REVIEW

Niger J Paed 2013; 40 (2): 119 - 124

Maternal factors in the aetiology of

small-for-gestational age among

term Nigerian babies

Oluwafemi RO

Njokanma OF

Disu EA

Ogunlesi TA

DOI:http://dx.doi.org/10.4314/njp.v40i2,3

Accepted: 8th August 2012

Abstract Background: Babies are

classified according to the relation-

ship between birth weight and ges-

tational age, the latter being the

strongest determinant of birth

weight. Small-for-gestational age

occipitofrontal circumference com-

pared to females p = 0.048 and p <

0.000 respectively). The prevalence

of infants with small-for-gestational

age was 7.2% (5.7% and 8.8%

among males and females respec-

tively). The proportion of mothers

who did not encounter significant

illness in pregnancy was lowest

among those who had SGA babies,

followed by mothers of LGA babies

and those of AGA babies in that

order. With respect to maternal age,

weight, height and body mass index

(except inter-pregnancy interval),

mothers of SGA babies had signifi-

cantly lower values compared to

mothers of the AGA and LGA ba-

bies (p < 0.03).

Oluwafemi RO

(

)

Department of Paediatrics,

Mother and Child Hospital, Akure,

Nigeria.

Email: bankyfem@yahoo.com

(

SGA) babies have birth weights

th

Njokanma OF, Disu EA

Department of Paediatrics and Child

Health, Lagos State University

Teaching Hospital,

less than the 10 percentile for age

and sex or more than two standard

deviations below the mean for age

and sex.

Ikeja, Lagos, Nigeria.

Objective: The study was carried

out to investigate the maternal fac-

tors associated with the delivery of

term small-for-gestational age ba-

bies in a Nigerian Hospital.

Methods: In the cross-sectional

survey, the anthropometric parame-

ters of term singleton infants were

related to maternal age, parity,

socio-economic class, anthropome-

try and medical disorders in preg-

nancy.

Results: A total of 825 babies were

surveyed within the first 24 hours

of life. The mean birth weight of

babies was 3233 ± 539g. The

males had significantly longer

mean crown-heel length and mean

Ogunlesi TA

Department of Paediatrics, Olabisi

Onabanjo University Teaching

Hospital, Sagamu, Nigeria.

Conclusion: This study identified

age, parity, anthropometry and hy-

pertension-related disorders as ma-

jor maternal factors associated with

the birth of SGA babies in Nigeria.

Keywords: Anthropometry, Intra-

uterine growth restriction, maternal

illness, Nigeria.

2

and grand-multiparity. Maternal nutritional status and

anthropometry also play a major role in the birth size of

a baby with low maternal weight,₅h_,₆eight and body mass

index implicated in SGA delivery.

The term ‘small- for-gestational age’ (SGA) describes a

th

baby whose birth weight is less than the 10 percentile

1

for age and sex. It may also be defined as birth weight

more than tw₁o standard deviations below the mean for

age and sex.

It is therefore expected that the prevalence of SGA ba-

bies will be relatively high in the tropics and sub-tropics.

In some advanced countries, the prevalence of SGA

ranged between 2.8 percent and 10 percent. A preva-

lence of 10% was reported in the United St₇ates with

higher incidence among the black population. A figure

Potential conditions that predispose babies to being

small at birth are quite common in tropical practice.

2

Some of which include general infections and malarial

3

infestations. S₄everal other factors may predispose to

SGA delivery. Maternal factors known to contribute to

SGA delivery include biological factors, nutritional fac-

tors, brief inter-pregnancy intervals, low socio-economic

class ₄and poor education, medical and obstetric prob-

lems. Maternal biological factors which may influence

8

of 4.1% was reported in Britain, as high as 16.5%

9

among t₁h₀e_,₁₁Chinese and other Asian women. While in

Nigeria,

babwe 7.6% was reported.

the prevalence is 12.8% and in Harare, Zim-

12

SGA delivery include extremes of maternal age

2

(

teenage and mothers older than 35 years), primiparity

1

20

It is important to identify the predisposing factors to

SGA delivery because there is a dearth of information

on the epidemiology of SGA and it is a known fact that

the weight at birth not only reflects the quality of intra-

uterine growth, but it als₃o exerts a strong influence on

cluded weekly standardization of the weighing scale,

using known weights. Length was measured in centime-

ters to one decimal place using a metal anthropometric

linear rule fixed to a horizontal flat board using standard

procedure. The OFC was measured to the nearest 0.1 cm

with a non stretchable tape usin₁g₇ the glabella and the tip

of the occiput as the landmarks.

1

the post-natal survival. identifying the predisposing

factors therefore will assist in making comprehensive

perinatal and neonatal care plans.

The gestational age was determined calculating from the

first day of last maternal menstrual period. This was

corroborated by the scores o₄ btained by using methods

There is, presently, a dearth of literature on the current

pattern of aetiology of small for gestational age infants.

Therefore, the current study is aimed at determining the

maternal factors associated with term small-for-

gestational age babies delivered in a major Nigerian city,

Lagos.

1

described by Ballard et al. Where the difference be-

tween both techniques was more than two weeks, the

gestational age obtained by using the New Ballard score

was upheld and recorded. SGA was defined as babies

th

whose birth weights are less than the 10 percentile on

the international growth ch₁a₈rt (Lubchenco chart of In-

trauterine growth pattern). Appropriate-for-gestational

th

Subjects and Methods

age (AGA) babies weighed between 10 and 90 per-

centiles while Large-for-gestational age (LGA) weighed

higher than the 90 percentiles.

th

The study was conducted in the maternity section of the

Lagos State University Teaching Hospital (LASUTH),

Ikeja, south-west, Nigeria between September and De-

cember 2009. The hospital serves as a referral centre for

private and public primary and secondary health institu-

tions in both Lagos and the neighboring Ogun state. The

maternity section shares a bed capacity of 165 with the

gynaecological section. The average delivery rate is

The maternal age, marital status, anthropometry, tribe,

socio-economic status. parity, inter-pregnancy interval,

maternal disease in pregnancy were all recorded. The

body mass index was also calculated for each mother.

The data was analyzed using Microsoft Excel program

and SPSS version 16.0. Descriptive and inferential sta-

tistics were applied in the course of analysis. Pearson’s

Chi-square test was used to assess relationships between

categorical variable. The Student t–test was used to

compare the means of continuous variable. Analysis of

variance (ANOVA) was used to compare three or more

group means. The p-value less than 0.05 defined statisti-

cal significance (95% confidence level).

4

000 babies per annum, with term babies accounting for

approximately 90%. There is no restriction on the type

of cases admitted into this facility. Thus, women of all

socioeconomic classes patronize the hospital.

Ethical clearance was obtained from the hospital’s Re-

search/Ethics Committee and written informed consent

was taken from mothers of subjects at contact.

The study was hospital based and cross sectional. Sub-

jects consisted of consecutive mother-baby pairs who

fulfilled set study criteria. Inclusion criteria included

term newborn babies, singleton birth of consenting

mothers while exclusion criterion was babies with gross

congenital abnormality. The babies were examined in

the first 24 hours of life within the acceptable limits fo₁r₄

physical examination as described by Ballard et al.

This 24-hour period also allowed for full recovery of

mothers from the effects of anaesthesia and post opera-

tive pain in cases of operative deliveries.

Results

There were a total of 1,052 live births during the study

period. Of this number, 195 pre-term babies, 27 prod-

ucts of multiple gestation, four babies with various con-

genital abnormalities and one with fractured femur were

excluded. Thus, 825 consecutive term, singleton babies

fulfilled the set criteria.

General characteristics

The minimum sample si₁z₅e_,₁₆for the study was derived

from a statistical formula

based on the prevalence of

Of these 825 babies, 53.3% were males while 46.7%

were females giving a male : female ratio of 1: 0.9. The

majority of the study subjects belonged to the upper

socio-economic class. Five hundred and seventeen ba-

bies (62.7%) were delivered by spontaneous vertex, 297

SGA delivery in a similar study conducted within the

1

0

same locality. The minimum sample size was esti-

mated as 686 but a total of 825 were studied in order to

allow for precision and attrition.

(

36.0%) by caesarean section and the remaining eleven

The recorded anthropometric parameters of the babies

included birth weight, crown-heel length (CHL) and

occipito-frontal circumference (OFC).

Each baby was weighed using the RGZ-20 weighing

scale. The scale records weights in grams to the nearest

(1.3%) by various types of assisted deliveries.

The mean gestational age and birth weight of babies

were 39.0 ± 1.29 weeks and 3233 ± 539g respectively.

The overall mean CHL was 49.0 ± 2.46cm. The males

had significantly longer mean CHL than females. The

mean length for males was 49.17 ± 2.44cm while mean

2

5g. It was adjusted for zero error before each reading.

Other measures taken to ensure reliability of results in-

1

21

for females was 48.83 ± 2.48cm (t = 1.98, p = 0.048).

The overall mean OFC was 34.6 ± 1.40cm with males

having a significantly higher mean OFC compared to

females (t = 4.06, p < 0.0000). Specifically, 59 neonates

were adjudged SGA. Thus, the prevalence rate of SGA

was 7.2% (5.7% and 8.8% in males and females respec-

pregnancy than those of SGA (p < 0.0001) as shown in

Table 3.

Table 3: Relationship between maternal illness and

intrauterine growth status

Maternal Illness

SGA

AGA/LGA

Total

2

tively: x = 3.07, p = 0.08). The corresponding preva-

Present

Absent

Total

29 (49.2)

30 (50.8)

59

137 (17.9)

629 (82.1)

766

166 (20.1)

659 (79.9)

825

lence rates of AGA and LGA babies were 635 (77.0%)

and 131 (15.9%) respectively. Table 1 shows the distri-

bution of infant’s anthropometric₁v₈alues using an inter-

national intrauterine growth chart.

SGA - Small-for-gestational age; AGA - Appropriate-for-gestational

age; LGA - Large-for-gestational age

Figures in parentheses are percentages of the total in the respective

column.

Table 1: Distribution of infant’s anthropometric values using

an international intrauterine growth chart

th

>90

<

10

10 to 90

percentile

In the next phase of analysis, cutoff values of maternal

characteristics were empirically chosen and the

Measurements

N (%)

associated frequency of SGA, AGA and LGA babies

determined. With respect to maternal age groups (Table

4), more than three quarters of mothers were aged be-

tween 20 years and 34 years. The highest SGA rate was

associated with teenage motherhood (20.0%) but this

Birth weight (g)

Length (cm)

Occipitofrontal circumfer- 2 (0.2)

ence (cm)

Ponderal Index (g/cm )

59 (7.2)

46 (5.6)

635 (77.0)

131 (15.9)

672 (81.5)

598 (72.5)

107 (13.0)

225 (27.3)

3

53 (6.4)

642 (77.8)

130 (15.8)

was not significantly higher than for mothers aged 20 to

Figures in brackets are percentages of total number of study subjects

(825)

2

4 years (X [Yates correction] = 0.31, p = 0.86). Also,

the SGA rate was lowest among the 171 mothers aged

5 years or more but not significantly lower than that for

3

Eight-hundred-and-eighteen mothers (99.2%) were

married while seven (0.8%) were single mothers. Three-

hundred-and-thirty-eight mothers (41.0%) were nul-

liparae, 460 (55.8%) were Para 2 to Para 4, while 27

2

mothers aged 20 to 34 years (4.7% Vs 7.7%: X = 1.89,

p = 0.17). Table 4 shows that the overall mean birth

weight of babies whose mothers were aged 20 to 34

years was significantly higher than that for babies born

to older mothers (p = 0.001).

(

3.2%) were grandmultiparous (> Para 5). Table 2 shows

the mean maternal age, anthropometry, inter-pregnancy

interval and their distribution according to intra-uterine

growth status. In all the characteristics except inter-

pregnancy interval, mothers of SGA babies had signifi-

cantly lower values than mothers of the AGA and LGA

babies (p < 0.03). The same pattern was observed when

analysis of SGA Vs (AGA + LGA) was done.

Table 4: Relationship between maternal age-groups and

intrauterine growth of babies with mean birth weights

Maternal age

(years)

Overall

SGA

AGA

LGA

<

20

2710 ± 288g

2450g

(n = 1)(20.0)

2775 ± 287g

(n = 4)

(n = 0) (0.0)

(

n = 5)

(80.0)

2

0 – 34

3219 ± 562g

(n = 649)

2392 ± 210g

(n = 50)

3145 ± 385g

(n = 494)

(76.1)

4035 ± 354g

(n = 105)

(16.2)

Table 2: Mean maternal age, anthropometry and inter-

pregnancy interval according to intrauterine growth status

(7.7)

>

35

3041 ± 614g

n = 171)

2222 ± 274g

(n = 8) (4.7)

3046 ± 352g

(n = 137)

4071 ± 309g

(n = 26)

(15.2)

t-test; (p-

value)

SGA

AGA/LGA

t

p-values

(

(80.1)

Age (years)

Weight (kg)

Height (cm)

29.1 ± 4.88

30.8 ± 4.74

(13 - 44)

2.63

4.79

2.80

3.89

0.15

0.01

t-test; (p-

value)

t-test; (p-

value)

t-test; (p-

value)

(

17 - 41)

68.6 ± 13.83

40 – 109)

1.57 ± 0.08

1.22 – 1.77)

27.8 ± 4.40

19.0 – 40.5)

2.83 ± 2.60

n = 24)

77.6 ± 15.02

(41 – 146)

1.60 ± 0.07

(1.40 – 1.85)

30.2 ± 5.27

(18.5 – 52.5)

2.91 ± 2.26

(n = 469)

0.000

0.007

0.000

0.88

2

0 – 34 Vs <

0

3.43; 0.001

*

2.85; 0.005

*

(

2

3

0 – 34 Vs >

5

3.96; 0.016

1.68; 0.13

2.56; 0.08

0.52

(

2

BMI (kg/m )

(

SGA - Small-for-gestational age; AGA - Appropriate-for-gestational

age; LGA - Large-for-gestational age.

Figures in brackets are percentages of N

IPI (year)

(

*

t-test not feasible because the numbers are too few to generate stan-

dard deviation.

SGA - Small-for-gestational age; AGA - Appropriate-for-gestational

age; LGA - Large-for-gestational age; BMI - Body mass index; IPI -

Inter-pregnancy interval (This interval applied to only 487 mothers

who had at least one previous pregnancy).

The prevalence of SGA delivery showed significant

disparity among the various maternal groups (p = 0.007)

as shown in Table 5. The rate was highest among nul-

liparous mothers being more than twice the value ob-

served for mothers in the Para 2 to Para 4 group (10.4%

Figures in brackets are ranges of values

The major illnesses recorded among the mothers in-

cluded hypertensive diseases (89; 10.8%), HIV/AIDS

2

Vs 4.8%: X = 9.12, p = 0.003). In addition, the mean

(

1

19; 2.3%), diabetes mellitus (18; 2.2%), malaria (14;

.7%) and sickle cell anaemia (9; 1.1%). Mothers of

birth weight of babies born to mothers who have had

two to four prior babies was significantly higher than

that of babies of nulliparous mothers (p = 0.0001) and

babies of grandmultiparous mothers (p = 0.01)

AGA/LGA subjects were significantly less likely to

have encountered a significant illness during the current

1

22

(

Table 5). More specifically, SGA babies born to nul-

Discussion

liparous mothers had a highly significantly lower mean

birth weight than their counterparts born to mothers in

the Para 2 to Para 4 group (p = 0.0001).

Several factors have been identified as being responsible

for SGA. The various factors may be grouped into ma-

2

ternal, utero-placental and fetal factors. Maternal bio-

logic factors known to contribute to SGA delivery in

developing countries include anthropometry, nutritional

Table 5: Relationship between maternal parity and intrauterine

growth status of babies with mean birth weights

1

0

Maternal

Parity

Overall

SGA

AGA

LGA

deficiencies and medical problems occurring in or co-

2

inciding with pregnancy. The influence of maternal size

1

3151 ± 583g

2197 ± 208g

(n =35)

3108 ± 340g

(n = 257)

(76.0)

3179 ± 341g

(n =355)(77.2)

4120 ± 418g

(n = 46)(13.6)

on infant’s birth weight was apparent in the present

study with low maternal weight, height and BMI being

associated with increased frequency of SGA babie₁s₀._,

This is in agreement with earlier studies from Nigeria,

(

n = 338)

(10.4)

2

– 4

5

3303 ± 499g

n = 460)

3072 ± 442g

n = 27)

2527 ± 72g

(n = 22)(4.8)

4040 ± 336g

(n = 83)(18.0)

(

>

2700g

(n =2 )(7.4)

3050 ± 426g

(n = 23)(85.2)

3700g

(n = 2)(7.4)

19

20

oth₂e₁r developing countries and the developed coun-

(

tries

all of which observed that maternal size is an

t-test; p-

value

t-test; p-value

2.55; 0.01

0.64; 0.53

1.42; 0.17

t-test; p-value

important determinant of intrauterine growth. The expla-

nation is not far-fetched. Anthropometry is a well

known index for nutritional status. Better nutritional

status in the mother translates to improved transplacen-

tal nutrient supply to the fetus. It is also known that fetal

size is dependent on innate/genetic as well as nutritional

factors. It is plausible therefore that the positive relation-

ship between maternal anthropometry and that of the

infant is partly a reflection of inherent genetic factor in

the determination of birth size.

Para 1 Vs

Para 2 - 4

3.86; 0.0001

8.60; 0.0001

1.11; 0.27

Para 1 Vs

Para > 5

0.87; 0.39

**

Para 2 - 4

Vs Para >

5

52.62; 0.01

SGA - Small-for-gestational age; AGA - Appropriate-for-gestational

age; LGA - Large-for-gestational age.

Figures in brackets are percentages of N

* t-test not feasible because the numbers are too few to generate

standard deviation.

*

The influence of extremes of maternal age was also in-

vestigated but the number of teenage mothers in the cur-

rent study (5) was too small to permit an in-depth analy-

sis or comments. Thus, although the SGA rate among

teenagers was higher than other maternal groups, this

observation remains anecdotal in view of the current

limitation regarding statistical analysis. However, teen-

age motherhood is often cite₁d₀ as being associated with

lower birth weight profiles. Using different methods,

The frequency of SGA delivery reduced progressively

while that of LGA delivery increased with increasing

maternal weight (p = 0.000) as shown in Table 6. Moth-

ers shorter than 155cm were significantly more likely to

deliver SGA babies than their taller counterparts

(

p = 0.009). On the contrary, the taller mothers were

more likely to give birth to LGA babies than shorter

2

ones (X = 10.86, p = 0.001). The same pattern was ob-

6

served for increasing maternal body mass index (p =

workers in Ile-Ife, Nigeria also established an associa-

2

0

.000). Mothers who had BMI above 30kg/m were sig-

tion between compromised intrauterine growth and teen-

age motherhood. A number of arguments may be raised

to explain this line of observation. It may be that teenage

parturients are not fully developed physically and emo-

tionally to cope with₂the nutritional and metabolic de-

nificantly less likely to give birth to SGA babies than

2

those with BMI less than 24.9kg/m (X = 5.26, p =

.022). They were, in addition, less likely to deliver

SGA babies than those with BMI between 25 and

0

2

9.9kg/m but this difference was not statistically sig-

2

mands of pregnancy. It may also be related to several

nificant. Also, mothers of LGA babies were more likely

social issues peculiar to unplanned teenage pregnancies.

At the other end of the age spectrum, it is noteworthy

that the lowest rate of contrast to findings in some other

studies which reported the best fetal growth res₁u₀lts in

2

to have BMI of 30 kg/m or more than mothers of AGA

2

(

X = 13.3, p = 0.000) or SGA subjects (X = 15.74, p =

0

.000).

association with mothers aged 30 to 34 years

with

Table 6: Frequency of SGA, AGA and LGA according to

those₁a₀g_,₂e₀d 35 years or more being at a distinct disadvan-

cutoff points of maternal anthropometry

tage. The reasons for the differences in findings are

2

N

SGA

AGA

LGA

X

p

not clear but could be indicative of the fact that maternal

age on its own is not the sole determinant of infant’s

size.

Weight kg

< 60

88 17 (19.3) 69 (78.4)

2 (2.3)

6

>

0 to 80 420 31 (7.4) 341 (81.2) 48 (11.4) 60.1

80 317 11 (3.5) 225 (71.0) 81 (25.6)

Height cm

0.000

With respect to maternal parity and other pregnancy-

related indices, our finding of a strong relationship b₂e₀-_,

tween nulliparity and SGA agrees with earlier reports

<

>

Body Mass Index kg/m

< 25 25

25 to < 30 310

> 30 397

155

170 20 (11.8) 137 (80.8)

655 39 (6₂.0) 498 (76.0) 118 (18.0) 6.86 0.009

13 (7.6)

21

in which birth weight was lowest with first-time moth-

13 (11.0) 100 (84.8)

5 (4.2)

26 (8.4) 247 (79.7) 37 (11.9) 34.8

20 (5.0) 288 (72.6) 89 (22.4)

ers. A number of reasons may explain this relationship.

It may be argued that the smaller birth size associated

with nulliparity is a reflection of smaller intrauterine

volum₃e, which in turn is correlated closely with birth

0.000

SGA - Small-for-gestational age; AGA - Appropriate-for-gestational

age; LGA - Large-for-gestational age

Figures in brackets are percentages

2

size. Short inter-pregnancy interval, particularly if it is

1

23

shorter than six months had earlier₂b₁een associated with

high prevalence of SGA delivery. A related observa-

tion in the current study is the noteworthy absence of

mothers with identifiable high risk factor of a short inter

ing with consequent reduction of blood flow and a cor-

responding₂reduction in oxygen and nutrient delivery to

the fetus. The end result is a varying degree of intrau-

terine growth restriction and the delivery of babies of

smaller growth achievements.

-pregnancy interval particularly with a duration of < 6

months. On the contrary, mothers of SGA babies had a

mean interval almost identical to that of mothers of

AGA babies. It may therefore be concluded that other

causes besides short inter-pregnancy interval was re-

sponsible for the babies in the present study being small

for gestational age.

Conclusion

Some maternal factors (anthropometry and gestational

illness) were found to be significantly associated with

birth size and the frequency of SGA delivery. Identified

maternal factors associated with SGA delivery were

primparity, low maternal weight (< 60 kg), short mater-

na₂l height (< 1.5 meters), body mass index below 25kg/

The spectrum of pregnancy-associated morbidities ill-

nesses identified among the mothers involved in the

1

0

study is similar to those of earlier Nigerian reports.

Specifically, maternal hypertensive disorders were sig-

nificantly associated with SGA delivery. This finding is

consistent with tha₂t₄ of an earlier report by Obed and

Aniteye in Ghana, it also agrees with that reported by

m

and hypertension-related illnesses.

Clearly, the identified predisposing factors to SGA de-

livery in this study constitute a valid prerequisite for

evolving the relevant intervention strategies. It is there-

fore recommended that steps be taken to improve the

nutritional status of mothers before and during preg-

nancy, as well as improve utilization of antenatal ser-

vices in order to ameliorate the identified risk factors.

1

9

6

Sadoh in Benin. Workers in Ilesa also demonstrated

that maternal hypertensive disease was present in 25%

of neonates who suffered fetal malnutrition. The finding

is not surprising considering the potential negative ef-

fects of hypertension on placental function. Hyperten-

sion is reportedly associated with pathological changes

in placental blood vessels, including shallow invasion by

fetal trophoblasts in maternal spiral arteries and narrow-

Conflict of interest : None

Funding : None

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