Skip to main content

Thank you for visiting 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.


Maternal short stature and under-weight status are independent risk factors for preterm birth and small for gestational age in rural Bangladesh



To estimate the risks of term-small for gestational age (SGA), preterm-appropriate for gestational age (AGA), and preterm SGA associated with maternal height and body mass index (BMI) and to calculate the population attributable fractions (PAF) of term SGA, preterm AGA, and preterm SGA associated with maternal short stature.


A population-based cohort of 13,230 women with pre-pregnancy height and weight followed from 2012 to 2016 in Sylhet, Bangladesh. We analyzed data of 2655 singleton live born infants. The babies born <37 weeks of gestation were considered preterm and weight <10th percentile of Intergrowth sex-specific gestational age were considered SGA. Risk factors for term SGA, preterm AGA, and preterm SGA were examined using multinomial logistic regression that estimated relative risk ratios (RRR) and 95% confidence intervals (CI).


Maternal short stature <145 cm was significantly associated with term SGA (RRR 1.88, 95% CI 1.37, 2.58; p < 0.001), preterm AGA (RRR 1.45, 95% CI 1.02, 2.05; p < 0.05), and preterm SGA (RRR 14.40, 95% CI 1.82, 113.85; p < 0.05). Maternal underweight status (BMI < 18.5 kg/m2) was significant predictor of term SGA (RRR 1.32, 95% CI 1.10, 1.59; p < 0.01), and preterm AGA (RRR 1.39, 95% CI 1.12, 1.71; p < 0.01). PAF for maternal short stature were 23.2, 7.3, and 73.9% for term SGA, preterm AGA, and preterm SGA, respectively.


To address the problem of undernutrition, Bangladesh needs to strengthen implementation of its multi-sectoral nutrition program comprising nutrition specific and sensitive interventions. Implementation of the program with high coverage and quality would improve maternal nutrition and perinatal outcomes including preterm births and SGA.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1


  1. 1.

    UNICEF, WHO. Low Birth Weight: Country. New York: Regional and Global Estimates; 2004.

  2. 2.

    Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller A-B, 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;379:2162–72.

    Article  Google Scholar 

  3. 3.

    Schlaudecker EP, Munoz FM, Bardaji A, Boghossian NS, Khalil A, Mousa H, et al. Small for gestational age: Case definition & guidelines for data collection, analysis, and presentation of maternal immunisation safety data. Vaccine. 2017;35:6518–28.

    Article  Google Scholar 

  4. 4.

    Lee AC, Kozuki N, Cousens S, Stevens GA, Blencowe H, Silveira MF, et al. Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21(st) standard: analysis of CHERG datasets. BMJ. 2017;358:j3677.

    Article  Google Scholar 

  5. 5.

    Katz J, Lee AC, Kozuki N, Lawn JE, Cousens S, Blencowe H, et al. Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis. Lancet. 2013;382:417–25.

    Article  Google Scholar 

  6. 6.

    Kozuki N, Katz J, Lee AC, Vogel JP, Silveira MF, Sania A, et al. Short maternal stature increases risk of small-for-gestational-age and preterm births in low- and middle-income countries: individual participant data meta-analysis and population attributable fraction. J Nutr. 2015;145:2542–50.

    CAS  Article  Google Scholar 

  7. 7.

    Kozuki N, Lee AC, Silveira MF, Sania A, Vogel JP, Adair L, et al. The associations of parity and maternal age with small-for-gestational-age, preterm, and neonatal and infant mortality: a meta-analysis. BMC Public Health. 2013;13(Suppl 3):S2.

    Article  Google Scholar 

  8. 8.

    Kozuki N, Katz J, LeClerq SC, Khatry SK, West KP Jr., Christian P. Risk factors and neonatal/infant mortality risk of small-for-gestational-age and preterm birth in rural Nepal. J Matern Fetal Neonatal Med. 2015;28:1019–25.

    CAS  Article  Google Scholar 

  9. 9.

    McCowan L, Horgan RP. Risk factors for small for gestational age infants. Best Pract Res Clin Obstet Gynaecol. 2009;23:779–93.

    Article  Google Scholar 

  10. 10.

    Simas TA, Waring ME, Liao X, Garrison A, Sullivan GM, Howard AE, et al. Prepregnancy weight, gestational weight gain, and risk of growth affected neonates. J Women Health. 2012;21:410–7.

    Article  Google Scholar 

  11. 11.

    Leng J, Hay J, Liu G, Zhang J, Wang J, Liu H, et al. Small-for-gestational age and its association with maternal blood glucose, body mass index and stature: a perinatal cohort study among Chinese women. BMJ Open. 2016;6:e010984.

    Article  Google Scholar 

  12. 12.

    Li X, Sundquist K, Sundquist J. Risks of small-for-gestational-age births in immigrants: a nationwide epidemiological study in Sweden. Scand J Public Health. 2012;40:634–40.

    CAS  Article  Google Scholar 

  13. 13.

    Xie C, Epstein LH, Eiden RD, Shenassa ED, Li X, Liao Y, et al. Stunting at 5 Years Among SGA Newborns. Pediatrics. 2016;137:e20152636.

    Article  Google Scholar 

  14. 14.

    Hayward I, Malcoe LH, Cleathero LA, Janssen PA, Lanphear BP, Hayes MV, et al. Investigating maternal risk factors as potential targets of intervention to reduce socioeconomic inequality in small for gestational age: a population-based study. BMC Public Health. 2012;12:333.

    Article  Google Scholar 

  15. 15.

    Derraik JG, Lundgren M, Cutfield WS, Ahlsson F. Maternal height and preterm birth: a study on 192,432 Swedish women. PLoS ONE. 2016;11:e0154304.

    Article  Google Scholar 

  16. 16.

    Vinturache A, McKeating A, Daly N, Sheehan S. M T. Maternal body mass index and the prevalence of spontaneous and elective preterm deliveries in an Irish obstetric population: a retrospective cohort study. BMJ Open. 2017;15:10.

    Google Scholar 

  17. 17.

    National Institute of Population Research and Training (NIPORT), Ministry of Health and Family Welfare, Mitra and Associates (MA) Bangladesh demographic and health survey 2014. RockVille, Maryland: The DHS program, ICF International; 2016..

  18. 18.

    Lee ACC, Quaiyum MA, Mullany LC, Mitra DK, Labrique A, Ahmed P, et al. Screening and treatment of maternal genitourinary tract infections in early pregnancy to prevent preterm birth in rural Sylhet, Bangladesh: a cluster randomized trial. BMC Pregnancy and Childbirth. 2015;15:1–14.

  19. 19.

    Baqui AH, Rosen HE, Lee AC, Applegate JA, El Arifeen S, Rahman SM, et al. Preterm birth and neonatal mortality in a rural Bangladeshi cohort: implications for health programs. J Perinatol. 2013;33:977–81.

    CAS  Article  Google Scholar 

  20. 20.

    Khanam Rasheda, Baqui Abdullah H, Syed MamunIbneMoin, Harrison Meagan, Begum Nazma, Quaiyum Abdul, et al. Can facility delivery reduce the risk of intrapartum complications related perinatal mortality: findings from a cohort study. J Glob Health. 2017;8:010408.

    Article  Google Scholar 

  21. 21.

    Villar J, Cheikh Ismail L, Victora CG, Ohuma EO, Bertino E, Altman DG, et al. International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet. 2014;384:857–68.

    Article  Google Scholar 

  22. 22.

    Centers for Disease Control. NHANES 2011–2012 Examination data 2014. (2014) Accessed on 31 January 2018.

  23. 23.

    Muhihi A, Sudfeld CR, Smith ER, Noor RA, Mshamu S, Briegleb C, et al. Risk factors for small-for-gestational-age and preterm births among 19,269 Tanzanian newborns. BMC Pregnancy Childbirth. 2016;16:110.

    Article  Google Scholar 

  24. 24.

    Ozaltin E, Hill K, Subramanian SV. Association of maternal stature with offspring mortality, underweight, and stunting in low- to middle-income countries. JAMA. 2010;303:1507–16.

    CAS  Article  Google Scholar 

  25. 25.

    Kramer MS, McLean FH, Eason EL, Usher RH. Maternal nutrition and spontaneous preterm birth. Am J Epidemiol. 1992;136:574–83.

    CAS  Article  Google Scholar 

  26. 26.

    Schaible UE, Kaufmann SH. Malnutrition and infection: complex mechanisms and global impacts. PLoS Med. 2007;4:e115.

    Article  Google Scholar 

  27. 27.

    Fowden AL, Forhead AJ, Coan PM, Burton GJ. The placenta and intrauterine programming. J Neuroendocrinol. 2008;20:439–50.

    CAS  Article  Google Scholar 

  28. 28.

    Timasheva Y, Putku M, Kivi R, Kozich V, Mannik J, Laan M. Developmental programming of growth: genetic variant in GH2 gene encoding placental growth hormone contributes to adult height determination. Placenta. 2013;34:995–1001.

    CAS  Article  Google Scholar 

  29. 29.

    Rodriguez G, Ventura P, Samper MP, Moreno L, Sarria A, Perez-Gonzalez JM. Changes in body composition during the initial hours of life in breast-fed healthy term newborns. Biol Neonate. 2000;77:12–6.

    CAS  Article  Google Scholar 

  30. 30.

    Gernand AD, Paul RR, Ullah B, Taher MA, Witter FR, Wu L, et al. A home calendar and recall method of last menstrual period for estimating gestational age in rural Bangladesh: a validation study. J Health Popul Nutr. 2016;35:34.

    Article  Google Scholar 

  31. 31.

    Osmani SR, Ahmed A, Ahmed T, Hossain N, Huq S, A. S. Strategic Review of Food Security and Nutrition in Bangladesh. Executive Summary. Rome, Italy: World Food Programme; 2016.

  32. 32.

    Mitra SN, Ahmed A1-Sabir, Anne R, Cross, Jamil. K Bangladesh Demographic and Health Survey, 1996-1997. Dhaka and Calverton, Maryland: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc.; 1997.

  33. 33.

    National Institute of Population Research and Training (NIPORT), Mitra and Associates (MA), ICF International Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates, and ICF International.; 2013.

  34. 34.

    Nisbett N, Davis P, Yosef S, Akhtar N. Bangladesh’s story of change in nutrition: Strong improvements in basic and underlying determinants with an unfinished agenda for direct community level support. Glob Food Secur. 2017;13:21–9.

    Article  Google Scholar 

  35. 35.

    Unicef. Learning from nutrition programme evaluations: a thematic evaluation synthesis report. (2014) Accessed on 11 May 2018.

  36. 36.

    Majumder MAA. World health statistics 2011: how does Bangladesh compare with other south-east Asian countries. South East Asia. J Public Health. 2013;1:4–11.

    Google Scholar 

  37. 37.

    Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382:452–77.

    Article  Google Scholar 

  38. 38.

    Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet. 2008;371:1936–44.

    Article  Google Scholar 

Download references


We acknowledge the contribution of the study women and the dedication of Projahnmo field team. Projahnmo is a research partnership of Johns Hopkins University, the Bangladesh Ministry of Health and Family Welfare and other Bangladeshi institutions including ICDDR,B, and Shimantik.

Author contributions

RK and AHB conceived and designed the analysis. AHB, ACL, DKM, SDG, AQ, LCM were involved in project implementation and conduct of study procedures. SDG developed and maintained the database with LCM. MR conducted data cleaning and analyses with RK. RK drafted the first version of the manuscript. All authors read, provided technical input and approved the final manuscript.


The study was funded by grants from the NICHD (R01 HD066156-02).

Author information



Corresponding author

Correspondence to Rasheda Khanam.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Khanam, R., Lee, A.C., Mitra, D.K. et al. Maternal short stature and under-weight status are independent risk factors for preterm birth and small for gestational age in rural Bangladesh. Eur J Clin Nutr 73, 733–742 (2019).

Download citation

Further reading


Quick links