Risk factors for inadequate and excessive gestational weight gain in 25 low- and middle-income countries: An individual-level participant meta-analysis

Abstract

Background

Many women experience suboptimal gestational weight gain (GWG) in low- and middle-income countries (LMICs), but our understanding of risk factors associated with GWG in these settings is limited. We investigated the relationships between demographic, anthropometric, lifestyle, and clinical factors and GWG in prospectively collected data from LMICs.

Methods and findings

We conducted an individual participant-level meta-analysis of risk factors for GWG outcomes among 138,286 pregnant women with singleton pregnancies in 55 studies (27 randomized controlled trials and 28 prospective cohorts from 25 LMICs). Data sources were identified through PubMed, Embase, and Web of Science searches for articles published from January 2000 to March 2019. Titles and abstracts of articles identified in all databases were independently screened by 2 team members according to the following eligibility criteria: following inclusion criteria: (1) GWG data collection took place in an LMIC; (2) the study was a prospective cohort or randomized trial; (3) study participants were pregnant; and (4) the study was not conducted exclusively among human immunodeficiency virus (HIV)-infected women or women with other health conditions that could limit the generalizability of the results. The Institute of Medicine (IOM) body mass index (BMI)-specific guidelines were used to determine the adequacy of GWG, which we calculated as the ratio of the total observed weight gain over the mean recommended weight gain. Study outcomes included severely inadequate GWG (percent adequacy of GWG <70), inadequate GWG (percent adequacy of GWG <90, inclusive of severely inadequate), and excessive GWG (percent adequacy of GWG >125). Multivariable estimates from each study were pooled using fixed-effects meta-analysis. Study-specific regression models for each risk factor included all other demographic risk factors measured in a particular study as potential confounders, as well as BMI, maternal height, pre-pregnancy smoking, and chronic hypertension. Risk factors occurring during pregnancy were further adjusted for receipt of study intervention (if any) and 3-month calendar period. The INTERGROWTH-21st standard was used to define high and low GWG among normal weight women in a sensitivity analysis. The prevalence of inadequate GWG was 54%, while the prevalence of excessive weight gain was 22%. In multivariable models, factors that were associated with a higher risk of inadequate GWG included short maternal stature (<145 cm), tobacco smoking, and HIV infection. A mid-upper arm circumference (MUAC) of ≥28.1 cm was associated with the largest increase in risk for excessive GWG (risk ratio (RR) 3.02, 95% confidence interval (CI) [2.86, 3.19]). The estimated pooled difference in absolute risk between those with MUAC of ≥28.1 cm compared to those with a MUAC of 24 to 28.09 cm was 5.8% (95% CI 3.1% to 8.4%). Higher levels of education and age <20 years were also associated with an increased risk of excessive GWG. Results using the INTERGROWTH-21st standard among normal weight women were similar but attenuated compared to the results using the IOM guidelines among normal weight women. Limitations of the study’s methodology include differences in the availability of risk factors and potential confounders measured in each individual dataset; not all risk factors or potential confounders of interest were available across datasets and data on potential confounders collected across studies.

Conclusions

Inadequate GWG is a significant public health concern in LMICs. We identified diverse nutritional, behavioral, and clinical risk factors for inadequate GWG, highlighting the need for integrated approaches to optimizing GWG in LMICs. The prevalence of excessive GWG suggests that attention to the emerging burden of excessive GWG in LMICs is also warranted.

Abstract

Using individual participant data from more than 140,000 pregnant women across 25 low- and middle-income countries, Anne Marie Darling and colleagues explore the risk factors associated with both inadequate and excessive gestational weight gain.

Author summary

Why was this study done?

• Gestational weight gain (GWG) during pregnancy is a useful indicator for detecting potential maternal and infant health concerns.

• GWG below the recommended range, termed “inadequate,” has been found to be associated with higher risk of stillbirth, small for gestational age (SGA), and preterm birth.

• GWG above the recommended range, termed “excessive,” has been found to be associated with higher risk of large for gestational age (LGA), macrosomia, cesarean delivery, postpartum weight retention, and child overweight.

• Identifying modifiable risk factors for inadequate and excessive GWG is necessary for the development of evidence-based policies and programs that promote GWG within recommended ranges, but the evidence base for these risk factors is limited in in low- and middle-income countries (LMICs).

What did the researchers do and find?

• We pooled data on pregnancy weight gain and potential risk factors from 55 prospective cohort and randomized clinical trials contributed by members of the GWG Pooling Project consortium to create a large dataset of 138,286 pregnant women from 25 countries.

• The pooled prevalence of severely inadequate, inadequate (inclusive of severely inadequate), and excess GWG was 34.2%, 53.9%, and 22.0%, respectively.

• Anthropometric factors such as body mass index (BMI), mid-upper arm circumference (MUAC), and height were strongly associated with inadequate, severely inadequate, and excessive weight gain.

• Smoking and HIV infection were associated with a higher risk of inadequate and severely inadequate weight gain, while higher levels of education were associated with a lower risk. Higher levels of education were also associated with a higher risk of excessive weight gain.

What do these findings mean?

• Inadequate GWG is a major public health concern in LMICs, and several demographic, nutritional, substance use, and clinical factors may perpetuate its occurrence.

• Comprehensive interventions to improve maternal health and nutrition status and promote healthy behaviors are needed.

• The extent of excessive GWG and its determinants is also a public health concern and warrants additional research.