Risk of adverse outcomes among infants of immigrant women according to birth-weight curves tailored to maternal world region of origin

Background:Infants of immigrant women in Western nations generally have lower birth weights than infants of native-born women. Whether this difference is physiologic or pathological is unclear. We determined whether the use of birth-weight curves tailored to maternal world region of origin would discriminate adverse neonatal and obstetric outcomes more accurately than a single birth-weight curve based on infants of Canadian-born women.Methods:We performed a retrospective cohort study of in-hospital singleton live births (328 387 to immigrant women, 761 260 to nonimmigrant women) in Ontario between 2002 and 2012 using population health services data linked to the national immigration database. We classified infants as small for gestational age (< 10th percentile) or large for gestational age (≥ 90th percentile) using both Canadian and world region–specific birth-weight curves and compared associations with adverse neonatal and obstetric outcomes.Results:Compared with world region–specific birth-weight curves, the Canadian curve classified 20 431 (6.2%) additional newborns of immigrant women as small for gestational age, of whom 15 467 (75.7%) were of East or South Asian descent. The odds of neonatal death were lower among small-for-gestational-age infants of immigrant women than among those of nonimmigrant women based on the Canadian birth-weight curve (adjusted odds ratio OR] 0.83, 95% confidence interval CI] 0.72–0.95), but higher when small for gestational age was defined by the world region–specific curves (adjusted OR 1.24, 95% CI 1.08–1.42). Conversely, the odds of some adverse outcomes were lower among large-for-gestational-age infants of immigrant women than among those of nonimmigrant women based on world region–specific birth-weight curves, but were similar based on the Canadian curve.Interpretation:World region–specific birth-weight curves seemed to be more appropriate than a single Canadian population-based curve for assessing the risk of adverse neonatal and obstetric outcomes among small- and large-for-gestational-age infants born to immigrant women, especially those from the East and South Asian regions.In many Western nations, an increasing proportion of births are to immigrant women, many from world regions where low birth weight and infant death are more frequent.^1–3 The birth-weight distribution of infants born to immigrant mothers in Canada and the United Kingdom is shifted toward lower birth-weight values than that of infants born to native-born women.^4,5 Accordingly, use of a conventional population-based birth-weight chart may not be appropriate for all immigrant groups, potentially leading to an overestimation of infants as small for gestational age (birth weight < 10th percentile) and an underestimation of infants as large for gestational age (birth weight ≥ 90th percentile). The question remains whether these differences reflect a physiologic or a pathological process.Potentially misclassifying the physiologically small, but healthy, newborn as small for gestational age may lead to unnecessary interventions and undue parental stress.⁶ To date, comparisons between a single population-based standard and customized standards, including ones that are based on ethnicity, have focused on small-for-gestational-age infants, but less attention has been paid to the potential under-classification of large infants.^7–9 Overlooking a fetus or infant who would be considered large for gestational age according to the birth-weight distribution in his mother’s country of origin, but not according to the higher cut-off of a birth-weight curve for infants of Canadian-born women, may fail to identify a higher risk of birth trauma or obstetric complications, such as perineal laceration, shoulder dystocia and postpartum hemorrhage.^10–12To date, there is no consensus regarding the minimal set of maternal characteristics that improves detection of adverse outcomes through the use of customized charts.^13–17 So far, the single characteristic that has been shown to influence the size of newborns in this way is maternal country of birth.¹⁸We conducted a study to determine whether use of world region–specific birth-weight curves would be more accurate than use of a single birth-weight curve based on infants of Canadian-born women in predicting adverse neonatal and obstetric outcomes known to be associated with small for gestational age and large for gestational age among infants born to immigrant women in Canada.