Objective: To examine the association of maternal obesity, race/ethnicity, and prenatal care on high gestational weight gain (GWG) and small for gestational age (SGA) infant birth.
Methods: This was a retrospective cohort study of births included in the PRAMS Phase 8 dataset (2016-2017). The study population was 53,893 non-diabetic women with a singleton in-hospital birth between 37 and 42 weeks gestational age.
Results: Only obese non-Hispanic white and Hispanic women showed a consistent decrease in adjusted odds of high GWG as prenatal care visit category increased. Only non-Hispanic white women showed a lower increase in adjusted odds of an SGA infant birth with more compared to intermediate prenatal care.
Conclusions: The effectiveness of prenatal care in reducing high GWG varies by race for women with a BMI outside a healthy range. More prenatal care did not reduce SGA infant births amongst overweight or obese women.
Policy implications: Interventions to improve prenatal care delivery for overweight or obese women should consider race

Bradford-Keel, Jeralyn T

Carter, Ariel

Dickinson, Emily

Dobbs, Tori

Hart, Victoria

Mercier, Charles E

English

ScholarWorks @ UVM

University of Vermont ScholarWorks @ UVM Master of Public Health Culminating Projects Larner College of Medicine 2020 The Association of Maternal Obesity and Race with Pregnancy Weight Gain and Small for Gestational Age Infant Birth: The Effect of Prenatal Care Charles E. Mercier University of Vermont Ariel Carter University of Vermont Tori Dobbs University of Vermont Jeralyn T. Bradford-Keel University of Vermont Emily Dickinson University of Vermont See next page for additional authors Follow this and additional works at: https://scholarworks.uvm.edu/mphcp  Part of the Public Health Commons Recommended Citation Mercier, Charles E.; Carter, Ariel; Dobbs, Tori; Bradford-Keel, Jeralyn T.; Dickinson, Emily; and Hart, Victoria, "The Association of Maternal Obesity and Race with Pregnancy Weight Gain and Small for Gestational Age Infant Birth: The Effect of Prenatal Care" (2020). Master of Public Health Culminating Projects. 9. https://scholarworks.uvm.edu/mphcp/9 This Project is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion in Master of Public Health Culminating Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contact donna.omalley@uvm.edu. Author Charles E. Mercier, Ariel Carter, Tori Dobbs, Jeralyn T. Bradford-Keel, Emily Dickinson, and Victoria Hart This project is available at ScholarWorks @ UVM: https://scholarworks.uvm.edu/mphcp/9 Abstract  Objective: To examine the association of maternal obesity, race/ethnicity, and prenatal care on high gestational weight gain (GWG) and small for gestational age (SGA) infant birth.  Methods: This was a retrospective cohort study of births included in the PRAMS Phase 8 dataset (2016-2017). The study population was 53,893 non-diabetic women with a singleton in-hospital birth between 37 and 42 weeks gestational age.  Results: Only obese non-Hispanic white and Hispanic women showed a consistent decrease in adjusted odds of high GWG as prenatal care visit category increased. Only non-Hispanic white women showed a lower increase in adjusted odds of an SGA infant birth with more compared to intermediate prenatal care.   Conclusions:  The effectiveness of prenatal care in reducing high GWG varies by race for women with a BMI outside a healthy range. More prenatal care did not reduce SGA infant births amongst overweight or obese women.  Policy implications: Interventions to improve prenatal care delivery for overweight or obese women should consider race.                        Abbreviations and Acronyms BMI – Body Mass Index CDC- Centers for Disease Control and Prevention  GWG – Gestational Weight Gain PRAMs - Pregnancy Risk Assessment Monitoring System SGA – Small for Gestational Age    Introduction  Recommendations for appropriate weight gain during pregnancy were established in 2009 by the Institute of Medicine and endorsed by the American College of Obstetricians and Gynecologists.1,2 Nevertheless, a large number of women gain more than recommended weight.  This is particularly true for women with high pre-pregnancy body mass index (BMI).3 High gestational weight gain (GWG) places the mother at risk for preeclampsia, gestational diabetes, and cesarean section.4 For the infant, adverse outcomes include abnormal birth weight for gestational age, and longer infant hospital stay.5,6  Prenatal care provides pregnant women with education designed to reduce adverse pregnancy outcomes. High GWG is a potentially modifiable pregnancy risk factor. Current prenatal care practice recommends diet and exercise during pregnancy and trained lifestyle coaching to limit GWG.7   The prevalence of overweight and obesity is higher in Hispanic and non-Hispanic black women than in non-Hispanic white women.8 Participation in prenatal care also varies by race: black women are more likely to be inadequate users of prenatal care services.9 How race and maternal weight associate to predict risk for high GWG has not been fully determined.  The Pregnancy Risk Assessment Monitoring System (PRAMS) is a Centers for Disease Control and Prevention (CDC) surveillance project evaluating pregnancy and birth outcomes. We used the PRAMS Phase 8 dataset (2016-2017), to examine the association of maternal obesity, race/ethnicity, and prenatal care on GWG and small for gestational age (SGA) infant birth. We hypothesized that prenatal care would decrease excessive GWG and SGA infant births for all overweight and obese women and would be most significant for non-Hispanic white women.   Methods Data Source: We performed a retrospective cohort study using the CDC PRAMS Phase 8 dataset (2016-2017).  The population was non-diabetic women with a singleton in-hospital birth between 37 and 42 weeks gestational age. The University of Vermont Institutional Review Board has reviewed this project and determined that it qualifies as exempt from additional review.  Dependent variables: Gestational weight gain (GWG) was defined as low, as recommended, or high based on Institute of Medicine guidelines.1 Small for gestational age (SGA) was defined as birth weight below the 10th percentile for gestational age by sex. Independent variables: Body Mass Index (BMI) was calculated using maternal pre-pregnancy height and weight and categorized as underweight (< 18.5), healthy weight (18.5-24.9), overweight (25-29.9) and obese ( > 30). Race was categorized as non-Hispanic white, non-Hispanic black, Hispanic and other.  Covariates: Several variables were analyzed with more than two categories. These variables included prenatal care (low: 8 or fewer visits, intermediate: 9-11 visits, high: 12 or more visits), maternal age (<20, 20-24, 25-29, 30-34, 35-39, >40 years), pregnancy intention (then/sooner, later/unsure, did not want), region (Northeast, South, Midwest, West, Puerto Rico), maternal insurance status during pregnancy (no insurance, Medicaid/government coverage, private insurance), and income (< $15,000, $15,000 – 29,999, $30,000 – 44,999, $45,000 – 59,999, $60,000 – 74,999, $75,000 – 89,999, >$90,000). The remaining analyzed variables were dichotomous:  Women, Infants, and Children (WIC) (yes/no), marital status (married/other), and any maternal smoking (yes/no).  Data Analysis: We performed multivariable logistic regression analysis using SPSS. Adjusted odds ratios and 95% confidence intervals were calculated for the dependent variables and stratified by prenatal care category.  Results  PRAMS Phase 8 questionnaires were completed by 74,543 women. Of these, 5,343 were diabetic, 1,115 gave birth out of the hospital, 4,099 had a multiple birth, and 10,093 gave birth to a preterm or post-term infant. Thus, there were 53,893 questionnaires for analysis (supplemental file; Figure 1). Multivariable logistic regression analysis evaluated questionnaires with complete data for regressed variables.  The study population was 46.9% non-Hispanic white, 18.1% non-Hispanic black, 17.8% Hispanic, and 15.5% other race from the Northeast (35.1%), Midwest (24.2%), West (21.5%), South (18.0%), and Puerto Rico (1.2%). The majority were 20-29 years of age (50.3%); married (59.1%); non-smokers (91.7%); and did not receive WIC (58.7%). Of the population, 48.9% had private insurance; 48.7% had Medicaid/government coverage (supplemental file; Table 2).  Adjusted odds ratios (AOR) and 95% confidence intervals (CI) of high GWG and SGA infant birth are presented by race and BMI, and stratified by prenatal care category, in Table 1. Overweight women of all races in all prenatal care categories had high GWG. Compared with intermediate prenatal care, more prenatal care reduced adjusted odds of high GWG for obese non-Hispanic white women [AOR=2.34, 95% CI (2.13-2.58); AOR= 2.70, 95% CI (2.37-3.09)] and Hispanic women [AOR=2.57, 95% CI (2.13-3.10); AOR = 2.99 95% CI (2.38-3.76)]. For all races of overweight and obese women with low prenatal care, adjusted odds of an SGA birth were not significant. With intermediate and high prenatal care, adjusted odds of SGA birth were increased for obese non-Hispanic white women [AOR=1.36, 95% CI (1.08-1.72); AOR=-1.38, 95% CI (1.14-1.67)]. For overweight non-Hispanic white women, SGA infant births were increased but trended lower from intermediate to high prenatal care [AOR=1.52, 95% CI (1.22-1.90);  AOR=1.21, 95% CI (1.10-1.44)].   Underweight women in all race and prenatal care categories had lower adjusted odds of high GWG. Compared with intermediate prenatal care, more prenatal care reduced adjusted odds of SGA infant birth for underweight non-Hispanic whites [AOR=0.45, 95% CI (0.33-0.62); AOR=0.35, 95% CI (0.27-0.46)] and Hispanics [AOR=0.68, 95% CI (0.19-0.69); AOR=0.31, 95% CI (0.18-0.53)].  Discussion Our large, population-based study of US women provides generalizable findings on the race specific effectiveness of prenatal care for GWG and SGA birth for women with a BMI outside a healthy range. This study also adds to the literature describing how adverse pregnancy outcomes vary when race and obesity are combined.6 When compared to women with healthy BMI, overweight and obese women of all race categories and all prenatal care categories had higher odds of high GWG. However, only obese non-Hispanic white and Hispanic women showed a decrease in high GWG with an increase in prenatal care visits. This suggests the impact of prenatal care varied by race for obese women and had no effect on GWG for overweight women regardless of race.  For obese women of all races, more prenatal care was not associated with trending lower adjusted odds of an SGA birth. For overweight women, more prenatal care was associated with a lower increase in adjusted odds of an SGA birth only for non-Hispanic white women, again showing varying association by race.  For underweight women of all races, all prenatal care categories were associated with lower adjusted odds of high GWG. Among underweight women who had 12 or more prenatal visits, all races except “other” were less likely to have an SGA infant birth. Whether GWG was low or appropriate for underweight women needs further evaluation.  Our study is limited by systemic biases in the PRAMS survey, missing data and issues with data categorization. We attempted to mitigate missing data issues by selecting only mothers for whom complete data for dependent and independent variables were available. Still, data on confounding variables could be missing from this selected population. The potential for recall bias during completion of the survey is likely. Finally, post survey categorization of variables may have had an impact on results. For example, mixed race is poorly accounted.   Public Health Implications  Our study reflects the variable effectiveness of prenatal care by race for women with a BMI outside a range considered healthy.  Interventions to improve prenatal care for overweight or obese women should consider race.10   References 1. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academies Press; 2009. doi: 10.17226/12584. 2. Weight gain during pregnancy. ACOG Committee Opinion Number 548, American College of Obstetricians and Gynecologists. Obstet Gynecol. 2013;121:210-212. doi: 10.1097/01.aog.0000425668.87506.4c. 3. Power ML, Lott ML, Mackeen AD, et al. A retrospective study of gestational weight gain in relation to the Institute of Medicine’s recommendations by maternal body mass in rural Pennsylvania form 2006 to 2015. BMC Pregnancy and Childbirth. 2018.18:239. doi: 10.1186/s12884-018-1883-1. 4. Dude AM, Grobman W, Haas D, et al. Gestational weight gain and pregnancy outcomes among nulliparous women. Am J Perinatol. 2019. doi: 10.1055/s-0039-1696640. 5. Baugh N, Harris DE, Aboueissa AM, et al. The impact of maternal obesity and excessive gestational weight gain on maternal and infant outcomes in Maine: Analysis of Pregnancy Risk Assessment Monitoring System results from 2000 to 2010. J Pregnancy. 2016;5871313. doi: 10.1155/2016/5871313. 6. Snowden JM, Mission JF, Marshall NE, et al. The impact of maternal obesity and race/ethnicity on perinatal outcomes: independent and joint effects. Obesity (Silver Spring) 2016;24: 1590-1598. doi: 10.1002/oby.21532. 7. Walker R, Bennett C, Blumfield M, et al. Attenuating pregnancy weight gain-what works and why: a systematic review and meta-analysis. Nutrients. 2018;10:944. doi: 10.3390/nu1007094. 8. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS Data Brief. 2017; 288,1-8. https://www.cdc.gov/nchs/data/databriefs/db288.pdf. Accessed April 5, 2020. 9. Gadson A, Akpovi E, Mehta PK. Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Semin Perinatol. 2017;41: 308-317. doi: 10.1053/j.semperi.2017.04.008. 10. Handler A, Johnson K. A call to revisit the prenatal period as a focus for action within the reproductive and perinatal care continuum. Matern Child Health J.  2016; 20:2217–2227. doi: 10.1007/s10995-016-2187-6Table 1. Adjusted odds ratios (95% CIs) comparing outcomes by maternal BMI and race stratified by prenatal care.     8 or fewer Prenatal Care Visits 9-11 Prenatal Care Visits 12 or more Prenatal Care Visits OUTCOME MATERNAL BMI Non- Hispanic White Non-Hispanic Black Hispanic Other Non- Hispanic White Non- Hispanic Black Hispanic Other Non- Hispanic White Non- Hispanic Black Hispanic Other High GWG Underweight 0.39 0.32 0.45 0.56 0.45 0.36 0.68 0.32 0.35 0.41 0.31 0.37 (0.24-0.64) (0.14-0.71) (0.20-1.03) (0.27-1.13) (0.33-0.62) (0.19-0.69) (0.37-1.23) (0.19-0.54) (0.27-0.46) (0.25-0.68) (0.18-0.53) (0.24-0.57) Healthy REFERENCE REFERENCE REFERENCE Overweight 3.40 2.38 3.46 3.15 3.51 2.65 3.71 3.36 3.33 2.87 2.40 2.74 (2.79-4.21) (1.80-3.14) (2.56-4.69) (2.38-4.17) (3.09-3.98) (2.13-3.30) (2.96-4.65) (2.68-4.21) (3.03-3.65) (2.40-3.43) (2.01-2.87) (2.27-3.31) Obese 2.95 2.28 3.69 3.09 2.70 2.06 2.99 3.25 2.34 2.10 2.57 2.59 (2.38-3.66) (1.76-3.00) (2.65-5.13) (2.25-4.25) (2.37-3.09) (1.68-2.55) (2.38-3.76) (2.55-4.16) (2.13-2.58) (1.78-2.48) (2.13-3.10) (2.11-3.16) SGA Underweight 0.40 0.61 0.51 0.74 1.01 0.59 1.64 0.36 0.40 0.50 0.75 0.67 (0.26-0.63) (0.30-1.25) (0.24-1.07) (0.33-1.68) (0.67-1.50) (0.31-1.13) (0.48-2.36) (0.21-0.62) (0.36-0.67) (0.26-0.96) (0.38-1.47) (0.36-1.24) Healthy REFERENCE REFERENCE REFERENCE Overweight 1.17 1.30 0.91 1.45 1.52 1.24 1.64 1.01 1.21 1.03 1.13 1.19 (0.85-1.62) (0.86-1.97) (0.57-1.45) (0.87-2.44) (1.22-1.90) (0.87-1.78) (1.11-2.43) (0.66-1.55) (1.10-1.44) (0.73-1.47) (0.80-1.60) (0.78-1.82) Obese 1.09 1.51 1.15 2.98 1.36 1.43 1.17 0.95 1.38 1.10 0..98 1.32 (0.80-1.50) (1.00-2.29) (0.84-1.86) (1.37-6.45) (1.08-1.72) (1.00-2.03) (0.81-1.69) (0.59-1.54) (1.14-1.67) (0.79-1.54) (0.69-1.39) (0.82-2.11) Supplemental File  Figure 1. Derivation of the study sample.       74,543 participantsMultiple Births = 4,099Maternal Diabetes = 5,34369,200 participants68,085 participantsPre- or post term Births = 10,09363, 986 participantsOut of Hospital Births = 1,11553,893 participantsSupplemental File  Table 2. Maternal Demographics and Characteristics Maternal Age (years) Frequency Percent < 20 2,931 / 53,891 5.4% 20-29 27,109 / 53,891 50.3% 30-39 22,338 / 53,891 41.5% > 40 1,513 / 53,891 2.8% Maternal Education   Less than High School 2,269 / 21,769 10.4% High School or more 19,500 / 21,769 89.6% Marital Status   Married 31,844 / 53,857 59.1% Other 22,013 / 53,857 40.9% Maternal Smoking   Yes 4,350 / 52,591 8.3% No 48,241 / 52,591 91.7% Pregnancy Intention   Then/sooner 30,233 / 53,030 57.0% Later/unsure 19,429 / 53,030 36.6% Did not want 3,368 / 53,030 6.4% Prenatal Care   8 or fewer visits 8,723 / 52,223 16.7% 9 – 11 visits 16,490 / 52,223 31.6% 12 or more visits 27,010 / 52,223 51.8% Income    < $15,000 11,377 / 48,895 23.2% $15,000 – 29,999 11,786 / 48,895 24.1% $30,000 – 44,999 5,282 / 48,895 10.8% $45,000 – 59,999 3,794 / 48,895 7.7% $60,000 – 74,999 2,596 / 48,895 5.3% $75,000 – 89,999 13,070 / 48,895 26.7% > $90,000 1,080 / 48,985 2.2% Maternal Insurance   Medicaid/Government 26,037 / 53,503 48.7% Private 26,174 / 53,503 48.9% Self-Pay or Other 1,292 / 53,503 2.4% WIC   Yes 21,938 / 53,137 41.3% No 31,201 / 53,137 58.7% Region   Northeast 18,892 / 53,893 35.1% South 9,731 / 53,893 18.0% Midwest 13,019 / 53,893 24.2% West 11,597 / 53,893 21.5% Puerto Rico 654 / 53,893 1.2%   

The Association of Maternal Obesity and Race with Pregnancy Weight Gain and Small for Gestational Age Infant Birth: The Effect of Prenatal Care

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The Association of Maternal Obesity and Race with Pregnancy Weight Gain and Small for Gestational Age Infant Birth: The Effect of Prenatal Care

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