Impact of maternal body mass index and gestational weight ... - PLOS

RESEARCH ARTICLE

Impact of maternal body mass index and gestational weight gain on neonatal outcomes among healthy Middle-Eastern females Tatiana Papazian1,2, Georges Abi Tayeh3, Darine Sibai2, Hala Hout2, Imad Melki4, Lydia Rabbaa Khabbaz1* 1 Laboratoire de Pharmacologie, Pharmacie Clinique et Controˆle de Qualite´ des Me´dicaments, Faculty of Pharmacy, Saint-Joseph University of Beirut, Beirut, Lebanon, 2 Department of Nutrition, Faculty of Pharmacy, Saint-Joseph University of Beirut, Beirut, Lebanon, 3 Department of Gynecology and Obstetrics, Hotel Dieu de France Hospital, Ashrafieh, Beirut, Lebanon, 4 Department of Pediatrics, Hotel Dieu de France Hospital, Ashrafieh, Beirut, Lebanon

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* [email protected]

Abstract Background

OPEN ACCESS Citation: Papazian T, Abi Tayeh G, Sibai D, Hout H, Melki I, Rabbaa Khabbaz L (2017) Impact of maternal body mass index and gestational weight gain on neonatal outcomes among healthy MiddleEastern females. PLoS ONE 12(7): e0181255. https://doi.org/10.1371/journal.pone.0181255 Editor: Marly Augusto Cardoso, Universidade de Sao Paulo, BRAZIL Received: October 14, 2016 Accepted: June 28, 2017 Published: July 17, 2017 Copyright: © 2017 Papazian et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and in supporting information files. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist.

Studies on the relative impact of body mass index in women in childbearing age and gestational weight gain on neonatal outcomes are scarce in the Middle East.

Objectives The primary objective of this research was to assess the impact of maternal body mass index (BMI) and gestational weight gain (GWG) on neonatal outcomes. The effect of maternal age and folic acid supplementation before and during pregnancy was also examined.

Subjects and methods This is a retrospective cross sectional observational study of 1000 full term deliveries of women enrolled thru the National Collaborative Perinatal Neonatal Network, in Lebanon. Maternal characteristics such as age, BMI and GWG and neonatal outcomes such as weight, height, head circumference and Apgar score were the primary studied variables in this study. Total maternal weight gain were compared to the guidelines depicted by the Institute of Medicine (IOM).

Results The negative outcomes of newborns such as lean body weight and macrosomia were significantly present in women who gained respectively below or above the IOM’s cut-off points. Pregestational body mass index influenced significantly the infants’ birth weight, in both the underweight and obese categories. Birth height, head circumference and Apgar score were not influenced by pregestational body mass index or gestational weight gain. No significant associations were found between maternal age and pregestational body mass index and gestational weight gain.

PLOS ONE | https://doi.org/10.1371/journal.pone.0181255 July 17, 2017

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Maternal body mass index, gestational weight gain and neonatal outcomes among healthy Middle-Eastern females

Conclusion Studies evaluating the impact of weight before and during pregnancy on neonatal outcomes and anthropometrics measurements are lacking in the Middle East. Our results highlight the importance of nutritional counseling in order to shed the extra weights before conceiving and monitor weight gain to avoid the negative impact on feto-maternal health.

Introduction Health features have changed across women in child bearing age and are affecting both maternal and neonatal outcomes. Women are entering maternity with a higher body mass index (BMI) and age, hence at a higher initial body weight. On the other hand, obesity, a growing global health problem, is affecting a high percentage of young women, with a negative impact on their own current health and future maternal and neonatal well-being. The 2011 Pregnancy Nutrition Surveillance on maternal health indicators showed respectively a prevalence of 4.5% and 53.7% of women having a prepregnancy BMI in the underweight and overweight category respectively [1]. The Eastern Mediterranean region is not an exception to this epidemic, since statistics highlight an alarming rise of obesity in the Arab world. Data from the Gulf region show gender differences in the prevalence of overweight and obesity, with women having higher rates than men, particularly starting in their mid-20s [2]. Lebanon, a middle income country in the Middle East, is experiencing as well the increased burden of obesity. Two national cross-sectional surveys conducted in Lebanon in 1997 and 2009 depicted an increase of 1.36 kg/m2 in the BMI of women aged between 20 and 39 years old [3]. This upward shift of the BMI in this subgroup of Lebanese women in childbearing age surpasses the reported estimate of 0.5 kg/m2 in the BMI per decade in woman worldwide [4]. Hence, the repercussion of this rising increase of weight on maternal and neonatal outcomes is essential to be studied. Weight gain indicators during pregnancy are the result of prepregnancy body mass index (BMI) and gestational weight gain (GWG). During the last decades, researchers studied the influence of those parameters on the development of maternal and neonatal complications, such as gestational diabetes [5], pregnancy induced hypertension [6], macrosomia [7], caesarean [8] and preterm delivery [9]. The main contributors of this excess adiposity are the intake of high energy foods and the sedentary lifestyles. On the other hand, a small percentage of women of child bearing age are underweight and following unbalanced dietary regimes for weight loss, thus predisposing themselves to undernutrition and delivering small-for-gestational age (SGA) infants with an increased risk of mortality and morbidity [10]. In 2009, the Institute of Medicine (IOM) released new guidelines for optimal weight gain during pregnancy, based on the WHO BMI cut-off points, rather than the Metropolitan life insurance tables as used before [11]. This revised version is intended for women of American origin and not applicable to shorter or thinner populations such as Asians; however, it could be applicable to Middle-Eastern women, since they belong to Caucasian origins. This review was necessary since pregestational BMI and GWG had increased worldwide and women’s characteristics had changed regarding their weight and age. Furthermore, those new standards got adopted and used worldwide by obstetricians and midwifes, since they were more specific and based on pregestational BMI, with a narrow weight gain range for obese women. The principal purpose of this cross-sectional retrospective study was to examine the effect of two anthropometric indicators (pregestational BMI and GWG) on neonatal outcomes in a sample of Lebanese women, since few data on this particular issue are published in the


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Middle-East and the Arab world. Relationships between maternal age and folic acid supplement intake and neonatal outcomes were also assessed.

Materials and methods Study design This was an observational retrospective cross-sectional study on data collected by the National Collaborative Perinatal Neonatal Network (NCPNN). This network, established in 1998, is constituted by volunteer professionals, working in different health care institutions in Lebanon. Their major aim is to collect and create a valid database on maternal and neonatal outcomes thru standardized questionnaires, administered in various member hospitals. NCPNN covers around 35% of national births and includes daily perinatal and neonatal data on all deliveries in participating hospitals. This research paper focused on 1000 singleton full-term live births registered to Lebanese mothers aged between 18–40 years, healthy and not suffering from chronic diseases, who delivered after 37th week of gestation in Hoˆtel-Dieu Hospital (HDF), during the period of 2012–2013. This hospital was selected because it is the university Hospital of Saint-Joseph University and the members of the research team are active working members of this institution. We selected term deliveries to avoid any effect of preterm deliveries on neonatal outcomes. All participants gave their formal written approval before participation. The NCPNN database project was reviewed and approved by the research ethics committee of the American University of Beirut and by the NCPNN representative of HDF.

Study instrument A standardized questionnaire designed by NCPNN (S1 and S2 Tables) was administered and completed by research assistants and midwives. It included items that cover parental sociodemographic characteristics, maternal and neonatal outcomes and complications. Face to face interviews were conducted by NCPNN trained research assistants with the participants after delivery and before discharge. All details concerning neonatal outcomes and delivery complications, and maternal anthropometric measurements were recorded directly from the medical records, in order not to end up with irrelevant data. The research team selected from the NCPNN database only the variables of interest with regards to the study purpose. The predictor variables concerning the mothers were age, weight before conception, weight at delivery, height, gestational age at delivery, smoking status, and folic acid supplement intake, weight, height, head circumference, Apgar test at 1 and 5 min, and admission or not to the neonatal intensive care unit were assessed by the medical team upon delivery and recorded by midwives and NCPNN research assistants and constituted the neonatal outcomes variables of this study. Newborns were categorized as low birth weight (LBW) when their weight at birth was less than 2500g, normal when between 2500–4000 g (NBW) and macrosomic when their birth weight was greater or equal to 4000g. Data collection was realized by midwives and NCPNN representatives. The research team derived two more variables by simple calculations: BMI as defined by weight before conception in kilograms divided by the square of height in meters and GWG as the subtraction between the actual weight at delivery and the initial weight just before becoming pregnant. The BMI classification were categorized according to the WHO cut-off points (underweight 30 kg/m2) [12]. To categorize GWG as below, within or above the recommendations, values were compared to 2009 IOM guidelines, for each prepregnancy BMI category, presented in Table 1 [11]. Women with a GWG within the IOM recommended range were categorized as having a


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Table 1. Gestational weight gain (GWG) recommendations. Prepregnancy BMI (kg/m2)

Recommended GWG (kg)

Recommended GWG (lb)

Underweight: BMI < 18.5

12.5–18

28–40

Normal weight: 18.5< BMI