The Association of Gestational Weight Gain and the Effect on Pregnancy Outcome Defined by BMI Group among Women Delivered in Hospital Kuala Lumpur (HKL), Malaysia: A Retrospective Study
Hayati Adilin Mohd Abd Majid,
Siti Shafura Abas,
Khairil Anuar Md. Isa
This study attempts to determine the association of gestational weight gain and the effect on pregnancy outcome defined by their Body Mass Index (BMI) among pregnant women. Retrospective study involved 436 singleton pregnancy women who delivered in Hospital Kuala Lumpur (HKL) from 1st January to 31st December 2010. The subjects were stratified into four BMI group according to World Health Organization (WHO) (underweight <18.5 kg m-2, normal: 18.5-24.9 kg m-2, overweight: 25-30 kg m-2 and obese: 30 kg m-2). Each of BMI group then, classified into 3 categories of Gestational Weight Gain (GWG) (lower increment, normal and high increment). This classifying of GWG group was done according to the US Institute of Medicine (IOM), 2009 guidelines. Pregnancy outcome been analyzed according to the GWG during pregnancy for each BMI group and calculated the crude OR from simple logistic regression modules. 15.1, 40.1, 28.7 and 16.1% of the subjects were underweight, normal BMI, overweight and obese, respectively. In normal BMI women, gestational age outcome and neonatal outcome were significantly associated with inadequate weight gain during pregnancy (p = 0.046 and p = 0.002). Among low GWG of normal BMI women, the crude OR for premature birth and low birth weight were 2.872 and 4.976 (95% CI = 1.009-8.170 and 1.316-18.815), respectively compared with normal GWG. This study shows that normal BMI with lower GWG may result in adverse outcome. In addition, inadequate weight gain during pregnancy can result in significant complication.
to cite this article:
Nurfazlin Rozlan, Hayati Adilin Mohd Abd Majid, Siti Shafura Abas, Ajau Danis and Khairil Anuar Md. Isa, 2012. The Association of Gestational Weight Gain and the Effect on Pregnancy Outcome Defined by BMI Group among Women Delivered in Hospital Kuala Lumpur (HKL), Malaysia: A Retrospective Study. Asian Journal of Clinical Nutrition, 4: 160-167.
Received: November 22, 2011;
Accepted: March 10, 2012;
Published: May 16, 2012
Gestational weight gain is a modifiable factor that can be controlled through
nutritional counseling in order to gain adequate weight gain during pregnancy
(Sajjad and Khan, 2010). Adequate gestational weight
gain can be protective in order to against poor maternal nourishment during
early pregnancy (Salihu et al., 2009; Khoushabi
and Saraswathi, 2010). Gestational Weight Gain (GWG) is one of the risk
factor of health consequences and it is very important factor to be controlled
(Tsukamoto et al., 2007; McDonald
et al., 2010; Cedergren, 2006).
Recommendations for weight gain during pregnancy were differed from a single
target for all women to different targets, depending on maternal Body Mass Index
(BMI). During pregnancy, pregnant women have been advised to gain certain weights
that have been recommended as to have a safe pregnancy and healthy infants without
any complication (Ochsenbein-Kolble et al., 2007;
Islam and Ullah, 2005; Borazjani
et al., 2011).
Women who gained less GWG were associated delivered small-gestational-age (SGA)
for infants or low birth weight, while large-gestational-age (LGA) for infants
or macrosomia infant associated with those having GWG outside the recommendation
(Devader et al., 2007). Excessive weight gain
might contribute to an increased risk of preterm delivery, cesarean delivery
and macrosomia, while inadequate weight gain during pregnancy will lead to preterm
delivery and low birth weight (Rodrigues et al.,
2010; Nohr et al., 2008; Briese
et al., 2009; Oken et al., 2009;
Kabali and Werler, 2007). Gaining high and low weight
gain have greater risk of low birth weight and high birth weight (macrosomia)
and might related to obesity in later life (Johansson et
al., 2007). Supported by Kiel et al. (2007),
women that gained less weight had significantly lower risk of LGA birth but
high significant in SGA birth. Abrams et al. (2000)
explained that, caesarean delivery and maternal weight gains was significant
when weight gain was exceeded 16 kg. Underweight and average height women with
low weight gain was tend to expose to preterm delivery, while overweight and
obese women that gained low GWG was having moderate risk of preterm delivery
(Wang et al., 2010; Schieve
et al., 2000; Mohsen and Wafay, 2007).
This study attempts to determine the association between GWG with pregnancy outcome that was categorized into three categories which were birth outcome, gestational age outcome and neonatal outcome defined by their BMI among pregnant women.
MATERIALS AND METHODS
Study design: This study was retrospective record review data approved by ethics committees and medical research, Ministry of Health, Malaysia and director of Hospital Kuala Lumpur was designed to identify the association between GWG and pregnancy outcome at Obstetrics and Gynecology (O and G) record data units of Hospital Kuala Lumpur.
Study subjects: Subjects were comprised of 436 live born and singleton pregnancy women from the Hospital Kuala Lumpur (HKL) on 1st January to 31st December 2010. Subjects involved in this study were selected through inclusion criteria and availability of certain information and also pre-pregnancy weight that had from phone call interview.
Maternal BMI and GWG: At enrollment, we obtained maternal data of height
and a phone call interview of pre-pregnancy weight gain, as to calculate pre-pregnancy
BMI and total weight gain, GWG. The data of BMI was divided according to the
Worlds Health Organizations definitions of underweight as having
BMI<18.5), normal weight (18.5 = BMI<25), overweight (25 = BMI<30),
and obese having BMI≥30). We determined total gestational weight gain as
the difference between phone call interview of pre-pregnancy weight and the
data reported of last clinically measured weight recorded prior to delivery.
Each of BMI group then, classified into 3 categories of GWG (lower increment,
normal and high increment. This classifying of GWG group was done according
to the US Institute of Medicine (IOM), 2009 Guidelines on Recommendations for
Total and Rate of Weight Gain during Pregnancy by Pre-pregnancy Body Mass Index
(BMI) of the mother (Mobasheri and Golalipour, 2007).
Pregnancy outcomes: Birth outcome was described as mode of delivery
of baby. In this study, birth outcome can be categorized as having normal or
caesarean delivery. Woman that was delivered the baby through surgical incisions
was categorized as caesarean delivery, while delivery of fetus through vaginal
known as normal delivery. Gestational age outcome defined as age of fetus the
moment the baby was delivered by the mother. Data of gestational age outcome
gained from the record data then was classified into premature and normal birth.
Premature birth can be described as baby born before 37 weeks of the gestation
while normal birth baby born between 37 to 42 weeks of gestation. Neonatal outcomes
identified as first weight of the newborn obtained after the birth. Neonatal
outcome in this study can be classified as low birth weight, normal and high
birth weight or macrosomia. Woman who having less than 2.5 kg weight of the
baby was categorized as low birth weight. Normal weigh of baby was between 2.5
kg to 4 kg, while macrosomia or high birth weight baby have weight more than
4.0 kg (Veghari, 2009). The data of subjects then were
categorized into these three categories.
Data analysis: The test that been used were descriptive test, Pearsons
chi square and simple logistic regression. Descriptive statistics test include
mean and Standard Deviation (SD) for continuous variable and frequency distribution
for categorical variables (Ojofeitimi et al., 2008).
Pearsons chi square test was performed to identify the association between
GWG and pregnancy outcome for each BMI group. The risk association of GWG with
pregnancy outcome was using simple logistic regression test. Binary logistic
test was used to determine the crude OR. The data was processed using Statistical
Package for Social Sciences (SPSS) version 16.0.
Table 1 showed a total of 436 women met the eligibility criteria. 15.1, 40.1, 28.7 and 16.1% of the subjects were underweight, normal BMI, overweight and obese, respectively. The age of underweight women reported in this study was younger than other BMI group (25.68±3.884, 28.03±4.015, 28.45±3.007 and 28.87±3.611, respectively). Malay was the higher ethnicity among the subjects (86.4, 82.9, 85.6 and 85.7%, respectively). The percentage of multigravida was the highest parity among the subjects (57.6, 65.7, 72 and 78.6%, respectively). In underweight group, the percentage of low increment GWG was higher than other BMI groups (62.1, 30.3, 17.6 and 16.1%, respectively). In caesarean delivery, overweight and obese was high than the other two groups (16.7, 32, 35.2 and 38.6%, respectively). While premature birth, underweight was the highest among other BMI group (25.8, 16, 16 and 7.1%, respectively). Low birth weight was the highest in underweight (16.7, 10.3, 7.2 and 1.4%, respectively) while macrosomia baby was high in overweight (4.8%) and obese (4.3%).
According to Table 2 showed the association of pregnancy outcome and GWG for each of BMI group. There was significantly association between GWG and gestational age outcome (Chi-square = 0.046, df = 2, p = 0.005). In addition, there was also a significantly association between GWG and neonatal outcome (Chi-square = 0.002, df = 2, p = 0.005). However, there was no significantly association between GWG and birth outcome (chi-square = 10.782), df = 2, p = 0.727) in normal BMI group. On the other hand, in underweight, overweight and obese there were no significant association between gestational weight gain and the incidence of pregnancy outcome.
|| Data of demographic, GWG, pregnancy outcome and parity data
of pregnant women in HKL
|*Normal GWG, Underweight: 12.7-18.1 kg, Normal: 11.3-15.9
kg, Overweight: 6.8-11.3 kg and Obese: 5-9 kg
The risk association of pregnancy outcome and Gestational Weight Gain (GWG) that was only significant in normal BMI group was listed in Table 3. In gestational age outcome, women that gained low GWG (less than 12.6 kg) have high risk of getting premature birth with crude OR 2.872 [1.009, 8.170] and it statistically significant (p<0.05). Besides that, in neonatal outcome, women who gained low GWG have high risk of low birth weight (crude OR 4.976 [1.316, 18.815] and it is statistically significant with p<0.05.
Result showed that, inadequate weight gain during pregnancy in normal BMI group
can result in significant complication. In normal BMI, low GWG was significant
associated in having premature birth and low birth weight. This study was supported
by study done by Choi et al. (2011) on the effect
of gestational weight gain towards perinatal outcome among Korean women found
that normal BMI women who were having less weight gain have significantly incidence
on having premature birth compared those gain within the recommendation. Moreover,
study by Galtier et al. (2008) explained that
low GWG and premature birth was notably associated. However, contra study by
Chen et al. (2010) found that, premature birth
was more significant occur in overweight and obese than normal BMI group. Durie
et al. (2011) and Baeten et al. (2001)
found that less than recommended weight gain were associated with small-gestational
weight gain or low birth weight infant in normal BMI group.
|| The association of pregnancy outcome and gestational weight
gain (GWG) for each of BMI group
|*Significant when p<0.05
|| The risk association of pregnancy outcome and GWG in normal
|*Significant when p<0.05
In present study also showed that, the risk of having premature birth is high
among normal BMI women that gained low gestational weight gain. Besides that,
normal women that gained GWG less than the recommendation have high risk to
get low birth weight infants. This study was supported by Abrams
et al. (2000) stated that low increment in gestational weight gain
(GWG) had significant higher risk of getting preterm delivery. In addition,
Salihu et al. (2009) conducted a study in 1989
through 1997 among women of Missouri found that low BMI had strongly high risk
for getting preterm birth baby. Nielsen et al. (2006)
had achieved, it was significantly higher risk in small-gestational-age or low
birth weight (SGA) infants among women that gained less than the recommendation.
Supported by Abrams et al. (2000) reported that
too little weight gain during pregnancy have high risk in having low birth weight
infants. In addition, study done by Devader et al.
(2007) performed a study on singleton women with normal pre-pregnancy BMI
using Missouri birth certificate data for 1999-2001 discovered that, the risk
of having small-gestational-age (SGA) infants or low birth weight was higher
with decreasing Gestational Weight Gain (GWG). Moreover, the increased risk
of SGA and decreased birth weight was associated with normal BMI (Merrill
et al., 2011).
There were some limitations to this study. The pre-pregnancy weight was obtained from self reported that get through phone call interview and we did not know whether the pregnant women were able to report their pre-pregnancy weight accurately. Besides that, even the total subjects were 436 subjects, when it stratified into four BMI group, the numbers of subject became smaller in each group of BMI. This is not enough to determine certain risk factors of pregnancy outcome and to determine the association between Gestational Weight Gain (GWG) and pregnancy outcome in other BMI group.
Despite such limitations, this study has several strengths. We comprehensively, analyzed the influence of Gestational Weight Gain (GWG) on pregnancy outcome in the same group of pregnant Malaysia women and confirmed that gestational weight gain has significant association on pregnancy outcome. In addition, present result suggested that, low Gestational Weight Gain (GWG) have high risk in normal BMI group that caused premature birth and low birth weight. As the overweight and obese population has rapidly increased nowadays all over the world, even in women in childbearing age, normal BMI pregnant women have been relatively neglected.
In conclusion, this study shows that normal BMI with lower Gestational Weight
Gain (GWG) may result in adverse outcome. In addition, inadequate weight gain
during pregnancy can result in significant complication. The result of this
study, are expected to be highly helpful during consultations with women of
childbearing age and pregnant women with respect to weight control and healthy
balance food intake.
The authors gratefully acknowledge the staff of unit record obstetrics and
gynecology (O and G), Hospital Kuala Lumpur (HKL) for the help and permission
for data collection. Appreciation is also given to our counterparts as well
as anyone involved either directly or indirectly in making this research project.
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