Shannon Gu

Professor Anna Plantinga

BIOST 311

2 June 2017

Final Project: Parity and Low Birth Weight in South African Women

Introduction

Developing countries tend to have high birth rates for a wide variety of reasons. For

instance, having more children in a family means having more sources of income, assuming that

all the children live to an age where they can start working. Another reason for high birth rates

could be the limited access to contraceptives. In developing countries, however, high-quality

healthcare is not readily available, particularly in rural areas, which means that pregnant women

may not receive the prenatal care they need. Not having proper prenatal care can lead to pregnancy

outcomes like low birth weight and pre-term delivery, among others, but the odds of such outcomes

will differ between women based on numerous factors.

The scientific question of interest in this analysis asks how a womans parity is associated

with low birth weight for her newborn. The data used is from a cohort study of 755 pregnant South

African women who could not afford private healthcare; the women were followed until childbirth,

at which point the infants birth weights were measured. To examine the association between parity

and low birth weightspecifically, the odds of having a low birth weight infanttwo logistic

regression models were used: the unadjusted model considered parity as the only predictor, while

the adjusted model also included age and smoking status as covariates. The logistic regression

models determined that the association between parity and low birth weight was not statistically

significant.
Methods

In the logistic regression models, the outcome of interest is low birth weight. Low birth

weight is defined as weight below 2500 grams at birth, so the outcome is treated as a binary

variable, with low birth weight = 1 and normal birth weight = 0. The predictor of interest is parity,

which is the number of prior deliveries, and it is treated as a continuous variable.

The unadjusted model is as follows:

Logit([low birth weight | parity]) = 0 + 1(parity)

Odds(low birth weight | parity) = exp(0)*exp(1(parity))

The adjusted model includes the covariates of age and smoking status. Age is treated as a

continuous variable, while smoking status is a binary variable, with smokers = 1 and nonsmokers

= 2. The adjusted model is as follows:

Logit([low birth weight | parity]) = 0 + 1(parity) + 2(age) + 3(smoker)

Odds(low birth weight | parity) = exp(0)*exp(1(parity))*exp(2(age))*exp(3(smoker))

Age and smoking status were chosen as a confounder and a precision variable, respectively.

Age is a confounder because older women are more likely to have more children, but older women

are also more likely to be in poorer health, leading to pregnancy complications and potentially low

birth weight. Meanwhile, smoking status is a precision variable because it is not associated with

parity, but can similarly cause pregnancy complications and subsequently low birth weight.

Descriptive Statistics

Table 1: Descriptive statistics of all variables in the logistic regression models.

Variable N (missing) Mean Median SD
Parity (# of prior 755 (0) 1.10 1.00 1.21
deliveries)
Age (yrs) 755 (0) 24.8 24.0 5.37
Smoker (yes = 1, 755 (4) 1.69 2.00 0.462
no = 2)
Birth Weight (g) 755 (4) 3106 3140 535
 For our variables of interest, there are very few missing data points (0.53% of the sample).

By comparing each variables mean to its median, the distribution of the samplenormal or

skewedcan be determined. For parity, age, and birth weight, the respective means and medians

are within 10% of each other, which suggests that their distributions are all normally distributed.

Meanwhile, for smoking status, the mean and median have a percent difference of 16.8%,

suggesting that the distribution for smoking status is skewed. Since the mean for smoking status

is less than the median, the distribution is left-skewed.

Figure 1: A plot of birth weights, according to parity. The horizontal line is drawn at birth weight
= 2500 g, which is the cutoff for low birth weight.

The plot shows that lower parities tend to have a higher variance in birth weight. Based on

the distribution of birth weights within each parity, all of the parities appear to have a mean birth

weight higher than 2500 g, the cutoff for low birth weight. The lower parities (0 3 prior

deliveries) also have a higher proportion of their infants birth weights under 2500 g as compared
to the higher parities (4 6 prior deliveries), suggesting that mothers of lower parity will have

higher odds of giving birth to a low birth weight child.

Results

Unadjusted model:

Coefficient Estimate 95% CI p-value

Intercept 0.128 (0.0929, 0.177) < 0.00005
Parity 0.861 (0.682, 1.09) 0.209

We do not have sufficient evidence to believe that parity is associated with low birth weight.

Comparing two women differing in parity by one birth, we estimate that the woman with the higher

parity has 13.9% lower odds of having a low birth weight baby than the woman with the lower

parity. Based on a 95% CI, this estimate would not be surprising if the true odds ratio was between

0.682 and 1.09. This association was not statistically significant (p = 0.209).

Adjusted model:

Coefficient Estimate 95% CI p-value

Intercept 0.721 (0.165, 3.15) 0.664
Parity 0.934 (0.668, 1.30) 0.687
Age 0.971 (0.910, 1.04) 0.378
Smoker 0.513 (0.314, 0.838) 0.0078

We do not have sufficient evidence to believe that parity is associated with low birth weight.

Comparing two women of the same age and smoking status who differ in parity by one birth, we

estimate that the woman with the higher parity has 6.6% lower odds of having a low birth weight

baby than the woman with the lower parity. Based on a 95% CI, this estimate would not be
surprising if the true odds ratio was between 0.668 and 1.30. This association was not statistically

significant (p = 0.687).

Logistic regression assumes that all observations are independent, and that the predictors

and log odds are linearly associated. When adjusting for the variables of the mothers age and

smoking status, the strength of the association changed, but the statistical significance did not

that is, after adjustment, the association was still not statistically significant, so the conclusions did

not change. A limitation of logistic regression is that it treats the outcome as a binary variable,

which can reduce precision in the results, especially at the cutoff value. For instance, is a 2499 g

infant significantly different than a 2501 g infant? Logistic regression can determine the odds of

having a low birth weight infant, but it cannot determine the exact weight of the infant or how far

away from the cutoff weight the infant is. A different model that could have been used is the

multiple regression model, which would treat birth weight as a continuous variable instead of a

binary variable (low birth weight versus normal birth weight). It would be able to determine the

difference in birth weight between women differing in parity by one birth instead of generalizing

birth weight as either low or normal, as well as estimate the infants birth weights from women of

different parities, ages, and smoking statuses.

Conclusions

Based on logistic regression models, we conclude that in South African women, the

association between parity and having a low birth weight infant is not significant. While the

associations showed that the odds of having a low birth weight infant were lower among women

of higher parity, the corresponding p-values were not below 0.05, even after adjusting for the

covariates of age and smoking status. In the adjusted model, smoking status was shown to have
the only significant association with having a low birth weight infant (p = 0.0078). In future

analyses, smoking status as well as other risk factors for low birth weight should be more

thoroughly investigated.
R Code

Low birth weight variable:

>pregout$lbw <- 0
>pregout$lbw[pregout$bweight < 2500] <- 1

Unadjusted:

Adjusted: