DETERMINANTS OF INADEQUATE WEIGHT GAIN IN PREGNANCY

Alina Delia Popa1, Ni Otilia2, Raluca Maria Popescu2, Andreea Gherasim2,3, Lidia
Iuliana Arhire2, Laura Mihalache2, Mariana Graur2
University of Medicine and Pharmacy Grigore T. Popa-Iai
Faculty of Medicine
1
Discipline of Nursing
2
Discipline of Diabetes, Nutrition and Metabolic Diseases
3
PhD Candidate
DETERMINANTS OF INADEQUATE WEIGHT GAIN IN PREGNANCY. Aim. The aim of
the study was to explore the anthropometric maternal characteristics and prenatal care as
determinants of pregnancy weight gain. Material and methods. We conducted a crosssectional study on a total of 400 pregnant women admitted to Cuza Voda Obstetrics and
Gynecology Clinical Hospital, Iai. Information on demographic characteristics, number of
prenatal visits, education on nutrition and food changes occurring during pregnancy were
recorded in a structured questionnaire. Anthropometric parameters analyzed were
pregestational BMI (body mass index) and weight gain during pregnancy. Results. Weight
gain was associated with pregestational BMI category. An increase in weight more than
recommended occured more frequently in overweight (53.1%) and obese women (66.7%)
(p<0.001). Weight gain during pregnancy was related to area of residence, age, APCU
(adequate prenatal care utilization) index. The multivariate analysis identified the following
variables as significant determinants of pregnancy weight gain: inadequate prenatal care,
BMI and changes in diet. Conclusions. Pregestational BMI and changes in diet during
pregnancy identified as determinants of weight gain suggests that overweight and
underweight women must carefully be counciled regarding recommendations for weight gain
in pregnancy. Tracking diet changes is important to ensure that a weight gain lies within the
guidelines recommendations. Keywords: PREGESTATIONAL BMI, WEIGHT GAIN
DURING PREGNANCY, PRENATAL VISITS, NUTRITIONAL EDUCATION
INTRODUCTION
The main purpose of recommendations for weight gain during pregnancy is
represented by a normal weight of newborns. Numerous factors can influence weight gain in
pregnant women, such as: previous nutritional status, age, parity, race and dietary habits (1).
Overweight is associated with an increased risk for preeclampsia, gestational diabetes and
caesarean section (2, 3). The pre- and postnatal nutritional environment is important in
shaping the future phenotype of the organism, influencing the risk of insulin resistance, type
2 diabetes and cardiovascular disease in adult life. The aim of the study was to explore the
determinants of inadequate weight gain during pregnancy.
MATERIAL AND METHODS
We conducted a cross-sectional study on a sample of 400 women, admitted to Cuza
Voda Obstetrics and Gynecology Clinical Hospital, Iasi, in August-September 2010.
Exclusion criteria were multiple pregnancy, patient refusal and obstetric pathology.
A standardized questionnaire provided information on age, pregestational weight, area
of residence, marital status, years of formal education, parity and prenatal care utilization
(date of registration, the number of medical visits to the family doctor and obstetrician).
Weight and height were measured in duplicate and recorded according to the standard

Corresponding author, e-mail: otyca95@yahoo.com, phone number:

+40742054311, address: 1, Independence Street, Iai, 700111, Romania
1

protocol. Prepregnancy nutritional status was classified based on BMI (body mass index),
according to the World Health Organization (WHO) criteria. Weight gain during pregnancy
was divided into three categories (less than 9 kg, 9-15 kg and above 15 kg) according to
general practitioner guidelines (4).
Adequacy of prenatal care utilization was assessed by determining the Adequacy of
Prenatal Care Utilization Index which takes into consideration the timing of prenatal care
initiation and the number of prenatal visits. The index is based on ACOG (American College
of Obstetricians and Gynecologists) recommendations for low risk pregnancies and has 4
categories. Inadequate prenatal care includes women who were registered after the fourth
month or had less than 50% of the number of recommended visits in pregnancy. Women
registered after the fourth month with a total of 50-79% of visits are included in the
intermediate care category. Initiation of prenatal consultation in the first 4 months of
pregnancy and a total of 80-109% of visits correspond to adequate care category. Adequate
plus category refers to the initiation of prenatal consultation in the first 4 months and total
medical checks of more than 110% compared to the number recommended (5).
The statistical package SPSS version 13.0 for Windows (Chicago, IL, USA) was used
for data analysis. For the prediction of inadequate weight gain, multinomial logistic
regression was used. Significance values of Goodness-of-Fit test were higher than 0.05, so
the model was adequate. Access to data observation sheet, the mother interview and the
measurements were made with the agreement of management of Cuza Voda Obstetrics and
Gynecology Hospital, and with the approval of Science and Ethics Committee of the
University of Medicine and Pharmacy Grigore T. Popa-Iai.
RESULTS
Almost half of the participants (45.8%) were from rural areas. The mean age was
27.53 years, and 63.8% of all women were between 19 and 30 years old. Pregnancy occurred
in married couples in 80.75% of cases. Primiparous women were predominant (49.5%) and
also those with a second child (32.3%) (tab. I).
TABLE I
Sociodemographic characteristics of the studied sample
Area of residence
Age (years)
Formal education
(years of schooling)

Marital status
Planned pregnancy

urban
rural
< 20
20
1-4
5-8
9-12
>12
married
unmarried
yes
no

No.
217
183
356
44
16
86
162
136
323
77
359
40

%
54,3
45,8
89,0
11,0
4,0
21,5
40,5
34,0
80,8
19,2
89,8
10,0

A proportion of 80% of women presented to the family doctor during the first
trimester of pregnancy. The mean total number of medical visits during pregnancy was
9.584.88.Almost half of women (53.5%) had an adequate plus prenatal care level, evaluated
by APCU (adequate prenatal care utilization) index, while 23% of them had inadequate care
during pregnancy. A proportion of 42.3% of women received advice about nutrition in
pregnancy. Only 33% declared they had no change in diet during pregnancy. Most women
were advised to breastfeed their children (83.5%).
The frequency of underweight women was 11.8%, 66.6% were normal weight, 17%
overweight and 4.6% were obese. Only 52.6% of women achieved a weight gain during
pregnancy as recommended by the guide for general practitioners (9-15 kg). Pregnancy
2

weight gain was influenced by area of residence and age. The number of women with weight
gain less than 9 kg was higher among those from rural areas. Pregnant women younger than
20 years old had more frequently a lower weight gain than recommended, but rarely an
increase of more than 15 kg (tab. II).
TABLE II
Sociodemographic characteristics related to weight gain during pregnancy
Sociodemographic characteristics
Area of residence
Planned pregnancy
Civil status
Age (years)
Formal education
(schooling years)
Parity

Urban
Rural
Yes
No
Married
Unmarried
20
< 20
<9
9
2
>2

Weight gain categories, %

< 9 kg
9,3
17,5
13,5
6,1
32,7
12,7
12,0
20,5
11,6
16,7
11,9
17,7

9-15 kg
48,6
57,8
51,1
66,7
48,1
50,6
51,3
64,1
51,0
57,8
51,6
58,1

> 15 kg
42,1
24,7
35,3
27,3
19,2
36,6
36,7
15,4
37,3
25,6
36,6
24,2

,001
,197
,173
,021
,095
,128

Most of underweight women had an adequate weight gain during pregnancy.

However, 39.5% had a weight gain of more than 15 kg. Women with obesity had more
frequently a reduced weight gain compared to other categories, but the proportion of those
with large increases in weight remained high (p=0.001) (tab. III).
TABLE III
Weight gain during pregnancy according to pregestational BMI
Weight gain,
kg
<9
9-15
>15

Underweight
4,7
55,8
39,5

Categories of BMI, %
Normal weight
Overweight
5,5
12,7
60,5
54
34
33,3

Obese
33,3
27,8
38,9

Pregnant women with adequate prenatal care had a higher mean weight gain
compared to those with inadequate or intermediate APCU index (p<0.001). Significant
differences were seen between women with inadequate and adequate care (12.53 kg vs. 14.42
kg., p = 0.041) and among those with inadequate and adequate + APCU index (12.53 kg vs.
15.05 kg, p<0.001). Weight gain of pregnant women with adequate + APCU index was also
significantly higher than the one seen in those with intermediate and adequate prenatal care
(15.05 kg vs. 12.53 kg, p <0.001, respectively 15.05 kg vs. 14.42 kg, p=0.007). (fig. 1).

Fig. 1. Association between weight gain and APCU index

A weight gain under the recommendations was noticed in 20.4% of women who
received advice on diet during pregnancy, compared to 25.5% of women who did not receive
such information. An increase in weight greater than recommended occurred in 35.3% of
women who received advice about diet, compared to 33.8% of them who have not received
such advice. Weight gain within the recommendations was more common among women
who received advice on nutrition during pregnancy, even if there was no statistical
significance (44.3% versus 40.7%, p = 0.496).
Multinomial logistic regression was performed to determine which of the following
factors are determinants of inadequate pregnancy weight gain: area of residence, age,
education, marital status, parity, planned pregnancy, APCU index, nutritional advice,
pregestational BMI, changes in diet during pregnancy (tab IV).
TABLE IV
Determinants of weight gain during pregnancy
Weight gain during pregnancya
Less
than
recommende
d

APCU index

Inadequate
Intermediary
Adequate

Age
Dietary
changes

Adequate +
<20 years
>20 years
Eat less
Eat more
Avoid salty foods
Eat more salty
Avoid certain foods

Pregestationa
l
BMI
(kg/m2)

More than
recommende
d

APCU index

No dietary changes
<18,5
18,5-24,9
<25-29.9
>30
Inadequate
Intermediary
Adequate

Age

Adequate +
<20 years

OR

,
009
,
657
,
374

3,06
4
1,30
1
1,56
5

,
535

95% Confidence
Interval
Lower Upper
Boun
Bound
d
1,31
7,123
8
,407
4,156
,583

4,201

1,35
8

,517

3,568

,
063
,
643
,
903
,
520
,
773

2,39
0
,818

,953

5,993

,349

1,914

,923

,256

3,325

,462

,044

4,864

1,27
9

,241

6,772

,
002
,
000
,110
.
,
136
,
023
,
368
.
,
036

,117

,031

,444

,041

,007

,243

,317
.b
,600

,078
.
,307

1,296
.
1,174

,292

,101

,846

1,36
4
.b
,346

,694

2,681

.
,128

.
,935

Dietary
changes

>20 years
Eat less
Eat more
Avoid salty foods
Eat more salty
Avoid certain foods

Pregestationa
l
BMI
(kg/m2)

No dietary changes
<18,5
18,5-24,9
<25-29.9
>30

,
009
,
007
,
738
,
874
,
532
,
172
,
375
,
350
.

,065

,008

,501

2,117

1,22
9
,517

3,649

,237

5,434

,476

4,220
7

,416

,118

1,463

,538

,137

2,117

,525

,136

2,029

.b

1,14
6
1,13
5
1,41
6

2,536

b-reference category

Variables that significantly contributed to distinguish between the three categories of

weight gain during pregnancy were: APCU index; pregestational BMI; changes in diet and
age. A weight gain lower than the recommended was associated with inadequate prenatal
care, pregestational BMI < 18.5 kg/m2 and normal pregestational weight. Weight gain higher
than recommendations was associated with changes in diet, age less than 20 years and an
intermediate value of APCU index.
DISCUSSIONS
Prenatal care is essential for screening and prevention of complications associated
with pregnancy (6). WHO recommends initiation of prenatal care during the first 4 months of
pregnancy (7). Continuity (8) and frequency of prenatal care (9) have positive effects on
mother and child health. APCU index combines in a single variable two quantitative factors:
gestational age, in months, at beginning of prenatal care and the number of prenatal visits
during pregnancy. Because prenatal care needs to be appropriate, registration should be done
during the first trimester and the number of prenatal visits should be at least nine. Although
the name includes the term appropriate, the index does not refer to the content of prenatal
consultation (5).
Our data show an improved addressability to general practicionner during the first
trimester of pregnancy compared to previous studies. In the study conducted by IOMC
"Nutritional status of pregnant women" almost 6% of women received no prenatal visit
during their last pregnancy, and 68.8% of mothers were presented at the first prenatal visit
during the first trimester of pregnancy (79.2% in urban and 58.5% rural) (10). The
Reproductive Health Survey 2004, most women (94%) received prenatal care, and 74% were
considered in the first trimester. Only 17% were considered in the second and 2% in the third
trimester. In 1999 it was found that 89% of women received prenatal care (10). The selfreported weight was used in the present study. For accurately assessing this parameter it is
recommended to use the self-reported weight in the first two months of pregnancy (11).
However, there are studies showing that mothers declared a value that correlates with real
weight (12).
Pregnancy is considered an appropriate time for promoting healthy changes in dietary
habits (13). Characteristics of intervention methods, content and frequency of educational
measures and socio-economic peculiarities led to discordant results of interventional studies.
The impact of recommendations on weight gain during pregnancy has been shown in

numerous studies, indicating that messages during prenatal consultation may influence
attitudes and perceptions of pregnant women on optimal growth. The impact of
recommendations on appropriate weight gain may be influenced by family and friends
attitude on prenatal education (14).
In this sample, it has been observed that only 57.6% of women had an optimal weight
gain. Studies in the U.S. have shown that 30-40% of pregnant women have a weight gain
outside the limits recommended by the Institute of Medicine (15). Our results show that the
number of prenatal visits influenced the proportion of women with optimal weight gain.
Pregnant women with inadequate prenatal care had more frequently a weight gain below the
recommended limits. Weight gain within the recommendations was more common among
women who received advice on nutrition during pregnancy. Other studies concluded that
belonging to certain ethnic groups (Hispanic), education level, decreased pregestational BMI
and the lack of nutritional advice were determinants of lower than recommended weight gain
(14). Overweight, young age and multiparity had a higher weight gain than considered
appropriate by the IOM (14). Weight gain above the recommended level was associated with
overweight and obesity in a study conducted in Brazil (16).
CONCLUSIONS
Pregestational BMI, APCU index and changes in diet during pregnancy identified as
determinants of weight gain suggests that overweight and underweight women must carefully
be counciled regarding recommendations for weight gain in pregnancy. Tracking diet changes
is important to ensure that a weight gain lies within the guidelines recommendations.
REFERENCES
1. Rodwell Williams S. Basic Nutrition and Diet Therapy, 11th edition. Mosby, 2001,179197.
2. Abenhaim H, Kinch R, Morin L,et al. Effect of prepregnancy body mass index categories
on obstetrical and neonatal outcomes. Arch Gynaecol Obstet 2007;275(1):39-43.
3. Dietz P, Callaghan W, Smith R, et al. Associations of low pregnancy weight gain with
three measures of small for gestational age infants. Am J Obstet Gynaecol
2009;201:53.e1-53.e7.
4. Centrul Naional de Studii pentru Medicina Familiei. ngrijiri prenatale de rutin n
sarcina cu risc sczut. Ghid de practic pentru medicii de familie, Ed. Infomedica, Iai,
2005, 48-59.
5. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a
proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994;
84:1414-1420.
6. Brawarsky P, Stotland NE, Jackson RA, et al. Pre-pregnancy and pregnancy-related
factors and the risk of excessive or inadequate gestational weight gain. Int J Gynaecol
Obstet 2005;91(2):125-131.
7. World Health Organisation (WHO). WHO Antenatal Care Randomised Trial: Manual for
the Implementation of the New model. Geneva, 2002, 12-29.
8. Waldenstrom U, Turnbull D. A systematic review comparing continuity of midwifery
care with standard maternity services. Br J Obstet Gynaecol 1998;105(11):1160-1170.
9. Khan-Neelofur D, Gulmezoglu M, Villar J. Who should provide routine antenatal care
for low-risk women, and how often? A systematic review of randomised controlled trials.
Paediatr Perinatal Epidemiol 1998;12(Suppl 2):7-26.
10. Institutul pentru Ocrotirea Mamei i Copilului Prof. Dr. Alfred Rusescu, UNICEF
Reprezentana n Romnia. Statusul nutriional al femeii gravide: Romnia 2005, vol.
I, Bucureti: MarLink, 2006, 31-70.

11. World Health Organisation (WHO) Expert Committee on Physical Status. The use and
interpretation of anthropometry physical status: the use and interpretation of
anthropometry: report of a WHO expert committee. WHO Techn Rep Ser 854, Geneva,
1995, 37-120.
12. Vilar J. Perinatal data reliability in a large teaching obstetric unit British. J Obstet
Gynaecol 1988;95:841-848.
13. Abrams B, Altman S, Picken K. Pregnancy weight gain: still controversial. Am J Clin
Nutr 2000;71(suppl):1233S-1241S.
14. Stotland NE, Haas JS, Brawarsky P, et al. Body mass index, provider advice, and target
gestational weight gain. Obstet Gynaecol 2005;105(3):633-638.
15. Cogswell ME, Parvanta I, Ickes L, et al. Iron supplementation during pregnancy, anemia,
and birth weight: a randomized controlled trial. Am J Clin Nutr 2003;78:773-781.
16. Fazio ES, Nomura RMY, GonalvesDias MC, et al. Consumo diettico de gestantes e
ganho ponderal materno aps aconselhamento nutricional. Rev Bras Ginecol Obstet
2011;33(2):87-92.