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

INTERNAL MEDICINE - PEDIATRICS

ORIGINAL PAPERS

DETERMINANTS OF INADEQUATE WEIGHT GAIN IN PREGNANCY

Alina Delia Popa1 , Otilia Ni2* , Raluca Maria Popescu2, Andreea Gherasim2,3,
Lidia Iuliana Arhire2, Laura Mihalache2 , Mariana Graur2
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 crosssectional study on a total of 400 pregnant women admitted to Cuza-Vod Obstetrics and Gynecology Clinical Hospital, Iai. Information on demographic characteristics, number of pr enatal visits, and education on nutrition and food changes occurring during pregnancy were
recorded in a structured questionnaire. Anthropometric parameters analyzed were pregestational BMI (body mass index) and weight gain during pregnancy. Results. Weight gain was
associated with pregestational BMI category. An increase in weight more than re commended
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 pren atal care utilization) index. The multivariate analysis identified the following variables as si gnificant 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 carefully be counseled regarding recommendations for weight gain in pregnancy. Tracking diet
changes is important to ensure that a weight gain lies within the guidelines recommend ations. Keywords: PREGESTATIONAL BMI, WEIGHT GAIN DURING PREGNANCY,
PRENATAL VISITS, NUTRITIONAL EDUCATION

The main purpose of recommendations

for weight gain during pregnancy is represented 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

352

environment is important in shaping the

future phenotype of the organism, influencing 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

a sample of 400 women, admitted to CuzaVod 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 according 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 prenatal 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 recommended 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 initiation of prenatal consultation in the first 4
months and total medical checks of more

than 110% compared to the number recommended (5).

The statistical package SPSS 13.0 for
Windows (Chicago, IL, USA) was used for
data analysis. For the prediction of inadequate 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 predominant (49.5%) and also those with a second
child (32.3%) (tab. I).
A proportion of 80% of women presented 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 prenatal care utilization) index, while 23% of
them had inadequate care during pregnancy. A proportion of 42.3% of women received 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,

353

Alina Delia Popa et al.

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
Area of residence
Age (years)
Formal education
(years of schooling)
Marital status
Planned pregnancy

urban
rural
< 20
20
1-4
5-8
9-12
>12
married
unmarried
yes
no

No.
217
183
356
44
16
86
162
136
323
77
359
40

%
54,3
45,8
89,0
11,0
4,0
21,5
40,5
34,0
80,8
19,2
89,8
10,0

TABLE II
Sociodemographic characteristics
related to weight gain during pregnancy
Sociodemographic characteristics
Urban
Area of residence
Rural
Yes
Planned pregnancy
No
Married
Civil status
Unmarried
20
Age (years)
< 20
<9
Formal education
(schooling years)
9
2
Parity
>2

Most of underweight women had an adequate weight gain during pregnancy.

However, 39.5% had a weight gain of more
than 15 kg. Women with obesity had more

354

Weight gain categories, %

< 9 kg 9-15 kg > 15 kg
9,3
48,6
42,1
17,5
57,8
24,7
13,5
51,1
35,3
6,1
66,7
27,3
32,7
48,1
19,2
12,7
50,6
36,6
12,0
51,3
36,7
20,5
64,1
15,4
11,6
51,0
37,3
16,7
57,8
25,6
11,9
51,6
36,6
17,7
58,1
24,2

P
,001
,197
,173
,021
,095
,128

frequently a reduced weight gain compared

to other categories, but the proportion of
those with large increases in weight remained high (p=0.001) (tab. III).

Determinants of inadequate weight gain in pregnancy

Pregnant women with adequate prenatal care had a higher mean weight gain
compared to those with inadequate or
intermediate APCU index (p<0.001). Significant 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 prenatal 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 recommendations 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 advice 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
<9
9-15
>15

Under
weight
4,7
55,8
39,5

Categories of BMI, %
Normal
Over
Obese
weight
weight
5,5
12,7
33,3
60,5
54
27,8
34
33,3
38,9

Fig. 1. Association between weight gain and APCU index

355

Alina Delia Popa et al.

Multinomial logistic regression was

performed to determine which of the following factors determinants of inadequate
pregnancy weight gain are: area of resi-

dence, age, education, marital status, parity, planned pregnancy, APCU index, nutritional advice, pregestational BMI, changes
in diet during pregnancy (tab IV).

TABLE IV
Determinants of weight gain during pregnancy
Weight gain during pregnancya

APCU
index
Age
Less than
recommended

Dietary
changes

Pregestational BMI
(kg/m2)
APCU
index
Age

More than
recommended

Dietary
changes

Pregestational BMI
(kg/m2 )

Inadequate
Intermediary
Adequate
Adequate +
<20 years
>20 years
Eat less
Eat more
Avoid salty foods
Eat more salty
Avoid certain foods
No dietary changes
<18,5
18,5-24,9
<25-29.9
>30
Inadequate
Intermediary
Adequate
Adequate +
<20 years
>20 years
Eat less
Eat more
Avoid salty foods
Eat more salty
Avoid certain foods
No dietary changes
<18,5
18,5-24,9
<25-29.9
>30

95% Confidence Interval

Lower
Upper
Bound
Bound
1,318
7,123
,407
4,156
,583
4,201

OR

,009
,657
,374

3,064
1,301
1,565

,535

1,358

,517

3,568

,063
,643
,903
,520
,773

2,390
,818
,923
,462
1,279

,953
,349
,256
,044
,241

5,993
1,914
3,325
4,864
6,772

,002
,000
,110
.
,136
,023
,368
.
,036

,117
,041
,317
.b
,600
,292
1,364
.b
,346

,031
,007
,078
.
,307
,101
,694
.
,128

,444
,243
1,296
.
1,174
,846
2,681
.
,935

,009
,007
,738
,874
,532

,065
2,117
1,146
1,135
1,416

,008
1,229
,517
,237
,476

,501
3,649
2,536
5,434
4,2207

,172
,375
,350
.

,416
,538
,525
.b

,118
,137
,136
.

1,463
2,117
2,029
.

b-reference category

Variables that significantly contributed

to distinguish between the three categories

356

of weight gain during pregnancy were:

APCU index; pregestational BMI; changes

Determinants of inadequate weight gain in pregnancy

in diet and age. A weight gain lower than

the recommended was associated with inadequate prenatal care, pregestational BMI
< 18.5 kg/m2 and normal pregestational
weight. Weight gain higher than recommendations was associated with changes in
diet, age less than 20 years and an intermediate 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 pregnancy. 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. Although the name includes the term appropriate, the index does not refer to the content of prenatal consultation (5).
Our data show an improved addressability 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 trimester 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 intervention methods, content and frequency of
educational measures and socio-economic
peculiarities led to discordant results of
interventional studies. The impact of recommendations on weight gain during pregnancy 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 recommended by the Institute of Medicine
(15). Our results show that the number of
prenatal visits influenced the proportion of
women with optimal weight gain. Pregnant 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-

357

Alina Delia Popa et al.

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 recommendations for weight gain in pregnancy. Tracking diet changes is important to
ensure that a weight gain lies within the
guidelines recommendations.

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