This among female sex in this present study.

This is the first
multilevel study that has shown both individual-level and community level factors
are essential predictors of macrosomia in Malawi. The present study revealed
the statistically significant clustering effects of macrosomia at the community level, suggesting that infants from
the same neighborhood are subject to common contextual influences. The
individual- and community-level factors considered in this study were able to
account for about 33% of these observed variations whilst about 7% of total
variation remained unexplained even after taking into account the individual-
and community-level characteristics. The fixed effects showed that sex of the
child, being a product of caesarian birth, parity, maternal education, and
community female education were statistically significantly associated with
fetal macrosomia.

In this present
study, we found that infants whose delivery occurred through cesarean section were more likely to be
macrosomic. Many previous studies have also demonstrated that very large babies
are at increased risk of cesarean section
252627. In this context, the cesarean section might indicate several pregnancy complications and associated risks
with high birth weight. For example, a multivariate analysis of the risk
factors and obstetric complications associated with macrosomia found out that high
birth weight was associated with higher rates of cesarean birth and other
pregnant birth complications 10. Prior studies have also
demonstrated that women who gain excessive weight in the course of the pregnancy
have a higher risk of having a very big child with a birth weight of over
4,000g or 4,500g, and in turn, they are more
likely to need a cesarean section 282930. Furthermore, gestational diabetes
during pregnancy may cause mothers to have a large baby or other complications
which might increase the chance of having a cesarean 31. Thus, it is necessary to address
the underlying cause of cesarean section in order to prevent macrosomia. 

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As with previous
studies 323334, male sex was associated with increased
risk of being macrosomic than
among female sex in this present study. The underlying mechanisms through which
male children weigh more than the female counterparts are poorly understood. However,
studies have suggested that male and female embryos are different metabolically
and grow at different rates 3536. It was demonstrated that male
embryos and fetuses start life with higher
rates of cell division and higher
metabolic rates, as such male fetuses need more caloric energy to develop
successfully 3738. Furthermore, other studies have
reported that male fetuses have greater sensitivity to maternal BMI and glucose
status during human pregnancy 39. For example, in a Spanish study,
male neonates were more likely than females to be larger for gestational age or
macrosomic if mothers had high pre-gestational BMI or altered maternal glucose
tolerance status during pregnancy 40.

Another influence on the
risk of fetal macrosomia in this study was the mother’s parity. We demonstrated
that as mother’s parity increased the odds of fetal macrosomia was also
increasing. This result is in line with earlier studies that showed that an
increase in parity is also related to the higher risk of fetal macrosomia 3334. The possible explanation on
this positive relationship might be that in the same woman, as the age and
parity increases, mothers tend to gain excessive weight, increase BMI, and
other metabolic disorders such as maternal hyperglycemia 41. Consequently, fetuses, from such mothers
have high risks of becoming macrosomic 42. Thus, multiparity tends to result
in higher birth weight due to changes in mothers body physiological composition. 

Maternal education
and community female education were also important characteristics predicting
the risk of macrosomia in this study. Consistent with previous studies 4344, we found that on the individual
level mothers with no formal education or primary education increased the risk
of giving birth to a macrosomic neonate. In the context of Malawi, this could be
related to cultural norms attributed to weight gain as being healthy 45. Furthermore, unlike educated
mothers, uneducated mothers may not be aware of gestation weight gain and its
implications on birth outcomes, thus they may be less likely to take
precautionary measures such as exercise, diet control, and better health-seeking
behaviors. For example, a study on women
with eating disorder showed that mothers were more likely to have higher birth
weight babies than their counterparts 46. Likewise, educated mothers have
been shown to have better health-seeking
behaviors which also has an influence on birth outcome 47.

Moreover, women
who resided in communities comprising middle or a high percentage of women with primary education and above exhibit
the reduced risk of delivering a macrosomic birth. This finding is consistent
with those of the previous study,
suggesting that a community with a high concentration of educated women can
increase health-seeking behavior
including utilization of health care services, better and healthy feeding practices, as well as excises 48. Prior evidence suggested that education
is frequently associated with increased access to health care services and more
knowledge regarding health behavior. Thus, enhancing the proportion of educated
women may facilitate the dissemination of knowledge to those with lower education,
aiding them in accessing health services and improvement of personal health
awareness through informal social networks and contacts 49. Taken together, these factors can
influence birthweight of babies.

Our study,
however, is not without limitations. First, due to the cross-sectional nature
of the data, we could not draw causal inferences in relationships of the individual- and community-level factors with macrosomia.
Second, the use of secondary data limited our ability to include other
variables that are related to macrosomia such as preconception BMI and maternal
commodities during pregnancy.


Our study has
indicated that both individual- and contextual-level factors have in?uences on
the risk of macrosomia. We found evidence
of clustering effects of macrosomia risks at community-level, which implies
that children from the same communities tended to have similar birth outcomes. Thus,
strategies aimed to improve poor birth outcomes in Malawi should address mothers
and their communities they live in.  Furthermore,
public health policies aimed at reducing the risk of macrosomia should be focused on the individual and community maternal
education so that mothers should be able to monitor their health alarms during pregnancy.