Low Birth Weight: Causes, Consequences and Interventions

Introduction

Low birth weight (LBW), defined by the World Health Organization (WHO) as a birth weight of less than 2.5 kilograms, remains a major public health challenge globally. Within this category, very low birth weight refers to infants weighing less than 1.5 kilograms. LBW can result from two primary conditions: preterm birth (delivery before 37 completed weeks of gestation) and Intrauterine Growth Restriction (IUGR), where the fetus fails to reach its genetically predetermined growth potential. IUGR is typically diagnosed when a fetus’s weight falls below the 10th percentile for its gestational age, and it can arise from a range of fetal, placental, and maternal factors. For instance, placental insufficiency—characterized by poor vascular adaptation at the uteroplacental interface—leads to reduced oxygen and nutrient delivery to the fetus, contributing to both IUGR and LBW.

The consequences of LBW are both immediate and long-lasting. In the short term, LBW infants are at significantly higher risk of neonatal morbidity and mortality. WHO estimates suggest they are up to 20 times more likely to die in the neonatal period than normal-weight infants, contributing to approximately 80% of neonatal deaths globally.1 Common neonatal complications associated with LBW include respiratory distress, hypoglycemia, sepsis, jaundice, and congenital anomalies.2 Over the long term, LBW has been linked to a heightened risk of chronic health conditions such as ischemic heart disease, stroke, Chronic Obstructive Pulmonary Disease (COPD), and metabolic disorders, as proposed by the Barker Hypothesis.3 Moreover, LBW has been associated with stunted physical growth, developmental delays, and adverse educational and occupational outcomes. A recent study in India found that LBW infants were significantly more likely to be stunted, wasted, and underweight compared to their normal-weight peers.4

The determinants of LBW are multifactorial and intersect across biological, social, and systemic domains. Socioeconomic status, maternal nutrition, access to quality antenatal care, obstetric history, cultural norms, and maternal knowledge all play critical roles in influencing birth outcomes. Understanding and addressing these diverse risk factors is essential for developing comprehensive strategies to reduce the burden of LBW and improve child health outcomes globally.

Socioeconomic Factors

Caste:

Caste system in India is the driving force in perpetuating severe disparity in provision of health services across different communities. The caste system primarily operates through the mechanisms of social exclusion, marginalization, and discriminatory practices, particularly untouchability, which consequently creates obstacles to equitable access to healthcare. Furthermore, compounding the resulting disadvantages are additional factors such as genetics, early environment, and opportunities associated with social mobility, further exacerbating the prevailing disparities between various caste groups.

Religion:

Religion plays an important role in shaping health-related beliefs and practices in India, a country characterized by significant religious diversity. Religious norms can influence attitudes toward maternal healthcare, including the use of institutional delivery services, antenatal care, and interactions with healthcare providers. For example, some religious groups may place restrictions on gender interaction or emphasize modesty, which can serve as barriers for women in accessing timely and appropriate healthcare. Given these socio-cultural dimensions, we hypothesize that religious affiliation may influence low birth weight outcomes. 

Work Type:

Research suggests that while moderate physical activity during pregnancy can yield positive outcomes—such as reducing the risk of cesarean delivery, gestational diabetes, hypertensive disorders, and antenatal or postnatal depression—excessive physical exertion may have detrimental effects on both maternal and neonatal health. There exists physiological evidence that intense physical labor during pregnancy can lead to fetal bradycardia and a reduction in utero-placental blood flow, as the body prioritizes oxygen and nutrient delivery to the working muscles. This diversion of resources, coupled with reduced maternal weight gain and fetal movement, may increase the likelihood of adverse birth outcomes, particularly low birth weight.

Obstetric Factors: 

Gravida:

Gravida refers to the number of times a woman has been pregnant. Primigravida status is a critical risk factor for adverse birth outcomes, particularly low birth weight (LBW). Physiologically, first-time mothers may struggle to adapt to the significant hormonal changes during pregnancy, which can contribute to increased anxiety during labor. This anxiety triggers elevated secretion of adrenaline, leading to excessive uterine contractions. These contractions cause vasoconstriction, thereby reducing utero-placental blood flow, which is essential for fetal nourishment and growth. Furthermore, primigravida mothers exhibit a higher incidence of Pregnancy-Induced Hypertension (PIH), also known as toxemia or preeclampsia. PIH is characterized by increased vascular resistance, impairing blood flow to multiple organs, including the placenta. As a result, the placenta may not develop adequately, compromising nutrient and oxygen delivery to the fetus and increasing the risk of placental abruption. Due to these interlinked factors—impaired placental development, vascular complications, and shorter gestational duration—primigravida mothers are more likely to give birth to low birth weight infants.

Previous Abortions

Previous Abortions refers to whether the mother had experienced any prior spontaneous pregnancy losses (miscarriages) before the index pregnancy. In this study, we explore its role as a potential risk factor for low birth weight (LBW) outcomes. Research suggests that previous miscarriages may contribute to adverse birth outcomes due to cervical incompetence, intrauterine infections, genetic or immunological abnormalities, or uterine scarring, all of which can compromise fetal growth. Miscarriages may also lead to reduced tensile strength of the cervix, making it less capable of sustaining a full-term pregnancy, thereby increasing the likelihood of preterm birth and intrauterine growth restriction—both key contributors to LBW. Moreover, the psychological effects of a prior loss, including maternal stress and depression, have also been linked to poor birth outcomes. In our study, we examine whether a history of spontaneous abortion increases the odds of LBW, while controlling for key socioeconomic and maternal health factors. 6.7.8

Previous LBW Birth

This variable captures whether the mother had previously given birth to a child with low birth weight (≤2 kg). Research shows that the recurrence of LBW is strongly influenced by multiple factors. A key reason is shared genetic predisposition, where maternal or fetal genetic traits—such as those influencing placental function, fetal growth regulation, or metabolism—are consistently passed on, increasing the likelihood of repeat LBW outcomes. Additionally, maternal health conditions such as hypertension, preeclampsia, or chronic undernutrition may persist across pregnancies and contribute to inadequate fetal growth. Socioeconomic determinants like limited access to quality antenatal care, poor dietary intake, and physical labor may remain unchanged between pregnancies, perpetuating risk. Finally, intergenerational effects—including persistent stress, early childbearing, and undernourishment carried over from the mother’s own early life—may also create a biological and social environment where LBW births are more likely to recur. Recognizing previous LBW births as a predictor is therefore vital for identifying high-risk mothers and enabling targeted maternal and child health interventions. While these are plausible reasons for expecting previous LBW birth to have an association with the subsequent birth, there is no conclusive association found up until now. Different papers have found different associations.

Multiple Pregnancies In The Past

Multiple past pregnancies refer to a mother’s history of having given birth to more than one child in previous pregnancies. Such a reproductive history may increase the likelihood of twin or multiple births in the current pregnancy, which are strongly associated with a higher risk of low birth weight due to shared intrauterine space, competition for nutrients, and greater chances of preterm delivery. 

Birth Interval:

Birth Interval refers to the period between the delivery of a mother’s previous live birth and the delivery of the current (index) pregnancy. This variable is critical in assessing maternal and neonatal health risks. According to the World Health Organization (WHO), an optimal inter-delivery interval (IDI) is approximately 33 months, allowing sufficient time for the mother’s body to return to a healthy baseline before the next pregnancy. Short birth intervals have been associated with maternal nutritional depletion—particularly folate deficiency—which can impair fetal growth and increase the risk of low birth weight (LBW). Short intervals are also linked to complications such as anemia, placental abruption, placenta previa, and uterine rupture. Conversely, long birth intervals may also pose risks, including hypertensive disorders and preeclampsia, both of which are associated with poor fetal outcomes such as LBW. Empirical evidence suggests a bimodal distribution in risk, with both very short and very long intervals increasing the likelihood of adverse maternal and neonatal outcomes, including preterm birth, stillbirth, neonatal death, very low birth weight (VLBW), and hospitalization. This variable helps capture a key temporal determinant of perinatal health in the study. 9

Twin Pregnancy:

Twin Pregnancy is a binary variable indicating whether the current pregnancy resulted in the birth of twins. Twin pregnancies are strongly associated with higher maternal age and a greater number of previous pregnancies, both of which increase the likelihood of multiple gestations. Twin pregnancies are a well-established risk factor for low birth weight, primarily due to restricted intrauterine growth. As pregnancy progresses—particularly in the third trimester—growth deceleration becomes pronounced due to increased competition for space and nutrients. One of the most critical physiological factors contributing to low birth weight in twin pregnancies is monochorionicity, which can result in unequal placental sharing or velamentous cord insertions, especially affecting one of the twins in cases of intrauterine growth restriction (IUGR). Additional contributing factors include intrauterine crowding and the presence of fetal malformations, both of which compromise optimal fetal development and birth outcomes.10

Breech Presentation:

Breech Presentation is a binary variable in the dataset that takes the value 1 if the newborn was in breech position at the time of delivery, and 0 otherwise. Breech presentation, wherein the fetus is positioned feet-first or buttocks-first in the womb, has been consistently associated with adverse birth outcomes, particularly low birth weight (LBW) and prematurity.

Several studies underscore the strong association between breech birth and lower neonatal weight. For instance, babies born in breech position are significantly more likely to be premature and exhibit proportionally lower birth weights compared to those in cephalic presentation . Research also suggests that the odds of breech presentation increase as the infant’s birth weight percentile decreases, highlighting a potential directional relationship between fetal growth and presentation at birth.

One explanation for this association lies in intrauterine growth retardation (IUGR). Smaller fetuses may experience growth restriction that inhibits fetal activity or reduces amniotic fluid volume, thereby diminishing the likelihood of rotating into a cephalic position before delivery. Furthermore, breech fetuses show significantly lower placental weights and fetal-to-placental ratios, which may further reflect compromised intrauterine growth and nutrient supply .

Since breech presentation is also highly correlated with preterm birth, which itself is a strong predictor of low birth weight, breech positioning serves as both a direct and indirect contributor to LBW outcomes.11,12,13

Mother’s age:

Maternal age has emerged as a significant, yet complex, determinant of low birth weight (LBW) in the literature. Early studies suggest that the risk of LBW increases with advancing maternal age, even after adjusting for race, education, parity, marital status, and prenatal care. This association has been attributed to age-related physiological changes, including a decline in uterine and endocrine function, which may impair nutrient transfer to the fetus. However, younger mothers also exhibit higher rates of LBW, largely due to adverse sociodemographic and sociomedical conditions. More recent research has nuanced this relationship. A Finnish study employed both between-family and within-family models and found that while increasing maternal age predicted higher LBW risk in between-family comparisons, this association disappeared in within-family models, indicating the influence of unobserved parental characteristics. Notably, older mothers may offset biological risks through healthier behaviours and earlier antenatal care. In China, evidence points to a non-linear relationship: birth weight increased with age until the mid-thirties and declined thereafter, with LBW risk decreasing up to age 36 and rising beyond it . Contrastingly, Indian data show a reversed trend, where the highest LBW incidence is among mothers under 20, and the risk declines with age, particularly among mothers aged 20–30 and 31–49 . These findings collectively suggest that maternal age is a proxy for intersecting biological, behavioural, and social processes, with its impact on LBW varying across contexts and populations.14,15,16,17

Preterm:

Preterm birth is defined as the delivery of a live infant before 37 completed weeks of gestation, calculated from the first day of the mother’s last menstrual period. In our study, this is a binary variable, coded as 1 if the birth was preterm and 0 otherwise.

Prematurity is one of the two primary causes of low birth weight, the other being intrauterine growth restriction (IUGR). A preterm infant has reduced time in utero to accumulate fat and muscle mass, as most fetal weight gain occurs in the final weeks of pregnancy. Clinical evidence shows that babies can gain up to 1 kilogram in the last four weeks of gestation, especially beyond 37 weeks. Therefore, even in the absence of growth restriction, being born early increases the likelihood of low birth weight outcomes.

Furthermore, while both preterm and growth-restricted infants can weigh less than 2500g, preterm birth refers to gestational age, not fetal size, and is an independent and critical predictor of neonatal health and survival.18,19,20,21

Access To Maternal Healthcare: 

Antenatal Care (ANC):
Antenatal care refers to the routine medical care and health checkups that a pregnant woman receives during pregnancy to ensure the well-being of both the mother and the fetus. In our study, ANC is captured as a categorical variable indicating the number and quality of visits made by the mother during pregnancy. According to the World Health Organization (WHO), a minimum of four ANC visits—with the first one preferably in the first trimester and performed by a skilled provider—is considered an indicator of quality ANC utilization.

During these checkups, women undergo a range of essential health assessments, including monitoring of weight gain, blood pressure, hemoglobin levels (to detect anemia), urine tests (to screen for infections and signs of pre-eclampsia), screening for gestational diabetes, and confirmation of blood group and Rhesus factor. These checks not only help identify medical risks such as hypertension, pre-eclampsia, or gestational diabetes, but also serve as an important educational platform to inform women about nutrition, danger signs, and safe delivery practices.

Evidence across multiple settings highlights the strong protective effect of ANC on low birth weight (LBW) outcomes. For instance, analysis from 18 countries using DHS data showed that mothers with ≥4 ANC visits had significantly lower odds of delivering LBW babies compared to those with fewer or no visits. Similarly, a study from Rwanda demonstrated that high-quality ANC led to a 4.18% reduction in LBW outcomes. In India, research in states like Uttar Pradesh and Rajasthan found that mothers with at least one ANC visit were 2.83 times less likely to have LBW births, and delayed registration or fewer ANC visits were significantly associated with adverse outcomes.

Thus, ANC is not only a reflection of healthcare access and utilization but also an important predictor of birth outcomes, with more frequent and earlier visits being associated with a reduced risk of LBW.

In our sample, 47 percent of the mothers have received four or more than four sessions of antenatal care. The variable “ANC Visits” variable takes the value 1 for mothers who have attended at least 4 or more antenatal sessions and 0 for the ones who have not.

Additionally, 72 percent of the mothers have registered with the ANM within the first three months of their pregnancy. The variable “Registration Within First Three Months” takes the value 1 if the mother has registered within the first three months and 0 if not. 22,23,24

Ultrasound:

Ultrasound is a prenatal diagnostic procedure that uses high-frequency sound waves to produce images of the fetus within the uterus. It is widely employed to monitor fetal growth and development, assess placental and uterine health, and detect potential complications during pregnancy. While existing literature (e.g., WHO and PMC5008608) indicates that ultrasound is not, by itself, a reliable screening tool for predicting low birth weight (LBW) outcomes, its clinical value lies in enabling timely detection of risk factors such as intrauterine growth restriction (IUGR), fetal anomalies, or placental insufficiency.

In this study, the variable “Ultrasound” is binary and takes the value 1 if the mother underwent at least one antenatal ultrasound during pregnancy, and 0 if not. The underlying hypothesis is that undergoing an ultrasound provides the mother and family with more information about the health and development of the fetus. This information could encourage better nutritional practices, more ANC checkups, or greater preparedness for delivery—each of which could, in turn, positively influence birth outcomes and reduce the likelihood of low birth weight.25,26

Iron and Folic Acid Supplements

Numerous studies have established a strong association between the consumption of iron and folic acid (IFA) tablets during pregnancy and reduced risk of low birth weight (LBW). Biologically, iron is essential for oxygen transport, and folic acid supports fetal growth and placental development; deficiencies in either are linked to intrauterine growth restriction. Meta-analyses show that daily IFA supplementation significantly lowers LBW risk. In India, despite national programs promoting IFA use, adherence remains low due to supply issues, side effects, and cultural beliefs. Studies using NFHS data found that women who consumed ≥100 IFA tablets had notably lower odds of delivering LBW babies. Early initiation and consistent intake are critical. However, systemic challenges like inadequate counseling and irregular supply chains continue to undermine program effectiveness. In our sample, 41 percent of mothers have consumed IFA tablets for less than 100 days . The variable takes the value 1 for mothers who have consumed IFA for greater than or equal to 100 days and 0 for the ones who have not. 

Nutrition During Pregnancy

Maternal nutrition is a critical determinant of birth outcomes, particularly low birth weight (LBW). Undernourishment during pregnancy is strongly linked to restricted fetal growth, often resulting in LBW infants. This association is well-documented in both global and Indian contexts, where inadequate intake of essential nutrients continues to be a pressing concern among women of reproductive age.

Undernutrition among pregnant women can arise from various factors including inadequate dietary intake, food insecurity, disease burden, poor maternal care, poverty, and an unconducive household environment. These factors often co-exist in low-resource settings, placing women and their unborn children at greater risk of adverse outcomes.

A study conducted in Tigray, Ethiopia found that women with a dietary diversity score of less than five were nearly twice as likely to give birth to LBW infants compared to women with more diverse diets. This highlights the critical role of dietary diversity in supporting fetal development. Similarly, a case-control study in Central India found that only a small percentage of pregnant women—around 18%—met the recommended dietary diversity threshold. In this study, mothers with higher dietary diversity had 20% lower odds of delivering LBW infants, indicating a protective effect of consuming a varied diet.28

Nutritional timing and content are also essential. Nutrient deficiencies during early pregnancy, particularly in the peri-implantation stage and during rapid placental development, are especially detrimental. Inadequate intake of proteins and micronutrients at these stages can impair cell growth, placental function, and fetal nutrient transfer.

Among key nutrient groups, energy intake is foundational. During pregnancy, caloric needs increase progressively—by approximately 85 kcal/day in the first trimester, 285 kcal/day in the second, and 475 kcal/day in the third. Failure to meet these increased energy demands can hinder placental and fetal growth. Protein intake, especially from animal sources such as dairy, has also shown a positive correlation with birth weight. Indian research has found that women who regularly consumed dairy products in early pregnancy had infants with significantly higher birth weights than those with minimal animal protein intake.

Essential fatty acids, particularly omega-3 and omega-6, play a role in prolonging gestation and enhancing fetal growth, yet their levels tend to decline during pregnancy. Similarly, iron is a crucial micronutrient. If a pregnant woman’s diet lacks sufficient iron, her body compensates by depleting iron stores, increasing the risk of anemia. Iron deficiency in early pregnancy has more severe consequences for fetal growth than deficiencies occurring later.29

Taken together, these findings underscore the importance of adequate maternal nutrition—both in quantity and quality—as a key factor in preventing low birth weight. Improving dietary diversity, ensuring sufficient intake of macro- and micronutrients, and addressing broader social determinants like poverty and food security are essential components of any strategy aimed at reducing the incidence of LBW.

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