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This article is part of the supplement: The Lives Saved Tool in 2013: new capabilities and applications

Open Access Review

The associations of parity and maternal age with small-for-gestational-age, preterm, and neonatal and infant mortality: a meta-analysis

Naoko Kozuki1, Anne CC Lee12, Mariangela F Silveira3, Ayesha Sania4, Joshua P Vogel56, Linda Adair7, Fernando Barros38, Laura E Caulfield1, Parul Christian1, Wafaie Fawzi9, Jean Humphrey110, Lieven Huybregts1112, Aroonsri Mongkolchati13, Robert Ntozini10, David Osrin14, Dominique Roberfroid12, James Tielsch1, Anjana Vaidya14, Robert E Black1, Joanne Katz1* and Child Health Epidemiology Reference Group (CHERG) Small-for-Gestational-Age-Preterm Birth Working Group1

Author affiliations

1 Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA

2 Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA

3 Programa de Pós-graduacao em Epidemiologia, Universidade Federal de Pelotas, Rua Marechal Deodoro 1160, 3o piso, Centro, CEP 96020-220, Pelotas, RS, Brazil

4 Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA

5 School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway Crawley WA 6009, Perth, Australia

6 UNDP/UNFPA/UNICEF/WHO/Word Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland

7 University of North Carolina School of Public Health, 135 Dauer Drive, Chapel Hill, NC 27599, USA

8 Programa de Pós-graduação em Saúde e Comportamento, Univertsidade Católica de Pelotas, Félix da Cunha, 412, CEP 96010-000, Centro, Pelotas, RS, Brazil

9 Departments of Nutrition, Epidemiology, and Global Health and Population, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA

10 Zvitambo, No 1 Borrowdale Road, Borrowdale, Harare, Zimbabwe

11 Department of Food Safety and Food Quality, Ghent University, Coupure Links 653, B – 9000, Ghent, Belgium

12 Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine Nationalestraat 155, 2000 Antwerpen, Belgium

13 ASEAN Institute for Health Development, Mahidol University, 999 Phuttamonthon 4 Rd, Salaya, Nakhon Pathom 73170, Thailand

14 Institute for Global Health, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK

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Citation and License

BMC Public Health 2013, 13(Suppl 3):S2  doi:10.1186/1471-2458-13-S3-S2

Published: 17 September 2013



Previous studies have reported on adverse neonatal outcomes associated with parity and maternal age. Many of these studies have relied on cross-sectional data, from which drawing causal inference is complex. We explore the associations between parity/maternal age and adverse neonatal outcomes using data from cohort studies conducted in low- and middle-income countries (LMIC).


Data from 14 cohort studies were included. Parity (nulliparous, parity 1-2, parity ≥3) and maternal age (<18 years, 18-<35 years, ≥35 years) categories were matched with each other to create exposure categories, with those who are parity 1-2 and age 18-<35 years as the reference. Outcomes included small-for-gestational-age (SGA), preterm, neonatal and infant mortality. Adjusted odds ratios (aOR) were calculated per study and meta-analyzed.


Nulliparous, age <18 year women, compared with women who were parity 1-2 and age 18-<35 years had the highest odds of SGA (pooled adjusted OR: 1.80), preterm (pooled aOR: 1.52), neonatal mortality (pooled aOR: 2.07), and infant mortality (pooled aOR: 1.49). Increased odds were also noted for SGA and neonatal mortality for nulliparous/age 18-<35 years, preterm, neonatal, and infant mortality for parity ≥3/age 18-<35 years, and preterm and neonatal mortality for parity ≥3/≥35 years.


Nulliparous women <18 years of age have the highest odds of adverse neonatal outcomes. Family planning has traditionally been the least successful in addressing young age as a risk factor; a renewed focus must be placed on finding effective interventions that delay age at first birth. Higher odds of adverse outcomes are also seen among parity ≥3 / age ≥35 mothers, suggesting that reproductive health interventions need to address the entirety of a woman’s reproductive period.


Funding was provided by the Bill & Melinda Gates Foundation (810-2054) by a grant to the US Fund for UNICEF to support the activities of the Child Health Epidemiology Reference Group.