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Research Article

Head Circumference at Birth as a Surrogate Measurement for Identifying Low Birth Weight Newborns

Kusharisupeni , Wahyu K.Y. Putra, Diah M. Utari and Isna A. Fajarini
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Background and Objective: The number of neonatal morbidity and mortality cases caused by low birth weight (LBW) can be reduced by providing appropriate care immediately after birth. However, in some rural areas, it is hard to detect LBW without the proper tools or equipment. The aim of this study was to find a simple, reliable and suitable surrogate measurement to detect LBW. Materials and Methods: This study was conducted at a maternal clinic in East Jakarta in 2014. All newborns, born during the study period, were included in the study. Birth weight, head circumference (HC) and chest circumference (CC) were measured according to standardized techniques by trained midwives. Receiver Operating Characteristic (ROC) curve analyses were carried out to calculate Area Under Curve (AUC). Results: Out of 100 newborns, 57% were male and 43% were female. The average birth weight was 3223±412.21 g, the average HC was 32.69±1.24 cm and average CC was 32.36±145. HC was identified as the optimal surrogate measurement to identify LBW (AUC: 0.74, 95% CI 0.55-0.92), with a cut-off value of 32.12 cm. Conclusion: We found that HC is a better surrogate measurement to detect LBW than CC. Further studies are required to validate the results in rural community settings.

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Kusharisupeni , Wahyu K.Y. Putra, Diah M. Utari and Isna A. Fajarini, 2019. Head Circumference at Birth as a Surrogate Measurement for Identifying Low Birth Weight Newborns. Pakistan Journal of Nutrition, 18: 739-742.

DOI: 10.3923/pjn.2019.739.742

Received: September 06, 2018; Accepted: February 02, 2019; Published: July 15, 2019

Copyright: © 2019. This is an open access article distributed under the terms of the creative commons attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.


Low birth weight (<2500 g) affects growth and development and is associated with slowed cognitive development, impaired growth (stunting) and increased morbidity and mortality. Low birth weight (LBW) rates are very high in Indonesia (stunting: 37.2%, mortality rate: 259/10,000 live births)1,2. According to Basic Health Research in Indonesia, the prevalence of LBW was 11.1% on 2010 and 10.2% on 2013, with the lowest prevalence in North Sumatera (7.2%) and the highest prevalence in Papua (16%) and South East Sulawesi (16.9%)3.

Providing health personnel to assist with labor can reduce morbidity and mortality caused by LBW; however, there is limited availability of labor-assisted health personnel, especially in the remote provinces of North Maluku (17.79%) and Papua (39.18%)4. On national level, merely 88.68% of labours are assisted by health personnel, the rest are done by non health personnel (traditional birth attendant)4. Additionally, any regions also do not have access to a reliable infant scale, making it difficult to detect LBW. One method to solve this problem is to replace the infant scale with a surrogate measurement such as head circumference or chest circumference5. With precise measurement, one could determine the exact weight of the newborn. Thus, appropriate care could be given to LBW newborns.

Many studies have attempted to find a simple, reliable and suitable anthropometric surrogate to identify LBW in newborns, yet there is no consensus on the most reliable anthropometric surrogate and a fix cut-off value6,7. Two possible surrogate measurements to detect LBW include head circumference (HC) and chest circumference (CC), as they are part of standard measurements performed on newborns and may be optimal surrogate measurements to detect LBW5,6,8; however, data on the validity of these measurements are still limited, especially in Indonesia. Therefore, the aim of this study was to identify a simple, reliable and suitable anthropometric surrogate measurement to detect LBW and to determine its cut-off value.


The study was conducted at the Anny Rahardjo Maternal Clinic, East Jakarta in 2014 using a cohort prospective design. Inform consent was obtained from mothers. The inclusion criteria for infants were as follows: (1) Born at the same clinic, (2) Born full term, (3) Singleton, (4) Visited the clinic for immunizations and other consultations regularly every month, Exclusively breast fed and (6) Availability of birth, weight, head circumference and chest circumference monthly measurements up to nine months of age records. Ethnic was not considered due to the similarity in ethnicity among the newborns. 100 infants met these criteria.

Birth weight and weight up to nine months of age were measured each month, as well head circumference and chest circumference. Standardized procedures were applied to measure body weight and other measurements; each measurement was performed twice by two midwives (four times in total), the results were recorded to the nearest 0.1 kg and then the average was calculated9. Body weight was measured using the Seca baby scale calibrated with a 10 kg burden, while head and chest circumference were measured using flexible measuring tape. HC was measured between glabella anteriorly and along the most prominent point posteriorly, whereas CC was measured at the level of nipple in the end phase of expiration. Two midwives who worked at the maternal clinic and have been trained prior to data collection took measurements.

Pearson’s correlation coefficient was used to measure the strength of the association between HC and CC with LBW. A Receiving Operating Curve (ROC) was used to determine the sensitivity and specificity, as well as the cut-off value, of the methods. ROC is the best analysis to predict dichotomous outcomes. Further analysis was performed to determine which surrogate measurement was more appropriate to detect LBW.


Descriptive characteristics: Across the nine months of the study, 100 deliveries took place; all newborns met the inclusion criteria. The proportion of male and female newborns was similar (male: 57%, female: 43%). The mean birth weight was 3,223±412.21 g, HC was 32.69±1.23 cm and CC was 32.36±1.45 cm (Table 1).

Correlation coefficients: Based on the results of a Pearson Correlation test, HC and CC were correlated with birth weight with r values of 0.4 and 0.6, respectively. The correlation between CC and birth weight was stronger compared to the correlation between HC and birth weight.

ROC curve analysis: ROC analysis was used to quantify the performance of a classifier (CC and HC at birth with LBW). HC had a higher AUC (0.74), indicating higher accuracy of the test, while CC (0.58) had a lower AUC (Fig. 1).

Table 1: Characteristics at birth

Table 2: Area under the curve, sensitivity and specificity of head and chest circumference

Fig. 1:
ROC curve of chest and head circumference for optimal birth weight surrogate

AUC, critical, limit, sensitivity and specificity: Head and chest measurement sensitivity and specificity were calculated and an operational cut-off value was determined by taking the value with the highest average of sensitivity and specificity. HC and CC had the same sensitivity (67%); however, HC had better specificity compared to CC (HC: 67%, CC: 53%). Due to the higher AUC of HC (0.74 (0.55-0.92)), a cut-off value was taken from HC (32.12 cm). Therefore, a HC less than 32.12 was categorized as LBW (Table 2).


Our study found that the average birth weight was 3,223 g (±412.2 g), which is relatively high compared to the average birth weight in Ghana (2,900±700 g) and India (2,398±560 g)8,10. The discrepancy in findings is likely due to differences in inclusion criteria, as our study only includes full-term and singleton newborns. The HC average in the present study is similar to results of a previous study by Sreeramareddy et al.5 (32.72±1.7 cm) in India; however, the values of this study were slightly different compared with the results of studies by Pankaj and Kanchan11 (33.59±1.18 cm) and Hadush et al.12 (34.6±1.5 cm). The average CC in the current study was similar to results of a previous study conducted by Sreeramareddy et al.5 (32.8±1.9 cm)but was slightly higher compared to results of a study by Suneetha and Kavitha10 (30.68±2.26 cm) and Pankaj and Kanchan11 (31.11±1.92 cm).

Several studies have attempted to find a reliable, simple and inexpensive surrogate measurement to detect LBW. In this study, we found that the best surrogate measurement was HC; this result is in line with previous studies conducted in Nepal, Ethiopia and Nigeria5,13,14. Although, HC and CC had the same sensitivity (67%), HC was chosen to be the best surrogate measurement due to its higher AUC (0.74) and specificity (67%). While HC may not be accurate due to the moulding of head as a result of prolonged and obstructed labor, newborns designated as LBW would be referred to other health care facilities with better medical equipment for further evaluation.Using ROC curve analysis, we determined the optimal cut-off points by choosing the value with highest average of sensitivity and specificity and identified a value of 32.12 cm for HC, such that values less than 32.12 cm would be considered LBW. This cut-off value is comparable to other studies conducted in developing countries, such as India (31.5 cm) and Nigeria (32.95 cm) but slightly lower compared to Ethiopia (33.25 cm) and Uganda (33.3 cm)7,13-14. The difference in cut-off values is likely due to differences in average birth weight.

This study has some limitations. We did not analyze differences in anthropometric measurements between males and females, as we did not find differences between genders. We also did not consider ethnic variables because our respondents were of the same ethnicity. Thus, higher average birth weight may be due to the low prevalence of LBW. It is possible that there were inter and intra-observer bias measurements. This study should be validated in rural communities.


The current study concludes that HC is a better surrogate measurement for detecting LBW in Indonesian newborns compared to CC. This study should be validated in rural community settings with a larger number of participants.


This study discovered the use of head circumference as an optimum surrogate measurement to detect low birth weight in neonates compared to chest circumference. The result of this study is useful to detect neonates low birth weight in rural settings.


We acknowledge and thank the director of Anny Rahardjo Maternal Clinic for permitting us to carry out this study.

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