Determinants of low birth weight in dire-dawa city public health facility eastern Ethiopia -unmatched case-control study

Background:-Low Birth Weight (LBW) is one of the leading public health problems in developing countries including Ethiopia. Worldwide, more than 20 million infants born low birth weight every year. Of which about 13% to 15% occur in Sub-Saharan Africa. Thus, knowing clear picture of the risk factors of LBW in the study area is essential. Therefore, this study was conducted to identify determinants of LBW in all public health facilities in dire dawa city administration eastern Ethiopia. Methods: Unmatched case-control study was employed from 1 June to 1 august the data were collected using structured and pretested interviewer administered questionnaire in all public health facilities in study areas. Consecutive sampling technique was used to select cases and controls respectively. Data were entered in to Epi-data software in version 3:1 and exported to SPSS version 23. Variables having with P-value <0.25 in the binary logistic regression were entered in to multivariate logistic regression model. Statistical signicance was considered at P.value <0.05. Results: -A total of 292 mothers with their respective newborns (73 cases and 219 controls) were included the study, mothers not having nutritional counseling (AOR= 3.13, 1.59--6.16),not consuming additional meal (AOR=2.37, 1.26--4.44),not having iron supplementation (AOR=2.21, 1.14--4.29),mothers being anemic (AOR=3.51, 1.64--7.53),and undernourished mothers (AOR=4.83, 2.49--9.38) were signicantly associated with the low birth weight in this study. Conclusion: Poor nutrition related activities interims of nutritional counseling, iron supplementation, maternal feeding especially and others were the main problems identied in this study.

Low birth weight has both long and short term complication, Among these, respiratory distress, sleep apnea, heart problems, jaundice, anemia, chronic lung disorders, mental retardation, stunting and developing non-communicable diseases in letter life. (8).
Having basic knowledge about determinants of low birth weight is important to identify and to give appropriate attention to those mothers at risk. Thus, this study was conducted to identify the determinants factors of low birth weight among newborn babies delivered at public health facilities, in dire-dawa city administration eastern Ethiopia.

Study design, Period and Area
Facility based unmatched case control study was conducted in public health facilities of dire-dawa city administration from June to august, 2020. The city is located 515 kilometers from Addis Ababa (capital city of Ethiopia), In terms of the distribution of health facilities, there are 2 governmental and 4 private hospitals, 8 health centers, 5 higher clinics, and 12 medium clinics in the city.
Cases: those live term singleton babies with birth weight < 2500 grams.
Controls: those live term singleton babies with birth weight ≥2500 grams Sample size determination The sample size was calculated by Stat-Calc module of Epi-Info 7 by assuming the proportion of women with anemia among exposed controls were 12%, with 80% power of the study, 5% α two-sided; 95% con dence level and 1:3 ratio of cases and controls with 5% non-response. The nal sample size of the study was 292(73 cases and 219 controls).

Data collection procedure
Pretested structured questionnaire, a face-to-face interview, anthropometric measurements and medical records reviews were used, the data were collected by 10 trained midwives working in delivery ward in the public health facilities and 4 supervisors. The questionnaire was taken from similar different published (validated) literatures and contextualized to study setting. The socio-demographic, obstetric, medical, behavioral and nutritional factors were the main variables. The weights of the newborns were measured within one hour of delivery using a digital Seca balance scale to the nearest 1 g. The scale was adjusted to the zero level before weighing each newborn. The serum hemoglobin level of mothers was extracted from their medical records since the hemoglobin level test is routinely done for all mothers who come for delivery services.(8) Data processing and analysis Data were entered by using EpiData version 3.1 and then exported to SPSS software version 23 for further analysis. Socio-demographic pro les of variables frequency distribution, summary measures such as mean and standard deviation were calculated for cases and controls. Presence of statistical association between each independent variables and dependent variable was observed by using bivariable logistic regression analysis. A P-Value <0.25 were used to select candidate variable for multivariable regression model. Multivariable logistic Regression (MLR) analysis with backward stepwise method was used to control confounders and determine signi cant determinants of LBW. Model tness was done by Hosmer and Lemeshow Goodness-of-t-test (P>0.05). A P≤0.05 and AOR and 95%CI were used to report signi cance and strength of association, respectively.

Results
Socio-demographic characteristics of the study A total of 292 mothers with their respective newborns (73 cases and 219 controls) were included in the study, with response rate of 97.9%. The mean ± SD of maternal age among cases and controls was 25.1 ± 4.94 and 24.8 ± 4.96 years, respectively. The majority 74% of mothers in both cases and controls were in the age group of 21-35 years, followed by 19.2% and 18.3% of maternal age <20 years in the cases and controls, respectively. More than 90% of the participants in both cases and controls were married. Moreover, 89.0% and 87.2%of mothers among cases and controls were living in urban setting, respectively, While 24.7%and 18.7%among cases and controls had not attended formal education, respectively. Almost half of mothers in both cases 56.2%and controls 48.9%were house wife. (Table 1)  Anthropometric and laboratory investigation characteristics of the study The maternal weight less than 50 kg were 12.3% and 7.3%among the cases and controls respectively. Likewise the maternal height less than 150cm were 15.1% and 9.1% among cases and controls respectively. Maternal MUAC among cases 52.1% and 20.1% controls had MUAC <23cm. Maternal Anemia status based on low hemoglobin concentration (< 110 g/L) among cases and controls 32.9% and 14.6%respectively. (Table 3)  gravidity, parity, birth interval, history of still birth, history of abortion, history of contraceptive methods, history of infection, using any substance abuse during current pregnancy were not signi cant associated with LBW (Table 5).  (Table 6).  Table 7 Multivariate logistic regression analysis with determinants of low birth weight for newborns delivered public health facilities in dire-dawa city eastern Ethiopia 2020 OR=odds ratio AOR=adjusted odds ratio CI=con dence interval *=p-value less than 0.05

Discussion
This study was conducted to indentify determinants of low birth weight babies delivered public health facility at dire dawa city administration.
The mothers who did not receive nutrition counseling during pregnancy had higher risk to deliver low birth weight babies compared to their counterparts. This nding was consistent with other studies done in Ethiopia (9-11)the reason might be nutritional counseling improve their feeding behavior and enhance their nutritional status which may help mothers to decrease risk of delivering low birth weight babies.
The mothers who did not take additional on daily meals during the current pregnancy were higher odds giving birth with LBW babies when compared to mothers who did take additional daily meals during current pregnancy. This nding was supported with studies done in Ethiopia (9)(10)(11)(12). This might be due to Mothers who did eat more foods during pregnancy 88% less likely to give low birth weight babies than their counterpart. There is mounting evidence from the controlled trails that improving food intake during pregnancy effectively reduces the risk of giving birth to low birth weight (13,14) Likewise mothers who did not take iron supplementation during pregnant were signi cantly associated to deliver low birth weight babies as compared to their counterparts. This nding is similar study from Bangladesh that founded intake of iron supplements during pregnancy could protect against low birth weight (15).these ndings were also supported with other studies done in Ethiopia(8-10, 16) the possible explanation could be due to iron supplementation during pregnancy protect mothers becoming anemic and subsequent increased risk of delivering low birth weight babies (17). Iron-alone supplementation could protect against LBW compared to multiple micronutrients supplementation(18)in addition, an overview of controlled trails suggested to 41% decline incidence of intra uterine growth retardation when  (19).
Furthermore in this study found that anemic had higher odds of delivering LBW baby, compared to their counterparts. This nding was also found with other studies done in Ethiopia (8, 10,11,13,15). As well as other studies done Pakistan and Nepal (20,21). The reason might be due to micronutrients de ciencies during pregnancy has been showed to have serious implications on developing fetus and hence birth weight, severe anemia could impair oxygen delivery to the fetus and thus interfere with normal intrauterine growth (22).
Moreover, the risk of low birth weight was higher among the mothers with under nutrition compared to their counterparts. supportive nding was obtained with other studies conducted in Ethiopia (8-11, 23) and somewhere else like Yemen (24)and India (13).This might be explained by the mistaken perception of women that frequent and much diet consumption during pregnancy could lead to excessive fetal growth which they perceive would be beyond tolerance of the birth canal and pose di culty during childbirth thus, they might be prone to under-nutrition (25,26).

Conclusion And Recommendation
Low birth weight is signi cance public health concern linked multiple factors. According to the ndings of this study Poor nutrition related activities interims of nutritional counseling, iron supplementation, maternal feeding especially during pregnancy and others were the main problems identi ed in this study. Therefore, Government and non-governmental NGOs would work together to reduce LBW by establishing appropriate intervention, awareness creation and behaviors change communication (BCC) and development of effective strategy and policy to improve maternal nutritional status and prevent maternal anemia are curtail. In addition, a large scale studies with strong study design like cohort and experimental needs to be conducted.