Effect of short inter-pregnancy interval on perinatal and maternal outcomes among pregnant women in SSA 2023: Systematic review and meta-analysis

BACKGROUND

After a live birth, the recommended interval before attempting the next pregnancy is at least 24 months (birth to pregnancy interval) in order to reduce the risk of adverse maternal, perinatal and infant outcomes. Short inter pregnancy interval associated with adverse perinatal and maternal outcomes.

OBJECTIVE

The objective of this review was to determine the effect of short inter pregnancy interval on perinatal and maternal outcomes in Sub-Saharan Africa 2023.

METHODS

A systematic and a comprehensive literature searching mechanism were used without any restriction, through Google scholar, PubMed, Scopus, Web of Sciences, and Grey literature databases for reporting the effect of short inter pregnancy interval. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. All statistical analyses were done using STATA version17 software for windows, and meta-analysis was used with a random-effects method. The results are presented using texts, tables and forest plots with measures of effect and 95% confidence interval.

RESULTS

Thirteen studies were included in this review and most of the studies level of heterogeneity across the study was considerable, mainly due to methodological variations, Statistical heterogeneity, and population and intervention variations of included studies. The effect of short inter pregnancy interval on perinatal and maternal outcome were low birth weight(RR (RR (95% CI) 1.98 (1.48, 2.47); I2:62.97%, preterm birth (RR (95% CI) 1.67 (1.31, 2.03); I2:51%, intra uterine growth retardation(RR (95% CI) 3.78 (2.07, 5.49); I2: 8.52%, low APGAR score(RR (95% CI) 3.49 (1.41, 5.57)); I2: 71.11%, premature rapture of membrane(RR (95% CI) 2.87 (1.22, 4.51)); I2: 49.22%, perinatal mortality(RR (95% CI) 2.95 (1.10, 4.81)); I2: 54.37% and maternal anemia(RR (95% CI) 3.06 (2.12, 3.99)); I2: 74.74%.

CONCLUSIONS

As per our review the main effect of short inter pregnancy interval is low birth weight, preterm birth, intra uterine growth retardation, low APGAR score, premature rapture of membrane, perinatal mortality and maternal anemia. This might be very useful for healthcare policymakers and NGOs to emphasize on it.

Girl child marriage, socioeconomic status, and undernutrition: evidence from 35 countries in Sub-Saharan Africa

BACKGROUND

Girl child marriage, a formal union of a female before age 18, and undernutrition remain common in Sub-Saharan Africa. The aim of this study is to establish the extent to which girl child marriage contributes to socioeconomic status and underweight, a measure of undernutrition, among adult women.

METHODS

We used data from 103 Demographic and Health Surveys (DHS), representing 35 African countries from 1991 to 2014. Girl child marriage was coded both as a binary variable (before 18 years) and categorical variable (before 14, 14 to 15 years, 16 to 17 years). The primary outcome was underweight (body mass index less than 18·5). Secondary outcomes were early and multiple childbearing, secondary education completion, and wealth index. Logistic regression models were used to estimate associations.

RESULTS

Fifty-five percent of women married before age 18. Girl child marriage was associated with reduced risk of being underweight both in models adjusted for basic confounders (risk difference = - 0.020, 95% CI [- 0.026, - 0.014], p < 0.01) and in models adjusted for childbearing, women's relative status, and socioeconomic outcomes (risk difference = - 0.018, 95% CI [- 0.024, - 0.011], p < 0.01). Conditional on completing primary education and community fixed-effects, women married before 18 years had an increased risk of early motherhood (risk difference = 0.38, 95% CI [0.38, 0.38], p < 0.01) and of being in the poorest quintile (risk difference = 0.024, 95% CI [0.012, 0.036], p < 0.01), and were 27 percentage points less likely to complete secondary education (risk difference = - 0.27, 95% CI [- 0.28, - 0.26)], p < 001), compared to women married as adults.

CONCLUSIONS

Though associated with substantially reduced socioeconomic status, girl child marriage appears to be associated with slightly reduced risk of being underweight in the population studied. Further research is needed to understand the determinants of undernutrition in this context as well as the broader relationship between socioeconomic status and nutritional outcomes.

Effects of Breastfeeding on Maternal Health and Well-Being

Lactation occurs as part of a reproductive and may have different effects on maternal nutritional status, depending on its duration and intensity. Thus, its effect on maternal health will differ with cultural setting and level of development. Lactation helps women to maintain a healthy body weight. Among well-nour-shed women, it may help to prevent obesity. Among poorly pour/shed women, breastfeeding also leads to weight loss, but with adequate birth spacing brought about by lactational anovulation, maternal depletion can be avoided. Lactation is probably not responsible for osteoporosis. Current evidence suggests that breastfeeding helps to prevent pre-menopausal breast cancer and is not associated with post-menopausal disease Furthermore, breastfeeding may also help reduce ovarian cancer. Positive effects of breastfeeding occur at all levels of development and are most likely when biological, political, and sociocultural conditions interact to support its initiation and continuation.

Polygyny and child growth in a traditional pastoral society : The case of the datoga of Tanzania

In this paper I use measures of childhood growth to assess from both an evolutionary theoretical and an applied public health perspective the impact of polygyny on maternal-child welfare among the Datoga pastoralists of Tanzania. I report that the growth and body composition of children varies in such a way as to suggest that polygyny is not generally beneficial to women in terms of offspring quality. Cross-sectional analysis of covariance by maternal marriage status revealed that children of first and second wives in polygynous marriages grow relatively poorly, that this is correlated with maternal physical status, and that the pattern is not modified by household wealth. I discuss how the dynamics of sexual conflicts operating during the formation and maintenance of marriages may be important factors in the etiology of poor child growth in this population, leading to complex patterns of variation in anthropometric indicators of both women and children. The theoretical conclusion is that improved evolutionary models of polygyny should be designed to examine the potential for adaptive tradeoffs between the currencies of offspring quality and quantity for all types of parents in a polygynous population. The practical conclusion is that a better understanding of the relationships between marriage practices and health outcomes would assist in the development of culturally appropriate health and nutrition interventions.

Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal mechanisms

This systematic review of 58 observational studies identified hypothetical causal mechanisms explaining the effects of short and long intervals between pregnancies on maternal, perinatal, infant, and child health, and critically examined the scientific evidence for each causal mechanism hypothesized. The following hypothetical causal mechanisms for explaining the association between short intervals and adverse outcomes were identified: maternal nutritional depletion, folate depletion, cervical insufficiency, vertical transmission of infections, suboptimal lactation related to breastfeeding-pregnancy overlap, sibling competition, transmission of infectious diseases among siblings, incomplete healing of uterine scar from previous cesarean delivery, and abnormal remodeling of endometrial blood vessels. Women's physiological regression is the only hypothetical causal mechanism that has been proposed to explain the association between long intervals and adverse outcomes. We found growing evidence supporting most of these hypotheses.

Impact of increasing inter-pregnancy interval on maternal and infant health

Short inter-pregnancy intervals (IPIs) have been associated with adverse maternal and infant health outcomes in the literature. However, many studies in this area have been lacking in quality and appropriate control for confounders known to be associated with both short IPIs and poor outcomes. The objective of this systematic review was to assess this relationship using more rigorous criteria, based on GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. We found too few higher-quality studies of the impact of IPIs (measured as the time between the birth of a previous child and conception of the next child) on maternal health to reach conclusions about maternal nutrition, morbidity or mortality. However, the evidence for infant effects justified meta-analyses. We found significant impacts of short IPIs for extreme preterm birth [<6 m adjusted odds ratio (aOR): 1.58 [95% confidence interval (CI) 1.40, 1.78], 6-11 m aOR: 1.23 [1.03, 1.46]], moderate preterm birth (<6 m aOR: 1.41 [1.20, 1.65], 6-11 m aOR: 1.09 [1.01, 1.18]), low birthweight (<6 m aOR: 1.44 [1.30, 1.61], 6-11 m aOR: 1.12 [1.08, 1.17]), stillbirth (aOR: 1.35 [1.07, 1.71] and early neonatal death (aOR: 1.29 [1.02, 1.64]) outcomes largely in high- and moderate-income countries. It is likely these effects would be greater in settings with poorer maternal health and nutrition. Future research in these settings is recommended. This is particularly important in developing countries, where often the pattern is to start childbearing at a young age, have all desired children quickly and then control fertility through permanent contraception, thereby contracting women's fertile years and potentially increasing their exposure to the ill effects of very short IPIs.

Prevalence and determinants of malnutrition among reproductive aged women of rural Bangladesh

Malnutrition among the rural Bangladeshi women of reproductive age is still very high. This high prevalence attributes to a range of adverse health consequences on the women and their offspring. A total of 2341 women aged between 20 and 45 years residing in the study area were interviewed in this cross-sectional study. Information on socioeconomic variables, nutritional status, and pregnancy-related history was obtained using interviewer administered questionnaire. A total of 34% of the reproductive aged rural women suffer from malnutrition. A multivariate analysis shows association between malnutrition and monthly household income, history of taking oral contraceptive, current pregnancy status, and history of breastfeeding. The final regression model shows a statistically significant decreasing trend in malnutrition status with increasing income (P for trend <.001). The economic and health consequences of malnutrition in this group of women are enormous. National nutritional program should target this women group for any intervention with a special priority.

Evolution of Infant and Young Child Feeding: Implications for Contemporary Public Health

Evolutionary anthropological and ethnographic studies are used to develop a general conceptual framework for understanding prehistoric, historic, and contemporary variation in human lactation and complementary feeding patterns. Comparison of similarities and differences in human and nonhuman primate lactation biology suggests humans have evolved an unusually flexible strategy for feeding young. Several lines of indirect evidence are consistent with a hypothesis that complementary feeding evolved as a facultative strategy that provided a unique adaptation for resolving tradeoffs between maternal costs of lactation and risk of poor infant outcomes. This evolved flexibility may have been adaptive in the environments in which humans evolved, but it creates potential for mismatch between optimal and actual feeding practices in many contemporary populations.

Does birth spacing affect maternal or child nutritional status? A systematic literature review

This review addresses the question of whether a short birth interval is associated with adverse nutritional outcomes for the mother or the child. Indices of anthropometric status (maternal weight or body mass index; child growth) and micronutrient status (e.g. iron or vitamin A) were included as outcomes. A computerized search of all relevant papers published since 1966 was completed, and the 'snowball' method was used to identify additional relevant published or unpublished papers. In total, 57 papers were found to contain data regarding the relationship between birth spacing and nutritional outcomes (35 for child nutrition, 11 for maternal anthropometric status, and 11 for maternal anaemia or micronutrient status). Of these, 23 papers were excluded from further consideration because they did not include any multivariate analysis, leaving 34 papers that met the criteria for the review (22 for child nutrition, eight for maternal anthropometric status, and four for maternal anaemia or micronutrient status). The studies on child nutrition outcomes indicate that a longer birth interval is associated with a lower risk of malnutrition in some populations, but not all. In those countries in which the relationship was significant, the reduction in stunting associated with a previous birth interval >or=36 months ranged from approximately 10% to 50%. Some of this reduction may be due to residual confounding, i.e. to factors not included in the analysis (such as breastfeeding and maternal height). The studies on maternal anthropometric outcomes yielded mixed results. Because the nutritional burden on the mother between pregnancies depends on the extent of breastfeeding, the interpregnancy interval is not the best measure of whether the mother has had a chance to recover from the pregnancy, in terms of repleting her nutritional status. Therefore, some studies examined the 'recuperative interval' (duration of the non-pregnant, non-lactating interval) instead. Taken as a whole, the studies do not provide clear evidence of a link between interpregnancy or recuperative interval and maternal anthropometric status. This may be due, in part, to changes in the hormonal regulation of nutrient partitioning between the mother and the fetus when a mother is malnourished. Only four papers were identified that related to micronutrient status, three of which examined maternal anaemia. One study showed an increased risk for maternal anaemia when the interpregnancy interval was <6 months, but the analysis did not control for iron supplementation during pregnancy. The other two studies did not show a significant association between interpregnancy interval and maternal anaemia. One study of micronutrient status indicated no significant relationship between interpregnancy interval and maternal serum zinc, copper, magnesium, ferritin, folate or thyroid-stimulating hormone. Important methodological limitations were apparent in most of the studies. Thus, further research with more comprehensive control of potentially confounding variables is needed.

Effect of prenatal food supplementation on birth weight: an observational study from Bangladesh

BACKGROUND

National nutrition programs in Bangladesh have included prenatal food supplementation to reduce maternal and child malnutrition. The knowledge base is weak regarding the effect of prenatal food supplementation on the birth weight (BW) of infants in populations in whom low BW is prevalent and regarding any variation in effect based on maternal nutritional status.

OBJECTIVE

We examined whether observational data support an effect of daily prenatal food supplementation on BW by considering the duration of supplementation and whether the effect is modified by maternal postpartum weight (a proxy of prepregnancy weight) groups.

DESIGN

A cohort of undernourished pregnant women (n = 777) who received prenatal food supplementation (608 kcal/d) was followed. The association between the uptake of food supplements and BW was analyzed after adjustment for potential confounders (n = 619 with complete information). Differential effects in lower and higher maternal postpartum weight groups were examined.

RESULTS

The average BW was 2521 g. On average, the women received daily supplements for 4 mo, which resulted in an increase in BW of 118 g (1.0 g/d). The strongest effect was found for births occurring in January and February. There was a linear dose-response relation between duration of supplementation and BW for women with higher postpartum weights (> or = 42 kg, above the median). In women with lower weights (< 42 kg, below median), a shorter duration of supplementation (< 4 mo) had no such dose-response relation with BW, but there was a linear dose-response relation for longer durations of supplementation.

CONCLUSIONS

The association between duration of prenatal food supplementation and BW varies with maternal postpartum weight. A large effect was observed after the season with food insecurity (mid-August to mid-November).

The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies

An adequate supply of nutrients is probably the single most important environmental factor affecting pregnancy outcome. Women with early or closely spaced pregnancies are at increased risk of entering a reproductive cycle with reduced reserves. Maternal nutrient depletion may contribute to the increased incidence of preterm births and fetal growth retardation among these women as well as the increased risk of maternal mortality and morbidity. In the past, it was assumed that the fetus functioned as a parasite and withdrew its nutritional needs from maternal tissues. Studies in both animals and humans demonstrate, however, that if the maternal nutrient supply is inadequate, the delicate balance between maternal and fetal needs is disturbed and a state of biological competition exists. Furthermore, maternal nutritional status at conception influences how nutrients are partitioned between the mother and fetal dyad. In severe deficiencies maternal nutrition is given preference; in a marginal state the fetal compartment is favored. Although the studies of nutrient partitioning have focused on energy and protein, the partitioning of micronutrients may also be influenced by the maternal nutritional status. Marginal intakes of iron and folic acid during the reproductive period induce a poor maternal status for these nutrients during the interpregnancy interval. Poor iron and folic acid status has also been linked to preterm births and fetal growth retardation. Supplementation with food and micronutrients during the interpregnancy period may improve pregnancy outcomes and maternal health among women with early or closely spaced pregnancies.

Associations between reproduction and maternal body weight: examining the component parts of a full reproductive cycle

OBJECTIVE

Many transitional societies currently face both extremes of nutritional status, undernutrition and overnutrition. Women of reproductive age are at high risk of these conditions. The purpose of this review is to consider evidence for relationships between reproduction and nutritional status in women from societies of varying economic development, using body weight or weight-for-height as indicators of maternal nutritional status.

DESIGN

The conceptual framework guiding this review is that the duration of the reproductive cycle varies as a function of its component parts, which include (i) pregnancy, (ii) lactation, (iii) the non-pregnant/non-lactating (NP/NL) interval or, possibly, (iv) an overlap between lactation and next pregnancy. All component parts of the complete cycle vary in length and are associated with changes in nutritional status. A variety of factors ('proximal and distal determinants') influence the duration of the component parts of the reproductive cycle. This framework is used to examine current knowledge of changes in maternal nutritional status during each of these parts.

RESULTS

Women in affluent societies retain some weight with each pregnancy, beyond that of non-pregnant women. Women in less affluent societies retain less weight with each pregnancy. During lactation, women in both affluent and less affluent societies experience only modest weight loss. During the NP/NL interval, women in affluent societies tend to gain weight, whereas weight of women in less affluent societies is likely to fluctuate.

CONCLUSIONS

We conclude that there is a dearth of information on certain parts of the cycle, particularly the periods of overlap of lactation with pregnancy and the NP/NL interval.

Postpartum consequences of an overlap of breastfeeding and pregnancy: reduced breast milk intake and growth during early infancy

OBJECTIVE

Despite cultural pressure to wean when a new pregnancy occurs, some women choose to continue breastfeeding. We determined the effect of an overlap of lactation and late pregnancy on breastfeeding and growth in early infancy.

METHODS

We studied 133 Peruvian pregnant women who were > or =18 years of age, had a child <4 years old, and who then had a vaginal birth with a healthy, normal weight infant. Of the 133 women, 68 breastfed during the last trimester of pregnancy (BFP), and 65 had not breastfed during pregnancy (NBFP). On day 2 and at 1-month postpartum, 24-hour intake of breast milk and other liquids was measured. Twice weekly home surveillance documented infant morbidity and dietary intakes. Anthropometry was taken at birth and at 1 month. Maternal anthropometric, health, and socioeconomic status data were collected pre- and postpartum.

RESULTS

Pregnant BFP mothers breastfed 5.3 +/- 4.3 times/day. BFP and NBFP infants did not differ in breastfeeding behavior or in colostrum intake on day 2. BFP infants breastfed longer per feed and per 24 hours (35.2 minutes/24 hours) than did NBFP infants; however, 1-month intakes per feed tended to be lower among the BFP infants. After controlling for confounders, BFP infants gained 125 g less than did NBFP infants (about 15% of mean weight gain). A sustained decline would result in a -0.7 z score change in weight-for-age by 6 months.

CONCLUSIONS

A lactation-pregnancy overlap had a negative effect on early infant outcomes. Additional studies are needed to determine whether the effect continues past 1 month of age.

God should give daughters to rich families only: attitudes towards childbearing among low-income women in Punjab, Pakistan

We evaluated perceptions and experiences of bearing sons and daughters among 42 women in Punjab, Pakistan, with special emphasis on son preference, changes in women's status within the marital family and resulting health effects. Data were collected through repeated, in-depth interviews in Urdu or Punjabi in an urban area in Lahore and a village 40 km. outside of Lahore. For triangulation purposes, four focus group discussions were performed with additional women, as well as in-depth interviews with eight mothers-in-law, three traditional practitioners and three medical practitioners. In general, these women felt that they had limited control over their lives, and this was exemplified by early marriages, high expectations on newly wed women to conceive and poor access to contraceptives. Women frequently expressed a strong preference for sons, mostly for economic reasons, reflecting women's subordinate position in society and the low economic value placed on women's work. Mothers of sons mainly discussed health problems during pregnancy and health effects of repeated childbearing. Mothers of daughters and women without children spoke of harassment in the family as well as in society. The results should be of importance in the public health planning in Pakistan as well as for those engaged in women's health issues internationally.

Age, reproductive history, seasonality, and maternal body composition during pregnancy for nomadic Turkana of Kenya

To evaluate the potential differences in maternal nutritional investment in pregnancy, data collected from nomadic Ngisonyoka Turkana women during a July 1993-July 1994 field season were utilized. The roles maternal age, parity, duration of the previous nonpregnant interval, overlap between pregnancy and lactation on trimester changes in weight and summed skinfolds during pregnancy were examined. Because seasonality is an important aspect of the Turkana environment, the effects of seasonality were also assessed. First trimester weight gain is positively associated with overlap in pregnancy and lactation. Second trimester maternal weight gain is negatively influenced by higher parity and by overlap between lactation and early pregnancy. Third trimester weight gain is influenced only by seasonally induced morbidity. First trimester changes in maternal skinfolds are negatively influenced by older maternal age and parity, and positively influenced by a longer nonpregnant interval, and overlap between pregnancy and lactation. Second and third trimester skinfolds are significantly associated only with overlap between lactation and pregnancy (negatively in the second, positively in the third). Seasonality does not influence maternal skinfolds. Differences in age- and parity-related patterns of maternal nutritional investment in pregnancy are not supported by the data. The possibility that Turkana cultural beliefs may influence nutritional status during pregnancy is discussed. Am. J. Hum. Biol. 11:658-672, 1999. Copyright 1999 Wiley-Liss, Inc.

Recognizing the reversible nature of child-feeding decisions: breastfeeding, weaning, and relactation patterns in a shanty town community of Lima, Peru

Researchers have normally considered weaning to be a non-reversible event. To determine the validity of this assumption, we interviewed 36 mothers of toddlers who were living in a poor shanty town of Lima, Peru. Data from 32 women were complete and used in this analysis. Mothers described their beliefs, practices, and decisions about breastfeeding, weaning, and relactation (the reintroduction of breastfeeding after weaning). We recorded attempted weaning events if the mother reported (1) purposefully not breastfeeding with the intention to wean, or (2) carrying out an action that was believed to cause the child to stop breastfeeding. Using a constant comparative approach, references to child-feeding decisions were coded, categorized, and analyzed. All mothers breastfed for at least 12 months; the median duration of breastfeeding was 25 months. There were several different patterns of child-feeding. Thirteen women never attempted to wean their children or had weaned on the first attempt. The majority (n = 19) of women, however, attempted to wean their children - some as early as 3 months of age but relactated between less than 1 day and 3 months later. Factors that influenced feeding decisions were primarily related to maternal and child health, and maternal time commitments. Children were weaned when there was a perceived problem of maternal health or time commitments and child health was not at risk of deterioration. Mothers postponed weaning because of poor child health. The primary reason for relactation was a child's negative reaction to weaning (e.g., incessant crying or refusal to eat). Personalities of the mother and child were important determinants of feeding decisions. These results demonstrate that maternal and child factors jointly influence child-feeding decisions and that these decisions are easily reversed. As relactation is culturally acceptable, health practitioners should consider recommending relactation when children have been prematurely weaned and human milk would improve their nutritional and health status.

Images of health and health care options among low income women in Punjab, Pakistan

We studied women's beliefs and experiences of health and health care among 42 women in an urban slum area in Lahore and a village 40 km outside of Lahore. Data were collected through repeated, in-depth interviews in Urdu or Punjabi totalling 200 hours. For triangulation purposes, four focus group discussions with additional women were performed, as well as in-depth interviews with eight mothers-in-law, three traditional practitioners and three medical practitioners. The women's images of health reflected expectations on the women in society. Women from the village and women from the lowest socioeconomic stratum (SES) spoke of health in terms of physical strength; women from the city and women from low SES spoke of health in terms of mental strength; and women from medium SES discussed it in terms of cultural competence. Overall, health had a very low priority in these women's lives. Two health problems were reported by all women: mental tension leading to headache and white vaginal discharge leading to body pains and fatigue. These health problems were seen as part of womanhood; if treatment was sought, it was often from traditional healers. Village women had a flexible, pragmatic attitude toward health care resources and used all types until treated. Their relation to the doctor was specific; they were mostly concerned with the medical treatment. In contrast, city women chose health care providers depending on type of illness, and being met with respect was for them of equal concern. Childbearing experiences influenced the perceptions of health and health care. Mothers of daughters were seen to both need and deserve less food, health care and attention. These mothers were less vocal about health complaints. Women without children spoke of health in terms of physical strength. These women may have less access to health care because children cannot be used as an "excuse", and because they are not worth spending resources on.

The effect of maternal nutritional variables on birthweight outcomes of infants born to Sherpa women at low and high altitudes in Nepal

A prospective, longitudinal study was conducted in Nepal to investigate the effects of maternal nutrition on the pregnancy outcome of Sherpa women living at low and high altitudes. It was hypothesized that variation in nutrition and energy expenditure of pregnant women would correlate with variation in infant birthweight. Anthropometric dimensions, energy consumption and expenditure, and demographic and migration information were collected on a large sample of women living in two regions of Nepal: the Khumbu region (3480-3930 m) and Kathmandu (1330 m). This paper reports findings for a subset of the sample; 17 women at low altitude and 21 women at high altitude who became pregnant and were followed during pregnancy. The results showed no significant differences for mean birthweights between the low (X = 3069 ± 341 grams) and high (X = 3099 ± 483 grams) altitude samples. Furthermore, larger birthweights were associated with larger weight gains during pregnancy for the high altitude sample. A stepwise regression analysis found a negative association between high energy expenditures during the second trimester and infant birthweight, but positive associations were found between third trimester calcium and second trimester protein intakes and birthweight. Prepregnancy BMI and stature were associated positively with infant birthweight, suggesting that good nutritional status prior to pregnancy may play an important role in pregnancy outcome for this population. Am. J. Hum. Biol. 9:751-763, 1997. © 1997 Wiley-Liss, Inc.