s e n t t o yo u
r e c e n t l y from t h e Mich igan De pa rt m en t o f P u b l i c H e a l t h . I a p p r e c i a t e
your response!
I n o t i c e d y o u d i d n o t s i g n t h e c o n s e n t f o r m w h i c h w o u l d a l l o w me t o
c o n t a c t y o u r p r e n a t a l c a r e p r o v i d e r . I t h o u g h t t h a t i f I s e n t you a copy
o f t h e p h y s i c i a n ' s q u e s t i o n n a i r e t h a t , p e r h a p s , you m ig ht r e c o n s i d e r . 1
am p r i m a r i l y i n t e r e s t e d i n y o u r r a t e o f w e i g h t g a i n , y o u r d i a s t o l i c
b l o o d p r e s s u r e a nd y o u r i r o n l e v e l s d u r i n g p r e g n a n c y . I h o p e y o u w i l l
r e c o n s i d e r n o t s i g n i n g t h e c o n s e n t f o r m k n o wi n g s p e c i f i c a l l y w h a t y o u r
d o c t o r w i l l be a s k e d a b o u t y o u r p r e g n a n c y .
Of c o u r s e , i f y o u s t i l l p r e f e r n o t t o a l l o w y o u r d o c t o r t o p r o v i d e me
w i t h t h e abov e i n f o r m a t i o n , 1 w i l l compl y w i t h y o u r w i s h e s . 1 woul d
a p p r e c i a t e i t , h o w e v e r , i f yo u c o u l d s i g n t h e c o n s e n t f o r m a n d r e t u r n i t
t o me i n t h e e n c l o s e d e n v e l o p e .
I h o p e y o u a r e h a v i n g a go o d summer!
Sincerely,

C a r o l A. F r i e s e n , M . S . , R.D.
Pregnancy P r o j e c t C o o rd in ato r
Michigan Department o f Public H ealth

P.S.

I f y o u w a n t t o t a l k t o me a b o u t t h i s , c a l l c o l l e c t
d u r i n g t h e e v e n i n g s o r weekends a t (517) 3 51- 83 34.

184

Z -2 5 4 /8 8

4

A p p e n d i x 25
F irst

L e t t e r S en t t o White S u b j e c t s '

P hysicians

3 35

STATE O F M ICH IG A N

JA M E S J BLANCHARD. G overnor

999

DEPARTMENT OF PUBLIC HEALTH
3 4 2 3 N. L O G A N

August 8 1989
’

Thomas Lowe, m . d T 0 ' BOX 30195' LANSING' MICHIGAN 48909
Westview C l i n i c
100 S o u t h v i e w B l v d .
E a s t L a n s i n g , MI 4 8 82 3

De ar Dr.

Lowe:

Yo u r a s s i s t a n c e i s n e e d e d i n a s t a t e w i d e r e s e a r c h p r o j e c t c o n d u c t e d by t h e
Michigan Department o f Public H e a lth .
The p u r p o s e s o f t h e s t u d y a r e : 1) t o
d e t e r m i n e i f t h e a t t a i n m e n t o f a s p e c i f i c p e r c e n t a g e o f a woma n' s d e s i r a b l e
b o d y w e i g h t i s a s s o c i a t e d w i t h s u c c e s s f u l f e t a l o u t c o m e , a n d 2) t o i d e n t i f y
a n d q u a n t i f y f a c t o r s a s s o c i a t e d w i t h l ow b i r t h w e i g h t (LBW) i n M i c h i g a n .
I d e n t i f i c a t i o n o f f a c t o r s c o n t r i b u t i n g t o , a n d t h e p r e v e n t i o n o f , LBW h a s
be come a p r i o r i t y p u b l i c h e a l t h c o n c e r n o f t h e D e p a r t m e n t .
You w e r e i d e n t i f i e d a s b e i n g t h e p r e n a t a l h e a l t h c a r e p r o v i d e r o f J a n e E.
Do e , who p r o v i d e d u s w i t h y o u r name and a d d r e s s . She h a s a u t h o r i z e d yo u t o
p r o v i d e us w i t h i n f o r m a t i o n from h e r m e d i c a l r e c o r d s a b o u t h e r p r e g n a n c y
w i t h B e a t r i c e Doe.
A l l i n f o r m a t i o n you r e p o r t w i l l b e k e p t s t r i c t l y
confidential.
No i n f o r m a t i o n w h i c h i d e n t i f i e s e i t h e r you o r t h e p a t i e n t
w i l l be r e l e a s e d .
Your p a r t i c i p a t i o n i s v o l u n t a r y . The d i r e c t o r o f p u b l i c
h e a l t h has d e c l a r e d t h i s a medical r e s e a r c h p r o j e c t under th e p r o v i s i o n of
MCL 3 3 3 . 2 6 3 1 - 3 3 3 . 2 6 3 5 . As s u c h , any i n f o r m a t i o n s h a r e d w i t h u s i s n o t
subject to disclosure.
The d a t a c o l l e c t e d w i l l be u s e d i n p r o g r a m p l a n n i n g
a n d e p i d e m i o l o g i c a l r e s e a r c h t o be p u b l i s h e d i n p r o f e s s i o n a l j o u r n a l s .
B e c a u s e t h i s s u r v e y i s b a s e d on a s m a l l r a n d o m s a m p l e o f M i c h i g a n women, i t
i s i m p o r t a n t t h a t we o b t a i n a s much i n f o r m a t i o n a s p o s s i b l e on a l l women i n
t h i s s t u d y . Due t o t h e l i m i t e d n u mb e r o f p h y s i c i a n s d e l i v e r i n g b a b i e s 1n
M i c h i g a n , y o u may h a v e d e l i v e r e d mor e t h a n f i v e r a n d o m l y s e l e c t e d s u b j e c t s .
I f s o , we w o u l d a p p r e c i a t e i t i f y o u wo u l d f i l l o u t f i v e s u r v e y s . Ho we v e r ,
we w o u l d b e g r a t e f u l i f y o u w o u l d c o m p l e t e a s many a s y o u r e c e i v e .
We w o u l d a p p r e c i a t e i t i f y o u , o r o n e o f y o u r s t a f f , w o u l d c o m p l e t e t h e
q u e s t i o n n a i r e and r e t u r n i t in t h e e n c l o s e d e n v e l o p e a t y o u r e a r l i e s t
convenience.
I f you s h o ul d have any q u e s t i o n s , p l e a s e c a l l t h e P r o j e c t
C o o r d i n a t o r , C a r o l F r i e s e n , a t ( 5 1 7 ) 3 5 1 - 8 3 3 4 . Your c o o p e r a t i o n i s g r e a t l y
appreciated.

Z -2 5 4 /8 8

Sincerely,

Sincerely,

G e o r g e Van Amburg, MPH
S ta te R e g is tra r & Chief
O ffice of the S tate R egistrar
an d C e n t e r f o r H e a l t h S t a t i s t i c s

G e o r g e H. B a k e r , J r . , M.D.
C h i e f , O f f i c e o f M a t e r n a l and
Child Health

4

A p p e n d i x 26
Second L e t t e r S en t t o W hite S u b j e c t s '

P hysicians

33 6

STATE O F M ICH IG A N

JA M E S J BLANCHARD. G overnor

DEPARTMENT OF PUBLIC HEALTH
3 4 2 3 N. LOGAN
P.O . BO X 3 0 1 9 5 , LA N SIN G . MICHIGAN 4 8 9 0 9

ggg

Se pte m be r 1,

1989

Thomas Lowe, M.D.
Westview C l i n i c
100 S o u t h v i e w B l v d .
E a s t . L a n s i n g , Ml
48823

D e ar Or.

Lowe:

A f e w w e e k s a g o we m a i l e d y o u a l e t t e r r e q u e s t i n g y o u r a s s i s t a n c e i n a
s t a t e w i d e r e s e a r c h p r o j e c t c o n d u c t e d by t h e M i c h i g a n D e p a r t m e n t o f P u b l i c
Health.
The p u r p o s e s o f t h e s t u d y a r e : 1) t o d e t e r m i n e i f t h e a t t a i n m e n t
o f a s p e c i f i c p e r c e n t a g e o f a wo m a n ' s d e s i r a b l e b o d y w e i g h t i s a s s o c i a t e d
w i t h s u c c e s s f u l f e t a l o u t c o m e , and 2) t o i d e n t i f y a n d q u a n t i f y f a c t o r s
a s s o c i a t e d w i t h l ow b i r t h w e i g h t (LBW) i n M i c h i g a n . I f y o u r e c e n t l y
r e t u r n e d t h e s u r v e y , p l e a s e a c c e p t o u r t h a n k s . I f n o t , we w o u l d a p p r e c i a t e
i t i f y o u , o r so me o n e i n y o u r o f f i c e , wou l d a s s i s t u s i n t h i s p r o j e c t by
c o m p l e t i n g t h e s u r v e y and r e t u r n i n g i t a s s oo n a s p o s s i b l e . Your r e s p o n s e
i s very im p o rta n t t o us.
You w e r e i d e n t i f i e d a s t h e p r e n a t a l h e a l t h c a r e p r o v i d e r o f J a n e E. Doe,
who p r o v i d e d us w i t h y o u r name and a d d r e s s . She h a s a u t h o r i z e d y o u t o
p r o v i d e us w i t h i n f o r m a t i o n f r o m h e r m e d i c a l r e c o r d s a b o u t h e r p r e g n a n c y
w i t h B e a t r i c e Doe.
A l l i n f o r m a t i o n yo u r e p o r t w i l l b e k e p t s t r i c t l y
confidential.
No i n f o r m a t i o n i d e n t i f y i n g e i t h e r y o u o r t h e p a t i e n t w i l l be
released.
Yo u r p a r t i c i p a t i o n i s v o l u n t a r y . The d i r e c t o r o f p u b l i c h e a l t h
h a s d e c l a r e d t h i s a m e d i c a l r e s e a r c h p r o j e c t u n d e r t h e p r o v i s i o n o f MCL
3 3 3 . 2 6 3 1 - 3 3 3 . 2 6 3 5 . As s u c h , a n y i n f o r m a t i o n s h a r e d w i t h u s i s n o t s u b j e c t
to disclosure.
The d a t a c o l l e c t e d w i l l be u s e d i n p r o g r a m p l a n n i n g a n d
e p i d e m i o l o g i c a l r e s e a r c h t o be p u b l i s h e d i n p r o f e s s i o n a l j o u r n a l s .
B e c a u s e t h i s s u r v e y i s b a s e d on a s m a l l r a n do m s a m p l e o f M i c h i g a n women, i t
i s i m p o r t a n t t h a t we o b t a i n a s much i n f o r m a t i o n a s p o s s i b l e on a l l women i n
t h i s s t u d y . We w o u l d a p p r e c i a t e i t i f y o u , o r o n e o f y o u r s t a f f , w o u l d
c o m p l e t e t h e q u e s t i o n n a i r e and r e t u r n i t i n t h e e n c l o s e d e n v e l o p e a t y o u r
e a r l i e s t convenience.
I f y o u s h o u l d h a v e any q u e s t i o n s , p l e a s e c a l l t h e
P r o j e c t C o o r d i n a t o r , Carol F r i e s e n , a t (517) 3 51 - 8 3 3 4 . Thank you f o r y o u r
cooperation.

Z -2 5 4 '8 8

Sincerely,

Sincerely,

G e o r g e Van Amburg, MPH
S ta te R e g istra r & Chief
O ffice of the S ta te R e g is tra r

G e o r g e H. B a k e r , J r . , M.D.
C h i e f , O f f i c e o f M a t e r n a l and
Child Health

4

A p p e n d i x 27

F i r s t L e t t e r Sent to Black S u b j e c t s ' P h y s ic i a n s

337

STATE OF MICHIGAN
t . **

JA M E S J BLANCHARD. G overnor

999

DEPARTMENT OF PUBLIC HEALTH

I homas Lowe, n.L).
Westview C l i n i c
100 S o u t h v i e w B l v d .
E a s t L a n s i n g , Ml
4 8 82 3

D e a r Dr .

po

box

3423 N LOGAN
a c i 95. l a n s i n g M i c h i g a n

, 1 , Q 1QDQ
Ju ly

28 ’

1989

48909

Lowe:

Your a s s i s t a n c e i s n e e d e d i n a s t a t e w i d e r e s e a r c h p r o j e c t c o n d u c t e d by t h e M i c h i g a n
Department o f P u b lic H e a lth .
The p u r p o s e s o f t h e s t u d y a r e : 1) t o d e t e r m i n e i f t h e
a t t a i n m e n t o f a s p e c i f i c p e r c e n t a g e o f a w o m a n ' s d e s i r a b l e bo d y w e i g h t i s a s s o c i a t e d
w i t h s u c c e s s f u l f e t a l o u t c o m e , and 2) t o i d e n t i f y a n d q u a n t i f y f a c t o r s a s s o c i a t e d
w i t h l ow b i r t h w e i g h t (LBW) i n M i c h i g a n .
Because Michigan ra n k s second o n l y t o t h e
D i s t r i c t o f C o l u m b i a i n t h e i n c i d e n c e o f l ow b i r t h w e i g h t (LBW), i d e n t i f i c a t i o n o f
f a c t o r s c o n t r i b u t i n g t o , a n d t h e p r e v e n t i o n o f , LBW h a s become a p r i o r i t y p u b l i c
h e a l t h concern o f th e Department.
You w e r e i d e n t i f i e d a s t h e p h y s i c i a n who d e l i v e r e d B e a t r i c e Doe, t h e b a b y o f J a n e E.
Doe, b o r n A p r i l 10, 1 9 8 8 . J a n e E. Doe was r a n d o m l y s e l e c t e d t o b e i n t h i s r e s e a r c h
study.
No i n f o r m a t i o n w h i c h i d e n t i f i e s e i t h e r y o u o r t h e p a t i e n t w i l l b e r e l e a s e d .
Your p a r t i c i p a t i o n i s v o l u n t a r y . The d i r e c t o r o f p u b l i c h e a l t h h a s d e c l a r e d t h i s a
m e d i c a l r e s e a r c h p r o j e c t u n d e r t h e p r o v i s i o n o f MCL 3 3 3 . 2 6 3 1 - 3 3 3 . 2 6 3 5 . As s u c h , any
i n f o r m a t i o n s h a r e d w i t h us i s n o t s u b j e c t t o d i s c l o s u r e .
The d a t a c o l l e c t e d w i l l be
u s e d i n p r o g r a m p l a n n i n g a n d e p i d e m i o l o g i c a l r e s e a r c h t o be p u b l i s h e d i n
professional jo u rn als.
T h i s s u r v e y i s b a s e d on a s m a l l r a n d o m s a m p l e o f M i c h i g a n
women, t h u s i t i s i m p o r t a n t t h a t we o b t a i n a s much i n f o r m a t i o n a s p o s s i b l e on a l l
women i n t h i s s t u d y . B e c a u s e o f t h e l i m i t e d n u mb e r o f p h y s i c i a n s d e l i v e r i n g b a b i e s
i n M i c h i g a n , y o u may h a v e b e e n t h e p h y s i c i a n o f r e c o r d f o r mo r e t h a n f i v e r a n d o m l y
s e l e c t e d s u b j e c t s . We w o u l d a p p r e c i a t e i t i f you wo u l d f i l l o u t f i v e o f t h e s u r v e y s .
H o we v e r , we w o u l d be g r a t e f u l i f y o u w o u l d c o m p l e t e a s many a s y o u r e c e i v e .
We w o u l d a p p r e c i a t e i t i f y o u , o r o n e o f y o u r s t a f f , w o u l d c o m p l e t e t h e
q u e s t i o n n a i r e and r e t u r n i t i n t h e e n c l o s e d e n v e l o p e a t y o u r e a r l i e s t c o n v e n i e n c e .
I f you s h o u l d have any q u e s t i o n s , p l e a s e c a l l t h e P r o j e c t C o o r d i n a t o r , C ar ol
F r i e s e n , a t (517) 351-8334.
I f y ou d i d n o t s e e J a n e E. Doe f o r h e r p r e n a t a l c a r e ,
b u t know who d i d , we w o u l d a p p r e c i a t e o b t a i n i n g t h a t i n d i v i d u a l ' s name a n d a d d r e s s .
I f y ou do n o t know w h e r e h e r c a r e was o b t a i n e d , p l e a s e i n d i c a t e t h i s on t h e s u r v e y
a nd r e t u r n i t i n t h e e n c l o s e d e n v e l o p e .
Your c o o p e r a t i o n

is g r e a tly appreciated.

Sincerely,

Sincerely,

G e o r g e Van Ambur g, MPH
S ta te R e g is tr a r & Chief
Office of the S ta te R e g is tra r
and C e n t e r f o r H e a l t h S t a t i s t i c s

Ge o r g e H. B a k e r , J r . , M.D.
C h i e f , O f f i c e o f M a t e r n a l and
Child Health

2 as, a a n

A p p e n d i x 28

Second L e t t e r Sent t o Black S u b j e c t s ' P h ys ic ia ns

338

STATE O F M IC H IG A N

T iS S ?

<sJ ? V v
JAM ES J

999

DEPARTMENT OF PUBLIC HEALTH . „ .
3423

inomas Lowe, M.u.
West vi ew C l i n i c
100 S o u t h v i e w B l v d .
East Lansing,

Dear Dr.

BLANCHARD. G overnor

Ml

P.O.

N LOGAN
b o x 30195. l a n s i n g . M i c h i g a n

, ,00Q

S e p t e m b e r 1,

1989

43909

4 8823

Lowe:

A f e w w e e k s a g o we s e n t a l e t t e r r e q u e s t i n g y o u r a s s i s t a n c e i n a s t a t e w i d e r e s e a r c h
p r o j e c t c o n d u c t e d by t h e M i c h i g a n D e p a r t m e n t o f P u b l i c H e a l t h . T h e p u r p o s e s o f t h e
s t u d y a r e : 1) t o d e t e r m i n e i f t h e a t t a i n m e n t o f a s p e c i f i c p e r c e n t a g e o f a woman’ s
d e s i r a b l e b o d y w e i g h t i s a s s o c i a t e d w i t h s u c c e s s f u l f e t a l o u t c o m e , a n d 2) t o
i d e n t i f y a n d q u a n t i f y f a c t o r s a s s o c i a t e d w i t h l o w b i r t h w e i g h t (LBW) i n M i c h i g a n .
Bo t h LBW i n f a n t s ( c a s e s ) and c o n t r o l s a r e i n c l u d e d i n t h i s s t u d y . I f y o u r e c e n t l y
r e t u r n e d t h e s u r v e y , p l e a s e a c c e p t o u r s i n c e r e t h a n k s . I f n o t , we w o u l d a p p r e c i a t e
i t i f y o u , o r one o f y o u r s t a f f , wou ld c o m p l e t e t h e s u r v e y and r e t u r n i t a t y o u r
e a r l i e s t c o n v e n i e n c e . Your r e s p o n s e i s i m p o r t a n t t o u s . I f t h e s u b j e c t ' s s o c i a l
s e c u r i t y n u m b e r w o u l d a s s i s t yo u i n p u l l i n g t h i s p a t i e n t ' s r e c o r d s , p l e a s e c a l l t h e
p r o j e c t c o o r d i n a t o r , Ca r o l F r i e s e n , a t ( 5 1 7 ) 3 5 1 - 8 3 3 4 , and s h e c a n o b t a i n i t f o r
you.
You w e r e i d e n t i f i e d a s t h e p h y s i c i a n who d e l i v e r e d B e a t r i c e Doe , t h e b a b y o f J a n e E.
Doe, b o r n A p r i l 10, 1 9 8 8 . J a n e E. Doe was r a n d o m l y s e l e c t e d t o b e i n t h i s r e s e a r c h
study.
No i n f o r m a t i o n w h i c h i d e n t i f i e s e i t h e r y o u o r t h e p a t i e n t w i l l be r e l e a s e d .
Your p a r t i c i p a t i o n i s v o l u n t a r y . The d i r e c t o r o f p u b l i c h e a l t h h a s d e c l a r e d t h i s a
m e d i c a l r e s e a r c h p r o j e c t u n d e r t h e p r o v i s i o n o f MCL 3 3 3 . 2 6 3 1 - 3 3 3 . 2 5 3 5 . As s u c h , any
i n f o r m a t i o n s h a r e d w i t h us i s n o t s u b j e c t t o d i s c l o s u r e .
Th e d a t a c o l l e c t e d w i l l be
u s e d i n p r o g r a m p l a n n i n g and e p i d e m i o l o g i c a l r e s e a r c h t o be p u b l i s h e d i n
professional journals.
T h i s s u r v e y i s b a s e d on a s m a l l r a n d o m s a m p l e o f M i c h i g a n
women, t h u s i t i s i m p o r t a n t t h a t we o b t a i n a s much i n f o r m a t i o n a s p o s s i b l e on a l l
women i n t h i s s t u d y .
We w o u l d a p p r e c i a t e i t i f y o u , o r o n e o f y o u r s t a f f , w o u l d c o m p l e t e t h e
q u e s t i o n n a i r e a nd r e t u r n i t i n t h e e n c l o s e d e n v e l o p e a t y o u r e a r l i e s t c o n v e n i e n c e .
I f y o u s h o u l d h a ve a ny q u e s t i o n s , p l e a s e c a l l t h e P r o j e c t C o o r d i n a t o r , C ar ol
F r i e s e n , a t (517) 351-8334.
I f you d i d n o t s e e J a n e E. Doe f o r h e r p r e n a t a l c a r e ,
b u t know who d i d , we w o u l d a p p r e c i a t e o b t a i n i n g t h a t i n d i v i d u a l ' s name a n d a d d r e s s
I f y o u d o n o t know w h e r e h e r c a r e was o b t a i n e d , p l e a s e i n d i c a t e t h i s on t h e s u r v e y
and r e t u r n i t i n t h e e n c l o s e d e n v e l o p e .
Your c o o p e r a t i o n i s g r e a t l y

appreciated.

Sincerely,

G e o r g e Van Ambur g, MPH
State R e g is tr a r & Chief
Office of the State R egistrar
and C e n t e r f o r H e a l t h S t a t i s t i c s

Z 25 4 88

Sincerely,

Ge o r g e H. B a k e r ,
Chief, O ffice of
Child Health

J r . , M.D.
M a t e r n a l and

4

Appendix 29
Supporting S t a t i s t i c a l Analys

3 39

Appendix 29-1

Response r a t e t o t h e Michigan Mother's Survey by wave.

Group

First
Wave

n (%)*

Second
Wave

Telephone
Contact

Look-Up
Unit

Surveys
Received

n (%)

n (%)

n (%)

n

3 (2)

1 (1)

171
45

LBW

139 (81)

28 (16)

MBW

37 (82)

7 (16)

-

1 (2)

OBW

146 (79)

38 (21)

-

-

184

TOTAL

322 (80)

73 (18)

3 (1)

2 (1)

400

Percent o f t o t a l surveys r e c e i v e d w it h in each group.

340

Appendix 2 9-2a

S te m le a f p l o t o f c a l o r i e d i s t r i b u t i o n p r io r t o a p p ly in g
a n y e x c l u s i o n c r i t e r i a (n = 3 8 0 ).

CALORIES
3SO.0

Valid cases:

tie d i an
57.

Std Err
Vari ance
Std Dev

2451 .828
2 29 9.280
2395.541

M ean'
T r i m

Missinq cases:

,

629.8800
7493.890
6864.010
1046.255

M in

322556.7
906.9491

M ax

Range
IQR."

Stem ?•

Fr e q u e n c y
9

1

OO

28

00

90

00

1
1

00
67 , C>0
42 , 0 0

2

102

21

7898<
012333444
56666667777888888888999999

*

,00

4

,00
1 1 . 00

3 .0 0

Leaf

555556
000111122233344
5677889

9
1

*

0

0238'

E x t r er n e s
,00 E x t r e m e s

64541),
(6444),

(4679),
67494)

64937),

65063),

65153),

65913)

+I

I

2 . 00

+

•* *

I
I

1. . 0 0

+
I
I

-1 .0 0
■2*00

+
i
i

-3. C>0 +

S k ew n ess
S E Skew
Kur t o s i s
S E Kur t

**-*
•**

.00 +
I
I
+
I
I

*

* * *

* *
* •*

*#
■**
*

**

25C>0
Normal

5C>C»6)
P lot

756>0

1.3079
. 1252
3.5707
.2497

341

Appendix 29-2b

S te m le a f and n orm al p l o t o f c a l o r i e d i s t r i b u t i o n a f t e r a p p ly in g th e
e x c l u s i o n c r i t e r i o n o f g r e a t e r th a n 4 ,5 0 0 c a l o r i e s and l e s s th a n 600
c a l o r i e s (n = 3 6 8 ).

CALORIES
Valid cases:

Mean
Median
57. Trim

368.0

2359.782
2247.210
2341.040

Sic Err
Variance
Std Dev

38.8700
Min
Max
556003.6 Max
Ran g e
745.6565 Range
IOR"

b29.SSOO
4443. 730
4443.730
3313.850
1011.298

CALORIES

Frequency

Stem ?<

Leaf

.

0
9. 00
28. 00
1
1
90. 00
‘jd
102.00
67. 00
r~\
42. 00
21. 00
7.00
4
2. 00 Extremes

789?<
012333444
55556666667777888888838999999
0000000011111111122223333333444444
5555566666777788833999
000111122233344
5677889
028<
(4370), C4444)

*

.
*

.
*

.
*

3 . 00 + t
i

*

2 . 00 +

•***
■**

1 . 00

■#**

*•**
■#**

.00

* * -*

-1 . 00

*■#

**
***

- 2 . 00
-

3.00

+

**

1600

3200

Normal P l o t

4800

Skewness
S E Skew
Kur t os is
S E Kurt

.4449
. 1272
-.0407
.2537

Appendix 2 9 -2 c

S t e m le a f and n orm al p l o t o f c a l o r i e d i s t r i b u t i o n a f t e r a p p ly in g t h e
e x c l u s i o n c r i t e r i o n o f g r e a t e r th a n 4,000 c a l o r i e s and l e s s th a n 600
(n = 3 5 9 ) .

Frequency

S t em &

4. 00
5 . 00
6 .00
13. 00
20. 00
32. 00
47.00
5 1.00
3 3.00
34. 00
2 7.00
2 4 . 00
20. 00
1 7 . 00
9. 00
7. 00
1 0 . 00

3. 00

2 .0 0

1 .0 0

.0 0

1 .0 0

2 .0 0

3 .0 0

0
0
1
1
1
1
1
2
2
O
2
>
3
o
o
w
n
w
o
w

s
t
f
s
.
■fr

t
f
5
.

*
t
f
s
.

Leaf
7S<
89
01
•“>
•z
*^ o o
bJ bJ
bZ/
444455555
6 66666666777777
8 S8888888 B 8 B 8 B 9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0 0011111111111111
2 222223333333333
4 4444444455555555
6 666666677777
888888899999
000011111
<U <b—X- O v J b j bJ

4455
677
88899

+
••
1
f

*
N o rm al

•4-

t•

•i
+
•i
ii
+
»
ii
.A.
*T*
t
«
j
+
1

P lo t

#
***
**•*

**
***
**
***
**
**
**
**

0

1200

2400

i
* 1
i• :
j |
«
<
••
ii
i•
ii
•i
»i
•
•i
i
ii
i•

**■*
*
•**

ti
+

ia
ii

3600

W ean
M e d ia n
S% T r i m
S td E rr
V ar ia n c e
S t d Dev

2 3 1 2 .7 3 1
2 2 2 6 . IS O
2 3 0 3 .4 3 *
3 6 .5 2 2 6
4 7 B B 7 0 .3
6 9 2 .0 0 4 6

M in
M ax
R ange
I OR
S kew ness
S E Skew
K urtosis
S E Kurt

6 2 9 .8 8 0 0
3 9 7 1 .8 4 0
3 3 4 1 .9 6 0
9 3 7 .2 6 0 0
.2 6 5 3
. 1287
-.2 7 4 7
.2 5 6 8

343

Appendix 29-3

E f f e c t o f problems in l o c a t i n g the prenatal care pr ov id er o f the
w hi t e c o n s e n t e r s on th e response r a t e t o th e Prenatal Care Survey.

P h y s ic ia ns
o f White
Consenters

Total
Number o f
Problems

Number o f
Problems
Solved (%)

LBW
MBW
OBW

12
7
13

6 (50)
4 (57)
7 (54)

TOTAL

32

17 (53)

344

Appendix 29-4a

C o m p a r i s o n o f W h i t e LBW R e s p o n d e r s a n d N o n - R e s p o n d e r s :
B i r t h C e r t i f i c a t e D a t e by Oneway ANOVA.

LOW BIRTH WEIGHT
Responders Non-Responders
(n=169)
(n=119)

Var iable

t

p

1 2 . 1±1.8

2.8 4

.0049

3 . 2±2 .0

4.0 7

.0001

SIGNIFICANT DIFFERENCES
Mother's e d u ca t io n , yrs

1 2 .7 ± 2 .0

Month prenatal care1 began

2 . 4 ± 1 .2

Number o f prenatal v i s i t s

1 1 .7 ±3.4

1 0 . 3± 4 .0

3 .1 6

.0017

Fathers e d u ca t io n , yrs

1 3 . 0 ± 1 .8

1 2 .5 + 1 .8

2.04

.0429

NOT SIGNIFICANTLY DIFFERENT
Birth weight

2187±309

2172+305

0.41

.6824

Mothers age, yrs

25.8+3.8

25.0+3.9

1.79

.0740

Weeks g e s t a t i o n

38.6+1.5

3 8 . 9 ± 1 .6

1.82

.0693

0 . 4 ± 0 .5

0 . 4 ±0.5

0. 32

.7448

2 8 . 6± 4.5

28 . 1 + 5 . 4

0. 82

.4093

1 minute Apgar

7 . 4 ± 1 .8

7.5+1.8

0.28

.7741

5 minute Apgar

8 . 7±1.1

8.7±0.8

0.26

.7887

Previous c h i l d
Fathers age, yrs

345
A ppendix 29-4b

C o m p a r i s o n o f B i r t h C e r t i f i c a t e D a t a o f W h i t e LBW
R e s p o n d e r s and N o n -R e s p o n d e rs : C h i - S q u a r e A n a l y s i s 3.

LOW BIRTH WEIGHT
Responders
Non-Responders
(n=169)
(n=119)

Var iable

X2

P

SIGNIFICANT DIFFERENCES
Named Parent
One parent named
Both parents named

20
149

34
85

11.2

.0008

Kessner Index
Adequate
Intermediate
Inadequate

132
33
4

73
31
15

15.2

.0005

.15

NOT SIGNIFICANTLY DIFFERENT
Sex o f Infant
Male
Female

71
98

61
58

2.03

Complications o f Pregnancy
Yes
No

30
135

21
98

.0006 .94

Concurrent I l l n e s s
Yes
No

7
159

7
110

.15

.69

Complications Labor/Delivery
Yes
No

65
100

43
74

.11

.75

Attendant (MD or DO)
MD
DO

143
26

103
16

.19

.66

aa f t e r Y a t e s c o r r e c t i o n .

346

Appendix 29-4c

Comparison o f White OBW Responders and Non-Responders:
Birth C e r t i f i c a t e Date by Oneway ANOVA.

OPTIMAL BIRTH WEIGHT
Non-Responders
Responders
(n=66)
(n=184)

Variable

t

P

SIGNIFICANT DIFFERENCES
Mother's e d u c a t i o n , yr s
Month prenatal ca re began
Fathers e d u c a t io n , yrs

13.5+2.0

1 2 . 2± 2.0

4.53

.0000

2.4±1.2

2 . 7 ± 1 .4

2.02

.0464

1 3 . 8 ± 2 .0

12.6±2.1

3.81

.0002

NOT SIGNIFICANTLY DIFFERENT
Bir th weight

3761±143

3732±148

1.38

.1698

Mothers age, y r s

26.9±3.4

26.0+3.8

1.75

.0819

Number prenatal v i s i t s

1 2 . 3 ± 2 .8

1 1 . 8 ± 3 .6

1.26

.2086

Weeks g e s t a t i o n

4 0 . 0 ± 1 .1

3 9 . 9 ± 1 .3

0 .7 2

.4711

Fathers age, yr s

29.6±5.0

2 8 . 7 ± 4 .7

1.16

.2469

1 minute Apgar

8 . 1±1.1

8 . 3 ± 1 .0

1.06

.2898

5 minute Apgar

9.1+0.4

9 . 2 ± 0 .6

1.87

.0628

347
Appendix 29-4d

C o m p a r i s o n o f B i r t h C e r t i f i c a t e D a t a o f W h i t e OBW
R e s p o n d e r s and N o n -R e s p o n d e rs : C h i - S q u a r e A n a l y s i s 3 .

OPTIMAL BIRTH WEIGHT
Responders
Non-Responders
(n=184)
(n=66)

Va riable

X2

P

1.3

.2515

SIGNIFICANT DIFFERENCES
none

NOT SIGNIFICANTLY DIFFERENT
Named Parent
One parent named
Both parents named

10
174

Kessner Index
Adequate
Intermediate
Inadequate

156
22
6

47
15
4

5. 9

.0534

Sex o f Infant
Male
Female

111
73

41
25

0.11

.912

Complications o f Pregnancy
Yes
No

8
176

7
59

2 .3 5

.125

Concurrent I l l n e s s
Yes
No

7
177

1
65

0 .2 5

.620

Complications Labor/Delivery
Yes
No

47
137

15
51

0.08

.770

Attendant (MD or DO)
MD
DO

160
24

55
11

0.2 7

.60

aa f t e r Y a t e s c o r r e c t i o n .

7
59

348

Appendix 29-5

Birth weight by percent o f 1983 Metropolitan Reference weig ht a t t a i n e d
at term by maternal s t a t u r e ( s h o r t , medium, t a l l ) .

% 1983 Metropolitan
Term Reference Weight

Short
(<62")

Medium
(62.5-65.5")

Tall
(>66")

< 90%

13 68 ± 373

2 3 73 ± 570

2031 ± 212

90-119%

2 5 1 8 ± 557

2 8 3 4 ± 777

2 9 2 9 ± 801

120-149%

3014 ± 874

3 1 5 0 ± 759

3 5 0 4 ± 576

150% or more

3 3 0 6 ± 729

3521 ± 430

3 4 3 4 ± 6 48

MEAN

2 7 2 9 ± 760

3 01 7 ± 773

3191 ± 763

96

156

N
F
Sig F

10.49
0 .0 0

144

34 9

A ppendix 2 9 -6 a

Estimated d a i l y m icr on u tri en t in ta k e during pregnancy between
c a s e s and c o n t r o l s ( W i l l e t t SQFFQ).

N ut r ie n t

LBW

OBW

t

Sig t

1289 + 596

1391 ± 548

1.58

.1152

Iron, mg

14 + 6

16 ± 6

2 .2 8

.0231

Zinc, mg

14 + 5

16 ± 5

2 .3 5

.0195

Ascorbic Acid, mg

179 + 122

192 ± 116

0 .9 5

.3421

Thiamin, mg

1.6 + 0 . 6

1.7 ± 0 . 6

2 .7 4

.0064

R i b o f l a v i n , mg

2. 5 + 1.0

2 . 7 ± 1.0

1.77

.0779

Py ridoxin e, mg

2. 2 + 0 . 8

2.4 ± 0.9

2.52

.0124

F o l a c i n , meg

305 + 140

337 ± 139

2. 04

.0423

A, IU

2683 + 2438

2876 ± 2638

0 .6 7

.5010

D, IU

352 + 195

394 ± 192

1.94

.0531

E, mg TE

8.0 + 5.4

9 . 2 ± 5. 7

1.69

.0920

9.7 + 7.7

10.2

0 .5 7

.5661

Calcium, mg

i: 7 . 6

350

Appendix 29-6b

Comparison o f the Index o f N u t r i t i o n a l Q u a li ty (N ut r ie n t per 1000
c a l o r i e s ) between mothers o f c a s e s and c o n t r o l s .

N ut ri en t

LBW

OBW

t

Sig t

Protein

1.80 + 0.32

1.87 ± 0 .3 0

2.2 0

.0289

Calcium

1.20 + 0. 44

1.24 + 0 . 3 9

0.8 7

.3827

Iron

0.53 ± 0.17

0 .5 7 ± 0 .2 0

2.0 0

.0466

Zinc

1.07 ± 0.21

1.14 ± 0 .2 9

2 .2 9

.0227

Ascorbic Acid

2.83 + 1.48

2.9 3 ± 1.59

0.61

.5247

Thiamin

1.17 + 0 . 2 5

1.25 ± 0 . 3 0

2 .7 8

.0058

R ib o f la v in

1.72 + 0 . 4 8

1. 78 ± 0 . 4 8

1.17

.2416

Pyridoxine

1.11 ± 0 . 2 9

1.19 ± 0 .3 4

2.1 9

.0294

Folacin

0.8 6 + 0 . 2 9

0.91 ± 0.3 3

1.64

.1025

A

0.7 6 + 0 .6 4

0 .7 7 ± 0 .6 6

0. 14

.8992

D

0.9 9 + 0 . 4 9

1.06 ± 0 .4 5

1.20

.2305

E

0. 90 + 0 . 4 5

1.00 ± 0 .6 5

1.50

.1305

B12

4. 96 + 3 . 5

4 .9 7 ± 3 .2 6

0 .0 0

.9720

IN0 Summary Scores
INQ-12

1.62 + 0 . 5 8

1.68 ± 0 .5 4

0 .9 6

.3384

INQ-4

0 .9 0 + 0 . 2 8

0 . 9 4 ± 0 .3 0

1.28

.2019

351

Appendix 29-7

A t t i t u d e Qu estions f o r each o f the Three C on st ru cts .

Weight Factor A t t i t u d e Questions (R=was recoded in the a n a l y s i s ) .
1.
2.
3.
4.
5.

I worried t h a t I might g e t f a t during my pregnancy. (R)
The weight I gained during my pregnancy made me f e e l
u n a t t r a c t i v e (R).
J u s t b ef o re I went t o the d o ct o r I t r i e d not to eat because
I was worried about my weight gain (R).
I was embarrassed by how big I go t during my pregnancy (R).
I t r i e d t o keep my weight down so I d i d n ' t look so pregnant (R).

N u t r i t i o n Factor A t t i t u d e Questions (R=was recoded in the a n a l y s i s ) .
1.
2.
3.
4.

Mothers who e a t good d i e t s d e l i v e r h e a l t h i e r babies than mother
who do not e a t w e l l .
Good e a t i n g
h a b i t s during pregnancy are very important t o the
baby's h e a l t h .
A poor d i e t
during pregnancy w i l l not a f f e c t the baby's
h e a lt h (R).
N u t r i t i o n i s important during pregnancy.

A t t i t u d e Toward Being Pregnant
1.
2.

I th in k a pregnant woman i s b e a u t i f u l .
Thinking back t o j u s t b ef o re you were pregnant, how did you f e e l
about becoming pregnant?
a.
I wanted to be pregnant sooner ( 5 ) .
b.
I wanted to be pregnant then ( 4 ) .
c.
I d o n ' t know or wish to say ( 3 ) .
d.
I wanted to be pregnant l a t e r ( 2 ) .
e.
I did not want to be pregnant at a l l ( 1 ) .

352
Appendix 29-8

M u l t i p l e r e g r e s s i o n formulas from which th e p a r t i a l r e g r e s s i o n
c o e f f i c i e n t s used in t h e model t o p r e d i c t b i r t h weight were determined.

Independent
Va ri a b le s

B

Dependent V ariab le
SE-B

Partial r

t

Sig t

.10
.33
.24
.25
-.15

2.237
7.439
5.46 8
5.62 0
3. 32 4
6. 52 9

.0259
.0000
.0000
.0000
.0010
.0000

B ir t h Weight
Sex o f i n f a n t
Weeks g e s t a t i o n
Mothers b ir t h weight
term r e f e r e n c e weight
# cigarettes/day
Constant

%

155
171
0 .3 2
9.38
-12.9
-5904

69. 3
23. 0
0 .0 6
1.66
3 .8 6
904

M u l t i p l e R 0.594
R2,%
35
SE-B
638 g
DF
( 5 ,3 3 9 )
F
36.92
.0000
P
% 1983 R eferen ce Weight, Term

Mother's age
Weight g a i n , lb s
Constant
M u l t i p l e R 0.402
R2,%
16
SE-B
19.1
DF
(2 ,3 9 3 )
37.91
F
.0000
P

0.89
0.65
7 8. 8

0.2 5
0.08
7.11

.16
.37

3. 5 6 0 .0004
7.7 35 .0000
11.0 8 .0000

353

Appendix 2 9 -8 ,

Independent
V ari ab le s

B

cont.

Dependent V ari ab le
SE-B

Partial r

t

Sig t

-.325
-. 1 2 2

6 . 7 8 0 .0000
2.534 .0117
7.881 .0000

.16
.06
-. 1 1
-.15

3.1 52
1.215
2.1 70
2 .8 2
- .8 9 1

.20
.13

3 .7 9 9 .0002
2.551 .0000
7 .0 2
.0000

Number o f C i g a r e t t e s / D a y
Mother's education
Attitude: nutrition
Constant

-1.43
-2.17
33 . 8 8

0.211
0.858
4.30

M u lt i p l e R 0.371
R2,%
14
SE-B
8 .2 7
DF
( 2 ,3 9 3 )
F
31 .4 0
p
.0000
Weight Gain
Weeks g e s t a t i o n
MAR-12 sc ore
# cigarettes/day
A t t i t u d e : weight gain
Constant

1.23
0.06
-0.15
-2.16
-14.5

0 .3 9
0.05
0 .0 7
0 .7 7
16.23

.0018
.2250
.0307
.0051
.3737

M u lt i p l e R 0.28 3
R2,%
7
SE-B
10.9
DF
( 4 ,3 5 0 )
F
7.5 9
p
.0000
D ie t Q u a li t y MAR-12
Attitude: Nutrition
Mother's Education
Constant
M u lti pl e R 0.26 6
R2,%
7
SE-B
11.4
DF
(2 ,3 5 6 )
F
13.50
.0000
P

4 .7 6
0.78
43.46

1.25
0.30
6.19

354

Appendix 29-9 a

Comparison o f black OBW responders and non-responders based on b ir t h
c e r t i f i c a t e data: Comparison o f mean d i f f e r e n c e s .

Variable

Responders
(n=122)

Non-Responders
(n=203)

t

P

SIGNIFICANT DIFFERENCES
Mother's ed u ca ti o n , yrs

1 3 . 5±1.7

1 2 . 8±1.6

3 .5 3

.0005

NOT SIGNIFICANTLY DIFFERENT
B irth weight

3753±137

37541144

0.06

.9502

Mothers age, yrs

2 5 .6 +4 .2

24.913.9

1.60

.1115

Month prenatal care began

2 . 8 ± 1 .5

2.6+1.5

1.04

.2984

Number prenatal v i s i t s

1 2 . 7±4.4

12.6+3.4

0.2 2

.8278

Weeks g e s t a t i o n (B50)

3 9 . 8 ± 1 .2

39.7+1.2

0 .6 7

.5041

Fathers age, yr s

2 9 . 4 ± 5 .8

28.3+4.9

1.22

.2215

Fathers e d u ca ti o n , yrs

13. 5+1 .7

13 . 1 + 1 . 5

1.55

.1233

1 minute Apgar

8.1+1.1

8.011.3

0.24

.4457

5 minute Apgar

9.0±0.5

8.9+0.6

0 .1 5

.8781

355

Appendix 29-9b

C o m p a r i s o n o f B i r t h C e r t i f i c a t e D a t a o f B l a c k OBW
R e s p o n d e r s and N o n -R e s p o n d e rs : C h i - S q u a r e A n a l y s i s 9 .

OPTIMAL BIRTH WEIGHT
Responders
Non-Responders
( n = l 22)
(n=203)

Variable

X2

P

SIGNIFICANT DIFFERENCES
none
NOT SIGNIFICANTLY DIFFERENT
Named Parent
One parent named
Both parents named

53
69

106
97

2.01

.1563

Kessner Index
Adequate
Intermediate
Inadequate

90
24
8

156
61
18

0.55

.7610

Sex o f Infant
Male
Female

71
51

129
125

0.71

.3997

Complications o f Pregnancy
Yes
No

6
115

3
200

2.23

.1350

Concurrent I l l n e s s
Yes
No
Drug Addiction

6
115
0

5
197
1

2 .0 2

.3645

39
84

59
144

0 .0 3

.8705

105
17

189
14

3.60

.0579

Complications Labor/Delivery
Yes
No
Attendant (MD or DO)
MD
DO
9a f t e r Y a t e s c o r r e c t i o n .

35 6

A ppendix 2 9-9c

Comparison o f black LBW responders and non-responders based
on b i r t h c e r t i f i c a t e data: t - t e s t o f mean d i f f e r e n c e s .

Variable

Responders
(n=134)

Non-Responders
(n=266)

t

P

SIGNIFICANTLY DIFFERENT
Mother's ed u ca t io n , y rs

12. 7+1 .7

12. 3 +1 .5

2.8 8

.0042

NOT SIGNIFICANTLY DIFFERENT
Birth weight

2225±284

2219+283

0.61

.8479

Mothers age, yr s

2 5 .1±4.1

25.2+4.0

0.0 2

.8935

Month prenatal care began

2.8±2.8

3 .1 + 3 . 1

0 .1 4

.1422

Number prenatal v i s i t s

11.3 +4 .0

11.5+5.1

0.7 4

.7411

Weeks g e s t a t i o n (B50)

38.6±1.5

38.7+1.4

0 .4 7

.4939

Fathers age, y rs

28.716.0

29.115.4

0 .1 5

.7037

Fathers ed u ca t io n , yrs

1 3 .0 +1 .8

1 2 .6 +1 .5

1.86

.1749

1 minute Apgar

7 .7 + 1 . 6

7.5+1.8

0.8 3

.3617

5 minute Apgar

8.8+0.8

8.6+1.0

3.70

.0551

357

A ppendix 29-9d

C o m p a r i s o n o f B i r t h C e r t i f i c a t e D a t a o f B l a c k LBW
R e s p o n d e r s and N o n - R e s p o n d e r s : C h i - S q u a r e A n a l y s i s 3 .

LOW BIRTH WEIGHT
Responders
Non-Responders
(n=134)
(n=266)

V ari ab le

X2

p

SIGNIFICANT DIFFERENCES
Named Parent
One parent named
Both parents named

77
56

184
82

4 .5 0 .0339

Complications o f Pregnancy
Yes
No

28
106

15
249

19.80 .0000

Concurrent I l l n e s s
Yes
No
Drug Abuse

10
124
0

26
348
15

8.78

.0124

0 .0 2

.9040

NOT SIGNIFICANTLY DIFFERENT
Sex o f Infant
Male
Female

56
78

108
158

Kessner Index
Adequate
Intermediate
Inadequate

92
31
11

174
61
31

Complications Lab or/Del ivery
Yes
No

41
93

109
156

3.77

.0521

120
14

251
15

2 .3 9

.1220

Attendant (MD or DO)
MD
DO

aa f t e r Y a t e s c o r r e c t i o n .

1.15 .5628

A p p e n d i x 30

I nfant M o r t a l it y Rate in Michigan by 50 g Birth Weight
I n t e r v a l s : 3 , 0 0 0 - 4 , 0 0 0 g, 1984-1986

35 8

Appendix 3 0 -a

White In fan t M o r t a l i t y Rate In Michigan by 50 g Bir th Weight
I n t e r v a l s : 3000-4500 g, 1984-1986.

Bir th Weight

1984

1985

1986

3001-3050
3051-3100
3101-3150
3151-3200
3201-3250
3251-3300
3301-3350
3351-3400
3401-3450
3451-3500
3501-3550
3551-3600
3601-3650
3651-3700
3701-3750
3751-3800
3801-3850
3851-3900
3901-3950
3951-4000
4001-4050
4051-4100
4101-4150
4151-4200
4201-4250
4251-4300
4301-4350
4351-4400
4401-4450
4451-4500

5.6
4.0
4.7
3.1
4.3
3.0
2.2
2.7
2.0
3.8
2. 3
2.6
4.6
3.3
2.9
3.7
1. 5
2.4
2.9
1.1
2.8
1. 9
6.3
3.8
2.3
1.7
1.9
1.2
2.2
3.0

5.1
3.4
4.3
4.2
2.8
4.0
4.2
5.0
2.6
3.6
3.4
2.4
1.0
4.3
2. 3
2. 3
0.0
0.1
0.7
2.5
3.5
0.4
2.0
4.6
1.2
0.0
4.5
3.4
2.0
0.0

3.4
5.1
3.6
3.8
3.3
4.6
3.4
4.8
3.8
1.6
2.9
2. 2
2.4
2.8
3.0
1.3
1.4
2.3
2.1
1. 8
0.7
3.6
3.3
4.2
3.6
1.7
3.8
1.1
0.0
5.0

4.7
4.2
4.2
3. 7
3.5
3.9
3.3
4.2
2.8
2.0
2.9
2. 4
2.7
3.5
2.7
2.4
1.0
1.6
1.9
1. 8
2. 3
2.0
3.9
4.2
2. 4
1.1
3.4
1.9
1.4
2. 7

MEAN:

3.1

3.0

3.0

3.0

Mean (84-1

359
Appendix 3 0 -b

Black I nfa nt M o r t a l it y Rate In Michigan by 50 g Birth Weight
I n t e r v a l s : 3000-4500 g , 1984-1986.

Bir th Weight

3001-3050
3051-3100
3101-3150
3151-3200
3201-3250
3251-3300
3301-3350
3351-3400
3401-3450
3451-3500
3501-3550
3551-3600
3601-3650
3651-3700
3701-3750
3751-3800
3801-3850
3851-3900
3901-3950
3951-4000
4001-4050
4051-4100
4101-4150
4151-4200
4201-4250
4251-4300
4301-4350
4351-4400
4401-4450
4451-4500
MEAN:

1984

1985

1986

Mean ( 84 -86 )

5.6
5.5
8.6
6.3
1.9
2. 0
1.1
1.2
5.5
1.3
2. 5
9.1
2. 7
5. 2
0.0
2.0
2.1
0.0
3.4
3.7
0.0
5.0
7.0
1.5
1.7
9.2
0.0
27. 0
0.0
0.0

6.6
5.1
4.5
4.9
7. 3
5.0
0.0
3.7
3.3
2.5
6.4
5. 7
2.4
6.8
3.9
2.3
0.0
8.3
3.3
3.9
8.8
1.1
6.1
7.0
0.0
0.0
21.5
29 .0
0.0
0.0

8.4
6.9
2.2
9.3
4. 7
0.0
2. 0
4. 0
4.9
3.6
3. 7
6.9
4.8
3. 3
1.9
2.2
7. 9
0.0
0.0
14.5
8.3
4.9
0.0
0. 0
0.0
0.0
0.0
0.0
0.0
0.0

6.9
5.8
5.1
6.8
4.6
2.3
1.0
3.0
4.6
2.5
4.2
7.2
3.3
5.1
1.9
2.2
3.3
2.8
2.2
7.4
5.7
3.7
4.4
2.8
0.6
3. 1
7.2
19.0
0.0
0.0

4.5

4.8

4.2

4.5

A p p e n d i x 31

Comparison o f the Unpublished NHANES II W ei ght -f or- H eig h t
Data f o r Women Between 20-24 Years o f Age with the 1983 and
1959 Me tr opolitan Reference Weight- fo r-H eigh t Standards

3 60

A p pe n dix 31a

Unpublished NHANES II W e i g h t - f o r - H e i g h t Data:
White Females 20-34 Years o f Age

^• ^«D0
0 o0 om 0
©
oo
^ ^ ^ A< IVN N

• * K'Cn'^fNtl^ONM

©• © «0 .
8n

n O r

r

• f

0 0 4^ OM'V«^ f - • i-^. N n
0*»NN»VNr«lflKlM
>0"

e

•

t“

<

VN O f

» • • i • • • « • i i •
N<rNf>*v<iQMr«o«M

O •*f3**«*^N'WNMP»r'

« **»r*w'Ono^0*,0 O «
• O M T i>' ^ N » 4 N i>
O O O O ^ r “ *“ *-ri»s,»^
i O t>

m f l i/mO n m .

• rKiOO-'*

O

•»•

n• n •o •w •^ r» N• O• N• '•O« K• O• *• ' • 0 •4

N04iro^r*»N0ov>n^Q

N < r 0 4 0 » " * < N i n v « i r v < 4

*

•

•

o nj o

©^• c*
i0 -*
e o**
a a l
0 00

•

•

• r> 0 N

•

•

«

•

t* p 0

•

•

«

•

•

•

4

•

•> N O r < 4

O

ry m r > « t i 0 » 4 N 4 p f >
«* N fglVr ^

9M©

7 . •

0'S
9

+>

m ni

'U V
c c r
X C

I

i sx ii

£u X
£ Z£
wy w w
e cc c

t o © O ,’ N ' n 4 I A 4 K 0 (

X X

wu

c c

8

Comparison: Weight-for-Height Standards
-1959, 1983 Metropofitan and NHANES IIW e ig h t, lb s

160
150
140
130
120

110

1959 M etropolitan
- 4 — 1983 M etropolitan

100

90
57

- G - NHANES II

58

59

60

61

62

63

64

65

66

Height, inches

67

68

69

70

71

72

A p p e n d ix 32

R e s p on s e R a t e t o t h e White M ich ig an M o t h e r ' s S u r v e y and
t h e P h y s i c i a n ' s P r e n a t a l Car e Sur ve y o f B l a c k M ich ig an
M o t h e r ' s by County o f B i r t h

362

A p p e n d ix 3 2 a

White M ic h i g a n M o th e r s Re sp on se R a t e by Cou nt y o f B i r t h

C o u n t y / C o u n t y Type

Responders
( n)

P r i m a r i l y Rural
( l e s s t h a n 20 S u b j e c t s 1)

E ligible
( n)

Re sp on se
Rate, %

129

186

69

24
16

36
26
23
77
30

P r i m a r i l y Urban
Genes ee
Ingham
Kalamazoo
Kent
Macomb
Oakl and
Washtenaw
Wayne
TOTAL

12
66

100
21
101

269

414

67
62
87
62
60
65
57
65
65

OVERALL RESPONSE RATE

398

600

66

20

48
18
65

1 C o u n t i e s i n c l u d e A l l e g h a n , A l p e n a , Bay, B e r r i e n , C a l h o u n , Cass
Cheboygan, Chippewa, C l a i r e , C l i n t o n , C r a w f o r d , D e l t a , D i c k e n s o n ,
Emmett, G o g e b i c , Grand T r a v e r s e , G r a t i o t , H i l l s d a l e , Houg ht on , Huron,
I o n i a , I o s c o , J a c k s o n , L a P e e r , Lenawee, M a r q u e t t e , Mason, M a c o s t a ,
M id l a n d , Monroe, Montcalm, Muskeegon, Newaygo, Oc e a n a , Ogemaw,
O s c e o l a , O t s e g o , O t t o w a , Sa g in aw , S t . C l a i r e , S a n a l a c , S h i a w a s e e , Van
B ur en , Wexford

363

Appendix 32b

P h y s i c i a n ' s P r e n a t a l Car e S u r v e y o f B l a c k M ic hi ga n M oth er s
R e s po ns e R a t e by County o f B i r t h

C o u n t y / C o u n t y Type

Responders
(n)

El i g i b l e
(n)

Response
Rate, %

49

74

66

P r i m a r i l y Urban
Berrien
G enesee
Ingham
Kent
Oakl and
Saginaw
Washtenaw
Wayne
TOTAL

17
21
23
15
29
21
9
113
248

20
60
26
37
80
32
23
473
751

85
35
88
41
36
66
39
24
33

OVERALL RESPONSE RATE

297

825

36

P r i m a r i l y Rura l
( l e s s t h a n 20 S u b j e c t s 1)

1 C o u n t i e s i n c l u d e C a l h o u n , C a s s , Emmett, I o s c o , J a c k s o n , Kalamazoo,
Lenawee, Macomb, M a r q u e t t e , M a c o s t a , Muskeegon, Newaygo, S t . C l a i r e ,
and Van Bur en.

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