Maternal fatness and viability of preterm infants

The views of first time mothers completing an intervention to reduce postpartum weight retention: A qualitative evaluation of the mums OnLiNE study

BACKGROUND

maternal postpartum weight retention (PPWR) has implications for short and long term weight-related health of both the mother and child. Little is known about how mothers perceive they may be best supported to achieve a healthy postpartum weight and healthy lifestyle behaviours. Evaluating existing postpartum weight focussed intervention strategies is an important step in the planning of future programs aimed at supporting new mothers.

AIM

to describe the perspectives of women who completed the mums OnLiNE pilot intervention, regarding the acceptability and effectiveness of a program which aimed to limit PPWR and promote healthy diet and physical activity behaviours in new mothers.

METHOD

descriptive qualitative research methods utilising semi-structured interview questions to explore new mothers' views regarding their participation in the mums OnLiNE intervention were used. All women who completed the intervention were invited to participate in one-on-one interviews via telephone. Interviews were digitally recorded and transcribed verbatim. Data were analysed utilising thematic analysis for common, emerging themes.

FINDINGS

twelve women participated in the interviews. Six main themes including program usefulness, intervention components, walking, self-monitoring, barriers and challenges and future recommendations described women's views of the mums OnLiNE intervention. Women felt well supported being part of the program and their reported awareness of healthy eating increased. Telephone support was the most valued and helpful component of the intervention and the smartphone application for self-monitoring was used more often than the website. Walking was by far the most preferred activity as it was considered enjoyable and achievable and some reported that their incidental walking increased as a result of being part of the program. Lack of time and motivation were the main barriers to participation in the program. Suggestions for future programs included encouraging group support and mother-baby exercise sessions.

CONCLUSION

women perceived the mums OnLiNE intervention to be useful in promoting a healthy lifestyle and valued the support provided. Whilst barriers to participation in healthy lifestyle programs exist, well planned interventions which consider time constraints of new mothers, utilize one-on-one support and offer social engagement with other new mothers may further support women in their attainment of healthy postpartum weight and lifestyle behaviours.

Trial for Reducing Weight Retention in New Mums: a randomised controlled trial evaluating a low intensity, postpartum weight management programme

BACKGROUND

Failure to return to pregnancy weight by 6 months postpartum is associated with long-term obesity, as well as adverse health outcomes. This research evaluated a postpartum weight management programme for women with a body mass index (BMI) > 25 kg m(-2) that combined behaviour change principles and a low-intensity delivery format with postpartum nutrition information.

METHODS

Women were randomised at 24-28 weeks to control (supported care; SC) or intervention (enhanced care; EC) groups, stratified by BMI cohort. At 36 weeks of gestation, SC women received a 'nutrition for breastfeeding' resource and EC women received a nutrition assessment and goal-setting session about post-natal nutrition, plus a 6-month correspondence intervention requiring return of self-monitoring sheets. Weight change, anthropometry, diet, physical activity, breastfeeding, fasting glucose and insulin measures were assessed at 6 weeks and 6 months postpartum.

RESULTS

Seventy-seven percent (40 EC and 41 SC) of the 105 women approached were recruited; 36 EC and 35 SC women received a programme and 66.7% and 48.6% completed the study, respectively. No significant differences were observed between any outcomes. Median [interquartile range (IQR)] weight change was EC: -1.1 (9.5) kg versus SC: -1.1 (7.5) kg (6 weeks to 6 months) and EC: +1.0 (8.7) kg versus SC: +2.3 (9) kg (prepregnancy to 6 months). Intervention women breastfed for half a month longer than control women (180 versus 164 days; P = 0.10). An average of 2.3 out of six activity sheets per participant was returned.

CONCLUSIONS

Despite low intervention engagement, the high retention rate suggests this remains an area of interest to women. Future strategies must facilitate women's engagement, be individually tailored, and include features that support behaviour change to decrease women's risk of chronic health issues.

Systematic review of lifestyle interventions to limit postpartum weight retention: implications for future opportunities to prevent maternal overweight and obesity following childbirth

Postpartum weight retention can predict future weight gain and long-term obesity. Moreover, failure to lose weight gained during pregnancy can lead to increased body mass index for subsequent pregnancies, increasing the risk of adverse maternal and foetal pregnancy outcomes. This systematic review evaluates the effectiveness of lifestyle interventions aimed at reducing postpartum weight retention. Seven electronic databases were searched for intervention studies and trials enrolling women with singleton pregnancies and published in English from January 1990 to October 2012. Studies were included when postpartum weight was a main outcome and when diet and/or exercise and/or weight monitoring were intervention components. No limitations were placed on age, body mass index or parity. Eleven studies were identified as eligible for inclusion in this review, of which 10 were randomized controlled trials. Seven studies were successful in decreasing postpartum weight retention, six of which included both dietary and physical activity components, incorporated via a range of methods and delivered by a variety of health practitioners. Few studies utilized modern technologies as alternatives to traditional face-to-face support and cost-effectiveness was not assessed in any of the studies. These results suggest that postpartum weight loss is achievable, which may form an important component of obesity prevention in mothers; however, the optimal setting, delivery, intervention length and recruitment approach remains unclear.

Mortality in infants of obese mothers: is risk modified by mode of delivery?

OBJECTIVE

To examine the association between maternal obesity and infant mortality, while including information about mode of delivery and interpregnancy weight change.

DESIGN

Register-based cohort study.

SETTING AND POPULATION

A total of 1 199 183 singletons, including 3481 infant deaths, from the Swedish Birth Register 1992-2006.

METHODS

Maternal body mass index (BMI) was obtained from self-reports in early pregnancy and categorized as underweight (<18.5 kg/m(2)), normal-weight (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), obese (30-34.9 kg/m(2)) and extremely obese (≥35 kg/m(2)). Cox regression was used to estimate hazard ratios (95% confidence intervals). Infants of normal-weight women were the referent.

MAIN OUTCOME MEASURES

Neonatal and infant mortality.

RESULTS

Infant mortality increased with increasing maternal fatness [adjusted hazard ratios 1.2 (1.1-1.3), 1.4 (1.2-1.6) and 2.1 (1.8-2.5) for overweight, obesity and extreme obesity, respectively]. When accounting for mode of delivery, neonatal mortality was increased in infants of obese and extremely obese mothers after spontaneous births [adjusted hazard ratios 1.8 (1.4-2.4) and 2.6 (1.8-4.0), respectively, after term births, and 1.4 (1.1-1.9) and 2.2 (1.5-3.3), respectively, after preterm births]. No excess risk was present for infants of obese mothers after induced term and preterm births (p-values for interaction <0.05). For post-neonatal mortality, no interaction between mode of delivery and maternal obesity was observed. In women with two subsequent pregnancies, high interpregnancy weight change >1 BMI unit (1 kg/m(2)) seemed to involve a modest increase in neonatal mortality in the second infant, but only after spontaneous births [adjusted odds ratio 1.3 (0.9-1.7)].

CONCLUSIONS

Maternal obesity, especially at levels that may involve cardiometabolic morbidity, was associated with increased mortality in the offspring.

Maternal obesity and infant outcomes

Obesity (Body mass index (BMI) above 30) is one of the major health issues of the 21st century. Over 1.1 billion of the world's population are now classified as obese. In the UK, women are more likely to be obese than men; over 50% of women of reproductive age are overweight or obese. Maternal obesity and the plethora of associated conditions, have a serious impact on the health and development of their offspring. In this review we describe the direct and indirect impact of maternal obesity on the health of the baby. Maternal obesity affects conception, duration and outcome of pregnancy. Offspring are at increased risk of both immediate and long term implications for health. We also briefly review potential mechanisms drawing on data from human and animal studies, and on the outcomes of clinical interventional studies.

Maternal obesity and the risk of infant death in the United States

BACKGROUND

Maternal obesity (defined as prepregnancy body mass index [BMI] >or=30 kg/m) is associated with increased risk of neonatal death. Its association with infant death, postneonatal death, and cause-specific infant death is less well-characterized.

METHODS

We studied the association between maternal obesity and the risk of infant death by using 1988 US National Maternal and Infant Health Survey data. A case-control analysis of 4265 infant deaths and 7293 controls was conducted using SUDAAN software. Self-reported prepregnancy BMI and weight gain were used in the primary analysis, whereas weight variables in medical records were used in a subset of 4308 women.

RESULTS

Compared with normal weight women (prepregnancy BMI = 18.5-24.9 kg/m) who gained 0.30 to 0.44 kg/wk during pregnancy, obese women had increased risk of neonatal death and overall infant death. For obese women who had weight gain during pregnancy of <0.15, 0.15 to 0.29, 0.30 to 0.44, and >or=0.45 kg/wk, the adjusted odds ratios of infant death were 1.75 (95% confidence interval = 1.28-2.39), 1.42 (1.07-1.89), 1.59 (1.00-2.51), and 2.87 (1.98-4.16), respectively. Nonobese women with very low weight gain during pregnancy also had a higher risk of infant death. The subset with weight information from medical records had similar results for recorded prepregnancy BMI and weight gain. Maternal obesity was associated with neonatal death from pregnancy complications or disorders relating to short gestation and unspecified low birth weight.

CONCLUSIONS

Maternal obesity is associated with increased overall risk of infant death, mainly neonatal death.

Obesity and pregnancy

Obesity is reaching pandemic proportions worldwide. It is increasingly being recognised as a risk factor during pregnancy. Women should ideally be counselled preconceptionally about the increased risks and encouraged to lose weight actively, some may be candidates for bariatric surgery. Maternal risks include gestational diabetes, hypertension and pre-eclampsia, increased incidence of operative delivery, postpartum haemorrhage, anaesthetic risks as well as infective and thrombo-embolic complications while fetal risks include miscarriage, neural-tube defects, macrosomia and stillbirth. Obstetric units should institute appropriate guidelines for the management of pregnancy in this 'high-risk' group of women.

Maternal obesity and neonatal mortality according to subtypes of preterm birth

OBJECTIVE

To examine the association between prepregnancy body mass index (BMI) and neonatal mortality while accounting for the timing of delivery and subtypes of preterm birth.

METHODS

The study population included 85,375 liveborn singletons of mothers in the Danish National Birth Cohort (1996-2002) who were interviewed during the second trimester. Information about pregnancy outcomes and neonatal deaths (n=230) was obtained from national registers. The association was estimated by Cox regression analyses and results were presented as hazard ratios with 95% confidence intervals (CIs).

RESULTS

Compared with infants of mothers who were at a normal weight before pregnancy (BMI of 18.5 or more but less than 25), neonatal mortality was increased in infants of mothers who were overweight (BMI of 25 or more but less than 30) or obese (BMI of 30 or more) (adjusted hazard ratios 1.7, CI 1.2-2.5, and 1.6, CI 1.0-2.4, respectively). For preterm infants (n=3,934, 136 deaths), neonatal mortality in infants born after preterm premature rupture of membranes (PROM) was significantly increased if they were born to an overweight or obese mother (adjusted hazard ratios 3.5, CI 1.4-8.7, and 5.7, CI 2.2-14.8). There were no associations between high BMI and neonatal mortality in infants born after spontaneous preterm birth without preterm PROM or in infants born after induced preterm delivery.

CONCLUSION

High maternal weight seems to increase the risk of neonatal mortality, especially in infants born after preterm PROM. Inflammation or infection related to obesity may be part of the causal pathway.

LEVEL OF EVIDENCE

II.

The effect of obesity on the outcome of infertility management in women with polycystic ovary syndrome

INTRODUCTION

Obesity has become a worldwide epidemic with ever increasing incidence and public health problems in both developing and developed countries.

OBJECTIVE

The objective of the study is to investigate the incidence of obesity among patients with polycystic ovarian syndrome attending infertility clinic and the effect on treatment outcome.

METHODOLOGY

Two hundred and seventy women with polycystic ovarian syndrome attending the infertility clinic were evaluated clinically, biochemically, and laparoscopically. They were stratified according to their body mass index (BMI) as follows: normal weight: 18-24; overweight: 25-29, obese:30-34, and grossly obese: > or = 35. Therapy included induction of ovulation with clomiphene citrate and gonadotrophins. The patients were followed up through during induction of ovulation and pregnancy.

RESULTS

There were ethnic differences in mean BMI. Significantly more obese women had oligomenorrhoea (p<0.01) and anovulation (p<0.01) than women with normal weight. Obesity adversely affected the outcome of ovulation induction with clomiphene citrate and gonadotrophins; 79% of women with BMI 18-24 ovulated at 6 months compared to 15.3% in those with BMI 30-34 (p<0.001) and 11.8% in women with BMI > or = 35 (p<0.001). The pregnancy rate and outcome were also adversely affected by obesity.

CONCLUSION

Obesity has a negative impact on the outcome of treatment of infertility. Weight reduction programme should be an essential component of infertility management.

Poor maternal care and high maternal body mass index in pregnancy as a risk factor for schizophrenia in offspring

OBJECTIVE

We investigated whether antenatal factors in mothers would increase the risk of schizophrenia in the offspring, and also examined any relationship between these factors and histories of obstetric complications (OCs).

METHOD

Using the Mother and Child Health Handbooks of 52 patients with schizophrenia and 284 healthy subjects, we evaluated the risk-increasing effects of the frequency of antenatal care visits and mothers' body mass index (BMI) at both early and late pregnancy.

RESULTS

In logistic regression analysis, there was a significant association between the number of antenatal care visits and the risk of the disorder; an increase in a unit of visits corresponds to a reduction of the risk by 12%. We also found a 24% increase in the risk with a one-unit increase of BMI at the early pregnancy, and a 19% increase at the late pregnancy. These antenatal factors were found to contribute, in part, to an excess of OCs in individuals with schizophrenia.

CONCLUSION

Poor maternal care during pregnancy and comparatively high maternal BMI especially at early pregnancy may cause a predisposition to schizophrenia in the offspring.

Maternal nutrition and perinatal survival

The simple relationship between maternal macronutrient status and perinatal survival (increased macronutrient intake --> increased maternal weight and/or weight gain --> increased fetal growth --> improved survival) that is usually posited is no longer defensible. First, maternal weight and weight gain are remarkably resistant to either dietary advice or supplementation; further, increased birth weight attributable to maternal nutrition does not necessarily increase perinatal survival (because prepregnant weight is positively associated with both birth weight and higher perinatal mortality). Finally, whereas dietary supplements during pregnancy may have a modest effect on birth weight in nonfamine conditions (by contrast with a large effect in famine or near-famine conditions), their impact is not mediated by maternal energy deposition. Rather, the component of maternal weight gain associated with accelerated fetal growth is maternal water (presumably plasma) volume.

Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London

OBJECTIVE

To examine the maternal and foetal risks of adverse pregnancy outcome in relation to maternal obesity, expressed as body mass index (BMI, kg/m(2)) in a large unselected geographical population.

DESIGN

Retrospective analysis of data from a validated maternity database system which includes all but one of the maternity units in the North West Thames Region. A comparison of pregnancy outcomes was made on the basis of maternal BMI at booking.

SUBJECTS

A total of 287,213 completed singleton pregnancies were studied including 176,923 (61.6%) normal weight (BMI 20--24.9), 79 014 (27.5%) moderately obese (BMI 25--29.9) and 31,276 (10.9%) very obese (BMI> or =30) women.

MEASUREMENTS

Ante-natal complications, intervention in labour, maternal morbidity and neonatal outcome were examined and data presented as raw frequencies and adjusted odds ratios with 99% confidence intervals following logistic regression analysis to account for confounding variables.

RESULTS

Compared to women with normal BMI, the following outcomes were significantly more common in obese pregnant women (odds ratio (99% confidence interval) for BMI 25--30 and BMI> or =30 respectively): gestational diabetes mellitus (1.68 (1.53--1.84), 3.6 (3.25--3.98)); proteinuric pre-eclampsia (1.44 (1.28--1.62), 2.14 (1.85--2.47)); induction of labour (2.14 (1.85--2.47), 1.70 (1.64--1.76)); delivery by emergency caesarian section (1.30 (1.25--1.34), 1.83 (1.74--1.93)); postpartum haemorrhage (1.16 (1.12--1.21), 1.39 (1.32--1.46)); genital tract infection (1.24 (1.09--1.41), 1.30 (1.07--1.56)); urinary tract infection (1.17 (1.04-1.33), 1.39 (1.18--1.63)); wound infection (1.27 (1.09--1.48), 2.24 (1.91--2.64)); birthweight above the 90th centile (1.57 (1.50--1.64), 2.36 (2.23--2.50)), and intrauterine death (1.10 (0.94--1.28), 1.40 (1.14--1.71)). However, delivery before 32 weeks' gestation (0.73 (0.65--0.82), 0.81 (0.69--0.95)) and breastfeeding at discharge (0.86 (0.84--0.88), 0.58 (0.56--0.60)) were significantly less likely in the overweight groups. In all cases, increasing maternal BMI was associated with increased magnitude of risk.

CONCLUSION

Maternal obesity carries significant risks for the mother and foetus. The risk increases with the degree of obesity and persists after accounting for other confounding demographic factors. The basis of many of the complications is likely to be related to the altered metabolic state associated with morbid obesity.

Perinatal outcomes of obese women: a review of the literature

OBJECTIVE

To review the literature addressing the effect of obesity on pregnancy outcomes and to identify practice and research implications.

DATA SOURCES

Computerized searches in Medline and CINAHL, as well as references cited in articles reviewed. Key words used in the search were as follows: pregnancy and obesity; pregnancy complications; weight gain and pregnancy; weight gain and complications; fat distribution and pregnancy and complications; and obstetrics and obesity.

STUDY SELECTION

Articles and comprehensive works from indexed journals in the English language relevant to key words and published after 1978 were evaluated.

DATA EXTRACTION

Data were extracted and organized under the following headings: methodologic issues; physiologic adjustments; antepartum, intrapartum, postpartum and newborn outcomes; and cost.

DATA SYNTHESIS

Obese pregnant women experience more gestational diabetes, neural tube defects, preeclampsia, induction, primary cesarean, and postpartum infection than pregnant women who are not obese.

CONCLUSIONS

Pregnant women who are obese are at increased risk for certain complications during pregnancy, birth, and postpartum. Little is known about the effect that fat distribution (upper versus lower, which is influential in nonpregnant populations) has on obstetric complications. Even less is known about obese pregnant women's perceptions of risk, changes in lifestyle, functioning, health behaviors, and symptoms experienced during pregnancy.

Prepregnancy weight and the risk of adverse pregnancy outcomes

BACKGROUND

Obesity before pregnancy is associated with an increased risk of several adverse outcomes of pregnancy. The risk profiles among lean, normal, or mildly overweight women are not, however, well established.

METHODS

We studied the associations between prepregnancy body-mass index (defined as the weight in kilograms divided by the square of the height in meters) and the frequency of late fetal death, early neonatal death, preterm delivery, and delivery of a small-for-gestational-age infant in a population-based cohort of 167,750 women in Sweden in 1992 and 1993. The women were categorized as follows, according to body-mass index: lean, less than 20.0; normal, 20.0 through 24.9; overweight, 25.0 through 29.9; and obese, 30.0 or more. The estimates were adjusted for maternal age, parity, smoking, education, whether the mother was living with the father, and maternal height.

RESULTS

Among nulliparous women, the odds ratios for late fetal death were increased among women with higher body-mass-index values as compared with lean women, as follows: normal women, 2.2 (95 percent confidence interval, 1.2 to 4.1); overweight women, 3.2 (95 percent confidence interval, 1.6 to 6.2); and obese women, 4.3 (95 percent confidence interval, 2.0 to 9.3). Among parous women, only obese women had a significant increase in the risk of late fetal death (odds ratio, 2.0; 95 percent confidence interval, 1.2 to 3.3). Among nulliparous women, the risk of very preterm delivery (at < or =32 weeks' gestation) was significantly increased among obese as compared with lean women (odds ratio, 1.6; 95 percent confidence interval, 1.1 to 2.3), whereas among parous women, the risk was highest among those who were lean. The risk of delivering a small-for-gestational-age infant decreased more with increasing body-mass index among parous than among nulliparous women.

CONCLUSIONS

Higher maternal weight before pregnancy increases the risk of late fetal death, although it protects against the delivery of a small-for-gestational-age infant.

Gestational weight gain as a predictor of birth and placenta weight according to pre-pregnancy body mass index

OBJECTIVE

To study the association between gestational weight gain and different birth weight indicators considering the pre-pregnancy body mass index. It was hypothesized that a high body mass index (BMI) would modify the effect of gestational weight gain and support the advice of keeping gestational weight gain at a moderate level in case of obesity.

STUDY DESIGN

A follow-up study of consecutively recruited women in two well defined geographical areas in Denmark. The recruitment lasted from 1984 to 1987 and 11,850 pregnant women and newborns were included in the study. The remaining analyses were restricted to non-diabetic women who gave birth between weeks 37 and 42 of gestation for whom weight gain was reported-altogether 7,122 women.

RESULTS

Birth and placenta weight were associated with gestational weight gain but with lower regression coefficients at higher BMI. The proportion of newborns with a birth weight of 4,500 grams or more increased with increasing gestational weight gain, especially in women with a BMI above 26.

CONCLUSION

The potential benefit of a high gestational weight gain in obese patients should be balanced by the higher risk of giving birth to babies with a birth weight of more than 4,500 grams and the risk of exaggerating a pre-existing state of obesity.

Dental asymmetry, maternal obesity, and smoking

This study examines the levels of fluctuating dental asymmetry in four samples of school children: those whose mothers were obese and had smoked during the pregnancy concerned (n = 111); those whose mothers were obese non-smokers (n = 114); those whose mothers were non-obese smokers (n = 104); and those whose mothers were lean non-smokers (n = 111). The degree of fluctuating asymmetry was assessed by means of a rescaled asymmetry measure. Obesity was defined as Quetelet's index in excess of 30, and smoking status as at least 20 cigarettes per day during the pregnancy concerned. When the magnitudes of fluctuating asymmetry in children of lean smokers were compared to the control group of lean non-smokers, no significant univariate differences were found. Children of obese mothers, whether these smoked or not, were found to have significantly raised levels of asymmetry. An analysis of variance confirmed that the combination of obesity and maternal smoking was a significant predictor of fluctuating dental asymmetry. The teeth involved tended to be the maxillary first incisor and molars. It is concluded that maternal obesity has a destabilizing effect on the developing fetus and that this effect appears to be enhanced in obese mothers who smoked. This effect was absent in lean mothers, irrespective of their smoking status.

Maternal obesity increases congenital malformations

There has been growing evidence that maternal obesity is associated with an increased risk of congenital malformations, particularly of neural tube defects. Two new studies confirm this relationship and indicate that it is independent of possible covariant confounders such as maternal age, socioeconomic status, education, smoking, and vitamin intake, including folic acid. There is a suggestion that folic acid loses its protective benefit in overweight and obese mothers. These new findings add to a long list of obstetric morbidities, and show a steep gradient with increasing maternal fatness and point to the urgent need to prevent excess weight gain in young women.

Bone mineralisation, body fat and anthropometric measurement in mothers delivering preterm

Twenty mothers of preterm babies who had survived to 1 year old, were matched for age and parity of the mother and time of birth of the baby, with 20 mothers delivering fullterm. Bone mineral, body composition and anthropometric measurements were obtained for each mother and analysed using paired t-tests. The only significant difference (P < 0.01) between the groups was a lower fat-free mass in the preterm mothers calculated from skinfold thickness measurements.

Inequalities in pregnancy outcome: a review of psychosocial and behavioural mediators

The purpose of this paper is to review the literature on psychosocial factors in pregnancy outcome and to present a model which attempts to integrate the findings theoretically. There are four sections. The first presents published data on the incidence of early childhood mortality and low birth weight. Changes over time and differences between countries are noted and attention is drawn to the marked inequalities between occupational groups in the British data. The second section reviews the evidence that a variety of psychosocial risk factors influence pregnancy outcome, notably social, emotional, cognitive and behavioural factors. The third section develops the theme of inequalities and examines theories which have been advanced to account for the differences in adult mortality. We argue that material deprivation goes some way towards explaining inequalities in pregnancy outcome, but that any proper account will have to explain the links between inputs and outcomes--the processes and mechanisms by which material deprivation is translated into observable mortality and morbidity. In the concluding section, we argue that some of the principal links are the psychosocial risk factors described in the second section, and we present a model which traces the pathways of mediation.