The material for this study was obtained from the maternity records relating to single births occurring in Malta throughout 1965.  In this year there were 5,719 total births; of these the sample studied covers 2,517 births (44.11 percent). The records were personally examined by one of the authors (Cremona, 1967) from St. Luke's Hospital Malta, from Maltese private Hospitals, and from the District Nursing Association. In Malta the mean birth weight for male babies is 3446g, and for female babies 3358g. The mean birth weight tends to increase with the mother's parity, and this trend continues even with the higher parities. The association between birth weight and rising maternal age remains uncertain. It is also probable that birth weight has a geographical determinant. Birth weight is a multifactorial product and cannot be very reliable as a clinical parameter. A new terminology is necessary to distinguish between three different groups of babies with low birth weights.peer-reviewe

Camilleri, Arthur P.

Cremona, V.

Please note that in the article, the author`s name is showing as  A. Cremona, whereas the actual name should have read as "V.Cremona"

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THE VARIABILITY OF BIRTH-WEIGHT A CREMONA, M.D., D.OBST.R.C.O.G. and AP. CAMILLERI, M.D., F.R.C.O.G., M.M.S.A., D.C.H. Department of Obstetrics and Gynaecology, Royal University of Malta Summary In MaJtar the mean birth-weight: for male babies is 3446g" and for female babies 3358g. The mean birth-weight tends to increase with the' mother's parity 1 and this trend continues even with the higher par-i,ties. The association between birth,..weight and ris~ng: maternal age. remains uncertain. It is al~sol probable that birth-weight has a geograph~cal determinant. Birth-weight is a multifactorial product and cannot be very reHable as, al clinical parameter. A new ter-minology is necessary to distinguish between three different groups of babies wirth low brith-weights. Introduction Far aver 200 years attempts haver been made to' study birth-we:ght accurate'ly. Since Raederer's publicatian (1753) this parameter has been measured repeatedly in several cauntries with the be·lie·f that it con-stitutes "the carnerstane af paed:atrtcs as we knaw it" (Cone, 1961) and a re'liable assessment in obstetr'c practice'. Internat-ianal study-groups cantinue tOo find na bet-ter yard-stick than birth-we'ght far defining prema,turity, althaugh the de,finition is univ-ersaUy admitted to be, inadequate and mis-lead:ng. It is impartant to bear in mi'nd that b:irth-weight depends upan a multitude ef factars. These' inolude nat onl:y the durat!an af gestation and the health af the' placenta, but al'so. the mather's age, he'r parity, height and we'ight, gl'ucase tolerance" sacial status, race and ethnic gro.up, and geagraph:cal laca'lity - quite, apart from such influences as faetal cangenital malformatian and mul-tiple pregnancy. In this investigatian spec'al, attent:an has been devated tOo alder mo.thers, high parity and aver-sized babies, s:ince infa·r-matian an these data is stil·1 insufficient in published wark. Material and Method The mateli!al· far this study was ob-. tained fram the maternity recards relating tOo single births accurring in Malta through-aut 1965. In th:s year there werei 5,719 tatal births; af these our sample co.ve,rs 2,517 births (44.11 per cent). The recards were persana,lly examined by one af us (Cremana, 1967) from St. Luke's Haspital, from private' Haspitals, andi from the District Nursing Assaciatian. Wh:le relatively few domidli!ary confinements co.uld be included in the study, yet it is cle~r that the' actual sampLe mv:ewed is clase,l,y representative af the tatal births in relatiO'n tOo aM the factars mentlaned eadier. TABLE I Comparison o,f sample with tatal births jn! Maltal for 1965 Total Live births Stillbirths Unknown Sex Males Females '-:atal 2922 2706 91 Sample 1276 '1171 60 10 (seen) Sample 1232 1126 (used) Table I shaws the campashion of aur sample. The 60 stHlbirths were nat can-sidered any further. The'reo were' allsa 99 cases which had to' be exciuded because af mulfpl'e pregnancy, unknawn se'x, ar in-adequarte, infarmation. Fram the' remai('l:ing 2,358 cases, recards we,re kept af the baby's se'x, bl:rth-weight, gestatian time, matemal age and parity. The means and: standard deviations o.f these var:abl'es are shawn ,in Table If. It is painted aut that in this sample the mean parity is appreciably higher than in 126 a v) a v) a v) ci <:: C"J..-L!) LO 00 00 +1 +1 00C") r--r--mm C")C") 0000 00 00 +1 +1 C"JO') ..- ..-NN 000') ..- ..-00 +1 +1 0000 00..-r'cx:i C"JC"J L!)OO C"JC"J tOtO ..- ..-+1 +1 <000 ~~ C")C") C"Jco C")C"J C"J..-..- ..-many s:milar investigations (Karn and Pen-rose, 1951; Fraccaro, 1956), because, our data are· not weighted by an undue pre-valence· of first-born bah:es. Results Table III is reproduced in order to demonstrate that, whereas parity exerts no ap:preciable effect on the duration of preg-nancy, the· mean birth-weight increases . stead:ly as parity liises. For instance, for pa'rities of 10 or more the, weight of the average mal'e baby exceeds the over-aB mean weight for males almost by 350g. In the higher parities the number of cases tends to be small. We have therefore analyzed the rele,vant datal fWi11I a paral,le! study on the, 'grande' mu!tipara' extending over prev,:ous years; thereby we' could add a further 290 cases of parit'es of 5 and over. The resullt is shown in Table IV. Our find-ings show that b!irth-weight incre'ases line-ar:ly with pali:ty and that th:s influence con-tinues unabated w;th the higher parities. These a,dditional 290 cases are not in-cluded in any other Table in th:s study, nor in any further c<;msidemtion. It might be argued that the effect which is be.ing attributed tOl rise ,in par:ty could be due, partly or whoMy, to the· concomitant in-crease in maternal! age: a mother who is Para 6 or 8 is very likelY to be much older than one who ;s Para 0 or 1. This difficulty shoul:d be clleared up. Wel sought to analyse the mean birth-weight of either sex for given parity in rising maternal, age-groups. The data in the various sub-groups were often too few, so that in many instances we re-grouped data together. Table V sums up our findings. We believe, thatl by and Ilarge these are incondusive. A trend is suspected for the older mother to bear a heav:er baby than her younger &ister .of identical parity; yet even if this wem so', the influence does not seem to be so strong as to accO'unt for the effect ascribed earlier to· parity. Tab11le VI demonstrates this uneven trend for the· mean b:,rth-weight to increase with Ii:sing ma,ternal a~e, although the effect O'f parity is not being taken into consider-ation. It is also intere·sting that the mother's agedoes not appear to' influence the' dur-ation of gestation. 127 TABLE III Mean Birth Weight and Mean Ges;ta.;t~on tlw.e, for given Parity Pa'/fty Weight (g.) Ge'stat'on time' (wk.) Mafe's Female's Males Fema{'elS NOI. Me'an NO'. Me'an No. Mean NO'. Mean, 0' 431 3346'.45 371 3255.58 431 39.85 371 39.86 1 278 3464.24 269 3371.90' 278 39.72 269 39.74 2 164 350'0.76 145 3403.26 164 39.77 145 39.86 3 111 3519.15 92 3374.55 111 39.68 92 39.45 4 66 3417.91 69 3393.56 66 39.53 69 39.65 5 39 350"1.56 47 340'6.40' 39 39.85 47 39.43 6 37 3611.0'5 39' 3524.26 37 39.62 39 40'.0'5 7 26 3497.15 26 3414.23 26 39.81 26 38.88 8-9 41 3436.80' 3D 3580'.87 41 39.80' 30' 39.83 10'+ 39' 3792.94 38 3551.87 39 40'.10' 38 39.45 All 1232 3446.35 1126 3358.49 1232 39.78 1126 39.73 The finding that gestation time bears nO' appreciable rel1afonship to parity (Table Ill) or to maternal! age (Table VI) lends greater value to Table VII, whe'rein the dis-tribut:on of birth-weight is tabulated in relation to gestation t:me,. From the same' data we have calculated the incidence of over-sized babies born in Malta. There were 272 babies whose birth-we,:ght exceeded 4DOOg. (11.5 per cent of the total sample), 36 babies over 45QQg. (1.5 per cent) and 2 b1ab:es over 5DQDg. (0'.0'8 per cent). This incidence is compared (Table VIII) to that obtaining in seven other countries, from data compiled by Koskel.a (1965). Our findings ftin with this author's suggestion that thel incidencel of large new-born babies seems tOl,increase from the Equator towards the Arctic Circle. Table IV Mean Birth-weight in High: Paritles Parity Male's Females NO'. Me'a'n NO'. Me'ain 5 75 3442.86 75 3480'.53 6 71 3579.61 58 3497.79 7 58 3593.93 49 3511.39 8+9 67 3590'.36 59 3537.58 10'+ 80' 370'3.87 70' 3645.0'0' Discussion Our study provides a re'Jiiable asses'>-ment of the average b:rth-weight in Mallta. The mean birth-weight of ma·le' babies ,is 3446g., and that of females is 3358g. These findings correspond fai'l1ly Cllose'I'y with an earlier study by Agius et al. (1966), who reported that theni~'aln we,:ght for births in Malta wa,s 7.6 Ibs. (3452g.) for boys and 7.29Ib. (33Q7g.) for girls. Their sample comprised 4,10'3 liive bitrths, although these were drawn from the births occurring durin~ the years 1951 to 1959 incfusive· (,i.e. 5.16 per cent of the potent:a·11 sample of 79,50'4 b!irths in these nine years). The effect of parity upon birth-weight continues to. provide interest. Seveml work-ers (Fraccam, 1956; Achar and Yankauer. 1962; Shaw, 1933; McKeown and Gibson, 1951) have, shown that there is a tendency for b:rth-we+ght to increase' l'inearly with the mother's parity, but doubt is o;f',ten e'xpress-ed on whether this; tendency remains ap-plicable to parities over 3, O'r over 8. How-· ever, studiies in which the, numbe'r of mothers w:th the higher parities was not smal,1 have· usualily demO'nstrated that the increase in birth-weight does tend to' con-tinue beyond the eighth pre1gnancy (Uttley, 1940'; Lee, 1948). This cO'nclusion also ap-pears to' result from Fraccaro's own analiysis of a large· sample. of Czechos·lovakian b:rths (Fraccaro, 1958), a'lthough he states that in the higher parit:es. the mean weights remain rather constant. Our data i:n the group of higher parit:es refer to an appreciable num-ber of mothers, and we' haVe! conclude'd that the tendency for the' mean birth-we'ight to increase Wilth parity continues even with the higher padies (CamiHeri and Cremona, 1969) . It would be' ntere!Sting to accumulate TABLE V Mean Birth Weight (g.) for given Parity and Maternal age; group (a) MAlJES Parity 0 1 2 3 4+5 6+7 8+9 10+ Mart. age 15- 3335.05 "L3440.60 3837.81 20- 3337.42 f 359'3.43 "L3471.43 25- 3370.84 3484.54 3456.25 3546.87 f 1.3509.04 1.3521.00 1 30- 3316.28 3417.93 3526.78 3532.86 3414.68 f f }3701.94 35 1. 3608.00 "L 1. 3678.14 3585.93 3572.86 J 40+ f3410.63 f3415.44 f3436.00 3121.33 3715.00 3108.18 3870.19 (b) FEMALES Parity 0 1 2 3 4+5 6+7 8+9 10+ Mart. age 15- 3')83.05 3382.00 1.3412.81 20- 3279.29 3334.93 f 1.3210.24 l3360.54 25- 3296.15 3336.94 3487.98 f j 3376.40 30- 3000.52 3448.51 3342.52 3483.07 3391.52 3464.52 3338.42 13731.94 35 L L "L l 3473.83 3586.12 3570.27 f 40+ f3387.30 f3563.05 f3339.18 f3489,.41 3386.91 3991.09 3732.00 3371.79 TABLE VI Mean Birth Weight and Mean Gestation time, for given Ma,ternal Age Weight (gl.) Gestation time' (wk.) Mat. Age Males Females Males Fe'mafes NO'. Me'8n NO'. Me'an NO'. Me'8n No. Mean 15- 67 3389.4 55 3204.7 67 39.57 55 40.13 20- 369 3390.2 293 3301.17 369 39.86 293 39.90 25- 331 3453.5 350 3343.49 331 39.91 350 39.80 30- 243 3448.3 229 3366,.9 243 39.63 229 39.44 35- 161 3560.9 137 3508.6 161 39.69 137 39.76 40+ 61 3499'.8 62 3487.8 61 39.61 62 39.26 128 TABLT VII Distribution of Birth Weight and Gesta,tioOl time:- All Births Wt. (g.) Gel$tation trm~' (weeks) 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 Total 5770.5 1 1 5450.5 5150.5 1 1 4850.5 2 3 2 1 8 4550.5 1 8 6 2 1 18 4250.5 - 2 5 15 32 20 13 4 1 92 3950.5 1 1 4 1.5 19 69 52 24 6 4 1 196 3650.5 1 5 8 31 81 131 92 42 8 5 1 405 3350.5 1 3 6 16 49 12'0 209 121 52 12 3 2 2 597 3050.5 2 2 3 8 12 60 98 194 87 30 4 6 4 1 511 2750.5 3 9 23 46 76 104 30 23 4 1 320 2450.5 1 1 2 8 10 16 22 19 26 18 5 1 '129 2150.5 1 2 3 2 9 6 8 12 3 1 1 49 1850.5 1 3 1 1 3 '1 10 1550.5 1 4 2 3 1 1 12 1250.5 1 1 2 950.5 1 2 1 4 650.5 1 1 2 350.5 1 '1 Total 1 3 2 3 7 15 23 41 9,1 239 437 792 434 195 41 16 14 2 1 1 2358 ,130 TABLE VIII Geegraphic d~s;tr1but1on 'Of large babies Country I ncidemce' of large ba'bies (per cent) 4oo0g. 4500g. 5000g. or more or more' or more Nigeria 0.28 Venezuela 2.71 0.33 0.023 U.S.A. 3.4 to 0.6,1 to 0.15 to 11.9 1.77 0'.2 Malta 11.5 1.5 0.08 France 9.2 1.6 Germany 9.3 0'.94 to 0.12 1.3 Russia· 11.38 Finland 17.1 3.19 0.32 evidence of alterations in b!rth-weight in successive pregnancies in the same mothers. Such a study woulid truly help to define the' e·ffect of parity on birth-weight, but the difficulties O'f cO'lllecting suffcient re,liabl'e data on these lines must ble, con-siderable. One cO>mpHcating factO'r in these stud-ies is the fact thart a nisei in parity is accom-panied by anincreasei in materna'I' age, since this age n itse'lf may exert a noticeable in-fPuence on birth-weight (Uuley, 1940; Lee, 1948; Grege1rsen, 1937). Th:s influence re-mains debateable. Thus McKeown and Gib-son (1951) concluded that there was no cO'nsi'stent association between we'ight and materna'l age when bi'rth rank was fixed. In the large' CzechO'sllovakian ser:es Fraccaro (1958) obse'rved a paraboHc distribution of mean birth weights for g,:ven mother's age, with the highest po:nt in the age-group 30-34 years, but he thought that this para-bO'la was probablv not re,a·\" Our own, results (Tables V and VI) again leave us in doubt on the true nature o,f the effect of maternal age upon birth-we,:ght. However, viewed in another way, these data do seem to strengthen our earl.ier contention that there is a trend for bi,rth-weights to be heavier in the hiqher parities. Yet another important factor wh;ch ap-pea'rs to be involved in thel study of bi:rth-wei!=1hts is that of geographical, vaniation. KORke,la (1~65) has drawn attention to'th:s point, empha'sizing that the' considerable variations in percentages of large babies born in d:fferent regions 'Of the world sug-gest that factors other than maternal diabetes or the pre-diabetic state play an appreciable role in determining foetall' size. One' may attempt to attribute these var:at-ions to genetic factors, dimate, social, con-ditions, maternal nutrition, parentall' size. For instance, Hollingsworth (1960) found that in Ghana the mean birth-weight 'Of babies of poor Africans was ,lower than that 'Of rich Africans, and that these, Patter we,;ghts were practically simi,lar to' thO'se' of European bab:es b~Jrn in the; same' hospital'. Never-thel.ess, one cannot lose sight of the evid-ence that the incidence of ,I'arge' newborn babies seems to' fO'llow al defi1nite geograp-hical pattern, increasing towards the' Arctic reg:on. Our own figures fO'r Malta' fit in weB within this pattern. As Brand'! (1949) has observed: "Ge'Ographicloca,lity has a modifying effect on the' size; of the newborn in the same way as geographic 'l'Ocal'ity causels mod:fications in p,lants and animal:s ·of one and the same speoies". It is e,vident the:refore: how unreHable birth-we,ight must be as a parameter for the asse'ssment of the duration of preqnancy. This paint is againemphas:zed by Table' VII, which shows a wide' extension of the' same hirth-we'ight over a span of gestation time, a'nd a. great var:ation in birth-weiqht at any one week of qestatiO'n. At the' same time, ,it is alsO' unreal·istic to define prematuritv as a birth-weight below 25OOg. In 1961 the W.H.O. recommended that the concept of prematurity should be substituted by that of low birth-wei1ght because' it i'spremature' by gestation time', O'~ be'cause of a hosti'le intra-uterine environment ("smallll for date's"). or s:mply because of natural detell'mininq fac-' tors (qenetic, geoqraphical!, and so' on). It ,is impO'rtant to' distinguish these three qroups of smaHinfants. It is time that the W.H.O. Expelrt Group discarded its aid ter-minol'o'gy and intl'oduced a new one. References ACHAR, S.T. and YANKAUER, A. (1962): Ind. J. Child Health, II, 157. AGIus, E.A., CACHIA, E.A. and LE~ICKER, H.M. (1966): St. Luke's Hosp. Gaz., Malta, I, 77. BRANDT, W. (1949): Lehrbuch der Embroyologle. Cited by Koskela, 1965. CAM1LLER1, A.P., and CREMONA, V. (1969): J. Obstet. Gynaec. Brit. Cwlth., in press. CONE, T.E. (1961): Paediatrics, 28, 490. CREMONA, V. (1967): Chest-Piece, Malta, I, 3I. FRACCARO, M. (1956): Ann. hum. Genet., 20, 282. FRACCARO, M. (1958): Hum. Bio!., 30, 142. GREGERSEN, N.F. (1937): Acta obstet. gynec. Scand., n, 75· HOLL1NGSWORTH, M.F. (1960): West Afr. med. J., 9 (n.s.), 256 . KARN, M.N. and PENROSE, L.S. (1951): Ann. Euge-nics, Lond., 16, 147. 131 KOSKELA, O. (I965): Ann. Chir. Gynec. Fenn., 54, 462 . LEE, C. (1948): Chinese med. J., 66, 153· McKEowN, T., and GIBS ON, J.R. (195 1): Brit. J. soc. Med., 5, 98 . ROEDERER, J .G. (I753): Commentaries of the Royal Society of G6ttingen, p. 410. Cited by Cone, 196I. SHAW, M.M. (1933): East Afr. med. J., ID, 32 . UTTLEY.. K.H. (1940): Chinese med. J., 58, 582 . W.H.O. (1961): Wld. Hlth. Org., Tech. Rep. Ser., No. 217. TU BO-OVARIAN ABSCESS AS A COMPLICATION OF TYPHOID FEVER LUIS VASSALLO B.sc., M.D., M.R.C.P. (LOND.), M.R.C.P. (ED1N.), M.R.C.P. (GLASG.) R<APHAEL A TIIARD B.Sc., M.D., F.R.C.S. (ENG.) St. Luke<'s Hospital. Th1s paper was read at a joint meeting of the, Association of Surgeons and Physi-cians of Malta and the Fi,fth Army Surgeons Travelling! Club at a meet!ng in Malta, in May 1968. Typhoid Fever has been notorious over the decades for 1Jhe, varie;ty of complicart'ions that may arise from it, and numerous re-ferences are to be found in the medical lite-rature devoted partly or exclusively to dis-cussion of these complications. (Keen, 1898; Osier, 1901; Rowland, 1961; Gadehoh & Madsen, 1963). In spite of the great variety and fre-quency of complications that have been des-cribed, abscess involvement of the ovaries Or Fallopian< tubes is one of the rarest of complications. A patient who developed this rare com-plication is here described and a short review of the literature' made. Factors that may have contributed to this complication will also be discussed. Case Report A 30 year old unmarried Maltese wo-man was referred to hospital on 3-9-65 by her doctor for fever of unknown origin. For the previous two months, the patient had been running an irregular fever reaching at times 102°F in the mornings and 105°F in the eV\3nings. She had complained of fre-quent frontal headaches, and dizziness. She had not experienced epistaxis. She admitted to having an occalsional dry cough, but had no expectoration. Her most prominent symptoms apa'rt from the pyrexia had been frequent moderately severe rigors. She: had no abdominal pain, but had had an episode of loose stools la,sting three days, 1lhough she had been generally constipated through-out her illness. She also complained of ge-neral weakness, though she did not look to-xic or very ill. Her appetite: was poor. An-other feature was frequency of micturition and moderate nocturia. She a,lso had mild dysuria. She gave a history of dysmen-

The variability of birth weight

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The variability of birth weight

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