title: Factors associated with ultrasound-aided detection of suboptimal fetal growth in a malaria-endemic area in Papua New Guinea.
abstract: BACKGROUND
  Fetal growth restriction (FGR) is associated with increased infant mortality rates and ill-health in adulthood. Evaluation of fetal growth requires ultrasound. As a result, ultrasound-assisted evaluations of causes of FGR in malaria-endemic developing countries are rare. We aimed to determine factors associated with indicators of abnormal fetal growth in rural lowland Papua New Guinea (PNG).
  
  
  METHODS
  Weights and growth of 671 ultrasound-dated singleton pregnancies (<25 gestational weeks) were prospectively monitored using estimated fetal weights and birthweights. Maternal nutritional status and haemoglobin levels were assessed at enrolment, and participants were screened for malaria on several occasions. FGR was suspected upon detection of an estimated fetal weight or birthweight <10(th) centile (small-for-gestational age) and/or low fetal weight gain, defined as a change in weight z-score in the first quartile. Factors associated with fetal weight and fetal weight gain were additionally assessed by evaluating differences in weight z-scores and change in weight z-scores. Log-binomial and linear mixed effect models were used to determine factors associated with indicators of FGR.
  
  
  RESULTS
  SGA and low weight gain were detected in 48.3% and 37.0% of pregnancies, respectively. Of participants, 13.8%, 21.2%, and 22.8% had a low mid-upper arm circumference (MUAC, <22 cms), short stature (<150 cms) and anaemia (haemoglobin <90 g/L) at first antenatal visit. 24.0% (161/671) of women had at least one malaria infection detected in peripheral blood. A low MUAC (adjusted risk ratio [aRR] 1.51, 95% CI 1.29, 1.76, P < 0.001), short stature (aRR 1.27, 95% CI 1.04, 1.55, P = 0.009), and anaemia (aRR 1.27, 95% CI 1.06, 1.51, P = 0.009) were associated with SGA, and a low body mass index was associated with low fetal weight gain (aRR 2.10, 95% CI 1.62, 2.71, P < 0.001). Additionally, recent receipt of intermittent preventive treatment in pregnancy was associated with increased weight z-scores, and anaemia with reduced change in weight z-scores. Malaria infection was associated with SGA on crude but not adjusted analyses (aRR 1.13, 95% CI 0.95, 1.34, P = 0.172).
  
  
  CONCLUSIONS
  Macronutrient undernutrition and anaemia increased the risk of FGR. Antenatal nutritional interventions and malaria prevention could improve fetal growth in PNG.
authors.affiliation: Papua New Guinea Institute of Medical Research (PNG IMR), 60, Goroka, Eastern Highlands Province 411, Papua New Guinea. hwunger@doctors.org.uk.|Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, VIC 3050, Melbourne, Australia. hwunger@doctors.org.uk.
authors.forename: Holger Werner
authors.initials: HW
authors.lastname: Unger
authors.affiliation: Papua New Guinea Institute of Medical Research (PNG IMR), 60, Goroka, Eastern Highlands Province 411, Papua New Guinea. marai.kaius@gmail.com.
authors.forename: Maria
authors.initials: M
authors.lastname: Ome-Kaius
authors.affiliation: Walter and Eliza Hall Institute of Medical Research (WEHI), 1G Royal Parade, Parkville 3052, Melbourne, Australia. karl@wehi.edu.au.
authors.forename: Stephan
authors.initials: S
authors.lastname: Karl
authors.affiliation: Papua New Guinea Institute of Medical Research (PNG IMR), 60, Goroka, Eastern Highlands Province 411, Papua New Guinea. holiveoil@gmail.com.
authors.forename: Dupain
authors.initials: D
authors.lastname: Singirok
authors.affiliation: Papua New Guinea Institute of Medical Research (PNG IMR), 60, Goroka, Eastern Highlands Province 411, Papua New Guinea. pmaxsiba@gmail.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Siba
authors.affiliation: Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK. Jane.Walker@nhslothian.scot.nhs.uk.
authors.forename: Jane
authors.initials: J
authors.lastname: Walker
authors.affiliation: Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, VIC 3050, Melbourne, Australia. wangnapi.regina@yahoo.com.
authors.forename: Regina Alice
authors.initials: RA
authors.lastname: Wangnapi
authors.affiliation: Walter and Eliza Hall Institute of Medical Research (WEHI), 1G Royal Parade, Parkville 3052, Melbourne, Australia. mueller@wehi.edu.au.|Barcelona Centre for International Health Research (CRESIB), Rosselo 132, 08036, Barcelona, Spain. mueller@wehi.edu.au.
authors.forename: Ivo
authors.initials: I
authors.lastname: Mueller
authors.affiliation: Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, VIC 3050, Melbourne, Australia. sroger@unimelb.edu.au.
authors.forename: Stephen John
authors.initials: SJ
authors.lastname: Rogerson
mesh_terms: D000293:Adolescent; D000328:Adult; D000740:Anemia / Q000453:epidemiology*; D001724:Birth Weight; D015331:Cohort Studies; D003906:Developing Countries; D019353:Endemic Diseases; D005260:Female; D005317:Fetal Growth Retardation / Q000000981:diagnostic imaging / Q000453:epidemiology*; D020567:Fetal Weight; D005865:Gestational Age; D006801:Humans; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007236:Infant, Small for Gestational Age; D016014:Linear Models; D008288:Malaria / Q000453:epidemiology*; D008297:Male; D044342:Malnutrition / Q000453:epidemiology*; D010219:Papua New Guinea / Q000453:epidemiology; D011247:Pregnancy; D011250:Pregnancy Complications, Hematologic / Q000453:epidemiology; D015597:Pregnancy Complications, Parasitic / Q000453:epidemiology*; D011446:Prospective Studies; D012307:Risk Factors; D012424:Rural Population; D016216:Ultrasonography, Prenatal; D055815:Young Adult