Journal of Perinatology (2016) 36, 4146

2016 Nature America, Inc. All rights reserved 0743-8346/16

www.nature.com/jp

ORIGINAL ARTICLE

Delivery modes and pregnancy outcomes of low birth weight

infants in China
Y Chen1, L Wu2, W Zhang1, L Zou1, G Li1 and L Fan1
OBJECTIVE: To investigate and analyze the perinatal outcomes of low birth weight (LBW) infants, thereby selecting the appropriate
mode and suitable time of delivery to improve the adverse pregnancy outcomes.
STUDY DESIGN: A retrospective analysis of 112 441 deliveries (from 39 hospitals of different levels in 14 provinces and autonomous
regions in China throughout 2011) were performed in this study to further evaluate the modes of delivery and pregnancy outcomes
of LBW infants.
RESULTS: The rate of cesarean section, stillbirth, neonatal asphyxia and mortality of LBW were signicantly higher than those of
normal birth weight (NBW) infants (odds ratio, 1.24, 56.56, 57.27 and 10.40 times higher, respectively). Stratied analysis showed
that adverse events were reduced with the increase in gestational weeks, especially at 34 to 36+6 weeks. However, LBW infants still
had higher risks of adverse events as compared with NBW infants. In particular, full-term LBW babies had a 23.81- and 26.06-fold
higher risk of stillbirth and neonatal death as compared with term babies with NBW. In addition, the cesarean delivery rate was
1.24-fold higher for LBW babies than for NBW babies. With an increase in gestational age in LBW infants, the rate of cesarean
section was also increased. The rates of stillbirth and neonatal mortality of full-term LBW infants who were delivered via cesarean
section (0.5% and 1.0%, respectively) were signicantly lower than in the vaginal-delivery group (5.2% and 6.9%, respectively).
CONCLUSION: LBW is one of the causes of perinatal death and other adverse pregnancy outcomes and increases the rate of
cesarean section. Individualized analysis according to gestational age and intrauterine fetal condition should be performed to
extend the gestational age to at least 34 weeks before delivery, cesarean section is a relatively safe mode of delivery, but cannot
completely eliminate complications. The key to improving mother and child outcomes is to strengthen pregnancy care and reduce
low birth weight infants and premature birth. LBW is one of the causes of adverse pregnancy outcomes in both premature and fullterm infants and increases the rate of cesarean section. Individualized analysis of the mode of delivery should be performed to
extend the gestational age to 34 weeks and so improve the survival rate.
Journal of Perinatology (2016) 36, 4146; doi:10.1038/jp.2015.137; published online 5 November 2015

INTRODUCTION
The development of society and economy and the progress of
modern medicine have seen the levels of treatment in prenatal
high-risk infants gradually increase, resulting in a higher incidence
of preterm delivery and low birth weight (LBW) infants. LBW is a
major cause of adverse perinatal outcomes and closely associated
with incidence of neonatal diseases and mortality. A review of the
literature shows a strong correlation between LBW in infants and
signicantly increases infant mortality, and also that it is a serious
threat to childrens health. Preterm birth is usually associated with
LBW, reduced gestational age, lower weight and a greater risk of
infant mortality.1,2 In addition, LBW infants are closely associated
with increased risks of hypertension, diabetes, other metabolic
diseases, mental illnesses and psychological problems in adulthood, placing a considerable burden on families and society.3,4 A
statistical analysis in China from 1996 to 2013 regarding preterm
labor or LBW, showed that infant mortality was declining.
However, the rate of infant mortality due to LBW or preterm
birth was increased, and LBW or preterm birth was seen as one of
the primary causes of infant mortality and threatened infant
health in China.5 In this study, a large-scale, multi-center analysis
was conducted to determine the appropriate mode and time of

delivery. This study provides a strong basis for further improvement of LBW pregnancy outcomes.
MATERIALS AND METHODS
This study was performed in seven administrative regions in northeastern,
northwestern, northern, central, eastern, southern and southwestern China
to randomly and proportionally select a number of hospitals (n = 39, at
different levels) in each region, covering a total of 14 provinces and
autonomous regions. A total of 112 441 deliveries performed in these
hospitals in 2011 were analyzed retrospectively. The clinical data collected
for each case included general information, medical history, prenatal care,
pregnancy complications, mode of delivery and pregnancy outcomes. To
protect patients privacy, data collection did not include the patients
name, phone number or home address. Exclusion criteria: incomplete basic
data; miscarriage before 28 weeks of gestation; fetal anomalies; and
intrauterine fetal death.
The questionnaire was designed by obstetric and statistical experts from
China and its feasibility was repeatedly discussed. The Beijing Obstetrics
and Gynecology Hospital at Capital Medical University served as the center
of the investigation. Investigators from all research units received the same
training to assess all pregnancy outcomes in various subunits, followed by
paper data entry and uploading data to the network. Specialized personnel
in each region were responsible for data-quality control. After collecting all

1
Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China and 2School of Public Health, Beijing Key Laboratory of
Epidemiology, Capital Medical University, Beijing, China. Correspondence: Dr L Fan, Department of Obstetrics, Beijing Obstetric and Gynecology Hospital, Capital Medical
University, Beijing 100026, China.
E-mail: fanling8027@sina.cn
Received 31 December 2014; revised 17 September 2015; accepted 22 September 2015; published online 5 November 2015

Low birth weight outcomes

Y Chen et al

42
data, the staff of the investigation center performed another round of
data-quality control and statistical data analysis. Gestational ages of all
pregnant women were determined and calculated based on the last
menstrual period. A rst trimester ultrasound was performed to conrm
the gestational age.
LBW refers to neonates with birth weights lower than 2500 g. Preterm
birth was dened as delivery after at least 28 weeks of gestation, but no
437 weeks of gestation. The diagnostic criteria of smaller than gestational
age and gestational hypertension were set in reference to the diagnostic
criteria in the book Obstetrics and Gynecology.6 Gestational diabetes refers
to the rst incidence of various degrees of impaired glucose tolerance
during the pregnancy. The threshold level of oral glucose tolerance test
results at fasting, 1 h and 2 h was 5.1, 10.0 and 8.5 mmol l 1 (92, 180,
153 mg dl 1), respectively. Any case in which these blood glucose levels
met or exceeded the aforementioned threshold values was diagnosed as
gestational diabetes mellitus.7
Data were analyzed using SPSS 18.0 statistical analysis software
packages. A descriptive analysis of birth weight was carried out. 2-tests
were performed to test for different outcomes comparing NWB and LBW.
For preterm infants, we performed stratied analysis to further explore the
effect of gestational age on study outcomes. Adjusted odds ratios for all
variables that were signicantly associated with outcome were computed
using a multiple logistic regression model for controlling the simultaneous
confounding effects of possible confounders. All statistical tests were twosided, and Po0.05 was considered to be statistically signicant.
The study and the electronic database used for this study were
approved by the Institutional Review Board of Beijing Obstetrics and
Gynecology Hospital in accordance with the Helsinki Declaration. Patient
consent for entry into the database was obtained from all participants and
patients were aware that this information would be used for research
purposes.

RESULTS
In this study, data were obtained from 112 441 cases and 8763
cases were excluded to produce a complete data set of 103 678
cases (accounting for 92.2% of all the data). The average birth
weight of newborns was 3263.04 540.29 g. A total of 7474 cases
were diagnosed as LBW (incidence = 7.2%), which involved 2.3%
(2,214/95,116 cases) of full-term LBW infants and 61.4% (5260/
8562 cases) of preterm LBW infants.
Comparison of perinatal outcomes of infants with normal and LBW
This study analyzed the intrapartum complications and neonatal
outcomes in cases of LBW. Prognostic analysis of LBW infants
showed the rate of cesarean section, stillbirth and the incidences
of neonatal asphyxia and death in LBW group to be 62.0%, 7.3%,
14.4% and 10.9%, respectively, These value were signicantly
higher than those of normal birth weight (NBW) infants, and the
differences were statistically signicant (P o0.001). A multivariable
logistic regression analysis were performed to control for the
possible simultaneous confounders and to explore any further
associations between exposure and adverse outcomes. The
confounding factors included maternal age, education, parity,
maternal gestational diabetes mellitus, gestational hypertension,

Table 1.

multiple pregnancies and abnormal amniotic uid. The adjusted

odds ratio showed that LBW had a higher risk for stillbirth,
neonatal death, neonatal asphyxia and neonatal complications
than infants with NBW (odds ratio, 56.56, 57.27, 10.40 and 14.21
times higher, respectively) (Table 1). Here, stratied analysis was
performed to further explore the effects of gestational age on
study outcomes. The neonates delivered preterm were stratied
from those delivered at term, Even among preterm infants,
perinatal outcomes such as neonatal asphyxia, stillbirth and
neonatal death were very different from those of infants born at
28 to 33+6 weeks, those born at 34 to 36+6 weeks and those born
at term age. Pregnancy outcome improved as gestational age
increased. Although the general outcomes proved to be better,
the infants born at 34 to 36+6 weeks with LBW still exhibited a
higher risk for adverse perinatal events as compared with those
with NBW. In full-term LBW babies, the risks for stillbirth and
neonatal death were 23.81- and 26.06-fold higher than that for
full-term NBW babies. In addition, the risks for neonatal asphyxia
and neonatal complications were also 4.34- and 6.12-fold higher in
LBW babies compared with NBW babies (Table 2).
Because most of the preterm infants have low body weight, to
investigate the relationship between gestational age and adverse
perinatal events, the preterm infants were divided into two
subgroups: infants who were small for gestational age (SGA) and
infants who were appropriate for gestational age (AGA). The
confounding factors, including maternal age, education, number
of delivery, and pregnancy complications, were excluded from the
analysis. Multivariate regression analysis showed that the outcomes of SGA and AGA improved as the number of gestational
weeks increased. The incidences of stillbirth, neonatal asphyxia
and neonatal death were all lower when the baby was born at 33
to 34+6 weeks. However, regardless of gestational age, the risk of
adverse events was higher in SGA than in AGA. In fact, for full-term
SGA babies, the risk of stillbirth and neonatal death was 8.98- and
11.21-fold higher than for full-term AGA ones. The overall risks of
stillbirth, neonatal death, neonatal asphyxia and complications
were 9.58-, 10.16-, 3.03- and 3.51-fold higher in SGA than for AGA,
respectively (Table 3).
Modes of delivery were analyzed across different gestational
ages, and results showed that the rate of cesarean section
increased with increasing gestational age from week 28 to week
36. The cesarean delivery rate was 60.89, 69.63 and 66.34% for the
LBW babies born at 33 to 34+6, 35 to 36+6 and at full term,
respectively (Table 4). The rates were 1.22-, 1.44 and 1.63-fold
higher than those for NBW babies born in the same gestational
period.
The indications of cesarean section were analyzed. In the babies
with NBW, social factors (no medical indication) contributed to
35.79% of cesarean section deliveries. Maternal and fetal factors
were the main indication of cesarean section in cases with LBW
infants. There were 3.90-fold more cesarean section deliveries
caused by maternal factors in LBW infants than in NBW ones.

Compare perinatal outcomes of normal birth weight infants and low birth weight infants

Outcome

Rate of CS
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

NBW

LBW

OR (95%CI)

47792
125
163
1306
314

53.6
0.1
0.2
1.49
0.3

4457
531
811
963
210

62.0
7.3
10.9
14.4
3.2

1.24
54.19
65.47
10.97
9.95

(1.191.30)
(44.8665.45)
(55.5877.12)
(10.0611.95)
(8.3411.87)

OR adj (95%CI)

1.24
56.56
57.27
10.40
14.21

(1.151.35)
(41.5776.96)
(43.6975.08)
(9.0911.90)
(11.0718.23)

Abbreviations: CI, condence interval; CS, cesarean section; LBW, low birth weight; NBW, normal birth weight; OR, odds ratio.

Journal of Perinatology (2016), 41 46

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Low birth weight outcomes

Y Chen et al

43
Table 2.

Analyze stratied perinatal outcomes of normal birth weight infants and low birth weight infants by gestational age

Outcome

NBW (%)

2833+6 weeks
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

2 (7.4)
8 (17.8)
1 (2.3)

LBW (%)

OR (95%CI)

OR adj (95%CI)

270
430
546
116

(11.8)
(17.6)
(23.8)
(5.1)

4.60 (1.1119.07)
1.79 (0.833.88)
2.75 (0.3820.13)

4.15 (0.9717.69)
1.41 (0.623.20)

3.33
3.54
2.94
2.77

3436+6 weeks
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

37
48
105
31

(1.2)
(1.5)
(3.3)
(1.0)

77
108
243
68

(2.9)
(4.0)
(9.1)
(2.7)

2.60
2.81
3.05
2.79

37 weeks
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

101
129
1309
281

(0.1)
(0.1)
(1.4)
(0.3)

44
59
114
22

(2.4)
(3.2)
(6.1)
(1.1)

20.02
21.76
4.38
3.40

(1.733.82)
(1.993.97)
(2.413.86)
(1.824.28)
(14.1328.38)
(16.1029.41)
(3.635.28)
(2.205.26)

23.81
26.06
4.34
6.12

(2.055.42)
(2.315.43)
(2.253.85)
(1.674.60)
(15.0736.11)
(18.1937.33)
(3.55.38)
(3.7010.12)

Abbreviations: CI, condence interval; LBW, low birth weight; NBW, normal birth weight; OR, odds ratio.

Table 3.

Analyze stratied perinatal outcomes of AGA and SGA infants by gestational age

Outcome

AGA (%)

SGA (%)

OR (95%CI)

OR adj (95%CI)

+6

2832 weeks
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

118
180
298
67

(10.0)
(14.9)
(28.0)
(6.5)

111
167
152
27

(26.8)
(38.4)
(50.2)
(9.9)

3.30
3.57
1.79
1.58

(2.274.41)
(2.784.58)
(0.833.88)
(0.992.53)

4.18
4.75
2.15
1.31

(2.796.26)
(3.366.71)
(1.513.05)
(0.672.55)

3334+6 weeks
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

41
58
114
28

(3.0)
(4.2)
(8.6)
(2.1)

42
57
90
16

(11.8)
(15.4)
(28.7)
(5.1)

4.35
4.17
4.29
2.50

(2.786.80)
(2.846.13)
(3.155.86)
(1.334.67)

7.13
6.92
3.12
2.16

(3.9512.87)
(4.1111.67)
(2.074.70)
(0.984.79)

3536+6 weeks
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

45
60
156
53

(1.1)
(1.5)
(3.9)
(1.3)

27
39
96
25

(3.7)
(5.2)
(13.0)
(3.6)

3.41
3.75
3.70
2.78

(2.105.52)
(2.495.65)
(2.824.85)
(1.714.50)

5.23
5.40
3.20
3.25

(2.919.43)
(3.248.98)
(2.304.44)
(1.845.73)

37 weeks
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

93
114
1228
266

(0.1)
(0.1)
(1.4)
(0.3)

55
80
208
38

(0.9)
(1.3)
(3.6)
(0.6)

8.95
10.59
2.62
2.17

(6.4012.50)
(7.9514.11)
(2.563.04)
(1.543.05)

8.98
11.21
2.32
3.29

(6.0713.29)
(7.9415.57)
(1.972.74)
(2.164.99)

Total
Stillbirth
Neonatal death
Neonatal asphyxia
Neonatal complication

297
412
1796
414

(0.3)
(0.4)
(1.9)
(0.6)

235
343
542
106

(3.2)
(4.6)
(7.6)
(1.5)

10.45
11.06
4.23
3.44

(8.7912.42)
(9.5612.79)
(3.834.67)
(2.774.26)

9.58
10.16
3.03
3.51

(7.7111.90)
(8.4712.20)
(2.693.41)
(2.674.60)

Abbreviation: AGA, appropriate for gestational age; CI, condence interval; OR, odds ratio; SGA, small for gestational age.

Among these factors, hypertensive disorders due to pregnancy

and gestational diabetes mellitus led to 8.06- and 2.66-fold more
cesarean section deliveries for LBW than for NBW infants. Older
maternal age and oligohydramnios led to 1.49- and 1.34-fold
more cesarean section deliveries for LBW than for NBW infants.
However, the cesarean section deliveries caused by fetal factors
were 4.66-fold more in LBW infants than in NBW ones. Among the
fetal factors, fetal growth restriction and multiple pregnancies led
to 87.01- and 15.38-fold more cesarean-section deliveries for LBW
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than for NBW infants; in addition, the number of cesarean section

deliveries due to abnormal fetal position or fetal distress was
greater in LBW infants than in NBW. The emergency cesarean
section rate was also 2.03-fold higher for LBW babies than for NBW
ones (Table 5).
In this study, the impact of different modes of delivery on LBW
pregnancy outcomes at different gestational ages was analyzed.
Results showed that the rates of stillbirth and neonatal death of
full-term LBW infants who had been delivered via cesarean section
Journal of Perinatology (2016), 41 46

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44
Table 4.

Comparison of different gestational age mode of delivery of

normal birth weight infants and low birth weight infants
Mode of delivery

NBW (%)

LBW (%)

OR (95%CI)

+6

2832 weeks
Vaginal delivery
Cesarean section

2 (66.67)
1 (33.33)

3334+6 weeks
Vaginal delivery
Cesarean section

126 (43.90)
161 (56.10)

3536+6 weeks
Vaginal delivery
Cesarean section

840 (50.97)
1.00
808 (49.03) 1.92 (0.1721.26)
575 (39.11)
1.00
895 (60.89) 1.22 (0.941.57)

1149 (38.15) 561 (30.37)

1.00
1863 (61.85) 1286 (69.63) 1.40 (1.241.58)

37 weeks
Vaginal delivery 42036 (45.31) 745 (33.66)
1.00
Cesarean section 50739 (54.69) 1468 (66.34) 1.63 (1.491.79)
Abbreviations: LBW, low birth weight; NBW, normal birth weight; OR,
odds ratio.

Table 5.

(0.5 and 0.9%, respectively) were signicantly lower than in the

vaginal-delivery group (5.2% and 6.7%, respectively) (P = 0.000).
Preterm birth LBW infants showed the same trend (P = 0.000).
DISCUSSION
According to World Health Organization (WHO), LBW infants are
dened as newborns with birth weight below 2500 g. With the
social and economic development, and as modern medicine has
fostered the gradual improvement of treatment of high-risk
perinatal infants, the incidences of preterm delivery and LBW
infants have increased gradually every year. This study showed the
overall incidence of LBW in China to be 7.2%, which was higher
than that reported in 2000 (5.87%).8 This may be due to the
continuous improvement in the levels of treatment of preterm
delivery and in obstetric interventions, which to some extent
increased the rate of premature birth and resulted in the
occurrence of LBW. Premature delivery is the leading cause of
perinatal and neonatal death in many countries, including China.9
LBW infants account for a large proportion of preterm infants. This
issue has been drawing more and more attention globally.10,11

Comparison of different indications of cesarean of NBW and LBW

Indication

NBW (%)

LBW (%)

OR (95%CI)

Time of CS
Scheduled CS
Emergency CS

36198 (68.66)
16523 (31.34)

2330 (51.86)
2163 (48.14)

1
2.03 (1.922.16)

Indication of CS
Social factors
Maternal factors
Fetal factors

13920 (35.79)
15555 (39.99)
9421 (24.22)

342 (11.75)
1489 (51.17)
1079 (37.08)

1
3.90 (3.464.39)
4.66 (4.125.28)

Maternal age
o35 years old
35 years old

37030 (87.96)
5069 (12.04)

2687 (83.06)
548 (16.94)

1
1.49 (1.351.64)

Multiple pregnancies
No
Yes

51709 (98.00)
1056 (2.00)

3422 (76.10)
1075 (23.90)

1
15.38 (14.0416.86)

Fetal distress
No
Yes

48036 (91.04)
4728 (8.96)

4028 (89.57)
469 (10.43)

1
1.18 (1.071.31)

Gestational hypertension
No
Yes

49788 (94.38)
2964 (5.62)

3035 (67.56)
1457 (32.44)

1
8.06 (7.508.67)

GDM
No
Yes
DM

49557 (93.93)
3107 (5.89)
98 (0.18)

4181 (92.97)
294 (6.54)
22 (0.49)

1
1.12 (0.991.27)
2.66 (1.674.23)

Fetal growth restriction

No
Yes

52672 (99.83)
92 (0.17)

3902 (86.81)
593 (13.19)

Amniotic uid volume

Normal
Oligohydramnios
Polyhydramnios

48974 (92.82)
2849 (5.40)
940 (1.78)

4089 (91.01)
318 (7.08)
86 (1.91)

1
1.34 (1.191.51)
1.10 (0.881.37)

Position of the fetus

Cephalic
Breech
Transverse

48610 (92.40)
3646 (6.93)
350 (0.67)

3649 (84.02)
617 (14.21)
77 (1.77)

1
2.25 (2.062.47)
2.93 (2.293.96)

1
87.01 (69.99108.64)

Abbreviations: CI, condence interval; CS, cesarean section; DM, diabetes mellitus; GDM, gestational diabetes mellitus; LBW, low birth weight; NBW, normal
birth weight; OR, odds ratio.

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45
In 2005, WHO proposed to reduce the incidence of LBW by 1/3 in
2010.12,13 The US Department of Health and Human Services also
proposed to reduce the incidence of LBW to 5% by 2020.14 For
these reasons, as a developing country, China should pay more
attention to the occurrence of LBW.
This study assesses the adverse outcomes such as the rate of
cesarean section, neonatal asphyxia, stillbirth, neonatal death and
neonatal complications between LBW infants and NBW infants,
and to evaluate their different intrapartum and postpartum
pregnancy outcomes. Findings showed that LBW infants were
associated with adverse pregnancy outcomes. The rate of
cesarean section and incidences of neonatal asphyxia, stillbirth,
neonatal death and neonatal complication were signicantly
higher in LBW infants than NBW infants. Perinatal outcomes were
very different across different gestation ages. Pregnancy outcome
improved as gestational age increased. At 34 gestational weeks,
the incidences of stillbirth, neonatal death and complications in
LBW infants were reduced signicantly, but were still several-fold
higher than in NBW infants. Importantly, term babies with LBW
had higher risks of adverse pregnancy outcomes than those with
NBW. These facts suggested that in addition to gestational factors,
LBW is an independent risk factor for adverse pregnancy events.
Birth weight and gestational age directly affect pregnancy
outcomes and prognoses. Premature birth and LBW are the major
causes of perinatal adverse outcomes and closely associated with
stillbirth, neonatal asphyxia and neonatal death.11 As most of the
preterm infants had LBW, to investigate the effects of gestational
age on the pregnancy outcomes, we performed stratied analysis
in preterm infants using SGA or AGA as stratum and obtained
similar results. LBW were at high risk for adverse outcomes of
pregnancy at levels similar to those of preterm infants and SGA
infants. These results were consistent with previous reports.11 The
outcomes of infants with SGA improved as the gestational ages
increased; the incidence of stillbirth, neonatal asphyxia and
neonatal death reduced signicantly when the gestational age
reached 33 to 34+6 weeks. Because LBW or SGA infants usually
showed fetal growth retardation, the nutrient exchanges between
mother and fetus were impaired, affecting oxygen and nutrient
uptake by the fetus and the development of the brain and heart.
Chronic intrauterine hypoxia may also occur especially when the
mothers are under stress or have problems affecting maternalfetal circulation during uterine contractions. This can cause
decompensation, exacerbated hypoxia and acidosis, resulting in
adverse pregnancy outcomes such as stillbirths and neonatal
death. It is also noteworthy that although full-term SGA babies
had overall lower incidences of adverse perinatal events, they
showed higher risks for such adverse events than did AGA babies
at other gestational ages. This fact suggested that the most of the
growth restrictions in full-term SGA babies were due to pathologic
causes. Therefore, full-term SGA babies should be monitored more
closely and evaluated more comprehensively to avoid adverse
events.
In recent years, the global rate of cesarean section has
increased, and the rate of cesarean section in China is far higher
than in western countries, over one-third of cesarean section
deliveries of NBW had no medical indications. This phenomenon
may be caused by Chinas one-child policy, overall lack of medical
knowledge, insufcient natural childbirth propaganda and so on;
and should draw more attention by public and medical care
practitioners. LBW is an important indication for cesarean section.
In this study, the rate of cesarean section among LBW infants was
signicantly higher than in the NBW group. The main indications
of cesarean section for LBW were fetal factors including fetal
growth restriction, multiple pregnancies and fetal depression; as
well as maternal factors including gestational hypertension,
gestational diabetes, abnormal amniotic uid and other pregnancy complications. These facts suggested that LBW is associated
with maternal and fetal complications; and pregnancy
2016 Nature America, Inc.

complications may lead to preterm birth, fetal growth restrictions

and LBW. Because of the co-existence of pregnancy complications,
low body weight and restricted intrauterine development, LBW
babies generally showed poor overall tolerance, which may lead
to increased cesarean section delivery rates. This result was
consistent with the study by Coutinho et al.,15 who reported that
the cesarean section rate of LBW cases was 2.4 times as high as
that of NBW group. With increasing gestational age in the preterm
LBW infants, the rate of cesarean section also increased to 60.89%
at 33 to 34+6 weeks. However, LBW cases with low gestational age,
most of them require early delivery due to complications or fetal
intrauterine distress. These cases have been related to growth
retardation, poor neonatal survival and uncertain long-term
prognosis. In addition, high medical costs are usually found in
children who were born preterm in China, Particularly in some
areas with poor medical infrastructure and low socioeconomic
levels, most of the preterm LBW cases were naturally abandoned
without treatment or resolved by therapeutic labor induction and
vaginal delivery. In this study, the selection of vaginal delivery for
fetus with low gestational age was consistent with a previous
report.16
China is a developing country; and the health-care quality in
China is relatively low, especially in some remote rural areas,
compared with other developed countries. In addition, the
treatment and survival rates of preterm babies vary among
different regions; and due to the high cost of treatment and
uncertainty of treatment outcomes, the health-care providers and
parents of preterm babies may not be proactive. This is particularly
true in underdeveloped areas, where babies with very low birth
weight or extremely low birth weight may not receive necessary
medical care. Only babies at 33 to 34+6 weeks of gestational age
which typically have higher survival rateare treated proactively.
This fact reects the current state of medical care in China. For
preterm LBW infants, different gestational ages and corresponding
pregnancy outcomes are closely correlated with each other.13 As
gestational age increases, the incidence of neonatal asphyxia,
stillbirth and neonatal death gradually decreased from 28 to
36 weeks of pregnancy. For cases with gestational age above
34 weeks (closer to full-term pregnancy), there were signicantly
more surviving neonates and more active treatment was used to
prevent reduced blood ow between the placental villi when the
uterus contracts during labor and to minimize fetal distress.
Hence, these cases were normally handled with cesarean section
for early delivery. The delivery modes of LBW infants directly affect
pregnancy outcome.17 In the present study we demonstrated that
the risk of LBW-associated stillbirth, neonatal complications and
neonatal death was less pronounced with cesarean section than
with vaginal delivery. These results are consistent with the results
of a study by Coutinho et al.15 Cesarean section may then prevent
the aggravation of hypoxia caused by vaginal delivery. Cesarean
section may also prevent the intracranial bleeding and infection of
newborns sometimes observed in vaginal delivery. We therefore
agree with others that cesarean section is generally a safer mode
of delivery mode for LBW infants than vaginal delivery.17 LBW is
one of the reasons for the increased rate of cesarean section
in China. It is necessary to strengthen the monitoring and
standardize the management of pregnancies to detect fetal
growth retardation, provide appropriate intervention and ensure a
reasonable range of fetal weight, thereby minimizing the rate of
cesarean section and improving the level of prenatal care.
Our study possesses certain limitations, as although these
results may apply to our population, they may not necessarily
apply to others. Furthermore, preterm birth is dened in China as
delivery after at least 28 weeks of gestation but no 437 weeks of
gestation, different from other developed countries. Therefore,
compared with developed countries, our study may underestimate the overall risk. In addition, due to the limitations of
medical resources in some remote primary care hospitals, medical
Journal of Perinatology (2016), 41 46

Low birth weight outcomes

Y Chen et al

46
data are often incomplete, such that we cannot always accurately
analyze the incidence of LBW within this part of the population.
We need to rst improve our primary healthcare in these remote
areas, and thereby strengthen our statistical power so as to make
the results more representative to the general population.
In summary, LBW is associated with severe adverse outcomes in
pregnancy, and fetal complications may occur at different
gestational ages; in addition, there are no standards regarding
mode of delivery or time of procedure in LBW cases. Although the
incidence of adverse perinatal outcomes was signicantly lower
after 34 weeks of pregnancy in China, it was associated with very
poor outcomes compared with NBW. Cesarean section is only a
mode of delivery and not always a suitable therapy. It alleviates
the incidence of stillbirths and neonatal deaths but cannot
completely eliminate complications. The key to reducing neonatal
complications and improving LBW adverse outcomes, then, is to
strengthen perinatal care, thus avoiding the risk to mothers and
infants. Active prevention and reasonable intervention are
necessary to reduce LBW and premature delivery; and to ensure
perinatal safety and improve overall quality of the health of the
general population.
CONFLICT OF INTEREST
The authors declare no conict of interest.

ACKNOWLEDGEMENTS
The 39 participating hospitals included NanFang Hospital of Southern Medical
University (Yanhong Yu), Afliated Obstetrics and Gynecology Hospital of
Fudan University (Xiaotian Li), First Afliated Hospital of Medical College of Xian
Jiaotong University (Wenli Gou), West China Second University Hospital (Xinghui Liu),
Shengjing Hospital of China Medical University (Caixia Liu), the Second Hospital of
Jilin University (Yanhui Zhao), Nanjing Drum Tower Hospital, the Afliated Hospital of
Nanjing University Medical School (Yimin Dai), Shandong Provincial Hospital
(Xietong Wang), First Hospital of Inner Mongolia Medical College (Muge Qi),
Cangzhou Central Hospital (Junfeng Zhang), Beijing Friendship Hospital, Capital
Medical University (Li Lin), Maternal and Child Health Hospital of Taiyuan, Shanxi
Province (Meihua Zhang), and the First Teaching Hospital of Xinjiang Medical
University (Qiying Zhu). This project was supported by the Special Research Fund in
Nonprot Health Care Industry of the Peoples Republic of China, granted to Weiyuan
Zhang (201002013) and the Research Fund for High-level Talented Individuals of
Beijing Health Bureau, granted to Weiyuan Zhang (2009-2-11). We would like to
submit our manuscript Delivery modes and pregnancy outcomes of low birth weight
infants in China. All authors have read and approved the submitted manuscript.

Journal of Perinatology (2016), 41 46

REFERENCES
1 Kramer MS. The epidemiology of low birth weight. Nestle Nutr Inst Workshop Ser
2013; 74: l10.
2 CIass QA, Rickert ME, Lichtenstein P, DOnofrio BM. Birth weight, physical
morbidity, and mortality: a population-based sibling comparison study. Am J
Epidemiol 2014; 179(5): 550558.
3 Chen W, Srinivasan SR, Yao L, Li S, Dasmahapatra P, Fernandez C et al. Low birth
weight is associated with higher blood pressure variability from childhood to
young adulthood: the Bogalusa Heart Study. Am J Epidemiol 2012; 176: 99105.
4 Christensen DL, Kapur A, Bygbjerg IC. Physiological adaption to maternal malaria
and other adverse exposure: low birth weight, functional capacity, and possible
metabolic disease in adult life. Int J Gynaecol Obstet 2011; 115: 16191.
5 Cui H, He CH, Miao L, Zhu J, Wang YP, Li Q et al. Trendency analysis of infant
mortality rate due to premature birth or low birth weight in China from 1996
to 2013. Clin J Prev Med 2015; 49(2): 161165.
6 Xie X, Gou WL. Obstetrics and Gynecology, 8th edn. Peoples Medical Publishing
House: Beijing, 2013.
7 International Association of Diabetes and Pregnancy Study Groups Consensus
Panel, Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA et al. International association of diabetes and pregnancy study groups recommendations
on the diagnosis and classication of hyperglycemia in pregnancy. Diabetes Care
2010; 33: 676682.
8 Lin L, Liu Y, Zhang X, Mi J, Cao L. Sampling survey on Low birth weight in China
in 1998. Zhonghua Yu Fang Yi Xue Za Zhi 2002; 36: 149153.
9 Zou LY, Wang X, Ruan Y, Li GH, Chen Y, Zhang WY. Preterm birth and nonatality in
China 2011. Int J Gynecol Obstet 2014; 127: 243247.
10 Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE et al. Global, regional, and
national causes of child mortality: an updated systematic analysis for 2010 with
time trends since 2000. Lancet 2012; 379: 21512161.
11 Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R et al.
National, regional, and worldwide estimates of preterm birth rates in the year
2010 with time trends since 1990 for selected countries: a systematic analysis and
implications. Lancet 2012; 379: 21622172.
12 World Health Organization: The World Health Report 2005. Make Every Mother and
Child Count. The Greatest Risks to Life are in its Beginning. WHO: Geneva,
Switzerland, 2005, pp 7981.
13 World Health Organization: Neonatal and Perinatal Mortality. Country, Regional
and Global Estimates. WHO Press: Geneva, Switzerland, 2006.
14 Rosa D, Darling RD, RNC-NIC. Risk factors for low birth weight in New York state
counties. Policy Polit Nurs Pract 2012; 13: 1726.
15 Coutinho PR, Cecatti JG, Surita FG, Costa ML, Morais SS. Perinatal outcomes
associated with low birth weight in a historical cohort. Reprod Health 2011; 17:
2331.
16 Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, Term Breech
Trial Collaborative Group. Planned caesarean section versus planned vaginal birth
for breech presentation at term: a randomized multi centre trial. Lancet 2000; 356:
13751383.
17 Robilio PA, Boe NM, Danielsen B, Gilbert WM. Vaginal vs. cesarean delivery for
preterm breech presentation of singleton infants in California: a population-based
study. Reprod Med 2007; 52: 473479.

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