Each year over 4 million infants die in the first four weeks of life (the neonatal period). Ninety-eight percent of neonatal deaths take place in the developing world, and the highest risk is in Africa, where an average of 41 neonatal deaths occur per 1000 live births [1]. Botswana, a middle-income country in southern Africa, has a well-developed medical infrastructure where 97% of women access antenatal care, 94% of births are overseen by a skilled attendant, and 80% of women access hospital-based obstetrical care for deliveries [1]. However, neonatal mortality in Botswana remains high, estimated at 46/1000 live births in 2004 [1].

Botswana is in the midst of a generalized HIV epidemic, and up to a third of infants are born to HIV-infected women [2]. HIV infection is associated with adverse birth outcomes and early infant mortality [3–12]. Although the use of combination antiretroviral drugs for maternal health and for the prevention of mother-to-child HIV transmission is likely to reduce overall infant mortality by decreasing HIV infection among infants [13–15], the use of antiretrovirals (ARVs) has also been associated with lower birth weights [16–19]. A better understanding of the links between HIV, ARVs, and birth outcomes is required, particularly in resource-limited settings where obstetric and pediatric resources are often limited [17].

Low birth weight infants (< 2500 grams) are at risk for early death [20, 21]. Weight by gestational age is an important outcome that controls for effects of prematurity and is interpreted as a proxy for intrauterine growth restriction [20, 22–25]. Small for gestational age infants (birth weight < 10^th percentile for gestational age) are at risk for complications such as peripartum asphyxia, birth trauma, hypoglycemia, impaired neurological development and perinatal mortality [26–30]. Because birth weights may vary regionally, the creation of specific norms for birth weight by gestational age in Botswana may be an important step towards identifying infants at risk for early death [27, 31, 32].

In this report we describe birth weight for gestational age for a large cohort of infants born to HIV-negative women in 6 hospitals in Botswana. Botswana is well-suited for development of these norms as the majority of births occur in hospital settings where information on birth weight, gestational age, and maternal HIV status is available. We compare these data with U.S. birth weight data for black infants with the goal of providing reference data for assessing birth weight for gestational age for both HIV-exposed and unexposed infants in Botswana.

The initial dataset (18,997 births) was first restricted to 11,814 live births, born to HIV-negative women, without congenital abnormality, between 26 and 44 weeks of gestation. An HIV status was recorded for 94% of mothers in the initial dataset. Of the excluded outcomes, 5,141 (72%) were births to HIV-positive women and 1,224 were to women of unknown HIV status. Among the excluded births to HIV-negative women, 181 were stillbirths, 175 had a congenital abnormality, 435 had unrecorded birth or congenital abnormality outcome, and 27 had gestational age less than 26 or greater than 44 weeks. In addition, sixty-one outliers were removed as described in the methods, leaving a total of 11,753 in the analysis dataset (Figure 1). For the final analysis dataset, 8,009 (68%) of captured births were from Princess Marina Hospital, 1,563 (13%) from Scottish Livingstone Hospital, 763 (8%) from Nyangabgwe (Francistown), while < 5% (700 or fewer) came from each of the remaining sites.

Data for weight by gestational age ranging from 26 to 44 weeks are shown in Table 1. The number of infants at each gestational age ranged from 9 at 26 weeks to 2482 at 40 weeks. Among all infants, the median gestational age at the time of birth was 39 weeks, and the median birth weight was 3100 (IQR 2800-3400) grams. Boys were generally heavier than girls at each gestational age with a median of 3160 (IQR 2850, 3480) grams compared with 3030 (IQR 2750, 3325) grams (p < .0001), respectively.

Figure 2 shows estimated percentile curves from 30-43 weeks gestation for 11,627 males and females combined from the final analysis dataset. These curves are similar to prior birth weight for gestational age data with increasing slope during the third trimester and leveling off beyond 40 weeks [25, 39].

Figure 3 shows percentile curves constructed from the Botswana dataset superimposed with curves for U.S.-born black infants [25]. Observation of the curves and the data (Table 1) suggest that Botswana-born infants tended to be larger than U.S.-born infants after shorter gestation (< 34 weeks) and smaller than U.S. born infants after longer gestation (≥ 34 weeks). These observed differences are significant at weeks 27-31 and weeks 37-42 (p ≤ .04, Table 1).

This report describes infant birth weight for gestational age for the largest cohort of infants born to HIV-negative women reported from southern Africa. These data may serve as a reference for identifying infants at risk for early complications and for assessing potential risk factors for adverse infant outcomes, including maternal HIV infection and exposure to antiretrovirals in utero.

These data may be representative for births in Botswana. Based on annual and estimated birth rates for Botswana, there were 114,620 births over the 29 months of surveillance [40]. The initial data set included 18,997 or about 17% of recorded births for the period. In addition, 10.8% of infants in this dataset meet the definition for low birth weight which is consistent with national statistics reporting 10% incidence [20]. Although Princess Marina Hospital, the largest hospital in the country, contributed the majority of the data, the additional sample sites were located throughout the country and included primary sites as well as regional and national referral centers. Because an estimated 80% of births occur in healthcare facilities, institutional deliveries should approximate population norms. Those 20% of births that were not captured may represent a combination of rural, poorer women who cannot readily access healthcare as well as more affluent women who access private clinics.

Birth weight monitoring is complicated in countries where the majority of births occur outside healthcare facilities. For most developing countries, birth weight data are collected via annual Demographic Health Survey records and birth weight for gestational age is generally unavailable [20, 41]. Institutional birth weight data from Botswana offer a more reliable representation of population norms compared to many other developing country settings since 80% of women access hospital-based obstetrical and neonatal care [1]. Data from hospital-based deliveries in Botswana may therefore be useful to other countries in southern Africa.

The Botswana-born infants had higher average birth weights pre-term (statistically significant at 27-31 weeks) and lower birth weights at term (statistically significant at 37-42 weeks) than U.S.-born infants in the referent dataset. Several studies have explored the potential inaccuracies of gestational age dating by last menstrual period. Dating is often inaccurate due to recall bias, variable menstrual cycles, and misinterpretation of bleeding at the time of embroyo implantation. The summation of these errors results in underestimation of prematurity (thus higher birth weights pre-term) and overestimation of post-dates (thus lower birth weights post-term) [42–46]. Distributions around term tend to be less affected by this variation, in part due to larger sample sizes. Among women in the analysis dataset who had antenatal clinic visit information (~50%), 98% had attended an antenatal clinic at least once, which may increase the reliability of the dating. Both datasets estimated gestation age based on last menstrual period, but it is likely that the larger numbers in the U.S. dataset improved precision. Our sample sizes exceeded 100 between 32-41 weeks and thus we have the most confidence in these numbers. It is also possible that Botswana-born children have lower birth weight at term than U.S.-born black infants due to ethnic and/or racial variability of third trimester birth weight for gestational age [25, 27, 32] or due to environmental differences.

Because Botswana-born term babies were smaller than U.S.-born babies, the 10^th percentile cut-offs were lower. By convention, the 10^th percentile is the cut-off to define small for gestational age [47]. Additional research will be required to assess whether infants at highest risk are those below the 10^th percentile or if in this setting a larger proportion of infants are at risk for early mortality.

There are several limitations to these data. Reported data were collected from six different hospitals, however 68% of the data were from Princess Marina Hospital, a tertiary referral site. These women may represent a wealthier urban population, as well as women referred with complicated pregnancies. In addition, these data were not restricted to singleton births, thus potentially skewing the data towards lower birth weights. Third, estimated gestational age may be inaccurate when estimated from last menstrual period [42, 45]. We attempted to correct the data by excluding implausible birth weights at each gestational age, and by restricting the dataset to include only infants from 26 to 44 weeks gestation. Multiple strategies for exclusion of implausible birth weights have been explored [32, 36, 39, 48–51] and several strategies were applied to these data. The method we employed resulted in the best fit for constructed growth curves. In addition, the comparison dataset was taken from published norms for black infants born in the U.S; however, birth weights by gestational age for black U.S.-born children are lower than for other U.S.-born groups [25, 39]. In addition, the reference dataset includes HIV-positive and HIV-negative mothers. Given that the HIV-prevalence for black women in the U.S. is estimated at 1.1%, this is unlikely to significantly impact the data [52]. Finally, we only included data for women who had a known negative HIV status; this limits population-wide applicability, but will facilitate future comparisons of HIV-exposed infants with the norms presented in this dataset. This group will publish the findings for infants born to the HIV-positive women in a separate manuscript [19].

We present a reference for birth weight for gestational age for a large sample of infants born to HIV-negative women in hospitals in Botswana, and demonstrate lower median term birth weights than reported for black infants born in the United States. These data should prove useful for future research investigating the determinants of neonatal mortality and for assessing the effects of HIV and antiretrovirals on infant birth weight.