Short inter-pregnancy intervals, parity, excessive pregnancy weight gain and risk of maternal obesity

Birth Spacing and Parents' Physical and Mental Health: An Analysis Using Individual and Sibling Fixed Effects

An extensive literature has examined the relationship between birth spacing and subsequent health outcomes for parents, particularly for mothers. However, this research has drawn almost exclusively on observational research designs, and almost all studies have been limited to adjusting for observable factors that could confound the relationship between birth spacing and health outcomes. In this study, we use Norwegian register data to examine the relationship between birth spacing and the number of general practitioner consultations for mothers' and fathers' physical and mental health concerns immediately after childbirth (1-5 and 6-11 months after childbirth), in the medium term (5-6 years after childbearing), and in the long term (10-11 years after childbearing). To examine short-term health outcomes, we estimate individual fixed-effects models: we hold constant factors that could influence parents' birth spacing behavior and their health, comparing health outcomes after different births to the same parent. We apply sibling fixed effects in our analysis of medium- and long-term outcomes, holding constant mothers' and fathers' family backgrounds. The results from our analyses that do not apply individual or sibling fixed effects are consistent with much of the previous literature: shorter and longer birth intervals are associated with worse health outcomes than birth intervals of approximately 2-3 years. Estimates from individual fixed-effects models suggest that particularly short intervals have a modest negative effect on maternal mental health in the short term, with more ambiguous evidence that particularly short or long intervals might modestly influence short-, medium-, and long-term physical health outcomes. Overall, these results are consistent with small to negligible effects of birth spacing behavior on (non-pregnancy-related) parental health outcomes.

An unwelcome inheritance: childhood obesity after diabetes in pregnancy

Diabetes in pregnancy affects 20 million women per year and is associated with increased risk of obesity in offspring, leading to insulin resistance and cardiometabolic disease. Despite the substantial public health ramifications, relatively little is known about the pathophysiological mechanisms underlying obesity in these high-risk children, which creates a barrier to successful intervention. While maternal glucose itself is undeniably a major stimulus upon intrauterine growth, the degree of offspring hyperinsulinism and disturbed lipid metabolism in mothers and offspring are also likely to be implicated in the disease process. The aim of this review is to summarise current understanding of the pathophysiology of childhood obesity after intrauterine exposure to maternal hyperglycaemia and to highlight possible opportunities for intervention. I present here a new unified hypothesis for the pathophysiology of childhood obesity in infants born to mothers with diabetes, which involves self-perpetuating twin cycles of pancreatic beta cell hyperfunction and altered lipid metabolism, both acutely and chronically upregulated by intrauterine exposure to maternal hyperglycaemia.

Adolescent childbirth and mobility disability among women ages 15-49: an analysis of population health surveys from 14 low-income and middle-income countries

OBJECTIVES

Adolescent childbirth is associated with older adult adverse health outcomes that negatively affect mobility function, but these associations have not been studied globally in large samples of reproductive-age women. This study examines the association between age at first childbirth and mobility disability in national surveys from low-income and middle-income countries, and hypotheses that adolescent childbirth is associated with mobility disability.

DESIGN

Cross-sectional analysis.

SETTING

Population health surveys from 2013 to 2018 containing mobility disability measures among ever-pregnant women ages 15-49. These included 13 Demographic Health Surveys from Haiti, Pakistan, Uganda, Cambodia, Colombia, South Africa, Timor-Leste, Albania, Gambia, Maldives, Peru, Senegal and Yemen and 1 Maternal Health Survey from Ghana.

PARTICIPANTS

The sample included 157 988 women ages 15-49 years.

PRIMARY OUTCOME MEASURE

Adolescent childbirth was defined as 10-19 years of age. Poisson regression models were used to estimate prevalence ratios (PRs) of mobility disability among women who first gave birth during adolescence and in adult life (ages 20-45 years) in each country and across the whole sample. Countries were also analysed according to the use of standard and non-standard mobility disability measures. Covariates included current age, urban/rural residence, education and household wealth.

RESULTS

Prevalence of adolescent childbirth (17.5%-66.2%) and mobility disability (0.32%-21.45%) varied widely across countries. Adolescent childbirth was significantly (p<0.05) associated with greater mobility disability in six of eight countries using standard disability measures. Among the six countries that did not use standard disability measures, none showed a statistically significant association between adolescent childbirth and mobility disability. Considering the whole sample and adjusting for all covariates, women who gave birth during adolescence had greater prevalence of mobility disability (pooled PR 1.19, 95% CI 1.06-1.31).

CONCLUSIONS

This analysis suggests a moderate and consistent association of adolescent childbearing with subsequent mobility disability.

Integrating contraceptive services into existing perinatal care: protocol for a community-based cluster randomised controlled trial in Shanghai, China

INTRODUCTION

Postpartum contraception is essential to preventing unintended pregnancies and short interpregnancy intervals. The first year after childbirth is a critical period with a high risk of unintended pregnancy and induced abortion. However, the postpartum contraceptive services are weak in China's existing maternal and child healthcare system. We propose to evaluate the effects of integrating postpartum contraceptive services into the existing perinatal care system via a cluster randomised controlled trial.

METHODS AND ANALYSIS

This cluster randomised controlled trial involves all 13 communities of Minhang District, Shanghai, China. Communities will be randomly allocated, seven in the intervention group and six in the control group. One thousand and three hundred women, 100 women in each community, will be recruited in the study. Women assigned to the intervention group will receive postpartum contraceptive education and counselling during pregnancy, childbirth hospitalisation, postpartum home visits and the 42-day postpartum clinic check-up. Women in the control group will receive routine antenatal and postpartum care. Participants will be recruited in the first trimester during pregnancy and followed up to 1 year postpartum. The primary outcome is the incidence of unintended pregnancy within 1 year after childbirth.

ETHICS AND DISSEMINATION

The trial received ethical approval from the Ethics Committee of Shanghai Minhang District Maternal and Child Health Care Hospital (#[2020]KS-02, #[2020]KS-05, #[2020]KS-05-EX). Results will be published in academic journals and disseminated in multiple formats for the health professionals and the public.

TRIAL REGISTRATION NUMBER

ChiCTR2000034603.

Intersections between adolescent fertility and obesity-pathways and research gaps focusing on Latin American populations

Latin America has notably elevated rates of adolescent fertility and obesity in women. Although numerous studies document associations between adolescent fertility and obesity across the life course, the pathways explaining their association are insufficiently theorized, especially regarding the factors in Latin America that may underpin both. Additionally, much of the existing research is from high-income countries, where fertility and obesity are trending down. In this paper, we review the various complex pathways linking adolescent fertility and obesity, highlighting research gaps and priorities, with a particular focus on Latin American populations. We carefully consider pregnancy's distinct impact on growth trajectories during the critical period of adolescence, as well as the cumulative effect that adolescent fertility may have over the life course. We also articulate a pathway through obesity as it may contribute to early puberty and thus, to adolescent fertility. If obesity is a cause of adolescent fertility, not a result of it, or if it is a mediator of early-life exposures to adulthood obesity, these are critical distinctions for policy aiming to prevent both obesity and early fertility. Research to better understand these pathways is essential for prevention efforts against obesity and undesired adolescent fertility in Latin America.

Excessive Gestational Weight Gain and Long-Term Maternal Cardiovascular Risk Profile: The Study of Women's Health Across the Nation

Background: Excessive gestational weight gain (GWG) is consistently linked with maternal risk of obesity. However, the literature on its long-term cardiovascular risk is minimal and conflicting. We evaluated whether excessive GWG is associated with a high-risk cardiovascular profile among parous women in midlife. Materials and Methods: Participants were women in the multiethnic cohort Study of Women's Health Across the Nation with a history of live birth(s). Excessive GWG was defined according to Institute of Medicine guidelines and collected by self-recall. Outcomes were the atherosclerotic cardiovascular disease (ASCVD) risk score and C-reactive protein (CRP), measured at the study baseline when mean age was 47 years, and at 10 follow-up visits (1996-2017). We estimated the association of excessive GWG with outcomes through linear mixed model regression. Results: The analytic sample included 1318 women with 3049 singleton births. Over 40% (536) reported one or more pregnancies with excessive GWG. Longitudinal models estimated that at a mean age of 67, women with a history of excessive GWG had a 9.8% (9.2, 10.5) 10-year ASCVD risk, compared to 9.5% (8.9, 10.1) for those without, and mean CRP of 2.20 mg/L (1.89, 2.57) versus 1.85 mg/L (1.61, 2.14), respectively, adjusted for participant characteristics. Conclusions: In this multiethnic cohort of parous women, a history of excessive GWG was associated with a small, but statistically significant difference in ASCVD risk, and a moderate, statistically significant difference in CRP across midlife. More research is necessary to understand the mechanistic pathway between excessive GWG and long-term maternal cardiovascular health.

Socioeconomic differences in the association between maternal age and maternal obesity: a register-based study of 707,728 women in Finland

AIMS

To examine the association between maternal age and maternal obesity across socioeconomic groups and to determine whether socioeconomic status modifies the association between maternal age and maternal obesity with a view to informing public health policies.

METHODS

Data for this register-based study were sourced from the Finnish Medical Birth Register and Statistics Finland, using the information of 707,728 women who gave birth in Finland from 2004 to 2015. We used multivariable regression models to assess the association between maternal age and maternal obesity across socioeconomic groups. We further assessed interactions on both multiplicative and additive scales.

RESULTS

Across all socioeconomic groups, the adjusted odds ratio for the association between maternal age and maternal obesity increased, peaking for women 35 years or older. Using women below 20 years of age in the category of upper-level employees as a single reference group, in the category of upper-level employees, the adjusted odds ratio and 95% confidence intervals among women 35 years or older was 1.92 (1.39-2.64) for maternal obesity. Equally, the adjusted odds ratio and 95% confidence intervals in the category of long-term unemployed was 4.35 (3.16-5.98). Synergistic interactions on both multiplicative and additive scales were found across age and socioeconomic groups.

CONCLUSIONS

The association between maternal age and maternal obesity was strongest among women 35 years or older with lower socioeconomic status. Population-level interventions that address maternal risk factors from teenage years are needed alongside individual-level interventions that target high-risk mothers in areas of low socioeconomic status and maternal obesity.

Predicting the earliest deviation in weight gain in the course towards manifest overweight in offspring exposed to obesity in pregnancy: a longitudinal cohort study

BACKGROUND

Obesity in pregnancy and related early-life factors place the offspring at the highest risk of being overweight. Despite convincing evidence on these associations, there is an unmet public health need to identify "high-risk" offspring by predicting very early deviations in weight gain patterns as a subclinical stage towards overweight. However, data and methods for individual risk prediction are lacking. We aimed to identify those infants exposed to obesity in pregnancy at ages 3 months, 1 year, and 2 years who likely will follow a higher-than-normal body mass index (BMI) growth trajectory towards manifest overweight by developing an early-risk quantification system.

METHODS

This study uses data from the prospective mother-child cohort study Programming of Enhanced Adiposity Risk in CHildhood-Early Screening (PEACHES) comprising 1671 mothers with pre-conception obesity and without (controls) and their offspring. Exposures were pre- and postnatal risks documented in patient-held maternal and child health records. The main outcome was a "higher-than-normal BMI growth pattern" preceding overweight, defined as BMI z-score >1 SD (i.e., World Health Organization [WHO] cut-off "at risk of overweight") at least twice during consecutive offspring growth periods between age 6 months and 5 years. The independent cohort PErinatal Prevention of Obesity (PEPO) comprising 11,730 mother-child pairs recruited close to school entry (around age 6 years) was available for data validation. Cluster analysis and sequential prediction modelling were performed.

RESULTS

Data of 1557 PEACHES mother-child pairs and the validation cohort were analyzed comprising more than 50,000 offspring BMI measurements. More than 1-in-5 offspring exposed to obesity in pregnancy belonged to an upper BMI z-score cluster as a distinct pattern of BMI development (above the cut-off of 1 SD) from the first months of life onwards resulting in preschool overweight/obesity (age 5 years: odds ratio [OR] 16.13; 95% confidence interval [CI] 9.98-26.05). Contributing early-life factors including excessive weight gain (OR 2.08; 95% CI 1.25-3.45) and smoking (OR 1.94; 95% CI 1.27-2.95) in pregnancy were instrumental in predicting a "higher-than-normal BMI growth pattern" at age 3 months and re-evaluating the risk at ages 1 year and 2 years (area under the receiver operating characteristic [AUROC] 0.69-0.79, sensitivity 70.7-76.0%, specificity 64.7-78.1%). External validation of prediction models demonstrated adequate predictive performances.

CONCLUSIONS

We devised a novel sequential strategy of individual prediction and re-evaluation of a higher-than-normal weight gain in "high-risk" infants well before developing overweight to guide decision-making. The strategy holds promise to elaborate interventions in an early preventive manner for integration in systems of well-child care.

Examining the association between short interpregnancy interval births and the type and timing of postpartum long acting reversible contraception

OBJECTIVE

To determine whether the type (intrauterine device or implant) or timing (immediately postpartum vs interval) of postpartum long-acting reversible contraception was associated with a reduction in short interpregnancy interval births.

STUDY DESIGN

We conducted a retrospective cohort study using linked Medicaid claims and birth certificate data from Oregon and South Carolina, 2010 - 2018. Our primary outcome was short interpregnancy interval, defined as repeat pregnancy within 18 months of the index delivery. We determined postpartum contraceptive method and timing of receipt. To assess the association of timing of long acting reversible contraception with short interpregnancy interval, we calculated adjusted probabilities from a logistic regression model incorporating covariate balanced propensity score weights, sociodemographic factors, and clustered at the woman-level.

RESULTS

Our study sample included 121,422 births to 97,084 individuals who had more than one birth during the study period; 41% had a short interpregnancy interval. A majority of individuals had not received any contraception by six months postpartum (68.6%). Overall, 15,477 individuals used long acting reversible contraception postpartum, with the majority receiving interval rather than immediate postpartum long acting reversible contraception (92.9% vs 7.1%). In multivariable analyses, both immediate postpartum (23.0%, 95% CI: 20.5 - 25.8%) and interval long acting reversible contraception (15.2%, 95% CI: 14.4 - 16.1%) are associated with a lower probability of short interpregnancy interval than short acting methods (42.1%, 95% CI: 41.2 - 43.0%).

CONCLUSION

Compared to short-acting methods, receipt of both immediate postpartum and interval long-acting reversible contraception is associated with lower probabilities of a subsequent short interpregnancy interval.

The relationship between fertility history and incident dementia in the US Health and Retirement Study

OBJECTIVES

An emerging literature suggests that fertility history, which includes measures of parity and birth timing, may influence cognitive health in older ages, especially among women given their differential exposure to pregnancy and sex hormones. Yet, few studies have examined associations between measures of fertility history and incident dementia in population-based samples.

METHODS

We examined the associations between parity, younger age at first birth, and older age at last birth with incident dementia over a 16-year period in a prospective sample of 15,361 men and women aged 51-100 years at baseline drawn from the Health and Retirement Study. We used Cox regression and the Fine and Gray model to obtain cause-specific (csHRs) and subdistribution hazard ratios (sdHRs) for incident dementia from gender-stratified models in which we accounted for the semi-competing risk of death.

RESULTS

During the follow-up period (median 13.0 years), the crude incidence rate for dementia was 16.6 and 19.9 per 1,000 person-years for men and women, respectively. In crude models estimating csHRs, higher parity (vs. parity 2) and younger age at first birth were associated with increased risk of dementia for both genders. These associations did not persist after full covariate adjustment. Across all models in which we estimated sdHRs, we observed a positive relationship between older age at last birth and incident dementia for women only.

DISCUSSION

In this population-based, multi-ethnic cohort, we observed limited evidence for an association between measures of fertility history and incident dementia among men and women after adjusting for potential confounders.

Unintended health consequences of Swedish parental leave policy (ParLeHealth): protocol for a quasi-experimental study

INTRODUCTION

Sweden has long been praised for a generous parental leave policy oriented towards facilitating a gender-equitable approach to work and parenting. Yet certain aspects of Swedish parental leave could also be responsible for the maintenance of (or even the increase in) health inequalities. Using a 'Health in All Policies' lens, this research project aims to assess the unintended health consequences of various components of Sweden's parental leave policy, including eligibility for and uptake of earnings based benefits.

METHODS AND ANALYSIS

We will use individual-level data from multiple Swedish registers. Sociodemographic information, including parental leave use, will be retrieved from the total population register, Longitudinal Integration Database for Health Insurance and Labour Market Studies and Social Insurance Agency registers. Health information for parents and children will be retrieved from the patient, prescribed drug, cause of death, medical birth and children's health registers. We will evaluate parents' mental, mothers' reproductive and children's general health outcomes in relation to several policy reforms aiming to protect parental leave benefits in short birth spacing (the speed premium) and to promote father's uptake (the father's quota) and sharing of parental leave days (the double days reform). We will also examine effects of increases in basic parental leave benefit levels. Using quasi-experimental designs, we will compare health outcomes across these reforms and eligibility thresholds with interrupted time series, difference-in-difference and regression discontinuity approaches to reduce the risk of health selection and assess causality in the link between parental leave use and health.

ETHICS AND DISSEMINATION

This project has been granted all necessary ethical permissions from the Stockholm Regional Ethical Review Board (Dnr 2019-04913) for accessing and analysing deidentified data. The final outputs will primarily be disseminated as scientific articles published in open-access, high-impact peer-reviewed international journals, as well as press releases and policy briefs.

Gestational weight gain and risk of epithelial ovarian cancer

OBJECTIVE

To examine the association between (GWG) and epithelial ovarian cancer (EOC).

METHODS

We compared GWG between 670 incident EOC cases and 1,551 community controls from a population-based, case-control study conducted in Pennsylvania, Ohio, and New York from 2003 to 2008. Multivariable unconditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) associated with GWG adjusting for potential confounders. To explore the potential effect of maternal long-term weight retention after childbearing, we restricted analyses to women who began their childbearing years as normal/underweight and examined differences in EOC risk between those who were normal/underweight versus those who were overweight/obese at study baseline reference date.

RESULTS

Average GWG per full-term pregnancy did not differ between cases and controls. Among women who were normal/underweight at study baseline, greater average GWG was not associated with EOC (OR = 0.9, 0.8, 0.7 for quartiles 2, 3 and 4 of GWG gain, respectively, compared to quartile 1). In contrast, among women who were overweight/obese at study baseline, greater average GWG was positively associated with EOC (OR = 1.4, 1.8, 1.2, for quartiles 2, 3, and 4 compared to quartile 1; interaction p = 0.04).

CONCLUSION

We posit that maternal post-partum weight retention and not gestational weight gain itself among normal/underweight women may impact subsequent risk of EOC. If our hypothesis is supported in other studies designed to assess this question directly, then counseling women on the importance of healthy weight management after a pregnancy could provide another means to help women reduce their risk of this often-fatal malignancy.

Impact of gestational low-protein intake on embryonic kidney microRNA expression and in nephron progenitor cells of the male fetus

BACKGROUND

Here, we have demonstrated that gestational low-protein (LP) intake offspring present lower birth weight, reduced nephron numbers, renal salt excretion, arterial hypertension, and renal failure development compared to regular protein (NP) intake rats in adulthood. We evaluated the expression of various miRNAs and predicted target genes in the kidney in gestational 17-days LP (DG-17) fetal metanephros to identify molecular pathways involved in the proliferation and differentiation of renal embryonic or fetal cells.

METHODS

Pregnant Wistar rats were classified into two groups based on protein supply during pregnancy: NP (regular protein diet, 17%) or LP diet (6%). Renal miRNA sequencing (miRNA-Seq) performed on the MiSeq platform, RT-qPCR of predicted target genes, immunohistochemistry, and morphological analysis of 17-DG NP and LP offspring were performed using previously described methods.

RESULTS

A total of 44 miRNAs, of which 19 were up and 25 downregulated, were identified in 17-DG LP fetuses compared to age-matched NP offspring. We selected 7 miRNAs involved in proliferation, differentiation, and cellular apoptosis. Our findings revealed reduced cell number and Six-2 and c-Myc immunoreactivity in metanephros cap (CM) and ureter bud (UB) in 17-DG LP fetuses. Ki-67 immunoreactivity in CM was 48% lesser in LP compared to age-matched NP fetuses. Conversely, in LP CM and UB, β-catenin was 154%, and 85% increased, respectively. Furthermore, mTOR immunoreactivity was higher in LP CM (139%) and UB (104%) compared to that in NP offspring. TGFβ-1 positive cells in the UB increased by approximately 30% in the LP offspring. Moreover, ZEB1 metanephros-stained cells increased by 30% in the LP offspring. ZEB2 immunofluorescence, although present in the entire metanephros, was similar in both experimental groups.

CONCLUSIONS

Maternal protein restriction changes the expression of miRNAs, mRNAs, and proteins involved in proliferation, differentiation, and apoptosis during renal development. Renal ontogenic dysfunction, caused by maternal protein restriction, promotes reduced reciprocal interaction between CM and UB; consequently, a programmed and expressive decrease in nephron number occurs in the fetus.

Short interpregnancy interval and low birth weight births in India: Evidence from National Family Health Survey 2015-16

Evidence on the effect of interpregnancy interval (IPI) on low birth weight (LBW) births is limited in developing countries including India. Our study aims to examine association between IPI and LBW births in India. We used data from the fourth round of the National Family Health Survey (NFHS-4) conducted in 2015–16 with a representative sample of 52,825 most recent births for examining the association between IPI and LBW. IPI is defined as the gap between the first month in which the index pregnancy was reported in the reproductive calendar (referred to as the month of conception) and the month of pregnancy outcome (including live births and terminations) of preceding pregnancy. Reproductive calendar data were used to estimate IPI. Association between IPI and LBW were examined using multivariable binary logistic regressions. Seventeen percent of the births in our sample were LBW, and more than half (57.6%) of these were accompanied with IPI less than 18 months. Prevalence of LBW births was highest among mother's who had IPI less than six months (19.4%). Regression results, adjusted for control variables, indicate that the risk of LBW was significantly higher among births whose mothers had IPI less than six months (odds ratio: 1.19, 95% CI:1.05-1.36) compared with those whose mothers had IPI between 18 and 23 months. This study provides additional evidence on the association between short IPI (<6 months) and LBW births in India. Promoting spacing methods of family planning is an option that India may consider for increasing the IPI and thereby reducing LBW births. Ensuring recommended iron and folic acid tablets/equivalent syrup and TT injections for every pregnant woman may offset the adverse consequences of shorter IPI.

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12% of the LBW births were accompanied with IPI <6 months, 20% between 6 and 11 months, and 25% between 12 and 17 months.

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The risk of LBW births is higher among mothers having an IPI of <6 months compared with mothers having an IPI of 18–23 months.

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Promoting spacing methods of family planning may consider for increasing the IPI and thereby reducing LBW births in India.

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Promoting recommended TT injections and iron-folic acid supplements may offset the adverse consequences of short IPI.

Pregestational overweight and obesity and symptoms of postpartum depression: Data from the Birth in Brazil Study

BACKGROUND

Relationship between pregestational overweight and obesity and symptoms of postpartum depression (PPD) has been documented in developed countries. In middle and low-income countries the studies are scarce and the pattern of findings is more mixed. Our objective is to assess the effect of pregestational overweight and obesity on development symptoms of PPD in a nationwide Brazilian study.

METHODS

The study included 23,894 puerperal women, from 2011 to 2012. The Edinburgh Postnatal Depression Scale (EPDS) was applied from 6 to 18 months postpartum, with ≥13 points as the cutoff. Classification of pregestational nutritional status followed the method recommended by the Institute of Medicine. Confounding variables were identified using directed acyclic graph (DAG), and propensity score estimated the effect of nutritional status on PPD symptoms.

RESULTS

Prevalence of PPD was 26.3%. Women with excess weight represented nearly 32% of the sample. In the crude analysis, women with pregestational obesity showed 23% higher odds of developing symptoms of PPD when compared to those with normal weight (OR=1.23 CI 95% 1.04-1.45). There was a loss of statistical significance after propensity score analysis (OR=1.14 CI 95% 0.91-1.42).

LIMITATIONS

The symptoms of PPD were measured in a single moment, and sensitivity analysis revealed the existence of omitted or non-measured variables potentially modifying these estimates.

CONCLUSIONS

Although we did not find a relationship between pregestational nutritional status and depressive symptoms, the results are important because of the problem's magnitude. Future studies should aim at a more comprehensive understanding of the complex relationship between the variables.

Predictors of patterns of weight change 1 year after delivery in a cohort of Mexican women

OBJECTIVE

To evaluate the associations of pregestational BMI, gestational weight gain (GWG) and breast-feeding at 1 month postpartum with four patterns of weight change during the first year after delivery: postpartum weight retention (PPWR), postpartum weight gain (PPWG), postpartum weight retention + gain (PPWR + WG) and return to pregestational weight.

DESIGN

In this secondary analysis of a prospective study, we categorised postpartum weight change into four patterns using pregestational weight and weights at 1, 6 and 12 months postpartum. We evaluated their associations with pregestational BMI, GWG and breast-feeding using multinomial logistic regression. Results are presented as relative risk ratios (RRR) and 95 % CI.

SETTING

Mexico City.

PARTICIPANTS

Women participating in the Programming Research in Obesity, Growth, Environment and Social Stressors pregnancy cohort.

RESULTS

Five hundred women were included (53 % of the cohort). Most women returned to their pregestational weight by 1 year postpartum (57 %); 8 % experienced PPWR, 14 % PPWG and 21 % PPWR + WG. Compared with normal weight, pregestational overweight (RRR 2·5, 95 % CI 1·3, 4·8) and obesity (RRR 2·2, 95 % CI 1·0, 4·7) were associated with a higher risk of PPWG. Exclusive breast-feeding, compared with no breast-feeding, was associated with a lower risk of PPWR (RRR 0·3, 95 % CI 0·1, 0·9). Excessive GWG, compared with adequate, was associated with a higher risk of PPWR (RRR 3·3, 95 % CI 1·6, 6·9) and PPWR + WG (RRR 2·4, 95 % CI 1·4, 4·2).

CONCLUSIONS

Targeting women with pregestational overweight or obesity and excessive GWG, as well as promoting breast-feeding, may impact the pattern of weight change after delivery and long-term women's health.

Interpregnancy and interbirth intervals and all-cause, cardiovascular-related and cancer-related maternal mortality: findings from a large population-based cohort study

INTRODUCTION

Scarce research is available regarding the association between interbirth intervals (IBI) and long-term maternal health outcomes, particularly cardiovascular disease (CVD) mortality. We aimed to assess whether IBIs were associated with all-cause, CVD-related and cancer-related mortality.

METHODS

We conducted a cohort study in the setting of the Jerusalem Perinatal Study. Women with at least two consecutive singleton live births in 1964-1976 (N=18 294) were followed through 2016. IBIs were calculated as the interval between women's first and second cohort birth. We estimated associations between IBIs and mortality using Cox's proportional hazards models, adjusting for age, parity, maternal education, maternal origin and paternal socioeconomic status. Date of last menstrual period was available for a subset of women. We assessed the interpregnancy interval (IPI) for these women and compared the models using IPI and IBI.

RESULTS

During 868 079 years of follow up (median follow-up: 49.0 years), 3337 women died. Women with IBIs <15 months had higher all-cause mortality rates (HR 1.18; 95% CI 1.05 to 1.33) compared to women with 33-month to 68-month IBIs (reference category). IBI and CVD mortality appeared to have a J-shaped association; IBIs of <15, 15-20, 21-2626-2632, 33-68 and ≥69 months had HRs of 1.44, 1.40, 1.33, 1.14, 1.00 and 1.30, respectively. No substantial association was found with cancer mortality. Models using IPIs and those using IBI were similar.

CONCLUSION

Our results support the WHO recommendations for IPIs of ≥24 months and add additional evidence regarding long-term CVD mortality.

Maternal obesity and its determinants: A neglected issue?

Maternal obesity is a global public health concern that affects every aspect of maternity care. It affects the short-term and long-term health of the mother and her offspring. Obese pregnant mothers are at an increased risk of developing complications during antenatal, intrapartum, and postnatal periods. Maternal complications include gestational diabetes mellitus, hypertensive disorder in pregnancy, pre-eclampsia and eclampsia, increased rate of cesarean delivery, pulmonary embolism, and maternal mortality; fetal complications include congenital malformation, stillbirth, and macrosomia. Moreover, both mother and infant are at an increased risk of developing subsequent non-communicable diseases and cardiovascular problems later in life. Several factors are associated with the likelihood of maternal obesity, including sociodemographic characteristics, obstetric characteristics, knowledge, and perception of health-promoting behavior. Gaining a sound understanding of these factors is vital to reaching the targets of Sustainable Developmental Goal 3-to reduce global maternal mortality and end preventable deaths of children under 5 years of age-by 2030. It is essential to identify pregnant women who are at risk of maternal obesity in order to plan and implement effective and timely interventions for optimal pregnancy outcomes. Importantly, maternal obesity as a significant pregnancy risk factor is largely modifiable.

Weight Trajectories After Delivery are Associated with Adiposity and Cardiometabolic Markers at 3 Years Postpartum Among Women in Project Viva

BACKGROUND

Postpartum weight trajectories and its implications on later cardiometabolic health are not entirely understood.

OBJECTIVES

Our objectives were: 1) to characterize maternal weight trajectories from 1 to 24 mo postpartum, 2) to determine the association of prepregnancy BMI, gestational weight gain (GWG), and pregnancy behaviors with the trajectories, and 3) to evaluate the association of weight trajectories with BMI, waist circumference (WC), lipid profile, glucose, insulin resistance, blood pressure, and inflammatory markers at 3 y postpartum.

METHODS

We studied 1359 mothers from the prospective cohort Project Viva. Using weights at 1, 6, 12, and 24 mo postpartum, we characterized weight trajectories using a latent class growth model. For objectives 2 and 3, we used multinomial logistic regression and multiple linear regression models, respectively.

RESULTS

Around 85% of women fell into a trajectory of sustained weight loss (1-12 mo) + maintenance (12-24 mo) (reference), 5.7% followed a trajectory characterized by fast weight loss + slight gain, and 9.7% fell into a trajectory of little weight loss + slight gain. Prepregnancy overweight and obesity increased the odds of falling into the fast weight loss + slight gain trajectory, compared with the reference. Prepregnancy overweight [OR 1.57 (95% CI: 1.01, 2.46)] and a higher total GWG rate [3.69 (2.90, 4.68)] increased the odds of falling into the little weight loss + slight gain trajectory, whereas a higher Prudent dietary pattern score was protective [0.73 (0.54, 0.98)]. Women in this trajectory had higher BMI, WC, weight gain from prepregnancy, low-density lipoprotein cholesterol, and inflammatory markers at 3 y postpartum.

CONCLUSIONS

Women following a trajectory of little weight loss + slight gain during the first 2 y postpartum had an adverse cardiometabolic profile 3 y after delivery. Targeting diet and GWG during pregnancy and facilitating postpartum weight loss could improve women's long-term health.

Coverage of immediate postpartum long-acting reversible contraception has improved birth intervals for at-risk populations

BACKGROUND

In 2012, South Carolina revised the Medicaid policy to cover reimbursement for immediate postpartum long-acting reversible contraception. Immediate postpartum long-acting reversible contraception may improve health outcomes for populations at risk with a subsequent short-interval pregnancy.

OBJECTIVES

We examined the impact of the Medicaid policy change on the initiation of long-acting and reversible contraception (immediate postpartum and postpartum) within key populations. We determined whether immediate postpartum long-acting and reversible contraception use varied by adequate prenatal care (>7 visits), metropolitan location, and medical comorbidities. We also tested the association of immediate postpartum and postpartum long-acting, reversible contraception on interpregnancy interval of less than 18 months.

STUDY DESIGN

We conducted a historical cohort study of live births among Medicaid recipients in South Carolina between 2010 and 2017, 2 years before and 5 years after the policy change. We used birth certificate data linked with Medicaid claims. Our primary outcome was immediate postpartum long-acting and reversible contraception, and our secondary outcome was short interpregnancy interval. We characterize trends in long-acting and reversible contraception use and interpregnancy interval over the study period. We used logistic regression models to test the association of key factors (rural, inadequate prenatal care, and medical comorbidities) with immediate and outpatient postpartum long-acting and reversible contraception following the policy change and to test the association of immediate postpartum and postpartum long-acting and reversible contraception with short interpregnancy interval.

RESULTS

Our sample included 187,438 births to 145,973 women. Overall, 44.7% of the sample was white, with a mean age of 25.0 years. A majority of the sample (61.5%) was multiparous and resided in metropolitan areas (79.5%). The odds of receipt of immediate postpartum long-acting and reversible contraception use increased after the policy change (adjusted odds ratio, 1.39, 95% confidence interval, 1.34-1.43). Women with inadequate prenatal care (adjusted odds ratio, 1.50, 95% confidence interval, 1.31-1.71) and medically complex pregnancies had higher odds of receipt of immediate postpartum long-acting and reversible contraception following the policy change (adjusted odds ratio, 1.47, 95% confidence interval, 1.29-1.67) compared with women with adequate prenatal care and normal pregnancies. Women residing in rural areas were less likely to receive immediate postpartum long-acting and reversible contraception (adjusted odds ratio, 0.36, 95% confidence interval, 0.30-0.44) than women in metropolitan areas. Utilization of immediate postpartum long-acting and reversible contraception was associated with a decreased odds of a subsequent short interpregnancy interval (adjusted odds ratio, 0.62, 95% confidence interval, 0.44-0.89).

CONCLUSION

Women at risk of a subsequent pregnancy and complications (inadequate prenatal care and medical comorbidities) are more likely to receive immediate postpartum long-acting and reversible contraception following the policy change. Efforts are needed to improve access in rural areas.

Prenatal and Infancy Nurse Home Visiting Effects on Mothers: 18-Year Follow-up of a Randomized Trial

BACKGROUND

Prenatal and infancy home-visiting by nurses is promoted as a means of improving maternal life-course, but evidence of long-term effects is limited. We hypothesized that nurse-visitation would lead to long-term reductions in public-benefit costs, maternal substance abuse and depression, and that cost-savings would be greater for mothers with initially higher psychological resources.

METHODS

We conducted an 18-year follow-up of 618 out of 742 low-income, primarily African-American mothers with no previous live births enrolled in an randomized clinical trial of prenatal and infancy home visiting by nurses. We compared nurse-visited and control-group women for public-benefit costs, rates of substance abuse and depression, and examined possible mediators of intervention effects.

RESULTS

Nurse-visited women, compared with controls, incurred $17 310 less in public benefit costs (P = .03), an effect more pronounced for women with higher psychological resources ($28 847, P = .01). These savings compare with program costs of $12 578. There were no program effects on substance abuseor depression. Nurse-visited women were more likely to be married from child age 2 through 18 (19.2% vs 14.8%, P = .04), and those with higher psychological resources had 4.64 fewer cumulative years rearing subsequent children after the birth of the first child (P = .03). Pregnancy planning was a significant mediator of program effects on public benefit costs.

CONCLUSIONS

Through child age 18, the program reduced public-benefit costs, an effect more pronounced for mothers with higher psychological resources and mediated by subsequent pregnancy planning. There were no effects on maternal substance abuse and depression.

The Effect of Gestational Weight Gain Across Reproductive History on Maternal Body Mass Index in Midlife: The Study of Women's Health Across the Nation

Background: Excessive weight gain during pregnancy is common and has been shown to be associated with increased long-term maternal weight. However, less is known on whether there is a cumulative effect of excessive gestational weight gain (GWG) over multiple pregnancies. Methods: Data from the Study of Women's Health Across the Nation were used, restricted to parous women with no history of stillbirth or premature birth. The effect of the number of excessive GWG pregnancies on body mass index (BMI) in midlife (age 42-53) was analyzed using multivariable linear regression. Fully adjusted models included parity, inadequate GWG, demographic, and behavioral characteristics. Results: The 1181 women included in this analysis reported a total of 2693 births. Overall, 466 (39.5%) were categorized as having at least one pregnancy with excessive GWG. The median BMI at midlife was 26.0 kg/m² (interquartile range 22.5-31.1). In fully adjusted models, each additional pregnancy with excessive GWG was associated with 0.021 higher estimated log BMI (p = 0.031). Among women with 1-3 births, adjusted mean (95% confidence interval) BMI for those with 0, 1, 2, and 3 excessive GWG pregnancies was 25.4 (24.9-25.9), 26.8 (26.1-27.5), 27.5 (26.6-28.4), and 28.8 (27.3-30.5), respectively. Conclusions: In this multiethnic study of women with a history of term live births, the number of pregnancies with excessive GWG was associated with increased maternal BMI in midlife. Our findings suggest that prevention of excessive GWG at any point in a woman's reproductive history can have an impact on long-term maternal health.

Contraceptive Options Following Gestational Diabetes: Current Perspectives

Gestational diabetes mellitus (GDM) complicates approximately 7% of pregnancies in the United States. Along with risk factors related to pregnancy, women with a history of GDM also have an increased risk of developing type 2 diabetes mellitus later in life. These women require special consideration when discussing contraception and other reproductive health issues. GDM carries a category 1 rating in the US Medical Eligibility Criteria for all contraceptive methods, which supports safety of the various methods but does not account for effectiveness. Contraceptive options differ in composition and mechanisms of action, and concerns have been raised about possible effects of contraception on metabolism. Clinical evidence is limited to suggest that hormonal contraception has significantly adverse effects on body weight, lipid, or glucose metabolism. In addition, the majority of evidence does not suggest a relationship between development of type 2 diabetes mellitus and use of hormonal contraception. Data are limited, so it is challenging to make a broad, general recommendation regarding contraception for women with a history of GDM. A woman’s history of GDM should be considered during contraceptive counseling. Discussion should focus on potential medical comorbidities and the implications of GDM on future health, with special consideration of issues including bone health, obesity, cardiovascular disease, and thrombosis risk. Providers must emphasize the importance of reliable, highly effective contraception for women with GDM, to optimize the timing of future pregnancies. This approach to comprehensive counseling will guide optimal decision-making on contraceptive use, lifestyle changes, and planning of subsequent pregnancies.

Maternal interpregnancy weight change and premature birth: Findings from an English population-based cohort study

Background

The relationship between maternal weight change between pregnancies and premature birth is unclear. This study aimed to investigate whether interpregnancy weight change between first and second, or second and third pregnancy is associated with premature birth.

Methods

Routinely collected data from 2003 to 2018 from one English maternity centre was used to produce two cohorts. The primary cohort (n = 14,961 women) consisted of first and second live-birth pregnancies. The secondary cohort (n = 5,108 women) consisted of second and third live-birth pregnancies. Logistic regression models were used to examine associations between interpregnancy BMI change and premature births adjusted for confounders. Subgroup analyses were carried out, stratifying by initial pregnancy BMI groups and analysing spontaneous and indicated premature births separately.

Results

In the primary cohort, 3.4% (n = 514) of births were premature compared to 4.2% (n = 212) in the secondary cohort, with fewer indicated than spontaneous premature births in both cohorts.

Primary cohort

Weight loss (>3kg/m²) was associated with increased odds of premature birth (adjusted odds ratio (aOR):3.50, 95% CI: 1.78–6.88), and spontaneous premature birth (aOR: 3.34, 95%CI: 1.60–6.98), in women who were normal weight (BMI 18.5-25kg/m²) at first pregnancy. Weight gain >1kg/m² was not associated with premature birth regardless of starting BMI.

Secondary cohort

Losing >3kg/m² was associated with increased odds of premature birth (aOR: 2.01, 95%CI: 1.05–3.87), when analysing the whole sample, but not when restricting the analysis to women who were overweight or obese at second pregnancy.

Conclusions

Normal-weight women who lose significant weight (>3kg/m²) between their first and second live pregnancies have greater odds of premature birth compared to normal-weight women who remain weight stable in the interpregnancy period. There was no evidence of association between weight change in women who were overweight or obese at the start of their first pregnancy and premature birth.

Pattern and determinant factors of birth intervals among Iranian women: a semi-parametric multilevel survival model

The interval between successive pregnancies (birth interval) is one of the main indexes used to evaluate the health of a mother and her child. This study evaluated birth intervals in Iran using data from the Iranian Multiple Indicators Demographic and Health Survey (IrMIDHS) conducted in 2010-2011. A total of 20,093 married Iranian women aged 15-54 years from the whole country constituted the study sample. Based on the nature of sampling and the unobserved population heterogeneity for birth intervals in each city and province, a multilevel survival frailty model was applied. Data were analysed for women's first three birth intervals. The median first and second birth intervals were 30.3 and 39.7 months respectively. Higher education, Caesarean delivery, contraceptive use and exposure to public mass media were found to decrease the hazard rate ratio (HRR) of giving birth. Meanwhile, higher monthly income increased the hazard of giving birth. The results suggest that public mass media can play an effective role in encouraging women to have the recommended birth interval. Furthermore, increasing family income could encourage Iranian couples to decrease the time to their next birth.

Report of the Office of Population Affairs' expert work group meeting on short birth spacing and adverse pregnancy outcomes: Methodological quality of existing studies and future directions for research

BACKGROUND

The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based.

METHODS

To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health.

RESULTS

Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work.

CONCLUSIONS

This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.

Short interpregnancy intervals and adverse maternal outcomes in high-resource settings: An updated systematic review

BACKGROUND

Currently, no federal guidelines provide recommendations on healthy birth spacing for women in the United States. This systematic review summarises associations between short interpregnancy intervals and adverse maternal outcomes to inform the development of birth spacing recommendations for the United States.

METHODS

PubMed/Medline, POPLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, and a previous systematic review were searched to identify relevant articles published from 1 January 2006 and 1 May 2017. Included studies reported maternal health outcomes following a short versus longer interpregnancy interval, were conducted in high-resource settings, and adjusted estimates for at least maternal age. Two investigators independently assessed study quality and applicability using established methods.

RESULTS

Seven cohort studies met inclusion criteria. There was limited but consistent evidence that short interpregnancy interval is associated with increased risk of precipitous labour and decreased risks of labour dystocia. There was some evidence that short interpregnancy interval is associated with increased risks of subsequent pre-pregnancy obesity and gestational diabetes, and decreased risk of preeclampsia. Among women with a previous caesarean delivery, short interpregnancy interval was associated with increased risk of uterine rupture in one study. No studies reported outcomes related to maternal depression, interpregnancy weight gain, maternal anaemia, or maternal mortality.

CONCLUSIONS

In studies from high-resource settings, short interpregnancy intervals are associated with both increased and decreased risks of adverse maternal outcomes. However, most outcomes were evaluated in single studies, and the strength of evidence supporting associations is low.

Patterns of Gestational Weight Gain and Infants Born Large-for-Gestational Age Across Consecutive Pregnancies

INTRODUCTION

Factors that occur between consecutive pregnancies may influence repeated excessive gestational weight gain (GWG) and infants born large-for-gestational age (LGA). We examined interpregnancy interval, weight retention, and GWG in women's first pregnancy as predictors of excessive GWG and LGA in women's second pregnancy.

METHODS

We used data from women's first two live births during the First Baby Study, a 3-year prospective observational cohort of first-time mothers (N = 549). GWG was calculated as weight at delivery minus prepregnancy weight for first and second pregnancies and categorized using the Institute of Medicine guidelines. Weight retention at 6 and 12 months and interpregnancy interval (time from first live birth to conception of second infant) were quantified. Infants were considered LGA if birthweight was in the 90th percentile or greater for gestational age.

RESULTS

Many women (51.7%) exceeded GWG recommendations in both pregnancies. Women who exceeded guidelines in their first pregnancy had a 5.08 greater odds (p < .01) for exceeding guidelines in their second pregnancy, compared with women who did not exceed guidelines in their first pregnancy. Interpregnancy interval and weight retention had no association with exceeding guidelines in women's second pregnancy. Exceeding guidelines in women's first pregnancy resulted in a 4.48 greater odds (p < .01) of first-born infants being LGA, and exceeding guidelines in women's second pregnancy resulted in a 1.82 greater odds of second-born infants being large-for-gestational age (p = .02), compared with women who met guidelines in their first or second pregnancy, respectively.

CONCLUSIONS

Exceeding GWG guidelines in women's first pregnancy predicted exceeding guidelines in their second pregnancy, independent of interpregnancy interval and weight retention.

Socioeconomic Position and Reproduction: Findings from the Australian Longitudinal Study on Women's Health

OBJECTIVE

To investigate the association of socioeconomic position (SEP) with reproductive outcomes among Australian women.

METHODS

Data from the Australian Longitudinal Study on Women's Health's (population-based cohort study) 1973-1978 cohort were used (N = 6899, aged 37-42 years in 2015). The association of SEP (childhood and own, multiple indicators) with age at first birth, birth-to-pregnancy (BTP) intervals and total number of children was analysed using multinomial logistic regression.

RESULTS

14% of women had their first birth aged < 24 years. 29% of multiparous women had a BTP interval within the WHO recommendation (18-27 months). Women with a low SEP had increased odds of a first birth < 24 years: low (OR 7.0: 95% C.I. 5.3, 9.3) or intermediate education (OR 3.8: 2.8, 5.1); living in rural (OR 1.8: 1.5, 2.2) or remote (OR 2.1: 1.7, 2.7) areas; who found it sometimes (OR 1.8: 1.5, 2.2) or always difficult (OR 2.0: 1.6, 2.7) to manage on their income; and did not know their parent's education (OR 4.5: 3.2, 6.4). Low SEP was associated with having a much longer than recommended BTP interval.

CONCLUSION

As the first Australian study describing social differences in reproductive characteristics, these findings provide a base for reducing social inequalities in reproduction. Assisting adequate BTP spacing is important, particularly for women with existing elevated risks due to social disadvantage; including having a first birth < 24 years of age and a longer than recommended BTP interval. This includes reviewing services/access to postnatal support, free family planning/contraception clinics, and improved family policies.

Association of Parity in Patients with Chronic Liver Disease

INTRODUCTION AND AIM

The impact of type of liver disease on parity rates hasn't been described. Our aim was to assess the parity rates among women with CLD.

MATERIAL AND METHODS

The National Health and Nutrition Examination Survey-III (1988-1994) data were used to identify adult female participants with a diagnosis of CLD. Participants were asked about their reproductive health status. Parity was defined as having at least one live birth. Hepatic ultrasound, serologic, medical examination and clinical data were available to determine the presence and type of CLD. Body mass index (kg/m2) was divided into 3 categories (< 30; 30-35; 36+).

RESULTS

A total of 3,502 (865 NAFLD, 737 other CLD, 1,901 control) subjects were included. Patients with NAFLD were more likely to have at least one live birth than patients with other CLD and controls (77% in NAFLD vs. 72% in controls). Multivariate analysis revealed that presence of CLD other than NAFLD (OR: 0.46 [95% CI, 0.34-0.63]) and having a college or higher degree (OR: 0.48 [95% CI, 0.34-0.68]) were negatively associated while having low income (OR: 11.06 [95% CI, 6.86-17.82]) and being African American (OR: 3.93 [95% CI, 2.59-5.98]) were positively associated with having at least one live birth.

CONCLUSIONS

This study revealed that patients with CLD other than NAFLD were less likely to have at least one live birth. NAFLD and obesity were associated with higher rates of live births which can potentially be explained by weight gain post live birth leading to obesity and its associated-NAFLD.

Long-Term Weight Gain and Risk of Overweight in Parous and Nulliparous Women

OBJECTIVE

In longitudinal studies, women gain significant amounts of weight during young adulthood, pointing to pregnancy as an important trigger for weight gain. Studies examining the effect of parity vary in their findings and are complicated by multiple potential confounders. This study examines the association between parity and long-term weight gain in a cohort of young women participating in the Australian Longitudinal Study on Women's Health (ALSWH).

METHODS

A sample of 8,009 parous and nulliparous women was drawn from this cohort and allocated to one of six parity groups (0-5+). Weight gain and factors associated with BMI ≥ 25 over a 16-year period were identified by using generalized linear equations.

RESULTS

Median BMI increased by between 2.95 and 4.9 units over 16 years, with women of parity 5 + showing the biggest gain. Associations between several variables and a BMI ≥ 25 (controlling for multiple demographic and behavioral factors) demonstrated no effect for parity but significant effects for survey year, no paid job, and depression. University education and high levels of physical activity were protective.

CONCLUSIONS

In this sample, parity was not associated with a BMI ≥ 25 over a 16-year period.

Maternal weight in the postpartum: results from the Delta healthy sprouts trial

Background

Excessive postnatal weight retention may pose a threat to a woman’s health and future pregnancies. Women in the Lower Mississippi Delta (LMD) region of Mississippi suffer from among the highest rates of obesity in the U.S. and are more likely to gain an excessive amount of weight during pregnancy. The aim of this study was to determine if LMD women who received a lifestyle enhanced maternal, infant, and early childhood home visiting (MIECHV) curriculum had more favorable weight outcomes through 12-months postpartum compared to women who received a standard MIECHV curriculum.

Methods

Delta Healthy Sprouts was a two-arm, randomized, controlled, comparative impact trial. Pregnant women at least 18 years of age, less than 19 weeks pregnant with a singleton pregnancy, and residing in the LMD region were recruited. On a monthly basis in the participant’s home, the control arm (PAT) received the Parents as Teachers curriculum while the experimental arm (PATE) received a lifestyle enhanced Parents as Teachers curriculum. Pre-pregnancy body weight via self-report and maternal body weight at baseline (gestational month 4) and at every subsequent monthly visit through 12 months postpartum was measured. Linear mixed models were used to test for significant treatment, time, and treatment by time effects on postnatal weight outcomes.

Results

Mean postnatal weight losses were 0.8 and 1.1 kg at postnatal month (PM) 6 and PM 12, respectively, for PAT participants. Mean postnatal weight losses for PATE participants were 1.5 and 1.2 kg at PM 6 and PM 12, respectively. Mean weight retention, based on pre-pregnancy weight, were 5.2, 4.0, and 3.6 kg at PM 1, PM 6, and PM 12, respectively, for PAT participants. Mean weight retention for PATE participants were 6.3, 4.5, and 4.0 kg at PM 1, PM 6, and PM 12, respectively. Significant effects were not found for treatment, time, or treatment by time.

Conclusions

An enhanced MIECHV curriculum was not associated with more favorable postpartum weight outcomes when compared to a standard MIECHV curriculum in a cohort of LMD women during the 12 months following the birth of their infant. Trial registration: clinicaltrials.gov, NCT01746394. Registered 5 December 2012.

Reproductive Investment and Health Costs in Roma Women

In this paper, we examine whether variation in reproductive investment affects the health of Roma women using a dataset collected through original anthropological fieldwork among Roma women in Serbia. Data were collected in 2014–2016 in several Roma semi-urban settlements in central Serbia. The sample consisted of 468 Roma women, averaging 44 years of age. We collected demographic data (age, school levels, socioeconomic status), risk behaviors (smoking and alcohol consumption), marital status, and reproductive history variables (the timing of reproduction, the intensity of reproduction, reproductive effort and investment after birth), in addition to self-reported health, height, and weight. Data analyses showed that somatic, short-term costs of reproduction were revealed in this population, while evolutionary, long-term costs were unobservable—contrariwise, Roma women in poor health contributed more to the gene pool of the next generation than their healthy counterparts. Our findings appear to be consistent with simple trade-off models that suggest inverse relationships between reproductive effort and health. Thus, personal sacrifice—poor health as an outcome—seems crucial for greater reproductive success.

Parity and Overweight/Obesity in Peruvian Women

Introduction

The rise in noncommunicable diseases and their risk factors in developing countries may have changed or intensified the effect of parity on obesity. We aimed to assess this association in Peruvian women using data from a nationally representative survey.

Methods

We used data from Peru’s Demographic and Health Survey, 2012. Parity was defined as the number of children ever born to a woman. We defined overweight as having a body mass index (BMI, kg/m²) of 25.0 to 29.9 and obesity as a BMI ≥30.0. Generalized linear models were used to evaluate the association between parity and BMI and BMI categories, by area of residence and age, adjusting for confounders.

Results

Data from 16,082 women were analyzed. Mean parity was 2.25 (95% confidence interval [CI], 2.17–2.33) among rural women and 1.40 (95% CI, 1.36–1.43) among urban women. Mean BMI was 26.0 (standard deviation, 4.6). We found evidence of an association between parity and BMI, particularly in younger women; BMI was up to 4 units higher in rural areas and 2 units higher in urban areas. An association between parity and BMI categories was observed in rural areas as a gradient, being highest in younger women.

Conclusion

We found a positive association between parity and overweight/obesity. This relationship was stronger in rural areas and among younger mothers.

Sociodemographic factors and pregnancy outcomes associated with prepregnancy obesity: effect modification of parity in the nationwide Epifane birth-cohort

Background

In light of the adverse outcomes for mothers and offspring related to maternal obesity, identification of subgroups of women at risk of prepregnancy obesity and its related-adverse issues is crucial for optimizing antenatal care. We aimed to identify sociodemographic factors and maternal and neonatal outcomes associated with prepregnancy obesity, and we tested the effect modification of parity on these associations.

Methods

In 2012, 3368 mothers who had delivered in 136 randomly selected maternity wards were included just after birth in the French birth cohort, Epifane. Maternal height and weight before and at the last month of pregnancy were self-reported. Maternal and neonatal outcomes were collected in medical records. Prepregnancy Body Mass Index (pBMI) was classified into underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9) and obesity (≥30.0). Since we found statistically significant interactions with parity, the multinomial logistic regression model estimating associations of pBMI class with sociodemographic characteristics and pregnancy outcomes was stratified on parity (1335 primiparous and 1814 multiparous).

Results

Before pregnancy, 7.6% of women were underweight, 64.2% were of normal weight, 18.0% were overweight and 10.2% were obese. Among the primiparous, maternal age of 25-29 years (OR = 2.09 [1.13-3.87]; vs. 30-34 years), high school level (OR = 2.22 [1.33-3.73]; vs. university level), gestational diabetes (OR = 2.80 [1.56-5.01]) and hypertensive complications (OR = 3.80 [1.83-7.89]) were independently associated with prepregnancy obesity. Among the multiparous, primary (OR = 6.30 [2.40-16.57]), junior high (OR = 2.89 [1.81-4.64]) and high school (OR = 1.86 [1.18-2.93]) education levels (vs. university level), no attendance at antenatal classes (OR = 1.77 [1.16-2.72]), excess gestational weight gain (OR = 1.82 [1.20-2.76]), gestational diabetes (OR =5.16 [3.15-8.46]), hypertensive complications (OR = 8.13 [3.97-16.64]), caesarean delivery (OR = 1.80 [1.18-2.77]) and infant birth weight ≥ 4 kg (OR = 1.70 [1.03-2.80]; vs. birth weight between 2.5 kg and 4 kg) were independently associated with prepregnancy obesity.

Conclusion

Obesity before pregnancy is associated with a set of sociodemographic characteristics and adverse pregnancy outcomes that differ across parity groups. Such findings are useful for targeted health policies aimed at attaining healthy prepregnancy weight and organizing perinatal care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1456-8) contains supplementary material, which is available to authorized users.

Racial and ethnic disparities in postpartum care and contraception in California's Medicaid program

BACKGROUND

Considerable racial and ethnic disparities have been identified in maternal and infant health in the United States, and access to postpartum care likely contributes to these disparities. Contraception is an important component of postpartum care that helps women and their families achieve optimal interpregnancy intervals and avoid rapid repeat pregnancies and preterm births. National quality measurements to assess postpartum contraception are being developed and piloted.

OBJECTIVE

To assess racial/ethnic variation in receipt of postpartum care and contraception among low-income women in California.

STUDY DESIGN

We conducted a prospective cohort study of 199,860 Californian women aged 15-44 with a Medicaid-funded delivery in 2012. We examined racial/ethnic variation of postpartum care and contraception using multivariable logistic regression to control for maternal age, language, cesarean delivery, Medicaid program, and residence in a primary care shortage area (PCSA).

RESULTS

Only one-half of mothers attended a postpartum visit (49.4%) or received contraception (47.5%). Compared with white women, black women attended postpartum visits less often (adjusted odds ratio [aOR], 0.73; 95% confidence interval [CI], 0.71-0.76), were less likely to receive any contraception (aOR, 0.83; 95% CI, 0.78-0.89) and were less likely to receive highly effective contraception (aOR, 0.64; 95% CI, 0.58-0.71). Women with Spanish as their primary language were more likely to get any contraception (aOR, 1.15; 95% CI, 1.11-1.19) but had significantly lower odds of receiving a highly effective method (aOR, 0.94; 95% CI, 0.90-0.99) compared with women with English as their primary language. Similarly, women in PCSAs had a greater odds of getting any contraception (aOR, 1.06; 95% CI, 1.03-1.09), but 24% lower odds of getting highly effective contraception than women not living in PCSAs (aOR, 0.76; 95% CI, 0.73-0.79).

CONCLUSION

Significant racial/ethnic disparities exist among low-income Californian mothers' likelihood of attending postpartum visits and receiving postpartum contraception as well as receiving highly effective contraception.

[Effects of gestational weight gain and breastfeeding on postpartum weight retention among women in the BRISA cohort]

This study analyzed the effects of gestational weight gain and breastfeeding on postpartum weight retention. The study followed 2,607 women from the BRISA cohort. The variables were age, socioeconomic status, parity, pre-gestational body mass index, gestational weight gain, duration of maternal breastfeeding, length of postpartum follow-up, and postpartum weight gain. Structural equation modeling was used to evaluate the total, direct, and indirect effects of the explanatory variables on postpartum weight retention. An increase of one standard deviation in gestational weight gain corresponded to a significant increase of 0.49 standard deviations in postpartum weight retention (p < 0.001). An increase of one standard deviation in duration of breastfeeding corresponded to mean decrease of 0.10 standard deviations in postpartum weight retention (p < 0.001). Independently of pre-gestational BMI, gestational weight gain is a risk factor and duration of breastfeeding is a protective factor against postpartum weight retention.

The effect of interpregnancy interval on obesity/overweight among women in the first trimester of pregnancy

OBJECTIVE

To determine the effect of interpregnancy interval (IPI) on obesity/overweight among pregnant Sudanese women in early pregnancy.

METHODS

A cross-sectional study was conducted at Saad Abu-Alela Hospital, Khartoum, Sudan, from January to December 2015. Women with a singleton pregnancy and at least one previous pregnancy were enrolled in the first trimester. A questionnaire was used to collect clinical and sociodemographic data from the participants, and current body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters.

RESULTS

Among 1045 participants, 344 (32.9%), 424 (40.6%), and 277 (26.5%) women had short (<18 months), normal (18-30 months), and long IPIs (>30 months), respectively. BMI indicated 18 (1.7%), 408 (39.0%), 381 (36.5%), and 238 (22.8%) women were underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0), respectively. Age and proportion using contraceptives were increased among women with long IPI (both P<0.001). When compared with women of normal weight, overweight women and obese women were more likely to have a long IPI (odds ratio 1.72, 95% confidence interval 1.08-2.93; and 1.71, 1.05-2.94, respectively).

CONCLUSION

Long IPI was associated with obesity and overweight, which were prevalent among pregnant Sudanese women.

The relationship between weight gain during pregnancy and allopregnanolone levels: a longitudinal study

OBJECTIVE

Large weight gain during pregnancy is a risk factor for complications for mother and fetus. Hunger and satiety are regulated in the hypothalamus, where the gamma-amino-butyric acid system (GABA) has an important role. Allopregnanolone, a progesterone metabolite, increases during pregnancy and is a potent GABA-A receptor modulating steroid. Allopregnanolone has been shown to induce overeating in rodents. The aim was to investigate whether there is a relationship between weight gain and allopregnanolone concentrations during pregnancy in humans.

DESIGN

A longitudinal, cohort study.

METHODS

Pregnant women (n = 56) were recruited in primary care in northern Sweden. Allopregnanolone concentrations in plasma were measured using radioimmunoassay and weight was measured in gestational weeks 12 and 35.

RESULTS

Weight increase correlated significantly to allopregnanolone in late pregnancy increase (r_s = 0.320; P = 0.016), indicating a positive relationship between weight increase and allopregnanolone increase. A positive relationship was also noted between allopregnanolone in the 35th gestational week and weight increase. Women who gained ≥11 kg during pregnancy showed higher allopregnanolone concentrations in week 35 and higher increase compared to women who increased <11 kg (P = 0.006 and P = 0.009 resp.). There was no difference in weight or allopregnanolone concentrations at the onset of pregnancy.

CONCLUSIONS

The results show a relationship between weight gain during pregnancy and increase in allopregnanolone concentrations.

Pre-pregnancy body mass index and inter-pregnancy weight change among women of Russian, Somali and Kurdish origin and the general Finnish population

Objectives: We studied the differences in the mean pre-pregnancy body mass index (BMI) and mean inter-pregnancy weight change in women of Russian, Somali and Kurdish origin and women in the general Finnish population. Methods: The population-based samples were from the Migrant Health and Wellbeing Study and the Health 2011 Survey conducted in six cities in Finland in 2010–2012. This study included women with at least one birth in Finland. Data on their previous pregnancies in Finland were obtained from the National Medical Birth Register for 318 Russian, 584 Somali and 373 Kurdish origin women and for 243 women in the general Finnish population (reference group). Data on pre-pregnancy weight and height were self-reported in early pregnancy. Linear logistic regression was the main method of analysis. Results: The unadjusted mean pre-pregnancy BMI was higher in Somali (27.0 kg/m2, p<0.001) and Kurdish (25.8 kg/m2, p<0.001) women, but lower in Russian (22.2 kg/m2, p<0.001) women than in the reference group (24.1 kg/m2). The adjusted coefficients for the difference in the mean pre-pregnancy BMI were −1.93 (95% CI −2.77 to −1.09) for Russian, 1.82 (95% CI 0.89–2.75) for Somali and 1.30 (95% CI 0.43–2.17) for Kurdish women compared with the reference group. Among women with at least two births, no statistically significant difference was observed in the mean inter-pregnancy weight change between the migrant groups and the reference group. Conclusions: Somali and Kurdish women had higher mean pre-pregnancy BMIs than women in the general Finnish population and may need special support and health promotion strategies for weight management.

Postpartum weight loss in overweight and obese women using the etonogestrel subdermal implant: a pilot study

OBJECTIVE

To compare weight loss during the first 6months postpartum in overweight and obese women using the etonogestrel implant, placed in the immediate postpartum period, with that of controls using nonhormonal contraception, utilizing a pilot design.

STUDY DESIGN

Pilot, prospective cohort study. Analysis groups were divided by body mass index (overweight: 25-29.9kg/m²; Class I Obesity: 30-34.5kg/m²; Class II Obesity: 35-39.9kg/m²) and grouped by use of etonogestrel implant or nonhormonal contraception for all outcomes. Primary outcome was the proportion of women in each group returning to pregravid weight by 6months postpartum. Secondary outcomes included waist circumference, motivation to lose weight, eating habits, physical activity, feasibility of study procedures and assessment of recruitment potential in the first 6months postpartum.

RESULTS

A total of 127 women enrolled between June 2014 and August 2015. Fifty-seven chose the etonogestrel implant for immediate postpartum contraception while 70 chose nonhormonal contraceptives. Six months after delivery, about half of women in each group returned to within 1.5 kg of pregravid weight (42% etonogestrel [ENG]-implant vs. 67% nonhormonal methods, p=.19). Retention rates were high with over 75% of total study population providing study data at 6months. Two nonhormonal contraceptive users conceived in the first 4months postpartum.

CONCLUSION

No statistical difference in percentage return to pregravid weight was detected between groups, but data suggest that a somewhat lower proportion of implant users lost weight at 6months. Rapid recruitment, high retention and marked acceptance of immediate ENG implant use demonstrate feasibility for a larger, adequately powered trial.

IMPLICATIONS

Immediate postpartum insertion of the ENG implant is safe and effective. Study findings suggest modest interference in overweight and obese women's ability to lose gestational weight. If future research demonstrates no statistical difference, increased uptake in immediate implant use should occur in most women, including those who are overweight or obese.

Predictors of Readiness for Hospital Discharge After Birth: Building Evidence for Practice

BACKGROUND

Preparation for hospital discharge after birth became a global concern when hospitals in many developing countries began implementing shorter lengths of stay for uncomplicated deliveries. A mother's perceived readiness for hospital discharge may be influenced by many factors that can ultimately shape postdischarge outcomes.

AIMS

The purpose of this study was to explore the antepartum, intrapartum, and postpartum predictors of discharge readiness, including nursing educational practices that are predictive of postpartum mothers' perceptions of readiness for hospital discharge.

METHODS

The Adaptation to Transitions conceptual framework guided the descriptive correlational study design and measures. A purposive sample of 185 English- and Spanish-speaking postpartum mothers who experienced an uneventful vaginal or cesarean birth of a healthy infant completed demographic, quality of discharge teaching, and readiness for hospital discharge questionnaires prior to discharge.

RESULTS

Mothers with three or more children, delivery mode, bottle-feeding, the delivery of education, and the difference between educational content received and needed, were significant predictors that accounted for 42% of the variance in readiness for hospital discharge (R² = 0.42, F_[10,174] = 14.52, p < .001). Nurses' skill in teaching and educational content received were significant predictors even with parity, feeding, and delivery mode in the model.

LINKING EVIDENCE TO ACTION

The relationship between quality of discharge teaching and discharge readiness provides evidence of the critical role nurses have in the discharge preparation process. Nurse education programs and evidence-based guidelines should be designed to enhance patient education focused on the adequacy and delivery of teaching content.

Exploring the need for interventions to manage weight and stress during interconception

Interventions to manage weight and stress during the interconception period (i.e., time immediately following childbirth to subsequent pregnancy) are needed to promote optimal maternal and infant health outcomes. To address this gap, we summarize the current state of knowledge, critically evaluate the research focused on weight and stress management during the interconception period, and provide future recommendations for research in this area. Evidence supports the importance of weight and stress management during the reproductive years and the impact of weight on maternal and child health outcomes. However, evidence-based treatment models that address postpartum weight loss and manage maternal stress during the interconception period are lacking. This problem is further compounded by inconsistent definitions and measurements of stress. Recommendations for future research include interventions that address weight and stress tailored for women in the interconception period, interventions that address healthcare providers' understanding of the significance of weight and stress management during interconception, and long-term follow-up studies that focus on the public health implications of weight and stress management during interconception. Addressing obesity and stress during the interconception period via a reproductive lens will be a starting point for women and their families to live long and healthy lives.

Combined effect of education and reproductive history on weight trajectories of young Australian women: A longitudinal study

OBJECTIVE

To investigate the combined effect of education and reproductive history on weight trajectory.

METHODS

The association of education with weight trajectory (1996-2012) in relation to reproductive history was analyzed among 9,336 women (born 1973-1978) from the Australian Longitudinal Study on Women's Health using random effects models.

RESULTS

Compared with women with a university degree/higher, lower-educated women were 2 kg heavier at baseline and gained an additional 0.24 kg/year. Giving birth was associated with an increase in weight which was more pronounced among women having their first birth <26 years of age (2.1 kg, 95% CI: 1.5-2.7), compared with 26 to 32 years or >32 years. While younger first-time mothers had a steeper weight trajectory (∼+0.16 kg/year, 95% CI: 0.1-0.3), this was less steep among lower-educated women. High-educated women with a second birth between 26 and 32 years had 0.9 kg decreased weight after this birth, while low-educated women gained 0.9 kg.

CONCLUSIONS

While the effect of having children on weight in young adulthood was minimal, women having their first birth <26 years of age had increased risk of weight gain, particularly primiparous women. Educational differences in weight persisted after accounting for reproductive history, suggesting a need to explore alternative mechanisms through which social differences in weight are generated.

Comparative effectiveness of group and individual prenatal care on gestational weight gain

This study examined differences in gestational weight gain for women in CenteringPregnancy (CP) group prenatal care versus individually delivered prenatal care. We conducted a retrospective chart review and used propensity scores to form a matched sample of 393 women (76 % African-American, 13 % Latina, 11 % White; average age 22 years) receiving prenatal care at a community health center in the South. Women were matched on a wide range of demographic and medical background characteristics. Compared to the matched group of women receiving standard individual prenatal care, CP participants were less likely to have excessive gestational weight gain, regardless of their pre-pregnancy weight (b = -.99, 95 % CI [-1.92, -.06], RRR = .37). CP reduced the risk of excessive weight gain during pregnancy to 54 % of what it would have been in the standard model of prenatal care (NNT = 5). The beneficial effect of CP was largest for women who were overweight or obese prior to their pregnancy. Effects did not vary by gestational age at delivery. Post-hoc analyses provided no evidence of adverse effects on newborn birth weight outcomes. Group prenatal care had statistically and clinically significant beneficial effects on reducing excessive gestational weight gain relative to traditional individual prenatal care.

Do short birth intervals have long-term implications for parental health? Results from analyses of complete cohort Norwegian register data

BACKGROUND

Short and very long interbirth intervals are associated with worse perinatal, infant and immediate maternal outcomes. Accumulated physiological, mental, social and economic stresses arising from raising children close in age may also mean that interbirth intervals have longer term implications for the health of mothers and fathers, but few previous studies have investigated this.

METHODS

Discrete-time hazards models were estimated to analyse associations between interbirth intervals and mortality risks for the period 1980-2008 in complete cohorts of Norwegian men and women born during 1935-1968 who had had two to four children. Associations between interbirth intervals and use of medication during 2004-2008 were also analysed using ordinary least-squares regression. Covariates included age, year, education, age at first birth, parity and change in coparent since the previous birth.

RESULTS

Mothers and fathers of two to three children with intervals between singleton births of less than 18 months, and mothers of twins, had raised mortality risks in midlife and early old age relative to parents with interbirth intervals of 30-41 months. For parents with three or four children, longer average interbirth intervals were associated with lower mortality. Short intervals between first and second births were also positively associated with medication use. Very long intervals were not associated with raised mortality or medication use when change of coparent since the previous birth was controlled.

CONCLUSIONS

Closely spaced and multiple births may have adverse long-term implications for parental health. Delayed entry to parenthood and increased use of fertility treatments mean that both are increasing, making this a public health issue which needs further investigation.