Relationship Among Placenta Previa, Fetal Growth

Restriction, and Preterm Delivery: A Population-

Based Study
Cande V. Ananth, PhD, MPH, Kitaw Demissie, MD, PhD,
John C. Smulian, MD, MPH, and Anthony M. Vintzileos, MD
OBJECTIVE: To examine the independent contributions of
prematurity and fetal growth restriction to low birth
weight among women with placenta previa.
METHODS: A population-based, retrospective cohort study
of singleton live births in New Jersey (198993) was per-
formed. Mother-infant pairs (n 544,734) were identied
from linked birth certicate and maternal and infant hos-
pital discharge summary data. Women diagnosed with
previa were included only if they were delivered by cesar-
ean. Fetal growth, dened as gestational age-specic ob-
served-to-expected mean birth weight, and preterm deliv-
ery (before 37 completed weeks) were examined in relation
to previa. Severe and moderate categories of fetal smallness
and large for gestational age were dened as observed-to-
expected birth weight ratios below 0.75, 0.750.85, and
over 1.15, respectively, all of which were compared with
appropriately grown infants (observed-to-expected birth
weight ratio 0.861.15).
RESULTS: Placenta previa was recorded in 5.0 per 1000
pregnancies (n 2744). After controlling for maternal age,
education, parity, smoking, alcohol and illicit drug use,
adequacy of prenatal care, maternal race, as well as obstet-
ric complications, previa was associated with severe (odds
ratio [OR] 1.37, 95% condence interval [CI] 1.25, 1.50)
and moderate fetal smallness (OR 1.24, 95% CI 1.17, 1.32)
births. Preterm delivery was also more common among
women with previa. Adjusted OR of delivery between
2023 weeks was 1.81 (95% CI 1.24, 2.63), and 2.90 (95% CI
2.46, 3.42) for delivery between 2427 weeks. OR for deliv-
ery by each week between 28 and 36 weeks ranged between
2.7 and 4.0. Approximately 12% of preterm delivery and
3.7% of growth restriction were attributable to placenta
previa.
CONCLUSION: The association between low birth weight
and placenta previa is chiey due to preterm delivery and
to a lesser extent with fetal growth restriction. The risk of
fetal smallness is increased slightly among women with
previa, but this association may be of little clinical signi-
cance. (Obstet Gynecol 2001;98:299306. 2001 by the
American College of Obstetricians and Gynecologists.)
Placenta previa is a signicant contributor to preterm
delivery, low birth weight, and perinatal mortality.
13
However, the contribution of fetal growth restriction in
low birth weight (under 2500 g) infants seen among
women with placenta previa remains largely unex-
plored. Indeed, the relationship between placenta previa
and fetal growth restriction is poorly understood. Earlier
studies have reported conicting results. Studies from
Britain have found an increased number of growth-
restricted infants among women diagnosed with placenta
previa in the 1970s and 1980s,
4,5
whereas others con-
ducted during this approximate time period failed to
corroborate these ndings.
6,7
Almost a decade ago, Wolf
et al
8
reported a lack of association between ultrasound-
diagnosed placenta previa and intrauterine growth re-
striction based on a small case-control study.
The major drawbacks of all these studies are small
sample size, with lack of statistical power to detect differ-
ences, and the lack of control for important confounding
factors. To overcome these limitations, we examined the
relationship between placenta previa, fetal growth re-
striction, and preterm delivery in a large population-
based setting comprised of over half a million pregnan-
cies, with extensive control for confounding variables.
PATIENTS AND METHODS
This retrospective cohort study was based on birth cer-
ticate data linked to the maternal and newborn hospital
discharge summaries for New Jersey residents. The
study was restricted to women who delivered singleton
live births in New Jersey hospitals between 1989 and
1993. Hospital discharge data for both mothers and
infants contain information that is abstracted from the
From the Section of Epidemiology and Biostatistics and the Division of Maternal-
Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences,
and Department of Environmental and Community Medicine, University of
Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School,
New Brunswick, New Jersey.
299 VOL. 98, NO. 2, AUGUST 2001 0029-7844/01/$20.00
2001 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc. PII S0029-7844(01)01413-2
medical record of the delivery hospitalization. The New
Jersey Department of Health routinely links birth certif-
icates with infant death certicates, which are then linked
to the mothers and infants hospital discharge data. The
match rate was successful in over 95% of these linkages.
Fetal growth, one of the outcomes evaluated, was
expressed as the ratio of the observed birth weight to the
expected mean birth weight for each gestational age; this
ratio was dened as the fetal growth ratio. The mean
birth weight for each week of gestation was derived from
the 198993 New Jersey singleton live births. Several
degrees of fetal smallness, based on the fetal growth
ratio, were dened as follows: severe when the fetal
growth ratio was below 0.75, moderate when the fetal
growth ratio was between 0.75 and 0.85, and large when
the ratio was over 1.15. These indices of fetal growth
were compared with appropriately grown infants (fetal
growth ratio 0.861.15). The cut-points for these indices
of fetal growth have been validated by investigators in
other populations.
9
We also examined the risks of deliv-
ering small for gestational age births, dened using birth
weight centiles, in women with and without placenta
previa. Birth weight centiles were dened as infants with
birth weight below the 1st centile, below the 3rd centile,
below the 5th centile, and those below the 10th centile,
all of which were compared with infants at or above the
10th centile. These birth weight centiles were derived
from the 198993 New Jersey singleton births.
Gestational age categories for dening preterm deliv-
ery included 2023 weeks, 2427 weeks, 2830 weeks,
and thereafter in 1-week intervals between 31 and 36
weeks, each of which was compared with pregnancies
that ended after 36 weeks. To minimize errors in the
assignment of gestational age, we restricted the analysis
to pregnancies that ended between 20 and 44 weeks, a
restriction shown to reduce the degree of error in gesta-
tional age.
10
Gestational age and birth weight were ob-
tained from birth certicate data.
Women whose medical records data contained an Inter-
national Classication of Diseases, 9th Revision, Clinical
Modication (ICD-9-CM) diagnosis code 641.0 or 641.1
were considered to have had placenta previa. However, the
severity and grades of previa were not recorded. Further-
more, we restricted this group only to women with a
diagnosis of previa who had a cesarean delivery. This
restriction was necessary to eliminate the probable and
suspected cases of previa, as well as cases diagnosed as
previa but which resolve later in pregnancy.
Sociodemographic and clinical variables that were con-
sidered as potential confounding variables included mater-
nal age, parity (primipara versus multipara), race-ethnicity
(white non-Hispanic, black non-Hispanic, black or white
Hispanic), and infant gender. Socioeconomic and lifestyle
factors included marital status (married or unmarried),
level of maternal education (below12, 12, 1316, and over
16 years of completed schooling), cigarette smoking, alco-
hol and illicit drug use, and prenatal care utilization (inade-
quate, intermediate, adequate, and adequate plus). Catego-
ries of prenatal care utilization were dened using the
Adequacy of Prenatal Care Utilization Index developed by
Kotelchuck.
11
These variables were obtained from the
birth certicate. Information on payer status (type of med-
ical insurance) was obtained from the mothers primary
medical insurance that was coded on the hospital Unied
Billing Patient Summary at the time of delivery. Insurance
type was grouped as Medicaid, Medicaid HealthStart, Self-
pay, Managed Care, and Indemnity for the purposes of this
study.
Information on medical complications of pregnancy
that were considered as potential confounders included
previous cesarean delivery (ICD-9-CM diagnosis code
654.2), diabetes (ICD-9-CM 250), preeclampsia (ICD-
9-CM642.4 to 642.5), chronic hypertension (ICD-9-CM
401 to 405 and 642.0 to 642.2), chronic renal disease
(ICD-9-CM 646.2), asthma during pregnancy (ICD-
9-CM 493), syphilis (ICD-9-CM 647), and abruptio pla-
centae (ICD-9-CM 641.2). Information on congenital
anomalies (ICD-9-CM 740 to 759) was also assessed.
Risks of fetal growth restriction and preterm delivery
were compared among women with and without a diag-
nosis of placenta previa. Unadjusted odds ratios were
computed as measures of effect. Odds ratios were de-
rived from multivariable logistic regression models after
adjusting for confounding variables. Potential confound-
ers were retained in the models for adjustment if their
presence changed the unadjusted relative risks by at least
10%. Because the two outcomes, degrees of fetal growth
restriction and preterm delivery, were categorical with
more than two levels, adjusted odds ratios (OR) with
95% condence intervals (CI) were derived from tting
multinomial polytomous logistic regression models.
12
We calculated the population attributable risk for de-
grees of fetal growth restriction and preterm delivery in
relation to placenta previa.
13
Finally, we also modeled
birth weight, gestational age, and fetal growth ratio as
continuous variables in a multivariable linear regression
model. From these models, we derived the mean differ-
ences in these outcomes for women with and without
placenta previa, after controlling for confounders. All
statistical analyses were performed using the SAS 8.0
software, SAS Institute, Cary, NC).
RESULTS
Among the 544,734 singleton live births, placenta previa
was recorded in 2744 pregnancies, yielding a rate of 5.0
300 Ananth et al Placenta Previa, Fetal Growth Restriction, and Prematurity OBSTETRICS & GYNECOLOGY
per 1000 pregnancies. Descriptive characteristics of
women diagnosed with placenta previa compared with
those who had no previa are shown in Table 1. Women
with placenta previa were more likely to be older and
multiparous. The frequencies of maternal complications
and congenital anomalies were more common among
women with previa than those without this condition.
The proportion of male fetuses and the proportion of
smokers were also increased among the previa than the
nonprevia group. Women diagnosed with placenta pre-
via were more likely to be delivered earlier than those
without placenta previa (Figure 1). By 36 weeks, 8% of
women without placenta previa had delivered compared
with a rate of almost 40% among those with placenta
previa.
After adjustments for potential confounding factors
including maternal age, parity, smoking, chronic hyper-
tension, diabetes, adequacy of prenatal care, as well as
gestational age, infants in the previa group weighed, on
average, 110 g (95% CI 91, 129) lighter than those in the
nonprevia group (Table 2). Similarly, the mean fetal
growth ratio was lower among previa cases compared
with infants in the nonprevia group, indicating smaller
fetal size of infants born to women with previa. Likewise,
women with previa were delivered approximately 2.1
weeks earlier than those without this condition. The
distribution of mean birth weight in the previa and
nonprevia cohorts were, however, similar (Figure 2).
Women diagnosed with placenta previa were more
likely to deliver smaller babies. Among women diag-
nosed with placenta previa, 6.52% delivered severely
small infant (fetal growth ratio below 0.75) compared
with 3.18% in the nonprevia group (adjusted OR 1.37,
95% CI 1.25, 1.50) (Table 3). Similarly, OR 1.24 (95%
Table 1. Characteristics of Women With and Without Placenta Previa
Characteristics Total births
Placenta previa
N (%) Odds ratio (95% CI)
Number of women 544,734 2744 (0.50)
Maternal age (y)
20 48,266 71 (0.15) 1.00 (Referent)
2024 106,659 315 (0.30) 2.05 (1.58, 2.67)
2529 170,322 722 (0.42) 2.95 (2.30, 3.79)
3034 153,711 986 (0.64) 4.46 (3.49, 5.72)
3539 57,235 538 (0.94) 6.54 (5.08, 8.43)
40 8541 111 (1.30) 9.12 (6.75, 12.34)
Parity
Parity 0 237,341 840 (0.35) 1.00 (Referent)
Parity 1 173,127 976 (0.56) 1.59 (1.45, 1.75)
Parity 24 117,029 809 (0.69) 1.95 (1.77, 2.15)
Parity 5 6603 54 (0.82) 2.31 (1.76, 3.04)
Race-ethnicity
White 330,923 1572 (0.48) 1.00 (Referent)
Black 100,652 551 (0.55) 1.15 (1.05, 1.23)
Hispanic 79,209 415 (0.52) 1.10 (0.99, 1.23)
Others 33,950 207 (0.61) 1.27 (1.11, 1.48)
Insurance Status
Indemnity 277,022 1585 (0.57) 1.00 (Referent)
Medicaid, nonHS 45,445 254 (0.56) 0.98 (0.86, 1.52)
Medicaid-HS 75,810 319 (0.42) 0.74 (0.65, 0.83)
Self-pay 42,556 224 (0.53) 0.92 (0.80, 1.06)
HMO 79,748 362 (0.45) 0.79 (0.71, 0.89)
Unknown 24,153
Substance use
None 475,678 2341 (0.49) 1.00 (Referent)
Smoker 59,280 332 (0.56) 1.19 (1.07, 1.33)
Alcohol use 6732 28 (0.42) 1.15 (0.93, 1.43)
Drug use 3044 43 (1.41) 2.83 (2.10, 3.82)
Infant sex
Females 266,159 1249 (0.47) 1.00 (Referent)
Males 278,566 1495 (0.54) 1.15 (1.06, 1.23)
Congenital anomalies
Absent 515,936 2497 (0.48) 1.00 (Referent)
Present 28,798 247 (0.86) 1.77 (1.56, 2.02)
CI condence interval; HS Health Start Program; HMO Health Maintenance Organization.
301 VOL. 98, NO. 2, AUGUST 2001 Ananth et al Placenta Previa, Fetal Growth Restriction, and Prematurity
CI 1.17, 1.32) was noted for the analysis pertaining to
moderately small infants (fetal growth ratio 0.750.84).
Small for gestational age births dened using birth
weight centiles (below 1, below 3, below 5, and below 10
centile) were also examined in relation to previa (Table
3). Among women diagnosed with placenta previa, the
rate of small for gestational age (below 10 centile) births
was 11.55%, compared with a rate of 9.9% in the non-
previa group, yielding an adjusted OR of 1.12 (95% CI
1.06, 1.18). The population attributable risk was 3.7%
(fetal growth ratio below 0.75 and 0.750.85 combined)
in relation to placenta previa.
Separate polytomous logistic regression models were
constructed for evaluating the associations between pla-
centa previa and pretermdelivery (Table 4). The risks of
delivering before 37 completed weeks for women with
and without placenta previa were 37.68% and 6.90%,
respectively. The adjusted ORfor delivering between 20
Figure 1. Cumulative delivery
rate by each week of gestation
for those diagnosed with pla-
centa previa (and delivered by
cesarean) (), and without pre-
via delivered by cesarean (E)
and vaginally ().
Ananth. Placenta Previa, Fetal Growth
Restriction, and Prematurity. Obstet
Gynecol 2001.
Table 2. Placenta Previa, Birthweight, Gestational Age, and Fetal Growth Ratio
Previa
(N 2744)
Nonprevia
(N 541,990)
Adjusted mean difference*
(95% CI) P Mean (SD) Mean (SD)
Birth weight (g) 2873 (772) 3360 (589) 110 (91, 129) .001
Preterm births (37 wk) 2250 (715) 2322 (784) 66 (31, 61) .001
Term births (37 wk) 3250 (520) 3437 (492) 105 (82, 128) .001
Gestational age (wk) 36.7 (3.5) 39.2 (2.2) 2.1 (2.0, 2.2) .001
Fetal growth ratio

0.98 (0.19) 1.00 (0.15) 0.03 (0.02, 0.03) .001

Preterm births (37 wk) 0.99 (0.18) 1.00 (0.14) 0.03 (0.01, 0.05) .001
Term births (37 wk) 0.98 (0.15) 1.01 (0.14) 0.02 (0.01, 0.03) .001
SD standard deviation; CI condence interval.
* Differences were adjusted for the effects of maternal age, parity, smoking, race-ethnicity, chronic hypertension, preeclampsia, diabetes,
adequacy of prenatal care, and insurance status through multivariable linear regression models. Analysis relating to birth weight was further
adjusted for gestational age at delivery.

Fetal growth ratio was dened as the ratio of observed-to-expected mean birth weight by gestational age.
302 Ananth et al Placenta Previa, Fetal Growth Restriction, and Prematurity OBSTETRICS & GYNECOLOGY
and 32 weeks in relation to previa ranged between 1.8
and 4.0. Thereafter, the relative risks progressively de-
clined. Finally, the population attributable risk for deliv-
ering before 37 completed weeks in relation to placenta
previa was 12%, implying that approximately one in
eight preterm deliveries in this cohort were attributable
to placenta previa.
DISCUSSION
Although the etiology of placenta previa is poorly under-
stood, several risk factors associated with this condition
have been established. These include advanced maternal
age, multiparity, smoking before and during pregnancy,
cocaine use, twin pregnancies, male fetuses, history of
Figure 2. Distribution of mean
birth weight by gestational age
at delivery among infants born
to women diagnosed with ()
and without placenta previa
(E).
Ananth. Placenta Previa, Fetal Growth
Restriction, and Prematurity. Obstet
Gynecol 2001.
Table 3. Placenta Previa and Fetal Growth Restriction
Fetal growth
restriction
Previa
(N 2744)
Nonprevia
(N 541,990) Odds ratio (95% CI)
N (%) N (%) Unadjusted Adjusted*
Fetal growth ratio

0.75 177 (6.45) 17,236 (3.18) 2.16 (1.87, 2.48) 1.37 (1.25, 1.50)
0.750.84 368 (13.41) 52,615 (9.71) 1.45 (1.32, 1.59) 1.24 (1.17, 1.32)
0.851.15 1820 (66.33) 401,220 (74.13) 1.00 (Referent) 1.00 (Referent)
1.15 379 (13.81) 70,919 (13.08) 0.99 (0.98, 1.00) 1.00 (0.94, 1.06)
Birth weight centiles
1st 43 (1.74) 5360 (1.09) 1.61 (1.20, 2.17) 1.20 (1.02, 1.42)
3rd 119 (4.67) 16,157 (3.20) 1.48 (1.23, 1.78) 1.21 (1.10, 1.34)
5th 178 (6.83) 26,813 (5.20) 1.33 (1.15, 1.55) 1.16 (1.07, 1.26)
10th 317 (11.55) 53,641 (9.90) 1.19 (1.06, 1.34) 1.12 (1.06, 1.18)
10th 2427 (88.45) 488,347 (91.10) 1.00 (Referent) 1.00 (Referent)
CI condence interval.
* Odds ratios were adjusted for the confounding effects of maternal age, parity, marital status, maternal education, race-ethnicity, diabetes,
preeclampsia, chronic hypertension, level of prenatal care, type of medical insurance, smoking, and alcohol use during pregnancy through
multivariable logistic regression models. Analysis relating to birth weight centiles was further adjusted for gestational age at delivery.

Fetal growth ratio was dened as the ratio of observed-to-expected mean birth weight by gestational age.
303 VOL. 98, NO. 2, AUGUST 2001 Ananth et al Placenta Previa, Fetal Growth Restriction, and Prematurity
spontaneous or induced abortions, as well as prior cesar-
ean and instrumental delivery.
1418
Finally, placenta
previa diagnosed in a prior pregnancy confers elevated
recurrence risk in subsequent pregnancy.
19,20
The association between placenta previa and lowbirth
weight has been fairly well established. However, the
association between previa and fetal growth is, at best,
equivocal. Prior studies have noted strong,
21
weak,
22
or
an absence of association
6,8
between placenta previa and
fetal growth restriction. Lowbirth weight is an extremely
heterogeneous index to assess fetal well-being because it
combines prematurity (delivery before 37 weeks), fetal
growth restriction, as well as other intrinsic fetal disor-
ders such as chromosomal abnormalities and congenital
malformations. Efforts to isolate these intrinsic pathways
that lead to lowbirth weight would benet fromstudying
the individual components, namely, prematurity and
growth restriction. In that regard, our study clearly
demonstrates that the association between placenta pre-
via and lowbirth weight is chiey due to the inuences of
prematurity, and virtually very little due to impaired
fetal growth. This might help explain the conicting
results from prior studies on placenta previa and growth
restriction. The small attributable risk for growth restric-
tion (3.7%) relative to that for preterm delivery (12%) in
relation to placenta previa further conrms our observa-
tion that the association between placenta previa and low
birth weight is chiey due to prematurity. Despite the
presence of a statistical association between placenta
previa and fetal smallness observed in our study, the
magnitude of these associations, from a clinical perspec-
tive, is likely to be of little signicance.
Barr et al
21
performed a continuous-wave Doppler
study of umbilical arteries on 100 women with placenta
previa who were matched with an equal number of
controls (women with normally implanted placentas) on
gestational age. Their results showed elevated placental
vascular resistance among patients with previa com-
pared with controls. Their study also showed an in-
creased rate of fetal growth restriction in cases than
controls. It is generally believed that the increased inci-
dence of small for gestational age births among women
with placenta previa is largely due to placental insuf-
ciency, thought to arise because of decreased placental
perfusion caused by suboptimal implantation site. Con-
sequently, this leads to decreased nutrient transfer from
the maternal to fetal circulation.
2
In a small hospital-
based case-control study of placenta previa, Wolf et al
8
reported an absence of association between previa and
small for gestational age births (4.1% among previa
patients and 5.8%among controls). They concluded that
the lack of association between placenta previa and small
for gestational age births was the result of conservative
management with maternal transfusions to maintain he-
matocrit levels, and bed rest to optimize placental perfu-
sion.
8
One could argue that if similar management pro-
tocols such as the one documented by Wolf et al
8
were
applied to all patients in our study, then the risk of small
for gestational age births among women diagnosed with
placenta previa would be expected to be even lower than
those reported here.
The incidence of placenta previa is generally reported
to range between three and seven per 1000 singleton
pregnancies.
14,17,19,23
We found an incidence of 5.0 per
1000 in this singleton population when cases were re-
stricted to those delivered by cesarean. The incidence of
previa in this cohort was 6.0 per 1000 births without the
restriction. Inclusion of women with placenta previa but
who delivered vaginally did not alter our conclusions
(data not shown).
Table 4. Placenta Previa and Gestational Age at Delivery
Gestational age at
delivery (wk)
Previa
(N 2744)
Nonprevia
(N 541,990) Odds ratio (95% CI)
N (%) N (%) Unadjusted Adjusted*
2023 13 (0.47) 1113 (0.21) 2.00 (1.52, 2.64) 1.81 (1.24, 2.63)
2427 56 (2.04) 2116 (0.40) 3.01 (2.63, 3.44) 2.90 (2.46, 3.42)
2830 130 (4.74) 2952 (0.54) 3.92 (3.58, 4.30) 3.68 (3.28, 4.12)
31 43 (1.57) 1294 (0.24) 3.41 (2.92, 3.98) 3.50 (2.94, 4.17)
32 93 (3.39) 2082 (0.38) 3.95 (3.55, 4.40) 4.00 (3.54, 4.52)
33 80 (2.92) 2334 (0.43) 3.46 (3.09, 3.88) 3.28 (2.86, 3.76)
34 148 (5.39) 4192 (0.77) 3.51 (3.22, 3.83) 3.53 (3.20, 3.89)
35 159 (5.79) 6530 (1.20) 2.92 (2.69, 3.17) 2.87 (2.61, 3.16)
36 312 (11.37) 14,723 (2.72) 2.72 (2.51, 2.96) 2.70 (2.52, 2.89)
3744 1710 (62.32) 504,584 (93.10) 1.00 (Referent) 1.00 (Referent)
CI condence interval.
Odds ratios were adjusted for the effects of maternal age, parity, marital status, maternal education, race-ethnicity, diabetes, preeclampsia, chronic
hypertension, asthma, syphilis, level of prenatal care, type of medical insurance, smoking, and alcohol use during pregnancy through multivariable
logistic regression models.
304 Ananth et al Placenta Previa, Fetal Growth Restriction, and Prematurity OBSTETRICS & GYNECOLOGY
A few limitations of our study merit attention. The
completeness and validity in the reporting of a diagnosis
of previa on hospital discharge summaries using the ICD
codes remain unknown. Although there is potential for
some degree of misclassication of previa cases, this bias
would have been nondifferential with respect to the
outcomes examined. The reported associations in the
presence of such a misclassication, if any, are likely to
drive the OR toward the null value.
24
Second, a small
fraction of women may have had more than one preg-
nancy during the 5 years studied (198993), which
violates the statistical assumption of independence in the
regression models. This, however, would have very little
impact on the CI although the effect measure (OR)
would be unaffected.
25
We were unable to correct for
this nonindependence during statistical analysis because
the linked vital statistics and hospital discharge summary
data do not identify subsequent pregnancies to the same
woman.
This large population-based cohort study comprising
over half million singleton births enabled us to carefully
examine the risks of fetal growth restriction in relation to
placenta previa. Not only were we able to evaluate
associations after adjustment for potential confounders,
but we also examined degrees of fetal growth ratio, as
well as risks of small for gestational age births based on
birth weight centiles. The concordance in the association
between placenta previa and growth restriction dened
using two different indices (fetal growth ratio and birth
weight centiles) further strengthens our conclusions. In
summary, our study offers two important conclusions:
Most of the association between placenta previa and low
birth weight is due to prematurity, and very little to fetal
smallness, and the statistical, but small differences in fetal
smallness between women with placenta previa and
nonprevia explain the conicting results of prior studies.
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Address reprint requests to: Cande V. Ananth, PhD, MPH,
Department of Obstetrics, Gynecology and Reproductive Sci-
ences, University of Medicine and Dentistry of New Jersey,
Robert Wood Johnson Medical School, 125 Paterson Street,
New Brunswick, NJ 08901-1977; E-mail: ananthcv@epi.
umdnj.edu.
Received December 8, 2000. Received in revised form February 13,
2001. Accepted March 14, 2001.
306 Ananth et al Placenta Previa, Fetal Growth Restriction, and Prematurity OBSTETRICS & GYNECOLOGY