Paritas

There is general agreement that pregnancy outcomes are more favourable for multiparae than
primiparae; grand multiparity, however, is often believed to constitute a risk. Several factors
may confound the association be- tween parity and intrauterine growth or gestational duration
(see Table 2). In particular, primiparae tend to be younger than multiparae. Although age does
not appear to have any independent effect on pregnancy outcome, young adolescents are
likely to differ from older women in their height, prepregnancy weight, gestational nutrition,
cigarette and alcohol consumption, and use of antenatal care. Control for age was therefore
considered essential for an SM rating. Grand multiparity may also be associated with racial/
ethnic origin, socioeconomic status, cigarette smoking, alcohol consumption, and genital
infection. Thus control is also required for these factors. In addition, as mothers of high parity
are likely to have had shorter intervals since their previous pregnancy, birth (or pregnancy)
interval should also be controlled. Because extremely high parity may also be associated with
poorer outcome, the effect ofgrand multiparity should be examined separately. Multivariate
statistical models of the effect of parity on birth weight or gestational age should ideally
contain a quadratic term for parity, in addition to the usual linear term, when parity is
expressed on a continuous scale. Finally, because age may modify the effect of parity,
evidence should also be sought for an ageparity interaction.

IMT
Any contribution of paternal height or weight to gestational growth or duration must, of
course, have a genetic basis. Because of assortive mating (the tendency of men and women of
similar relative stature and weight to marry), maternal height and prepregnancy weight are
important confounding variables that require control. Similarly, because weight usually
increases with age, (maternal) age should also be controlled. Since in developed countries
eating habits resulting in over nutrition are often linked to smoking and drinking habits (and
secondarily, therefore, to such habits in wives), these too should be adjusted for. Finally,
racial/ethnic origin and socioeconomic status are also associated with height and weight in
men, and since these variables' may be linked to gestational duration or growth independent
of paternal size, they too require control.

WEIGHT
As with maternal height, maternal prepregnancy weight is influenced by both genetic and
environmental factors. Even after correcting for stature, body weight is in part genetically
determined, and genes that control adiposity or lean body mass could, theoretically, be
expressed in the newborn. Even in the absence of such expression, however, maternal weight
prior to conception reflects nutritional stores potentially available to the growing fetus. Since
heavier women are generally taller and have a greater caloric requirement than thinner

women, isolation of the effect of maternal pre pregnancy weight requires control for the
confounding effects of maternal height and caloric intake (or gestational weight gain).
Control for maternal height could be achieved either by using a weight-for-height index (e.g.,
body mass index, ponderal index, or relative weight), by stratifying the weight effect by
height, or by including height as one of the independent variables, along with prepregnancy
weight, in a multi- variate analysis. Since teenagers recently past their menarche are likely to
be thinner than older, physio- logically more mature women, age should also be controlled.
Nicotine is a well-known appetite suppressant, and, all else being equal, women who smoke
may be lighter than those who do not. Since cigarette smoking might also affect the outcome
of pregnancy, it too needs to be controlled in the analysis. Finally, since weight is likely to
covary with racial/ethnic origin and socioeconomic status, and since these factors may be
linked to intrauterine growth or gestational duration independent of their relationship to
weight,

HEIGHT
A mother's height during pregnancy is determined by three factors: her genetic potential for
growth; her state of skeletal maturity; and the effect of environmental influences during the
period of skeletal immaturity. These factors differ in their modifiability. Genetic potential is
presumably fixed, but these should also be controlled. The methodological standards used to
assess studies of pre-pregnancy weight are shown in Table 2 (pp. 670-1). In order to receive
an SM or PM rating, the studies had to include some form ofcontrol forheight. Also, only
those studies were assessed that reported the effect ofweight prior to conception, since
weights measured during or after pregnancy include the effect of gestational weight gain.
Most pre pregnancy weights represent mothers' self-reports, usually obtained by interview
during the course of antenatal care or immediately postpartum.

ANC
Paritas
There is general agreement that pregnancy outcomes are more favourable for multiparae than
primiparae; grand multiparity, however, is often believed to constitute a risk. Several factors
may confound the association be- tween parity and intrauterine growth or gestational duration
(see Table 2). In particular, primiparae tend to be younger than multiparae. Although age does
not appear to have any independent effect on pregnancy outcome, young adolescents are
likely to differ from older women in their height, prepregnancy weight, gestational nutrition,
cigarette and alcohol consumption, and use of antenatal care. Control for age was therefore
considered essential for an SM rating. Grand multiparity may also be associated with racial/
ethnic origin, socioeconomic status, cigarette smoking, alcohol consumption, and genital
infection. Thus control is also required for these factors. In addition, as mothers of high parity
are likely to have had shorter intervals since their previous pregnancy, birth (or pregnancy)

interval should also be controlled. Because extremely high parity may also be associated with
poorer outcome, the effect ofgrand multiparity should be examined separately. Multivariate
statistical models of the effect of parity on birth weight or gestational age should ideally
contain a quadratic term for parity, in addition to the usual linear term, when parity is
expressed on a continuous scale. Finally, because age may modify the effect of parity,
evidence should also be sought for an ageparity interaction.

IMT
Any contribution of paternal height or weight to gestational growth or duration must, of
course, have a genetic basis. Because of assortive mating (the tendency of men and women of
similar relative stature and weight to marry), maternal height and prepregnancy weight are
important confounding variables that require control. Similarly, because weight usually
increases with age, (maternal) age should also be controlled. Since in developed countries
eating habits resulting in over nutrition are often linked to smoking and drinking habits (and
secondarily, therefore, to such habits in wives), these too should be adjusted for. Finally,
racial/ethnic origin and socioeconomic status are also associated with height and weight in
men, and since these variables' may be linked to gestational duration or growth independent
of paternal size, they too require control.

WEIGHT
As with maternal height, maternal prepregnancy weight is influenced by both genetic and
environmental factors. Even after correcting for stature, body weight is in part genetically
determined, and genes that control adiposity or lean body mass could, theoretically, be
expressed in the newborn. Even in the absence of such expression, however, maternal weight
prior to conception reflects nutritional stores potentially available to the growing fetus. Since
heavier women are generally taller and have a greater caloric requirement than thinner
women, isolation of the effect of maternal pre pregnancy weight requires control for the
confounding effects of maternal height and caloric intake (or gestational weight gain).
Control for maternal height could be achieved either by using a weight-for-height index (e.g.,
body mass index, ponderal index, or relative weight), by stratifying the weight effect by
height, or by including height as one of the independent variables, along with prepregnancy
weight, in a multi- variate analysis. Since teenagers recently past their menarche are likely to
be thinner than older, physio- logically more mature women, age should also be controlled.
Nicotine is a well-known appetite suppressant, and, all else being equal, women who smoke
may be lighter than those who do not. Since cigarette smoking might also affect the outcome
of pregnancy, it too needs to be controlled in the analysis. Finally, since weight is likely to
covary with racial/ethnic origin and socioeconomic status, and since these factors may be

linked to intrauterine growth or gestational duration independent of their relationship to

weight,

HEIGHT
A mother's height during pregnancy is determined by three factors: her genetic potential for
growth; her state of skeletal maturity; and the effect of environmental influences during the
period of skeletal immaturity. These factors differ in their modifiability. Genetic potential is
presumably fixed, but these should also be controlled. The methodological standards used to
assess studies of pre-pregnancy weight are shown in Table 2 (pp. 670-1). In order to receive
an SM or PM rating, the studies had to include some form ofcontrol forheight. Also, only
those studies were assessed that reported the effect ofweight prior to conception, since
weights measured during or after pregnancy include the effect of gestational weight gain.
Most pre pregnancy weights represent mothers' self-reports, usually obtained by interview
during the course of antenatal care or immediately postpartum.

ANC
Antenatal care could have a beneficial impact on intrauterine growth or gestational duration,
either by diagnosis and timely treatment ofpregnancy complications (such as toxaemia,
gestational hyper- tension or diabetes, antepartum haemorrhage, or cervical incompetence) or
by eliminating or reducing modifiable risk factors.d The results of the assessd It should be re-emphasized that this assessment ofthe impactof antenatal care pertains to
women without underlying chronic disease. Obviously, antenatal care might have substantial
benefits in women with complaints such as pre-existing diabetes or sickle cell anaemia, but
such women were excluded from this assessment.
DETERMINANTS OF LOW BIRTH WEIGHT
ment indicate that those risk factors that seem most amenable to such an impact include
caloric intake, cigarette smoking, alcohol consumption, and malaria prophylaxis or treatment.
Other modifiable deter- minants that may affect pregnancy outcome are maternal work and
genital tract infection. The stage in pregnancy at which a woman is first seen for antenatal
care might be ofgreat importance, because the effects of many pregnancy complications and
risk factors, if attended to early in gestation, could then be sub- stantially mitigated. One
methodological difficulty in evaluating the potential impact of initial antenatal care is related
to pre-term delivery and the now familiar cause-and- effect problem. Women who deliver
prematurely will have had a shorter period before attending their first antenatal visit. This
should not create a major problem if those who seek care in the first or early second trimester
are compared in studies with those who do not. In many developing countries, however, and
even among the poor in developed countries, women may not seek care until rather late in
pregnancy, and thus premature labour and delivery may prevent them from receiving any

antenatal care at all. Although this "prematurity artefact" should not affect an analysis
ofgestational-age-adjusted birth weight or IUGR, it would constitute a major bias in assessing
the effect on gestational duration. The use of life-table techniques (survival analysis) would
be one way ofcontrolling for such bias. Studies that had a bearing on gestational duration
were therefore considered eligible for an SM or PM rating only if they incorporated some
procedure for reducing or eliminating bias from this source. Women who begin antenatal care
at a late stage in their pregnancy and those who never begin are likely to differ in
prognostically important ways from those who seek early antenatal care: they are more likely
to be young, primiparous, poor, members of a racial/ ethnic minority, or undernourished, and
may be more likely to smoke or drink. Any attempt to isolate an independent effect for
antenatal care should, there- fore, control for these confounding factors (Table 2). Negative
confounding is also possible for this factor. If women who seek early antenatal care are those
who experience problems at an early stage of gestation, such use of antenatal care could
either appear to be associated with worse outcomes, or a true beneficial effect ofearly care
might be obscured. The reason why antenatal care is first sought thus becomes a source
ofconfounding, and the best way ofavoiding such "confounding by indication", as well as the
other methodological pitfalls discussed above, would be to randomly allocate a group of
women to early versus late antenatal care.

Number of antenatal care visits

Background. The biological and methodological issues for the number ofantenatal visits are
similar to those discussed for first antenatal care (see Table 2). Theoretically, the greater the
number ofcontacts with health professionals who attempt to reduce or elimi- nate risk factors
and treat pregnancy complications, the better the outcome should be. Because women who
deliver prematurely have a shorter time for visits, control for this artefact is essential. Similar
also is the possibility for negative "confounding by indication", since women whose
pregnancy is proceeding normally without symptomatic complications may feel they require
fewer visits.
Quality of antenatal care comprises any qualitative attribute of the content (structure or
process) of the care, including continuous versus episodic care, specialist versus generalist
care, and the evaluation of antenatal care programmes targeted for specific at-risk groups
(e.g., teenagers or the poor). Here, I have attempted to isolate the impact of these aspects of
antenatal care from those associated with the timing of the first visit and the number of visits.
The methodological requirements for this "factor" are very similar to those already discussed
for other aspects of antenatal care (see Table 2). The artefact caused by prematurity might be
less important for the quality of antenatal care, however, unless women who deliver early
have a lesser chance of being referred or recruited into special care programmes. Because
motivation for participating in such pro- grammes may be closely linked to other prognostically favourable factors, control for confounding is essential in attempts to evaluate their
impact. Randomized allocation to special versus routine antenatal care is therefore the
preferred study design.