Rev. Med. Chir. Soc. Med. Nat., Iai 2014 vol. 118, no.

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I NTERNAL MEDI CI NE - PEDI ATRI CS ORIGINAL PAPERS
352
DETERMINANTS OF INADEQUATE WEIGHT GAIN IN PREGNANCY
Alina Delia Popa
1
, Otilia Ni
2*
, Raluca Maria Popescu
2
, Andreea Gherasim
2,3
,
Lidia Iuliana Arhire
2
, Laura Mihalache
2
, Mariana Graur
2
University of Medicine and PharmacyGrigore T. Popa-Iai
Faculty of Medicine
1. Discipline of Nursing
2. Discipline of Diabetes, Nutrition and Metabolic Diseases
3. Ph.D. student
*Corresponding author. E-mail: otyca95@yahoo.com
DETERMINANTS OF INADEQUATE WEIGHT GAIN IN PREGNANCY. Aim. The aim
of the study was to explore the anthropometric maternal characteristics and prenatal care as
determinants of pregnancy weight gain. Material and methods. We conducted a cross-
sectional study on a total of 400 pregnant women admitted to Cuza-Vod Obstetrics and Gy-
necology Clinical Hospital, Iai. Information on demographic characteristics, number of pr e-
natal visits, and education on nutrition and food changes occurring during pregnancy were
recorded in a structured questionnaire. Anthropometric parameters analyzed were pregesta-
tional BMI (body mass index) and weight gain during pregnancy. Results. Weight gain was
associated with pregestational BMI category. An increase in weight more than recommended
occured more frequently in overweight (53.1%) and obese women (66.7%) (p<0.001).
Weight gain during pregnancy was related to area of residence, age, APCU (adequate prena-
tal care utilization) index. The multivariate analysis identified the following variables as si g-
nificant determinants of pregnancy weight gain: inadequate prenatal care, BMI and changes
in diet. Conclusions. Pregestational BMI and changes in diet during pregnancy identified as
determinants of weight gain suggests that overweight and underweight women must careful-
ly be counseled regarding recommendations for weight gain in pregnancy. Tracking diet
changes is important to ensure that a weight gain lies within the guidelines recommenda-
tions. Keywords: PREGESTATIONAL BMI, WEIGHT GAIN DURING PREGNANCY,
PRENATAL VISITS, NUTRITIONAL EDUCATION
The main purpose of recommendations
for weight gain during pregnancy is repre-
sented by a normal weight of newborns.
Numerous factors can influence weight
gain in pregnant women, such as: previous
nutritional status, age, parity, race and
dietary habits (1). Overweight is associated
with an increased risk for preeclampsia,
gestational diabetes and caesarean section
(2, 3). The pre- and postnatal nutritional
environment is important in shaping the
future phenotype of the organism, influenc-
ing the risk of insulin resistance, type 2
diabetes and cardiovascular disease in adult
life. The aim of the study was to explore
the determinants of inadequate weight gain
during pregnancy.

MATERIAL AND METHODS
We conducted a cross-sectional study on
Determinants of inadequate weight gain in pregnancy
353
a sample of 400 women, admitted to Cuza-
Vod Obstetrics and Gynecology Clinical
Hospital, Iasi, in August-September 2010.
Exclusion criteria were multiple pregnancy,
patient refusal and obstetric pathology.
A standardized questionnaire provided
information on age, pregestational weight,
area of residence, marital status, years of
formal education, parity and prenatal care
utilization (date of registration, the number
of medical visits to the family doctor and
obstetrician). Weight and height were
measured in duplicate and recorded accord-
ing to the standard protocol. Prepregnancy
nutritional status was classified based on
BMI (body mass index), according to the
World Health Organization (WHO) criteria.
Weight gain during pregnancy was divided
into three categories (less than 9 kg, 9-15
kg and above 15 kg) according to general
practitioner guidelines (4).
Adequacy of prenatal care utilization
was assessed by determining the Adequacy
of Prenatal Care Utilization Index which
takes into consideration the timing of pre-
natal care initiation and the number of
prenatal visits. The index is based on
ACOG (American College of Obstetricians
and Gynecologists) recommendations for
low risk pregnancies and has 4 categories.
Inadequate prenatal care includes women
who were registered after the fourth month
or had less than 50% of the number of rec-
ommended visits in pregnancy. Women
registered after the fourth month with a
total of 50-79% of visits are included in the
intermediate care category. Initiation of
prenatal consultation in the first 4 months
of pregnancy and a total of 80-109% of
visits correspond to adequate care category.
Adequate plus category refers to the initia-
tion of prenatal consultation in the first 4
months and total medical checks of more
than 110% compared to the number rec-
ommended (5).
The statistical package SPSS 13.0 for
Windows (Chicago, IL, USA) was used for
data analysis. For the prediction of inade-
quate weight gain, multinomial logistic
regression was used. Significance values of
Goodness-of-Fit test were higher than 0.05,
so the model was adequate. Access to data
observation sheet, the mother interview and
the measurements were made with the
agreement of management of Cuza-Vod
Obstetrics and Gynecology Hospital, and
with the approval of Science and Ethics
Committee of the University of Medicine
and Pharmacy Grigore T. Popa- Iai.

RESULTS
Almost half of the participants (45.8%)
were from rural areas. The mean age was
27.53 years, and 63.8% of all women were
between 19 and 30 years old. Pregnancy
occurred in married couples in 80.75% of
cases. Primiparous women were predomi-
nant (49.5%) and also those with a second
child (32.3%) (tab. I).
A proportion of 80% of women present-
ed to the family doctor during the first
trimester of pregnancy. The mean total
number of medical visits during pregnancy
was 9.584.88.Almost half of women
(53.5%) had an adequate plus prenatal care
level, evaluated by APCU (adequate prena-
tal care utilization) index, while 23% of
them had inadequate care during pregnan-
cy. A proportion of 42.3% of women re-
ceived advice about nutrition in pregnancy.
Only 33% declared they had no change in
diet during pregnancy. Most women were
advised to breastfeed their children
(83.5%).
The frequency of underweight women
was 11.8%, 66.6% were normal weight,
Alina Delia Popa et al.
354
17% overweight and 4.6% were obese.
Only 52.6% of women achieved a weight
gain during pregnancy as recommended by
the guide for general practitioners (9-15
kg). Pregnancy weight gain was influenced
by area of residence and age. The number
of women with weight gain less than 9 kg
was higher among those from rural areas.
Pregnant women younger than 20 years old
had more frequently a lower weight gain
than recommended, but rarely an increase
of more than 15 kg (tab. II).

TABLE I
Sociodemographic characteristics of the studied sample
No. %
Area of residence
urban 217 54,3
rural 183 45,8
Age (years)
< 20 356 89,0
20 44 11,0
Formal education
(years of schooling)
1-4 16 4,0
5-8 86 21,5
9-12 162 40,5
>12 136 34,0
Marital status
married 323 80,8
unmarried 77 19,2
Planned pregnancy
yes 359 89,8
no 40 10,0

TABLE II
Sociodemographic characteristics
related to weight gain during pregnancy
Socio-
demographic characteristics
Weight gain categories, %
P
< 9 kg 9-15 kg > 15 kg
Area of residence
Urban 9,3 48,6 42,1
,001
Rural 17,5 57,8 24,7
Planned pregnancy
Yes 13,5 51,1 35,3
,197
No 6,1 66,7 27,3
Civil status
Married 32,7 48,1 19,2
,173
Unmarried 12,7 50,6 36,6
Age (years)
20 12,0 51,3 36,7
,021
< 20 20,5 64,1 15,4
Formal education
(schooling years)
< 9 11,6 51,0 37,3
,095
9 16,7 57,8 25,6
Parity
2 11,9 51,6 36,6
,128
> 2 17,7 58,1 24,2

Most of underweight women had an ad-
equate weight gain during pregnancy.
However, 39.5% had a weight gain of more
than 15 kg. Women with obesity had more
frequently a reduced weight gain compared
to other categories, but the proportion of
those with large increases in weight re-
mained high (p=0.001) (tab. III).
Determinants of inadequate weight gain in pregnancy
355
Pregnant women with adequate prena-
tal care had a higher mean weight gain
compared to those with inadequate or
intermediate APCU index (p<0.001). Sig-
nificant differences were seen between
women with inadequate and adequate care
(12.53 kg vs. 14.42 kg., p = 0.041) and
among those with inadequate and adequate
+ APCU index (12.53 kg vs. 15.05 kg,
p<0.001). Weight gain of pregnant women
with adequate + APCU index was also
significantly higher than the one seen in
those with intermediate and adequate pre-
natal care (15.05 kg vs. 12.53 kg, p
<0.001, respectively 15.05 kg vs. 14.42
kg, p=0.007). (fig. 1).
A weight gain under the recommenda-
tions was noticed in 20.4% of women who
received advice on diet during pregnancy,
compared to 25.5% of women who did not
receive such information. An increase in
weight greater than recommended occurred
in 35.3% of women who received advice
about diet, compared to 33.8% of them who
have not received such advice. Weight gain
within the recommendations was more
common among women who received ad-
vice on nutrition during pregnancy, even if
there was no statistical significance (44.3%
vs. 40.7%, p = 0.496).

TABLE III
Weight gain during pregnancy according to pregestational BMI
Weight
gain, kg
Categories of BMI, %
Under
weight
Normal
weight
Over
weight
Obese
<9 4,7 5,5 12,7 33,3
9-15 55,8 60,5 54 27,8
>15 39,5 34 33,3 38,9


Fig. 1. Association between weight gain and APCU index

Alina Delia Popa et al.
356

Multinomial logistic regression was
performed to determine which of the fol-
lowing factors determinants of inadequate
pregnancy weight gain are: area of resi-
dence, age, education, marital status, pari-
ty, planned pregnancy, APCU index, nutri-
tional advice, pregestational BMI, changes
in diet during pregnancy (tab IV).

TABLE IV
Determinants of weight gain during pregnancy
Weight gain during pregnancy
a
P OR
95% Confidence Interval
Lower
Bound
Upper
Bound
Less than
recommended
APCU
index
Inadequate ,009 3,064 1,318 7,123
Intermediary ,657 1,301 ,407 4,156
Adequate ,374 1,565 ,583 4,201
Adequate +
Age
<20 years ,535 1,358 ,517 3,568
>20 years
Dietary
changes
Eat less ,063 2,390 ,953 5,993
Eat more ,643 ,818 ,349 1,914
Avoid salty foods ,903 ,923 ,256 3,325
Eat more salty ,520 ,462 ,044 4,864
Avoid certain foods ,773 1,279 ,241 6,772
No dietary changes
Pregesta-
tional BMI
(kg/m
2
)
<18,5 ,002 ,117 ,031 ,444
18,5-24,9 ,000 ,041 ,007 ,243
<25-29.9 ,110 ,317 ,078 1,296
>30 . .
b
. .
More than
recommended
APCU
index
Inadequate ,136 ,600 ,307 1,174
Intermediary ,023 ,292 ,101 ,846
Adequate ,368 1,364 ,694 2,681
Adequate + . .
b
. .
Age
<20 years ,036 ,346 ,128 ,935
>20 years
Dietary
changes
Eat less ,009 ,065 ,008 ,501
Eat more ,007 2,117 1,229 3,649
Avoid salty foods ,738 1,146 ,517 2,536
Eat more salty ,874 1,135 ,237 5,434
Avoid certain foods ,532 1,416 ,476 4,2207
No dietary changes
Pregestation-
al BMI
(kg/m
2
)
<18,5 ,172 ,416 ,118 1,463
18,5-24,9 ,375 ,538 ,137 2,117
<25-29.9 ,350 ,525 ,136 2,029
>30 . .
b
. .
b-reference category

Variables that significantly contributed
to distinguish between the three categories
of weight gain during pregnancy were:
APCU index; pregestational BMI; changes
Determinants of inadequate weight gain in pregnancy
357
in diet and age. A weight gain lower than
the recommended was associated with in-
adequate prenatal care, pregestational BMI
< 18.5 kg/m
2
and normal pregestational
weight. Weight gain higher than recom-
mendations was associated with changes in
diet, age less than 20 years and an interme-
diate value of APCU index.

DISCUSSION
Prenatal care is essential for screening
and prevention of complications associated
with pregnancy (6). WHO recommends
initiation of prenatal care during the first 4
months of pregnancy (7). Continuity (8)
and frequency of prenatal care (9) have
positive effects on mother and child health.
APCU index combines in a single variable
two quantitative factors: gestational age, in
months, at beginning of prenatal care and
the number of prenatal visits during preg-
nancy. Because prenatal care needs to be
appropriate, registration should be done
during the first trimester and the number of
prenatal visits should be at least nine. Alt-
hough the name includes the term appro-
priate, the index does not refer to the con-
tent of prenatal consultation (5).
Our data show an improved addressa-
bility to general practicionner during the
first trimester of pregnancy compared to
previous studies. In the study conducted
by IOMC "Nutritional status of pregnant
women" almost 6% of women received no
prenatal visit during their last pregnancy,
and 68.8% of mothers were presented at
the first prenatal visit during the first tri-
mester of pregnancy (79.2% in urban and
58.5% rural) (10). The Reproductive
Health Survey 2004, most women (94%)
received prenatal care, and 74% were
considered in the first trimester. Only 17%
were considered in the second and 2% in
the third trimester. In 1999 it was found
that 89% of women received prenatal care
(10). The self-reported weight was used in
the present study. For accurately assessing
this parameter it is recommended to use
the self-reported weight in the first two
months of pregnancy (11). However, there
are studies showing that mothers declared
a value that correlates with real weight
(12).
Pregnancy is considered an appropriate
time for promoting healthy changes in
dietary habits (13). Characteristics of inter-
vention methods, content and frequency of
educational measures and socio-economic
peculiarities led to discordant results of
interventional studies. The impact of rec-
ommendations on weight gain during preg-
nancy has been shown in numerous studies,
indicating that messages during prenatal
consultation may influence attitudes and
perceptions of pregnant women on optimal
growth. The impact of recommendations on
appropriate weight gain may be influenced
by family and friends attitude on prenatal
education (14).
In this sample, it has been observed
that only 57.6% of women had an optimal
weight gain. Studies in the U.S. have
shown that 30-40% of pregnant women
have a weight gain outside the limits rec-
ommended by the Institute of Medicine
(15). Our results show that the number of
prenatal visits influenced the proportion of
women with optimal weight gain. Preg-
nant women with inadequate prenatal care
had more frequently a weight gain below
the recommended limits. Weight gain
within the recommendations was more
common among women who received
advice on nutrition during pregnancy.
Other studies concluded that belonging to
certain ethnic groups (Hispanic), educa-
Alina Delia Popa et al.
358
tion level, decreased pregestational BMI
and the lack of nutritional advice were
determinants of lower than recommended
weight gain (14). Overweight, young age
and multiparity had a higher weight gain
than considered appropriate by the IOM
(14). Weight gain above the recommended
level was associated with overweight and
obesity in a study conducted in Brazil
(16).
CONCLUSIONS
Pregestational BMI, APCU index and
changes in diet during pregnancy identified
as determinants of weight gain suggests
that overweight and underweight women
must carefully be counciled regarding rec-
ommendations for weight gain in pregnan-
cy. Tracking diet changes is important to
ensure that a weight gain lies within the
guidelines recommendations.
REFERENCES
1. Rodwell Williams S. Basic Nutrition and Diet Therapy, 11
th
edition. Mosby, 2001,179-197.
2. Abenhaim H, Kinch R, Morin L,et al. Effect of prepregnancy body mass index categories on obstetri-
cal and neonatal outcomes. Arch Gynaecol Obstet 2007;275(1):39-43.
3. Dietz P, Callaghan W, Smith R, et al. Associations of low pregnancy weight gain with three measures
of small for gestational age infants. Am J Obstet Gynaecol 2009;201:53.e1-53.e7.
4. Centrul Naional de Studii pentru Medicina Familiei. ngrijiri prenatale de rutin n sarcina cu risc
sczut. Ghid de practic pentru medicii de familie, Ed. Infomedica, Iai, 2005, 48-59.
5. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Ade-
quacy of Prenatal Care Utilization Index. Am J Public Health 1994; 84:1414-1420.
6. Brawarsky P, Stotland NE, Jackson RA, et al. Pre-pregnancy and pregnancy-related factors and the
risk of excessive or inadequate gestational weight gain. Int J Gynaecol Obstet 2005;91(2):125-131.
7. World Health Organisation (WHO). WHO Antenatal Care Randomised Trial: Manual for the Imple-
mentation of the New model. Geneva, 2002, 12-29.
8. Waldenstrom U, Turnbull D. A systematic review comparing continuity of midwifery care with
standard maternity services. Br J Obstet Gynaecol 1998;105(11):1160-1170.
9. Khan-Neelofur D, Gulmezoglu M, Villar J. Who should provide routine antenatal care for low-risk
women, and how often? A systematic review of randomised controlled trials. Paediatr Perinatal Epi-
demiol 1998;12(Suppl 2):7-26.
10. Institutul pentru Ocrotirea Mamei i Copilului Prof. Dr. Alfred Rusescu, UNICEF Reprezentana
n Romnia. Statusul nutriional al femeii gravide: Romnia 2005, vol. I, Bucureti: MarLink,
2006, 31-70.
11. World Health Organisation (WHO) Expert Committee on Physical Status. The use and interpretation
of anthropometry physical status: the use and interpretation of anthropometry: report of a WHO ex-
pert committee. WHO Techn Rep Ser 854, Geneva, 1995, 37-120.
12. Vilar J. Perinatal data reliability in a large teaching obstetric unit British. J Obstet Gynaecol
1988;95:841-848.
13. Abrams B, Altman S, Picken K. Pregnancy weight gain: still controversial. Am J Clin Nutr
2000;71(suppl):1233S-1241S.
14. Stotland NE, Haas JS, Brawarsky P, et al. Body mass index, provider advice, and target gestati onal
weight gain. Obstet Gynaecol 2005;105(3):633-638.
15. Cogswell ME, Parvanta I, Ickes L, et al. Iron supplementation during pregnancy, anemia, and birth
weight: a randomized controlled trial. Am J Clin Nutr 2003;78:773-781.
16. Fazio ES, Nomura RMY, GonalvesDias MC, et al. Consumo diettico de gestantes e ganho ponderal
materno aps aconselhamento nutricional. Rev Bras Ginecol Obstet 2011;33(2):87-92.