Vol. 25, No. 12, pp.

1321-1327,
Printed in Great Britain All rights reserved
Sot. Sci. Med.

1987

0277-9536/87 $3.00 + 0.00

Copyright 0 1987Pergamon Journals Ltd

PREDICTING
LOW BIRTHWEIGHT
AND
COMPLICATED
LABOR IN URBAN BLACK
WOMEN: A BIOPSYCHOSOCIAL
PERSPECTIVE
KENNETH G. REEB,* ANT~NNETIEV. GRAHAM, STEPHEN J. ZYZANSKI and GAY C. KIT~ON
Departments of Family Medicine and Anthropology, Case Western Reserve University and University
Hospitals of Cleveland, Cleveland, Ohio, U.S.A.
Abstract-This
study explored demographic, biomedical and psychosocial factors as predictors of two
adverse pregnancy outcomes: intrapartum complications and low birthweight, in 140 urban black
pregnant women. The intrapartum complication rate was 18%. A four factor equation (low family
functioning, advanced maternal age, working during pregnancy, and short stature) predicted intrapartum
complications (80% sensitivity, 67% specificity and 35% positive predictive value). The low birthweight
rate was 14%. Four factors (low family functioning, stressful events, Quetelets Index, and cigarette
smoking) predicted low birthweight (65% sensitivity, 84% specificity and 42% positive predictive value).
Family functioning, alone, predicted low birthweight with 65% sensitivity, 64% specificity and 31%
positive predictive value. Family functioning, was the only predictor for both outcomes. Family
functioning and other psychosocial risk factors may potentially improve identification of high risk
pregnant urban black women.
Key words-prenatal

screening, risk assessment, low birthweight, family functioning, stress

INTRODUCHON

The early identification

of pregnant
risk for intrapartum
complications

women

at high

(IPC) and for

delivery of low birthweight (LBW) infants is a prerequisite for the development of cost effective preventive obstetrics programs [l, 21. Such programs are
badly needed to reduce prematurity and other adverse pregnancy outcomes (APO). Low birthweight
infants bear a disproportionate
risk for neonatal
mortality and morbidity; the LBW and infant mortality rates for U.S. blacks are approximately twice
those for whites [3]. The World Health Organization
recently acknowledged the worldwide importance of
prematurity by designating the LBW rate as a global
indicator of health [4]. Primary care providers must
be able to identify high risk women who will benefit
from preventive services, consultation or referral to
appropriate tertiary care obstetrical centers [5].
The usefulness of currently available prenatal risk
scoring systems (RSS) is limited. Their specificity and
sensitivity is generally low [6,7]. Improving the per-

formance of such measures is difficult because of the

relatively infrequent occurrence of most major medical risk factors for prematurity, such as severe preeclampsia and placenta previa [8]. Most available
RSS focus primarily on biomedical factors, often
assuming that psychosocial information, if indeed
pertinent, is difficult for physicians to obtain and
interpret and, furthermore, is considered beyond the
scope of present day obstetrics [9]. However, the
*Correspondence should be addressed to: Dr Kenneth G.
Reeb, Chairman, Department of Family Medicine,
Campus Box 7595-Gravely Building, University of
North Carolina at Chapel Hill, Chapel Hill, NC 27599,
U.S.A.
Presented, in part, at North American primary Care
Research Group Annual Meeting, Seattle, Washington,
April, 1985.

etiology of adverse pregnancy outcomes is probably

multifactorial with a biomedical, psychological and
socioeconomic synergism between stressors [ 10, 111.
The stress response becomes pathogenic, especially in
women with inadequate familial or interpersonal
support or other resources which otherwise might
help them to cope (12, 131. Most risk scoring systems
do not specifically screen for stress or inadequate
support, however.
Present RSS and premature birth prevention programs for urban black women in the United States
have limited effectiveness. These women have an
overall higher risk for prematurity and other adverse
pregnancy outcomes [14]. Any national program to
improve perinatal health should include the development of more effective prenatal risk screening and
preventive services for black women.
This study explores the effectiveness of a practical
RSS, for use with pregnant urban black women,
which combines psychosocial and biomedical factors,
as predictors of two important types of adverse
pregnancy outcomes: intrapartum
complications
(IPC) and low birthweight (LBW) infants. It addresses three related research questions: (1) Which
prenatal medical and psychosocial factors correlate
best with IPC and with LBW in this sample of urban
black pregnant women? (2) gow well do profiles of
independent prenatal factors predict IPC and LBW
in this population? (3) To what extent do prenatal
psychosocial factors account for these two adverse
pregnancy outcomes independent of known biomedical risk factors?
METHODS
Sample

A consecutive sample of 140 black pregnant

women in their seventh month of gestation was

1321

1322

KENNETH G. F&EB et al.

recruited between May 1982 and August 1983. All

women were patients of an urban university hospitalbased family practice center located in Cleveland,
Ohio. Patients are self-referred
to this primary care
facility. Seventy-six women were patients prior to this
pregnancy. Of the 64 women who joined the practice
while pregnant,
47 (34% of total sample) began
prenatal care after their four month of gestation.
Women attend the center for their prenatal care
which is provided by family physicians with on-site
obstetrical consultation
available. Patients judged to
be at obstetrical
risk are referred to the high risk
obstetrics clinic. (Four subjects received some high
risk services.) Intrapartum
care was provided on the
teaching hospitals obstetrical service. Informed consent was obtained prior to a structured interview by
a trained, mature black woman interviewer. Prenatal
and intrapartum
clinical data were obtained
in
routine clinical fashion and were recorded on the
Cleveland Regional Perinatal Network Prenatal Risk
Scoring Forms adopted from Hobel [I 51. Of the 146
eligible women contacted,
140 agreed to participate
for a 96% response rate.
The subjects average age was 24 years with 18%
in the 14-19 year group and 6% 35 years and older.
Twenty-seven
percent were primagravidas.
Eightyone percent were in the two lowest socioeconomic
groups, using Hollingsheads
Index of Social Position
[16]; they were equally distributed with 40.5% each in
Groups IV and V. Thirty-four
percent were married
and an additional
16% unmarried but living with a
partner; thus, 50% of subjects were living with a male
partner.

weeks gestation [17]; (3) cigarette smoking; and (4)

maternal history of a previous preterm birth.
Psychosocial
variables include: (1) stressful life
events which occurred during pregnancy
[ 181; (2)
maternal worries about adjusting to life with a new
baby, a type of anticipated stress (Cronbachs
alpha
reliability = 0.83); (3) two scales of interpersonal
support: emotional (alpha = 0.69) and instrumental
(alpha = 0.64) which use items identified as important
in this population by Stack [19]; (4) maternal depression, using the depression
subscale of the Brief
Symptom Inventory
(alpha = 0.85) [20]; (5) family
size, defined as the number of persons named by the
respondent
as perceived family members
[21]; (6)
family functioning,
defined as the womans perception of her familys instrumental
and emotional activities and her satisfaction
with her familys performance.
Family functioning
was determined
by
scores obtained
on three scales: (1) Smilksteins
five-item Family APGAR [22], using a five point scale
(Cronbachs
alpha reliability = 0.90), with scores
greater than 16 empirically defined as functional and
16 or less as dysfunctional;
(2) a truncated version of
Olsons FACES II [23] with five-item Adaptability
(alpha = 0.59) and Cohension
Subscales (alpha =
0.76); and (3) a shortened
16-item version
of
Hudsons
Index
of Family
Relationships
[24]
(alpha = 0.95). A standardized
composite
z score
consisting of these subscales, was computed for each
woman (alpha = 0.86). This composite
score was
dichotomized
into functional and dysfunctional
categories using an empirically derived cut-off point of
-0.85. (Copies of all instruments are available from
the authors on request.)

Variables

Analysis

Dependent study variables include: (1) intrapartum

complications
and (2) low birthweight infants. Intrapartum complications
cases are operationally
defined
as having three or more significant problems occurring during labor and delivery, as recorded on the
intrapartum
risk form of the Cleveland
Regional
Perinatal Network (CRPN) risk scoring system adopted from Hobel [15]. Severity of intrapartum
problems was judged independently
by two clinicians as
being sufficient to warrant management in a high-risk
obstetrical unit. Twenty-five IPC cases (18% of 136)
were identified in this sample.
Low birthweight
infants are those infants born in
the study weighing 2500 g or less, regardless of their
gestational age. Twenty LBW infants (14% of 139)
were delivered in this study. Missing data on one or
more variables for ten subjects limited final analysis
to a sample of 130 subjects for LBW and to 136
subjects for IPC.
Independent
variables were categorized
as demographic, biomedical
or psychosocial
(see Table 1).
Those associated with either dependent
variable at
P < 0.10 are discussed in the following paragraphs.
Demographic
variables include: (1) maternal
age,
dichotomized
into 13-34 and 3541 years; (2) employment status, dichotomized
into women employed
full-time or on maternity leave versus those employed
part-time, unemployed,
or working as homemakers.
Biomedical variables include: (1) maternal height;
(2) Quetelets Index (weight/height
squared) at 12-l 6

The analysis was conducted

in three stages; univariate analyses, stepwise discriminant
analysis, and
hierarchical
discriminant
analysis. First, univariate
t-test or chi square analyses determined all independent variables significantly
associated with each of
the two dependent
variables. Next, a stepwise discriminant analysis determined
the independent
contribution each of these independent
variables made to
the prediction of the two adverse outcomes, and the
effects of combining
predictors
to yield the best
discrimination
between
groups.
Finally,
a hierarchical discriminant
analysis estimated the independent contribution
psychosocial variables made to the
prediction of adverse outcomes by forcing a block of
demographic
and biomedical variables into the equation in a hierarchical fashion, and then assessing the
increase in the percent of cases correctly classified by
entering psychosocial predictors in the second block.
RESULTS

Table 1 displays a representative

profile of the large
number of demographic,
biomedical
and psychosocial independent
variables
tested for statistical
associations
with IPC and/or LBW. In general, demographic variables tend to be associated with IPC,
and biomedical
and psychosocial
variables
with
LBW. Only one factor, family functioning, a psychosocial variable, was significantly associated with both
outcomes.

Predicting

low birthweight

1323

in black women

Table 1. Probabilities of tests of association between predictor variables and adverse

pregnancy outcomes
Adverse outcomes
Study variables
Demographic

Maternal age c 19
Maternal age > 35 years
Employment status-employed
Socioeconomic status
Maternal education
Household income
Marital status
Household size

Intrapartum
complications

Low
birtbweigbt

0.006
0.03
-

Biomedical

Maternal height
Quetelets Index
Cigarette smoking
Primaparity
Previous preterm birth
Past history:
-Hypertension
-Urinary
tract infection
-Pre-eclampsia
Prenatal risk scores:
-Initial (at registration)
-Developing problems (prenatal)

0.01
-

0.02
0.025
0.09

Psychosocial

Prenatal stressful events

Maternal worries
Interpersonal support:
-Emotional
-Instrumental
Maternal depression
Maternal anxiety
Family size
Family functioning--(Family
APGAR)
Family functioning-(composite)
-Not

0.01
0.01
0.02
0.01
0.01
0.005
0.09
0.006

0.001
0.005

significant at P = 0.10.

Table 2 presents the results of a stepwise discriminant analysis of those prenatal factors which, at seven
months gestation, predict intrapartum
complications. The variables are displayed by their order of
entry in the equation. All variables shown by univariate analyses to correlate significantly with intrapartum complications were eligible for entry into the
analysis.
The composite family functioning score was the
single best predictor of complicated labor and delivery; women in dysfunctional families are at higher
risk. Maternal age, with women 35 and older being
at higher risk, was second. Employment status, with
working women at higher risk, was third. Maternal
height was the fourth variable, with shorter women
being at higher risk. The absence of traditional
biomedical risk factors such as prenatal infections or
pre-eclampsia in this equation is notable.
Table 3 presents the sensitivity and specificity
obtained using this four factor discriminant equation
Table 2. Variables associated with intrapartum

of risk for intrapartum complications. This scale has

a sensitivity of 80%, and a specificity of 67%. In this
sample of women, which has an 18% incidence of
high risk labors, 20 of the 57 women predicted to
have IPC actually experienced complicated labors,
giving this scale a 35% positive predictive value and
a 94% negative predictive value.
Table 4 presents the results of a stepwise discriminant analysis of those prenatal factors which at seven
months gestation predict low birthweight. Family
functioning as determined by the Family APGAR
was the single best predictor of a subsequent low
birthweight infant. Women with low family functioning scores were at higher risk. The reporting of
one or more stressful life events during the course of
pregnancy was the second predictor; Quetelets Index
at 12-16 weeks gestation was the third predictor, and
cigarette smoking of more than one pack per day was
fourth. The profile of women with low family functioning, one or more stressful events, and lower
complications by stepwise discriminant analysis
Means/%

Step
no.
I.

2.
3.
4.

Variable entereh
Family function:
composite score (% < -0.85)
Age: years (% > 35)
Employment status (% working)
Maternal height (mean in.)

Complicated
(n = 25)

Uncomplicated
(n = 111)

to enter

60%
16%
44%
62.8 in.

31%
3%
22%
64 in.

1.91
6.51
5.30
3.94

0.006
0.025
0.025
0.05

For four-variable equation: F = 6.25, df = 4, 131, P < 0.001

1324
Table

KENNETH

3. Discriminant
function
without intrapartum

AClU0l
intrapartum
status

prediction
of women
complications
(IPC)
Predicted

Complicated
(2i%,

(&,
Uncomplicated
Total
x2 = 18.25, df=

$0,
57

(&%,
79

I. P < 0.001. Sensitivity

and

Table

5. Discriminant
function classification
of women
birthweizht and nomml catezories

IPC status

Uncomplicated

Complicated

with

REEB t?t al.

Predicted
Actual birth
Weight status

Total
25
(100%)
Ill
(100%)
136

= 80%; specificity = 67%.

Quetelets indices, who are smokers, was at highest

risk.
The sensitivity and specificity obtained through the
use of this four factor scale to predict low birthweight
are presented in Table 5. A 65% sensitivity and 84%
specificity are obtained. With a 15% incidence of low
birthweight
in the 130 subjects included in the analysis, a 42% positive predictive
value and a 93%
negative predictive value are obtained.
Table 6 displays the results of a hierarchical
discriminant analysis and a univariate prediction model
which both address the extent to which prenatal
family functioning
contributes
to the prediction
of
subsequent IPC. Family functioning adds 20% to the
60% sensitivity obtained using the block of demographic and biomedical variables which were included in the previous stepwise discriminant
equation.
This improvement
in sensitivity is highly statistically
significant (P < 0.005). Family functioning
reduces
the 70% specificity of the previous three variables by
3%, yielding 67% specificity. The 39% positive predictive value is also reduced slightly (-4%).
Family
functioning (composite score) used alone as a predictor of IPC yields a 60% sensitivity, a 70% specificity
and a 3 1% positive predictive value-quite
comparable to that obtained by the combination
of maternal
height, age and employment
status.
Table 7 presents the contribution
made to the
sensitivity and specificity of the prediction of LBW
made by psychosocial
variables, independent
of the
major biomedical
predictors.
Family APGAR and
stress together add 10% to the 55% sensitivity which
was obtained
using the combination
of Quetelets
Index and maternal smoking. These two psychosocial
factors also add 11% to the specificity and 15% to the
positive predictive value of this equation. The Family
APGAR, alone outperforms
the two strongest biomedical
predictors,
yielding
65 %
sensitivity
compared
to the latters 55%, and 74% specificity
compared to 73% and 3 1% positive predictive value,

Table 4. Stepwise discriminant

LBW

N0lXlal

I.
2.
3.
4.

Variable

entered

Family APGAR (% Q 16)

Stressful life events
(% having one or more)
Quetelets Index
(mean at 12-16 week)
Smoking
(% smoking > one pack/day)

For four-variable

equation:

status
Total

Low birthweight
(Z,,

,,:,,

(Z%,
31

(K%)
99

N0lXlal
Total

x2 = 22.04, df = I. P < 0.001. Sensitivity

(HZ%,
110
(100%)
130

= 65%; specificity = 84%.

compared to 27% for the combination

Index and smoking.

of Quetelets

DISCUSSION

This study distinguishes

between two types of
adverse pregnancy
outcomes-intrapartum
complications and low birthweight
infants-and
presents
evidence for different risk profiles for each outcome
in a sample of urban black women. Existing risk
scoring systems either address high risk pregnancies
in general or focus on one condition
such as prematurity
or intrauterine
growth retardation.
The
former, nonspecific,
approach
decreases a scoring
systems predictive value. Risks of intrapartum
complications have received little attention. Those problems which occur during labor and delivery have been
included as risk factors in scoring systems for subsequent pediatric problems such as mental retardation, as opposed to using them as dependent variables [ 151. Earlier identification
of women-at-risk
for
problems of labor and delivery in regionalized perinatal care systems could reduce resultant maternal
and infant morbidity and mortality by enabling referral of these women to tertiary care obstetrics
facilities.
The risk profiles developed for both outcomes in
this study are generated from the broad profile of
biopsychosocial
factors summarized in Table 1. Some
of the factors included in these risk profiles are
known to be predictors
of adverse pregnancy
outcomes. Advanced maternal age [9,26,28], maternal
short stature [26,27], low maternal weight in early
pregnancy [26,27], and cigarette smoking [26,27] are
included in other scoring systems. Working during
pregnancy is a controversial
risk factor. However, it
has been associated
with prematurity
in France,
where an intervention
program
includes releasing
pregnant women from heavy work duties [29]. The
role of stress is receiving increasing attention, but it

analysis

of low birthweight

(LBW) status

MIXIS/%
step
no.

birthweight

into low

LBW
(n = 20)

Normal
(n = 110)

to eFnter

65%

27%

12.48

0.001

85%

55%

9.44

0.001

22. I

25.5

7.40

0.001

40%

16%

5.10

0.02

F = 9.34, d f = 4, 125, P < 0.001.

Predicting low birthweight in black women :,

Table

6. Sensitivity/specificity

of intrapartum
status: hierarchical
prediction models (n = 136)

Variables
Block 1:
Height
Age
Employment
Block

Sensitivity
W)

1325

and univariate
Positive
predictive
value
W)

Specificity
W)

60

70

39

20
80

-3
67

-4
35

60

70

31

2:

Family functioning*
(composite)
Total
Family functioning
(composite), alone
F = 7.92, 1, 131 d/, P < 0.005.

Table 7. Sensitivity/specificity
of low birthweight status: hierarchical
variate prediction models (n = 130)

Variables
Block 1:
Quetelets Index
Smoking
Block 2:
Family APGAR*
Stresst
Total
Family APGAR, alone

Sensitivity
W)

Specificity
W)

and uni-

Positive
predictive
value
W)

55

73

27

10
65
65

II
84
74

15
42
31

F= 7.92, 1, 126 df, P <0.005.

tF = 5.64, 1, 125 dJ P < 0.025.

has not been systematically included in existing

scoring systems [12,30]. Family functioning has received even less attention [31, 321. Although it is
difficult to determine causality, the strong association
between a pregnant womans satisfaction with her
family and both types of subsequent adverse pregnancy outcomes suggests that her immediate social
support network may play an important role in the
healthy progress of her pregnancy. It is also possible
that other, unexamined factors may play a role.
The lack of association between marital status and
adverse pregnancy outcomes in this study differs from
previous reports [26-281. Neither being unmarried
nor living apart from the babys father significantly
increased a pregnant womans risks for an adverse
outcome. However, this studys new measurements of
the size and functioning
of the womans selfperceived family predicted one or both types of
problems. For example, the fewer the number of
kinfolk a woman perceives as members of her family,
the greater her chances for intrapartum complications. Alternative family structures seem capable of
substituting for the nuclear family. The functional
capability of these urban black families appears to be
independent of traditional structures.
A substantial number of other demographic and
biomedical risk factors which have been identified in
other studies did not yield statistically significant
associations with our study outcomes. The relative
homogeneity of demographic factors such as the
socioeconomic status of this population may reduce
their impact on these women. The relatively small
sample size may have provided insufficient numbers
of clinically important, but infrequently-occurring

biomedical factors, such as pre-eclampsia, to permit

them to reach statistical significance. Self-selection of
women attending this primary care facility could also
have excluded a few potentially high risk women, and
a small number of women with biomedical problems
may have been referred out of this practice prior to
the third trimester enrollment time. On the other
hand, the 15% LBW rate in this sample is comparable to the 1982 reported prematurity rate of 14.5% in
the census tracts in which most of these patients
reside [25] and to the 1980 rate of 12.5% for black
infants in the United States.
Psychosocial factors, particularly family functioning, are shown to be strong predictors of adverse
pregnancy outcomes in this study. Despite growing
evidence for the role of psychosocial risk factors in
pregnancy, both from direct empirical studies and
from indirect epidemiologic evidence (such as the
marked disparity in prematurity and infant mortality
rates for blacks and whites in the United States),
psychological arCd social factors have received scant
attention in most currently used risk scoring systems.
These systems ignore the multifactorial causation of
preterm delivery and the nature of pregnancy as a
sociobiological process. The inclusion of brief indices
of psychosocial factors such as family functioning
and stressful life events, promises to improve the
predictive value of prenatal risk scoring systems. To
the extent that these factors can be corrected, they
may also serve as fruitful prospects for future preventive interventions.
It will be important to confirm whether these
findings based on maternal factors at seven months
gestation also replicate in early pregnancy, when

KENNETH G. REEB et al.

1326

preventive interventions
would be more likely to be
effective.
This study focuses on pregnant
urban black
women, a population
at empirically
high risk for
prematurity
and for infant mortality in the United
States [3]. These rates are particularly high in many
cities in the Northeastern
U.S. In 1982, the city of
Cleveland
reported
infant
mortality
rates
of
16.3/1000 for white infants and 29.7/1000 for blacks
[25]. To date, risk scoring systems have not focused
on particular
sub-population
groups. An ethnic or
racial group-specific
risk system is likely to improve
precision. In addition, psychosocial instrument scores
may differ between ethnic groups. For example, a
colleague found significant differences between mean
scores of these family functioning
instruments
for
low-income
blacks
compared
to middle-income
blacks
and to low- and middle-income
whites
(M.
Schein,
personal
communication,
1985).
Although previous studies have shown associations
between other psychosocial
variables and adverse
pregnancy
outcomes
[1 l-1 3.31.321.
it should be
emphasized that the factors identified here are based
on current state-of-the-art
questionnaires
and that
they are strong predictors of these outcomes in low
income urban black women.
Development
of a broadly-based,
biopsychosocially-oriented
prenatal risk scoring system appears
to be feasible, judging
by the strength
of these
reported associations.
Each of these factors can be
converted to a practical, clinical questionnaire.
Thus,
they can be incorporated
in any one of several
existing RSS to produce a screening device tailored
for use in urban black pregnant women. An effective
screening program can then be coupled with a preventive intervention
program focused on women at
highest risk. This can improve the programs practicality and its likelihood of effectiveness in reducing
the distressingly
high prematurity
and infant mortality rates among U.S. urban black women. A logical
outgrowth of our findings will be a family-oriented,
support-building,
stress-lessening
intervention
designed to reduce adverse pregnancy outcomes. Olds
er al. [33] have reported
a similar trial in rural,
predominantly
white women.
One key to improving the maternal-fetal
health of
black women in the United States may be to broaden
t:ic xope of prenatal assessment and maternal health
service.; to include a psychosocial
and family focus.
Decreasing
adverse pregnancy
outcomes
in urban
biack women may well become a family matter.

2.
3.

4.
5.

6.

7.

8.

9.

IO.

I I.
12.

13.

14.

15.

16.

17.
18.

19.
20.

Acknowledgements-We

are indebted to Sandra McGee,

Patricia Ross and Julie Ziegler for technical assistance and
to Jean Szucs for preparation
of the manuscript.
This
research was supported
in part by the Robert Wood Johnson Foundations
Research and Development
Program to
Improve Patient Functional
Status (grant no. 7144) and was
aided by Social and Behavioral Science Research grant no.
12-156 from the March of Dimes Birth Defects Foundation.

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