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DOI: 10.1111/1471-0528.12193
www.bjog.org
School of Nursing and Midwifery, Queens University, Belfast, UK b Centre for Public Health, School of Medicine, Dentistry and Biomedical
Sciences, Queens University, Belfast, UK c Royal Jubilee Maternity Service, Belfast Health and Social Care Trust, Belfast, UK
Correspondence: Dr V Holmes, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University, Belfast,
ICS Block B, Grosvenor Road, Belfast, BT12 6BA, UK. Email v.holmes@qub.ac.uk
Accepted 28 January 2013. Published Online 27 March 2013.
period, 20042011.
Methods Women were categorised according to World Health
Introduction
Obesity has become an epidemic throughout the world.
Worldwide, obesity rates have doubled in the last 30 years,1
with rates also increasing among pregnant women.2,3
Maternal obesity has significant health implications, contributing to increased morbidity and mortality for both
mother and baby. A higher proportion of women who die
in pregnancy/postpartum are obese.4,5
Antenatally, obesity increases the risk of miscarriage, gestational diabetes mellitus (GDM), gestational hypertension,
932
thromboembolism, and pre-eclampsia.6 Obesity is associated with poor labour outcomes, with obese women less
likely to go into labour spontaneously, more likely to have
prolonged pregnancies and have their labour induced, and
less likely to achieve a normal delivery, being at increased
risk of caesarean section.2,713 Postnatally, obese women are
less likely to breastfeed successfully, have a longer postnatal
stay in hospital, and are at risk of postnatal infections.710,14
Obesity is also associated with a higher risk of adverse neonatal outcomes, including stillbirth, congenital anomalies,
neonatal intensive care admission, and neonatal death.2,79
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
Methods
This retrospective study used data from births between January 2004 and December 2011 within a tertiary referral
unit, with over 5000 births per year in Northern Ireland.
This study was designed as a clinical audit and therefore
did not require approval from a Research Ethics Committee. Local audit committee approval was obtained to use
the data routinely collected using the Northern Ireland
Maternity System (NIMATS), a computerised clinical database for recording information on an individual pregnant
womens medical history and pregnancy outcomes, including the antenatal, intranatal, and immediate postnatal
(until discharge from hospital) periods.
Anonymised data on 43 267 babies were collated with
data retrieved relating to each baby delivered within the 8year study period. Exclusion criteria were: births at less
than 24 weeks of gestation (n = 99); multiple pregnancies
(n = 1724); BMI recorded after 16 weeks of gestation
(n = 8986); and no BMI recorded (2160). The final cohort
consisted of 30 298 cases (Figure 1).
Data from NIMATS were transferred into SPSS 17. The
BMIs (kg/m) were calculated from the heights and
weights measured during the antenatal booking visits.
Women were categorised using the WHO classification:
underweight
(BMI < 18.50 kg/m);
normal
weight
(BMI 18.5024.99 kg/m; reference group); overweight
(BMI 25.0029.99 kg/m); obese class I (BMI 3034.99 kg/
m); obese class II (BMI 3539.99 kg/m); and obese class
III (BMI 40 kg/m).26 Social deprivation scores were
calculated using the Northern Ireland Multiple Deprivation Measure,27 with women in the bottom third decile
considered to be socially deprived. Data are expressed as
Exclusions
Live births under 24 weeks' gestation
n = 99
Multiple births
n = 1724
No recorded BMI
n = 2160
FINAL COHORT
n = 30298
Figure 1. Cohort selection.
Results
An early pregnancy BMI (at 16 weeks of gestation) was
available for 93.3% of women who met other inclusion criteria. Within this cohort, women were categorised as
underweight (2.8%), normal weight (52.5%), overweight
(27.8%), obese class I (11.0%), obese class II (3.9%), and
obese class III (1.9%). Demographic and clinical characteristics are outlined in Table 1. Compared with women of
normal weight, a higher proportion of underweight women
were younger, nulliparous, unmarried, smokers, and
socially deprived. By contrast, as BMI increased, so did
maternal age and parity.
Antenatal outcomes are outlined in Table 2. The risk for
GDM increased across the overweight and obese categories,
to an OR of 8.5 (99% CI 5.712.9) for women classified as
obese class III. Likewise, the risk of hypertensive disorders
of pregnancy also increased in relation to an increase in
BMI classification, to an OR of 6.6 (99% CI 4.98.9) for
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
933
Scott-Pillai et al.
26.2
477
395
327
511
274
36
0
1
(6.2)
(55.3)
(45.8)
(37.9)
(59.3)
(31.8)
(4.2)
(0)
(0.1)
Normal
BMI 18.5024.99
n = 15 908
29.7
6096
10 665
8917
7600
3122
709
84
73
Overweight
BMI 25.0029.99
n = 8415
(6.0)
(38.3)
(67.0)
(56.1)
(47.8)
(19.6)
(4.5)
(0.5)
(0.5)
30.6
3259
5853
4903
3398
1625
372
112
78
(5.7)
(38.7)
(69.6)
(58.3)
(40.4)
(19.3)
(4.4)
(1.3)
(0.9)
Obese class I
BMI 30.0034.99
n = 3333
30.4
1501
2267
1864
1281
699
135
54
65
(5.7)
(45.0)
(68.0)
(55.9)
(38.4)
(21.0)
(4.1)
(1.6)
(2.0)
Obese class II
BMI 35.0039.99
n = 1194
30.5
563
808
642
418
267
41
35
39
(5.5)
(47.2)
(67.7)
(53.8)
(35.0)
(22.4)
(3.4)
(2.9)
(3.3)
(5.5)
(44.7)
(61.6)
(51.9)
(36.7)
(20.5)
(3.1)
(4.4)
(5.1)
934
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
5079
209
304
9794
1510
13 540
171
1854
0.109
0.552
0.141
0.024
0.553
73
71
(0.71.1)
(0.91.3)
(0.91.5)
(0.71.0)
(0.71.3)
3981
161
401
0.9
1.0
1.2
0.8
0.9
1809
8709
16 512
4027
9694
4615
668
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
Normal BMI
18.5024.99
n = 15 908
(1.11.3)
(0.80.9)
(0.70.9)
(1.31.5)
(1.21.4)
<0.001
<0.001
<0.001
<0.001
<0.001
1.2
0.8
0.8
1.4
1.3
Overweight
BMI 25.0029.99
n = 8415
(1.21.5)
(0.60.8)
(0.60.8)
(1.62.0)
(1.41.9)
<0.001
<0.001
<0.001
<0.001
<0.001
1.3
0.7
0.7
1.8
1.6
Obese class I
BMI 30.0034.99
n = 3333
(1.21.7)
(0.50.6)
(0.30.6)
(2.12.9)
(2.02.9)
<0.001
<0.001
<0.001
<0.001
<0.001
1.4
0.6
0.5
2.5
2.4
Obese class II
BMI 35.0039.99
n = 1194
(1.32.0)
(0.40.6)
(0.30.7)
(2.43.5)
(2.03.3)
<0.001
<0.001
<0.001
<0.001
<0.001
1.6
0.5
0.5
2.8
2.6
<0.001/<0.001
<0.001/<0.001
<0.001/<0.001
<0.001/<0.001
0.003/0.001
0.001/0.031
0.671/0.755
<0.001/<0.001
<0.001/<0.001
<0.001/<0.001
<0.001/<0.001
<0.001/<0.001
<0.001/<0.001
0.855/0.793
0.347/0.788
<0.001/<0.001
0.227/0.993
0.002/0.096
<0.001/<0.001
<0.001/<0.001
P (unadjusted/
adjusted)
All variables are adjusted for age, parity, social deprivation, smoking, and year of birth. Values presented as OR (99% CI), with P < 0.01 considered to be significant (shown in bold). See
Table S1 for data presented with 95% CIs.
*Analysis of vaginal births only (n = 20 604).
**Wound problems following caesarean section (n = 9694).
Gestational diabetes
mellitus
Hypertensive disorders
of pregnancy
Anaemia
Placenta praevia
Other antepartum
haemorrhage
Placental abruption
Pulmonary embolism/
deep vein thrombosis
Induction of labour
Normal delivery
Instrumental delivery
Caesarean section
Elective caesarean
section
Emergency caesarean
section
Shoulder dystocia*
Third- or fourth-degree
perineal tear*
Postpartum haemorrhage
Postpartum haemorrhage,
excluding caesarean
section*
Breastfed
Wound problem**
Length of postnatal stay
Underweight
BMI <18.50
n = 862
935
936
(0.82.4) 0.118
(0.71.6) 0.751
(0.71.3) 0.754
(1.13.6) 0.002
(1.02.6) 0.008
(1.01.7) 0.043
0.012/0.002
0.693/0.077
0.004/<0.001
<0.001/<0.001
0.055/0.013
0.069/0.105
0.036/0.127
0.458/0.024
<0.001/<0.001
0.952/0.237
(1.12.5) 0.003
(0.41.7) 0.396
(0.21.0) 0.011
(2.44.1) <0.001
(1.09.3) 0.010
(0.219.2) 0.406
1.6
0.8
0.5
3.2
3.0
2.1
2.0
1.6
1.3
(0.91.7) 0.079
(0.51.6) 0.681
(0.30.9) 0.002
(1.72.6) <0.001
(0.95.7) 0.027
(1.014.2) 0.014
(1.246.5) 0.004
(0.51.6) 0.537
(1.22.2) 0.001
(0.71.1) 0.187
1.3
0.9
0.5
2.1
2.2
3.7
7.5
0.9
1.6
0.9
(1.01.6) 0.004
(0.51.1) 0.047
(0.51.0) 0.007
(1.62.2) <0.001
(0.32.0) 0.528
(0.13.5) 0.400
(0.110.2) 0.904
(0.71.4) 0.985
(1.11.7) 0.001
(0.91.1) 0.902
1.3
0.8
0.7
1.9
0.8
0.5
1.1
1.0
1.3
1.0
(1.01.3) 0.036
(0.71.1) 0.170
(0.61.0) 0.010
(1.31.6) <0.001
(0.92.5) 0.054
(0.32.3) 0.574
(0.47.1) 0.408
(0.91.4) 0.241
(0.913) 0.269
(0.91.1) 0.510
1.1
0.9
0.8
1.5
1.5
0.8
1.6
1.1
1.1
1.0
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
(0.91.8) 0.150
(0.21.0) 0.016
(1.02.4) 0.010
(0.30.7) 0.001
(0.66.0) 0.125
(0.116.6) 0.903
1.2
0.5
1.6
0.5
2.0
1.1
1.4
1.1
1.0
1750
907
1491
4391
126
54
25
623
1675
3867
Gestation <37 weeks (preterm)*
Gestation >41 weeks*
Low birthweight (<2.5 kg)**
Macrosomia (>4.0 kg)**
Stillbirth
Cardiac defect
Neural tube defect
Apgar <7 at 5 minutes
Admission to NNU***
Infant stay >5 days
Underweight
BMI <18.50
n = 862
Normal BMI
18.5024.99
n = 15 908
Overweight
BMI 25.0029.99
n = 8415
OBESE CLASS I
BMI 30.0034.99
n = 3333
OBESE CLASS II
BMI 35.0039.99
n = 1194
P (unadjusted/
adjusted)
Scott-Pillai et al.
Discussion
Main findings
This large retrospective study clearly demonstrates that
being overweight or obese increases the risk of adverse
maternal and neonatal outcomes. In particular, by categorising women into subclassifications of obesity this study
highlights a relationship between increasing BMI (from
overweight to obese class III) and increasing risk of adverse
outcomes, including gestational diabetes mellitus (GDM),
hypertensive disorders of pregnancy, caesarean section,
macrosomia, and neonatal unit admission, with women in
the highest obesity group at risk of additional adverse outcomes, including stillbirth, a longer postnatal stay, and
wound problems following caesarean section. Importantly,
as BMI increases women were less likely to achieve a normal delivery and were less likely to breastfeed.
Current UK guidelines recommend that women with a
BMI > 30 should be offered a glucose tolerance test antenatally, and that those with a BMI > 35 should have additional monitoring for pre-eclampsia.28 In the study
reported here, obese women were at an increased risk of
GDM and hypertensive disorders of pregnancy, and this
risk increased as BMI increased, a finding consistent with
other studies.2,7,9,1113,21,23 However, women who were
overweight were also at increased risk of hypertensive disorders of pregnancy and GDM, and therefore at risk
women who are overweight or obese (class I) may not be
offered appropriate antenatal screening under the current
guidelines. Intranatally, obesity contributes to poorer outcomes. As found in other studies, in the current study
women who were obese were more likely to have their
labour induced, were less likely to have a vaginal delivery,
and were at increased risk of PPH.2,8,9,11,23,29,30 To the best
of the authors knowledge, no studies to date have investigated the role of intranatal management on outcomes for
women who are overweight or obese, and thus further
research is now needed to elucidate the optimal intranatal
management for women who are overweight or obese.
Postnatally, in this study, women who were obese were less
likely to breastfeed successfully, which has been reported
elsewhere.14 This has long-term implications for health, in
particular with regard to obesity, as breastfeeding has been
associated with women losing more weight postnatally, and
breastfed babies are less likely to become obese.31,32
In terms of neonatal outcomes, maternal BMI clearly
influenced birthweight in the current study, with women
who were underweight being more likely to deliver a baby
of low birthweight, and women in obese class III being
more likely to have a macrosomic baby. In agreement with
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
Interpretation
This study infers that women who are obese are more likely
to require specialist medical care during their pregnancy, as
a result of the increased risks associated with obesity.
Women who were overweight or obese were less likely to
labour without medical intervention, and were more likely
to need a caesarean section, increasing the level of medical
input, with cost implications for intranatal care. Although
women in the highest BMI category were at the highest risk
for an adverse outcome, these women, as expected, represented the smallest group in this study (1.9%). The largest
at risk groups were women who were overweight or in
obese class I, representing 38.8% of the cohort studied. As
national guidelines currently focus primarily on women
within the highest BMI groups, and given resource allocation pressures within the health service, women who are
overweight or in obese class I may not receive additional
screening or management. Admittedly, these women may
not have the same level of risk as women with the highest
BMI; however, they are still at increased risk of several
adverse outcomes, as highlighted in this study. This provides
a challenge for healthcare professionals, as a substantial proportion of women they care for will be at risk as a result of
being overweight or obese, yet may not be identified as such,
according to local policy and national guidelines.
In summary, being overweight or obese has a significant
adverse impact on maternal and neonatal outcomes, with
risk increasing across BMI categories. These risks have
obvious implications for the management of these women
during their pregnancy, labour, and postnatal period. It is
important when planning care for women who are overweight or obese that resources are allocated appropriately
in order to minimise the risk factors for these women.
While current guidelines consider women who are obese,
women who are overweight are also at an increased risk,
and should therefore also be monitored closely during
pregnancy and delivery to ensure optimum outcomes for
women and their babies.
Disclosure of interests
None of the authors have any potential conflicts of interest
to declare.
Contribution to authorship
DS and VAH conceived and designed the study, with input
from RS, AH, and CC. DS and VAH obtained audit committee approval and acquired the data. RS undertook the
analysis and interpretation of the data, with input from
CC, DS, and VAH. RS wrote the first draft of the article.
AH provided obstetrical expertise. All authors participated
in the editing of this article and approved the final version
for publication.
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
937
Scott-Pillai et al.
Ethics approval
This study was designed as an audit, and thus did not
require ethics committee approval. Local audit committee
approval was granted. The data provided to the researchers
in this study were anonymised. No identifiable data were
available to the researchers. The study was performed in an
ethical manner.
Funding
This study received no external funding.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Maternal outcomes by BMI category (kg/m2).
Table S2. Neonatal outcomes by BMI category (kg/m2). &
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