Addressing selective outcome reporting and reference group biases in perinatal epidemiology of adverse birth outcomes

To highlight the issues, implications, and recommendations for addressing selective outcomes reporting bias in the perinatal epidemiology of adverse birth outcomes (ABOs) where research has disproportionately focused on the lower extremes (preterm birth, low birth weight, and small for gestational age) while neglecting the higher extremes (post-term birth, high birth weight or macrosomia, and large for gestational age). Additionally, trinomial classification of ABOs was also advocated to reduce reference group bias.

A brief descriptive review was conducted.

An advanced search was conducted in PubMed on May 2, 2025, using search terms and keywords for both extremes of gestational age and birth weight. The number of studies on the lower and higher extremes of ABOs was compared to assess the disparities in research focus.

The PubMed search showed 78,693 records for lower extremes of ABOs (small vulnerable newborns) compared to 11,432 records on higher extremes of ABOs (large vulnerable newborns).

Although both extremes of gestational age and birth weight are critical, the disproportionate and predominant focus on the lower extremes of ABOs contributes to selective outcome reporting bias, hindering complete understanding of the full spectrum of ABOs for evidence-based decision-making. Future studies should consider each ABO as trinomial rather than binary classification, whether as an outcome, exposure, or covariate variable, and use the appropriate reference groups (term birth, normal birth weight, and appropriate for gestational age). These will address both reporting and reference group biases, which are essential to improve the accuracy and applicability of perinatal research on ABOs.