Examining the provisional guidelines for weight gain in twin pregnancies: a retrospective cohort study.

BACKGROUND: Weight gain during pregnancy has an important impact on maternal and neonatal health. Unlike the Institute of Medicine (IOM) recommendations for weight gain in singleton pregnancies, those for twin gestations are termed "provisional", as they are based on limited data. The objectives of this study were to determine the neonatal and maternal outcomes associated with gaining weight below, within and above the IOM provisional guidelines on gestational weight gain in twin pregnancies, and additionally, to explore ranges of gestational weight gain among women who delivered twins at the recommended gestational age and birth weight, and those who did not. METHODS: A retrospective cohort study of women who gave birth to twins at ≥20 weeks gestation, with a birth weight ≥ 500 g was conducted in Nova Scotia, Canada (2003-2014). Our primary outcome of interest was small for gestational age (<10th percentile). In order to account for gestational age at delivery, weekly rates of 2nd and 3rd trimester weight gain were used to categorize women as gaining below, within, or above guidelines. We performed traditional regression analyses for maternal outcomes, and to account for the correlated nature of the neonatal outcomes in twins, we used generalized estimating equations (GEE). RESULTS: A total of 1482 twins and 741 mothers were included, of whom 27%, 43%, and 30% gained below, within, and above guidelines, respectively. The incidence of small for gestational age in these three groups was 30%, 21%, and 20%, respectively, and relative to gaining within guidelines, the adjusted odds ratios were 1.44 (95% CI 1.01-2.06) for gaining below and 0.92 (95% CI 0.62-1.36) for gaining above. The gestational weight gain in women who delivered twins at 37-42 weeks with average birth weight ≥ 2500 g and those who delivered twins outside of the recommend ranges were comparable to each other and the IOM recommendations. CONCLUSIONS: While gestational weight gain below guidelines for twins was associated with some adverse neonatal outcomes, additional research exploring alternate ranges of gestational weight gain in twin pregnancies is warranted, in order to optimize neonatal and maternal outcomes.

Are women who quit smoking at high risk of excess weight gain throughout pregnancy?

BACKGROUND: Smoking cessation has been reported to be associated with high total gestational weight gain (GWG), which itself is a risk factor for adverse maternal-infant outcomes. Recent studies have criticized conventional single measures of GWG, since they may lead to biased results. Therefore, we aimed to compare patterns of GWG based on serial antenatal weight measurements between women who: never smoked, quit during pregnancy, continued to smoke. METHODS: Participants (N = 509) of our longitudinal study were recruited from seven antenatal clinics in Southwestern Ontario. Serial GWG measurements were abstracted from medical charts, while information on smoking status was obtained from a self-administered questionnaire at a median gestational age of 32 (27-37) weeks. GWG patterns were assessed by fitting piecewise mixed-effects models. First trimester weight gains and weekly rates for the last two trimesters were compared by smoking status. RESULTS: During the first trimester, women who never smoked and those who quit during pregnancy gained on average 1.7 kg (95 % CI: 1.4-2.1) and 1.2 kg (0.3-2.1), respectively, whereas women who continued smoking gained more than twice as much (3.5 kg, 2.4-4.6). Weekly rate of gain in the second and third trimesters was highest in women who quit smoking (0.60 kg/week, 0.54-0.65), approximately 20 and 50 % higher than in women who never smoked and those who smoked during pregnancy, respectively. CONCLUSIONS: In this longitudinal study to examine GWG by smoking status based on serial GWG measurements, we found that women who quit smoking experienced a rapid rate of gain during the last two trimesters, suggesting that this high-risk group may benefit from targeted interventions.

Binge Eating Predicts Excess Gestational Weight Gain: A Pilot Prospective Cohort Study.

OBJECTIVE: One half of women's gestational weight gain (GWG) exceeds the recommended amount. In attempting to prevent this, randomized trials targeting diet and/or exercise have been generally unsuccessful. In response, study of psychological factors has been called for. We aimed to determine the feasibility of a full-scale prospective cohort study examining psychological and other factors affecting GWG and to obtain prospective pilot data. METHODS: We conducted a prospective cohort feasibility study in seven clinics in southwestern Ontario. Women with a singleton pregnancy were recruited between May and September 2013 and subsequently completed a questionnaire. GWG was abstracted from medical records and was categorized as below, within, or above guideline-recommended limits. RESULTS: All clinics and 89.7% of women approached (n = 525) agreed to participate, and 514 were eligible for analysis. For the prospective analysis, we included participants enrolled during their first or second trimester (27%), because only 11% were less than 21 weeks' gestation. Planning GWG predicted excess GWG (adjusted RR [aRR] 9.44; 95% CI 2.64 to 33.80), as did binge eating (aRR 6.51; 95% CI 1.03 to 41.18). Dietary restraint was not significantly associated with excess GWG (aRR 2.74; 95% CI 0.67 to 11.22) or inadequate GWG (aRR 3.86; 95% CI 0.82 to 18.11). CONCLUSION: This prospective pilot study demonstrated the feasibility of a full-scale study and identified a need for additional strategies to permit recruitment before 21 weeks, such as a longer recruitment period and involvement of more clinics. Previously identified knowledge factors, particularly planned weight gain, were predictive of excess GWG. However, psychological factors identified in this study, especially binge eating (which was found to be independently predictive for the first time) and dietary restraint, are areas requiring further study.

Objectif : Dans la moitié des cas, le gain pondéral gestationnel (GPG) dépasse les recommandations. Des essais randomisés ont constaté que les efforts qui ont cherché à prévenir cette situation en ciblant le régime alimentaire et/ou l'exercice se sont, d'ordre général, soldés en échec. En guise de réponse, l'attention s'est tournée vers des facteurs psychologiques. Nous avons donc cherché à déterminer la faisabilité d'une étude de cohorte prospective exhaustive examinant les facteurs psychologiques et autres qui affectent le GPG, ainsi qu'à obtenir des données préliminaires en menant un essai pilote prospectif. Méthodes : Nous avons mené une étude de cohorte prospective de faisabilité auprès de sept cliniques du sud-ouest de l'Ontario. La participation de femmes connaissant une grossesse monofœtale a été sollicitée entre mai et septembre 2013; nous avons par la suite demandé à ces femmes de remplir un questionnaire. Le GPG a été tiré des dossiers médicaux et a été réparti en trois catégories : en deçà, à l'intérieur ou au-delà des limites recommandées par les lignes directrices. Résultats : Toutes les cliniques et 89,7 % des femmes sollicitées (n = 525) ont consenti à participer, et 514 d'entre elles se sont avérées admissibles à l'analyse. Aux fins de l'analyse prospective, nous avons inclus les participantes admises au cours de leur premier ou de leur deuxième trimestre (27 %), car seulement 11 % des participantes en étaient à moins de 21 semaines de gestation. Le fait d'avoir procédé à la planification du GPG constituait un facteur permettant de prédire l'obtention d'un GPG excessif (RR corrigé [RRc], 9,44; IC à 95 %, 2,64 - 33,80), tout comme l'hyperphagie (RRc, 6,51; IC à 95 %, 1,03 - 41,18). Les restrictions alimentaires n'ont pas été associées de façon significative à l'obtention d'un GPG excessif (RRc, 2,74; IC à 95 %, 0,67 - 11,22) ou d'un GPG inadéquat (RRc, 3,86; IC à 95 %, 0,82 - 18,11). Conclusion : Cette étude pilote prospective a démontré la faisabilité d'une étude exhaustive et a identifié un besoin quant à l'obtention de stratégies additionnelles qui permettraient de solliciter la participation de femmes dont la grossesse n'a pas encore atteint 21 semaines de gestation (comme l'utilisation d'une période de sollicitation prolongée et la participation d'un plus grand nombre de cliniques). Des facteurs ayant déjà été identifiés (plus particulièrement, le gain pondéral planifié) ont permis de prédire l'obtention d'un GPG excessif. Toutefois, certains des facteurs psychologiques identifiés dans le cadre de cette étude, particulièrement l'hyperphagie (identifiée comme étant un facteur prédictif indépendant pour la première fois) et les restrictions alimentaires, constituent des domaines qui nécessitent la tenue d'études plus approfondies.

The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review.

BACKGROUND: Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon. METHODS AND FINDINGS: We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology. CONCLUSIONS: This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.

A population-based cohort study of breastfeeding according to gestational age at term delivery.

OBJECTIVE: Because breastfeeding is the optimal form of infant feeding, this study was conducted to determine the effect of gestational age on breastfeeding in term infants. STUDY DESIGN: A retrospective population-based cohort study of singleton/twin hospital births was conducted in Ontario, Canada between April 1, 2009, and March 31, 2010. Multivariate logistic regression was used to determine the adjusted effect of gestational age on breastfeeding. RESULTS: Our study population comprised 92,364 infants, of whom 80,297 (86.9%) were exclusively or partially breastfed at the time of hospital discharge. Multivariate logistic regression analyses demonstrated that early-term infants had lower odds of being breastfed compared with infants born at 41 weeks gestation (40 weeks: aOR, 0.93; 95% CI, 0.86-0.99; 39 weeks: aOR, 0.87; 95% CI, 0.81-0.93; 38 weeks: aOR, 0.81; 95% CI, 0.75-0.88; 37 weeks: aOR, 0.74; 95% CI, 0.67-0.82). CONCLUSION: Using a population-based approach, we found that infants born at 40, 39, 38, and 37 weeks gestation had increasingly lower odds of being breastfed compared with infants born at 41 weeks. Clinicians need to be made aware of the differences in outcomes of infants delivered at early and late term, so that appropriate breastfeeding support can be provided to women at risk for not breastfeeding.

Maternal height and the risk of preterm birth and low birth weight: a systematic review and meta-analyses.

OBJECTIVE: Preterm birth (PTB) and low birth weight (LBW) are the leading causes of neonatal morbidity and mortality, but the effect of maternal height on these outcomes continues to be debated. Our objective was to determine the relationships between maternal height and PTB and LBW. DATA SOURCES: Medline and EMBASE were searched from their inceptions. STUDY SELECTION: Studies with a reference group that assessed the effect of maternal height on PTB (< 37 weeks) and LBW (< 2500 grams) in singletons were included. DATA EXTRACTION: Data were extracted independently by two reviewers. DATA SYNTHESIS: Fifty-six studies were included involving 333 505 women. In the cohort studies, the unadjusted risk of PTB in short-statured women was increased (relative risk [RR] 1.23; 95% CI 1.11 to 1.37), as was the unadjusted risk of LBW (RR 1.81; 95% CI 1.47 to 2.23), although not all of the studies with adjusted data found the same association. Maternal tall stature was not associated with PTB (unadjusted RR 0.97; 95% CI 0.82 to 1.14), although LBW was decreased (unadjusted RR 0.56; 95% CI 0.46 to 0.69), but not in the adjusted data. CONCLUSION: From our complete systematic review and meta-analyses, to our knowledge the first in this area, we conclude that short-statured women have higher unadjusted risks of PTB and LBW and tall women have approximately one half the unadjusted risk of LBW of women of reference height.

Little congruence between health care provider and patient perceptions of counselling on gestational weight gain.

OBJECTIVE: To determine the self-reported counselling practices of health care providers with regard to prenatal weight gain and the risks of inappropriate gain. METHODS: We conducted a cross-sectional survey using a self-administered questionnaire at obstetrician, midwifery, and family medicine clinics in Hamilton, Ontario. Health care providers were eligible to participate if they provided prenatal care and could read English sufficiently well to complete the survey. RESULTS: Forty-two health care providers completed the survey; of these, 95% reported counselling women to gain a specific amount of weight, and 81% reported that they recommended values that were in accordance with the 2009 Institute of Medicine/Health Canada guidelines. The risks of excess and inadequate gain were reported as being discussed with their patients by 87% and 76% of health care providers, respectively. CONCLUSION: In this first study to the best of our knowledge of gestational weight gain counselling since the publication of the 2009 guidelines, most health care providers reported discussing weight gain and the risks of inappropriate gain, which is incongruent with previously published information on their patients' reports of counselling.

A systematic review of maternal and infant outcomes following magnesium sulfate for pre-eclampsia/eclampsia in real-world use.

BACKGROUND: Evidence from RCTs shows that magnesium sulfate reduces the risk of seizures and mortality for women with pre-eclampsia/eclampsia. However, it has been argued that outcomes within trials may not reflect real-world outcomes with the same intervention. OBJECTIVE: To assess whether outcomes for women with pre-eclampsia/eclampsia who received magnesium sulfate in the real world were comparable to those in RCTs. SEARCH STRATEGY: EMBASE and MEDLINE were searched (January 1990-July 2010). SELECTION CRITERIA: Cohort, before-and-after, and serial cross-sectional studies were included. Participants were women with eclampsia who received magnesium sulfate or another anticonvulsant, and women with pre-eclampsia who received magnesium sulfate or no anticonvulsant. Primary outcomes were death (maternal, fetal, neonatal) or recurrent seizures. DATA COLLECTION AND ANALYSIS: Data were extracted independently by 2 reviewers. MAIN RESULTS: Six studies (1831 women with eclampsia) were included, from academic centers in Bangladesh, India, Pakistan, and Nigeria, together with 2 population-based UK studies. Magnesium sulfate for eclampsia was associated with lower risks of maternal death, recurrent seizure, and major morbidity; for pre-eclampsia, it was associated with lower risks of eclampsia. CONCLUSION: Improvements in maternal outcome with magnesium sulfate for pre-eclampsia/eclampsia in real-world use are comparable to those reported in RCTs.

Comparison of midwifery, family medicine, and obstetric patients' understanding of weight gain during pregnancy: a minority of women report correct counselling.

OBJECTIVE: We hypothesized that differences in models of care between health care providers would result in variations in patients' reports of counselling. Our objective was to compare what women reported being advised about weight gain during pregnancy and the risks of inappropriate weight gain according to their type of health care provider. METHODS: A cross-sectional survey was conducted using a self-administered questionnaire at obstetric, midwifery, and family medicine clinics in Hamilton, Ontario. Women were eligible to participate if they had had at least one prenatal visit, could read English, and had a live, singleton pregnancy. RESULTS: Three hundred and eight women completed the survey, a 93% response rate. Care for 90% of the group was divided approximately evenly between midwives, family physicians, and obstetricians. A minority of women looked after by any of the types of care providers reported being counselled correctly about how much weight to gain during pregnancy (16.3%, 10.3%, 9.2%, and 5.7% of patients of midwives, family physicians, obstetricians, or other types of care providers, respectively, P = 0.349). A minority of women with any category of care provider was planning to gain an amount of weight that fell within the guidelines or reported being told that there were risks to themselves or their babies with inappropriate gain. CONCLUSION: In this study comparing reported counselling between patients of obstetricians, midwives, family physicians, and other health care providers, low rates of counselling about gestational weight gain were universally reported. There is a common need for more effective counselling.

High gestational weight gain and the risk of preterm birth and low birth weight: a systematic review and meta-analysis.

OBJECTIVE: Many women have high gestational weight gain (GWG), but potential neonatal consequences are not yet well quantified. We sought to determine the relationship between high GWG and preterm birth (PTB) and low birth weight (LBW) in singleton births. DATA SOURCES: We searched Medline and Embase and reference lists. STUDY SELECTION: Two assessors independently performed all steps. We selected studies assessing high total or weekly GWG on PTB (< 37 weeks) and LBW (< 2500 grams). DATA EXTRACTION AND SYNTHESIS: Thirty-eight studies, 24 cohort and 14 case-control, were included involving 2 124 907 women. Most contained unadjusted data. Women with high total GWG had a decreased risk overall of PTB < 37 weeks (relative risk [RR] 0.75; 95% CI 0.60 to 0.96), PTB 32 to 36 weeks (RR 0.70; 95% CI 0.70 to 0.71), and < 32 weeks (RR 0.87; 95% CI 0.85 to 0.90). High GWG was associated with lower risk of LBW (RR 0.64; 95% CI 0.53 to 0.78). Women with the highest GWG had lower risks of LBW (RR 0.55; 95% CI 0.32 to 0.94) than women with moderately high GWG (RR 0.73; 95% CI 0.60 to 0.89). Women with the highest weekly GWG had greater risks of PTB (RR 1.51; 95% CI 1.47 to 1.55) than women with moderately high weekly GWG (RR 1.09; 95% CI 1.05 to 1.13). Women with high weekly GWG were at increased risk of PTB 32 to 36 weeks (RR 1.14; 95% CI 1.10 to 1.17 and < 32 weeks (RR 1.81; 95% CI 1.73 to 1.90). CONCLUSION: Although women with high total GWG have lower unadjusted risks of PTB and LBW, high weekly GWG is associated with increased PTB, and more adjusted studies are needed, as are more studies in obese women. Potential benefits of high GWG for the infant must be balanced against maternal risks and other known infant risks such as high birth weight.

Despite 2009 guidelines, few women report being counseled correctly about weight gain during pregnancy.

OBJECTIVE: The purpose of this study was to determine the information that pregnant women report receiving when being counseled about weight gain and the risks of inappropriate gain. STUDY DESIGN: With the use of a self-administered questionnaire at prenatal clinics in Hamilton, Ontario, Canada, a cross-sectional survey was conducted of women who had had at least 1 prenatal visit, who could read English, and who had a live singleton gestation. RESULTS: Three hundred ten women completed the survey, which was a 93.6% response rate. Although 28.5% (95% confidence interval, 23.5-33.6%) reported that their health care provider had made a recommendation about how much weight they should gain, only 12.0% (95% confidence interval, 8-16.1%) of the women reported having achieved the recommended weight gain in accordance with the 2009 guidelines. One quarter of the women reported being told that there were risks with inappropriate gain. CONCLUSION: Despite the recent 2009 publication of the gestational weight gain guidelines, only 12% of women reported being counseled correctly, which suggests an urgent need for improved patient education.

Low gestational weight gain and the risk of preterm birth and low birthweight: a systematic review and meta-analyses.

BACKGROUND: Low gestational weight gain is common, with potential adverse perinatal outcomes. OBJECTIVE: To determine the relation between low gestational weight gain and preterm birth and low birthweight in singletons in developing and developed countries. DATA SOURCES: Medline, EMBASE and reference lists were searched, identifying 6,283 titles and abstracts. METHODS OF STUDY SELECTION: Following the MOOSE consensus statement, two assessors independently reviewed titles, abstracts, full articles, extracted data and assessed quality. RESULTS: Fifty-five studies, 37 cohort and 18 case-control, were included, involving 3,467,638 women. In the cohort studies (crude data, generally supported where available by adjusted data and case-control studies), women with low total gestational weight gain had increases in preterm birth <37 weeks [RR 1.64 (95%CI 1.62-1.65)], 32-36 weeks [RR 1.39 (95%CI 1.38-1.40)] and ≤ 32 weeks [RR 3.80 (95%CI 3.72-3.88)]. Low total gestational weight gain was associated with increased risks of low birthweight <2,500 g [RR 1.85 (95%CI 1.72-2.00)], in developing and developed countries [RR 1.84 (95%CI 1.71-1.99) and RR 3.02 (95%CI 1.37-6.63), respectively], 1,500-2,500 g [RR 2.02 (95%CI 1.88-2.17)] and <1,500 g (RR 2.00 (95%CI 1.67-2.40)]. Women with low weekly gestational weight gain were at increased risk of preterm birth [RR 1.56 (95%CI 1.26-1.94)], 32-36 weeks [RR 2.43 (95%CI 2.37-2.50)] and ≤ 32 weeks [RR 2.31 (95%CI 2.20-2.42)] but not low birthweight [RR 1.64 (95%CI 0.89-3.02)]. CONCLUSIONS: In this systematic review, we determined that singletons born to women with low total gestational weight gain have higher risks of preterm birth and low birthweight, with the lower the gain, the higher the risks.