Information on birthweight has been collected in standard DHS surveys since 1988 (Phase 2 onwards). Previous studies have questioned the quality of birthweight data from such surveys, and methods have been developed to enable their use to produce estimates of LBW based on available data [1, 2]. However, few studies have looked in detail, combining quantitative and qualitative analyses, at the time taken for women to answer these questions and the factors associated with missing and low-quality birthweight data in order to inform birthweight data improvements in surveys. Birthweight questions took less than 1 min on average to answer. We found gaps in availability of birthweight data particularly for home births and neonatal deaths, as well as major issues of heaping for birthweight data reported from both card and recall—up to 80% of data being heaped in some sites. In addition, in this study, we address an important previously identified gap in the understanding of community and family demand for birthweight data and found that knowing birthweight was universally perceived as important for livebirths across these five different populations in Asia and Africa. Improving birthweight data in surveys is likely to require improvements in measurement of birthweight at the time of birth, improved communication between health workers and women and further improvements in survey questions and implementation.
Home birth remains a large barrier to measuring birthweight. We found that just 12.4% of women with home births reported that their baby was weighed, compared to 85.1% of facility births. In view of the barriers of accessing facilities in the immediate postnatal period, interventions to increase birthweight measurement should focus on bringing accurate weighing equipment to the mothers and newborn. This will require improved, low-cost, robust and accurate weighing scales to be made available in communities. There is limited literature on potential innovations to improve the measurement of birthweight for home births, although the provision of weighing scales, training of healthcare workers and traditional birth attendants, and community engagement have been shown to increase coverage of weighing at birth [25,26,27]. The person best placed to weigh babies at birth in the community is likely to vary in different settings and may include community volunteers, community midwives or traditional birth attendants. The findings of this study highlight the importance of understanding local context-specific barriers which may impact successful implementation of community weighing, for example fear of witchcraft or the ‘evil eye’ and concerns about exposing the newborn to the elements.
Coverage of facility births is increasing in all settings [28], and the weighing of newborns should be relatively straightforward for these births [7, 29]. However, in this study women reported lack of suitable weighing scales in health facilities, especially in the private sector. The finding of the lack of birthweight measurement for very sick or stillborn babies is similar to other studies [1]. However, this finding may be context-specific. For example, the Every Newborn-BIRTH multi-site study found that the majority of stillbirths were routinely weighed in four out of five study facilities, but that weight was not always communicated to the mothers [30].
In many settings, information about birthweight is communicated verbally to the woman and her family soon after the baby is weighed. However, high workload and time pressures on healthcare workers, and healthcare workers’ perceptions of a woman’s desire or need for this information may influence the effectiveness of this communication, or even whether this information is communicated at all. Pre- and in-service health worker training would be an important first step in closing this gap. In this study, we found that 13.7% of women whose babies were weighed did not know the birthweight. Whilst some of these women may have forgotten the weight, our qualitative findings provide evidence of communication challenges between healthcare providers and women with regard to birthweight, which are important to close.
Health cards are potentially an effective way of communicating information to a woman from one health provider to another, or to an interviewer in a household survey [31]. Health cards are therefore an important potential method for improving birthweight data in surveys. In this study, 62.4% of women reported that their baby was weighed at birth, but only a third of these had a health card recording this information available at the time of the survey. These findings are consistent with previous findings that even in settings where there is a policy for hand-held records, their practical utility is limited by factors such as lack of government funding to maintain implementation, regular stock outs and low quality of completion of various elements, including missing data and illegible entries [32, 33]. Our qualitative findings suggest that whilst health cards were seen as an important way to communicate birthweight, frequent challenges were faced including missing cards, cards being held by men and illegible or missing birthweight information.
Misreporting of birthweight is thought to be common in surveys. For half of babies reported to be weighed at birth, only information from recall and not card birthweight was available. Findings regarding the reliability of recalled birthweight data collected during routine surveys to adequately classify LBW babies have been varied [10, 34,35,36,37,38]. Errors due to heaping are especially pronounced in populations with higher LBW rates where a larger number of babies have a birthweight around the 2500-g cut-off. Overall, evidence suggests some errors in the precision of recalled birthweight at an individual level [2, 12]; however, no previous studies have sought to describe factors associated with increased heaping. In our study, heaping was not associated with socioeconomic status, but was less common in women with secondary or higher education compared to those with primary only or no education. Whilst heaping of birthweights at 500-g intervals was more marked in our recall data, consistent with other studies it was also evident in card data [12], suggesting that at least part of the issue may be due to errors in measurement or recording at the time of birth. Addressing these will require appropriately calibrated weighing scales and trained personnel with sufficient time to record results rapidly after measuring.
Our analysis showed a large gap between the proportion of facility livebirths and known birthweight, especially amongst neonatal deaths which varied by site. Closing the birthweight measurement gap for facility births is an important first step to improving the availability of birthweight data at a population level. In particular, attention should be given to improving the weighing of small and sick babies at birth and the communication of this information to their mothers. Health cards may have an important role to play in bridging gaps in the flow and availability of information, but only if health workers record the birthweight on these, even if the baby has died.
Strengths of this study include the large survey dataset from five LMICs, with consistent questions and analyses, plus multi-site comparable, qualitative data. To our knowledge, this is the first study to undertake qualitative research with both women and interviewers alongside a quantitative survey to seek to understand the reporting and measurement of birthweight. Since our study was undertaken with women in HDSS sites who were under regular surveillance, their knowledge about birthweight may differ from women not under surveillance. Our findings differ from a previous study in rural Bangladesh where knowing birthweight was not considered a priority [39]. In this study, 62% of babies were weighed compared to 48% across all DHS surveys between 2000 and 2016, and 21% compared to 14% had birthweight recorded on a card that was available at the time of the survey. However, in view of the large inter-site variations observed, and as some of these differences may be accounted for by increases in coverage of both facility birth and health cards over this time, it is likely that our results may be relevant across many LMICs. In this study, the assessment of birthweight data quality was limited by the women’s ability to report this information, an assessment of heaping and the plausibility of the distribution of reported birthweights. A further limitation was lack of information from health facilities to support the information and perceptions reported by women and interviewers in the qualitative data. However, a recent facility-based study in Tanzania found birthweight to be highly valued by health care providers, with barriers including gaps in weighing equipment and knowing how data would be used, thus aligning with our findings [29].
Hand-held records, either traditional paper-based health cards or electronic records could play an important role in closing this gap, but investments are required to improve understanding of how to ameliorate the quality of recorded information. Training interviewers in how best to use these card data to supplement women’s responses could facilitate more information being captured in household surveys. Further research is needed to explore challenges faced by health care providers in the communication of birthweight and other health-related information to women. This could include exploring how documentation can be streamlined to reduce duplication, strengthen the woman-provider relationship and enable women and health providers to inform the care that they receive and provide.
This paper has focused on improving birthweight capture and data quality in population-based surveys as an important short- to medium-term method to improve the availability of birthweight information at a population level. However, large-scale household surveys are expensive to undertake, with large time lags of up to 5 years between the birth and the capture of birthweight information and even longer before this information is available to inform policy and programmes. Investment in both HMIS and CRVS systems in many LMICs is increasing, and including birthweight information for every birth captured in these platforms as they expand will be important for improving access to timely data to drive action.