National LLow BBirth WWeight SSurvey - UNICEF · PDF fileNational LLow BBirth WWeight SSurvey...

National LLow BBirth WWeight SSurveyof BBangladesh, 22003-22004

September 2005

BANGLADESH BBUREAU OOF SSTATISTICSPlanning Division, Ministry of Planning

Government of the People's Republic of Bangladesh

Published by:Monitoring the Situation of Children and Women ProjectBangladesh Bureau of StatisticsParisankhyan BhabanE-27/A Agargaon, Sher-e-Bangla Nagar, Dhakawith assistant from UNICEF

Cover Photo : Kiron/MAP/UNICEF

Design & Layout: Dhrupadi

ISBN-984-508-602-0

CONTENTSLIST OF TABLES ......................................................................................................................................................ivLIST OF ABBREVIATIONS.......................................................................................................................................vFOREWORD .............................................................................................................................................................viiPREFACE .................................................................................................................................................................viiiACKNOWLEDGEMENT ..........................................................................................................................................ixMAP OF BANGLADESH...........................................................................................................................................xEXECUTIVE SUMMARY.........................................................................................................................................xi1. INTRODUCTION...............................................................................................................................................1

1.1 Public health problem of low birth weight ...............................................................................................11.2 Causes of low birth weight........................................................................................................................11.3 Consequences of low birth weight ............................................................................................................21.4 Low birth weight in Bangladesh ...............................................................................................................21.5 Aim and objectives of the National Low Birth Weight Survey................................................................3

2. METHODOLOGY..............................................................................................................................................42.1 Survey area ................................................................................................................................................42.2 Survey population......................................................................................................................................42.3 Survey period ............................................................................................................................................42.4 Sample size and sampling design..............................................................................................................42.5 Field staff and training ..............................................................................................................................52.6 Data collection...........................................................................................................................................52.7 Monitoring and quality control .................................................................................................................72.8 Core Expert Group ....................................................................................................................................72.9 Technical Committee.................................................................................................................................82.10 Ethical considerations................................................................................................................................82.11 Data processing and analysis ....................................................................................................................82.12 Limitation of the survey and adjustment of prevalence data....................................................................9

3. CHARACTERICS OF THE MOTHERS AND THEIR HOUSEHOLDS ..................................................103.1 Pregnancies detected and birth weights recorded ...................................................................................103.2 Demographic and socio-economic characteristics of the households.....................................................113.3 Background characteristics of the pregnant women ...............................................................................123.4 Health, nutrition and care during pregnancy...........................................................................................133.5 Delivery ...................................................................................................................................................14

4. BIRTH WEIGHT AND LENGTH...................................................................................................................154.1 Pregnancy outcomes and care of newborns ............................................................................................154.2 Birth weight .............................................................................................................................................154.3 Birth length..............................................................................................................................................17

5. ASSOCIATIONS OF BIRTH WEIGHT AND LENGTH ............................................................................185.1 Household demography and socio-economic status ...............................................................................185.2 Background characteristics of pregnant women .....................................................................................205.3 Health, nutrition and care during pregnancy...........................................................................................205.4 Sex, gestational age, place and season of delivery .................................................................................225.5 Mother's perception on the size and health of her infant at birth ...........................................................23

6. DISCUSSION ....................................................................................................................................................247. CONCLUSIONS AND RECOMMENDATIONS ..........................................................................................26

7.1 Conclusions..................................................................................................................................................267.2 Recommendations........................................................................................................................................26Annex 1 Difference in birth weights measured by two different weighing scales and adjustment of data ....28Annex 2 Questionnaires of the LBW Survey...................................................................................................29Annex 3 (A) Members of Core Expert Group ................................................................................................43Annex 3 (B) Members of Technical Committee ..............................................................................................44Annex 4 Contributors of LBW Survey ...........................................................................................................45Annex 5 Comparison of the household and maternal characteristics of infants whose birth weights were

measured within 72 hrs with infants whose birth weights were not measured within 72 hrs ..........47Annex 6 References..........................................................................................................................................50

National Low Birth Weight Surveyof Bangladesh, 2003-2004 iii

LIST OF TABLESTable 1.1: Latest available data on the prevalence of low birth weight in South Asian countries ..........1

Table 1.2: Results of previous studies in Bangladesh that have measured the prevalence of LBW ......2

Table 3.1: Pregnancies identified and birth weights measured in the survey............................................10

Table 3.2: Demographic and socio-economic characteristics of the households .....................................11

Table 3.3: Background characteristics of the pregnant women ..................................................................12

Table 3.4: Health, nutrition and care during pregnancy ..............................................................................13

Table 3.5: Place of delivery, type of delivery, and assistance and complications during delivery ........14

Table 4.1: Pregnancy outcomes and care of the newborns...........................................................................15

Table 4.2: Mean birth weight by sex and division.........................................................................................16

Table 4.3: Prevalence of LBW by sex and division ......................................................................................16

Table 4.4: Distribution of birth weights by sex and area of residence .......................................................17

Table 4.5: Mean birth length by sex and division..........................................................................................17

Table 5.1: Birth weight, LBW and birth length by household demographic and socio-economiccharacteristics....................................................................................................................................18

Table 5.2: Birth weight, LBW and birth length by background characteristics of mothers ...................20

Table 5.3: Birth weight, LBW and birth length by health, nutrition, and care during pregnancy .........21

Table 5.4: Birth weight, LBW and birth length by gestational age, place of delivery and season ofdelivery...............................................................................................................................................22

Table 5.5: Birth weight, LBW and birth length by mother's perception on the size and health of herinfant...................................................................................................................................................23

Table A 5.1: Demographic and socio-economic characteristics of the householdsof infants whose birth weight was measured within 72 h of delivery andinfants whose birth was not measured within 72 h of delivery............................................47

Table A 5.2: Background characteristics of the pregnant mothers of infants whose birthweight was measured within 72 h of delivery and infants whose birthwas not measured within 72 h of delivery............................................................................48

Table A 5.3: Health, nutrition and care during pregnancy of the mothers of infants whosebirth weight was measured within 72 h of delivery and infants whosebirth was not measured within 72 h of delivery ...................................................................49

National Low Birth Weight Surveyof Bangladesh, 2003-2004iv

LIST OF ABBREVIATIONS

BBS Bangladesh Bureau of StatisticsBMRC Bangladesh Medical Research CouncilBSL Barisal DivisionBW Birth weightCEG Core Expert GroupCTG Chittagong DivisionDGHS Directorate General Health ServicesDHA Dhaka DivisionDPE Directorate of Primary EducationDWA Directorate of Women AffairsDPHE Department of Public Health EngineeringEDD Expected date of deliveryEOC Emergency obstetric cardERD Economic Relations DivisionHKI Helen Keller InternationalICDDR,B ICDDR,B Centre for Health and Population ResearchIPHN Institute of Public Health NutritionISRT Institute of Statistical Research and Training (Dhaka University)IUGR Intra-uterine growth retardationKHL Khulna DivisionLBW Low birth weightLMP Last menstrual periodMCHTI Maternal and Child Health Training InstituteMUAC Mid-upper arm circumferenceNGO Non-government organizationQC Quality controlRAJ Rajshahi DivisionRFA Resident Field AssistantSYL Sylhet DivisionTARC Training and Resource CentersUNICEF United Nations Children's FundVLBW Very low birth weight

National Low Birth Weight Surveyof Bangladesh, 2003-2004 v

National Low Birth Weight Surveyof Bangladesh, 2003-2004vi

Malnutrition is one of the serious chronic problems of Bangladesh. The worst sufferers of malnutrition areunder-2 children, pregnant and lactating mothers and the adolescents. It is the outcome of poor nutritionalstatus of the pregnant mothers during their reproductive period. A large number of children in Bangladeshare born with lower birth weight than the standard birth weight of 2500 grams. In the past, no survey wasundertaken for identifying the prevalence of low birth weight that could represent the whole country's case.I am very happy to know that Bangladesh Bureau of Statistics has conducted a nationwide Low BirthWeight Survey in 2003-2004 with the financial assistance of UNICEF and that the final report is beingpublished now.

It is observed from the findings of the survey that the situation of low birth weight is alarming inBangladesh, with more than one-third of total births occurring with low birth weight.

The government is committed to reduce malnutrition of children and mother within the shortest possibletime. The Health, Nutrition and Population Sector Programme (HNPSP) is being implemented by thegovernment for the period 2003-2007. Multidimensional approaches are being pursued for nutritionalattainment of the children and mothers. Among the government interventions the National NutritionProgramme (NNP) is notable. Under the NNP programme food supplement is provided to themalnourished children under-2 years and pregnant and lactating mothers. Supported by the NNPprogramme, Community approach is adapted for vegetable gardening and rearing of poultry which are thecheaper source of nutrition for the poor households.

I hope that the report will be very useful for the planners, policy makers, researchers and nutritionscientists to formulate programmes and policies for reduction of malnutrition and low birth weight.

I express my sincere thanks to all those involved in guiding the survey and bringing out the report. Mythanks are also to the UNICEF who helped in the survey.

September, 2005 (M. Saifur Rahman, M.P)Minister for Finance and Planning


National Low Birth Weight Surveyof Bangladesh, 2003-2004 vii

FOREWORD

Millions of Bangladeshi children, like those in many other developing countries, suffer from nutritionaldeficiencies from their very early days. Due to their mothers' poor nutritional status prior to and duringtheir pregnancy, children are often born with low birth weight. Small-scaled studies in the past haveindicated that the prevalence of low birth weight, a birth weight of less than 2,500 g, in Bangladesh isamong the highest in the world. In order to get a full understanding of the extent of the problem forformulation of appropriate policy, the National Low Birth Weight Survey 2003-2004 was conducted byBangladesh Bureau of Statistics, in collaboration with UNICEF. The results of the survey are presented inthis report.

The survey confirms that low birth weight is a major public health problem in Bangladesh. More than oneout of every three children, or 1.03 million babies each year, are born with low birth weight. Children bornwith low birth weight are likely to suffer developmental impairment and have risk of illness and prematuredeath.

The situation calls for an urgent action. Findings from this survey are intended to expand the understandingof low birth weight and its underlying causes, and set out actions to reduce its incidence. Interventions likeimproving maternal nutrition will directly benefit the health and nutrition status of mothers and children.On the other hand, providing access to health care before and during pregnancy will increase the facility-based delivery and reduce risks associated with pregnancy.

There is no doubt that creating a child friendly environment will lead to achieving the MillenniumDevelopment Goals. There is also no doubt that BBS will continue to play an active role in measuring theprogress of children and women in Bangladesh.

This report will be useful for policy-makers, planners, project managers, researchers, and developmentpartners engaged in all relevant sectors in formulating appropriate policy and designing interventions. BBSofficials and UNICEF deserve thanks for undertaking the venture

September, 2005 (Akhtar Husain Khan)Secretary

Planning DivisionMinistry of Planning


PREFACE

National Low Birth Weight Surveyof Bangladesh, 2003-2004viii

This report contains the result of the National Low Birth Weight Survey 2003-04 conducted by BangladeshBureau of Statistics, in collaboration with UNICEF. It is the second in the series of special surveysconducted under the UNICEF-supported Monitoring the Situation of the Children and Women Project,following the Anaemia Prevalence Survey of Urban Bangladesh and Rural Chittagong Hill Tracts 2003.

The survey measured the birth weights of 3,085 newly born children from 3,046 households within 72hours of delivery. Data were collected by a locally recruited female worker in randomly selected 107sample clusters both from urban and rural areas of Bangladesh. To capture possible seasonal fluctuationsin birth weight, the data collection lasted for one year, between April 2003 and March 2004.

It should be noted that this survey is the first national survey on low birth weight conducted in Bangladesh.In a country where close to ninety per cent of births take place in the home environment, designing thesurvey method and managing the field work to measure a large number of birth weights at an appropriatetiming (within 72 hours of delivery) throughout the year around the country was a major achievement initself. Collaboration of all partners- particularly the involvement of BRAC in most steps of the study hasenabled this survey to be one of the unique "community-based" surveys.

I would like to take this opportunity to recognize the hard work of all the concerned staff of BangladeshBureau of Statistics, particularly Mr. Abdur Rashid Sikder, Director and Mr. A.K.M Abdus Salam, ProjectDirector, Monitoring the Situation of Children and Women Project, in implementing the survey andbringing out this report. I would also like to thank all contributors, including Prof. HKM Yusuf and Ms.Farhana Haseen of BRAC, and Dr. Harriet Torlesse and Ms. Naomi Ichikawa of UNICEF.

I also express my sincere gratitude to the members of the Core Expert Group and the Technical Committeefor their untiring technical support in finalizing the survey methodology and the report.

I hope that the report will be useful to the planners, policy makers, development partners and the users.Suggestions and comments for the improvement of the report are most welcome.

September, 2005 (A.K.M Musa)Director General

Bangladesh Bureau of Statistics

National Low Birth Weight Surveyof Bangladesh, 2003-2004 ix

ACKNOWLEDGEMENT

Introduction

In countries affected by a high prevalence of undernutrition, many malnourished adolescent girls andwomen give birth to babies that are born thin and stunted. These low birth weight (LBW) infants growpoorly and fail to thrive in subsequent years and, if they are girls, become malnourished mothersthemselves (ACC/SCN, 2000). In this way, undernutrition is handed down from one generation to the next.Low birth weight, defined as a birth weight <2,500 g, is also linked with diet-related diseases in adulthoodsuch as diabetes, coronary heart disease and hypertension. These consequences take a toll on the lives andproductivity of communities as well as placing heavy burdens on overstretched health systems.

Aim

A National Low Birth Weight Survey was conducted for the first time in Bangladesh to provide nationallyrepresentative data on the prevalence of LBW to assess the scale of the public health problem and toprovide baseline data against which to measure progress towards its alleviation.

Methodology

Adolescent girls and women who had missed at least two menstrual periods in 107 randomly selected ruraland urban clusters were enrolled in the survey and followed up to delivery. Of the total 4,414 pregnanciesidentified, there were 3,843 live births, 76 abortions/miscarriages, 186 stillbirths, and 331 women werelost to follow-up. A total of 3,085 birth weights (1,548 boys and 1,537 girls) were taken within 72 hoursof the delivery and were included in the analysis of birth weight.

Birth weight and length measurements were taken and recorded by locally recruited women calledResident Field Assistants (RFA). Birth weights were measured using Seca Baby Scales to the nearest 10 gor UNISCALEs to the nearest 100 g.

The Bangladesh Bureau of Statistics (BBS) of the Ministry of Planning designed the survey and performedthe sampling and household listing, with technical assistance from SURCH. The data collection, dataanalysis and draft report writing were conducted by BRAC, with technical assistance from BBS, SURCHand UNICEF. UNICEF provided financial and technical assistance for the survey.

Summary of findings

1. The mean birth weight of infants in Bangladesh is 2,632 g and the mean birth length is 48.5 cm.

2. Low birth weight (<2,500 g) affects 36% of infants in Bangladesh, more than twice the 15%threshold that indicates a public health problem. Less than 1% of infants were born with very lowbirth weight (<1,500 g).

3. The prevalence of LBW was higher among girls (38%) than boys (33%). However, this finding isnot necessarily a cause for concern as birth weights throughout the world tend to be lower among

National Low Birth Weight Surveyof Bangladesh, 2003-2004 xi

EXECUTIVE SUMMARY

girls than boys. The higher prevalence among girls is merely because the cut-off point for LBWis the same for all infants regardless of sex.

4. At least 77% of LBW infants were growth retarded, confirming that intrauterine growthretardation is the major cause of LBW in Bangladesh.

5. The prevalence of LBW was found to be higher in rural areas (37%) than urban areas (29%).Other risk factors for LBW include low socio-economic status, low level of parental education,young (<20 years) or old (>35 years) maternal age, primigravidity, multigravidity, short stature,lack of antenatal check-ups and iron supplementation during pregnancy, pre-term delivery, andlack of adequate rest during pregnancy.

Recommendations

1. Because of the severity of the LBW problem in Bangladesh and its potential threat to the growth,health and survival of both children and adults, the prevention of LBW should be given immediatepriority in the future.

2. Integrated and complementary strategies are needed to address the major causes of LBW inBangladesh. Special attention should be given to health and nutrition of adolescent girls andwomen before their first pregnancy and between pregnancies, as well as to pregnant womenthemselves. As antenatal clinic attendance is low, there is need for community-based interventionsthat are accessible to all.

3. An advocacy and behavioral communication change (BCC) campaign is needed to ensure thatLBW prevention is given a high profile and accepted as important and necessary at all levels,including policy makers, service providers, opinion leaders, community-based organizations,caregivers, adolescents and women of childbearing age, their family members, and the widerpublic, and to create demand and behavior change for its prevention. Social and cultural practicesthat contribute to LBW, including early marriage leading to pregnancy at a young age and socialpractices affecting the quality and quantity of food consumed by girls and women, should beaddressed.

4. Where necessary, interventions studies and operational research should be conducted to identifyeffective new approaches to LBW prevention.

5. A LBW survey should be repeated every 5 years to measure progress towards the reduction ofLBW prevalence in the country.

National Low Birth Weight Surveyof Bangladesh, 2003-2004xii

National Low Birth Weight Surveyof Bangladesh, 2003-2004 1

1.1 Public health problem of low birth weight

In countries affected by a high prevalence of undernutrition, many malnourished adolescent girls and womengive birth to babies that are born thin and stunted. These infants grow poorly and fail to thrive in subsequentyears and, if they are girls, become malnourished mothers themselves (ACC/SCN, 2000). In this way,undernutrition is handed down from one generation to the next. This intergenerational problem is particularlycommon in countries where poor adolescent girls become pregnant before their own growth is completed.Globally about 17% of all infants that are born alive each year have a low birth weight (LBW), defined asa body weight of less than 2,500 g at birth (WHO, 1980,1984). Ninety percent (90%) of these infants areborn in developing countries. Low birth weight is considered a major public health problem in populationswhere the prevalence is greater than 15% (ACC/SCN, 2000). Asia, and particularly South Asia, has ahigher prevalence of LBW than any other continent in the world. In South Asia, the prevalence rangesfrom 15% to 30% (UNICEF & WHO, 2004) (Table 1.1).

Table 1.1: Latest available data on the prevalence of low birth weight in South Asian countries

Source: UNICEF & WHO (2004)

1.2 Causes of low birth weight

Infants are born with low weight either because they are premature (<37 weeks gestation at birth) and/orbecause they suffered intrauterine growth retardation (IUGR). The majority of LBW infants in developingcountries are the latter.

Low birth weight is strongly associated with undernutrition in mothers. According to one estimate, abouthalf of all IUGR in developing countries is attributable to low maternal weight and stature at conceptionand low weight gain during pregnancy (Kramer, 1987; ACC/SCN, 2000). Iron deficiency and anaemia arealso associated with LBW (Allen, 2000; Rasmussen, 2001)

Mothers who are young (<20 years) or old (>35 years) are more likely to give birth to LBW infants thanthose aged 20-35 years (Eisner et al., 1979; Lee et al., 1988; Tin et al., 1994; Dhar et al., 2003).Childbearing during adolescence imposes a double set of nutritional demands on the young mother, as shestruggles to complete her own growth while also providing the nutrients needed for the development ofthe fetus. Low birth weight is also more common among mothers of parity 1 and >6 than those of parity1-6 (Tin et al., 1994).

1: INTRODUCTION

Country Year LBW (%)Bhutan 1999 15 India 1999 30Maldives 2001 22Nepal 2001 21Pakistan 1991 19Sri Lanka 2000 22

Other important causes of LBW include malaria in endemic areas (Tomkins et al., 1994); maternalinfections that cause a loss of appetite, higher nutrient losses or requirements, abnormal placental bloodflow or structure and fetal infections (Tomkins and Watson, 1989); pre-eclampsia (Evans et al., 2003);passive or active smoking (Horta et al., 1997; Moore and Zaccaro, 2000; Goel et al., 2004; Margee et al.,2004); and heavy alcohol drinking (Virgi, 1991; Faden and Craubard, 1994; Parazzani et al, 2003).

Mothers who give birth to LBW infants tend to have a lower level of education (Shoham-Yakubovich andBarell, 1988; Dhar et al., 2003) and are of lower socio-economic status (Dhar et al., 2003; Dickute et al.,2004) than those who give birth to normal weight infants.

1.3 Consequences of low birth weight

Birth weight is one of the most important determinants of infant survival. Low birth weight infants havea much greater risk of dying in the neonatal period and in later life. Pre-term LBW infants tend to be atgreater risk of dying in the neonatal period, while growth-retarded LBW infants tend to be at greater riskin the post-neonatal period. It has been estimated that almost half of infant deaths in Bangladesh fromdiarrhea or pneumonia could be prevented if LBW was eliminated (ACC/SCN, 2000).

Pre-term infants usually grow very rapidly after birth and catch-up their growth with full-term births asearly as two to three months of age (Piekkala et al., 1989). Children with LBW due to IUGR, however, donot experience much catch-up growth in subsequent years. They are also much more likely to fall sick,they enter school late, they do not learn well, and they are less productive as adults. As adults, they aremore likely to suffer from diet-related diseases such as diabetes, coronary heart disease and hypertension(ACC/SCN, 2000). These consequences take a toll on the lives and productivity of communities as wellas placing heavy burdens on overstretched health systems.

1.4 Low birth weight in Bangladesh

The prevalence of LBW in Bangladesh is believed to be amongst the highest in the world. However, theextent of LBW in the country has not been well surveyed or documented, largely because most (88%)adolescent girls and women deliver at home (BBS/UNICEF, 2004), which makes the large scale datacollection of birth weights difficult, and because most areas of the country lack the equipment or practiceof measuring birth weight at home or at the community-level.

Table 1.2 shows the results of several small-scale surveys and studies in Bangladesh that have estimatedthe prevalence of LBW. The prevalence ranges from 15% in an urban government maternity hospital to47% in Shaharasthi sub-district (upazila) in the southeast of the country.

Table 1.2: Results of previous studies in Bangladesh that have measured the prevalence of LBW

National Low Birth Weight Surveyof Bangladesh, 2003-20042

Location Year ofdata

collectionSample

sizeMean

birth weight(g)

Prevalenceof LBW

(%)Reference

Rural Bangladesh 2,420 51 Goodburn et al., 1994

Shaharasthi sub-district,Comilla District 1999 447 2,513 48 Shaheen et al., 2000

Slum areas of Dhaka 1994-5 1,654 2,516 46 Arifeen et al., 2000

Government maternityhospital in Dhaka city 1999 316 2,889 15 Dhar et al., 2002

1.5 Aim and objectives of the National Low Birth Weight Survey

The aim of the LBW survey was to provide nationally representative data on the prevalence of LBW toassess the scale of the public health problem and to provide baseline data against which to measureprogress towards its alleviation. The specific objectives were as follows:

a) To estimate the prevalence of LBW, mean birth weight and mean birth length in rural areas ofthe six divisions in the country, in urban areas and in the country as a whole.

b) To examine the associations of LBW, birth weight and birth length with demographic, socio-economic, and maternal characteristics.


2.1 Survey area

To obtain the national prevalence of LBW in Bangladesh, the survey was conducted in rural areas of allsix divisions in the country and in urban areas of four divisions (Dhaka, Chittagong, Khulna and Rajshahi).

2.2 Survey population

Adolescent girls and women of child-bearing age who had missed at least two menstrual periods andbelieved themselves to be pregnant were enrolled in the survey and followed-up to delivery. A date of lastmenstruation period (LMP) of 21 June 2003 was taken as the limit for enrolment so that it was possibleto follow up all births within the survey period. Any pregnant woman who migrated to a surveyed clusterfrom elsewhere in the country during her pregnancy was also included in the survey.

2.3 Survey period

Enrollment of the survey population in the study began in March 2003 and ended in March 2004. All birthweight measurements were taken between April 2003 and March 2004, a one year period to capturepossible seasonal fluctuations in birth weight.

2.4 Sample size and sampling design

The survey was designed to provide divisionally representative data for rural areas, and nationallyrepresentative data for urban areas and the country as a whole. The sample size for each of the six ruraldivisions and for the urban areas was calculated based on an assumed LBW prevalence of 40% and anerror of +0.06, using the formula provided below.

where, p= assumed prevalence of the indicator (0.40)z= standard normal value with 95% confidence (1.96)e= admissible level of error or precision (0.06)deft= design effect due to cluster sampling (1.25)

Based on this calculation, a minimum of 320 births was required for each of the six rural divisions and forthe urban areas. After adjustment for loss-to-follow-up due to migration to other areas, pregnancy loss(abortions, miscarriages and stillbirths), and failure to measure birth weight within 72 hours of delivery, asample size of 400 was proposed for each of the six rural divisions and for the urban areas. The estimatedtotal sample size of the survey was therefore 2,800. This sample size provides a national estimate of LBWprevalence with a precision of +0.02.

A total of 107 clusters were selected nationwide, 15 clusters from each rural division and urban non-slumarea, and 4 half-clusters from urban slums. A cluster was defined as a compact area of approximately 300households, thus the total number of households in the survey was 32,100. A household was defined as a


deft)1(2

2

×−=e

zppn

2: METHODOLOGY

group of people sharing food from the same kitchen, irrespective of their place of dwelling. Each clusterof 300 households was estimated to have 30 pregnant women, giving a total expected number ofpregnancies of 3,210 (107*30). The actual number of pregnancies detected during the survey was 4,414(see Table 3.1).

The birth weights of all children born during the 12-month survey period in the clusters were measured assoon as possible after delivery. Birth weights measured within 72 hours of birth were considered valid forthe analysis, as previous studies in Bangladesh have shown that there is little change in an infant's weightduring the first 3 days of life (Goodburn, 1994; Arifeen, 1997).

2.5 Field staff and training

The data collection was conducted by a total of 110 Resident Field Assistants (RFAs) and 17 supervisors.

All RFAs were female and were locally recruited from the selected clusters where they resided during theentire survey period. The minimum selection criteria for RFAs included that they were permanent residentsof the cluster, had completed at least Class X, were aged 35 years or less, preferably married andreportedly not pregnant. RFAs were responsible for identifying pregnant women in their assigned cluster,monitoring the pregnancies, and measuring birth weights and birth lengths of the newborn infants within72 hours of delivery. Each RFA was responsible for one cluster, except in clusters where houses weresparsely distributed, for example in Rangamati District of the Chittagong Hill Tracts.

Supervisors were recruited by the BRAC Head Office in Dhaka. The minimum qualification of thesupervisors was a college graduate degree (14 years of education), however, many also held a Master'sdegree. Each supervisor was responsible for supervising the activities of RFAs in 5-8 clusters and forcollecting household data and maternal anthropometric data in these clusters.

The training of field staff was done in two stages. Firstly, all the supervisors and Quality Control (QC)Officers (see Section 2.7) were given a 7-day training in Dhaka on anthropometric measurements and allaspects of the survey administration including the techniques used to monitor the RFAs' activities in thefield. The training sessions were conducted jointly by BRAC, BBS and UNICEF, with resource personsfrom Helen Keller International (HKI) and Dhaka University. The training included a 4-day classroomsession followed by a 3-day field training at the Maternal and Child Health Training Institute (MCHTI) inAzimpur, Dhaka, and in slums and villages nearby.

In the second stage, the training of the RFAs was conducted in six divisions in BRAC Training andResource Centers (TARC) located in Rangamati, Comilla, Srimangal, Bogra, Jessore, Barisal andMymensingh. The previously trained supervisors and QC officers acted as trainers in conducting thesesessions for the RFAs together with other resource persons from BRAC, BBS, HKI and UNICEF. TheRFAs were trained to take anthropometric measurements, and to determine the date of the LMP andexpected data of delivery (EDD). The training included a 3-day classroom session (including one-daytraining on infant anthropometric measurements) and a 4-day field training in the hospital and in thecommunity. The training was conducted in batches of 15 RFAs.

2.6 Data collection

Birth weight data were collected between April 2003 and March 2004. The one-year duration of the surveywas proposed taking into account of possible seasonal fluctuation in the birth weight trend.


During the first few months of the data collection, the RFAs visited all 300 households in their assignedclusters every month (approximately 10 households per day) to identify any new pregnant women. TheRFAs listed all women who had missed at least two menstrual periods and considered themselves to bepregnant or possibly pregnant. The expected date of delivery (EDD) was calculated from the LMP. Allpregnant women were registered for pregnancy follow-up using the "Pregnant Woman's Registration andNewborn's Information Card" (Annex 2). Copies of this card were kept with both the pregnant woman andthe RFA.

The "Prepartum Questionnaire" (Annex 2) was administered by the supervisor at the enrolment of eachpregnant woman in the survey. It was used to record information on the age, educational attainment,reproductive history and anthropometric measurements (weight, height and mid-upper arm circumference)of each pregnant woman, and on her household's demography and socio-economic status. TheUNISCALE (Seca, Hamburg, Germany) was used to measure weight to the nearest 100 g. Height wasmeasured using a wooden height scale to the nearest 1 cm. Mid-upper arm circumference (MUAC) wasmeasured using MUAC tapes to the nearest 0.1cm.

RFAs visited each pregnant woman in their homes at least once a month during the early stages ofpregnancy, and 2-4 times a month as the pregnancy advanced. During each visit, the RFAs collectedpregnancy-related information using the "Pregnant Woman's Registration and Newborn's InformationCard". It contained information on the date of the last menstrual period and expected date of delivery; amonthly record on antenatal care received, micronutrient supplementation taken, food intake, andperceived physical and mental health condition of the pregnant woman; and the delivery plan (where thewoman planned to give birth). The card also served as a record of the number of visits made by the RFAand the supervisor to the pregnant women during the pregnancy.

Each pregnant woman was given a "Notification card", which indicated her name, address and otherinformation needed to locate the woman as soon as she delivered. After consultation with the familymembers, one person from each household was entrusted with the responsibility of informing the RFAabout the birth immediately after delivery. The informant was financially compensated for his/her work.This birth notification system ensured that the RFAs were notified promptly about the birth to maximizethe number of birth weight measurements that were taken within 72 hours of the birth. In addition, RFAswere encouraged to visit pregnant women at least every other day when they were close to their EDD. Assoon as the RFA was informed about a birth, she went to the place of birth to measure the weight andlength of the newborn.

Birth weights and lengths were measured by the RFA using standard anthropometrical proceduresdescribed by Frisancho (1990). Birth weights were measured using either a Seca baby scale (Seca Model345 or 346, Hamburg, Germany) to the nearest 10 g, or a UNISCALE to the nearest 100 g. The recumbentlength of the newborns was measured to the nearest 0.1cm with a length measuring mat. It was onlypossible to collect birth length data in 90 of the 107 clusters due to shortage in the availability of the lengthmeasuring mats.

After the delivery, the "Pregnant Woman's Registration and Newborn's Information Card" was used by theRFA to record information on the delivery, including the date, time and place of delivery; the sex, weight,length, and perceived health condition of the newborn. The "Postpartum Questionnaire" (Annex 2) wasadministered by the supervisors to record additional information on the pregnancy and delivery of thenewborn, such as complications during pregnancy, delivery and in the postpartum period, food intake andmicronutrient supplementation during pregnancy, and anthropometric measurements of the woman(weight, height and MUAC).


All weighing scales were checked by RFAs using standard weights immediately before anthropometricmeasurements were taken. Supervisors also checked the weighing scales during each visit to a RFA.Malfunctioning scales were reported to BBS and replacements were promptly sent to the RFAs.

The three types of questionnaires used in the survey (Pregnant Woman's Registration and Newborn'sInformation Card, Prepartum Questionnaire, and Postpartum Questionnaire) were first prepared inEnglish, then translated into Bangla after finalization. All questionnaires were pre-tested at the communitylevel in urban slums and villages prior to finalization.

To obtain local community support for the survey, appraisal meetings were arranged with the local elitessuch as the Upazila Statistical Officers, Upazila Health and Family Planning Officers, Health Assistants,Family Welfare Assistants, NGO staff, religious leaders and school teachers. They were informed aboutthe objectives of the survey, the issue of LBW, and the importance of obtaining the prevalence of LBWfor future policy planning to reduce LBW and improve child health.

2.7 Monitoring and quality control

A number of activities were carried out to ensure the quality of the data. The work of the RFAs was closelymonitored by the supervisors, while the overall quality of data collection was monitored by a QC officerand a Field Manager. A detailed work plan for quality control activities was prepared prior to the fieldactivities.

The supervisors visited each RFA twice each month and compiled a monthly report, which was submittedto the QC Officer and the Field Manager. All supervisors met once a month in a meeting at the BRACHead Office in Dhaka to review the questionnaires collected during the previous month, and to resolve anyissues encountered during data collection. These meetings also provided refreshers' training.

During the entire data collection period, the QC officer visited the clusters frequently and randomly andmonitored the activities of the RFAs and supervisors. The QC officer traveled independently from theRFAs and supervisors, and directly reported to the Project Coordinator at Dhaka Head Office. During fieldvisits, the QC officer checked the accuracy of the weighing scales and the measurement procedurespracticed by the RFAs. He kept records and shared any issues with the field staff for necessary correctionand follow-up. The QC Officer reviewed monthly reports compiled by the supervisors and followed-upany concerns that they raised. The Dhaka-based Project Coordinator was regularly informed of all issues,and provided support for improvement or solution, as necessary.

The Field Manager, based in Dhaka, monitored and coordinated all the field data collection activities andtraveled to field locations when any major corrective measures were needed. The Field Manager compiledall the monthly reports submitted by the supervisors and reported to the Project Coordinator.

The research team at BRAC and the officials from BBS and UNICEF kept a close watch on the progressand quality of the work. Experts from BBS and UNICEF randomly visited clusters to monitor the qualityof data collection. The progress of the field activities and any constraints encountered were discussed withBBS and UNICEF regularly, and suggestions and solutions were provided.


2.8 Core Expert Group

A Core Expert Group (CEG) was formed in January 2002 by the Planning Division and met four times toprovide technical input to the survey. The group was chaired by the Secretary, Planning Division, Ministryof Planning, and comprised individuals and institutions with expertise in LBW and related fields includingthe Planning Division, Directorate General of Health Services (DGHS), BBS, Institute of Public HealthNutrition (IPHN), UNICEF, HKI, BRAC, Institute of Food and Nutrition Sciences (INFS), Institute ofStatistical Research and Training (ISRT) and ICDDR/B. The list of members is provided in Annex 3 (A).Prior to the survey, the CEG reviewed and finalized the survey methodology, including the questionnairesand implementation plan. During the survey, the CEG advised the survey team whenever technicalguidance was needed. The CEG also reviewed the findings of the draft report and provided suggestionsand recommendations for the finalization of the report. In addition to the formal meetings, a number ofinformal meetings and exchanges took place where individual members of the CEG were consulted onspecific issues.

2.9 Technical Committee

As per the Technical Assistance Project Proforma (TAPP) of the Monitoring the Situation of Children andWomen Project of BBS, a Technical Committee was formed to officially approve the survey, following therecommendation made by the CEG, and to review the findings of the draft report and provide commentsfor finalization of the report. The members included officials from Directorate General of Health Service(DGHS), Planning Commission, Economic Relations Division (ERD), Implementation Monitoring andEvaluation Division, Department of Public Health Engineering (DPHE), Directorate of Primary Education(DPE), Department of Women Affairs (DWA), ISRT, Planning Ministry's Statistics Wing, BBS, andUNICEF. The list of members is provided in Annex 3 (B).

2.10 Ethical considerations

Ethical clearance was obtained by BBS from the Bangladesh Medical Research Council (BMRC), theresponsible department of the government of Bangladesh. Verbal informed consent was obtained fromeach household head and respondent for taking the weight and length of newborns. All surveyed pregnantwomen were given a one-month supply of iron-folate supplements free of cost after delivery. AnEmergency Obstetric Care (EOC) Card, which describes the five danger signs of pregnancy and deliveryand provides key health and nutrition messages, was also distributed to all pregnant women at enrollment.

2.11 Data processing and analysis

All questionnaires were reviewed for completeness and consistency by the field staff, QC Officers, andthe Dhaka-based survey staff before submission for processing. All forms were then edited and codedmanually by professional coders at the Coding Section of BRAC. One trained data entry supervisorsupervised the data entry and processing at the Data Processing Unit of BRAC. Data were analyzed withSPSSWIN Version 10.0. Significance tests were conducted to analyze whether a difference betweengroups of samples was statistically significant. Differences were considered significant at P<0.05.

In order to calculate the national prevalence of LBW, rural divisional and urban weights were applied. Theweighting factors for each rural division and for urban areas were determined by dividing the estimatednumber of pregnant women in each rural division/urban area by the surveyed number of women. Theestimated number of pregnant women was calculated by multiplying the percentage of households with a


pregnant women in rural each division/urban area (as observed from the clusters surveyed) by the numberof households (from the 1991 and 2001 population census) in each division/urban area.

2.12 Limitation of the survey and adjustment of prevalence data

The survey originally planned to measure all birth weights using the Seca baby scales (SECA Models 345and 346), which have a precision of 10 g. However, a number of Seca scales became malfunctional duringthe course of the survey and were replaced with UNISCALES (precision 100 g). Overall, 56% of validbirth weights (birth weights taken within 72 hours of delivery) were measured with Seca baby scales and44% were taken with UNISCALEs. As the UNISCALE has a precision of 100 g, it rounds weights ofbetween 2,450 g and 2,490 g up to 2,500 g, and therefore underestimates the prevalence of LBW. Annex1 explains how the LBW prevalence data collected using the UNISCALE were adjusted to provide a moreaccurate estimate of the LBW prevalence.


3.1 Pregnancies detected and birth weights recorded

Table 3.1 shows that of the 4,414 pregnancies identified during the survey, there were 76abortions/miscarriages, 186 stillbirths, 331 were lost to follow-up and 3,843 live births. Urban areas hadhigher loss-to-follow-up than rural areas, possibly because urban mothers change their residence morefrequently. Of the 3,843 live births, the birth weights of 3,085 newborns (80.3%) were measured within72 hours of delivery and were included in the analysis of birth weight measurements. Of the remainder,321 birth weights were taken after 72 hours of delivery and excluded from analysis, and 437 birth weightscould not be taken for various reasons, including migration, non-consent and neonatal deaths.

Table 3.1: Pregnancies identified and birth weights measured in the survey

BW = Birth weight; BSL = Barisal; CTG = Chittagong; DHA = Dhaka; KHL = Khulna; RAJ = Rajshahi; SYL = Sylhet

The background and maternal characteristics of infants whose birth weight was measured within 72 hrswere compared with those of infants whose birth weights were not measured within 72 h to examinewhether the drop-outs were biased (see Annex 5). The latter group includes both pregnancies that werelost to follow-up and infants whose birth weight was taken after 72 hrs. The comparison showed that drop-outs tended to be of slightly higher socio-economic status than non-drop-outs, as indicated by parentaleducation level, land ownership, household assets, household expenditure and construction materials ofhome. Mothers of drop-outs were slightly younger, were more likely to report eating more duringpregnancy, were more likely to have had an antenatal visit and to take iron supplements than non-drop-outs. They were also much more likely to be pregnant for the first time (42% vs. 27%). It is difficult todraw conclusions from this comparison, as risk factors for low birth weight (low socio-economic status,young age, restriction of food intake, lack of antenatal care, lack of use of iron-supplements, andprimgravidae) are split amongst both groups.


3: CHARACTERICS OF THE MOTHERS ANDTHEIR HOUSEHOLDS

Indicator Rural (by Division)Urban NationalBSL CTG DHA KHL RAJ SYL Total

Pregnancies identified 660 645 656 54 9 501 905 3916 498 4414- Abortion/miscarriage 16 10 10 9 10 14 69 7 76- Still birth 18 20 26 24 15 62 165 21 186- Lost of follow up 43 43 46 49 22 57 260 71 331Live birth 584 577 579 467 456 779 3442 401 3843- Live birth single 582 567 569 467 452 765 3402 397 3799- Live birth multiple 2 10 10 0 4 14 40 4 44 BW taken within 72 hrs 490 466 409 353 402 654 2774 311 3085- BW taken after 72 hrs 29 66 78 25 11 75 284 37 321- Live birth but weight not

taken 65 45 92 89 43 50 384 53 437

3.2 Demographic and socio-economic characteristics of the households

The demographic and socio-economic characteristics of the sampled households are presented in Table3.2. The mean household size was 5.4, which is comparable to the 2001 Population Census (BBS, 2003),with 28% of households having 7 or more family members. The proportion of female-headed householdwas 3%, urban areas having a higher percentage (7%) than rural areas (3%). Only 25% of rural householdshad electricity, 19% had an electric fan and 14% had a television, while in urban households thecorresponding figures were 76%, 65% and 44%. Large differences were also seen in sanitation facilities:40% of urban households had a water-seal latrine, compared with only 14% of rural households. Despitethese differences, the two areas were remarkably similar in perceived household economic status.

Table 3.2: Demographic and socio-economic characteristics of the households a

(Cont.)


Indicator Rural (n=2,740)

Urban (n=306)

National(n=3,046)

Mean household size (persons) 5.5 4.9 5.4

Household size (%)<4 persons4-6 persons7+ persons

23.448.028.6

30.449.719.9

24.348.227.5

Female headed household (%) 3.0 6.5 3.4

Educational level of father (%)IlliterateCan sign onlyPassed I-VPassed VI-IXPassed SSC and above

22.726.920.917.711.8

17.022.223.515.721.6

21.926.321.217.513.1

Main occupation of father (%)Professional, technical, administration and managerial Clerical, sales, service, production and retailed workersand transport workers Agricultural, animal husbandry, forestry and fisheries Others (unemployed, beggar, disabled, retired etc.)

5.546.9

45.71.9

4.274.8

17.33.6

4.274.8

17.33.6

Cultivable land owned by the household in acres (%)Landless0.01-0.991.00-1.99≥2.00

45.531.011.512.1

77.115.73.93.3

49.629.010.510.9

Household assets (%)Bed (Khat)ElectricityElectric fanTelevision

31.225.119.313.9

44.476.165.043.8

33.031.825.317.8

Household expenditure on shoes in last year/person (%)<100 Tk≥100 Tk

66.433.6

45.854.2

63.736.3

Material of roof of house (%)TinCement (Pucca) Other (Chon, Bamboo, Polythene, Wood, Golpata)

82.22.1

15.8

82.413.73.9

82.23.6

14.2

a Includes households of infants whose birth weights were measured within 72 hr of birth. Households of twin infants were counted twice.

3.3 Background characteristics of the pregnant women

The mean age of the pregnant women at enrolment in the survey was about 25 years, with one-fifth (21%)less than 20 years (Table 3.3). Most of the women married when they were less than 18 years (74%).About one-quarter (24%) were illiterate and almost all (97%) were housewives. The current pregnancywas the first pregnancy among 28% of the women.

Table 3.3: Background characteristics of the pregnant women a



Urban (n=306)

National(n=3,046)

Material of floor of house (%)EarthCement (Pucca)Other (Bamboo, Wood)

94.35.30.4

55.642.52.0

89.310.10.6

Type of latrine (%)Water sealPitHanging and Open

13.934.851.3

39.538.222.2

17.335.247.5

Perceived economic status of household (%)SurplusEqualDeficit

31.331.537.2

31.729.139.2

31.431.237.4


Urban(n=306)

National(n=3,046)

Mother's age in years (mean ±SD) 24.6 (5.9) 24.9 (5.6) 24.6 (5.9)Mother's current age in years (%)

<2020-34≥35

21.870.47.8

16.076.17.8

21.171.17.8

Age at first marriage in years (%)<18 18-24 ≥25

73.925.50.5

70.329.10.7

73.526.00.5

Educational level of the pregnant women (%) IlliterateCan sign onlyPassed I-VPassed VI-IXPassed SSC and above

25.421.024.823.25.6

18.022.225.523.211.1

24.421.224.923.26.3

Main occupation of the pregnant women (%)HousewifeWorking outside the home

97.62.4

91.58.5

96.83.2

Number of pregnancies including the present pregnancy (%)12-5≥6

27.760.212.0

25.867.66.5

27.561.211.3

Number of previous spontaneous abortions/ miscarriage (%)01≥2

87.99.32.8

85.312.12.6

87.59.72.8

a Includes mothers of infants whose birth weights were measured within 72 hr of birth. Mothers of twin infants were counted twice.

3.4 Health, nutrition and care during pregnancy

Table 3.4 shows that the average height of the women was 149.9 cm, with 16% being less than 145 cm,an indicator of chronic malnutrition and risk factor for obstructed labor. Only 13% of the women werebreastfeeding a child at the time of enrollment in the survey.

The most common complications that pregnant women reported between 6 months of pregnancy anddelivery included fever (40%), edema (34%) and vomiting (28%). Only 30% women made any antenatalvisits during pregnancy, the percentage being much less in rural areas (27%) than in urban areas (51%).Similarly, only 26% of rural mothers took iron supplements during pregnancy compared with 48% inurban areas. Common reasons for not taking iron supplements were 'Not available' (48%) and 'Notnecessary' (27%). Only 16% of women reported that they ate more during pregnancy and as many as 43%reported that they reduced their food intake.

Table 3.4: Health, nutrition and care during pregnancy a



Urban (n=306)

National(n=3,046)

Height in cmMean ± SD 149.9+5.1 1149.9+5.1 149.9+5.1

Height in cm (%)<145 cm 16.1 13.4 15.7

Currently breastfeeding (%)YesNo /no child

12.987.1

9.790.3

12.587.5

Any complication between 6 months of pregnancy anddelivery (%)

FeverEdemaVomitingBleedingNone

39.834.128.74.5

24.1

38.134.825.43.3

18.7

39.634.228.34.3

23.4

Took adequate rest during pregnancy (%) 84.2 93.3 85.4Amount of food taken during pregnancy (%)

More than normalSame as usualLess than normal

15.041.243.8

20.738.840.5

15.740.943.4

Antenatal visits during pregnancy (%) 26.6 51.2 29.8

Iron supplements taken during pregnancy (%) 26.0 47.5 28.8Duration of taking iron supplements (%)

Never taken <1 month1-3 months4 months and more

74.06.9

12.26.7

52.512.719.115.7

71.27.6

13.17.9

From which month in pregnancytook iron supplements (%)

Never taken≥3rd month4-6th month7-9th month

74.05.4

12.48.1

52.511.022.713.7

71.26.1

13.88.9

(Cont.)

a Includes mothers of infants whose birth weights were measured within 72 hr of birth. Mothers of twin infants were counted twice.

3.5 Delivery

Ninety three percent (93%) of births took place at home (Table 3.5). The proportions of caesarian andother types of deliveries were higher in urban areas (11%) than in rural areas (3%). In rural areas, 50% ofthe deliveries were assisted by neighbors/relatives, followed by untrained (30%) and trained (13%)traditional birth attendants (TBAs); only 7% cases were assisted by doctors/nurses. In urban areas, 20%of deliveries were assisted by doctors/nurses and 32% were assisted by neighbour/relatives. One quarter(25%) of all women experienced prolonged labor (>12 hours).

Table 3.5: Place of delivery, type of delivery, assistance and complications during delivery a

a Includes deliveries of infants whose birth weight were measured within 72 hr of birth. If a delivery resulted in twin infants, it was counted twice.



Urban (n=306)

National(n=3,046)

Source of iron supplements (%)Government hospital, clinic, FWA, HA or FWVPharmacyNGO

35.048.516.5

23.948.627.5

32.648.518.9

Reason for not taking iron supplements (%))Not available Not necessary Side effects Don't know

48.626.08.6

16.8

44.633.812.78.9

48.326.79.0

16.0


Urban (n=299)

National(n=2,967)

Place of delivery (%)Government hospital/clinicPrivate hospital/clinic Home

2.92.8

94.3

11.96.8

81.4

4.13.3

92.6Type of delivery (%)

NormalCaesarian and other

97.52.5

88.611.4

96.33.7

Who assisted the delivery (%)Doctor, nurse or FWATrained TBAUntrained TBANeighbor, relative or others

7.012.930.050.1

20.418.428.832.4

8.813.629.847.8

Any complication during delivery (%)Prolonged labor (>12 hrs)BleedingNone

25.016.938.9

21.710.744.5

24.616.139.6

4.1 Pregnancy outcomes and care of newborns

Table 4.1 shows that 15% of births were pre-term (premature) births (<37 gestation weeks). Less than 1%of births were twins or other multiple births. The sex ratio of the newborn boys to girls was 1.00:0.98.Twenty-eight percent (28%) of mothers perceived that their children were small at birth, and 9% perceivedthat the health of their infant was bad. Breastfeeding was initiated within 4 hours of birth by almost 50%of mothers in both rural and urban areas and by a further 25% of mothers between 4-23 hours. Pre-lactealfoods were given to about two-thirds (65%) of infants.

Table 4.1: Pregnancy outcomes and care of newborns a

a Includes infants whose birth weights were measured within 72 hr of birth.

4.2 Birth weight

The mean birth weight in Bangladesh was 2,632 g (Table 4.2). Boys were significantly heavier than girlsby 66 g (2,665 g vs. 2,599 g; P=0.005). The mean birth weight in rural areas was significantly lower by76 g than in urban areas (2,622 g vs. 2,698 g; P=0.001). In rural areas, the mean birth weight ranged from2,577 g in Dhaka Division to 2,721 g in Chittagong Division.


4. BIRTH WEIGHT AND LENGTH


Urban (n=311)

National(n=3,085)

Gestation at delivery (%)<37 weeks (pre-term)≥37 weeks (full-term)

15.884.2

11.688.4

15.384.7

Outcome of pregnancy (%)Single babyMultiple babies

99.40.6

99.30.7

99.30.7

Sex of child (%)BoyGirl

50.449.6

50.849.2

50.549.5

Mother's perception of size of infant at birth (%)BigNormalSmall

29.242.628.2

27.144.528.4

28.942.828.2

Mother's perception on infant's health (%)GoodNormalBad

65.226.08.8

74.219.46.4

66.425.18.5

Pre-lacteal food given to the infant (%) 65.7 61.9 65.2

Initiation of breastfeeding in hours after delivery (%)<44-2324-71>72

49.025.018.57.4

51.921.118.48.6

49.424.518.57.6

Table 4.2: Mean birth weight by sex and division a

a Includes infants whose birth weights were measured within 72 hr of birth. b Divisional data include rural data only.

Table 4.3 shows that the prevalence of LBW in Bangladesh was 36%. The prevalence was significantlyhigher among girls (38%) than boys (33%) by five percentage points (P=0.002), and was significantlyhigher in rural areas (37%) than urban areas (29%) by eight percentage points. In rural areas, theprevalence ranged from 28% in Chittagong Division to 44% in Dhaka Division.

Table 4.3: Prevalence of LBW by sex and division a

a Includes infants whose birth weights were measured within 72 hr of birthb Data are adjusted for the low precision of UNISCALEs (see Annex 1)c Divisional data include rural data only.

Table 4.4 shows that the prevalence of very low birth weight (VLBW <1,500 g) was <1%. The majorityof the newborns (62%) had birth weights between 2,500 g and 3,499 g, and about 2% had a birth weightof more than 3,500 g.


IndicatorMean (±SD) birth weight (g)

Rural (n=2,774)

Urban (n=311)

National(n=3,085)

All 2,622 (439) 2,698 ( 389) 2,632 (433)

Sex Girls Boys

2,589 (433)2,655 (442)

2,663 (327)2,731 (438)

2,599 (421)2,665 (442)

Division b Barisal ChittagongDhakaKhulnaRajshahiSylhet

2,620 (429)2,721 (472)2,577 (432)2,635 (425)2,606 (409)2,610 (458)

IndicatorPrevalence of LBW (birth weight <2,500 g)a,b

Rural (n=2,774)

Urban (n=311)

National(n=3,085)

All 36.7 29.0 35.6

Sex Girls Boys

38.834.4

31.426.6

37.933.3

Divisionc Barisal ChittagongDhakaKhulnaRajshahiSylhet

38.728.043.735.537.337.6

Table 4.4: Distribution of birth weights by sex and area of residence a, b

a Includes infants whose birth weights were measured within 72 hr of birthbData are adjusted for the low precision of UNISCALEs (see Annex 1)

4.3 Birth length

The mean birth length in Bangladesh was 48.5 cm (Table 4.5). There was no significant difference betweenthe birth length of boys and girls, or between the birth length in rural and urban areas.

Table 4.5: Mean birth length by sex and division a

a Includes infants whose birth weights were measured within 72 hr of birthb Divisional data include rural data only.


Birth weight (g)Rural (%) Urban (%) National (%)

Boy(n=1,390)

Girl (n=1,384)

Total (n=2,774)

Boy (n=158)

Girl (n=153)

Total (n=311)

Boy (n=1,548)

Girl (n=1,537)

Total (n=3,085)

<1500 0.7 0.8 0.7 0.7 0.0 0.4 0.7 0.7 0.7 1500-2499 33.4 38.1 36.0 25.9 31.4 28.6 32.6 37.2 34.92500-3499 63.1 59.6 61.2 67.3 66.9 67.1 63.6 60.6 62.1≥3500 2.7 1.5 2.1 6.1 1.7 3.9 3.1 1.6 2.3

IndicatorMean (±SD) birth length in cm

Rural (n=2,255)

Urban (n=264)

National(n=2,519)

All 48.4 (4.0) 49.2 (2.7) 48.5 (3.9)

Sex Girls Boys

48.1 (4.6)48.6 (3.3)

49.2 (2.3)49.2 (3.1)

48.2 (4.4)48.7 (3.3)

Division b Barisal ChittagongDhakaKhulnaRajshahiSylhet

48.3 (3.1)49.3 (2.9)47.7 (4.6)48.8 (3.1)48.6 (3.8)48.9 (3.9)

During the survey, information was collected on household demography, socio-economic status andmaternal characteristics, including reproductive history, nutritional status, morbidity during pregnancy,and care during pregnancy. Statistical analysis was performed to see whether these factors were associatedwith birth weight, the prevalence of LBW and birth length. The analysis used the entire national dataset,since the sizes of each division's dataset and the urban dataset were too small. Except where otherwisestated, the LBW data in this chapter are not adjusted for the low precision of UNISCALEs.

5.1 Household demography and socio-economic status

Table 5.1 shows that the mean birth weight was higher among households with higher socio-economicstatus, as indicated by the father's education level, household assets and household expenditure. Birthweight increased with increasing education level of the father; was significantly lower among children ofunskilled fathers than skilled/professional fathers; was higher among households with assets such as aKhat bed, electricity, electric fan, television, water seal latrine, and houses made with a cement roof, non-earth floor than those without these assets; and was significantly higher among households spending atleast Tk 100/person last year on shoes and those that perceived themselves to be surplus in householdeconomy. Birth length was also higher among households with higher socio-economic status, as indicatedby the father's education level, household assets and household expenditure. The results for the prevalenceof LBW were a inverse of these findings, with the prevalence being significantly lower among householdswith higher socio-economic status. The sex of household head and the amount of cultivable land were notassociated with birth weight, birth length or LBW.

Table 5.1: Birth weight, LBW and birth length by household demographic and socio-economiccharacteristics a, b


5. ASSOCIATIONS OF BIRTH AND LENGTH

Indicator

Birth weight(n=3,046)

Birth Length(n=2,482)

Mean ing(±SD)

LBWc(%)

Mean in cm(±SD)

Household size<44-67+

2,634 (423)2,634 (409)2,636 (476

33.733.633.6

48.5 (3.2)48.4 (4.1)48.6 (4.0)

Head of householdWomanMan

2,633 (433)2,666 (400)

28.633.8

48.5 (3.9)48.1 (3.6)

Educational level of fatherIlliterateCan sign onlyPassed I-VPassed VI-IXPassed SSC and above

2,568 (409)2,627 (408)2,636 (442)2,655 (459)2,732 (440)

***

39.433.633.631.327.0

**

47.8 (5.3)48.4 (3.1)48.6 (3.1)48.8 (3.2)49.0 (4.4)

**

(Cont.)


Indicator



Mean ing(±SD)

LBWc(%)

Mean in cm(±SD)

Main occupation of fatherProfessional, technical, administration and managerialClerical, sales, service, production and retailed workersand transport workers Agricultural, animal husbandry, forestry and fisheries Others (unemployed, beggar, disabled, retired etc.)

2,745 (378)

2,662 (445)2,590 (418)2,564 (394)

***

22.5

31.737.139.5***

49.3 (3.1)

48.6 (3.5)48.2 (4.4)48.2 (3.4)

**Cultivable land owned by HH in acres

Landless0.01-0.991.00-1.99≥2.00

2,635 (438)2,636 (409)2,642 (406)2,617 (482)

33.633.532.834.9

48.4 (3.6)48.5 (4.8)48.5 (2.9)48.6 (3.2)

Household assets Bed (Khat)YesNo

2,697 (450)2,604 (419)

***

29.535.6**

48.9 (3.7)48.2 (3.9)

**Electricity

YesNo

2,696 (435)2,606 (427)

***

26.936.7***

49.0 (2.8)48.0 (4.3)

***Electric fan

YesNo

2,699 (437)2,613 (428)

***

27.535.7***

49.1 (2.7)48.3 (4.2)

**Television

YesNo

2,725 (454)2,615 (424)

***

25.735.3***

49.1 (4.1)48.3 (3.8)

**Household expenditure on shoes in last year/person

<100 Tk≥100 Tk

2,602 (416)2,692 (451)

***

36.328.9***

48.1 (4.3)49.1 (3.0)

*** Material of roof of house

TinCement (Pucca)Other

2,632 (430)2,799 (439)2,604 (432)

***

33.522.437.0***

48.3 (3.9)50.3 (2.5)48.8 (3.7)

**Material of floor of house

EarthCement (Pucca)Other

2,623 (430)2,730 (443)2,768 (258)

***

34.526.613.4***

48.3 (4.0)49.5 (2.8)49.7 (1.8)

**Type of latrine

Water sealPitHanging and open

2,707 (434)2,638 (446)2,606 (416)

***

26.532.237.2***

49.0 (3.0)49.0 (3.6)48.1 (4.3)

**Perceived economic status of HH

SurplusEqualDeficit

2,692 (439)2,611 (436)2,606 (417)

***

29.335.935.4**

49.1 (3.0)48.3 (4.5)48.1 (3.9)

***a Includes infants whose birth weights were measured within 72 hr of birthb P value: *= <0.05, **= <0.01, and ***= <0.001.c LBW data not adjusted for the low precision of UNISCALEs

5.2 Background characteristics of pregnant women

Table 5.2 shows that mean birth weight and length were significantly higher among women currently aged20-34 years than those aged <20 years or ≥35 years. Birth weight and length increased significantly withthe educational level of the mother and were significantly higher among women with 2-5 previouspregnancies than primigravidae (women who had no previous pregnancies) and mothers with 6 or moreprevious pregnancies. The findings for LBW prevalence were the inverse of mean birth weight. Birthweight and length were not associated with the mother's age at first marriage, the main occupation of themother or the number of previous spontaneous abortions/miscarriages.

Table 5.2: Birth weight, LBW and birth length by background characteristics of mothers a, b

a Includes infants whose birth weights were measured within 72 hr of birthb P value: *= <0.05, **= <0.01, and ***= <0.001.c LBW data not adjusted for the low precision of UNISCALEs

5.3 Health, nutrition and care during pregnancy

Table 5.3 shows that infants of taller women (>145 cm) were heavier, less likely to be of LBW and longerthan those of shorter women (<145 cm). Infants were also more likely to be heavier, less likely to be ofLBW and longer if their mother had made one or more antenatal visits during pregnancy and if the motherperceived that she was able to take adequate rest during pregnancy. Surprisingly, mean birth weight washighest among mothers who said that they ate less than normal during pregnancy, followed by those who


Indicator



Mean ing(±SD)

LBWc(%)

Mean in cm(±SD)

Mother's age in years>2020-34≥35

2,552 (434)2,663 (428)2,595 (428)

***

37.731.938.4

*

48.1 (3.1)48.6 (4.1)48.3 (2.9)

*Age at first marriage in years

< 18 years18-24 years≥25 years

2,627 (427)2,651 (439)2,844 (598)

33.733.527.3

48.4 (3.5)48.7 (4.8)49.9 (2.3)

Educational level of the pregnant womenIlliterateCan sign onlyPassed I-VPassed VI-IXPassed SSC and above

2,588 (407)2,602 (427)2,624 (431)2,682 (451)2,793 (418)

***

37.736.633.729.123.8***

48.0 (5.0)48.2 (3.1)48.7 (4.1)48.6 (3.1)49.9 (2.8)

***Main occupation of the pregnant women

HousewifeWorking outside

2,633 (431)2,687 (445)

33.730.1

48.5 (3.9)48.7 (2.6)

Number of pregnancies including the present pregnancy 12-5≥6

2,566 (440)2,674 (419)2,585 (453)

***

38.330.538.8***

48.1 (3.9)48.7 (3.6)48.1 (5.1)

**Number of previous spontaneous abortions/ miscarriages

01≥2

2,636 (429)2,636 (412)2,565 (557)

33.433.342.6

48.5 (3.9)48.6 (3.4)48.7 (3.3)

ate more than usual, but these findings were not reflected in the LBW findings: the prevalence of LBWwas lowest amongst women who ate more than normal during pregnancy than those who ate the same orless than usual, but the differences between these categories were not significant.

Intake of iron supplements during pregnancy was significantly associated with higher birth weight andbirth length and a lower prevalence of LBW. Birth weight and length decreased with increasing gestationalage at the start of iron supplementation and increased with the duration of iron supplementation.

There was no association between birth weight or length and the breastfeeding status of the mother duringpregnancy.

Table 5.3: Birth weight, LBW and birth length by health, nutrition, and care during pregnancy a, b



Indicator



Mean in g(±SD)

LBW C

(%)Mean in cm

(±SD)Height (cm)

<145 ≥145

2,559 (407)2,650 (435)

***

41.932.1***

48.0 (3.4)48.6 (4.0)

**Breastfeeding status of mother during pregnancy

YesNo / No child

2,644 (432)2,663 (424)

35.331.3

48.8 (3.0)48.6 (4.0)

Antenatal visits during pregnancy YesNo

2,724 (437)2,596 (423)

***

27.236.4***

49.1 (3.7)48.2 (3.9)

***Took adequate rest during pregnancy

YesNo

2,650 (431)2,542 (423)

***

32.142.9***

48.6 (3.6)47.7 (5.1)

***Amount of food taken during pregnancy


2,636 (437)2,607 (438)2,663 (419)

**

30.035.133.3

48.6 (2.9)48.7 (3.2)48.2 (4.8)

Iron supplements taken during pregnancy YesNo

2,702 (423)2,607 (431)

***

28.535.8***

49.2 (3.7)48.2 (3.9)

***Duration of taking iron supplements during pregnancy

Never taken <1 month1 - 3 months4 months and more

2,607 (431)2,629 (414)2,699 (428)2,774 (418)

***

35.840.224.624.4***

48.2 (3.9)48.9 (2.8)49.1 (4.5)49.7 (2.8)

***From which month in pregnancy took iron supplements

Never taken<3rd month4-6th month7-9th month

2,607 (431)2,784 (450)2,705 (426)2,640 (391)

***

35.824.326.135.1***

48.2 (4.0)49.6 (2.9)49.1 (4.5)48.9 (2.6)

***

5.4 Sex, gestational age, place and season of delivery

Table 5.4 shows that infants were more likely to be smaller and shorter if they were girls, born prematurely(<37 weeks gestation) and born in rural areas. LBW prevalence was higher in the Rainy and Autumnseasons (36%-37%) than in the Winter and Spring seasons (30%-31%). However, LBW was notsignificantly associated with seasonality.

Over one-fifth (23%) of LBW infants were preterm, compared with 11% of normal weight infants (datanot shown). The remaining 77% LBW infants were full-term, which indicates they were small due toIUGR. Some of the preterm LBW infants may have been growth retarded as well as preterm. Thisconfirms that the majority of LBW infants in Bangladesh are small due to IUGR.

Table 5.4: Birth weight, LBW and birth length by sex, gestational age, place and season of delivery a,b

a Includes infants whose birth weights were measured within 72 hr of birthb P value: *= <0.05, **= <0.01, and ***= <0.001.c LBW data are adjusted for the low precision of UNISCALEsd LBW data not adjusted for the low precision of UNISCALEs


IndicatorBirth weight

(n=3,046)Birth Length

(n=2,482)Mean in g

(±SD)LBWc

(%)Mean in cm

(±SD)Sex of infant c

GirlBoy

2,599 (421)2,665 (442)

***

37.933.3

**

48.2 (4.4)48.7 (3.3)

***

Gestation at delivery d<37 weeks (pre-term)≥37 weeks (full-term)

2,415 (489)2,671 (410)

***

52.430.3***

46.9 (5.9)48.8 (3.3)

***

Location of delivery cUrban Rural

2,698 (389)2,622 (439)

**

29.0 36.7

**

49.2 (2.7)48.4 (4.0)

**

Divisional variation (rural data only) cBarisalChittagongDhakaKhulnaRajshahiSylhet

2,620 (429)2,721 (472)2,577 (432)2,635 (425)2,606 (409)2,610 (458)

**

38.728.043.735.537.337.6

*

48.3 (3.1)49.3 (2.9)47.7 (4.6)48.8 (3.1)48.6 (3.8)48.9 (3.9)

***Seasonal variation d

Winter (December-February)Spring (March-May) Rainy (June-August)Autumn (September-November)

2,653 (414)2,663 (419)2,609 (426)2,619 (456)

30.529.836.635.7

48.3 (3.3)49.1 (3.2)48.7 (2.9)48.2 (5.0)

**

5.5 Mother's perception on the size and health of her infant at birth

Table 5.5 shows that there was some, but not complete, agreement between mother's perception on the sizeof their infant and the infant's actual weight: 64% of infants described as 'small' by their mothers wereLBW, however 13% of infants described as 'big' and 28% of infants described as 'normal' were in factLBW. Mothers who described their infant's health as 'good' were heavier, longer and less likely to be LBWthan those who described their infant's health as 'poor'. The associations of both these perceptions withLBW are significant.

Table 5.5: Birth weight, LBW and birth length by mother's perception on the size and health of her infant a,b



Indicator



Mean in g(±SD)

LBW C

(%)Mean in cm

(±SD)Mother's perception of size of the infant at birth

BigNormalSmall

2,872 (385)2,665 (356)2,343 (413)

***

13.427.563.9***

49.6 (2.9)48.6 (4.0)47.2 (4.3)

***Mother's perception of infant's health

GoodNormalBad

2,692 (415)2,565 (404)2,423 (499)

***

28.840.049.8***

48.6 (4.2)48.2 (3.1)48.4 (3.7)

**

The findings of the National Low Birth Weight Survey, the first of its kind in Bangladesh, confirm thatLBW (<2,500 g) is a major public health problem in Bangladesh. Over one-third of infants (36%) hadLBW, a prevalence which is more than twice 15% threshold that indicates a public health problem. Lessthan 1% of infants were born with VLBW (<1,500 g).

The mean birth weight (2,632 g) is higher than findings from all previous small-scale studies inBangladesh (2,430 to 2,516 g) (Goodburn et al.; 1994; Arifeen et al., 2000; Shaheen et al., 2000), exceptone study in a government maternity hospital in Dhaka city (2,889 g) (Dhar et al., 2002). This may eitherbe a consequence of the national coverage of the present survey and/or may reflect progress made inreducing LBW in the country since the previous studies were conducted.

Fifteen percent (15%) of infants were preterm (<37 weeks). This data should be treated with cautionbecause the LMP dates of some women were not known with accuracy and were estimated.Notwithstanding, 15% is within the range reported by other small-scale studies in Bangladesh, whichrange from 10% (Canosa, 1989) to 17% (Arifeen, 2000). Only 23% of all LBW infants were pre-term,which means that remainder (77%) of LBW infants were growth retarded. Some of the preterm LBWinfants may have been growth retarded as well as preterm. This confirms that the majority of LBW infantsin Bangladesh are small due to IUGR.

The prevalence of LBW varied geographically, with urban areas having a lower prevalence (29%) thanrural areas (37%). There are many possible reasons why the LBW prevalence is highest in rural areas.Data from the Bangladesh Demographic and Health Survey show that the prevalence of maternalmalnutrition, which is linked with LBW, is higher in rural than urban areas (BDHS, 2001). A multitude ofother rural-urban differences, including socio-economic status, access to health and nutrition services andknowledge, attitudes and practices related to care of adolescent girls and women during pregnancy, mayalso explain the higher prevalence in rural areas. Furthermore, the incidence of pre-term delivery wasslightly higher in rural areas (16%) than in urban areas (12%). The LBW prevalence varied by over tenpercentage points between the six rural divisions, from 28% in Chittagong Division to 44% in DhakaDivision. The explanation for this divisional variation is not known.

Birth weight varied seasonally, with LBW prevalence being highest in the Rainy and Autumn seasons(June to November) and lowest in the Winter to Spring seasons (December to May). These seasonalvariations may reflect seasonal variations in the availability and access to food. In Bangladesh, the monthsof September to November are the 'lean' pre-harvest months, when agricultural work is difficult to find,while the variety and abundance of vegetables is greatest in Winter and early Spring.

Throughout the world, birth weight tends to be slightly higher among boys than in girls, and so the higherprevalence of LBW in girls (38%) than boys (33%) is not necessarily a cause of concern. Very few pregnantwomen in Bangladesh know the sex of their infant before birth and therefore they lack the opportunity tochange their behaviour during pregnancy according to the sex of the infant. The higher prevalence amonggirls is because the cut-off point for LBW is the same for all infants regardless of sex (2,500 g).

A large number of socio-economic and maternal factors were significantly associated with LBW. Lowbirth weight was more prevalent among households with lower socio-economic status as indicated by the


6. DISCUSSION

father and mother's education level, household assets and household expenditure. Previous studies inBangladesh and elsewhere in the world have also demonstrated that mothers who give birth to LBWinfants tend to have a lower level of education (Shoham-Yakubovich and Barell, 1988; Dhar et al., 2003)and are of lower socio-economic status (Dhar et al., 2003; Duckute et al., 2004) than those who give birthto normal weight infants.

Adolescent pregnancy (<20 years) and pregnancy at a late age ( ≥35 years) increased the risk of LBW, inagreement with the findings of previous studies in both developed and developing countries (Eisner et al.,1979; Lee et al., 1988; Tin et al., 1994; Dhar et al., 2003). In Bangladesh, many women marry asadolescents and become pregnant by the age of 18 years. Almost three-quarters (74%) of the pregnantwomen in the survey married when they were less than 18 years, one-fifth (21%) were currently less than20 years and 8% were at least 35 years. Low birth weight was also more likely if the mothers wereprimigravidae or multigravidae (≥6), which is linked, in part, to the age of the mother.

Short stature (<145 cm) was a risk factor for LBW, confirming earlier findings from a small scale study inDhaka (Das and Khanam, 1997). The risk of LBW was also lower among mothers who took ironsupplements during pregnancy. The risk of LBW decreased with the duration of iron supplementation andwas lowest among those who began supplementation in early pregnancy. Iron deficiency and anaemia areassociated with LBW (Allen, 2000; Rasmnssen, 2001), and therefore the use of iron supplements toprevent and control iron deficiency anaemia may result in higher birth weights in Bangladesh.

There was some, but not complete, agreement between mother's perception on the size of their infant andthe infant's actual weight: 64% of infants described as 'small' by their mothers were LBW, however 13%of infants described as 'big' and 28% of infants described as 'normal' were in fact LBW. These findingsindicate that some mothers do not have a realistic understanding of how large an infant should be at birth.The mean length of the infants at birth was found to be 48.5 cm. Birth length varied with socio-economicstatus, maternal characteristics and variables related to the birth in a similar pattern to birth weight.


7.1 Conclusions

The following conclusions are drawn from the survey:

1. The mean birth weight of infants in Bangladesh is 2,632 g and the mean birth length is 48.5 cm.

2. Low birth weight (<2,500 g) affects 36% of infants in Bangladesh, more than twice the 15%threshold that indicates a public health problem. Less than 1% of infants were born with very lowbirth weight (<1,500 g).

3. The prevalence of LBW was higher among girls (38%) than boys (33%). However, this finding isnot necessarily a cause for concern as birth weights throughout the world tend to be lower amonggirls than boys. The higher prevalence among girls is because the cut-off point for LBW is the samefor all infants regardless of sex.

4. At least 77% of LBW infants were growth retarded, confirming that IUGR is the major cause ofLBW in Bangladesh

5. The prevalence of LBW was found to be higher in rural areas (37%) than urban areas (29%). Otherrisk factors for LBW include low socio-economic status, low level of parental education, young (<20years) or old (≥35 years) maternal age, primigravidity, multigravidity, short stature, lack of antenatalcheck-ups and iron supplementation during pregnancy, pre-term delivery, and lack of adequate restduring pregnancy.

7.2 Recommendations

1. Because of the severity of the LBW problem in Bangladesh and its potential threat to the growth,health and survival of both children and adults, the prevention of LBW should be given immediatepriority in the future.

2. Integrated and complementary strategies are needed to address the major causes of LBW inBangladesh. Special attention should be given to health and nutrition of adolescent girls and womenbefore their first pregnancy and between pregnancies, as well as to pregnant women themselves. Asantenatal clinic attendance is low, there is need for community-based interventions that are accessibleto all.

3. An advocacy and behavioral communication change (BCC) campaign is needed to ensure that LBWprevention is given a high profile and accepted as important and necessary at all levels, includingpolicy makers, service providers, opinion leaders, community-based organizations, caregivers,adolescents and women of childbearing age and the wider public, and to create demand and behaviorchange for its prevention. Social and cultural practices that contribute to LBW, including earlymarriage leading to pregnancy at a young age and social practices affecting the quality and quantityof food consumed by girls and women, should be addressed.


7. CONCLUSIONS AND RECOMMENDATIONS

4. Where necessary, interventions studies and operational research should be conducted to identifyeffective new approaches to LBW prevention.

5. A LBW survey should be repeated every 5 years to measure progress towards the reduction of LBWin the country.


The survey originally planned to measure all birth weights using the Seca baby scales (SECA Models 345and 346), which have a precision of 10 g. However, a number of Seca scales became malfunctional duringthe course of the survey and were replaced with UNISCALES (precision 100 g). Overall, 56% of validbirth weights (birth weights taken within 72 hours of delivery) were measured with Seca baby scales and44% were taken with UNISCALEs.

As the UNISCALE has a precision of 100 g, it rounds weights of between 2,450 g and 2,490 g up to 2,500g, and therefore underestimates the prevalence of LBW. Table A1.1 shows that the mean birth weights ofmeasurements taken by these two scales differed by 62 g (Seca = 2,605 g; UNISCALE = 2,667 g). Theprevalence of LBW taken by the two scales differed by about 6 percentage points (Seca = 36.4%;UNISCALE = 30.2%). Box 1 describes how the data were adjusted to correct for the lower precision ofUNISCALEs.

Table A1.1: Birth weight data collected using Seca baby scales (Models 345 and 346) and UNISCALES

Box 1 Example of how data were adjusted for low precision of UNISCALES

National Law Birth weight Survey of Bangladesh, 2003-200428

DIFFERENCE IN BIRTH WEIGHTS MEASURED BY TWO DIFFERENT WEIGHINGSCALES AND ADJUSTMENT OF DATA

Annex 1

Indicators Seca baby scales(n=1,740)

UNISCALEs(n=1,345)

Total(n=3,085)

Mean birth weight (±SD) (g) 2,605 (419) 2,667 (449) 2,632 (433)

Low birth weight infants <2500 g (%) 36.4 30.2 33.7

We can calculate the probability of a birth weight being less than 2,500 g on the assumption that the distributionof the data is Normal. The mean birth weight for UNISCALEs is 2,667 g. We first calculate how many standarddeviations from the mean value of 2,500 g using the standard deviation for Seca baby scales (419 g). The Secababy scales' standard deviation is used because it is more accurate than that estimated using UNISCALEs. Thenumber of standard deviations is given by:

2,500 - 2,667 = 0.40419

Statistical tables for the Normal distribution (areas in one tail) are then used to find that the probability of beingless than 0.40 is 0.3446, i.e. 34.5%.

The data from UNISCALEs and Seca baby scales are then combined to get the overall prevalence of LBW:

(0.345 * 1345) +(0.364*2605) = 35.6%(1345+2605)

National Law Birth weight Survey of Bangladesh, 2003-2004 29

Government of the People's Republic of BangladeshMinistry of Planning


Stratum: -------------------------------1=Rural; 2=Urban (Non-Slum); 3=Urban (Slum)

Division ___________________ District ____________

Upazila/ Municipality ___________ Union/Ward_____________

Mauza/Mahalla/Slum _______________ Cluster No._____________

Household No. DateDay Month Year

Name of Responden

Supervisor: Name Signature

Quality Control Officer: Name Signature

BBS Coordinator/Supervisor: Name Signature

Instruments: Editor : ………............…………………….….

Height Scale No. Coder : ……………………............……….….

Uniscale No. Entrier : …………............……………………..

Checker : ………............…………………….….

Verbal Consent of Respondent(Supervisor: Please read out the following clearly to the respondent and take his/her verbal consent before taking interview)In order to improve the quality of health services in Bangladesh, the Government has decided to a conduct"National Survey on Low Birth Weight" through the Bangladesh Bureau of Statistics in collaboration withBRAC. For this, the weight and length of newborns of all pregnant women in your locality will bemeasured. Other information about the selected households will also be collected. You will be informed

QUESTIONNAIRES OF THE LBW SURVEY

Confidentialfor research purpose only

Data Collection Form: PrepartumNational Survey on Low Birth Weight - 2003

(This form will be filled out by the Supervisors)

Converted Number

Annex 2


about the weight and length measurements on the spot. You will be advised to consult with doctor if themeasurements of newborns of your household are found lower than normal. This and other informationgiven by you will be treated as confidential.

Under this circumstances to facilitate government efforts to improve health services are you willing tohave the members of your household measured for weight and length and give other informations aboutyour household?

Start the interview after having consent of the respondent or the household head.

Y N


HOUSEHOLD GENERAL INFORMATION:

01. Religion of the HH: 1 = Islam, 2 = Hinduism, 3 = Christianity, 4 = Buddhism, 5=Others

02. Number of males in the household

Number of females in the household

03. Information about Household:

04. Sex of the household head:(Male=1, Female=2)

Code:

Sl. No. Members ofhousehold

Name Relationwith

householdhead

Age (Year)

MainOccupation(write only

code

Class passed(write only

code)

(1) (2) (3) (4) (5) (6) (7)

01. Household Head 01

02. Pregnant Women

03. Husband ofPregnant women

(4) Relation withthe household head:

01. Self02. Wife03. Daughter04. Daughter-in-law05. Grand daughter06. Sister07. Sister-in-law08. Niece09. Mother/Mother-in-law10. Others__

6) Main Occupation:

01. Agriculture (Only own land)02. Farmer (Only leased land)03. Farmer (Own & Leased land)04. Agri-labour/Day-labour/05. Unskilled labour06. Government worker07. Part-time maid servant08. Non motorized transport driver09. Motorized transport driver10. Potter/Blacksmith/Cobbler/

Tailor/Construction worker/Fisher etc.

11. Petty or middle class business

12. Big businessman (Whole seller)13. Govt.or non-Govt (non officers)14. Govt. or non-Govt. officers15. Professional (Teacher/Lawyer

/Doctor/Nurse)16. Beggar17. Unemployed

(>10 yrs)18. Student (>6 yrs) 19. Housework/Housewife20. Disabled/Old aged21. Retired22. Others___

(7 Education:

Write the class/grade,which s/he has passed.00. No education66. Can sign only77. Non formal

education

(See Manual forEducation codes)

PART-A


Economic ConditionNo. Questions Code05. Total land owned by the household:

Homestead (with surroundings) -------------------(Decimal)Cultivated land ----------------------------------------(Decimal)

06. Does the household have the following items? 1 =Yes; 2=NoMosquito netBlanket/quiltChair / TableChouki (plain cot)CotBicycleElectricityElectric fanTelevisionFreeze

07. What kind of vegetables did you grow around your house in the last year? 1 =Yes; 2=No Green/colored leafy vegetables (Lal, Pui, Kachu etc.)Colored non leafy vegetables (Carrot, Pumpkin, Peas etc.)Roots (Potato, Kochu, Raddish etc.)Others vegetables (Lau, Potol, Bringal etc)

08. What kind of fruits did you grow around your house in the last year? 1 = Yes; 2=No Papaya Banana BoroiLemon Mango Pineapple Water-melonGuava Other (specify)---------------------

09. What are the building materials of your main building room? 1=Earth, 2=Straw/Cchone, 3=Polythene 4=Brick, 5=Tin, 6=Bamboo, 7= other (specify)

Roof--------------- Wall------------- Floor--------------

10. Area of that room : Length ------------------ Hands

Breadth -------------------Hands11. Type of latrine : 1 = Water seal; 2 = Pit; 3 = Hanging; 4= Open defecations

12. What was the income -expenditure profile in your household last year?1 = Surplus; 2 = Equal; 3 = sometimes deficit; 4 = Always deficit


13. How much did you spend for shoes/sandals in your family last year? ------------Taka14. How much did you spend for clothing for your family last year? ------------------Taka15. Did you have enough warm clothing last winter? 1 = Yes; 2 =No 16. Is any member of this household involved in any Association, Saving or Income

generating activities? 1 = Yes; 2 = No17. If yes, name of organization---------------------18. How long is the involvement?

---------------------------month19. (For Urban Slum stratum only)

How long have you been living in the city / town? --------------------------month


INFORMATION ABOUT CURRENTLY PREGNANT WOMEN IN THE HOUSEHOLD(USE SEPARATE QUESTIONNAIRE FOR EACH PREGNANT WOMAN)

PART- B

Cluster No. Household No. Sl. No. Name of the pregnant woman Age (years)

No. Questions Code01. What was your age at marriage? (age at first marriage in case of multiple marriages) -----years

02. Total number of living children at present (write 00 if o children)

Boys --------------

Girls--------------

03. Did you ever give birth to a child who cried or had a sign of life immediately afterbirth but died after few hours or days or months or years? (write 0 if no such child)

Boys --------------

Girls--------------

04. Did any of your under 5 children died during last 5 years? (write 0 if no such child)

Boys --------------

Girls--------------

05. Did any of your pregnancy fail? If yes, how many? --------------------(Write 0 if no such incident)

06. Total number of pregnancy including the present one -------------------(write adding together Q. 02 + 03+ 05+ present conceptions)

07. Do you remember the size of your last baby at birth? 1=Very big; 2 =Big; 3=Normal; 4=Small; 5=Very small

08. When did your last pregnancy terminate? ---------------------months

09. How did your last pregnancy terminate ? 1 = Live (singlet); 2 = Live (twin); 3 = still birth; 4 = Abortion; 5 =Miscarriage

10. Type of your last delivery: 1=Normal; 2 =Caesarian; 3 = Other(Forcep ek.)

11. Do you have any physical illness at present? 1 = Yes; 2 = No

Severe headache

Vomiting

Fever

Convulsion

Bleeding

High blood Pressurs

Oedema


Other -----------

No complication

12. Weight of pregnant Women ---------------------kg

13. Hight of pregnant women ----------------------cm

14. MUAC of pregnant women ---------------------mm

15. Last menstrual period -------------day/--------month/2003

16. Pregnant for how long ? ----------------------months

17. Is it your first pregnancy? 1 =Yes; 2 =No

18. If answer to Q.17 is no,Do you breast feed now ? 1 =Yes; 2 = No; 8 = No child

19. Do you smoke? 1 =Yes; 2 =No;

20. If yes, how many per day? -----------------

30




Stratum: -------------------------------1=Rural; 2=Urban (Non-Slum); 3=Urban (Slum)

Division ___________________ District ________________



Household No. Date

Name of Respondent

Supervisor: Name Signature

Quality Control Officer: Name Signature

BBS Coordinator/Supervisor: Name Signature

Instruments: Editor : ………............…………………….….

Height Scale No. Coder : ……………………............……….….

Uniscale No. Entrier : …………............……………………..

Checker : ………............…………………….….


Data Collection Form: PrepartumNational Survey on Low Birth Weight - 2003

(This form will be filled out by the Supervisors)

Converted Number

Day Month Year


Information related to pregnancy and delivery of the mothers of newborn

Cluster No. Household No. Sl. No.mother

Name of mother Age (years)

No. Questions Code01. How many days ago did your pregnancy terminated? -------------------- days

02. What was the outcome of the pregnancy? 1 = Live (single); 2 = Live (twine); 3 = still birth

03. Type of this delivery? 1=Normal; 2 =Caesarian; 3 = Others (forceps etc.)

04. Place of this delivery ? 1=Govt. Hospital/Health Centre; 2=Private/NGO Health Centre; 3=Home Delivery/N/R/Other

05. Who assisted this delivery ? 1=Doctor/ Nurse/FWV; 2=Trained TBA; 3=Untrained TBA; 4=Neighbor/Relative/Others

06. Did you face any complications after 6 moths of your pregnancy up to the time ofdelivery?1 =Yes; 2 =No

Severe headache

Vomiting

Fever

Convulsion

Bleeding

Oedema

Other ------------

No complication

07. Did you have any complication at the time of this delivery? 1 = Yes 2 = No

Severe headache

Vomiting

Fever

Convulsion

More than 12-hours long labour

High blood Pressurs

Bleeding

Hand/leg came out first

Others---------------

No complication


08. Did you have any problem within 2 weeks of delivery? 1 = Yes 2 = No

Sever headache

Abnormal bleeding

Bleeding with bad smell

Fever

Convulsion

09. If yes, where / to whom did you go for treatment? 1 = Yes 2 = No

Govt. Hospital/Clinic/TH/DH/MCWC/FWC/RD/ HA/FWA/FWV

Village doctor

NGO clinic

Private clininc

Pharmacy

Did not go

Do not know

Others (specify, e.g. Bless-blow; bless-water etc.)

10. Who gave decision regarding treatment of your antenatal/delivery complication? 1 = Husband; 2 = Myself; 3 =We together; 4 =Other members of family (father/mother-in-law); 5 =Others ------

11. How much food did you take during this pregnancy? 1 = More than normal; 2 = Less than normal; 3 =As before; 4 = Can't recall

12. Did you take iron tablets during this pregnancy? 1 = Yes 2 = No (If answer is no, then go to Q. 16)

13. From which month of pregnancy did you take iron tablets? -------------------months

14. If taken, for how long? 1 = Less than one month; 2 =1 - 2 months; 3 =2 - 3months; 4 =3 - 4 months or above; 5 =Can't recall

15. What was the source of these iron tablets? 1 =Govt. Hospital/Clinic/FWA/HA/FWV; 2 =Pharmacy; 3 =NGO; 4 =Don't know

16. If not taken, why? 1=Not available; 2=Not necessary; 3=Did not know; 4=Side effect

17. Do you smoke now? 1 = Yes 2 = No

18. If yes, how many sticks / times a day? ---------------sticks/times

19. What you think the size of your baby was at birth? 1= Very big; 2=Big; 3=Normal; 4=Small; 5=Very small

20. What did you give in his/her mouth after birth? 1 =Colostrum; 2 =Honey; 3 =Sugar water; 4 =Mustard oil; 5 =Plain water; 6 = Others (specify)--------------

21. If not colostrums, ask the following questionAfter how many hours did you give breast milk to your baby? ----------------------- hours

22. Did you expel some milk before breast feeding for the first time? 1 = Yes 2 = No

23. In your opinion, what should be given to the baby after birth?1 =Colostrum; 2 =Honey; 3 =Sugar water; 4 =Mustard oil; 5 =Plain water; 6 = Others (specify)----------------

24. For how many months should the baby be breast fed (96= don't know-------------months

25. For how many months should the baby be exclusively breast fed (96= don't know) --------months


26. Did you practice the following during pregnancy? 1 = Yes 2 = No

Regular check-up

Take TT injection

Eat balanced food

Take adequate rest

Stay neat and clean

27. What is your perception about your own health? 1=Good; 2 =Average; 3 =Bad

28. What is your perception about the health of your baby? 1=Good; 2 =Average; 3 =Bad

29. Weight of lactaing mother ----------------------Kg

30. MUAC of lactating mother ---------------------mm


3. Information about pregnancy:



Stratum: ----------------------------1=Rural; 2=Urban (Non-Slum); 3=Urban (Slum)

Division ___________________ District _______________



Household No. DateDay Month Year

Name of pregnant woman Sl. No. of pregnant woman ----------

Name of RFA ----------------------------------

1. Date of last Menstrual Period: 2. Expected date of delivery:

Day Month Year Day Month Year


Pragnant Woman’s Registration and newborbonr’s Informantion Card

National Survey on Low Birth Weight - 2003(This Card will be filled out by the RFA)

Converted Number

Month

Date

ANC? 1 =Yes;2=No

Iron tablet(number taken)

Vitamin tablet(number taken)

Food intake1 = More than

normal; 2 = Less than

normal; 3 = As before

Perception aboutown health

1=Good ; 2= Average;3= Bad

Mental stress ofmother(RFAs

assessment)1= None; 2=Little;

3=High; 4=Very high

Month 3

Month 4

Month 5

Month 6


6. Delivery plan:

7. Delivery result:

8. Information on newborn:

Month 7

Month 8

Month 9

Month 10

4. Get the followingANC advice? 1 =Yes ; 2=No

Month3

Month4

Month5

Month6

Month7

Month8

Month9

Month10

Regular check up

TT injection

Balanced food

Adequate rest

Neat and clean

5. Have followingproblem? 1 =Yes; 2=No

Month3

Month4

Month5

Month6

Month7

Month8

Month9

Month10

Severe headache

Vomiting

Fever

Convulsion

Bleeding

High blood pressure

Edema

No complain

Where (address)

Maternaldeath: 1=Yes2= No

Cause of maternal death : 1 = Prolong labour; 2=Placental obstruction;3=Bleeding; 4= Hand, leg, placenta came outfirst; 5=Convulsion

Place of delivery:1=Govt. Hospital/Clinic; 2=PrivateHospital/Clinic; 3=House

Date and time of birth:-------Day -------Month-------Year

1= Morning; 2= Noon; 3=Afternoon; 4= Evening/night

Date and time of taking birth weight: -------Day --------Month------Year

1= Morning; 2= Noon; 3=Afternoon; 4= Evening/night


9. Description of visit:

Outcome ofpregnancy

1 = Live birth; 2=Stillbirth, 3=Abortion;

4=Death after live birth

Sl. No. ofNewborn

Sex 1=Boy;2=Girl

Weight (gm)

0000.0

Length(cm)000.0

Perception aboutbaby's health

1=Good; 2= Average; 3= Bad

RFAs comments duringmeasurement

1=Baby was quite; 2=Baby wasrestless/crying

(1) (2) (3) (4) (5) (6) (7)

Visit by RFASignature

DateSignature

DateSignature

DateSignature

DateSig nature

DateSignature

DateSignature

DateSignature

Date

Visit bySupervisor Signature

DateSignature

DateSignature

DateSignature

DateSig nature

DateSignature

Date Signature

DateSignature

Date

Instruments: 1. SECA Baby Scale No 2. Length Mat No.


1. Mr. M. Fazlur Rahman, Secretary, Planning Division2. Mr. A.K.M Musa, Director General, Bangladesh Bureau of Statistics3. Mr. Saleuddin M. Musa, Joint-Secretary, Planning Division4. Mr. Kamal Uddin Ahmed, Deputy Secretary, Planning Division5. Prof. Dr. Kohinoor Begum, Gyneocology Deptt, Dhaka Medical College Hospital6. Prof. Dr. U.H. Farida Khatun, Director, Institute of Public Health Nutrition7. Prof. Dr. Mamunur Rashid, Former Director, Institute of Public Health Nutrition8. Dr. Jafar Ahmed Hakim, Director (MCH), Directorate of Family Planning9. Prof. Dr. Golam Mowla, Director, Institute of Nutrition and Food Science, Dhaka University10. Prof. Quazi Salamatullah, Former Director, Institute of Nutrition & Food Science, Dhaka University11. Mr. Abdur Rashid Sikder, Director, Bangladesh Bureau of Statistics12. Ms. Ferdous Nurun Ara, Director, Bangladesh Bureau of Statistics13. Prof. Shahadat Ali Mallick, Department of Statistics, Dhaka University14. Dr. Abbas Bhuyan, Head, Social and Behavioural Science, ICDDR,B15. Dr. Shams EL Arifeen, Head, Child Health Unit, ICDDR,B16. Prof. Dr. H.K.M. Yusuf, Team leader, LBW Survey, BRAC17. Mr. Muhammad Shuaib, Associate Professor, ISRT, Dhaka University18. Ms. Farhana Haseen, Research Associate, BRAC19. Dr. Syed Masud Ahmed, SMO, BRAC20. Dr. Nawshad Ahmed, Programme Officer, UNICEF- Bangladesh21. Ms. Naomi Ichikawa, Project Officer, Planning Section, UNICEF- Bangladesh22. Dr. Harriet Torlesse, Project Officer Nutrition, UNICEF- Bangladesh23. Dr. Indrani Chakma, Assistant Project Officer Nutrition, UNICEF- Bangladesh24. Ms. Gudrun Stallkamp, Nutrition Programme Officer, HKI Bangladesh25. Ms. Monoara Begum, Deputy Director, Bangladesh Integrated Nutrition Project26. Ms. Rashada Akhter, Sr. Asstt. Secretary, Planning Division27. Mr. Md. Ehsan E-Elahi, P.S. to Secretary, Planning Division28. Mr. Alamgir Hossain, Statistical Officer, Bangladesh Bureau of Statistics29. Mr. Md. Golam Razzaque, Statistical Officer, Bangladesh Bureau of Statistics30. Mr. A. K.M. Abdus Salam, Project Director, MSCW Project, Bangladesh Bureau of Statistics

MEMBERS/OFFICERS ATTENDED THE MEETINGS OF THE CORE EXPERTGROUP ON THE LBW SURVEY 2003-2004

Annex 3 A


1. Mr. A. K. M Musa, Director General, Bangladesh Bureau of Statistics2. Mr. Md. Abu Zafar, Joint- Secretary, Statistics Wing, Planning Division3. S. M Tajul Islam, Deputy Director General, Bangladesh Bureau of Statistics4. Mr. Mustak Hassan Md. Iftekhar, Deputy Secretary, Statistics Wing, Planning Division 5. Mr. A B M Khorshed Alam, Deputy Secretary, Statistics Wing6. Mr. Md. Ashraf Hossain, Deputy Secretary, ERD7. Mr. Abdur Rashid Sikder, Director, Bangladesh Bureau of Statistics8. Ms. Ferdous Nurun Ara, Director, Bangladesh Bureau of Statistics9. Mr. Md. Ataur Rahman, Director, IMED, M/o Planning10. Mr. Md. Abdul Mannan, Deputy Chief, SCYSWAM Wing, Planning Commission 11. Mr. Md. Abdul Hye, Deputy Chief, SCYSWAM Wing, Planning Commission 12. Mr. A K M Abdus Salam, Project Director, MSCW Project, Bangladesh Bureau of Statistics 13. Dr. Abdur Rahim Khan, DPM, Social Science Research Council, Planning Division14. Ms. Rashada Akhter, Senior Assisstant Secretary, Statistics Wing15. Prof. H. K. M. Yusuf, Team Leader, LBW Survey, BRAC16. Dr. Syed Shahadat Hossain, Director, ISRT, Dhaka University17. Ms. Misaki A Ueda, Chief, PME Section, UNICEF18. Dr. Nawshad Ahmed, Planning Officer, PME Section, UNICEF19. Dr. Harriet Torlesse, Programme Officer, Nutrition Section, UNICEF 20. Ms. Naomi Ichikawa, Project Officer, PME Section, UNICEF21. Mr. Muhammad Shuaib, SURCH/ ISRT, DU22. Ms. Shamima Akhter, Senior Assistant Chief, ERD23. Ms. Zakia Yasmin Joarder, Deputy Director, Department of Women Affairs24. S. M. Arshad Imam, Assistant Director, IMED, M/o Planning25. Dr. S. M. Mustafa Anower, Assistant Director, Directorate General of Health Services26. Dr. Faruque Ahmed Khan, Institute of Public Health Nutrition27. Mr. Humayun Kabir, Assistant Director, Directorate of Primary Education 28. Mr. Md. Anwar Hussain, Assistant Director, Directorate of Primary Education29. Mr. Alamgir Hossain, Statistical Officer, Bangladesh Bureau of Statistics30. Mr. Md. Golam Razzaque, Statistical Officer, Bangladesh Bureau of Statistics

MEMBERS/OFFICERS ATTENDED IN THE MEETINGS OF THE TECHNICALCOMMITTEE OF THE PROJECT

Annex 3 B


CONTRIBUTORS TO THE NATIONAL LOW BIRTH WEIGHT SURVEY OFBANGLADESH, 2003-2004

Annex 4

A.K.M MusaAbdur Rashid SikderA.K.M. Abdus Salam

Alamgir HossamMd. Golam Razzaque

Delwara Begum

Director General, BBSDirector, BBSProject Director, MSCW Project, BBS Statistical Officer, BBSStatistical Officer, BBSAsstt. Statistical Officer, BBS

Satya Ranjan MondalMd. Abdul Kader

Md. Emdadul HaqueMohammad Hossam

Shamir Kumar KahaliMd. Israil Hossam Sikder

Md. Abdul Mazid MiaMaksuda Shilpi

Md. Zahidul Hoq SarderMd. Alauddin al Azad

Md. Nasiruddin AhmedMd. Shahin

Md. AbdullahA K M Abdur Razzaque

Md. Aynul KabirBidhan BaralMir Hossam

AFM Fazlul HoqueMd. Nuriddm AhmedMd. Mizanur Rahman

Ghosh Shuvabrata

RSO, DhakaRSO, Mymenshingh RSO, Jamalpur RSO, Kishoreganj RSO, Tangail RSO, Faridpur RSO, Rajshahi RSO, PabnaRSO, Rangpur RSO, BograRSO, Dinajpur RSO, Chittagong RSO, RangamatiRSO, Noakhali RSO, Comilla RSO, Khulna RSO, Jessore RSO, Kushtia RSO, Barisal RSO, Patuakhali RSO, Sylhet

Khodeza BegumA K M Shamsuzzaman

Jahan AftozNazeen Sultana Khan

Abid Mia

Field Supervisor.Field Supervisor Field Supervisor Field Supervisor Field Supervisor

Md. Abdul Hakim Field Supervisor

BBS

Regional Statistical Officers, BBS

Statistical Investigators

Thana Statistician


Nawshad Ahmed Naomi IchikawaHarriet Torlesse

Planning Officer, Planning M&E Section Project Officer, Planning M&E SectionProject Officer, Health & Nutrition Section

H.K.M Yusuf, Ph.DS. M. Ziauddin Hayder, Ph.D

Farhana HaseenIftekhar Quasem

CSB JalalFarid Ahmed

Mizanur Rahman

Team LeaderPrincipal InvestigatorProject CoordinatorResearch AssociatedResearch AssociatedField ManagerField Manager

Quality Control OfficerField Manager

Resident Field assistance

217110

Muhammad Shuaib UNICEF consultant (Statistics)

UNICEF

BRAC

Data Collection

SURCH

Rokeya BegumA K M Faruk Ahmed Mollah

Setara BegumKhohinoor Hossain

S. M. Anwar Husain

Field Supervisor Field Supervisor Field Supervisor Field SupervisorField Supervisor,Data management and checking

Statistical Assistants


Table A5.1: Demographic and socio-economic characteristics of the households of infants whose birthweight was measured within 72 h of delivery and infants whose birth was not measuredwithin 72 h of deliverya.

Comparison of the household and maternal characteristics of infants whose birth weights weremeasured within 72 hrs with infants whose birth weights were not measured within 72 hrs

Annex 5

IndicatorBW data

within 72 h(n=3,046)

No BW datawithin 72 h b

(n=6,93)Significance c

Mean household size (persons) 5.5 5.4 N.SHousehold size (%)

<4 persons4-6 persons7+ persons

24.348.227.5

30.140.929.1

**

Female headed household (%) 3.4 3.1 N.SEducational level of father (%)

IlliterateCan sign onlyPassed I-VPassed VI-IXPassed SSC and above

21.926.321.217.513.1

18.719.622.220.419.0

***

Main occupation of father (%)Professional, technical, administration and managerial Clerical, sales, service, production and retailed workersand transport workers Agricultural, animal husbandry, forestry and fisheries Others (unemployed, beggar, disabled, retired etc.)

5.350.6

42.02.1

6.753.1

38.02.2

N.S

Cultivable land owned by the household in acres (%)Landless0.01-0.991.00-1.99≥2.00

49.629.010.510.9

48.626.99.7

14.9

*

Household assets (%)Bed (Khat)ElectricityElectric fanTelevision

33.031.825.317.8

38.937.032.721.9

**********

Household expenditure on shoes in last year/person (%)<100 Tk≥100 Tk

63.736.3

55.944.1

******

Material of roof of house (%)TinCement (Pucca) Other (Chon, Bamboo, Polythene, Wood, Golpata)

82.23.6

14.2

82.87.39.9

***

Material of floor of house (%)EarthCement (Pucca)Other (Bamboo, Wood)

89.310.10.6

82.916.30.8

***

(Cont.)


a Includes households of infants whose birth weights were measured within 72 hr of birth. Households of twin infants were counted twice.b Includes both pregnancies that were lost to follow-up and infants whose birth weight was taken after 72 hrs.c P value: *= <0.05, **= <0.01, and ***= <0.001.

Table A5.2: Background characteristics of the pregnant mothers of infants whose birth weight wasmeasured within 72 h of delivery and infants whose birth was not measured within 72 h ofdelivery.

a Includes mothers of infants whose birth weights were measured within 72 hr of birth. Mothers of twin infants were counted twice.b Includes both pregnancies that were lost to follow-up and infants whose birth weight was taken after 72 hrs.c P value: *= <0.05, **= <0.01, and ***= <0.001.

Type of latrine (%))Water sealPitHanging and Open

17.335.247.5

23.136.840.2

***

Perceived economic status of household (%)SurplusEqualDeficit

31.431.237.4

34.231.234.6

N.S

IndicatorBW data

within 72 h a(n=3,046)



Mother's age in years (mean ±SD) 24.6±5.9 23.3±5.5 ***Mother's current age in years (%)

<2020-34≥35

21.171.17.8

26.467.26.4

**

Age at first marriage in years (%)<18 18-24 ≥25

73.526.00.5

68.630.41.0

N.S.

Educational level of the pregnant women (%)IlliterateCan sign onlyPassed I-VPassed VI-IXPassed SSC and above

24.421.224.923.26.3

22.112.323.830.910.9

***

Main occupation of the pregnant women (%)HousewifeWorking outside the home

96.83.2

96.33.7 N.S

Number of pregnancies including the present pregnancy (%)12-5≥6

27.561.211.3

41.751.66.7

***

Number of previous spontaneous abortions/ miscarriage (%)01≥2

87.59.72.8

88.09.42.6

N.S


Table A5.3: Health, nutrition and care during pregnancy of the mothers of infants whose birth weight wasmeasured within 72 h of delivery and infants whose birth was not measured within 72 h ofdelivery.

a Includes mothers of infants whose birth weights were measured within 72 hr of birth. Mothers of twin infants were counted twice.b Includes both pregnancies that were lost to follow-up and infants whose birth weight was taken after 72 hrs.c P value: *= <0.05, **= <0.01, and ***= <0.001.

IndicatorBW data

within 72 h a(n=3,046)



Height in cmMean ± SD

Height in cm (%)<145 cm

149.9±5.1

15.7

149.4±5.4

18.2

N.S.

N.S.

Currently breastfeeding (%)YesNo /no child

12.587.5

15.784.3 N.S.

Any complication between 6 months of pregnancy and delivery (%)FeverEdemaVomitingBleedingNone

39.634.228.34.3

23.4

37.342.731.72.5

22.8

****

N.S.*

N.S.Took adequate rest during pregnancy (%) 85.4 88.3 N.SAmount of food taken during pregnancy (%)


15.740.943.4

19.443.736.9

**

Antenatal visits during pregnancy (%) 29.8 33.7 **

Iron supplements taken during pregnancy (%) 28.8 32.8 **Duration of taking iron supplements (%)

Never taken <1 month1-3 months4 months and more

71.27.6

13.17.9

67.25.4

14.013.3

***

From which month in pregnancy took iron supplements (%)Never taken≤3rd month4-6th month7-9th month

71.26.1

13.88.9

67.28.8

15.28.8

*

Source of iron supplements (%)Government hospital /clinic/ FWA /HA/FWVPharmacyNGO

32.648.518.9

32.453.514.1

N.S.

Reason for not taking iron supplements (%)Not available Not necessary Side effects Don't know

48.326.79.0

16.0

45.627.69.2

17.6

N.S.


ACC/SCN (2000) Low Birthweight: Report of a Meeting in Dhaka, Bangladesh on 14-17 June 1999. Eds.Pojda J and Kelly L. Nutrition Policy Paper #18. Geneva: ACC/SCN in collaboration with ICDDR,B.

Allen LH. (2000), Anemia and iron deficiency: effects on pregnancy outcome. Am J clin Nutr 71(5 Suppl):1280S-4S

Arifeen SE. (1997). Birth weight, intrauterine growth retardation and prematurity: a prospective study ofinfant growth and survival in the slums of Dhaka, Bangladesh. Doctor of Public Health dissertation. JohnsHopkins University School of Hygiene and Public Health, Baltimore.

Arifeen SE, Balck RE, Caulfield LE, et al. (2000) Infant growth patterns in the slums of Dhaka in relationto birth weight, intrauterine growth retardation, and prematurity. Am. J. Clin. Nutr. 72: 1010-1017.

BBS (2003) Population Census-2001 (Provisional). Bangladesh Bureau of Statistics, Ministry ofPlanning, Dhaka.

BBS/UNICEF (2004). Progotir Pathey 2003. Dhaka, Bangladesh Bureau of Statistics and UNICEF.

BDHS (2001) Bangladesh Demographic and Health Survey, 1999-2000. National Institute of PopulationResearch and Training (NIPORT)/Mitra and Associates/ORC Macro, Dhaka, Bangladesh and Calverton,Mayland, USA.

Canosa CA. (1989) Intrauterine growth retardation in India and Bangladesh. In: Sentre J, ed. Intrauterinegrowth retardation. Nestle Nutrition Workshop Series. Vol. 18. New York: Raven Press; 183-204.

Das JC, Khanam ST. (1997) Correlation of anthropometric measurements of mothers and their newborns.Bangladesh Med. Res. Council Bull. 23: 10-15.

Dhar B, Mowlah G, Kabir DM. (2003) Newborn anthropometry and its relationship with maternal factors.Bangladesh Med. Res. Council Bull. 29: 45-58.

Dhar B, Mowlah G, Nahar S, Islam N. (2002) Birth weight status of newborns and its relationship withother anthropometric parameters in a public maternity hospital in Dhaka, Bangladesh. J. Health Popul.Nutr. 20: 36-41.

Dickute J, Padaiga Z, Grabauskas V. et al. (2004) Maternal socio-economic factors and the risk of lowbirth weight in Lithuania. Medicina 40: 475-482.

Eisner V, Brazie JV, Pratt MW, Hexter AC. (1979). The risk of low birth weight. Am. J. Public Health 69:887-893.

Evans RW, Powers RW, Ness RB. (2003) Maternal and fetal amino acid concentrations and fetal outcomesduring pre-eclampsia. Reproduction 125 (6): 785-90.

REFERENCES

Annex 6


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