The intergenerational relationship between mother's birthweight, infant birthweight and infant mortality in black and white mothers

Summary. The relationship between the birthweight of white and black mothers and the outcomes of their infants were examined using the 1988 National Maternal and Infant Health Survey. White and black women who were low birthweight themselves were at increased risk of delivering very low birthweight (VLBW), moderately low birthweight (MLBW), extremely preterm and small size for gestational age (SGA) infants. Adjustment for the confounding effects of prepregnant weight and height reduced the risks of all these outcomes slightly, and more substantially reduced the maternal birthweight associated risk of moderately low birthweight among white mothers. There was little effect of maternal birthweight on infant birthweight-specific infant mortality in white mothers; however, black mothers who weighed less than 4 lbs at birth were at significantly increased risk of delivering a normal birthweight infant who subsequently died. Although the risks for the various outcomes associated with low maternal birthweight were not consistently higher in black mothers compared with white mothers, adjustment for prepregnant weight and height had a greater effect in white mothers than in black mothers. We suggest that interventions to reduce the risks for adverse pregnancy outcomes associated with low maternal birthweight should attempt to optimise prepregnant weight and foster child health and growth.     

The influence of maternal cigarette smoking, snuff use and passive smoking on pregnancy outcomes: the Birth To Ten Study

This article describes the patterns and effects of maternal snuff use, cigarette smoking and exposure to environmental tobacco smoke during pregnancy on birthweight and gestational age, in women living in Johannesburg and Soweto in 1990. A cohort of 1593 women with singleton live births provided information about their own and household members' usage of tobacco products during pregnancy. The women completed a questionnaire while attending antenatal services. Data on gestational age and birthweight were obtained from birth records. Women who smoked cigarettes or used snuff during pregnancy accounted for 6.1% and 7.5% of the study population respectively. The mean birthweight of non-tobacco users was 3148 g [95% CI 3123, 3173] and that of the smokers 2982 g [95% CI 2875, 3090], resulting in a significantly lower mean birthweight of 165 g for babies of smoking mothers (P = 0.005). In contrast, women using snuff gave birth to infants with a mean birthweight of 3118 g [95% CI 3043, 3192], which is a non-significant (P = 0.52) decrease (29.4 g) in their infants' birthweights compared with those not using tobacco. A linear regression analysis identified short gestational age, female infant, a mother without hypertension during pregnancy, coloured (mixed racial ancestry), and Asian infants compared with black infants, lower parity, less than 12 years of education and smoking cigarettes as significant predictors of low birthweight, while the use of snuff during pregnancy was not associated with low birthweight. The snuff users, however, had a significant shorter gestational age than the other two groups of women. The birthweight reduction adjusted for possible confounders was 137 g [95% CI 26.6, 247.3 (P = 0.015)] for cigarette smokers and 17.1 g [95% CI -69.5, -102.7, P = 0.69] for snuff users respectively, compared with the birthweight of non-tobacco users. Among women who did not smoke cigarettes or use snuff, exposure to environmental tobacco smoke did not result in significant effects on the birthweight of their infants. In conclusion, infants of cigarette smokers had significantly lower birthweights than those of non-tobacco users or snuff users who are exposed to nicotine during pregnancy. Passive smoking did not affect birthweight significantly in this population.     

The perinatal advantage of Mexican-origin Latina women

PURPOSE: To determine if there is a perinatal advantage for birth outcomes among Mexican-origin Latina (Latina) women compared to white non-Hispanic (white) women, after adjusting for maternal, paternal, and infant factors.

METHODS: 1,439,583 births from the 1990–1993 California linked birth and infant death certificate data sets were analyzed for the risk of low birth weight infants and infant mortality.

RESULTS: Latina women had a statistically higher unadjusted risk of low birth weight infants and infant mortality compared to white women. After adjusting for potential confounders, Latina women had a similar risk of low birth weight infants and a lower risk of infant mortality relative to white women. In multivariate analyses, the most significant risk factor for low infant birth weight was young gestational age (OR = 82.91 for gestational age 1–230 days and OR = 10.62 for gestational age 231–258 days) and the most significant risk factor for infant mortality was low birth weight (OR = 53.99 for infant birth weight <500 grams and OR = 9.27 for infant birth weight 500–2499 grams).

CONCLUSION: There was some evidence of a perinatal advantage for Latina women, when compared to white women and after adjusting for numerous potential confounders. To further reduce the risk of low birth weight infants and infant mortality, additional research is needed for etiologic clues beyond race/ethnicity and other traditional risk factors.     

Birth weights of black African babies of migrant and nonmigrant mothers compared with those of babies of European mothers in Portugal

PURPOSE: The study aim is to investigate differences in birth weights between babies of foreign-born black African, Portugal-born black African, and Portugal-born white mothers. METHODS: Hospital records for Amadora and Sintra from July 2001 to June 2002 were collated and 2949 Portugal-born white, 461 Portugal-born black African, and 817 foreign-born black African live singleton babies were identified. The impact of biologic and social factors (infant sex, maternal age, parity, gestational age, and maternal smoking, education, and occupational class) and mode of delivery on birth weights was assessed by using multivariable regression models. RESULTS: African mothers were more likely to be of lower socioeconomic status than white Portuguese mothers, among whom rates of smoking were two to three times greater (21% among white Portuguese mothers). Small preterm babies comprised 1.5% of white Portuguese babies, 2.3% of babies of Portugal-born African mothers, and 3.9% of babies of foreign-born African mothers (p < 0.05 compared with white Portuguese babies). Compared with white Portuguese babies, mean birth weight of term babies, adjusted for sex, among Portugal-born African mothers was -24.6 g (95% confidence interval, -70.1-20.9), and among foreign-born African mothers, was +38.8 g (95% confidence interval, 2.9-74.8). Adjustment for parity, maternal age, and gestational age decreased the significant birth weight advantage of babies of foreign-born African mothers to +2.3 g (95% confidence interval, -31.9-36.5). Among nonsmokers, after adjusting for these factors, white Portuguese babies were heavier (40 g; p < 0.05) than babies of foreign-born African mothers, but among smokers, they were lighter (163 g; p < 0.05). CONCLUSIONS: Compared with white Portuguese babies, mean birth weight of term babies of foreign-born African mothers was greater, and that of babies of Portugal-born African mothers was intermediate. These differences were related to a combination of biologic factors and smoking.     

The effects of cigarette smoking and gestational weight change on birth outcomes in obese and normal-weight women.

OBJECTIVES: The associations of infant birth outcomes with maternal pregravid obesity, gestational weight gain, and prenatal cigarette smoking were examined. METHODS: A retrospective analysis of 1343 obese and normal-weight gravidas evaluated the associations of cigarette smoking, gestational weight change, and pregravid body mass index with birthweight, low birthweight, and small- and large-for-gestational-age births. RESULTS: Smoking was associated with the delivery of lower-birthweight infants for both obese and normal-weight women, and gestational weight gain did not eliminate the birthweight-lowering effects of smoking. Women at highest risk of delivering lower-birthweight infants were obese smokers whose gestational gains were less than 7 kg and normal-weight smokers whose gestational gains were less than 11.5 kg. CONCLUSIONS: To balance the risks of small and large-size infants, gains of 7 to 11.5 kg for obese women and 11.5 to 16 kg for normal-weight women appear appropriate.     

Risk factors for sudden infant death syndrome in the US Collaborative Perinatal Project

Risk factors for sudden infant death syndrome (SIDS) were studied among infants born to the nearly 56,000 women enrolled in the US Collaborative Perinatal Project from 1959 through 1966. The 193 SIDS cases identified in the cohort were compared with 1930 controls randomly selected from infants who survived the first year of life. The previously documented excess risk associated with black race disappeared after adjusting for maternal education and family income. Maternal smoking, maternal anaemia during pregnancy, and lack of early prenatal care were all positively associated with SIDS. After adjustment for gestational age, infants with low weight and length at birth were still at increased SIDS risk, suggesting that intrauterine growth retardation may be a risk factor. Neurological abnormalities diagnosed before death were associated with SIDS, but much of the association was removed by adjusting for birthweight. The negative association of breastfeeding with SIDS was much reduced upon adjustment by maternal education and birthweight. These findings may have important implications in our understanding of the epidemiology of SIDS.     

Factors that influence the outcome of pregnancy in middle-class women

A retrospective analysis was made of 1,080 singleton pregnancies of middle-class women to identify factors that influence outcome as measured by birth weight, gestational age, Apgar scores, and the incidence of complications. Increased birth weight was associated with increases in weight gain, maternal age, gestational age, maternal initial body weight, maternal hemoglobin and hematocrit values at 3 months, hemoglobin levels at 7 months, and socioeconomic status. For women whose initial weights were 90% to 135% of the standard, highest birth weights occurred when weight gains exceeded 29 lb. A 1 lb gain in maternal weight was associated with a 6 gm increase in birth weight. Birth weight was negatively correlated with a complicated obstetrical history and maternal cigarette smoking. Infants of heavy smokers weighed an average of 156 gm less than infants of nonsmokers. One-minute Apgar scores were significantly lower for infants of mothers who consumed alcohol and those who had had a complicated obstetrical history. Initial maternal weight and the husband's occupation positively influenced gestational age. There was no relationship between the incidence of maternal or infant complications and independent variables.     

Developing a Maternally Linked Birth Dataset to Study the Generational Recurrence of Low Birthweight in Virginia

This paper examined the generational recurrence of low birthweight (LBW) among first-born singletons using a statewide maternally-linked birth dataset. An intergenerational dataset was created by linking 2005–2009 to 1960–1997 Virginia resident live birth data. Maternal information from the recent birth cohort was linked to infant information in the historic birth file using various combinations of mother’s name and birthdate. The linked dataset contained 170,624 records (87 % of all eligible records). The analysis dataset was limited to non-Hispanic black and non-Hispanic white first-born singleton infants linked to their mother’s own birth record (n = 69,702). Maternal birthweight was a significant predictor of LBW for first-born singletons. The birthweight distribution for both non-Hispanic black and non-Hispanic white infants was shifted toward lower birthweights for infants whose mothers were born LBW. Even after adjusting for known maternal risk factors in the current pregnancy, non-Hispanic black (AOR = 1.6 [95 % CI 1.4, 1.8]) and non-Hispanic white (AOR = 2.0 [95 % CI 1.8, 2.3]) infants had increased odds of being born LBW if their mother was born LBW. A mother’s early life experiences can impact the health of her children. These findings underscore the importance of applying a life course perspective to the prevention of LBW. Routine linkage of maternal and infant birth data is needed to strengthen the evidence base for policies and programs that address issues affecting maternal and child health throughout the life course.     

Overview of the National Infant Mortality Surveillance (NIMS) project

A slowdown in the decline of infant mortality in the United States and a continuing high risk of death among black infants (twice that of white infants) prompted a consortium of Public Health Service agencies, in collaboration with all states, to develop a national data base of linked birth and infant death certificates for the 1980 birth cohort. This project, referred to as National Infant Mortality Surveillance (NIMS), provides neonatal, postneonatal, and infant mortality risks for blacks, whites, and all races in 12 categories of birthweights. Tabulations were requested for infants born in single and multiple deliveries. For single-delivery births, tabulations included birthweight, age at death, race of infant, and each of these characteristics: infant's live-birth order, sex, gestation, type of delivery, and cause of death; and mother's age, education, prenatal care history, and number of prior fetal losses at greater than or equal to 20 weeks' gestation. An estimated 95% of eligible infant deaths were included in the NIMS tabulations. Analyses have focused on various components of infant mortality, including birthweight distribution of live births, neonatal mortality, and postneonatal mortality. The most important predictor for infant survival is birthweight; survival increases exponentially as birthweight increases to its optimal level. The nearly twofold higher risk of infant mortality among blacks than among whites was related to a higher prevalence of low birthweights, to higher mortality risks in the neonatal period for infants with birthweights of greater than or equal to 3,000 g, and to higher mortality during the postneonatal period for all infants, regardless of birthweight. Moreover, the black-white gap persisted for infants with birthweight of greater than or equal to 2,500 g, regardless of other infant or maternal risk factors.     

Racial/ethnic differences in smoking, other risk factors, and low birth weight among low-income pregnant women, 1978-1988

Because of the adverse effects of low birth weight (LBW) on infant morbidity and mortality, one of the 1990 health objectives for the nation has been to reduce the incidence of LBW to 5% among all live births in the United States. Public health surveillance of cigarette smoking during pregnancy has demonstrated an association between smoking and an increased risk of LBW, defined as birth weight of less than 2,500 g. For the period 1978-1988, information on nearly 248,000 women from CDC's Pregnancy Nutrition Surveillance System showed an LBW rate of 6.9%, a high prevalence of smoking during pregnancy (29.7%); and a strong association between smoking during pregnancy and the likelihood of delivering an LBW infant in all age, racial/ethnic, and prepregnancy weight groups. The risk of LBW was greater for smokers than for nonsmokers (9.9% versus 5.7%), creating an excess LBW risk of 4.2% associated with smoking. Overall, the average birth-weight deficit related to smoking was 178 g. Among both smokers and nonsmokers, black women had a higher percentage of LBW infants than did white women, and the risk of LBW related to smoking was greater among black women. That risk tended to increase with age, especially among women with low pregravid weight. Major reductions in LBW might be achieved if smoking were eliminated among pregnant women.     

Maternal Pre-Pregnancy Weight and Gestational Weight Gain and Their Association with Birthweight with a Focus on Racial Differences

Our objectives were to examine the interaction between maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) and their association with birthweight, with a focus on racial differences. We used birth certificate data from live singleton births of South Carolina resident mothers, who self-reported their race as non-Hispanic white (NHW, n = 140, 128) or non-Hispanic black (NHB, n = 82,492) and who delivered at 34–44 weeks of gestation between 2004 and 2008 to conduct a cross-sectional study. Linear regression was used to examine the relationship between our exposures (i.e., race, BMI and GWG) and our outcome birthweight. Based on 2009 Institute of Medicine guidelines, the prevalence of adequate, inadequate and excessive GWG was 27.1, 24.2 and 48.7%, respectively, in NHW women and 24.2, 34.8 and 41.0%, respectively, in NHB women. Adjusting for infant sex, gestational age, maternal age, tobacco use, education, prenatal care, and Medicaid, the difference in birthweight between excessive and adequate GWG at a maternal BMI of 30 kg/m² was 118 g (95% CI: 109, 127) in NHW women and 101 g (95% CI: 91, 111) in NHB women. Moreover, excessive versus adequate GWG conveyed similar protection from having a small for gestational age infant in NHW [OR = 0.64 (95% CI 0.61, 0.67)] and NHB women [OR = 0.68 (95% CI: 0.65, 0.72)]. In conclusion, we report a strong association between excessive GWG and higher infant birthweight across maternal BMI classes in NHW and NHB women. Given the high prevalence of excessive GWG even a small increase in birthweight may have considerable implications at the population level.     

Changing patterns of low birthweight and preterm birth in the United States, 1981-98

Low birthweight (LBW) and preterm birth are primary risk factors for infant morbidity and mortality in the US. With increasing multiple births and delayed childbearing, it is important to examine the separate contributions of these characteristics to the increases in LBW and preterm birth rates. US natality records from 1981, 1990 and 1998 were used to calculate LBW (% births <1500, 1500-2499, <2500 g) and preterm (% births <29, 29-32, 33-36, <37 weeks gestation) rates. Data were stratified by maternal race (black or white) and plurality (singleton vs. multiple birth). LBW and preterm rates among singletons were adjusted for maternal age to examine the influence of demographic shifts on LBW trends. From 1981 to 1998, LBW increased 12% among white infants, but remained relatively stable among black infants. During the same time, preterm birth increased 23% among white infants compared with 3% among black infants. For both black and white infants, the increase in LBW and preterm births was greater among multiple births than among singletons. Adjustment for maternal age did not reduce the temporal increase in LBW or preterm birth among singletons. Black infants continue to experience a markedly higher incidence of LBW and preterm birth, but the racial gap in these outcomes has narrowed slightly in recent years as a result of increasing LBW and preterm birth among white births. The differing trends for white and black infants are the consequence of a disparate trend in the incidence and outcome of multiple births coupled with increases in LBW and preterm birth among white singletons. Understanding the differential patterns in birth outcomes among white and black infants is necessary to develop effective interventions designed to decrease racial disparities in pregnancy outcome.     

Racial differences in birthweight for gestational age and infant mortality in extremely-low-risk US populations

Using national data, we develop and contrast the birth-weight percentiles for gestational age by infants of extremely-low-risk (ELR) White and African-American women and examine racial differences in the proportion of small-for-gestational-age (SGA) births. We then scrutinise racial variations in infant mortality rates of the infants of ELR women. We further compare the infant mortality rates of infants at or below the 10th percentile of birthweight for gestational age of each race group to determine whether infants with similar restricted fetal growth have comparable risks of subsequent mortality. Single live births, 34-42 weeks' gestation, to White and African-American US-resident mothers were selected from the 1990-91 US Linked Live Birth--Infant Death File (n = 4,360,829). Extremely-low-risk mothers were defined as: married, aged 20-34 years, 13+ years of education, multiparae, with average parity for age, adequate prenatal care, vaginal delivery, and no reports of medical risk factors, tobacco use or alcohol use during pregnancy. Marked racial variation in birthweight percentiles by gestational age was evident. Compared with ELR White mothers, the risk of an SGA infant was 2.64 times greater for ELR African-American mothers and the risk of infant mortality was 1.61 times greater. For the ELR group, the infant mortality rates of African-American and White infants at or below the 10th percentile of birthweight for gestational age of their respective maternal race group were essentially identical after controlling for gestational age. In conclusion, race differences in fetal growth patterns remained after controlling for risk status. Efforts to remove racial disparities in infant mortality will need to develop aetiological pathways that can explain why African-Americans have relatively higher rates of preterm birth and higher infant mortality rates among term and non-SGA infants.     

Changes in the black-white infant mortality gap from 1983 to 1991 in the United States

Background: The long-standing difference in infant mortality in the United States between black and white infants has increased in recent years. To help identify the cause, we evaluated changes in birthweight distributions (BDs) and birthweight-specific mortality rates (BSMRs) among black and white infants born in the United States between 1983 and 1991.Methods: Using national linked birth and death certificate data, we limited analyses to singleton births that occurred in the United States to resident, non-Hispanic black and white women. Birthweight data were analyzed in 500 g increments. The black-white gap was partitioned into deaths due to differences in BDs and BSMRs.Results: The black-white infant mortality rate ratio increased from 2.1 in 1983 to 2.4 in 1991. Decreases in BSMRs among infants weighing from 500 to 2499 g occurred in both groups but were smaller among black than white infants; consequently, the percentage of excess deaths to black infants due to differences in BSMRs almost doubled during the study period, from 6.5% to 11.9%. Rates of very low birthweight (VLBW, <1,500 g) increased for black infants, but the BD for white infants changed little. Although about 90% of the excess deaths to black infants resulted from differences in BDs, the changes in BDs had a minimal effect on the widening infant mortality gap.Conclusions: A significant reduction in the black-white infant mortality gap will require a reduction in VLBW and low birthweight (LBW, <2,500 g). To keep the gap from growing, we must also investigate why decreases in BSMRs were smaller among black than white infants between 1983 and 1991.     

Infant Mortality: Explaining Black/White Disparities in Wisconsin

Objectives: Understanding the factors contributing to black/white disparities in infant mortality rates in Wisconsin is a prerequisite to decreasing these disparities and improving birth outcomes. We examined multiple determinants of infant mortality to understand the impact of specific risk factors on the infant mortality rates of blacks and whites in Wisconsin. Methods: We used the Wisconsin Interactive Statistics on Health database to examine infant mortality data for the 5-year time period, 1998–2002 (N=32,166 black infant births; 272,559 white infant births). We conducted a bivariate analysis of relative risks (RR) of infant mortality (black vs. white) using specific variables available in the database. We then examined the relationship between infant mortality rate and selected risk factors using regression analyses. Results: Unadjusted, black infants were 3.0 times more likely to die during their first year of life, compared with white infants. Adjusting for gestational age black infants were only 1.9 times more likely to die. The risk was further reduced, after adjusting for birth weight, to 1.3. However, stratifying and adjusting for 8 other multiple variables accounted for some, but not all of the disparity. Black infants who had the same risk profile as white infants still had a 2-fold excess risk of death. In addition, simultaneously controlling for 4 of the 8 risk factors (maternal age, maternal education, adequacy of prenatal care received, and region of the state) also reduced, but did not eliminate, this excess risk (RR was still 2.2 for black infants). Independent of maternal age and region of the state, adequate prenatal care and higher levels of education are significant indicators of the racial disparity between whites and blacks. Conclusions: These results suggest that, within a given racial group, increasing access to prenatal care and increasing maternal educational attainment will improve infant mortality rates but will not eliminate the black/white disparity in infant mortality. In fact, these interventions may actually widen the disparity in infant mortality rate between blacks and whites, especially if funds and programs are applied equally throughout the population, rather than targeted to high-risk individuals, who lag significantly behind the majority population. The Wisconsin white population, which has already attained an infant mortality rate of 4.5 per 1,000 live births, will continue to have greatest benefit from these programs compared to blacks who have a rate of 19.2 in 2004; thus, the disparity is not eliminated and the gap widens probably due to differential uptake of health messages secondary to health literacy issues. Further research is needed to fully understand the additional, more difficult to measure factors that contribute significantly to infant mortality, especially among black women.     

Maternal serum caffeine metabolites and small-for-gestational age birth.

To determine whether the third-trimester maternal serum concentration of paraxanthine, caffeine's primary metabolite, is associated with delivery of a small-for-gestational age infant (birth weight less than the 10th percentile for gestational age, gender, and ethnicity) and whether this association differs by smoking, the authors studied 2,515 women who participated in the Collaborative Perinatal Project from 1959 to 1966. The women provided a third-trimester serum sample and had been controls for a nested case-control study of spontaneous abortion. The mean serum paraxanthine concentration was greater in women who gave birth to small-for-gestational age infants (754 ng/ml) than to appropriately grown infants (653 ng/ml, p = 0.02). However, the linear trend for increasing serum paraxanthine concentration to be associated with increasing risk of small-for-gestational age birth was confined to women who also smoked (p = 0.03). There was no association between paraxanthine and fetal growth in nonsmokers (p = 0.48). Adjustment for maternal age, pre-pregnant weight, education, parity, ethnicity, and the number of cigarettes smoked per day did not alter the results substantially, although the p value for trend among smokers increased to 0.07. The authors conclude that maternal third-trimester serum paraxanthine concentration, which reflects caffeine consumption, was associated with a higher risk of reduced fetal growth, particularly among women who smoked.     

Utilisation of prenatal services and birth outcomes: a community-based study in Israel

Summary
The purpose of this paper was to assess several measures of utilisation of prenatal care as predictors of birth outcome in a community where the availability and quality of services were equal for all pregnant women. A case-control study was conducted in a small community in Israel, comparing 189 women whose pregnancy resulted in an unfavourable outcome (perinatal mortality, preterm birth and low birthweight at term) with 384 women, matched by birth order, who had a live, full-term infant weighing 2500 g or more. In a multivariable analysis, adjusting for pregnancy complications, maternal age, parity and socio-economic disadvantage, gestational age at initiation of prenatal care was not an independent predictor of unfavourable outcome; neither was lower than the recommended number of visits for the period under care. However, a higher than expected number of visits was associated with unfavourable outcome [odds ratio (OR)=6.10, 95% CI 2.09–17.78], as was non-compliance with medical recommendations [OR=2.02, 95% CI 1.24–3.29. The context of prenatal care delivery, as well as the process of care and compliance with recommendations, should be assessed in order to determine the impact of prenatal care on birth outcomes.     

Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women with gestational diabetes

OBJECTIVE: To study the influence of energy and macronutrient intake on infant birthweight in women with gestational diabetes mellitus undergoing intensive management. DESIGN: This prospective study evaluated the impact of intensive management of gestational diabetes on maternal and fetal morbidity, and addressed the relationship between food intake and infant birthweight. SETTING: Fifteen maternity hospitals in northern France. SUBJECTS: Ninety-nine women with gestational diabetes or gestational mild hyperglycemia diagnosed between 24 and 34 weeks of gestation were surveyed. After 1 was excluded because of a premature birth and 18 were excluded as underreporters, 80 women were included in the final analysis. Diet intake was assessed by a dietary history at the first interview, and by two 3-day diet records at the 3rd and 7th week after diagnosis. RESULTS: In a forward-stepwise regression analysis (controlling for maternal age; smoking; parity; prepregnancy BMI; pregnancy weight gain; gestational duration; infant sex; fasting and 2-hour postprandial serum glucose; insulin therapy; and energy, fat, protein and carbohydrate intake during treatment) infant birthweight was positively associated with gestational duration (beta = +0.34, P<.002), and negatively with smoking (beta = -0.27, P<.02) and carbohydrate intake (beta = -0.24, P<.03). There were no large-for-gestational-age infants among women whose carbohydrate intake exceeded 210 g/day. CONCLUSION: For women with gestational diabetes undergoing intensive management, higher carbohydrate intake is associated with decreased incidence of macrosomia. APPLICATION: These findings suggest that nutrition counseling in gestational diabetes must be directed to maintain a sufficient carbohydrate intake (at least 250 g per day), which implies a low-fat diet to limit energy intake. A careful distribution of carbohydrate throughout the day and the use of low-glycemic index foods may help limit postprandial hyperglycemia.