Ali et al.

BMC Pregnancy and Childbirth (2017) 17:111

DOI 10.1186/s12884-017-1275-y

RESEARCH ARTICLE Open Access

Impact of maternal respiratory infections

on low birth weight - a community based
longitudinal study in an urban setting in
Pakistan
Asad Ali1* , Umber Zaman1, Sadia Mahmud1, Gul-e-Shehwar Zahid1, Momin Kazi1, William A. Petri2,
Zulfiqar Bhutta1, Anita Zaidi1 and Molly A. Hughes2

Abstract
Background: The health of mothers and their newborns is intricately related. The weight of the infant at birth is a
powerful predictor of infant growth and survival, and is considered to be partly dependent on maternal health and
nutrition during pregnancy. We conducted a longitudinal study in an urban community within Karachi to
determine maternal predictors of newborn birth weight.
Methods: Four hundred pregnant women were enrolled in the study during the period 2011–2013. Data related to
symptoms of acute respiratory illness (fever, cough, difficulty breathing, runny nose, sore throat, headache, chills,
and myalgia/lethargy) in the pregnant women were collected weekly until delivery. Birth weight of the newborn
was recorded within 14 days of delivery and the weight of <2.5 kg was classified as low birth weight (LBW).
Results: A total of 9,853 symptom episodes were recorded of fever, cough, difficulty breathing, runny nose, sore
throat, headache, chills, myalgias/lethargy in the enrolled pregnant women during the study. Out of 243 pregnant
women whose newborns were weighed within 14 days of birth, LBW proportion was 21% (n = 53). On multivariate
analysis, independent significant risk factors noted for delivering LBW babies were early pregnancy weight of < 57.
5 kg [odds ratio adjusted (ORadj) = 5.1, 95% CI: (1.3, 19.9)] and gestational age [ORadj = 0.3, 95% CI (0.2, 0.7) for every
one week increase in gestational age]. Among mothers with high socioeconomic status (SES), every 50-unit
increase in the number of episodes of respiratory illness/100 weeks of pregnancy had a trend of association with an
increased risk of delivering LBW infants [ORadj = 1.7, 95% CI: (1.0, 3.1)]. However, among mothers belonging to low
SES, there was no association of the number of episodes of maternal respiratory illness during pregnancy with
infants having LBW [ORadj = 0.9, 95% CI: (0.5, 3.5)].
Conclusions: While overall respiratory illnesses during pregnancy did not impact newborn weight in our study, we
found this trend in the sub-group of mothers belonging to the higher SES. Whether this is because in mothers
belonging to lower SES, the effects of respiratory illnesses were overshadowed by other risk factors associated with
poverty need to be further studied.
Keywords: Pregnancy, Respiratory illness, ARI, Newborn weight, Longitudinal observational study

* Correspondence: Asad.ali@aku.edu
1
Department of Pediatrics and Child Health, The Aga Khan University, Karachi
74800, Pakistan
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ali et al. BMC Pregnancy and Childbirth (2017) 17:111 Page 2 of 7

Background The sample size calculated for pregnant women was

An estimated 358,000 women die annually due to com- approximately 300 based on an assumption of 5% influ-
plications that develop during pregnancy and childbirth enza rates in adults, with a margin of error of 5.62% and
[1]. For every woman who dies, at least 20 more suffer 95% confidence level. The total number of pregnant
from pregnancy related injuries, infections, diseases and women enrolled in the study was 400 in order to ac-
disabilities, often with lifelong consequences [2]. The count for attrition due to noncompliance with the study
health of mothers and newborns is intricately related, so protocol, withdrawal from the study, and movement of
improving outcomes in either requires effective nutri- participants out of the area.
tion, infection control measures, and antenatal care. Illness in the pregnant women was detected either by
Pregnant women are vulnerable to viral respiratory in- once weekly household visits by trained study health
fections [3, 4] and are considered to be at high risk for care workers, or through the pregnant women contact-
influenza [5] and its complications [6–8]. Preventing in- ing project personnel at the field office, an easy walk
fluenza in mothers leads to increase in birth weights [9] from all of the homes enrolled in the study. On each
and reduced infections in newborns [10, 11]. While the weekly visit, the participants were questioned regarding
impact of influenza during pregnancy on newborns is symptoms of respiratory illness, diarrhea, vomiting and
now better understood [7, 8, 12, 13], the importance of fever in the last seven days. A brief standard question-
other respiratory infections has not been studied. In naire was administered either at home or in the clinic if
order to improve maternal and neonatal outcomes and a pregnant woman had developed signs or symptoms of
to develop appropriate preventive and treatment strat- acute respiratory illness (ARI). The clinic in the field of-
egies, the association between common maternal illness fice is staffed with an obstetrics/gynecology medical offi-
and newborn’s health needs to be studied. Therefore, we cer who provided free care to the study participants and
conducted this study to identify the association between their immediate family, with health care available at the
maternal respiratory illnesses and infant birth weight in government hospital when the clinic was closed. The
an urban slum of Pakistan. field teams encouraged the study participants to visit the
clinic for any symptom. Appropriate and standard health
Methods care was provided to all the study participants according
This study was conducted under approval by institutional to the local standards.
review boards at the Aga Khan University, Karachi,
Pakistan and University of Virginia, Charlottesville, Statistical methods
Virginia, USA. Informed consent was obtained from the Descriptive statistics and inferential data analyses were
adult participants and by a parent’s informed consent for conducted using SPSS 17.0 [14]. Mean and standard de-
newborns. The study was conducted during the period viation were computed for quantitative and proportions
from July 2011 to June 2013 in Bilal Colony, which is an for categorical variables.
urban settlement within Karachi, Pakistan. The total The outcome variable, weight of the newborns, was
population of Bilal Colony is 76,361. The total number of measured within 0–14 days of birth. The mean age of
women of reproductive age (15–49 years) is 17,351, and infants when the birth weight was recorded was 4.9 days
the number of children less than five years old is 11,023 (SD 3.7 days). The weight of the mothers was measured at
(2010 baseline survey). This site has an ongoing demo- the mean gestational age of 12.7 weeks (SD 4.4 Weeks).
graphic surveillance system (DSS) where baseline census The signs and symptoms of maternal respiratory illness
has been performed. Information on the following are during pregnancy were recorded as the number of epi-
conducted routinely every three months: number of sodes of fever, cough, difficulty breathing, runny nose, sore
events of pregnancy, births, and deaths; migration in or throat, headache, chills, and myalgias/lethargy throughout
out of the community; and number of married women. the follow-up period. The number of episodes of each of
A longitudinal, observational cohort study was con- these signs and symptoms per 100 weeks of pregnancy
ducted in which women in their first trimester or early were computed. A principle component analysis [15] of
second trimester of pregnancy were randomly selected the eight respiratory illness signs and symptoms episodes
from the list of pregnant women of Bilal Colony (DSS). per 100 weeks of pregnancy was conducted. The first
Informed consent was obtained, and participants were principle component explains 38%, and the second 17%,
enrolled and subsequently followed once weekly for of the total variance of the 8 items. The values of eigen-
symptoms of respiratory or febrile illness until delivery. vector of the first principle component indicate that all 8
The study was designed to document the timing and se- items contribute to the total score for the first component,
quence of respiratory symptom episodes and to identify and no item dominates. Scores based on the first compo-
any association of these symptoms in the pregnant nent correlate highly with the total number of episodes of
women to the newborn’s weight. signs and symptoms of respiratory illness per 100 weeks
Ali et al. BMC Pregnancy and Childbirth (2017) 17:111 Page 3 of 7

of pregnancy (r = 0.989). Hence, in order to quantify ma- runny nose, sore throat, headache, chills, and myalgias/
ternal respiratory illness during pregnancy, we used the lethargy of the pregnant women during their pregnancy.
total number of episodes of signs and symptoms of re- In the multivariable model, factors associated with LBW
spiratory illness per 100 weeks of pregnancy. were lower weight of mother at first visit, higher gravidity,
Multivariable logistic regression analysis was conducted shorter gestational age of newborn, higher household
to identify factors associated independently with infant socio-economic status, higher number of episodes of re-
LBW; LBW was categorized as < 2.5 kg. We conducted spiratory symptoms, and higher number of fever episodes.
univariable logistic regression analysis for each of the There were two interactions in the model; one between
socio-demographic and clinical characteristics of the preg- number of episodes of respiratory symptoms and SES, and
nant mothers compared to delivery of LBW newborns. The another between gravidity and number of fever episodes.
criteria for selecting a variable for inclusion in the multivar- After adjusting for other variables in the model infants
iable model was a (likelihood ratio test) p-value < 0.25 from born to mothers with weight at first visit of < 57.5 kg were
the univariable logistic regression analysis, and variables at 5-fold risk for LBW relative to mothers with weight ≥
considered to be of biological importance. In the multivari- 57.5 kg [ORadj = 5.1, 95% CI: (1.3, 19.9)] (Table 3).
able model, scale of all continuous predictor variables was There is evidence for an interaction between number
examined using the quartile analysis method. Confounding of episodes of maternal respiratory illness symptoms/
effects of variables, with insignificant Wald p-values in the 100 weeks of pregnancy with the pregnant mother's SES.
multivariable model on other variables, were assessed. This implies that the effect of maternal respiratory ill-
Biologically meaningful interactions between variables in ness symptom episodes during pregnancy on infant
the model were assessed for statistical significance [16]. LBW outcome depends on a mother's SES. Among
mothers with high SES, for every 50-unit increase in
Results number of episodes of respiratory illness/100 weeks of
Among the 400 women initially enrolled in the study, 157 pregnancy the risk of infant’s LBW increased 1.7 times
were lost to follow-up by the time of delivery, mainly due [ORadj = 1.7, 95% CI: (1.0, 3.1)]. However, among preg-
to migration before or at the time of delivery. Out of the nant mothers belonging to lower SES there is no signifi-
243 infant deliveries, 21% (n = 51) were LBW newborns. cant association of number of episodes of maternal
At the first clinic visit of the pregnant mother, the average respiratory illness during pregnancy with a subsequent
age and average weight of the pregnant women in the newborn with LBW [ORadj = 0.9, 95% CI: (0.5, 3.5)]
study were 24.1 years and 56.1 kg, respectively. Thirty two (Table 3). In addition, there was an interaction between
percent (n=76) of the mothers had primary education or number of fever episodes/100 weeks of pregnancy and
above, and only 26% (n=62) of the women had antenatal gravidity in the multivariable model. If gravidity is 3 or
visits during their pregnancy. The mean age of mothers less, there is no significant impact of maternal fever epi-
(23 years) was found to be lower in those who had new- sodes during pregnancy on whether a newborn is LBW
borns with lower birth weights compared to those who or not. However, with increasing gravidity there is a sig-
had newborns with birth weight > 2.5 kg (24.4 years). In nificant and progressively increasing adverse association
our study cohort, the major source of drinking water was of the number of maternal fever episodes during preg-
piped water in the households, which was more frequently nancy with a newborn having LBW. Infants born to
available for pregnant women who had newborns weigh- mothers who had ≥ 11 fever episodes/100 weeks of preg-
ing >2.5 kg (36.9%) compared to pregnant women who nancy had more than 3 times higher risk when gravidity
had LBW newborns (31.4%). Use of water bought from was 5 [ORadj = 3.4, 95% CI:(1.1, 10.5)] and 9 times higher
drums was a more frequent practice of mothers of infants risk when gravidity was 7 [ORadj = 9.0, 95%CI:(1.4, 57.6)]
with LBW (37.2%) compared to mothers of infants with relative to infants born to mothers who had < 11 fever
birth weight > 2.5 kg (29.7%) (Table 1). episodes/100 weeks of pregnancy (Table 3).
The results of univariate logistic regression analysis are
reported in Table 2. The socio-demographic characteris- Discussion
tics of pregnant women associated with infants with low We found that low maternal body weight during early
birth weight included age, gravidity, and maternal weight pregnancy and gestational age of a newborn are signifi-
at first visit. A higher total score for household assets cant risk factors for infant LBW in our study. In the
correlated with a decreased risk of delivering LBW infant. population of women with a high incidence of respira-
Increased gestational age was associated with a signifi- tory infections, we found that an effect of the number of
cantly reduced risk of LBW (Table 2). episodes of maternal respiratory illness/100 weeks of
Complete data sets were available for 222 women for pregnancy on infant LBW may depend on the pregnant
the multivariable model. There were a total of 9,853 symp- mother's SES, with the impact of maternal respiratory
tom episodes recorded of fever, cough, difficulty breathing, illnesses on infant birth weight being greater on women
Ali et al. BMC Pregnancy and Childbirth (2017) 17:111 Page 4 of 7

Table 1 Descriptive Analysis of the characteristics of pregnant Table 1 Descriptive Analysis of the characteristics of pregnant
women with low birth weight infants compared to those with women with low birth weight infants compared to those with
normal birth weight infants normal birth weight infants (Continued)
Pregnant women characteristics Sample Birth weight Headache ~ 243 18.7 (13.3) 20.4 (13.1)
size (n)
<2.5 kg > = 2.5 kg Chills ~ 243 6.6 (6.1) 5.3 (6.2)
(n = 51) (n = 192)
Myalgias/Lethargy 243 19.0 (9.8) 18.0 (9.0)
Age of pregnant women 243 23.0 (3.8) 24.4 (4.5)
Mean(SD); years Diarrhea ~ 243 3.3 (4.3) 4.6 (6.8)
Pregnant women’s education; Vomiting ~ 243 6.2 (9.0) 6.2 (8.9)
n (%)
Total number of Respiratory 243 102.9 (49.7) 96.1 (41.3)
No formal schooling 237 35 (68.6) 126 (65.6) symptom episodes* ~
th
Below 10 grade 8 (15.7) 38 (19.8) Infant characteristics Mean (SD) Mean (SD)
10th grade and above 6 (11.8) 24 (12.5) Weight of the infant(kg) 243 2.1 (0.2) 3.0 (0.4)
Weight at first visit of 243 49.0 (9.0) 53.6 (11.7) Height of the infant (cm) 243 45.6 (2.5) 49.5 (3.2)
pregnant women
mean(SD); kg MUAC** of infant (cm) 241 8.4 (0.9) 9.8 (0.8)

Height of pregnant 243 153.1 (4.5) 152.6 (11.5) OFC*** of infant(cm) 242 31.7 (1.3) 34.2 (1.4)
women mean(SD); cm * Respiratory symptoms included eight symptoms (cough, difficulty breathing,
runny nose, sore throat, headache, chills, and myalgia/lethargy)
Gravidity, Median (IQR) 240 3 (2) 3 (3) ~ Episodes per 100 weeks of pregnancy
Household characteristics **Mid upper arm circumference
***Occipitofrontal circumference
No of people living in 243 8.9 (5.5) 8.7 (5.5)
household, Mean(SD)
No of rooms in the 242 2.5 (1.5) 2.4 (1.4)
household Mean(SD) belonging to high SES. One explanation for this observa-
Total score of household 243 154.3 (141.9) 201.1 (179.0) tion is that amongst women from low SES, there are
assets, Mean(SD) other factors including poor maternal nutritional status,
Main source of drinking 242 low education and inaccessibility to appropriate water
water; n (%)
sources that influence the weight of the newborn
Piped into the house 16 (31.4) 71 (36.9) adversely. As a result, the effect of maternal respiratory
Bought from tankers 16 (31.4) 63 (32.8) illnesses on low birth weight is blunted and a trend of
Bought from drums 19 (37.2) 57 (29.7) association was not shown in that subset of mothers
Use of flush toilet 237 0 (0) 2 (1.0) with lower SES.
facility; n (%) This study explores an association between newborn
Use of boiled water; n (%) 243 10 (19.6) 40 (20.8) birth weights with the maternal respiratory morbid-
Antenatal characteristics
ities during pregnancy in the community settings.
Other studies have explored associations of vaginal
Age at first pregnancy 243 18.8 (2.2) 18.9 (3.6)
(years) Mean(SD) infections [17] and periodontal infections [18] in
pregnancy with delivering LBW infants. The strength
Child gestational age in 241 36.6 (1.2) 36.7 (3.9)
weeks Mean(SD) of our study lies in the observational cohort design,
Number of antenatal 238
where we actively followed pregnant women every
visits during current week for presence of fever and respiratory symptoms
pregnancy; n (%) in the previous seven days. Through this study design,
0 36 (70.6) 140 (72.9) we were able to demonstrate an appropriate temporal
1 5 (9.8) 9 (4.7) sequence between exposure of pregnant women with
2 4 (7.8) 23 (11.9)
fever and respiratory illnesses and the outcome of
LBW newborns. In our study sample, we found 21%
3 and above 5 (9.8) 16 (8.3)
of delivered newborns had LBW, which is comparable
Clinical characteristics Mean (SD) Mean (SD) to the Pakistan Demographic and Health Survey data
Fever~ 243 7.2 (7.4) 6.8 (7.9) (26% low birth weight infants) for the period 2006–
Cough ~ 243 10.2 (9.4) 8.5 (7.3) 2007 [19].
Difficulty breathing ~ 243 10.6 (10.9) 8.2 (7.7) In univariate analysis, we observed an association be-
Runny nose ~ 243 10.7 (8.5) 10.9 (7.3)
tween increased parity and a decreased risk of having a
newborn with LBW. It is consistent with the finding that
Sore throat ~ 243 10.0 (9.1) 9.1 (8.1)
second and third newborns usually weigh more than the
Ali et al. BMC Pregnancy and Childbirth (2017) 17:111 Page 5 of 7

Table 2 Univariate Logistic Regression Analysis of the characteristics of pregnant women to identify factors associated with low
birth weight of infants (n = 222)
Pregnant women characteristics Crude OR (95% CI) P-value
Pregnant women age (years) For every 5 year increase 0.7 (0.5 0.9) 0.032
Age at first pregnancy (years) For every 5 year increase 0.9 (0.6 1.5) 0.796
Gravidity (total number of pregnancies) For every 1 unit increase 0.8 (0.7 0.9) 0.031
Weight at first visit (kg) For every 10 kg weight increase 0.6 (0.5 0.9) 0.006
Height of pregnant women (cm) For every 10 cm increase 0.9 (0.7 1.3) 0.739
Pregnant women education No education 1 0.805
Below high school equivalent 0.8 (0.3 1.8)
High school equivalent and above 0.9 (0.3 2.4)
Household characteristics
No of people living in house hold For every 1 unit increase 1.0 (0.9 1.1) 0.766
No of rooms in the household For every 1 unit increase 1.0 (0.8 1.3) 0.738
Total score of household assets For every 200 unit increase 0.7 (0.4 0.9) 0.073
Source of drinking water Piped water 1 0.578
Water bought from tankers 1.1 (0.5 2.4)
Water bought from drums 1.5 (0.7 3.1)
Use of boiled water Yes 0.9 (0.4 2.0) 0.847
No 1.0 -
Antenatal characteristics
Child gestational age in weeks For every 1 week increase 0.4 (0.2 0.8) 0.000
First pregnancy No 1 0.798
Yes 0.9 (0.4 2.1)
Number of antenatal visits during current pregnancy For every 1 visit increase 1.0 (0.8 1.3) 0.828
Delivery location of last child No previous pregnancy 1 (0.4 2.6) 0.815
Maternity home 1.0
Home 1.2 (0.5 2.9)
Clinical characteristics
Maternal fevera For every 10 episode increase 1.1 (0.7 1.6) 0.698
Maternal diarrheaa For every 5 episode increase 0.8 (0.6 1.1) 0.178
a
Maternal vomiting For every 10 episode increase 0.9 (0.7 1.4) 0.969
Total number of Respiratory symptom episodesa For every 50 episodes increase 1.2 (0.8 1.8) 0.313
a
Episodes per 100 weeks of pregnancy

first newborn in a family [20]. Similar to other previously places around the peri partum period. Another limitation
published studies, this study supports that low SES of is that the birth weight was recorded within 0–14 days of
the pregnant mother is associated with an increase in birth (mean age 4.9 days) due to the fact that in this
the risk of having a newborn with LBW [21]. community, access to the mother and the newborn baby
There are several limitations of the current study which can be difficult in the immediate post-partum period. The
include small sample size, assessment of illness by report gestational age was measured by taking the date of the last
only and limited ability to identify severity of illness. menstrual period from the mothers instead of by ultra-
Although we enrolled 400 pregnant women, a 100 more sound documentation due to logistic constraints. Finally,
than the required sample size to account for the expected we could not assess some interactions for significance in
loss of follow-up in this long surveillance study, 39% the final multivariable model due to sparse data (that led
dropout was still higher than expected. Major reason for to zero cell counts and hence numerically unstable logistic
this dropout was migration of pregnant women to native regression model).
Ali et al. BMC Pregnancy and Childbirth (2017) 17:111 Page 6 of 7

Table 3 Multivariable Logistic Regression Modela to identify Abbreviations

factors associated with infant low birth weight (n = 222) ARI: Acute respiratory infections; CI: Confidence interval; DSS: Demographic
surveillance system; LBW: Low birth weight; OR: Odds ratio; PCA: Principal
Variables Adj OR (95% CI) component analysis; SD: Standard deviation; SES: Socio-economic status.
Mother’s weight at first visit
Acknowledgments
<57.5 Kg 5.1 (1.3 19.9) We thank all the patients and their families for participating in this study.
≥57.5 Kg 1 - We acknowledge Samana Zaidi for making substantial contributions to the
acquisition of data and supervision of the field staff.
Child gestational age (weeks) 0.3b (0.2 0.7)
Association between number of episodes of Funding
respiratory illness /100 weeks of pregnancy and SESc This project was funded by a grant from the US DOD (HDTRA1-10-1-0082).

High SES 1.7d (1.0 3.1) Availability of data and materials

The datasets used and analysed during the current study available from the
number of episodes of respiratory illness /
corresponding author on reasonable request.
100 weeks of pregnancy
Low SES
Author's contributions
number of episodes of respiratory illness / 0.9d (0.5 3.5) AA substantially contributed in the design, conduct and write up of the study.
100 weeks of pregnancy UZ has made substantial contributions (1) to design, acquisition and analysis
and interpretation of data; 2) have been involved in drafting the manuscript
Interaction between number of fever episodes/ and revising it critically for important intellectual content. SM conducted the
100 weeks of pregnancy and Gravidity principal component analysis for respiratory symptoms, and made the major
number of fever episodes/100 weeks of pregnancy contribution for conducting multivariable logistic regression analysis, wrote the
Graviditye = 2 (0.3, 2.2) results and interpretations from these inferential models and critically reviewed
the manuscript. GSZ has made substantial contributions in the analysis and
≥11 0.8 - write-ups of the manuscript. MK has made substantial contributions in the
<11 1.0 design and conduct of the study. WP has made substantial contributions in the
design and planning of the study and critical review of the manuscript. ZB has
Gravidity =3 (0.5, 3.0) made substantial contributions in the design and conduct of the study and
≥11 1.3 - critical review of the manuscript. AZ has made substantial contributions in the
design and conduct of the study and critical review of the manuscript. MH has
<11 1.0 made substantial contributions in the design, planning and conduct of the
study as well as critical review of the manuscript. All the listed authors have
Gravidity =5 (1.1, 10.5)
read and approved the final manuscript.
≥11 3.4 -
Competing interests
<11 1.0 The authors declare that they have no competing interests.
Gravidity =7 (1.4, 57.6)
Consent for publication
≥11 9.0 - Not Applicable
<11 1.0
Ethics approval and consent to participate
Gravidity =9 (1.7, 357.2) This study was conducted under approval by institutional review boards at
≥11 24.2 - the Aga Khan University, Karachi, Pakistan and University of Virginia,
Charlottesville, Virginia, USA. Informed consent was obtained from the adult
<11 1.0 participants and by a parent’s informed consent for newborns.
a
. Adjusted for mother's age and number of episodes of diarrhea/100 weeks
of pregnancy Publisher’s Note
−2 Log-Likelihood = 187.701, Hosmer & Lemeshow goodness of fit
Springer Nature remains neutral with regard to jurisdictional claims in
test p-value = 0.566
b published maps and institutional affiliations.
. Odds Ratio (and 95% CI) corresponds to every one week increase in
gestational age
c
. SES (Socio-Economic Status). Total score of assets <142 is labeled as "low" Author details
1
and ≥ 142 as "high" SES Department of Pediatrics and Child Health, The Aga Khan University, Karachi
d
. Odds Ratio (and 95% CI) corresponds to every 50 unit increase in number of 74800, Pakistan. 2Division of Infectious Diseases, University of Virginia School
episodes of respiratory illness /100 weeks of pregnancy of Medicine Carter-Harrison Building, Room 1704, 345 Crispell Drive,
e
. For values of "Gravidity" minimum = 1, maximum =11, 25th percentile = 2, Charlottesville, VA 22908, USA.
50th percentile = 3, 75th percentile = 5
Received: 15 November 2016 Accepted: 11 March 2017

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