Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Original Article
  • Published:

Risk of stillbirth at extremes of birth weight between 20 to 41 weeks gestation

Journal of Perinatology volume 32, pages 829–836 (2012)Cite this article

Subjects

Abstract

Objective:

To determine the risk of stillbirth between 20 to 41 weeks gestation, at highly detailed weight percentiles, including extreme degrees of small (SGA) and large (LGA) for gestational age birth weight.

Study Design:

We completed a population-based study of all births in Ontario, Canada between 2002 and 2007. We included 767 016 liveborn and 4,697 stillborn singletons delivered between 20 and 41 weeks gestation. Smoothed birthweight percentile curves were generated for males and females, combining livebirths and stillbirths. Quantile regression was used to calculate sex-specific absolute birthweight differences and 95% confidence intervals (CI) between stillborns vs liveborns at various gestational ages. Logistic regression was used to calculate the odds ratios (OR) for stillbirth at various sex-specific birthweight percentiles, including <1st and ⩾99th percentile. OR were adjusted for maternal age and parity.

Result:

At the 10th percentile, stillborns weighed significantly less than liveborns starting at 24 weeks gestation. By 32 weeks, this difference was 590 g (95% CI 430 to 750) for males and 551 g (95% CI 345 to 448) for females. A reverse J-shaped association was observed between birthweight percentile and risk of stillbirth across all gestational ages. Relative to the 40th to 60th percentile referent, the adjusted OR for stillbirth was 9.63 (95% CI 8.39 to 11.06) at a birth weight <1st percentile. At ⩾99th percentile, the adjusted OR was 2.24 (95% CI 1.76 to 2.86). The risk of stillbirth at extreme birthweight percentiles was robustly observed across gestational ages.

Conclusion:

Substantial birthweight differences exist between stillborns and newborns. As a possible hallmark of impending intrauterine death, severe SGA and LGA may each be potential targets for future stillbirth prevention initiatives.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1
Figure 2

Similar content being viewed by others

Article 16 February 2023

Evdokia Dimitriadis, Daniel L. Rolnik, … Ellen Menkhorst

References

  1. Reidpath DD, Allotey P . Infant mortality rate as an indicator of population health. J Epidemiol Community Health 2003; 57: 344–346.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Loudon I . Death in Childbirth. Clarendon Press: Oxford, England, 1992.

    Book  Google Scholar 

  3. Hughes P, Turton P, Hopper E, Evans CD . Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study. Lancet 2002; 360: 114–118.

    Article  CAS  PubMed  Google Scholar 

  4. Kohner N, Henley A . When A Baby dies. The Experience of Late Miscarriage, Stillbirth and Neonatal Death. Pandora: London, 1995.

    Google Scholar 

  5. Mullan Z, Horton R . Bringing stillbirths out of the shadows. Lancet 2011; 377: 1291–1292.

    Article  PubMed  Google Scholar 

  6. Frøen JF, Cacciatore J, McClure EM, Kuti O, Jokhio AH, Islam M et al., Lancet's Stillbirths Series steering committee. Stillbirths: why they matter. Lancet 2011; 377: 1353–1366.

    Article  PubMed  Google Scholar 

  7. Rådestad I, Steineck G, Nordin C, Sjögren B . Psychological complications after stillbirth--influence of memories and immediate management: population based study. BMJ 1996; 312: 1505–1508.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Vance JC, Najman JM, Thearle MJ, Embelton G, Foster WJ, Boyle FM . Psychological changes in parents eight months after the loss of an infant from stillbirth, neonatal death, or sudden infant death syndrome--a longitudinal study. Pediatrics 1995; 96: 933–938.

    CAS  PubMed  Google Scholar 

  9. Flenady V, Koopmans L, Middleton P, Frøen JF, Smith GC, Gibbons K et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011; 377: 1331–1340.

    Article  PubMed  Google Scholar 

  10. Ananth CV, Vintzileos AM . Distinguishing pathological from constitutional small for gestational age births in population-based studies. Early Hum Dev 2009; 85: 653–658.

    Article  PubMed  Google Scholar 

  11. Zhang X, Platt RW, Cnattingius S, Joseph KS, Kramer MS . The use of customised versus population-based birthweight standards in predicting perinatal mortality. BJOG 2007; 114: 474–477.

    Article  CAS  PubMed  Google Scholar 

  12. Clausson B, Gardosi J, Francis A, Cnattingius S . Perinatal outcome in SGA births defined by customised versus population-based birthweight standards. BJOG 2001; 108: 830–834.

    CAS  PubMed  Google Scholar 

  13. Zhang X, Decker A, Platt RW, Kramer MS . How big is too big? The perinatal consequences of fetal macrosomia. Am J Obstet Gynecol. 2008; 198: 517.e1–517.e6.

    Article  Google Scholar 

  14. Anoon SS, Rizk DE, Ezimokhai M . Obstetric outcome of excessively overgrown fetuses (&gt; or = 5000 g): a case-control study. J Perinat Med 2003; 31: 295–301.

    Article  PubMed  Google Scholar 

  15. Yarcheski A, Mahon NE, Yarcheski TJ, Hanks MM, Cannella BL . A meta-analytic study of predictors of maternal-fetal attachment. Int J Nurs Stud 2009; 46: 708–715.

    Article  PubMed  Google Scholar 

  16. Boukydis CF, Treadwell MC, Delaney-Black V, Boyes K, King M, Robinson T et al. Women's responses to ultrasound examinations during routine screens in an obstetric clinic. J Ultrasound Med 2006; 25: 721–728.

    Article  PubMed  Google Scholar 

  17. Stephens BE, Tucker R, Vohr BR . Special health care needs of infants born at the limits of viability. Pediatrics 2010; 125: 1152–1158.

    Article  PubMed  Google Scholar 

  18. Campbell S, Warsof SL, Little D, Cooper DJ . Routine ultrasound screening for the prediction of gestational age. Obstet Gynecol 1985; 65: 613–620.

    CAS  PubMed  Google Scholar 

  19. You JJ, Alter DA, Stukel TA, McDonald SD, Laupacis A, Liu Y et al. Proliferation of prenatal ultrasonography. CMAJ 2010; 182: 143–151.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Public Health Agency of Canada. What Mothers Say: The Canadian Maternity Experiences Survey. Public Health Agency of Canada: Ottawa, Canada, 2009, http://www.phac-aspc.gc.ca/rhs-ssg/pdf/survey-eng.pdf (accessed April 19, 2011).

  21. Goldenberg RL, Cutter GR, Nelson KG, Foster J . Effects of very low birth weights on fetal and neonatal mortality rates in Alabama. Public Health Rep 1989; 104: 488–492.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. Alexander GR, Himes JH, Kaufman RB, Mor J, Kogan M . A United States national reference for fetal growth. Obstet Gynecol 1996; 87: 163–168.

    Article  CAS  PubMed  Google Scholar 

  23. Wilson AL, Fenton LJ, Munson DP . State reporting of live births of newborns weighing less than 500 grams: impact on neonatal mortality rates. Pediatrics 1986; 78: 850–854.

    CAS  PubMed  Google Scholar 

  24. Korteweg FJ, Gordijn SJ, Timmer A, Erwich JJ, Bergman KA, Bouman K et al. The Tulip classification of perinatal mortality: introduction and multidisciplinary inter-rater agreement. BJOG 2006; 113: 393–401.

    Article  CAS  PubMed  Google Scholar 

  25. Wei Y, Pere A, Koenker R, He X . Quantile regression methods for reference growth charts. Stat Med 2006; 25: 1369–1382.

    Article  PubMed  Google Scholar 

  26. Lyon V, Howatson A, Khan KS, Owen P . Unadjusted and customised weight centiles in the identification of growth restriction among stillborn infants. BJOG 2004; 111: 1460–1463.

    Article  PubMed  Google Scholar 

  27. Frøen JF, Gardosi JO, Thurmann A, Francis A, Stray-Pedersen B . Restricted fetal growth in sudden intrauterine unexplained death. Acta Obstet Gynecol Scand 2004; 83: 801–807.

    Article  PubMed  Google Scholar 

  28. Beard JR, Lincoln D, Donoghue D, Taylor D, Summerhayes R, Dunn TM et al. Socioeconomic and maternal determinants of small-for-gestational age births: patterns of increasing disparity. Acta Obstet Gynecol Scand 2009; 88: 575–583.

    Article  PubMed  Google Scholar 

  29. Shoham-Vardi I, Leiberman JR, Kopernik G . The association of primiparity with intrauterine growth retardation. Eur J Obstet Gynecol Reprod Biol 1994; 53: 95–101.

    Article  CAS  PubMed  Google Scholar 

  30. Rockhill B, Newman B, Weinberg C . Use and misuse of population attributable fractions. Am J Public Health 1998; 88: 15–19.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Fretts RC . Etiology and prevention of stillbirth. Am J Obstet Gynecol 2005; 193: 1923–1935.

    Article  PubMed  Google Scholar 

  32. Gardosi J, Kady SM, McGeown P, Francis A, Tonks A . Classification of stillbirth by relevant condition at death (ReCoDe): population based cohort study. BMJ 2005; 331: 1113–1117.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Flenady V, Frøen JF, Pinar H, Torabi R, Saastad E, Guyon G et al. An evaluation of classification systems for stillbirth. BMC Pregnancy Childbirth 2009; 9: 24.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Korteweg FJ, Erwich JJ, Holm JP, Ravisé JM, van der Meer J, Veeger NJ et al. Diverse placental pathologies as the main causes of fetal death. Obstet Gynecol 2009; 114: 809–817.

    Article  PubMed  Google Scholar 

  35. Wilcox AJ . Intrauterine growth retardation: beyond birthweight criteria. Early Hum Dev 1983; 8: 189–193.

    Article  CAS  PubMed  Google Scholar 

  36. Zhang J, Mikolajczyk R, Grewal J, Neta G, Klebanoff M . Prenatal application of the individualized fetal growth reference. Am J Epidemiol 2011; 173: 539–543.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Knüpfer M . Clinical management of small-for-gestational-age babies. In: Kiess W, Chernausek SD, Hokken-Koelega ACS (eds) Small for Gestational Age. Causes and Consequences. Pediatr Adolesc Med. Basel: Karger, 2009, pp 99–115.

    Google Scholar 

  38. Maaten S, Guttmann A, Kopp A, Handa M, Jaakkimainen L . Care of Women During Pregnancy and Childbirth. Primary Care in Ontario ICES Atlas: Toronto, 2006.

    Google Scholar 

  39. Genest DR, Williams MA, Greene MF . Estimation of the time of death in stillborn fetuses: I. Histologic evaluation of fetal organs: an autopsy study of 150 stillborn. Obstet Gynecol 1992; 80: 575–584.

    CAS  PubMed  Google Scholar 

  40. James WH . Sex ratios of offspring and the causes of placental pathology. Hum Reprod 1995; 10: 1403–1406.

    Article  CAS  PubMed  Google Scholar 

  41. Clifton VL . Review: Sex and the human placenta: mediating differential strategies of fetal growth and survival. Placenta 2010; 31 (Suppl): S33–S39.

    Article  PubMed  Google Scholar 

  42. Joseph KS, Kramer MS . Recent trends in Canadian infant mortality rates: effect of changes in registration of live newborns weighing less than 500 g. CMAJ 1996; 155: 1047–1052.

    CAS  PubMed  PubMed Central  Google Scholar 

  43. Savitz DA, Terry Jr JW, Dole N, Thorp Jr JM, Siega-Riz AM, Herring AH . Comparison of pregnancy dating by last menstrual period, ultrasound scanning, and their combination. Am J Obstet Gynecol 2002; 187: 1660–1666.

    Article  PubMed  Google Scholar 

  44. Delaney M, Roggensack A, Leduc DC, Ballermann C, Biringer A, Delaney M, et al., Clinical Practice Obstetrics Committee; Maternal Fetal Medicine Committee. Guidelines for the management of pregnancy at 41+0 to 42+0 weeks. J Obstet Gynaecol Can 2008; 30: 800–823.

    Article  PubMed  Google Scholar 

  45. Smith GC . Predicting antepartum stillbirth. Clin Obstet Gynecol 2010; 53: 597–606.

    Article  PubMed  Google Scholar 

  46. Imdad A, Yakoob MY, Siddiqui S, Bhutta ZA . Screening and triage of intrauterine growth restriction (IUGR) in general population and high risk pregnancies: a systematic review with a focus on reduction of IUGR related stillbirths. BMC Public Health 2011; 11 (Suppl 3): S1.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Boers KE, Vijgen SM, Bijlenga D, van der Post JA, Bekedam DJ, Kwee A, et al., DIGITAT study group. Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT). BMJ 2010; 341: c7087.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. The GRIT Study Group. Infant wellbeing at 2 years of age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled trial. Lancet 2004; 364: 513–520.

    Article  Google Scholar 

  49. Bukowski R, Smith GC, Malone FD, Ball RH, Nyberg DA, Comstock CH, et al., FASTER Research Consortium. Fetal growth in early pregnancy and risk of delivering low birth weight infant: prospective cohort study. BMJ 2007; 334: 836.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Mook-Kanamori DO, Steegers EA, Eilers PH, Raat H, Hofman A, Jaddoe VW . Risk factors and outcomes associated with first-trimester fetal growth restriction. JAMA 2010; 303: 527–534.

    Article  CAS  PubMed  Google Scholar 

  51. Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E et al. Stillbirths: what difference can we make and at what cost? Lancet 2011; 377: 1523–1538.

    Article  PubMed  Google Scholar 

  52. Imdad A, Yakoob MY, Bhutta ZA . The effect of folic acid, protein energy and multiple micronutrient supplements in pregnancy on stillbirths. BMC Public Health 2011; 11 (Suppl 3): S4.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Ray JG, Vermeulen MJ, Schull MJ, McDonald S, Redelmeier DA . Metabolic syndrome and the risk of placental dysfunction. J Obstet Gynaecol Can 2005; 27: 1095–1101.

    Article  PubMed  Google Scholar 

  54. Ananth CV, Peltier MR, Kinzler WL, Smulian JC, Vintzileos AM . Chronic hypertension and risk of placental abruption: is the association modified by ischemic placental disease? Am J Obstet Gynecol 2007; 197: 273.e1–273.e7.

    Article  Google Scholar 

Download references

Acknowledgements

This work was funded by the Canadian Foundation for the Study of Infant Deaths. We were personally salaried by their institutions during the period of writing (though no specific salary was set aside or given for the writing of this paper).

Disclaimer

No funding bodies had any role in the study design, data collection, analysis, decision to publish or preparation of the manuscript.

Ethics

Permission to complete the study was obtained from the Research Ethics Board of St. Michael's Hospital, Toronto, Ontario, February 2011.

Author contributions

Ray contributed to the study conception, design and analysis, drafting of manuscript, manuscript revision, approval of final version.

Urquia contributed to the study conception, design and analysis, drafting of manuscript, manuscript revision, approval of final version.

Author information

Authors and Affiliations

  1. Departments of Medicine, Health Policy Management and Evaluation, and Obstetrics and Gynecology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada,

    J G Ray

  2. Centre for Research on Inner City Health, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada,

    M L Urquia

Authors
  1. J G Ray
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M L Urquia
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J G Ray.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Additional information

Supplementary Information accompanies the paper on the Journal of Perinatology website

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ray, J., Urquia, M. Risk of stillbirth at extremes of birth weight between 20 to 41 weeks gestation. J Perinatol 32, 829–836 (2012). https://doi.org/10.1038/jp.2012.60

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/jp.2012.60

Keywords

This article is cited by

Search

Advanced search

Quick links