Short Maternal Stature Increases Risk of Small-for-Gestational-Age and Preterm Births in Low- and Middle-Income Countries: Individual Participant Data Meta-Analysis and Population Attributable Fraction

Abstract

Background: Small-for-gestational-age (SGA) and preterm births are associated with adverse health consequences, including neonatal and infant mortality, childhood undernutrition, and adulthood chronic disease.

Objectives: The specific aims of this study were to estimate the association between short maternal stature and outcomes of SGA alone, preterm birth alone, or both, and to calculate the population attributable fraction of SGA and preterm birth associated with short maternal stature.

Methods: We conducted an individual participant data meta-analysis with the use of data sets from 12 population-based cohort studies and the WHO Global Survey on Maternal and Perinatal Health (13 of 24 available data sets used) from low- and middle-income countries (LMIC). We included those with weight taken within 72 h of birth, gestational age, and maternal height data (n = 177,000). For each of these studies, we individually calculated RRs between height exposure categories of < 145 cm, 145 to < 150 cm, and 150 to < 155 cm (reference: ≥ 155 cm) and outcomes of SGA, preterm birth, and their combination categories. SGA was defined with the use of both the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) birth weight standard and the 1991 US birth weight reference. The associations were then meta-analyzed.

Results: All short stature categories were statistically significantly associated with term SGA, preterm appropriate-for-gestational-age (AGA), and preterm SGA births (reference: term AGA). When using the INTERGROWTH-21st standard to define SGA, women < 145 cm had the highest adjusted risk ratios (aRRs) (term SGA-aRR: 2.03; 95% CI: 1.76, 2.35; preterm AGA-aRR: 1.45; 95% CI: 1.26, 1.66; preterm SGA-aRR: 2.13; 95% CI: 1.42, 3.21). Similar associations were seen for SGA defined by the US reference. Annually, 5.5 million term SGA (18.6% of the global total), 550,800 preterm AGA (5.0% of the global total), and 458,000 preterm SGA (16.5% of the global total) births may be associated with maternal short stature.

Conclusions: Approximately 6.5 million SGA and/or preterm births in LMIC may be associated with short maternal stature annually. A reduction in this burden requires primary prevention of SGA, improvement in postnatal growth through early childhood, and possibly further intervention in late childhood and adolescence. It is vital for researchers to broaden the evidence base for addressing chronic malnutrition through multiple life stages, and for program implementers to explore effective, sustainable ways of reaching the most vulnerable populations.

Keywords: chronic malnutrition; maternal health; maternal height; neonatal health; small-for-gestational-age.

FIGURE 1

Pooled adjusted RRs between short maternal stature (<145 cm, 145 to <150 cm, and 150 to <155 cm, reference: ≥155 cm) and adverse neonatal outcomes with the use of the INTERGROWTH-21st standard to define SGA. SGA <10%, SGA <3%, and preterm birth (A). Term SGA, preterm AGA, and preterm SGA (B). n = number of studies included in the pooled association. AGA, appropriate-for-gestational-age; INTERGROWTH-21st, International Fetal and Newborn Growth Consortium for the 21st Century; SGA, small-for-gestational-age.

FIGURE 2

Height distribution in women of reproductive age by UN Millennium Development Goal subregions, with NHANES data used as the theoretical minimum. Data derived from 80 nationally representative surveys (52 demographic and health surveys, 24 stepwise approach to surveillance surveys, and 4 others). C, Central; E, Eastern; LAC, Latin America and the Caribbean; MDG, Millennium Development Goal; N, Northern; S, South; SE, Southeast; SS, Sub-Saharan; W, Western.