Tasya Fitri Ramadanti

Best Practice & Research Clinical Obstetrics and Gynaecology 68 (2020) 109e117
Contents lists available at ScienceDirect
Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn
Optimal Intrapartum Care - Vol. 67 Multiple Choice Answers

1. (a) T, (b) F, (c) T, (d) F, (e) T
The maturing fetal adrenals produce DHEAS, which is a substrate for placental production of the
uterine-activating hormone oestrogen, and also cortisol, which matures the fetal lungs and other or-
gans. The catecholamine surge occurs in late labour due to pressure on the fetal head and hypoxic
stress. It provides protection at this time from the inevitable hypoxia of the powerful late-labour
contractions and begins to prepare the fetus for life outside the womb, including by supporting a
successful respiratory transition. The evolutionary importance of a safe environment for birth supports
the mother's subjective sense of safety for the onset of labour. Progesterone maintains quiescence until
labour onset, and its actions are eventually over-ridden by high levels of the activating hormone
oestrogen. Fetal fibronectin is present in the ‘glue’ that adheres the fetal membranes to the uterine
wall, and its presence in cervical fluid is used to assess the risk of preterm labour.
2. (a) T, (b) F, (c) F, (d) F
Oestrogen is produced in the placenta from fetal DHEAS and enters the maternal circulation, where
it increases uterine gap junctions, oxytocin receptors, and other activating processes. The fetal adrenals
produce cortisol, which matures the fetal lungs, and also DHEAS, which is a placental substrate for
oestrogen, as described above. Prelabour sterile inflammatory changes promote uterine activation
through increased levels of cytokines, interleukins and prostaglandins, which also soften and ripen the
cervix. Only low levels of oxytocin (equivalent to 4e9mU/min) are needed to cause contractions at the
spontaneous onset of labour, This is due to high uterine sensitivity from an oestrogen -driven up-
regulation of uterine oxytocin receptors.
3. (a) T, (b) F, (c) F, (d) T
The World Health Organization (WHO) incorporated patterns of cervical dilatation along with other
proposed clinical measures such as the cervical effacement, the foetal heart rate, the frequency and
intensity of contractions, the descent and moulding of the foetal head, the status of the amniotic fluid,
and other maternal clinical signs in the partogram tool. The cervicograph (a graph of cervical dilatation
over time) component of the partogram is often the main factor considered in clinical practice to
suspect labour protraction and arrest and to guide the use of interventions to alleviate the maternal,
foetal and neonatal risks associated with abnormally prolonged labours. However, cervical dilatation
over time as an isolated indicator may not be used to define labour arrest; other parameters such as
frequency and duration of contractions, cervical effacement, and foetal station need to be considered.
In recent years, the ‘one centimetre per hour rule’ of the cervicograph has been challenged, and
alternative labour curves have been proposed to provide a reference for labour progress. Labour
https://doi.org/10.1016/j.bpobgyn.2020.10.002
1521-6934
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part10@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights
reserved.
110 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 68 (2020) 109e117
progression should be thought as a hyperbolic process rather than a linear process, with the inflexion
point close to 5 cm dilatation in both nulliparous and parous women. Cervical dilation alone does not
have a precise or direct relationship with time. The effacement of the cervix, which has been used by
clinicians as a traditional part of the definition of active labour, also plays an important role in the
duration of labour. The modelled calculations could have the potential to adapt to the conditions of the
woman and produce a quantitative evaluation in percentiles being the low ones those that indicate an
alert. Some of the factors proposed for these multivariable prediction models are dilation, station,
effacement at the previous examination and the presence or absence of epidural anaesthesia.
4. (a) T, (b) F
There is a tendency for longer labours to positively skew the statistical distribution. Thus, medians
and 5th and 95th percentiles are better indicators of central tendency and dispersion. The data pre-
sented as means and the corresponding 95% Confidence Intervals should be interpreted with caution.
Four studies reported the median duration of the second stage in nulliparous, ranging from 14 to 66
minutes (P 95th: 65 to 138). Two of these studies described epidural use in 48 and 100% of women, and
reported longer median durations (53e66 minutes P 95th: 138 to 216). For parous women, two studies
reported a median duration of 6e12 minutes (P 95th: 58 to 76). The subpopulation of women with
100% epidural in one of these studies had longer median duration too (18e24 minutes, P 95th: 96 to
120).
5. (a) T, (b) F
The values of 95th percentile data across studies show that it is possible for some women to have
longer labours when the time to advance centimetre by centimetre is considered, but otherwise
normal as they achieve full dilatation and give birth vaginally without adverse perinatal outcomes.
Both the systematic review and the individual studies published after that show that an expectation of
an average cervical dilatation threshold of 1 cm/hour before women reach 5 or 6 cm dilatation is
unrealistically fast for most healthy nulliparous and parous women.
6. (a) T, (b) F
The individual diagnostic accuracy of some of the predictors of labour progression included in the
partogram (such as the suboptimal number or duration of uterine contractions, slow descent, abnormal
position of foetal head), as well as the cardiovascular maternal clinical signs (maternal heart rate,
systolic and diastolic blood pressure), also presented poor performance in the prediction. Nevertheless,
the surveillance of the foetal clinical condition still plays a role in the care of labouring women. Absence
of foetal movements, abnormal foetal heart rate, significant caput succedaneum or moulding, meco-
nium stained liquor, and maternal fever were associated with mild to moderate increased odds of
severe adverse birth outcomes. The universal application of clinical standards based only on an
expectation of linear labour progress (at a threshold of 1 cm per hour during active first stage) in all
women is not accurate for monitoring labour progress. The cervicograph reference curves of the
partogram should be reviewed to adapt to new evidence of how labour progresses in women with
normal maternal and perinatal outcomes.
7. (a) F, (b) F, (c) T, (d) T, (e) T
The Friedman curve, also known as the cervicograph denotes the curve of cervical dilatation that
Friedman presented on the basis of statistical deviations from the mean cervical-dilatation-time curve.
Most partographs include observations on both the mother's- and the fetus' condition in addition to
observations on labour progression presented by cervical dilatation and effacement, decent of the
presenting part and characteristics of the contractions. The partograph was developed by Philpott
based on the cervicograph by Dr Friedman. The alert line expecting a cervical dilatation of one
reserved.
Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 68 (2020) 109e117 111
centimetre per hour is a modification of the mean rate of cervical dilatation in the slowest 10% of the
included women in Philpot's study. The main aim of including an alert line on to the partograph was to
identify slow progress of labour and enable transfer of slow progressing women to the hospital where
active management could be offered within four hours of crossing the alert line. In 1994 the WHO
revised and approved the partograph and recommended it to be used in all labour wards as part of the
Safe Motherhood Initiative to reduce maternal and foetal mortality. However WHO no longer
recommend the use of alert and action lines. Researchers around the world have presented modified
labour progression guidelines and partographs in order to come closer to an expected labour pro-
gression for contemporary women. In the WHO recommendations “Intrapartum care for a positive
childbirth experience” the Guideline Development group (GDG) agreed not to recommend using the 1-
cm/hour threshold and alert line to assess labour progress. The GDG identified the development of a
labour progression monitoring tool, especially measured by cervical dilatation, as a research priority.
8. (a)T, (b) F, (c) F, (d) F, (e) F
The partograph provides a pictorial presentation of labour and gives a good overview of labour
progression. Regarding the use of the Partograph versus no partograph, it is uncertain whether there is
any clear difference in caesarean section rates. Birth attendants in low-resource settings report inad-
equate training in using the partograph, which led to lack of confidence in using the tool, and that the
partographs in some cases were completed retrospectively due to fear of litigation. This misuse of the
tool gives no benefits in assessing labour progression. The partograph is used incorrectly in many
settings, but even if used correctly, birth attendants report challenges in initiating proper labour
management and necessary interventions due to lack of access to resources. Regarding the use of the
Partograph versus no partograph, it is uncertain whether there is any clear difference in the use of
Oxytocin. To use the partograph as intended, to identify risk and to act or intervene when needed, one
relies on skilled midwives and obstetricians with knowledge on how to use the tool, and capacity to act
in accordance with required interventions. Even if the partograph is used as intended, the standardized
labour progression monitoring tool leaves little room for individual assessment and personalized
management of labour.
9. (a)F, (b) F, (c) T, (d) F, (e) T
In three studies comparing partograph with no partograph there was no evidence to suggest that
standard use of the partograph was favourable to no partograph. A cluster randomised controlled trial,
conducted in Norway, including 7277 women and fourteen clusters compared the modified WHO
partograph with Zhang's guidelines and failed to show any differences in the primary outcome,
caesarean section rate. Kenchaveeriah et al. found that caesarean section and oxytocin augmentation
rates were higher when the partograph which included a latent phase was used. When investigating
women's experience with birth care according to routine interventions, the use of the partograph is
rarely included, hence we know little about the experience from the women's perspective. The liter-
ature suggests that the partograph is well supported by health professionals, who generally talk
positively about the tool. However, despite this, the majority of papers report that it is often used
incorrectly or not used at all.
10. (a) F, (b) T, (c) F, (d) F, (e) F
Only four of the domains have been identified. Although financial incentives may increase parto-
graph use, this is not evidence based and is currently not recommended. The five domains are based on
the evidence from 92 studies, as part of a realist review. C is incorrect. Development of protocols on
partograph use, on their own, is likely to be ineffective. Implementation of protocols would be
imbedded in the domain of health system support. d and e are incorrect based on b -the correct
statement which states that “Health worker acceptability, health system support, effective referral
systems, human resources and health provider competence.”
reserved.
11. (a) F, (b) F, (c) F, (d) T
Electronic fetal monitoring was developed in 1957 and was commonly used starting in the 1970s to
determine fetal well-being. Despite increased use of EFM, the reliability and reproducibility of the fetal
heart rate tracing recognition is limited and has not improved perinatal outcomes. In fact, there has
been an increase in caesarean and operative vaginal delivery.
12. (a) F, (b) F, (c) F, (d) T
There are new emerging technologies in order to improve electronic fetal monitoring. Currently,
remote devices being used are the Monica Novii and Moyo. Fetal scalp blood sampling has fallen out of
practice due to its invasive nature. Fetal ECGs have been shown to be beneficial in European studies but
not in the United States.
13. (a) F, (b) F, (c) T, (d) F
The Monica Novii is a remote monitoring device that allows patient to remain wireless and more
comfortable throughout their labor course. It is able to detect the maternal and fetal heart rates via the
Novii Patch which is placed on the maternal abdomen. It also is able to detect uterine activity and is
reliable is patients with a high BMI.
14. (a) T, (b) F, (c) F, (d) T, (e) T
Due to lack of space for the occiput in the anterior segment of the pelvic inlet there is a tendency to
occipito-posterior position. Restitution is the re-alignment of the head with the shoulders after birth of
the head. External rotation takes place as the shoulders undergo internal rotation. Anterior rotation is
the mechanism whereby a face presentation in the mento-posterior position may deliver. The better
the flexion, the better the chance of the occiput rotating anteriorly. The sub-occipito-bregmatic
diameter presents when the head is well flexed.
15. (a) F, (b) F, (c) F, (d) T, (e) F
It is recommended to await descent of the presenting part and for the mother to bear down when
she feels the urge to do so. Forceps have been found to cause more maternal injury but less injury to the
baby than vacuum delivery. There is no robust evidence that manual fundal pressure improves out-
comes. Gentle digital stretching of the perineum has been found to reduce the risk of tears. The supine
position should be avoided because of the risk of impaired uteroplacental blood flow.
16. (a) T, (b) F, (c) F, (d) T, (e) T
Erb's palsy is most commonly sustained during efforts to deliver the anterior shoulder hence recent
trends are to focus on delivery of the posterior shoulder. The second stage of labour is completed when
the baby or babies are completely delivered. The main hormonal uterine stimulant in the second stage
of labour is oxytocin. Traction on the baby may cause extension of the arms and head. Traction forces of
19Kg have been measured with the rigid cup compared with 11Kg with the flexible cup.
17. (a) F, (b) F, (c) T, (d) T, (e) F
Companionship should be continued precisely because the mother may be distress sed. There is no
evidence of improved outcome with routine episiotomy. Recent research has shown good outcomes
with longer second stage than previously defined ‘normal’ limits. An additional hour is allowed with
reserved.
epidural analgesia to limit the high rate of operative interventions as bearing down may be delayed
with epidural analgesia. Keilland's forceps are used for rotational deliveries, not Wrigley's.
18. (a) F, (b) T, (c) T, (d) F, (e) T
Network analysis demonstrates that use of several uterotonic agents individually (oxytocin, ergo-
metrine, misoprostol, carbetocin) significantly reduce the risk of PPH so a uterotonic agent should be
given at home birth by the birth attendant, with the chosen agent being one that can be safely
administered in this setting. Oral misoprostol can be administered in the home setting; it is easy to
administer, does not require refrigeration and there are several studies where it has been employed in
this context. Delayed cord clamping has been shown to have benefit for the fetus and is practicable in
low resource emergency settings. Evidence shows minimal benefit from CCT, unless following ergo-
metrine. It is a skilled procedure and it is recommended that it should not be performed by an unskilled
birth attendant. Early suckling at the breast stimulated endogenous oxytocin release which enable
uterine contraction and is also beneficial for the neonate (skin to skin and enables breast feeding).
19. (a) T, (b) F, (c) F, (d) T, (e) F
Network analysis shows i.m. oxytocin is effective for preventing PPH in third stage. Although most
research is on vaginal delivery, there is no pharmacological reason why it should not have same efficacy
at CS. One systematic review shows increased blood loss with manual placental removal compared to
controlled traction after placental separation. Network analysis shows oxytocin to be the uterotonic of
choice in terms of efficacy and side effect profile. Also, the parenteral route is indicated at CS, and
misoprostol has no parenteral preparation. International obstetric guidelines and anesthetic consensus
documents differ on preferred route and dose of oxytocin. Rapid iv boluses of oxytocin at CS have been
shown by pharmacokinetic studies and in some case reports to cause maternal hypotension (not
hypertension).
20. (a) F, (b) F, (c) T, (d) T, (e) T
Deferred, or delayed cord clamping is now recommended by all major guidelines internationally.
There appears to be no benefit to the mother, but the transfer of oxygenated blood to the baby in the
first minutes after birth appears to have major effects on the baby. The oxygen in the placental blood
improves oxygenation and resuscitation, whilst the increased haemoglobin reduces infant anaemia. It
is probably the improved iron stores (important for neurone growth) that leads to the improved
neurological function seen in the long-term follow-up studies of babies randomised to early or delayed
cord clamping. The optimal delay is not known, but the studies showing improved long-term outcomes
were all conducted using a delay of 3 minutes. Randomised studies of delayed cord clamping in pre-
mature babies together show a 30% reduction in mortality. The reason is likely to be a combination of
improved oxygenation, improved blood pressure, a more stable transition to respiration, higher blood
volume and haemoglobin. There are no studies that show an effect of delayed cord clamping on the
neonatal mortality of healthy term infants. Neonatal mortality is very rare in this group, and so, even if
there were to be a reduction in mortality with delayed cord clamping, it would take an enormous
randomised trial to show it and this has not been done.
21. (a) T, (b) T, (c) F, (d) F, (e) F
The large WHO controlled cord traction study found no difference overall in PPH rates between
those who had CCT and who didn't in women given intramuscular oxytocin for 3rd stage management.
Intriguingly, however, there was a small subgroup who were mistakenly given a combination oxytocin/
ergometrine in the study who needed the CCT to prevent retained placenta. This hints that CCT may be
necessary in this subgroup. The ergometrine risk is supported by the Begley study in which women
who had PPH prophylaxis with intravenous ergometrine and CCT had very high rates of retained
reserved.
placenta compared to those with physiological management. Ultrasound studies have provided an
insight into the mechanisms of retained placenta and show that the retroplacental myometrium is last
part of the myometrium to contract, and results in the shearing off of the placenta. Failure of this area to
contract is the cause of one of the three types of retained placenta, ‘placenta adherens’. Several studies
have tried to deliver oxytocin to this area of the uterus by injecting oxytocin into the umbilical vein so
that it reaches the myometrium through the placenta. Despite early promise however, large double-
blind studies have been unable to replicate the results.
22. (a) T, (b) F, (c) F, (d) F
In multiparous woman with a prolonged latent phase of labour, a strategy of observation and
support has been found to be superior to augmentation by amniotomy or oxytocin. There is no evi-
dence that either antispasmodic or intravenous fluid is effective.
23. (a) F, (b) F, (c) T, (d) F
Oxytocin infusion is considered if the frequency of contractions is less than 3 contractions per 20
minutes and/or if the intensity of contractions is less than 25 mm Hg above the baseline.
24. (a) T, (b) F, (c) F, (d) F
Oxytocin is a peptide of nine amino acids (a nonapeptide). It has been shown to be released by the
fetus during labour. It has an important role in milk ejection. It is inactivated by oxytocinase.
25. (a) F, (b) F, (c) F, (d) T
Oxytocin is synthesized in the hypothalamus, in magnocellular neurosecretory cells of the supra-

optic and paraventricular nuclei, and is stored in Herring bodies at the axon terminals in the posterior
pituitary. It is then released into the blood from the posterior lobe (neurohypophysis) of the pituitary
gland. It has some antidiuretic action.
26. (a) F, (b) F, (c) F, (d) T
Tachysystole e There are no differences in risk of caesarean, infection and postpartum haemorrhage
but there is a lower risk of tachysystole with the use of an intracervical balloon catheter compared to
prostaglandins.
27. (a) F, (b) F, (c) T, (d) F
The combination of misoprostol and cervical Foley concurrently has been shown to lead to the
shortest delivery.
28. (a) F, (b) F, (c) F, (d) T
Oxytocin is an induction agent and not a cervical ripening agent.
29. (a) T, (b) T, (c) T, (d) F, (e) F
CSE results in a faster onset of pain relief than both DPE or standard epidural, as medications are
delivered directly into the intrathecal space. A study that compared the DPE technique with both
CSE and standard epidural for labour analgesia found the CSE technique provided significantly
quicker pain relief (median time to numeric pain rating scale 1) of 2 minutes compared to both
reserved.
the DPE (11 minutes) and standard epidural (18 minutes). The postulated mechanism of fetal heart
rate (FHR) abnormalities and bradycardia after neuraxial analgesia including CSE is a sudden
decrease in maternal circulating catecholamines (including epinephrine). Epinephrine acts as a
uterine relaxant, and so an abrupt reduction can induce reflex uterine hypertonus and impair flow
through the uteroplacental circulation, leading to FHR changes. Pruritis (from opioids given
intrathecally) is more common and severe with a CSE than with techniques such as DPE or standard
epidural in which opioids are given epidurally, and thus not directly into the cerebro-spinal fluid
(CSF). To date there is no evidence to suggest an increased rate of post-dural puncture headache
(PDPH) and subsequent need for epidural blood patch (EBP) with techniques that involve an
intentional dural puncture (i.e. CSE or DPE) compared to a standard epidural in which the dura is
not breached. Modern day labour analgesia using CSE or DPE is often performed with a small-
gauge, pencil-point spinal needle. Epidural catheters placed during a CSE actually fail less
frequently than those placed during a standard epidural. In addition, CSE is associated with earlier
recognition of failed catheters. These catheter failures are lower during labour (i.e. less incomplete
analgesia) and at the time of conversion to surgical anaesthesia (e.g. for caesarean delivery).
30. (a) T, (b) F, (c) T, (d) T, (e) F
Overall local anesthetic consumption (in mg of local anesthetic such as bupivacaine or ropivacaine)
is reduced when using dilute epidural solutions of local anesthetics and opioids compared to more
concentrated solutions. The most likely explanation is improved spread with the relatively larger
volumes associated with dilute solutions. One of the major benefits of dilute epidural solutions is the
ability to provide excellent analgesia (via sensory blockade) while minimizing the amount of motor
block and leg weakness that labouring women may experience. This is the principle that has led to the
phenomenon of the “walking epidural”, in which women may (depending on hospital policy) ambulate
while receiving epidural analgesia. It has been well-demonstrated in large studies and meta-analyses
that comparable levels of pain relief can be obtained with more dilute epidural solutions compared to
more concentrated ones. Dilute epidural solutions are associated with reduced motor block as well as
reduced rates of instrumental vaginal delivery compared to concentrated solutions. Additionally, when
compared to non-neuraxial analgesia, no difference in instrumental vaginal delivery or caesarean
delivery rates were found with dilute epidural solutions. Studies have found either better or no dif-
ferences in maternal satisfaction with more dilute epidural solutions compared to more concentrated
ones. The higher satisfaction may be related to less motor block.
31. (a) T, (b) T, (c) F, (d) F, (e) T
Neuraxial analgesia is the gold standard for pain relief in labour. Using a modality such as PIEB
(programmed intermittent epidural bolus) with or without a patient-controlled epidural analgesia
(PCEA) component compared to a basal, continuous epidural infusion (CEI) allows for better pain
relief. Maternal satisfaction is higher with PIEB compared to CEI, likely due to the better labour
analgesia obtained and reduced incidence of motor block. Reduced motor block seen with PIEB
resulted in decreased rates of assisted/instrumental vaginal delivery in nulliparous women in a
prospective, randomised-controlled trial. PIEB allows for more extensive spread of epidural solution
in the epidural space. The effective concentration around motor nerves at any one spinal level is
therefore reduced, reducing the incidence and severity of clinically significant motor weakness.
Overall local anesthetic consumption is lower when using PIEB compared to CEI while still obtaining
a similar degree of pain relief. PIEB allows for more extensive spread of epidural solution in the
epidural space. Therefore the effective concentration around motor nerves at any one spinal level is
reduced, decreasing the incidence and severity of clinically significant motor weakness while
epidural analgesia is being utilized.
reserved.
32. (a) T, (b) F, (c) F, (d) T, (e) F
Some studies have found that women report high satisfaction despite limited analgesia provided
with N2O. These results suggest that the degree of pain relief is not the only determinant of a positive
experience with any labour analgesia therapeutic modality. Neuraxial analgesia remains the gold
standard for pain relief in labour. N2O appears to be associated with a variable and inconsistent degree
of analgesic efficacy. Although generally well tolerated, N2O is associated with a number of potential
side effects including nausea, dizziness, dysphoria, and drowsiness. Systems currently in use either
blend pure N2O with oxygen or deliver them already pre-combined in a 50:50% ratio. This allows for
sub-anesthetic (i.e. analgesic) doses of N2O to be administered while also minimizing the risk of
hypoxemia in the patient. N2O is odourless, tasteless, and not irritating or noxious, which makes it an
attractive inhaled agent to use for labour pain relief in awake patients.
33. (a) F, (b) F, (c) T, (d) T, (e) T
All women should be allowed to have at least one person of their choice present as a labour
companion (spouse/partner, family member, friend, or doula). However, women should not be
required to have a labour companion present if they do not want one. Improving accountability, and
audit and feedback related to respectful care is important; however, it is not recommended for punitive
measures against providers (such as withholding salaries) to be taken at this point. Women and their
families should be able to lodge complaints about the care provided. The mechanisms for lodging
complaints may vary across settings, but could include a complaints box or other ways to provide
anonymous or confidential feedback. Maternity ward staff should be treated respectfully by their
employers, and this includes the provision of refreshments. Separation of the newborn from the
mother (and/or other family or friends) is not recommended. Maintaining the mother-baby dyad
encourages skin-to-skin contact and early breastfeeding.
34. (a) T, (b) T, (c) F, (d) T, (e) F
Midwife-led continuity-of-care models, in which a known midwife or small group of known

midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum, are
recommended for pregnant women in settings with well-functioning midwifery programmes. Oral
fluids and food intake during labour is recommended for low-risk women in order to maintain strength
and hydration throughout labour. Encouraging the adoption of mobility and an upright position during
labour in women at low risk is recommended. However, women should be able to adopt a position of
their choice, including during the second stage of labour. Dorsal/supine/lithotomy positions may be
disempowering for women to give birth in, with an increase in adverse maternal outcomes. Manual
techniques, such as massage or application of warm packs, are recommended for healthy pregnant
women requesting pain relief during labour, depending on a woman's preferences. Application of
manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended.
35. (a) F, (b) T, (c) F, (d) T, (e) T
In the labour observation, over 40% of women had an observed experience of physical or verbal
abuse or discrimination. Physical abuse included actions such as slapping or pinching the woman.
Verbal abuse included actions such as shouting at the woman or threatening her with poor health
outcomes. Women were discriminated against based on their age, ethnicity, socioeconomic status,
among others. 59% of women did not consent to their first vaginal examination. Consent was measured
as given if the woman received information about the procedure or examination before it was con-
ducted, and that she agreed to the procedure or examination. In the labour observation, 4.5% of women
gave birth in the health facility without a provider present. This means that women and their families
may have overcome serious access barriers to arrive at the health facility, but were not cared for by any
healthcare provider while the baby was born. The measurement tools are openly available in English,
reserved.
French, Yoruba, Sousou, Malinke, Poular, Twi, and Myanmar language. In the community survey, 56% of
women reported that they had unconsented episiotomies. Consent was measured as that the woman
received information about the procedure or examination before it was conducted, and that she agreed
to the procedure or examination.
36. (a) T, (b) T, (c) F, (d) T, (e) F
A qualitative evidence synthesis found that when women experience disrespectful care, they may
be less likely to use facility-based maternity care services in the future and may be more likely to have
negative birth experiences. The value that women and their families place on different aspects of
respectful care may vary across both settings and individuals. Therefore, it is important for healthcare
providers to ask women about their values, needs, and fears, and support women to have positive
childbirth experiences. The emphasis on quality care in nursing, midwifery, and medicine began
formally in the 1960s and 1970s, and has used a variety of terms, such as quality care, humanized care,
rights-based care, family-centred, patient-centred, woman centred care, and respectful care. In ma-
ternity care, these concepts appeared in the 1970s along with the women's rights movement, which
included woman's health and rights, and impacted provider-thinking about provision of care.
Providing respectful maternity care is a human rights issue. All women have the right to freedom from
harm and ill treatment, the right to provide informed consent and refusal to consent, and respect for
choices and preferences, including companionship during maternity care. All women should be
allowed to have a companion of their choice present in the labour and delivery room. In settings where
labour and/or delivery rooms have more than one bed, privacy measures (such as curtains or parti-
tions) should be consistently available and used to maintain privacy for all women.
reserved.
Sexual & Reproductive Healthcare 23 (2020) 100464
Contents lists available at ScienceDirect
Sexual & Reproductive Healthcare

journal homepage: www.elsevier.com/locate/srhc
Study protocols
Perceived barriers to utilization of antenatal care services in northern T

Uganda: A qualitative study
⁎
Cecilie Skaarup Uldbjerga, , Stine Schramma, Felix Ocaka Kaducub, Emilio Ovugac,
Morten Sodemanna
a
Centre for Global Health, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
b
Department of Public Health, Faculty of Medicine, Gulu University, Uganda
c
Department of Mental Health, Faculty of Medicine, Gulu University, Uganda
A R T I C LE I N FO A B S T R A C T
Keywords: Objective: Antenatal care (ANC) utilization remains a challenge in efforts to reduce maternal mortality and
Maternal health improve maternal health in Uganda. This study aimed to identify perceived barriers to utilization of ANC ser-
Antenatal care vices in a rural post-conflict area in northern Uganda.
Uganda Methods: A qualitative study using in-depth interviews and focus group discussions of seventeen participants
Post-conflict
(pregnant women, health workers and a traditional birth attendant). The study was informed through a phe-
Qualitative
nomenological approach to capture perceived barriers to utilization of ANC. The study was carried out in post-
conflict Awach sub-county, Gulu District, northern Uganda. Data was analyzed using inductive conventional
content analysis.
Results: The main perceived barriers to ANC utilization were identified as: poor quality of care, including poor
attitude of health workers; socio-cultural practices not being successfully aligned to ANC; and lack of support
from the husband, including difficulties in encouraging him to attend ANC. Additionally, institutional structures
and procedures at the health centers in terms of compulsory HIV testing and material requirements and trans-
portation were perceived to prevent some pregnant women from attending ANC.
Conclusions: Identifying local barriers to ANC utilization are important and should be considered when planning
ANC programs. We propose that future efforts should focus on how to ensure a good patient-provider re-
lationship and perceived quality of care, and further how to improve inter-spousal communication and sensi-
tization of husbands for increased involvement in ANC. We recommend more research on how socio-cultural
context can meaningfully be aligned to ANC to improve maternal health and reduce maternal mortality.
Introduction appropriate nutrition and recognizing complications [6]. This is

achieved by providing a platform for important health care functions,
The burden of maternal mortality continues to be a great public including health education, screening, diagnosis and disease prevention
health concern and is part of the Sustainable Development Goals fra- [5]. Evidence suggests that ANC not only saves lives but is critical in
mework [1]. Despite global efforts to improve maternal health out- improving health status, quality of care and health service utilization
comes, reducing maternal mortality rates (MMR) remain a key chal- [5]. The government of Uganda encourages the use of ANC during
lenge in many developing countries [2], including Uganda. The MMR in pregnancies [4]. However, according to the most recent data from
Uganda remains high at 336 deaths per 100,000 [3,4]. As a model to 2016, the proportion of pregnant women in Uganda who received the
improve maternal health and prevent maternal mortality, the World recommended number of ANC visits was only 60% [3]. Inadequate use
Health Organization recommends that pregnant women in developing of ANC services may pose a significant health risk for both mothers and
countries attend at least four ANC visits in each pregnancy [5]. ANC their children [5,7].
programs are developed to ensure the use of skilled attendants at birth In northern Uganda, the MMR is estimated to be higher than the
and to promote healthy behaviors during pregnancy, such as national average [8]. Northern Uganda is a post-conflict area, which is
⁎
Corresponding author.
E-mail addresses: cecilie@uldbjerg.com (C.S. Uldbjerg), stis@si-folkesundhed.dk (S. Schramm), fkaducu@gmail.com (F.O. Kaducu),
emilio.ovuga@gmail.com (E. Ovuga), msodemann@health.sdu.dk (M. Sodemann).
https://doi.org/10.1016/j.srhc.2019.100464
Received 29 April 2019; Received in revised form 10 October 2019; Accepted 24 October 2019
1877-5756/ © 2019 Elsevier B.V. All rights reserved.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part10@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 27,
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
C.S. Uldbjerg, et al. Sexual & Reproductive Healthcare 23 (2020) 100464
recovering from 20 years (1986–2006) of civil war between Lord’s from Gulu HDSS, not published). Quantitative information on pregnant
Resistance Army and the government of Uganda [9,10]. The conflict women who did not attend ANC during pregnancy was not available
resulted in disruption of health services, damage to the infrastructure from the Gulu HDSS.
and massive population displacement with nearly 90% of the popula- During the qualitative data collection, Awach sub-county was part
tion living in camps as internally displaced persons. After the conflict of an intervention group in a scale-up project to reduce maternal and
ended, resettlement resulted in movement out of camps to rural areas newborn deaths [21]. The study by Sensalire et al. took place from
with poor services [11], posing challenges to access and quality of ANC February 2015 to December 2016 and was in the initial phase of im-
services [8–10]. plementation when data was collected for this study. In 2016 at the end
Previous studies exploring barriers to uptake of ANC and maternal of the scale-up project, Sensalire et al. estimated the MMR to be slightly
health services have indicated that a complex and interrelated set of below the national average, in contrast to previous estimates [21].
barriers affects the utilization of ANC. In Uganda, studies have found
that perceived quality of care [12,13], long distances [6,10,12], lack of Study population
male partner support [12,14,15], lack of financial resources
[6,10,12,16], routine HIV testing [15,17] and cultural barriers The study was based on interviews with seventeen participants: ten
[12,14,18] were inhibiting factors to ANC attendance and number of pregnant women who attended ANC during their pregnancy (ANC
ANC visits. Despite existing literature into factors influencing ANC users), three pregnant women who did not attend ANC during their
utilization, there is a need for a deeper and more context-specific un- pregnancy (ANC non-users), three health workers, and one traditional
derstanding of pregnant women’s uptake of ANC. This will support birth attendant (TBA). The participants were selected through purpo-
development of contextualized and appropriate interventions for im- sive sampling in which participants were selected based on their ex-
proved maternal health in specific settings. Therefore, this study aimed perience and knowledge of ANC utilization in the study setting [22].
to identify perceived barriers to utilization of ANC services in a rural This sampling technique was used to ensure a diverse study population
post-conflict area in northern Uganda. that was information-rich and had in-depth experience to identify de-
scriptive perceptions and perspectives of barriers to ANC utilization.
Methods The selection was based on the following criteria: pregnant women
(currently using/not currently using ANC services), health workers
Study design (nurses/midwives) and traditional birth attendants. Participants were
either recruited through the network of local field assistants working
The study applied a qualitative study design to identify perceived with Gulu HDSS or at the health centers. Identified participants were
barriers to utilization of ANC services in northern Uganda. A phe- invited to participate mainly through face-to-face or phone calls by field
nomenological approach was used to develop the qualitative frame. assistants employed by Gulu HDSS. All participants who were contacted
Phenomenology is a research method that is used to describe how agreed to participate and only one health worker was ultimately unable
human beings experience a certain phenomenon [19,20]. The phe- to participate due to a busy working schedule.
nomenological approach was therefore chosen to explore under- The health workers interviewed were between 29 and 35 years of
standings and perceptions of ANC utilization through the lived ex- age and had between 5 and 15 years of professional experience. In
periences of the selected participants (pregnant women, health workers comparison, the interviewed TBA was 54 years of age and had 27 years
and a TBA). The study design provides a depth of insight and ex- of experience (data not illustrated). The pregnant women interviewed
planations of the phenomenon in order to answer the overall research were between 16 and 38 years of age. Characteristics of pregnant
question: What are the main perceived barriers to utilization of ANC women by ANC-users and ANC non-users are summarized in Table 1.
services in rural post-conflict northern Uganda?
Study setting Data collection
The study was carried out in Awach sub-county, Gulu District, The study used both in-depth interviews and focus group discus-
northern Uganda, under the Gulu Health and Demographic Surveillance sions to capture the participants’ different experiences and perceptions.
System (HDSS). The Gulu HDSS was established in 2010 by Gulu In-depth interviews were used with health workers, ANC non-users and
University to provide a framework for continuous registration and the TBA, whereas focus group discussions were used with ANC users.
monitoring of vital demographic indicators in the post-conflict recovery The different methods of interviewing reflected different sensitivity
process. Awach sub-county has a population of about 17,000 people, of
which approximately 50% are below 15 years of age, and covers Table 1
Characteristics of pregnant women by ANC users and ANC non-users.
250 km2 divided into four administrative parishes. Each parish has a
health center; Awach Health Centre IV, Gwengdiya Health Centre II, ANC users (n = 10) ANC non-users (n = 3)
Paibona HC II and Pukony Health Centre II. All health centers provide
Age
ANC for pregnant women. < 19 1 –
In 2015, about 2,000 women in Awach sub-county were in the re- 19–24 7 –
productive age (15–49 years). Gulu HDSS registered pregnant women > 24 2 3
who attended ANC through a questionnaire-based interview and as- Level of education
sessment of anthropometric measurements. Follow-up was conducted at P1-P4 2 3
the women’s home, at the time they were giving birth. During follow- > P4 8 –
up, the child’s birth weight was measured and a questionnaire-based Previous pregnancies
interview was carried out. During this quantitative data collection from 0 1 –
May 1st 2015 to April 30th 2016, a total of 421 pregnancies were re- 1–2 4 –
>2 5 3
ported. Among the registered women with a live birth, 60% attended
ANC four times during their pregnancy. Additionally, 11% of these Distance to ANC
< 2 km 5 2
women were below 18 years of age and 16% were 35 years of age or
2–4 km 3 1
older; 55% had not completed primary school (P7); 7% were HIV po- > 4 km 2 –
sitive; and 27% reported malaria symptoms during the pregnancy (data
2
levels of the topic among the participants. In-depth interviews were Table 2
chosen for ANC non-users to ensure truthful answers as the topic might Identified categories and subcategories of perceived barriers to utilization of
be considered sensitive. Focus group discussions were chosen for ANC ANC services.
users to stimulate fruitful discussions as the topic was not considered Categories Subcategories
sensitive for this particular group.
Semi-structured interview guides were created in English to facil- Poor quality of care Lack of resources at health centers
Poor attitude of health workers
itate the interviews. The interview guides were developed with broad
Misalignment between ANC and Poor acceptance of cultural practices
open-ended questions to encourage detailed and descriptive percep- socio-cultural practices and beliefs at health centers
tions of the research topic. Examples included, “Why do you think some Lack of support from the husband
women do not attend ANC in your community?” and “Can you tell me during pregnancy
Young or old maternal age
about some of the barriers pregnant women experience in using ANC
Restricting structures and procedures Compulsory HIV testing
services at the health facilities?”. Prior to data collection, the interview at health centers Material requirements and
guides were discussed and pre-tested with a small group from the study transportation
population in close cooperation with local field assistants to match the
specific context. The local field assistants were employed by Gulu
University and had at least one year of experience working with ma- from all participants prior to the start of each interview. Participants
ternal health, including extensive training in interview techniques and were allowed to withdraw from the study at any time.
data collection methods. Final interview guides were reviewed and
approved by senior researchers of the study. Results
Interviews with health workers were carried out in English, and
interviews with pregnant women and the TBA were carried out in the Three overall categories of perceived barriers to utilization of ANC
local language, Acholi Luo. Two local field assistants assisted the data services were identified; (1) poor quality of care, (2) misalignment
collection and acted as interpreters for interviews with pregnant between ANC and socio-cultural practices and (3) restricting structures
women and the TBA. All interviews were facilitated by the first author and procedures at health centers (table 2). Each category including the
and one local field assistant. respective subcategories will be further described and illustrated by
Data was collected in the period between August to October 2015. quotations.
Each interview lasted from one to two hours. Interviews were con-
ducted at private settings outside the health centers or outside parti- Poor quality of care
cipants’ homes. Data collection was continued until the main researcher
and the field assistants sensed to have reached data saturation and Lack of resources at health centers
quality in data. This was indicated by a full understanding of the par- Lack of resources at the health centers was perceived as a crucial
ticipants’ perspective, when the same themes were recurring and no barrier to pregnant women’s ANC utilization. Six of the ten ANC users
new insights were given by additional sources of data. interviewed had experienced long waiting time at the health centers,
mainly due to a shortage of health workers. Two of these stressed that
Data management and analysis pregnant women often have to leave the health centers without re-
ceiving any service:
All interviews were audio-recorded, transcribed and then imported
into NVivo for further analysis. Data was analyzed using inductive It is happening to almost every woman that they will come and sometimes
conventional content analysis, as described by Hsieh and Shannon [23]. not get the midwife – and you will go back home. They will tell you to
This strategy was used to interpret meaning from the content of text come another day. (ANC user, 23 years)
data through a systematic classification process of coding and identi- Sometimes they will not get a health worker at the health center. Because
fying themes. In the inductive approach, the coding categories were here, there have few health workers, so sometimes there are no one at the
derived directly from the text data. The first step included reading the antenatal unit (…) Then they just go home. (ANC user, 24 years)
transcripts several times in order to obtain an overall understanding of
the data and the perceived barriers to utilization of ANC services in the In addition, two participants spoke about episodes in which women
study area. The next step in the analytical process included organizing had to give birth outside the health center because they could not find a
the raw data through an initial open coding to extract all emerging present or available health worker.
codes corresponding to the research question. This helped to direct the
further analysis. In the following step, identified codes were further There was one day, when a woman came and did not find any health
grouped and reduced to a number of categories by combining similar worker. So she delivered from outside. (ANC user, 23 years)
headings into broader categories [23]. For instance “lack of resources at
health centers” and “poor attitude of health workers” were combined Similarly, the health workers expressed a need for more support at
into the overall category “poor quality of care”. In the final step, the the health centers in order to ensure good quality of care to the preg-
identified categories were used to compose possible answers to how the nant women.
participants perceived barriers to utilization of ANC services. The lack of resources was also expressed in terms of shortage in
First and second author critically reviewed and compared the vaccines, commodities, and other supplements for pregnant women.
identified categories and all researcher quality assured the findings to Participants complained that they sometimes could not receive the
ensure reliability. The researchers were both familiar with the local needed medicine or services due to stock-outs.
context and hold degrees in either medicine or public health.
Poor attitude of health workers
Ethical considerations All participants in the study mentioned the attitude of the health
workers as an important factor in receiving good quality of care and in
The Research and Ethics Committees of Gulu University and The deciding whether to attend ANC. About half of the pregnant women,
Uganda National Council for Science and Technology (UNCST) (study both ANC users and ANC non-users, argued that the attitude of many
ref: SS 3407) approved routine procedures by Gulu HDSS, including health workers was poor and that some health workers were profoundly
pregnancy registration and monitoring. Verbal consent was obtained disrespectful and abusive. The fear of being neglected, humiliated or
3
verbally abused was a continuing perceived matter among the pregnant non-user, 38 years)
women. They either described their own past experiences of dis-
respectful behavior from health workers, or they knew of women with Timing of first ANC was perceived as a barrier for not completing all
bad experiences. four recommended ANC visits. This was explained by the cultural
perception that the pregnancy is not officially acknowledged until the
Some of the nurses, they will just abuse you because the way you are stomach is visible. In this regard, the health workers highlighted that
dressed. Maybe they will tell you that you are not smart, and they only many pregnant women do not attend ANC until relatively late in the
want those who are smart. (ANC user, 24 years) pregnancy.
It depends on the nurses, but there was one time, when the nurse started
abusing her, and saying ‘you are not clean and whatever’. (ANC user, They think that, when the stomach is big, then is when you should come.
16 years) (Midwife, 35 years)
Similarly, the TBA stated that many pregnant women come to her Lack of support from the husband during pregnancy
because of mistreatment at the health centers: In Uganda, it is required that the husband accompanies the first
ANC visit. To meet this requirement, the husband has to be willing and
The reason why most women come here is because many nurses just able to attend. The participants indicated several challenges in en-
abuse those mothers – like, ‘I am not the one who put that pregnancy on couraging the husbands to attend ANC. Both the health workers and the
you. You just go away’. (TBA) pregnant women mentioned that it was problematic if the husband was
out of town or unavailable. They explained that in Acholi culture, it is
However, the perceived quality of care by health workers was also common for men to have more than one wife; so the husband might
explained to be depending on the specific health center and the in- stay with another wife in a different location or he might not feel
dividual health worker: committed to the pregnancy.
People like coming for ANC here [one of the health centers in the study Their husbands postpone coming to the health center, maybe because
area], but nurses at another health center [in the study area] like abusing they are having another appointment with another wife. They will tell
people. (ANC user, 23 years) you that let us go tomorrow. (ANC user, 23 years)
The health workers did not indicate any problems with the patient- Additionally, several participants including all ANC non-users ar-
provider relationship in terms of attitudes and quality of care. One gued that many husbands do not understand why it is important for
midwife said she made great efforts in welcoming the pregnant women them to attend ANC. The husbands believed that the pregnancy is the
in a good way so they would come back. wives’ responsibility; therefore, they should not participate or engage in
pregnancy-related matters. Four pregnant women explained how their
Misalignment between ANC and socio-cultural practices husband would either refuse to go to ANC or continue to postpone it.
Poor acceptance of cultural practices and beliefs at health centers When she [participant] wants to go for ANC at the health center, she will
The participants reported that many cultural rituals as part of the first ask the husband. Then the husband will say that “I’m not the one
pregnancy and birth experience are mainly performed after giving who is pregnant, so you have to go alone”. (ANC non-user, 26 years)
birth. However, some cultural behaviors and practices were still per-
ceived to influence ANC utilization. Two of the three ANC non-users Young or old maternal age
explained how they did not believe it was necessary to attend ANC In Uganda, the fertility rate is high; women on average give birth to
unless you experienced complications. This reflected some women’s 5.4 children [3]. Women get pregnant at all ages, both at very young
view that a pregnancy is a healthy state in which there was little reason and very old ages. Nevertheless, ‘unusual’ maternal age was generally
to go to ANC when the perceived health risk was low. If a pregnant perceived as a barrier to ANC utilization among the participants.
woman experienced complications, she would often consult a TBA. In Pregnant women showed great fear in going to ANC because they be-
general, the pregnant women, both ANC users and ANC non-users, lieved that they did not reflect the expected age group to be pregnant.
expressed a positive attitude towards seeking advice and guidance from One ANC non-user explained that the health workers often were young,
local TBAs, especially when only experiencing mild complications. and she believed that she had more experience than them. In addition,
another ANC non-user explained how she refused to attend ANC be-
She [participant] went to the TBA, because she was feeling pain all cause she could meet her own daughters there:
around the waist. So she was given local herbs that helped to stop those
pains. (ANC user, 24 years) She [participant] is having like 5 grandsons and 4 granddaughters. So
She [participant] fears to go to the health center though she is having she fears to go. Even her daughters are going to the health center for the
some problems. Nowadays, she uses traditional herbs from the TBA. antenatal. (ANC non-user, 38 years)
(ANC non-user, 36 years)
In addition, the participants stressed that many pregnant women in
Another perceived cultural barrier was expressed in the position for the study area are teenagers when they get pregnant and the majority of
giving birth at the health centers. Some pregnant women in the study these young girls would fear going to the health centers because of
area feared going to the health centers because they would encourage shame and stigmatization.
you to give birth while lying down. Instead, the cultural practice is to
give birth in a squad position. Some girls fear because of their age. Some are too young to be pregnant
and they fear what other people think. (ANC user, 16 years)
Some people fear to deliver from the health center, because the nurse will
force you to lay down with one leg on one side and your other leg on the Restricting structures and procedures at health centers
other side. (ANC user, 23 years)
She [participant] fears going for delivery at health centers because of Compulsory HIV testing
they way they make you deliver. That’s why she goes for the TBA. (ANC In Uganda, there has been a strong focus on reducing the prevalence
4
of HIV including introducing routine HIV testing as part of the ANC poor quality of care, including poor attitude of the health workers;
services [24]. The health workers reported that this has led to more HIV misalignment between ANC and socio-cultural practices; and lack of
testing at the health centers and several positive effects such as in- support from the husband, including difficulties in encouraging him to
creased knowledge and awareness about HIV in the communities. De- attend ANC. Furthermore, institutional structures and procedures, such
spite a suggested positive impact of the compulsory HIV testing, the as compulsory HIV testing and required materials, were perceived to
participants still perceived the HIV testing as a critical barrier to ANC prevent some pregnant women in the study area from attending ANC.
utilization. They indicated that some pregnant women would fear being Our findings are similar to what has been reported in existing lit-
diagnosed with HIV and therefore avoid attending ANC: erature about barriers to ANC utilization in Uganda [10,12–14,25–28].
Access to high-quality maternal health care has already proven critical
Some people are living positively (HIV), and they may know before they in improving maternal health [13,29]. In this study, the poor perceived
go to the health center. They fear to come because you are going to get quality of care was mostly discussed around a poor attitude of the
tested and diagnosed. (ANC user, 24 years) health workers. We found that some pregnant women in the study area
People fear coming to the health center, because they live positively were reluctant to go to ANC if they perceived the health worker’s at-
(HIV). They will stay at home during the pregnancy and deliver at home, titude as negative and unwelcoming. Other studies from Uganda have
because they know if you reach the health center, the health worker will likewise identified the patient-provider relationship to have a large
know you are HIV positive. (ANC user, 23 years) impact on ANC utilization [12,25,26,29]. These studies indicate that a
negative reputation and perception of health workers and previous
This fear of getting diagnosed with HIV during ANC appeared mistreatment at the health centers can result in fear among pregnant
stronger when women had co-wives. Three of the thirteen pregnant women, which negatively affects their health-seeking behavior and
women in the study were in polygamous marriages and they anticipated utilization of ANC services. A study from northern Uganda emphasized
to be HIV positive and therefore feared to get tested. that the conflict has resulted in multiple challenges for health workers,
including increased workload, longer working days, lack of payment
Her [participant] husband has four other women. So she fears to test for and more complex cases than qualified to care for [11]. Staff motivation
HIV. She fears the result. (ANC non-user, 38 years) and supervision may therefore be important focus points to improve
quality of care in ANC in post-conflict settings, where health system
In addition, participants explained that some husbands would si- governance and management is often poor [30]. Further, there is
milarly hesitate to attend ANC because of the HIV testing. growing consensus that midwifery care contributes to high-quality
maternal services and reduction in maternal deaths. As such, future
Material requirements and transportation planning of ANC may benefit from resource allocation to scale up
In Uganda, health care is free for all pregnant women. However, midwifery practices, including ANC [31]. This resource allocation may
participants still perceived ANC to be associated with some required further support the use of midwife-led continuity of care (MLCC), in
payments. The participants stressed that pregnant women routinely are which pregnant women receive support by a known and trusted mid-
expected to provide certain materials such as a basin, soap, blankets wife throughout the antenatal period. Evidence on the effect of MLCC
and clothing. These materials are required for giving birth at the health report higher level of satisfaction among women and benefits for both
centers as part of the ANC program, though not provided for the mother and babies by experiencing better pregnancy outcomes [32].
pregnant women. The participants emphasized this requirement as a However, MLCC are complex interventions and require that well-
crucial barrier for attending ANC, especially for those with lack of fi- trained midwifes are available in sufficient numbers [5,33]. Due to
nancial resources. significant staffing issues in the study area and similar settings, con-
cerns have evolved around the feasibility of the model in low-resource
In most health centers, health workers will just demand for a lot of things. settings [5]. Despite potential challenges in implementation, struc-
You have to come with a basin and other things. (ANC non-user, turing ANC to incorporate some of the active ingredients of MLCC may
26 years) be worth considering [5]. Sensalire et al. implemented a scale-up pro-
ject with quality improvement strategies in districts of northern
In addition, almost all participants mentioned that pregnant women Uganda, including Awach sub-county [21]. They reported overall po-
would feel ashamed if they could not provide the required materials. sitive trends towards increased ANC utilization and decreased maternal
They would not go to ANC because of fear of humiliation. One parti- and perinatal deaths during the intervention period. A system-
cipant explained how some pregnant women would rather stay at home strengthening approach focusing on quality improvement was sug-
and avoid the embarrassment: gested to address barriers of poor quality of care and strengthen health
systems to reduce preventable maternal and perinatal deaths [21]. This
Sometimes women don’t have money to buy baby things. So they think could be done through training of health workers, community outreach
instead of coming here being ashamed, it is better that they deliver at activities and community mobilization messages.
home. Because from home, nobody will know [that you cannot provide The role of socio-cultural beliefs and practices in relation to preg-
the required materials]. (ANC user, 30 years) nancy was recognized as important in achieving effective ANC utiliza-
tion. In our study, cultural beliefs and practices were identified as
Attending ANC was for also perceived to be associated with pay- consulting TBAs, getting pregnant at a very young/old age, late ac-
ments to transportation, as not all pregnant women lived in walking knowledgement of pregnancy and giving birth in a squad position.
distance to the health centers. Due to lack of financial resources among These key practices in Acholi culture were perceived as not successfully
some pregnant women, this was too perceived as a crucial barrier to aligned to ANC services and negatively impacting ANC utilization in the
ANC. study area. Literature from similar low-income developing countries
have likewise indicated a misalignment between ANC services and
Some women, they don’t want to attend ANC because lack some money cultural practices [34]. Studies specifically from Uganda have re-
to transport. (ANC user, 23 years) cognized a preference of TBAs in some rural areas and suggested that
TBAs sometimes have a more appreciated and accepted role in local
Discussion communities [10,14,28,35]. Some women consider TBAs to have more
experience, be more knowledgeable and be more aware about culture
We identified the main perceived barriers to ANC utilization as: and traditional matters in reproductive health, and thus they appear to
5
have more respect for local conditions of poverty, culture and disease may still be associated with financial stresses [12,25]. In a study from
[25]. Our findings suggested that pregnant women in the study area western region of Uganda, the authors tested cash transfer systems as a
still consult TBAs during pregnancy despite the TBA encouraging method to address this barrier and found that even modest cash in-
pregnant women to attend ANC at the health centers. Whether the TBA centives may improve access to ANC and maternal health services. [43].
actually referred pregnant women to the health centers was not clar-
ified. Other studies exploring cultural barriers to ANC utilization have Strengths and limitations
further emphasized the cultural view and perception of pregnant
women. In some cultures, the social status of pregnant women is linked The main strength of the study was the qualitative phenomen-
to their reproduction and ability to give birth to a healthy baby ological approach to gain knowledge and insight into how the study
[18,28,35]. It is therefore implied that pregnant women should go population perceived barriers to utilization of ANC services. The phe-
unsupported through the pregnancy. This particular cultural view was nomenological approach ensured that data was obtained without im-
not stressed in our study, but participants did explain that many posing preconceived categories, enabling all perspectives and percep-
pregnant women do not perceive it as necessary to attend ANC unless tions to appear. This research methodology could be seen as a limitation
experiencing complications. since the analysis relied heavily on the researchers’ interpretation. To
Another aspect of the socio-cultural beliefs from our study was the avoid individual research bias, the researchers critically reviewed and
perception that men should not necessarily take part in the pregnancy. compared codes and findings. Additionally, researchers were in-
Participants perceived lack of support from the husband as a critical dependent and had no conflict of interest to declare.
barrier to ANC utilization. Previous studies have recognized that en- A limitation of the study was the relatively small sample size. The
couraging and involving husbands in their wife’s pregnancy increases interviews were all considered thick in information and knowledge;
the use of antenatal care services [36–38]. But studies provide different therefore the researchers estimated sufficient depth of understanding
perspectives on how men want to be involved in pregnancy-related without additional interviews. Furthermore, only one TBA was inter-
matters. Some men do not wish to be actively involved in ANC because viewed, as this was the only available TBA that the research group and
they do not understand why it is their responsibility or because it has the local field assistants could identify as preferred by pregnant women.
not been a part of their tradition [14,37]. Similar to our findings, a Purposive sampling was used to identify participants and hence the
recent study from Uganda found that many male partners refuse to take study findings might have limited generalizability to other geographical
part of the ANC due to the compulsory HIV testing [15]. Kaye et al. locations in Uganda.
(2014) argued that men actually want to participate in the pregnancy,
but they do not know their role or what the health care system expects Conclusions
from them [36]. The specific male perspective and perceptions of ANC
was not explored in our study. Long-term observations from our re- Identifying local barriers to ANC utilization are important and
search group have recognized that some women actually felt proud should be considered when planning ANC programs. This research
when they did not involve their husbands in their pregnancy because highlights the significance of improving the quality and utility of ANC
the pregnancy was culturally considered a woman’s affair. It was ob- and provides useful insight into pregnant women’s health seeking pat-
served that many believed that the husband’s love and affection for his terns. In light of these findings, we propose that future efforts in
wife was increased if the wife was able to give birth successfully northern Uganda and similar settings should focus on how to improve
without his involvement (personal experiences with health care prac- engagement between pregnant women and health workers to ensure a
tices in Uganda, data not published). Male involvement interventions good patient-provider relationship and perceived quality of care, and
have been identified as promising to improve maternal health care further how to improve inter-spousal communication and sensitization
[39]. A review by Tokhi et al. determined that interventions to engage of husbands for increased involvement in ANC. We recommend more
men in maternal health have proven to increase health care-seeking research on how socio-cultural context can meaningfully be aligned to
behavior and support couple communication and joint decision-making ANC to improve maternal health and reduce maternal mortality.
[39]. Engaging men through family and community education have
been suggested as effective means of changing attitudes and sensitizing
Funding
men on their involvement in ANC [39]. Strategies to increase women’s
autonomy may further enhance ANC utilization, as women’s autonomy
This research was supported by DANIDA, Denmark (project-code:
has been positively associated with male involvement in maternal
12-057-SDU) and the Centre for Global Health, Department of Clinical
health care and a predictor of pregnant women’s health-seeking beha-
Research, University of Southern Denmark.
vior [16,39,40]. Increasing male partner involvement alone may in fact
have detrimental effects by reinforcing unequal gender relations and
disempower women [39]. Approaches to male involvement must Declaration of Competing Interest
therefore be carefully considered in order to be inclusive and support
women’s autonomy. Inter-spousal communication has in this regard None.
been indicated as a mediating factor in enhancing both women’s au-
tonomy and husband’s involvement [40]. Acknowledgements
The institutional structures and procedures at the health centers
were perceived as restricting in encouraging pregnant women to attend The authors would like to thank all pregnant women who partici-
ANC. Especially the compulsory HIV testing and consequent fear of pated in the study for their time and information. We thank the TBA
being diagnosed with HIV was perceived as a crucial barrier. Other and the health workers for their overall help and collaboration.
studies from Uganda indicate that stigmatization against HIV con- Furthermore, we thank the Gulu HDSS field assistants for their excep-
tributes to a negative health-seeking behavior during pregnancies tional support and hard work during the data collection. The study was
[41,42]. Despite positive intentions of increasing HIV testing and re- conducted as a part of the Gulu HDSS.
ducing HIV-related stigma, routine HIV testing was perceived to affect
ANC attendance by both pregnant women and their partner. Certain Appendix A. Supplementary material
payments in terms of required materials and transportation were also
perceived to prevent some pregnant women from utilizing ANC. Similar Supplementary data to this article can be found online at https://
studies from Uganda have recognized that even though ANC is free, it doi.org/10.1016/j.srhc.2019.100464.
6
References CA: SAGE; 2002.

[23] Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual
Health Res 2005;15:1277–88.
[1] United Nations Department of Economic and Social Affairs. Sustainable [24] Ministry of Health. National Implementation Guidelines for HIV Counselling and
Development Goals Knowledge Platform. United Nations 2015. https:// Testing in Uganda. Kampala: 2010.
sustainabledevelopment.un.org/?menu=1300 (accessed February 4, 2019). [25] Armstrong A. The Impact of Traditions and Traditional Birth Attendants on
[2] World Health Organization. Trends in Maternal Mortality: 1990 to 2015. Geneva: Maternal Mortality: A Case Study of Nyakayojo sub-County, Mbarara District,
2015. Uganda. Undergrad Honor Thesis 2011; 697.
[3] Uganda Bureau of Statistics (UBOS). Demograhic and Health Survey 2016: Key [26] Gloria C. Factors Influencing the Utilisation of Late Antenatal Care Services in Rural
Indicators Report. Kampala, Uganda: 2017. Areas: A Case Study of Kisoro District. Makerere University; 2010.
[4] Ministry of Finance Planning and Economic Development. Millennium Development [27] Kiwanuka SN, Ekirapa EK, Peterson S, Okui O, Rahman MH, Peters D, et al. Access
Goals Report for Uganda 2015. Kampala: 2015. to and utilisation of health services for the poor in Uganda: a systematic review of
[5] World Health Organization. WHO recommendations on antenatal care for a positive available evidence. Trans R Soc Trop Med Hyg 2008;102:1067–74.
pregnancy experience. Geneva: 2016. [28] Kyomuhendo G. Low use of rural maternity services in Uganda: impact of women’s
[6] Bbaale E. Factors influencing the utilisation of antenatal care content in Uganda. status, traditional beliefs and limited resources. Reprod Health Matters
Australas Med J 2011;4:516–25. 2003;11:16–26.
[7] Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal [29] Conrad P, De Allegri M, Moses A, Larsson EC, Neuhann F, Müller O, et al. Antenatal
mortality and serious morbidity? an overview of the evidence. Paediatr Perinat care services in rural Uganda: missed opportunities for good-quality care. Qual
Epidemiol 2001;15:1–42. Health Res 2012;22:619–29.
[8] Namasivayam A, González PA, Delgado RC, Chi PC. The effect of Armed conflict on [30] Mills A. Health systems in low- and middle-income countries. Oxford Handb Heal
the utilization of maternal health services in Uganda: a population-based study. Econ 2012;370:552–7.
PLoS Curr 2017:1–12. [31] Homer CS, Friberg IK, Dias MA, ten Hoope-Bender P, Sandall J, Speciale AM, et al.
[9] Chi PC, Bulage P, Urdal H, Sundby J. Perceptions of the effects of armed conflict on The projected effect of scaling up midwifery. Lancet 2014;384:1146–57.
maternal and reproductive health services and outcomes in Burundi and Northern [32] Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models
Uganda: a qualitative study. BMC Int Health Hum Rights 2015;15:7. versus other models of care for childbearing women. Cochrane Database Syst Rev
[10] Chi PC, Bulage P, Urdal H, Sundby J. A qualitative study exploring the determinants 2015;15.
of maternal health service uptake in post-conflict Burundi and Northern Uganda. [33] Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu A. Provision and uptake of routine
BMC Pregn Childbirth 2015;15:1–14. antenatal services: a qualitative evidence synthesis. Cochrane Database Syst Rev
[11] Namakula J, Witter S. Living through conflict and post-conflict: experiences of 2019.
health workers in northern Uganda and lessons for people-centred health systems. [34] Finlayson K, Downe S. Why do women not use antenatal services in low- and
Health Policy Plan 2014;29. ii6–14. middle-income countries ? a meta-synthesis of qualitative studies. PLoS Med
[12] Anastasi E, Borchert M, Campbell OMR, Sondorp E, Kaducu F, Hill O, et al. Losing 2013;10.
women along the path to safe motherhood: why is there such a gap between wo- [35] Baird MB, Smith CM, Debacco KM. Perspectives of northern Ugandan health pro-
men’s use of antenatal care and skilled birth attendance? a mixed methods study in viders about the effect of cultural beliefs and practices on birth outcomes. Health
northern Uganda. BMC Pregn Childbirth 2015;15:287. Care Women Int 2014:1–16.
[13] Tetui M, Ekirapa E, Bua J, Mutebi A, Tweheyo R, Waiswa P. Quality of Antenatal [36] Kaye DK, Kakaire O, Nakimuli A, Osinde MO, Mbalinda SN, Kakande N. Male in-
care services in eastern Uganda: implications for interventions. Pan Afr Med J volvement during pregnancy and childbirth: men’s perceptions, practices and ex-
2012;13:1–15. periences during the care for women who developed childbirth complications in
[14] Kawungezi PC, Akiibua D, Aleni C, Chitayi M, Kazibwe A, Sunya E, et al. Attendance Mulago Hospital. Uganda. BMC Pregn Childbirth 2014;14:54.
and utilization of antenatal care (ANC) services: multi-center study in upcountry [37] Singh D, Lample M, Earnest J. The involvement of men in maternal health care:
areas of Uganda. Open J Prev Med 2015;5:132–42. cross-sectional, pilot case studies from Maligita and Kibibi, Uganda. Reprod Health
[15] Rudrum S, Oliffe JL, Brown H. Antenatal care and couples’ HIV testing in rural 2014;11:68.
northern Uganda: a gender relations analysis. Am J Mens Health 2017;11:811–22. [38] Tweheyo R, Konde-Lule J, Tumwesigye NM, Sekandi JN. Male partner attendance
[16] Wilson M, Patterson K, Nkalubo J, Lwasa S, Namanya D, Twesigomwe S, et al. of skilled antenatal care in peri-urban Gulu district, Northern Uganda. BMC Pregn
Assessing the determinants of antenatal care adherence for Indigenous and non- Childbirth 2010;10:53.
Indigenous women in southwestern Uganda. Midwifery 2019;78:16–24. https:// [39] Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving
doi.org/10.1016/j.midw.2019.07.005. men to improve maternal and newborn health: a systematic review of the effec-
[17] Larsson EC, Thorson A, Pariyo G, Conrad P, Arinaitwe M, Kemigisa M, et al. Opt-out tiveness of interventions. e0191620-e191620 PLoS ONE 2018;13. https://doi.org/
HIV testing during antenatal care: experiences of pregnant women in rural Uganda. 10.1371/journal.pone.0191620.
Health Policy Plan 2011;27:69–75. https://doi.org/10.1093/heapol/czr009. [40] Thapa DK, Niehof A. Women’s autonomy and husbands’ involvement in maternal
[18] Atekyereza P, Mubiru K. Influence of pregnancy perceptions on patterns of seeking health care in Nepal. Soc Sci Med 2013;93:1–10. https://doi.org/10.1016/j.
antenatal care among women in reproductive age of Masaka District Uganda. socscimed.2013.06.003.
Tanzan J Health Res 2014;16:1–12. [41] Ashaba S, Kaida A, Coleman JN, Burns BF, Dunkley E, O’Neil K, et al. Psychosocial
[19] Creswell JW. Qualitative Inquiry & Research Design: Choosing among Five challenges facing women living with HIV during the perinatal period in rural
Approaches. 3. Thousand Oaks. CA: SAGE; 2013. Uganda. PLoS ONE 2017;12:1–15.
[20] Creswell JW. Research design: Qualitative, Quantitative, and Mixed Methods [42] Courtney KN, Alexander CT. Proximate context of HIV-related stigma and women’s
Approached. 4. Thousand Oaks. CA: Sage Publications; 2009. use of skilled childbirth services in Uganda. AIDS Behav 2017;21:307–16.
[21] Sensalire S, Isabirye P, Karamagi E, Byabagambi J, Rahimzai M, Calnan J. Saving [43] Kahn C, Iraguha M, Iraguha M, Baganizi M, Kolenič GE, Paccione GA, et al. Cash
mothers, giving life approach for strengthening health systems to reduce maternal transfers to increase antenatal care utilization in Kisoro, Uganda : a pilot study. Afr
and newborn deaths in 7 scale-up districts in northern Uganda. Glob Heal Sci Pract J Reprod Health 2015;19:144–50.
2019;7:S168–87.
[22] Patton MQ. Qualiative research and evaluation methods. 3rd ed. Thousand Oaks,
7
Comment
Postnatal care: increasing coverage, equity, and quality

As the Millennium Development Goals came to a guidelines? Is care provided to the mother–baby dyad Published Online
May 12, 2016
close last year and we entered the new Sustainable integrated, culturally-sensitive, and patient-centred? http://dx.doi.org/10.1016/
Development Goals (SDGs) era, the global health Is increased service use contributing to improved health S2214-109X(16)30092-4
community took stock of accomplishments over the outcomes? Quality of care encompasses many complex For the SDG3 targets
see https://sustainable
past decades and continuing challenges for the future. notions that need to be unpacked, including the development.un.org/sdg3
Despite impressive reductions in maternal and under-5 possibility of iatrogenesis that can occur when the level
mortality rates, neonatal mortality reduction continues of quality is poor or unknown.9
to lag behind.1 Neonates account for an increasing share Strengthening health systems is crucial for improving
of child deaths, now reaching almost half (45%) of the the quality of care for mothers and neonates. To increase
burden of under-5 mortality.1 the responsiveness of systems and improve quality, it
Most maternal and infant deaths occur in first 42 days is essential to improve infrastructure and equipment;
after childbirth.1,2 Despite the critical importance of this access to energy, water, and sanitation; and recruitment,
period for both maternal and child survival,3 postnatal training, and retention of health workers. Postnatal care
care consistently has among the lowest coverage quality needs to be addressed at the facility, household,
of interventions on the continuum of maternal and and community levels.3 Pregnancy surveillance, health
child care, with a reported median for the Countdown education, promotion of facility use, and limited
countries at just 28%.4 To reduce mortality and improve preventive, diagnostic, and curative treatments can be
health and survival rates of neonates, both access to and carried out in households and at community levels.10
quality of services must be addressed. Tracking and improving the quality and increasing
We are in the midst of a paradigm shift for antenatal “effective coverage”—ie, coverage of quality postnatal
and intrapartum care: from focusing mainly on coverage content11—at facility and community levels should thus
to also considering quality as an essential component of be one of the priorities for the new global health agenda.
improving health systems, as stated in the WHO vision Addressing quality also means paying close attention
on quality of care5 and other efforts. For intrapartum to equity and advancing policies that help reduce
care, poor quality at facilities, perceived or actual, is disparities between advantaged and more vulnerable
now recognised as an important deterrent to care people. Poorer, less educated, and rural women have
seeking and use.6 Just as women who felt that their been shown to have lower coverage of postnatal
antenatal care was of poor quality will not return for care;12 these are the same disadvantaged groups
intrapartum care,7 families will not bring neonates for that experience more discrimination and disrespect
postnatal care visits at facilities if they are discouraged in facilities as well.6 Reducing barriers to access,
by staff or treated poorly at prior visits.8 Yet discussions including distance and cost, are imperative. Efforts to
on reproductive and obstetric care have to date mitigate inequities in transport to facilities, such as
insufficiently addressed the critical issue of quality of bus and voucher schemes, have shown effectiveness
postnatal care services. in improving equity of access.12 Yet more effort and
The SDGs include a specific target on neonatal investment is needed in ensuring services for all are
mortality rate reduction. Nevertheless, this is an accessible and high quality.
indicator of mortality and falls short of measuring the It took a long time for the global health community to
content and quality of care. Efforts to improve postnatal seriously address the quality of the content of antenatal
care need to include more sensitive metrics for care and intrapartum care, beyond coverage indicators.
monitoring progress not only of population coverage, We need to learn from this experience and ensure that
but quality and patient satisfaction as well. What is quality and integration of postnatal care for mothers
needed is greater attention on the content of postnatal and neonates gets political attention and investment
care itself: for example, which specific interventions sooner. It is incumbent on us to accelerate the trajectory
are delivered to parturient women and neonates? Are and talk about content and quality for postnatal care
these interventions following state-of-the-art clinical within continuing efforts to increase coverage and
Downloaded for Fakultas Kedokteran

www.thelancet.com/lancetgh Universitas
Vol 4 July 2016 Muslim Indonesia (eucrasia2018part10@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on Marche442
27,
Comment
equity. The time to unpack the “black box” of postnatal 1 Lawn JE, Blencowe H, Oza S, et al. Every Newborn: progress, priorities, and
potential beyond survival. Lancet 2014; 384: 189–205.
care services delivery is now and greater attention 2 Ronsmans C, Graham WJ, Lancet Maternal Survival Series steering group.
should be provided to quality postnatal care in research, Maternal mortality: who, when, where, and why. Lancet 2006;
368: 1189–200.
For the Global Strategy for policy, and practice. The Global Strategy for Women’s, 3 Tinker A, ten Hoope-Bender P, Azfar S, Bustreo F, Bell R. A continuum of
Women’s, Children’s and
Adolescents’ Health, 2016–
Children’s and Adolescents’ Health 2016–2030 aims to care to save newborn lives. Lancet 2005; 365: 822–25.
4 Victora CG, Requejo JH, Barros AJ, et al. Countdown to 2015: a decade of
2030 see http://www.who.int/ help people survive, thrive, and transform; thus, the new tracking progress for maternal, newborn, and child survival. Lancet 2015;
life-course/partners/global- published online Oct 22. http://dx.doi.org/10.1016/S0140-
strategy/global-
era cannot only be about survival, but efforts must be 6736(15)00519-X.
strategy-2016-2030/en/ made to improve and transform health systems. Quality 5 Tuncalp O, Were WM, MacLennan C, et al. Quality of care for pregnant
women and newborns—the WHO vision. BJOG 2015; 122: 1045–49.
needs to be understood and addressed if we are serious
6 Bohren MA, Vogel JP, Hunter EC, et al. The mistreatment of women during
about reducing neonatal, maternal, and child mortality; childbirth in health facilities globally: a mixed-methods systematic review.
PLoS Med 2015; 12: e1001847.
progressing toward universal health coverage; and 7 Berhan Y, Berhan A. Antenatal care as a means of increasing birth in the
achieving the SDGs. health facility and reducing maternal mortality: a systematic review.
Ethiopian J Health Sci 2014; 24 (suppl): 93–104.
8 Sacks E, Kinney MV. Respectful maternal and newborn care: building a
*Emma Sacks, Étienne V Langlois common agenda. Reprod Health 2015; 12: 46.
9 Chaturvedi S, Randive B, Diwan V, De Costa A. Quality of obstetric referral
Department of International Health, Johns Hopkins School of services in India’s JSY cash transfer programme for institutional births: a
Public Health, Washington, DC, USA (ES); and Alliance for Health study from Madhya Pradesh province. PLoS One 2014; 9: e96773.
Policy and Systems Research, World Health Organization, Geneva, 10 World Health Organization. WHO recommendations on postnatal care of
Switzerland (EVL) the mother and newborn. Geneva: World Health Organization, 2014.
11 Hodgins S, D’Agostino A. The quality-coverage gap in antenatal care:
esacks@jhu.edu toward better measurement of effective coverage. Glob Health Sci Pract
We thank Özge Tuncalp and Steve Hodgins for their review and feedback on a 2014; 2: 173–81.
draft of this piece. We declare no competing interests. 12 Langlois EV, Miszkurka M, Zunzunegui MV, Ghaffar A, Ziegler D, Karp I.
Inequities in postnatal care in low- and middle-income countries:
© Copyright Sacks et al. Open Access article distributed under the terms of a systematic review and meta-analysis. Bull World Health Organ 2015;
CC BY-NC-ND. 93: 259–70.
e443 ClinicalKey.com by Elsevier
www.thelancet.com/lancetgh Vol 4onJuly
March
201627,
p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1
Available online at www.sciencedirect.com
Public Health
journal homepage: www.elsevier.com/puhe
Original Research
Antenatal care and skilled birth attendance in

Bangladesh are influenced by female education and
family affordability: BDHS 2014
J. Bhowmik a,*, R.K. Biswas b, M. Woldegiorgis a

a
Department of Statistics Data Science and Epidemiology, Swinburne University of Technology, Australia
b
Transport and Road Safety Research, University of New South Wales, Australia
article info abstract
Article history: Objectives: Antenatal care (ANC) during pregnancy and skilled birth attendance (SBA) during
Received 29 June 2018 delivery are important policy concerns to reduce maternal deaths. Bangladesh is one of the
Received in revised form developing countries which has made remarkable progress in both services during the last
11 February 2019 couple of decades by improving the SBA service rate from 16% in 2004 to 42.1% in 2014.
Accepted 26 February 2019 However, this rate remains below the targeted level (50%) of the Health Population and
Available online 13 April 2019 Nutrition Sector Development Program set by the Ministry of the Health and Family Wel-
fare of Bangladesh. This article explored the sociodemographic factors associated with the
Keywords: ANC and SBA service attainment. Furthermore, the possible implication of using ANC on
Maternal health SBA was also investigated.
Bangladesh Study design: The study followed a cross-sectional design using the Bangladesh de-
Education mographic and health survey 2014, with a sample of size 4603 women with at least one live
Sociodemographic factors birth 3 years preceding the survey.
Heath services Methods: Following a bivariate analysis, linear mixed-effect models were used to assess the
Health policy relationship between sociodemographic factors and the outcome indicators (ANC and
SBA). Finally, the association between SBA and ANC was evaluated through another mixed-
effect model.
Results: Wealth index, participation in household decisions, and partner's and respondent's
education were significant predictors of ANC; whereas, residence, age at first birth, wealth
index, working status, participation in household decisions, and partner and respondent's
education were significant for SBA. Female education and household affordability were the
strongest predictors for both ANC and SBA. ANC showed significant association with SBA
as women accessing essential ANC during delivery seemed to be 4 times more likely (95%
confidence interval: 3.05e5.93) to avail SBA services.
Conclusions: Overall, four factors were significant: residence, wealth index, education, and
ANC access. Women residing in urban areas, having higher financial solvency, completing
higher education, and accessing ANC by skilled personnel were more likely to receive SBA
at delivery than their counterparts. Accessibility to skilled care during pregnancy leads to
increased professional care during delivery. Thus, policies to encourage women and heads
* Corresponding author. Tel.: þ61 3 9214 8367

E-mail addresses: jbhowmik@swin.edu.au (J. Bhowmik), RaajKishore.Biswas@student.unsw.edu.au (R.K. Biswas), mwoldegiorgis@
swin.edu.au (M. Woldegiorgis).
https://doi.org/10.1016/j.puhe.2019.02.027
0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
114 p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1
of families to seek skilled care during pregnancy would be beneficial to reach the maternal
healthcare targets of Bangladesh.
© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
as a qualified carer, which was considered as the definition of

Introduction SBA in this study as well.24 Contrarily, orthodox village doc-
tors without academic qualifications, uncertified community
During the last couple of decades, Bangladesh has experi- workers, and untrained conventional midwives are consid-
enced remarkable success in public health sector despite ered as TBAs.
being a low-income country.1e3 Bangladesh also performed The healthcare system in a developing country like
well with the targets of Millennium Development Goals Bangladesh is compromised in multiple sectors, particularly for
(MDGs) 2015, particularly in reduction of maternal and child women who have limited physical and financial access to
mortality. For example, the maternal mortality ratio (MMR) health facilities, small window for personal opinion and
and infant mortality rate per 100,000 live births declined from decision-making authority in the family, and almost no edu-
507 to 149 in 1990 to 209 and 53 in 2010, respectively.4 As such, cation or health awareness.25e27 In developing countries, most
the country is also believed to be on the track to achieve the of the women still have deliveries at home with the aid of un-
Sustainable Development Goals (SDGs).5e8 One of the objec- certified TBAs.28 Similar situation persists in Bangladesh where
tives of Bangladesh National Strategy for Maternal Health the rate is below the target (50%) set by the Ministry of the
2014e2024 is to bring down the current MMR of 176 per 100,000 Health and Family Welfare of Bangladesh Government.29 The
live births to 50 by 2024.9,10 However, according to the recent latest BDHS 2014 revealed that the percentage of deliveries
MDG progress report, Bangladesh performed poorly with attended by SBA in Bangladesh increased from 16% in 2004 to
scoring below the median point (36 on a scale from 0 to 100; 42% in 2014.24 However, the coverage varied across different
details in Lim et al. [2016]) in skilled birth attendance (SBA) population groups; for example, rural women were disadvan-
service performance.11 taged from maternal health services because of financial
It is well-known that a part of the maternal service utili- hardship and lack of education.12,30 There were solicited mul-
zation is access to antenatal care (ANC) and skilled birth as- tiple stipend programs, both to educate mothers and train new
sistants during delivery.12 Delivery assisted by a skilled birth SBAs, in rural Bangladesh.31,32,15 However, there were multiple
attendant (SBA is aimed to reduce MMR and any other controversies regarding the effectiveness of these training
complication that could occur during delivery). Multiple public programs and skill-set of the providers of ANC and SBAs (e.g.
and non-governmental programs are currently active to train competence of SBAs in practical field and lack of community
traditional birth attendants (TBAs) and increase the aware- involvement).33,13 Even then, SBAs are considered effective as-
ness in the population.13e16 Bearing in mind that these sets to reduce maternal mortality rate in Bangladesh.10,9
training programs are running for decades, this study aimed The deployment of SBAs at delivery is low in Bangladesh.
to explore the sociodemographic factors associated with the This study aimed to analyze factors affecting utilization of
attainment of these services in Bangladesh, which would help ANC and SBA services during delivery in Bangladesh using the
identify the vulnerable cohorts of women that require greater information from BDHS 2014. A limited number of studies
attention. The contribution of ANC in accessing SBA would be assessed the sociodemographic determinants of delivery by
evaluated as well. SBAs and subsequent effect of ANC on SBA services in
Skilled birth attendants generally refer to health pro- Bangladesh. For example, Islam et al. found that women's
fessionals, particularly doctors, nurses, and midwives, who occupation, household income, ANC by SBAs, and complica-
are trained to provide health care to mothers and newborn tion during pregnancy have significant association with the
babies before and during delivery to manage normal deliveries delivery by SBA using a cohort from a subdistrict of Narsingdi
and diagnose, manage, or refer obstetric complications.17e20 district in Bangladesh.34 A review of the existing literature on
ANC refers to the care given before delivery including medi- the subject also reveals a growing research focus on exam-
cal interventions and advice to mothers during pregnancy.21,22 ining the factors that affect maternal healthcareeseeking
In Bangladesh, the nurse and midwives who typically have 4 behavior,35 with previous studies indicating that such
years of training through government or non-governmental behavior is influenced by various personal, sociocultural, and
organizations and instructed to provide skilled obstetric care environmental factors, such as individual perceptions of
including management of normal labor, medical treatment of health, self-efficacy, motivation, social values, and belief
problem pregnancies, and neonatal care are referred to as systems.36e38 Another study noted that women's education,
SBAs, in addition to the qualified doctors and gynecologists, religion, and household economic backgrounds are important
who also provide these services.23 According to the report of predictors for SBAs service uptake.39 Residence and educa-
Bangladesh Demographic and Health Survey (BDHS) 2014, a tional status are key factors as well for SBA service uptake.
qualified doctor, nurse, midwife, paramedic, family welfare This study noted that women living in urban areas and having
visitor (FWV), community skilled birth attendant, or sub- higher education with greater financial capacity are more
assistant community medical officer (SACMO) is considered likely to access SBA services.40 In addition to the effects of
p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1 115
these socio-economic factors, SBA services are further (‘No’), and the rest who decided these herself or together with
affected by the shortage of work force in the health sector, her husband was considered as participated in family de-
with approximately five physicians and two nurses per 10,000 cisions (‘Yes’).
population in Bangladesh, whereas countries like Australia
and Germany have 120e140 nurses for similar population Statistical analysis
ratio.41,9,42
With the aim of addressing the individual, fertility, and In computing ANC and skilled birth attendance services in-
contextual variables that could affect the service delivery of dicators, multiple responses were managed by considering
ANC and SBAs all over Bangladesh, this study warranted an one provider for each indicator. In this regard, the one with
evaluation of the most vulnerable households that lack the the highest qualification was considered for those who re-
services of ANC providers and SBAs. Findings from this study ported more than one attendant during the course of their
should help to improve the health policy to achieve the goal of pregnancy and/or during delivery. Models were adjusted by
50% of deliveries through SBAs set by Bangladesh and also to the cluster-wise effects.44
take Bangladesh one step closer to achieving the maternal As both outcomes (ANC and SBA services) were binary, a
mortality target of the United Nations SDGs.29 regression model with binomial family of distributions would
be suitable. As BDHS data were collected from 600 clusters,
there is a requirement to adjust these for generalization of the
Methods outcomes. A mixed-effect model where clusters were
adjusted using random effect would be acceptable, which is
Data overview used to assess applied research on DHS data sets.45 This
model is a common approach to fit multivariate distributions
BDHS, a nationally representative cross-sectional survey, has for non-normal data incorporating random effects into the
been conducted in Bangladesh since 1993 collaborating with linear predictors.46 To express the basic model, let Y be the
the Demographic and Health Survey (DHS), operated by Mea- observed data vector and, conditional on the random effects,
sure DHSþ.43,24 A list of enumeration areas (EAs) from the u, assume that the elements of Y are independent and drawn
census is used as the sampling frame.24 Two-stage stratified from a distribution in the exponential family; assuming a
cluster sampling techniques are used for this survey. In the first distribution for u depending on parameters, D47
stage, 600 EAs (or clusters) are selected using probability pro-
portional to size sampling method. In the second stage, an f(yiju) (yju,b,4) ¼ exp{(yhi c(hi))/a(4) þ d(y,4)}u ~ fu(ujD) (1)
equal probability systematic sampling method is applied to
draw an average of 30 households from each cluster. This study Here, hi ¼ x'ib þ z'iu, with x'i represents ith row of the fixed
used the most recent BDHS of 2014, where only the females effect X and z'i is the same for random effect Z. The mixed-
were considered as respondents and the temporary (de jure) effect models were fitted using R package glmer (lme4).
residents were excluded in the sample. Of 17,863 women of Linear mixed-effect model with binary outcome variable
reproductive health age group (15e49 years) surveyed in 2014, was used to assess the significance of the relationships be-
4603 had at least one live birth 3 years preceding the survey. tween the sociodemographic factors and outcome indicators
(ANC and SBA services). Following the mixed-effect models,
Outcome and exposure variables association between SBA services and ANC was evaluated
again through a mixed-effect model. All computations were
This study assessed predictors of ANC and SBA in Bangladesh. conducted in SPSS (version 23) and R (3.5.0).
Both outcomes were binary. In grouping the service providers
as to skilled and other providers, BDHS 2014 report as well as
DHS VI standard recode manual were followed.43 As explained Results
earlier, a qualified doctor, nurse, midwife, paramedic, FWV,
Medical Assistant (MA), and SACMO were considered as skil- Descriptive analysis
led ANC providers and SBAs. Based on previous literature and
pre-analysis, the selected sociodemographic factors were as Table 1 shows the distribution of the women during their
follows: age at first cohabitation (years); age at first birth reproductive age across different sociodemographic factors.
(years); number of living children (numeric); number of chil- Among the 17,863 women with at least one live birth 3 years
dren that died (numeric); residence (urban, rural); wealth preceding the survey, the average age of the participants was
index (poorest, poorest, middle, richer, richest); working sta- 31 years (standard deviation [SD] ¼ 9.2), whereas the average
tus (yes, no); participation in family decisions (yes, no); edu- age at first marriage and first birth was 16 years (SD ¼ 3)
cation of both respondent and her partner (none, primary, and 18 years (SD ¼ 3.4), respectively. The mean number of
secondary, higher); and birth order of children. ‘Participation living and deceased children per woman was 2.2 and 0.22,
in family decisions’ was based on four questions asked during respectively. Table 2 presents distribution of SBA by
interviews: whether the woman participates in decisions on different groups corresponding to the sociodemographic
how to spend respondent's earnings, respondent's health care, variables. More than two-thirds of the study participants
large household purchases, and visits to family or relatives. A (71%) resided in a rural area. With regard to wealth
participant who did not take any one of these decisions was index, there was nearly equal distribution of participants
considered that she did not participate in family decisions across each quintile as designed by the survey through
116 p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1
Table 1 e The distribution of the women aged 15e49 years and those who had a live birth in the 3 years preceding the
survey across the selected sociodemographic variables (continuous).
Sociodemographic variables All women 15e49 years Women with live birth
N Mean (SD) N Mean (SD)
Respondent's current age (years) 17,863 30.8 (15.0) 4603 24.6 (8.0)
Age at first cohabitation (years) 17,863 15.8 (3.0) 4603 16.3 (4.0)
Age of respondent at 1st birth (years) 16,153 17.9 (3.0) 4603 18.3 (4.0)
Husband's age (years) 16,840 39.5 (18.0) 4538 32.9 (9.0)
Number of living children (n) 17,863 2.3 (2.0) 4603 2.0 (2.0)
Number of deceased children (n) 17,863 0.22 (0.0) 4603 0.15 (0.0)
SD, standard deviation.
Table 2 e The distribution skilled antenatal care and skilled birth attendance (for the most recent birth) by
sociodemographic factors (categorical), among women aged 15e49 years who had a live-birth in 3 years preceding the
survey, BDHS 2014.
Sociodemographic Group N (%) of N (%) of women % of skilled % of skilled
variables all study with live birth Antenatal delivery
participants care
Residence Rural 12,816 (71.1) 3302 (65.5) 63.0 36.3
Urban 5047 (28.3) 1201 (34.5) 82.1 61.3
Wealth index Poorest 3359 (18.8) 998 (18.2) 39.8 18
Poorer 3408 (19.1) 870 (18.8) 60.1 30.1
Middle 3560 (19.9) 880 (20.3) 69.6 39.3
Richer 3758 (21.0) 949 (21.1) 78.8 52.8
Richest 3778 (21.1) 906 (21.6) 92.3 75.2
Division Barisal 1111 (6.2) 268 (12.0) 65.2 36.9
Chittagong 3301 (18.5) 1007 (16.0) 69.1 43.3
Dhaka 6223 (34.8) 1626 (17.3) 68.7 45.2
Khulna 1838 (10.3) 369 (14.5) 80.4 58.8
Rajshahi 2103 (11.8) 463 (14.1) 68.9 41.9
Rangpur 2056 (11.5) 443 (14.2) 66.7 38.6
Sylhet 1232 (6.9) 427 (12.0) 54.9 27.6
Working status No 11,950 (66.9) 3517 (76.4) 61.6 45.5
Yes 5912 (33.1) 1086 (23.6) 70.1 34.1
Participated in No 9000 (77.6) 2537 (70.6) 71.8 41.9
household decisions Yes 2600 (22.4) 502 (29.4) 58.2 41.5
Respondent's education None 4455 (24.9) 652 (23.6) 43.5 17.5
Primary 5209 (29.2) 1286 (29.3) 55.5 29.9
Secondary 6679 (37.4) 2194 (37.6) 76.8 50.1
Higher 1520 (8.5) 471 (9.6) 93.3 79.6
Husband/partner's None 5189 (29.1) 1097 (28.3) 48.6 21.9
education Primary 4879 (27.3) 1383 (27.2) 59.3 33.2
Secondary 5325 (29.8) 1456 (29.5) 79.8 51.8
Higher 2467 (13.8) 664 (15.0) 90.9 77.6
Order of birth First 3960 (22.2) 1837 (22.3) 74.7 53.1
Second 4746 (26.6) 1388 (26.4) 70.3 44.5
Third 3392 (19.0) 743 (18.6) 64.0 34.5
Forth and above 5764 (32.3) 635 (32.7) 48.9 18.9
ANC No 1415 (31.9) 1407 (31.9) 17.5
Yes 3015 (68.1) 3000 (68.1) 55.2
BDHS, Bangladesh Demographic and Health Survey; ANC, antenatal care.
principal component analysis (PCA),43 ranging between and visits to family or relatives. Education status of partici-
18.8% (poorest) and 21.1% (richest). pants and their partners showed that while about 74% of
The distribution of women who participated in the survey women succeeded in completing primary school, about 72%
and who had at least one live birth 3 years preceding the of the husbands achieved the same level of education. About
survey across the six divisions (regions) ranged from 12% 80% of Bangladesh women who participated in the survey
both in Barisal and Sylhet to 17% in Dhaka (Table 2). Only 22% were multipara, having more than one live birth or having
of women responded that they participated in all four major twins.
family management decisions regarding respondent's earn- Although ANC and SBA services in Bangladesh reached
ings, respondent's health care, large household purchases, 68% and 43%, respectively, of those with live births 3 years
p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1 117
preceding the survey, the coverage significantly varied across in urban areas had higher likelihood to attain SBA services
different background variables. While 82% and 61% of urban (1.69 times) compared with rural residents, as expected.
dwellers received ANC and SBA services, respectively, only Similarly, a greater age at child birth lead to skilled medical
63% and 36% of rural residents had access to these services. attendance. The richest households had 5.08- and 4.31-times
The highest improvement in the services uptake was observed greater odds of seeking ANC and SBA, respectively, in refer-
across increasing educational status and wealth index of the ence to the poorest households. However, both ANC and SBA
participant. Even though only 10% of women completed services showed a negative association with women's partic-
higher education, 93% of these women received ANC and 77% ipation in household decisions. Education of the women was
received SBA service, while only 18% of those with no edu- observed as a significant positive indicator, with women who
cation accessed SBA service. Similarly, the coverage increased received higher education were over 3 times more likely to
significantly from the lower quartile to upper quintile from attain these services (Table 3). Similarly, husband or partner's
below 40% to over 75%. Over 68% women had at least one ANC education was not significant for attaining ANC and SBA
service from a skilled provider during the course of their services.
pregnancy, and the coverage of skilled delivery among those
was 55%. However, only 17% of the pregnant women who Association between SBA service and ANC
never received ANC service were attended by skilled
personnel during delivery. As ANC is acquired by women during pregnancy and before
delivery, there is a natural expectation that women who seek
Mixed-effect model SBA might already have received ANC services. As the 2 2
Table 4 shows, women who attained ANC, almost 56% of them
The association of each sociodemographic variable with ANC had SBAs during delivery. Both ANC and SBA had a significant
and SBA services are presented in Table 3. Wealth index, association (c2(1) ¼ 561.93, P < 0.001). It was interesting to find
participation in household decisions, and partner and re- a cohort of 249 women with live births who received SBA
spondent's education were significant for ANC; however, services but not the skilled ANC. A further analysis on the
residence, age at first birth, wealth index, working status, distribution of this cohort showed that the mean age of the
participation in household decisions, and partner and re- participants (mean ¼ 24.7, SD ¼ 6.1) was about 8 years lower
spondent's education were significant for SBA. Women living than the overall study participantsdwomen with a live birth 3
Table 3 e Mixed-effect model fitted with antenatal care and skilled birth attendance to the sociodemographic factors, where
cluster-wise variations were considered as random effect.
Sociodemographic factors Antenatal care Skilled birth attendance
Odds ratio (95% CI) P-value Odds ratio (95% CI) P-value
Random effect (variance) 1.914 1.789
Residence (ref: Rural)
Urban 1.10 (0.86, 1.42) 0.439 1.69 (1.35, 2.11) <0.001
Age at first cohabitation 0.98 (0.94, 1.03) 0.467 0.96 (0.92, 1.00) 0.061
Age at first birth 1.05 (1.01, 1.09) 0.027 1.09 (1.05, 1.13) <0.001
Wealth index (ref: poorest)
Poorer 1.52 (1.21, 1.90) <0.001 1.47 (1.14, 1.91) 0.003
Middle 2.04 (1.59, 2.60) <0.001 1.91 (1.47, 2.49) <0.001
Richer 2.61 (1.98, 3.42) <0.001 2.46 (1.87, 3.24) <0.001
Richest 5.08 (3.50, 7.38) <0.001 4.31 (3.13, 5.93) <0.001
Number of living children 0.88 (0.75, 1.02) 0.095 0.83 (0.66, 1.03) 0.093
Number of children died 1.00 (0.81, 1.24) 0.992 0.98 (0.74, 1.28) 0.861
Working status (ref: No)
Yes 0.92 (0.76, 1.11) 0.377 0.76 (0.63, 0.92) 0.004
Participation in household decisions (ref: No)
Yes 0.81 (0.68, 0.96) 0.015 0.78 (0.66, 0.93) 0.005
Respondents education (ref:none)
Primary 1.30 (1.02, 1.66) 0.035 1.33 (1.00, 1.77) 0.051
Secondary 1.98 (1.52, 2.58) <0.001 1.87 (1.40, 2.51) <0.001
Higher 3.45 (2.05, 5.83) <0.001 3.33 (2.20, 5.04) <0.001
Partners education (ref: none)
Primary 1.04 (0.85, 1.28) 0.699 1.20 (0.96, 1.50) 0.118
Secondary 1.74 (1.37, 2.21) <0.001 1.48 (1.17, 1.89) 0.001
Higher 2.81 (1.87, 4.23) <0.001 2.52 (1.82, 3.50) <0.001
Order of birth (ref: First)
Second 1.15 (0.78, 1.69) 0.482 1.04 (0.65, 1.67) 0.862
Third 1.03 (0.63, 1.70) 0.894 0.93 (0.49, 1.76) 0.817
Fourth 1.08 (0.57, 2.01) 0.821 1.00 (0.43, 2.32) 0.999
CI, confidence interval.
118 p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1
Table 4 e 2 £ 2 table for SBA and ANC with Chi-squared Table 5 e Mixed-effect model fitted skilled birth
test of association. attendance to ANC adjusted by other sociodemographic
Skilled birth P-value factors, where cluster-wise variations were considered as
attendance (c2(1) test) random effect.
Sociodemographic factors Odds ratio (95% CI) P-value
No Yes
Random effect (variance) 1.441
Antenatal No 1158 249 (17.7%) <0.001
Residence (ref: Rural)
care (82.3%)
Urban 1.68 (1.23, 2.31) 0.001
Yes 1331 (44.4%) 1670 (55.6%)
Age at first birth 1.05 (1.00, 1.10) 0.037
Working status (ref: No)
years preceding the survey; however, their age at first mar- Yes 0.73 (0.52, 1.01) 0.056
riage (mean ¼ 18.7, SD ¼ 3.1) was 1 year higher than the overall Wealth index (ref: poorest)
Poorer 1.39 (0.88, 2.20) 0.155
participants (Tables A and B in supplementary file - see
Middle 1.90 (1.21, 2.97) 0.005
Appendix). Among the participants in this cohort, most of the
Richer 2.26 (1.43, 3.55) <0.001
women resided in rural areas (78.1%) and were reported not Richest 3.58 (2.17, 5.91) <0.001
being engaged in any paid work (73.6%). 43% of this sample Participation in household decisions (ref: No)
had no education or only attained primary education and Yes 0.73 (0.54, 0.97) 0.030
were part of the poor quarter in the wealth index. Respondents education (ref: none)
To test the association between ANC and SBA services, Primary 0.86 (0.50, 1.48) 0.588
Secondary 1.28 (0.76, 2.15) 0.357
another mixed-effect model (cluster as random effect), where
Higher 2.91 (1.45, 5.81) 0.002
ANC was a covariate fitted to SBAs, and the model was Partners education (ref: none)
adjusted by previous significant sociodemographic factors Primary 0.73 (0.43, 1.27) 0.269
(Table 5). ANC showed significant association with SBAs, as Secondary 1.15 (0.70, 1.88) 0.582
mothers who availed appropriate ANC seemed to be four Higher 0.76 (0.46, 1.26) 0.285
times more likely to opt for SBAs, which indicated the possible Antenatal care (ref: No)
Yes 4.25 (3.05, 5.93) <0.001
roll-out of skilled care from pregnancy to delivery.
ANC, antenatal care; CI, confidence interval.
Discussion
Bangladesh. The households belonging to the lower wealth
It is well-established that MMR and utilization of SBA services quintile do not have the capacity to bear the cost of services
are two of the most important metrics of weighing the prog- like ANC and SBA. Two different mindsets generally bar these
ress toward the achievement of the maternal goals of SDGs. families from accessing SBA; first, they do not go to hospitals
Bangladesh registered great headway with the target of MDGs, or access any means of health care as it would be a financial
particularly as the countrywide coverage of SBAs increased trade-off for basic necessities like food and clothing. These
from 5% in 1991 to 42.1% in 2014.3,48 However, despite such compel them to use services from TBAs providing cheap ser-
advancement, the coverage is still lagging behind the target vice in the locality for a long time. TBAs are often referred by
fixed by the Ministry of Health.39,38 Furthermore, in a recent friends and neighbors, encouraging them to choose the
MDG assessment,11 Bangladesh scored only 36 out of 100 in cheaper unprofessional service.51,39,52,50 Second, with limited
SBA performance, which demands more attention on SBAs. trained professionals working in the distant villages (rural and
Part of the maternal healthcare target as MDG assessment is remote areas) of Bangladesh, the SBAs would prefer to serve
also to provide ANC to pregnant women all over the nation.49 those households where they are paid handsomely.10 All
The presence of SBAs is crucial in childbirth to reduce the these add to the travel cost to access SBA services, which
MMR and to achieve the maternal mortality target of the again is cheaper through home delivery by a TBA.53 Thus, the
United Nations SDG. gap is filled by TBAs, and the poor cohort remains devoid of
The concept of SBA is not new in Bangladesh; in fact, it was essential delivery care.
introduced back in 2004.33,50 However, the application of SBA Another important factor associated with awareness of
seems to be limited to the privileged and informed part of the health services is education, both women and their husband/
society. The results of this study ascertain the point that partner's. Women, who completed their secondary and higher
women belonging to the richer households and with higher education, are generally well-informed of the various health
education (along with an educated partner) were more likely issues, particularly the problems of seeking traditional un-
to access SBAs. Furthermore, those of who already received scientific cheap treatments.31,54,55 It compels them to rethink
ANC from skilled personnel were more likely to receive SBA before availing the same service their ancestors did, a time
service during delivery. Therefore, the sociodemographic when modern medical services were rare in rural
variables are required to assess the overall public health sce- Bangladesh.39 Further awareness from the household head or
nario of Bangladesh to identify and understand the reasons the husband/partner is important because in the patriarchal
behind vulnerable households’ lack of access to essential de- society of Bangladesh, a man usually makes most of the de-
livery service through SBA. cisions for the family, particularly in circumstances that
Household economic condition is one of the primary fac- involve spending money. Hence, a highly educated partner
tors contributing to the access of various health services in would be aware of the risk from an unskilled carer or TBA and
p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1 119
comprehend the worth of spending the money on ANC and intervention strategies are warranted to ensure Bangladesh
SBA services.54,56,57 It takes a highly educated family to rise attains the targets of the SDGs set by United Nations. This
above the long-established mindset of the community and go study concludes that focusing on women's education,
against the flow to seek modern medical help.58 increasing affordability by poverty reduction, minimizing the
The results of this study also revealed that ANC from a gaps of the SBA services between the rich and the poor, and
skilled professional during the period of pregnancy increased increasing ANC services for smoother access to SBAs, with
the likelihood of seeking delivery from an SBA. Al Kibria et al. particular attention to rural and poor communities, could
reasonably argues that the duration of pregnancy is the per- substantially contribute to the national maternal health ser-
fect intervention period for skilled delivery services as the vices during delivery, which would enhance the national
medical personnel could explain the complexities associated mortality prevention programs.
with a delivery and the consequence of inefficient deliveries
by TBAs.29 A high number of complications following delivery
are found to be associated with traditional delivery services at Author statements
home.59 However, a trained provider of ANC could be an
intervention to encourage the women and their families to Acknowledgments
access the modern services in a health facility.60 As of BHDS
2014 report,24 37% of births are delivered in a health facility, The authors would like to acknowledge DHS (Demographic
which is an increasing trend (12%, 17%, and 29% in 2004, 2007, and Health Surveys) who has made their data available for
and 2011, respectively). These results support the necessity of free.
reaching appropriate ANC and SBA visits throughout the
period of pregnancy to ensure essential assistance for delivery Author's contribution
and postnatal care.
This study analyzed the latest available nationwide health J.B. conceptualized the study, structured the manuscript,
data on Bangladesh and identified the most vulnerable conducted literature review, and edited the manuscript.
households, where women still lack skilled delivery assis- R.K.B. developed the analysis plan, aided in variable selec-
tance. However, this study was limited by a few factors. First, tion, and drafted the manuscript. M.W. compiled the data,
although the geographical clusters were adjusted, it is limited synthesized the analysis plan, and performed statistical
by district-wise data. A spatial analysis would have identified analysis. The final manuscript was read and approved by all
the most compromised regions of the country, and a follow- the authors.
up policy intervention on these areas could be discussed.
Second, some qualitative analyses could have portrayed Ethical approval
women's opinion regarding their position to choose TBA or
SBA during delivery. These would have verified whether there This article does not contain any studies with human partic-
is a causal relationship between patriarchy and access to ipants performed by any of the authors. The Bangladesh de-
health services. Third, as the data were cross-sectional, the mographic and health Surveys were approved by ICF Macro
study could only reflect on the association of the factors, and it Institutional Review Board and the National Research Ethics
should not be interpreted in a causal manner. Further studies Committee of the Bangladesh Medical Research Council. A
with SBA interventions in a controlled environment (e.g. written consent about the survey was given by participants
different training schemes for SBAs and community engage- before interview. All identification of the respondents was dis-
ment programs) could warrant the validation of the findings. identified before publishing data. The secondary data sets
Future studies can also investigate the cohort of 249 in- analyzed during the current study are freely available upon
dividuals who received no ANC but availed SBA services, request from the DHS website at http://dhsprogram.com/
which could potentially decipher issues like lack of commu- data/available-datasets.com.
nity engagement of ANCs or insufficient ANC services in the
locality. Funding
Conclusion This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.
During the last two decades, the financial development in
Bangladesh has led to an improved public health scenario Competing interest
including ANC and SBA services. Foreign aid and locally active
NGOs patronized by Bangladesh Government are continu- There is no conflict of interest among the authors.
ously strengthening this sector. These resulted in increased
setup of local health facilities and consequently more trained
references
SBAs in local communities. This study analyzed the most
recent BDHS 2014 data to investigate the determinants of ANC
and SBA service utilization at delivery including wealth index,
1. Chowdhury AMR, Bhuiya A, Chowdhury ME, Rasheed S,
education of women, and their participation in household Hussain Z, Chen LC. The Bangladesh paradox: exceptional
decision making. The findings demonstrate that interventions health achievement despite economic poverty. Lancet
are required for the poor and uneducated women. Several 2013;382(9906):1734e45.
120 p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1
2. Ahmed SM, Evans TG, Standing H, Mahmud S. Harnessing 19. Kruk ME, Prescott MR, Galea S. Equity of skilled birth
pluralism for better health in Bangladesh. Lancet attendant utilization in developing countries: financing and
2013;382(9906):1746e55. policy determinants. Am J Public Health 2008;98(1):142e7.
3. El Arifeen S, Christou A, Reichenbach L, Osman FA, Azad K, 20. Shimamoto K, Gipson JD. The relationship of womens status
Islam KS, Ahmed F, Perry HB, Peters DH. Community-based and empowerment with skilled birth attendant use in
approaches and partnerships: innovations in health-service Senegal and Tanzania. BMC Pregnancy Childbirth
delivery in Bangladesh. Lancet 2013;382(9909):2012e26. 2015;15(1):154.
4. Islam A, Biswas T. Bangladesh health system and the 21. Kamal SM, Hassan CH, Islam MN. Factors associated with the
millennium development goals: strategic policy options for timing of antenatal care seeking in Bangladesh. Asia Pac J
sustained progress in maternal and child health. Eur J Prev Public Health 2015;27(2):NP1467e80.
Med 2015;3(3):63e70. 22. G. Saad-Haddad, J. DeJong, N. Terreri, M. C. Restrepo-Mendez,
5. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, J. Perin, L. Vaz, H. Newby, A. Amouzou, A. J. Barros, J. Bryce,
Marcus JR, Dwyer-Lindgren L, Lofgren KT, Phillips D, Patterns and determinants of antenatal care utilization:
Atkinson C, et al. Progress towards millennium development analysis of national survey data in seven countdown
goals 4 and 5 on maternal and child mortality: an updated countries, J Glob Health 6 (1).
systematic analysis. Lancet 2011;378(9797):1139e65. 23. Blum LS, Sharmin T, Ronsmans C. Attending home vs.
6. Chowdhury S, Banu L, Chowdhury T, Rubayet S, Khatoon S. clinic-based deliveries: perspectives of skilled birth
Achieving millennium development goals 4 and 5 in attendants in matlab, Bangladesh. Reprod Health Matters
Bangladesh, BJOG. An Int J Obstet Gynaecol 2011;118(s2):36e46. 2006;14(27):51e60.
7. El Arifeen S, Hill K, Ahsan KZ, Jamil K, Nahar Q, Streatfield PK. 24. DHS. Bangladesh demographic and health survey. National
Maternal mortality in Bangladesh: a countdown to 2015 institute of population research and training(niport); 2014.
country case study. Lancet 2014;384(9951):1366e74. 25. Matsuoka S, Aiga H, Rasmey LC, Rathavy T, Okitsu A.
8. Kumar S, Kumar N, Vivekadhish S. Millennium development Perceived barriers to utilization of maternal health services in
goals (mdgs) to sustainable development goals (sdgs): rural Cambodia. Health Policy 2010;95(2):255e63.
addressing unfinished agenda and strengthening sustainable 26. Dupas P. Health behavior in developing countries. Annu Rev
development and partnership. Indian J Community Med Off Publ Econ 2011;3(1):425e49.
Indian Assoc Prev Soc Med 2016;41(1):1. 27. Bhalotra S, Rawlings SB. Intergenerational persistence in
9. S. Munabi-Babigumira, C. Glenton, S. Lewin, A. Fretheim, H. health in developing countries: the penalty of gender
Nabudere, Factors that influence the provision of intrapartum inequality? J Public Econ 2011;95(3e4):286e99.
and postnatal care by skilled birth attendants in low-and 28. Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where
middle-income countries: a qualitative evidence synthesis, do poor women in developing countries give birth? a multi-
The Cochrane Library. country analysis of demographic and health survey data. PLoS
10. M. Saha, E. N. Odjidja, Access to a skilled birth attendant in One 2011;6(2):e17155.
Bangladesh: what we know and what health system 29. Al Kibria GM, Ghosh S, Hossen S, Barsha RAA, Sharmeen A,
framework can teach us, Health Sys Pol Res 4 (4). Uddin SI. Factors affecting deliveries attended by skilled birth
11. Lim SS, Allen K, Bhutta ZA, Dandona L, Forouzanfar MH, attendants in Bangladesh, Maternal health. Neonatol Perinatol
Fullman N, Gething PW, Goldberg EM, Hay SI, Holmberg M, 2017;3(1):7.
et al. Measuring the health-related sustainable development 30. Nguyen HT, Hatt L, Islam M, Sloan NL, Chowdhury J,
goals in 188 countries: a baseline analysis from the global Schmidt J-O, Hossain A, Wang H. Encouraging maternal
burden of disease study 2015. Lancet 2016;388(10053):1813e50. health service utilization: an evaluation of the Bangladesh
12. Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic voucher program. Soc Sci Med 2012;74(7):989e96.
status, education and empowerment: implications for 31. Paul BK, Rumsey DJ. Utilization of health facilities and trained
maternal health service utilization in developing countries. birth attendants for childbirth in rural Bangladesh: an
PLoS One 2010;5(6):e11190. empirical study. Soc Sci Med 2002;54(12):1755e65.
13. Harvey SA, Blando n YCW, McCaw-Binns A, Sandino I, 32. Bhuiyan A, Mukherjee S, Acharya S, Haider S, Begum F.
Urbina L, Rodrıguez C, Ǵ omez I, Ayabaca P, Djibrina S. Are Evaluation of a skilled birth attendant pilot training program
skilled birth attendants really skilled? a measurement in Bangladesh. Int J Gynecol Obstet 2005;90(1):56e60.
method, some disturbing results and a potential way forward. 33. Murakami I, Egami Y, Jimba M, Wakai S. Training of skilled
Bull World Health Organ 2007;85(10):783e90. birth attendants in Bangladesh. Lancet 2003;362(9399):1940.
14. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, 34. Islam N, Islam MT, Yoshimura Y. Practices and determinants
Williams EK, Seraji HR, Mannan I, Rahman SM, Shah R, of delivery by skilled birth attendants in Bangladesh. Reprod
Saha SK, et al. Effect of community-based newborn-care Health 2014;11(1):86.
intervention package implemented through two service- 35. Woldemicael G, Tenkorang EY. Women's autonomy and
delivery strategies in sylhet district, Bangladesh: a cluster- maternal health-seeking behavior in Ethiopia. Matern Child
randomised controlled trial. Lancet 2008;371(9628):1936e44. Health J 2010;14(6):988e98.
15. Ahmed T, Jakaria S. Community-based skilled birth 36. Steinberg L. A social neuroscience perspective on adolescent
attendants in Bangladesh: attending deliveries at home. risk-taking. Dev Rev 2008;28(1):78e106.
Reprod Health Matters 2009;17(33):45e50. 37. El Mhamdi S, Salah AB, Bouanene I, Hlaiem I, Hadhri S,
16. Byrne A, Morgan A. How the integration of traditional birth Maatouk W, Soltani M. Obstetric and psychological
attendants with formal health systems can increase skilled characteristics of women seeking multiple abortions in the
birth attendance. Int J Gynecol Obstet 2011;115(2):127e34. region of Monastir (Tunisia): results of a cross-sectional
17. World Health Organization and others, Making pregnancy design. BMC Women's Health 2015;15(1):40.
safer: the critical role of the skilled attendant: a joint 38. Yaya S, Bishwajit G, Ekholuenetale M. Factors associated with
statement by who, icm and figo. the utilization of institutional delivery services in
18. Yanagisawa S, Oum S, Wakai S. Determinants of skilled birth Bangladesh. PLoS One 2017;12(2):e0171573.
attendance in rural Cambodia. Trop Med Int Health 39. Kamal SM, Hassan CH, Kabir M. Inequality of the use of
2006;11(2):238e51. skilled birth assistance among rural women in Bangladesh:
p u b l i c h e a l t h 1 7 0 ( 2 0 1 9 ) 1 1 3 e1 2 1 121
facts and factors. Asia Pac J Public Health 52. Sarker BK, Rahman M, Rahman T, Hossain J, Reichenbach L,
2015;27(2):NP1321e32. Mitra DK. Reasons for preference of home delivery with
40. Hajizadeh M, Alam N, Nandi A. Social inequalities in the traditional birth attendants (tbas) in rural Bangladesh: a
utilization of maternal care in Bangladesh: have they qualitative exploration. PLoS One 2016;11(1):e0146161.
widened or narrowed in recent years? Int J Equity Health 53. Shahabuddin A, Delvaux T, Abouchadi S, Sarker M, De
2014;13(1):120. Brouwere V. Utilization of maternal health services among
41. Ahmed SM, Hossain MA, RajaChowdhury AM, Bhuiya AU. The adolescent women in Bangladesh: a scoping review of the
health workforce crisis in Bangladesh: shortage, literature. Trop Med Int Health 2015;20(7):822e9.
inappropriate skill-mix and inequitable distribution. Hum 54. Gabrysch S, Campbell OM. Still too far to walk: literature
Resour Health 2011;9(1):3. review of the determinants of delivery service use. BMC
42. The World Bank. Nurses and midwives (per 1,000 people. 2017. Pregnancy Childbirth 2009;9(1):34.
URL, https://data.worldbank.org/indicator/SH.MED.NUMW. 55. Akter T, Dawson A, Sibbritt D. The determinants of essential
P3. [Accessed 2 May 2019]. newborn care for home births in Bangladesh. Publ Health
43. Rutstein SO, Johnson K, MEASURE OM, et al. The DHS wealth 2016;141:7e16.
index. ORC Macro, MEASURE DHS; 2004. 56. Anastasi E, Borchert M, Campbell OM, Sondorp E, Kaducu F,
44. Measure D. Icf international, demographic and health surveys Hill O, Okeng D, Odong VN, Lange IL. Losing women along the
methodology: standard recode manual for DHS 6. Demographic and path to safe motherhood: why is there such a gap between
health survey toolkit of methodology for the MEASURE DHS phase womens use of antenatal care and skilled birth attendance? a
III. 2008e2013. mixed methods study in northern Uganda. BMC Pregnancy
45. Biswas RK, Kabir E. Influence of distance between residence Childbirth 2015;15(1):287.
and health facilities on non-communicable diseases: an 57. McDougal L, Rusch ML, Silverman JG, Raj A. Linkages within
assessment over hypertension and diabetes in Bangladesh. the reproductive and maternal health continuum of care in
PLoS One 2017;12(5):e0177027. Bangladesh. Asia Pac J Public Health 2016;28(5):423e37.
46. McCulloch CE, Neuhaus JM. Generalized linear mixed models. 58. Mullany BC, Becker S, Hindin M. The impact of including
Wiley Online Library; 2013. husbands in antenatal health education services on maternal
47. McCulloch CE. Maximum likelihood algorithms for health practices in urban Nepal: results from a randomized
generalized linear mixed models. J Am Stat Assoc controlled trial. Health Educ Res 2006;22(2):166e76.
1997;92(437):162e70. 59. Islam MA, Chowdhury RI, Akhter HH. Complications during
48. United Nations Development Programme, MDG. Bangladesh pregnancy, delivery, and postnatal stages and place of delivery
progress report 2015, general economics division (GED), planning in rural Bangladesh. Health Care Women Int 2006;27(9):807e21.
commission. Government of the People’s Republic of 60. Rahman M. Deliveries among adolescent mothers in rural
Bangladesh; 2015. Bangladesh: who provides assistance? World Health Popul
49. R. Kabir, H. Khan, Utilization of antenatal care among 2009;11(2):5e14.
pregnant women of urban slums of Dhaka city, Bangladesh.
50. S. Talukder, D. Farhana, B. Vitta, T. Greiner, In A rural area of
Bangladesh, traditional birth attendant training improved
Appendix A. Supplementary data
early infant feeding practices: a pragmatic cluster
randomized trial, Maternal & child nutrition 13 (1).
51. Shah N, Rohra DK, Shams H, Khan NH. Home deliveries: Supplementary data to this article can be found online at
reasons and adverse outcomes in women presenting to a https://doi.org/10.1016/j.puhe.2019.02.027.
tertiary care hospital. JPMA (J Pak Med Assoc) 2010;60(7):555.
SOGC CLINICAL PRACTICE GUIDELINE
It is SOGC policy to review the content 5 years after publication, at which time the document may be re-affirmed or revised to reflect
emergent new evidence and changes in practice.
No. 391, November 2019 (Replaces No. 239, February 2010)
Guideline No. 391-Pregnancy and Maternal

Obesity Part 1: Pre-conception and Prenatal
Care
This Clinical Practice Guideline has been prepared by the *Maternal-Fetal Medicine Committee: Hayley Bos, MD, Victoria,
authors and reviewed by the Society of Obstetricians and BC (co-chair); Richard Brown, MD, Beaconsfield, QC; Sheryl Choo,
Gynaecologists of Canada (SOGC)’s Maternal-Fetal Medicine MD, London, ON; Venu Jain, MD, Edmonton, AB; Lisa Kuechler,
Committee*, Family Physician Advisory Committee, and RN, Victoria, BC; Heather Martin, RM, Edmonton, AB; N. Lynne
Guideline Management and Oversight Committee; and McLeod, MD, Halifax, NS; William Mundle, MD, Windsor, ON
approved by the Board of the SOGC. Parts 1 and 2 of this (co-chair);Kirsten Niles, MD, Toronto, ON; Frank Sanderson, MD,
Clinical Practice Guideline supersede the original version Saint John, NB; Jennifer Walsh, MD, Calgary, AB
(#239) that was published in February 2010. Disclosure statements have been received from all authors.
Note: Team Planning for Delivery and Postpartum Care is covered Key Words: Pregnancy, maternal obesity, labour and delivery,
in Part 2. vaginal birth, Caesarean birth, wound disruption, venous
thromboembolism, maternal morbidity, fetal/neonatal morbidity,
Cynthia Maxwell, MD, Toronto, ON
fetal ultrasound, weight loss surgery, gestational weight gain,
Laura Gaudet, MD, Ottawa, ON stillbirth, vaginal birth after Caesarean
Gabrielle Cassir, MD, Beaconsfield, QC
Corresponding author: Dr. Cynthia Maxwell:
Christina Nowik, MD, Vancouver, BC
cynthiadr.maxwell@sinaihealthsystem.ca
N. Lynne McLeod, MD, Halifax, NS

Claude-Emilie Jacob, MD, Montre al, QC
Mark Walker, MD, Ottawa, ON
CHANGES IN PRACTICE
1. Aspirin prophylaxis
2. Increased surveillance following bariatric surgery
3. Delivery by term
J Obstet Gynaecol Can 2019;41(11):1623−1640 KEY MESSAGES

https://doi.org/10.1016/j.jogc.2019.03.026 1. Pregnancy care requires maternal medical assessment
2. Team planning enhances care and reduces risks for patients
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La and caregivers
Société des obstétriciens et gynécologues du Canada. Published by 3. Increased awareness is needed for weight bias in obstetrics
Elsevier Inc. All rights reserved.
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these
opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior
written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate
informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and tailored to their needs.
This guideline was written using language that places women at the centre of care. The SOGC is committed to respecting the rights of all people—
including transgender, gender non-binary, and intersex people—for whom the guideline may apply. We encourage health care providers to engage in
respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate care. The values, beliefs, and
individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient
should be respected.
Indonesia fromJOGC
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part10@gmail.com) at University of MuslimNOVEMBER ClinicalKey.com
NOVEMBREby Elsevier
2019on March
162327,
Abstract 2. There are limited options for weight loss and management during
pregnancy (II-2).
3. Guidelines can assist with individualized recommendations regard-
Objective: This guideline will review key aspects in the pregnancy care
ing maternal gestational weight gain and calorie and nutrient intake
of women with obesity. Part I will focus on pre-conception and
during pregnancy (II-2).
pregnancy care. Part II will focus on team planning for delivery and
4. Maternal obesity is a risk factor for fetal macrosomia (II-2).
Postpartum Care.
5. The accuracy of fetal imaging for pregnancy dating, anatomical
Intended Users: All health care providers (obstetricians, family assessment, and fetal weight estimates is reduced in the setting of
doctors, midwives, nurses, anaesthesiologists) who provide maternal obesity (II-2).
pregnancy-related care to women with obesity. 6. Stillbirth is more common with maternal obesity (II-1).
7. Multiple gestations carry additional risks in pregnancies complicated
Target Population: Women with obesity who are pregnant or planning by maternal obesity (II-2).
pregnancies. 8. Weight loss surgery before pregnancy, while generally conferring
benefits to mother and fetus, also carries rare and serious morbidity
Evidence: Literature was retrieved through searches of Statistics during gestation (II-1).
Canada, Medline, and The Cochrane Library on the impact of obesity
in pregnancy on antepartum and intrapartum care, maternal morbidity
and mortality, obstetrical anaesthesia, and perinatal morbidity and Recommendations:
mortality. Results were restricted to systematic reviews, randomized 1. Weight management strategies prior to pregnancy may include die-
controlled trials/controlled clinical trials, and observational studies. tary, exercise, medical, and surgical approaches. When pursued
There were no date or language restrictions. Searches were updated before pregnancy, health benefits may carry forward into future
on a regular basis and incorporated in the guideline to September pregnancies (III B).
2018. Grey (unpublished) literature was identified through searching 2. As obesity carries many medical risks, assessment for conditions
the websites of health technology assessment and related agencies, of the cardiac, pulmonary, renal, endocrine, and skin systems, as
clinical practice guideline collections, clinical trial registries, and well as obstructive sleep apnea, is warranted in the pre-pregnancy
national and international medical specialty societies. period (II-3 B).
3. Folic acid supplementation in the 3 months prior to conception
Validation Methods: The content and recommendations were drafted
is warranted given the increased risks of congenital abnormali-
and agreed upon by the authors. Then the Maternal-Fetal Medicine
ties of the fetal heart and neural tube related to maternal obe-
Committee peer reviewed the content and submitted comments for
sity (II-2 A).
consideration, and the Board of the Society of Obstetricians and
4. It is recommended that both monitoring of gestational weight gain
Gynaecologists of Canada (SOGC) approved the final draft for
and approaches for gestational weight gain management be for-
publication. Areas of disagreement were discussed during
mally integrated into routine prenatal care (III A).
meetings, at which time consensus was reached. The level of
5. There is good evidence to support the role of exercise in pregnancy
evidence and quality of the recommendation made were described
(I A).
using the Evaluation of Evidence criteria of the Canadian Task
6. There is good evidence to support supplementation with folic acid
Force on Preventive Health Care.
(at least 0.4 mg) and vitamin D (400 IU) during pregnancy (II-2 A).
Benefits, Harms, and Costs: Implementation of the recommendations 7. Fetal macrosomia may be altered by well-controlled maternal ges-
in these guidelines may increase obstetrical provider recognition of tational weight gain (II-2 A).
the issues affected pregnant individuals with obesity, including 8. Increased fetal surveillance for well-being is suggested in the third
clinical prevention strategies, communication between the health trimester if the reduced fetal movements are reported, given the
care team, the patient and family as well as equipment and human increased rate of stillbirth (II-3).
resource planning. It is hoped that regional, provincial and federal 9. Aspirin prophylaxis can be recommended for women with obesity
agencies will assist in the education and support of coordinated when other risk factors are present for the prevention of preeclamp-
care for pregnant individuals with obesity. sia (I A).
10. It is recommended that delivery be considered at 39−40 weeks
Guideline Update: SOGC guidelines will be automatically reviewed gestation for women with a body mass index of 40 kg/m2 or greater
5 years after publication. However, authors can propose another given the increased rate of stillbirth (II-2 A).
review date if they feel that 5 years is too short/long based on their 11. Multiple gestations in women with obesity require increased sur-
expert knowledge of the subject matter. veillance and may benefit from consultation with a Maternal-Fetal
Medicine consultant, especially in the setting of monochorionic
Sponsors: This guideline was developed with resources funded by the gestations (II-2 A).
SOGC. 12. Pregnancy after weight loss surgery may benefit from Maternal-
Fetal Medicine consultation given the potential for significant albeit
Summary Statements:
rare maternal morbidity (III B).
1. Maternal obesity carries both maternal and fetal risks (II-2).
Downloaded
1624 NOVEMBER JOGC NOVEMBRE
for Fakultas Kedokteran Universitas Muslim
2019Indonesia (eucrasia2018part10@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 27,
Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care
Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on
Preventative Health Care
Quality of Evidence Assessmenta Classification of Recommendationsb
I: Evidence obtained from at least 1 properly randomized controlled A. There is good evidence to recommend the clinical preventive action.
trial
II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive action.
randomization
II-2: Evidence from well-designed cohort (prospective or C. The existing evidence is conflicting and does not allow to make a
retrospective) or case-control studies, preferably from more than 1 recommendation for or against use of the clinical preventive action;
centre or research group however, other factors may influence decision making.
II-3: Evidence obtained from comparisons between times or places D. There is fair evidence to recommend against the clinical preventive
with or without the intervention. Dramatic results in uncontrolled action.
experiments (such as the results of treatment with penicillin in the
1940s) could also be included in the category.
III: Opinions of respected authorities, based on clinical experience, E. There is good evidence to recommend against the clinical preventive
descriptive studies, or reports of expert committees action
I. There is insufficient evidence (in quantity or quality) to make a
recommendation; however, other factors may influence decision
making.
a
The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive
Health Care.
b
Recommendations included in these guidelines have been adapted from the classification of recommendations criteria described in The Canadian Task Force on
Preventive Health Care.
INTRODUCTION Definition of Obesity

The most widely accepted guidelines for the classification
uccessful outcomes are possible for pregnancies affected
S by maternal obesity. There are a number of considera-
of obesity are produced by the World Health Organiza-
tion.19 As demonstrated in Table 4, obesity is classified as a
tions for all obstetrical care providers, pregnant patients, and BMI ≥30 kg/m2. Obesity can subsequently be further clas-
their families (Table 1 is a key to evidence statements and sified by class I, II, and III (the term “morbidly obese” is to
grading of recommendations). For example, there has been be avoided).4 The published literature does not consistently
an alarming increase in obesity (body mass index [BMI] >30 use these classifications when reporting study results, dem-
kg/m2) and overweight (BMI 25−29.9 kg/m2) globally; in onstrating a limitation of current scientific evidence.
2014, 40% of Canadians reported a BMI as overweight or
obese.1,2 Maternal weight during pregnancy has a profound
impact on the health of both mothers and their offspring. REFERS TO SUMMARY STATEMENT 1
Women with obesity have greater difficulty achieving a
term pregnancy as they are at higher risk of miscarriage.3
They are at higher risk of adverse pregnancy outcomes PRE-CONCEPTION COUNSELLING, EVALUATION,
including development of gestational diabetes,4−7 hyperten- AND MANAGEMENT
sion,4,6−8 preeclampsia,5−9 and thromboembolism.10 Women
with obesity are more likely to have increased interventions, Excess amounts of adipose tissue can impair vascular, met-
including induction of labour5,11 and Caesarean birth4,11 abolic, and inflammatory pathways in many organs, thereby
(Table 2).5−14 They have a significantly elevated risk of infant leading to adverse pregnancy outcomes.20 Women with
mortality9,15−17 (Table 3).5−7,9,14−20 The perinatal risks asso- obesity should thus be informed of the benefits of weight
ciated with maternal obesity include stillbirth,5,7,9,17 macroso- loss before conception, notably on reproductive function,
mia,5−7,9,14 shoulder dystocia,7,9,14 and meconium obstetrical outcome, and overall maternal health.22 Though
aspiration.14 The newborns are also more likely to require weight management strategies implemented during
medical intervention following delivery14 and admission to pregnancy have some effect in reducing maternal and neo-
the neonatal intensive care unit8,14 (Table 3). Children born to natal complications, the effect is limited. Therefore, it is
mothers with obesity21 are at increased risk of obesity them- recommended that a weight-control program including
selves, as well as associated disease states including diabetes diet, exercise, and behavioral modification be encouraged
and cardiovascular disease.7 in the pre-pregnancy period.23,24 In fact, a moderate weight
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
162527,
Table 2. Maternal risks associated with obesity as compared with normal weight
Odds ratio/adjusted odds ratio compared to women with normal weight BMI <25 kg/m2
Overweight Obese I−II Obese III
BMI 25−29.9 kg/m2 BMI 30−39.9 kg/m2 BMI ≥40 kg/m2
Gestational diabetes 1.68−4.255,6 2.60−6.285−7 7.444
4,6,12 4−8
Hypertension 1.74−2.15 2.50−6.31 4.874
Preeclampsia 1.445 2.14−3.905−7,9 4.829
1.916
1.44−1.915,6
Venous thromboembolism in pregnancy 1.8012 9.7010
Placental abruption 1.408
8,13
Spontaneous miscarriage 1.67 1.203
Recurrent miscarriage 3.503
Hemorrhage/blood loss >500 ml 1.16 5
1.39−1.505,14
Genital tract infection 1.245 1.305
5
Urinary tract infection 1.17 1.39−1.905,14
Wound infection 1.275 2.245
5
Induction of labour 1.27 1.60−1.705,11
Failure to progress in labour 2.608
Caesarean birth 1.504 1.60−2.024,11 2.544
5−6 4
Emergency Caesarean birth 1.30−1.52 2.02 2.544
1.916
1.835
2.0015
1.83−2.025,6,14
Instrumental delivery 1.169 1.349
1.189
1.6014
Failed instrumental delivery 1.7511
Breastfeeding issues 0.865 0.585
BMI: body mass index.
loss of 5% to 10% in non-pregnant women has led to an when possible. Orlistat has a half-life of 2 hours and works
amelioration of obesity-associated metabolic disorders, by blocking lipase activity, which prevents about 30% of
including renal function and blood sugars,25−29 and has dietary fat from being broken down into free fatty acids
the potential to improve maternal as well as fetal obstetrical and causes it to be excreted in the feces.35 Many large stud-
outcomes.30 Proper nutritional counselling, including die- ies have shown that most patients on orlistat for 1 year lost
tary changes aiming to modify BMI and ensure adequate significantly more weight than those on placebo.36−38
micronutrient intake, is suggested as optimal diet is Between 5.8%37 and 8.5%36 of initial body weight was lost
required for a healthy immune balance.31−33 in those without type 2 diabetes, and an average of 6.2%38
was lost in those with associated diabetes mellitus.
Weight Management
Weight management strategies should address adjunctive On the other hand, liraglutide has a half-life of 13 hours
medical therapy or weight loss surgery when appropriate. and acts as a glucagon-like peptide-1 (GLP-1) receptor
Pharmacotherapy can be considered in patients with a stimulator, suppressing appetite39 and reducing gastric
BMI ≥30 kg/m2 or a BMI ≥27 kg/m2 with comorbid- emptying, which slows the digestion of nutrients and
ities.34 In Canada, there are 2 main drug therapies: orlistat decreases the post-prandial serum glucose load.40 Ran-
and liraglutide 3.0 mg. Neither is approved during preg- domized controlled trials entitled the Satiety and Clinical
nancy and both should be discontinued prior to conception Adiposity − Liraglutide Evidence in individuals with and
Downloaded
Table 3. Neonatal risks associated with maternal obesity

Odds ratio/adjusted odds ratio (95% confidence interval)
Overweight Obese Obese
BMI 25−29.9kg/m2 BMI 30−40 kg/m2 BMI ≥40 kg/m2
Stillbirth 1.40−3.105,7,9,17 2.799
7,9,14
Shoulder dystocia 2.14−3.60 3.149
Meconium aspiration 1.64−2.879 2.859
9
Fetal distress 1.61−2.13 2.529
Mortality 1.2515 1.37−2.709,15−17 2.44−3.419,15
5 5
Large for gestational age/macrosomia 1.57 2.36 3.559
1.696 2.976
2.307
2.159
3.039
2.1014
2.10−3.035−7,9,14
Major congenital anomalies/birth defect 1.0518 1.12−1.584,19 1.37−3.414,19
11
Neural tube defects 1.20
Spinal bifida 1.80−2.607,11
11,19
Congenital cardiac anomalies 1.05−1.17 1.15−1.307,11,19,20 1.4418
Nervous system defects 1.1518 1.44−1.6519 1.8818
7
Omphalocele 3.30
Anencephaly 1.3911
Cleft palate 1.2011
Late term birth (>41 weeks) 1.4011
Preterm birth 1.507 2.134
8,14
NICU admission 1.20−1.50 2.774
Hypoglycemia 2.574 7.144
Jaundice 2.134
Low Apgar scores 1.165 1.455
Gastric tube 1.5014
Neonatal trauma 1.5014
BMI: body mass index; NICU: neonatal intensive care unit.
without obesity (SCALE) have examined its use as an Weight loss surgery is an option for patients with a BMI
adjunctive therapy. Two of these trials showed that patients ≥40 kg/m2 or a BMI ≥35 kg/m2 with comorbidities and
without type 2 diabetes lost 8.0% of their initial body who have not been successful with other weight manage-
weight41 and those with type 2 diabetes lost 6.0%.42 ment options.34 It has the best long-term result regarding
quantity of weight lost,43 and as of 2014, sleeve gastrec-
Table 4. World Health Organization classification of body tomy (SG) is the most common bariatric procedure per-
mass index (BMI)19
formed worldwide (45.9%), followed by Roux-en-Y gastric
BMI kg/m2 Classification bypass (39.6%), adjustable gastric banding (7.4%), and bil-
<18.5 Underweight iopancreatic diversion (1.1%)44 (Table 5).43,45−60 In gen-
18.5−24.99 Normal weight eral, weight loss surgery decreases the risk of women with
25.00−29.99 Overweight obesity developing hypertensive disorders in pregnancy by
≥30.00 Obese
as much as 75%,45,61−64 with a meta-analysis published in
2014 demonstrating that bariatric surgery could reduce the
30.00−34.99 Obese class I
risk of preeclampsia in itself by 50% (odds ratio [OR] 0.45;
35.00−39.99 Obese class II
95% confidence interval [CI] 0.25−0.80).64 Furthermore,
≥40.00 Obese class III
malabsorptive weight loss surgery has also been associated
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
162727,
Table 5. Types of weight loss surgery and their effects

Excess body weight loss Likelihood of
Surgery type Mechanism of action 12 months post procedure nutritional deficiencies
SG Transection of the stomach, produces volume restriction46 38%−70%47−49 Low
RYGB Mechanical restriction and malabsorption through creation 68%−77%50-52 High
of 15-mL gastric pouch43 Especially fat soluble vitamins53,54,a
AGB Gastric capacity restriction55,56 41%−54%43,57,58 Lowb
BD Gastric capacity restriction and malabsorption45 66%−74%57,58 Moderate
AGB: adjustable gastric banding; BD: biliopancreatic diversion; RYGB: Roux-en-Y gastric bypass; SG: sleeve gastrectomy.
a
Suggest supplementation of iron, folate, calcium, vitamin B12, and vitamin D.
b
Suggest adjustment of the band during pregnancy in the context of hyperemesis gravidarum or abnormal weight gain.58−60
with a reduction in the risk of large for gestational age cuffs should be properly calibrated. Spirometry has also
fetuses (OR 0.46; 95% CI 0.34−0.62), though there is evi- shown that in non-pregnant individuals with obesity, lung
dence to suggest an increased risk of small for gestational volumes decrease as BMI increases, with conditions such
age fetuses (OR 1.93; 95% CI 1.52−2.44).64 This is likely as asthma, obesity hypoventilation syndrome, and OSA
related to post-surgical malabsorption issues and/or poor being more prevalent.71 OSA is characterized by repetitive
maternal nutrition; hence, health care providers should episodes of upper airway obstruction during sleep leading
consider screening for inadequate nutrition (and micronu- to reduced airflow as well as hypoxemia, and normal
trient deficiencies) and perform serial growth ultrasounds physiologic changes in pregnancy can exacerbate the con-
in the third trimester. dition. Prevalence is not well defined, but in a prospective
study of 175 pregnant women with obesity who had in-
Of note, time-to-conception interval following bariatric home portable polysomnogram studies, 15.4% were diag-
surgery has been a recent subject of debate. A large popu- nosed with OSA.72 In a large U.S. national database study
lation-based study published in 2016 showed a time-to- between 1998 and 2009, women with OSA had a higher
birth interval of less than 2 years to be associated with risk of preeclampsia (OR 2.5; 95% CI 2.2−2.9), eclampsia
increased rates of neonatal intensive care unit admissions (OR 5.4; 95% CI 3.3−8.9), cardiomyopathy (OR 9.0;
(12.1% vs. 17.7%; Relative Risk RR, 1.54; 95% CI 1.05 95% CI 7.5−10.9), as well as gestational diabetes (OR
−2.25), preterm delivery (11.8% vs. 17.2%; RR, 1.48; 95% 1.9; 95% CI 1.7−2.1) and were found to have a 5-fold
CI 1.00−2.19), and small for gestational age status (9.2% increased odds of dying in hospital, when adjusted for
vs. 12.7%; RR, 1.51; 95% CI 0.94−2.42).65 Therefore, it is comorbidities, age, ethnicity and socioeconomic status.73
suggested that patients wait a minimum of 24 months fol- Treatment is mainly by way of continuous positive airway
lowing bariatric surgery before trying to conceive. pressure.
Pre-pregnancy Counselling and Screening Baseline screening where indicated could include renal
Pre-pregnancy counselling constitutes the ideal time for function (with screening for proteinuria and serum creati-
health care providers to screen the woman with obesity nine levels), liver function tests, cholesterol, triglycerides,
for associated comorbidities, as weight loss can improve thyroid stimulating hormone, diabetes screen, electrocar-
many of these conditions.66 More particularly, obesity is diogram, pulmonary function tests if there are any respi-
associated with an increased risk of chronic hypertension, ratory concerns on anamnesis/examination, OSA studies
type 2 diabetes mellitus, dyslipidemia, cardiovascular dis- if the patient screens positive on the Berlin question-
ease, arrhythmias, stroke, osteoarthritis, non-alcoholic naire,74 and an echocardiogram to evaluate global heart
fatty liver disease, chronic kidney disease, depression, function and left ventricular function in those with a his-
obstructive sleep apnea (OSA), and venous thromboem- tory of chronic hypertension of 5 or more years.75 Con-
bolism.66,67 In fact, the major contributor to type 2 diabe- sultations to appropriate specialists could also be ordered,
tes mellitus is excess weight,68 and the degree of insulin smoking cessation encouraged, and supplementation with
resistance is highest with central/abdominal obesity, a minimum of 0.4 mg/day of folic acid (with consider-
defined as a pre-pregnancy waist circumference ≥88 cm ation of up to 5 mg as maternal obesity may be consid-
in women.69 Hypertension occurs in approximately 40% ered “high risk” in some cases) should be commenced 3
of individuals who have obesity,70 and blood pressure months prior to conceiving in light of an increased risk
Downloaded
for neural tube defects in the obese population.76 Careful obesity. There is some evidence that women with class III
physical examination should include evaluation of excess obesity could gain less weight without increasing the risk of
adipose tissue distribution; cardiorespiratory assessment; adverse pregnancy outcomes.85 Close surveillance of fetal
and screening for signs of venous thromboembolism, growth is advised in this scenario.
abdominal hernias, pressure wounds, or intertriginous
infection. Many women with obesity are unaware that excessive
GWG is a concern or that excessive GWG is associated
During pre-pregnancy discussions, the patient should with pregnancy and neonatal complications.86,87 Women
also be informed of the potential pregnancy complica- want to receive this information,88,89 but studies show that
tions associated with obesity, more particularly gesta- maternity care providers usually do not provide it.90
tional diabetes mellitus and hypertensive disorders of
pregnancy. The use of metformin to improve insulin Simple strategies that may improve the achievement of
sensitivity in pregnancy has also been studied given its ideal GWG include setting a clear goal for GWG, deliber-
theoretical benefit. A meta-analysis of 2 randomized tri- ately planning meals and snacks, decreasing sedentary
als77,78 in women with obesity but without pre-existing behavior, and self-weighing.91,92 Furthermore, adequate
diabetes showed a statistically significant reduction in sleep patterns have been shown to be associated with
maternal gestational weight gain (GWG). However, there improved GWG, and good sleep hygiene should be
was no benefit regarding the development of gestational encouraged.93 In addition to counselling, evidence shows
diabetes mellitus, large for gestational age fetuses, or that supervised physical activity (PA) programs or person-
adverse neonatal outcomes; as such, use of metformin alized prescription/goals improve adherence to GWG tar-
to decrease adverse pregnancy outcomes in non-diabetic gets. Evidence is mounting that intensive lifestyle
women with obesity is not recommended.79 Further- interventions can be effectively delivered using newer tech-
more, as previously discussed, obesity is an independent nologies, such as mobile phones,94 a strategy that could
risk factor for gestational hypertension both with and decrease burden on maternity care providers.
without proteinuria, and those with a BMI >30 kg/m2
should start taking aspirin prior to 16 weeks gestation to Maternal Nutrition in Pregnancies Affected by
prevent placentally mediated complications if additional Obesity
risk factors are present (see Table 8).80−82 Management of maternal nutrition in pregnancies compli-
cated by obesity is both complex and challenging. Ideally,
multidisciplinary care including a nutritionist should be
REFERS TO SUMMARY STATEMENT 2 & available to these patients. It is recognized that the majority
RECOMMEDATIONS 1, 2, AND 3 of Canadian maternity care sites do not have access to
such resources. The information presented in this section
is not comprehensive but is meant to provide some general
PREGNANCY CARE
information to both care providers and expectant mothers.
Weight Management
It is well accepted that weight gain during pregnancy can Macronutrients
influence pregnancy outcomes, with both too much and All fetuses need access to macronutrients (carbohydrates,
too little weight gain being detrimental. Excessive GWG is fat, and protein) to develop and grow optimally. It is gener-
associated with increased risks of gestational hypertension, ally accepted that an additional 100 kilocalories (kcal) per
preeclampsia and diabetes, fetal overgrowth, operative day are needed in the first half of pregnancy, increasing to
delivery, and postpartum weight retention. Inadequate 300 kcal per day beyond 20 weeks gestation. For most
GWG is associated with fetal growth restriction.83 women with obesity, a baseline caloric intake of 2100 kcal
is sufficient in the first half of pregnancy, increasing to
GWG is a dynamic process—the “right” amount of weight 2400 kcal daily after 20 weeks.95 The presence of coexist-
gain in pregnancy should be individualized among women ing diabetes, whether diagnosed prior to pregnancy or
with obesity. For a singleton pregnancy, the Institute of gestational diabetes, will require additional dietary
Medicine recommends that women with a pre-pregnancy modifications.
or first trimester BMI of ≥30 kg/m2 gain 5.0−9.0 kg
(11−20 pounds).84 The timing of this weight gain is impor- Carbohydrate intake in pregnancy should focus on high-
tant, with evidence showing that minimizing GWG in the quality, minimally processed sources in appropriate portion
first half of pregnancy may be beneficial for women with sizes and constitute 40% to 55% of daily calories. Higher
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
162927,
maternal intake of carbohydrates,96 specifically sugar, is carbonate or 4 g of calcium citrate. This recommendation
associated with unfavourable infant and child BMI peak was based on reducing the risk of gestational hypertension
characteristics.97 In particular, the consumption of sugar- but may also reduce the risk of dental carries in children at
sweetened beverages should be avoided.98−100 7 years of age.
Fat intake in pregnancy should comprise 25% to 30% of

daily caloric intake, with monounsaturated fats preferred. Probiotics
Saturated fat should be limited to 10% of daily caloric Studies have shown that women with obesity have an
intake.98 altered microbiome, compared with women of normal
weight. Probiotics have been defined as “live microorgan-
During pregnancy, women require a minimum of 60 g of isms that, when administered in adequate amounts, confer
protein a day, which accounts for 20% to 25% of the daily a health benefit on the host.”109 At the present time, there
caloric intake. A variety of protein sources are recom- is insufficient evidence to recommend probiotic supple-
mended, including legumes; nuts; and lean animal protein mentation to women with obesity during pregnancy,
sources, including eggs, dairy, fish, poultry, and red meat. although the results from several large trials are anticipated
in the future.
Women should be advised to consume 20−35 g of fiber
each day.96
Omega-3/Fish Oil
Inflammation, whether chronic, low grade, or metabolic, is
central to obesity-related insulin resistance. Currently, sup-
Micronutrients
plementation with omega-3 fatty acids shows mixed effects
It is recommended that all pregnant women take a prenatal
on inflammatory markers.110 There is insufficient evidence
vitamin that contains at least 400 mg of folic acid every day.101
to recommend omega-3 supplementation at this time.
Multivitamin use has been associated with reduced risks of
congenital anomalies and preeclampsia.102 Women with obe-
Physical Activity
sity may be less likely to consume multivitamins before and
The benefits of regular physical activity during uncompli-
during pregnancy, so the importance should be reinforced by
cated pregnancy are well documented. Ideally, women who
both primary and maternity care providers.103
are pregnant and have obesity should have access to care
Folic acid supplementation is discussed in the Pre- that promotes awareness of a healthy lifestyle and
pregnancy Counselling and Screening section of this guide- addresses barriers to lifestyle changes and personalized sol-
line. Women with obesity may benefit from an increased utions to engaging in physical activity.111 Healthy women
dose of daily folic acid beginning at least 3 months before with obesity who engage in regular physical activity have
pregnancy and continuing until the end of the first improved pregnancy outcomes and healthier GWG, with-
trimester.104,105 out increasing the risk of preterm birth.112−117 Further-
more, there may be positive downstream effects on
Obesity is associated with lower vitamin D status, a prob- childhood weight and health.118
lem that is further exacerbated in pregnancy.106 A Swedish
study has shown that 50% of pregnant women with obesity Recommendations for physical activity are reviewed in
had suboptimal vitamin D status.104 Women with pre- Table 6. The safety of structured walking activities has
pregnancy obesity should be advised to take a total daily been demonstrated in women with obesity.119 Women
supplementation of 400 IU of vitamin D during pregnancy with obesity who engaged in regular physical activity pre-
and while breastfeeding.107 pregnancy should be encouraged to maintain their current
level of activity with modifications as needed, depending
Obesity has also been reported to be associated with iron on their medical status, comfort, and ability. Modest phys-
deficiency.108 During pregnancy, it is recommended that ical activity prescription can be provided for healthy, pre-
women with obesity have their hemoglobin, mean corpus- viously sedentary women with overweight and obesity,
cular volume, ferritin, and vitamin B12 levels assessed, with with heart rate target zones of 102−124 beats per minute
reflex supplementation as needed. for women aged 20 to 29 and 101−120 for women aged
30 to 39.120 Walking appears to be the most common
The World Health Organization also recommends daily activity for pregnant women and has the ability to
supplementation with a total of 1.5−2.0 g of elemental cal- improve aerobic capacity.119,121 Pregnant women with
cium a day, which is equivalent to 2.5 g of calcium overweight and obesity may have medical pre-screening
Downloaded
Table 6. Physical activity recommendations for pregnant women with obesity

Review contraindications Screen woman with PARmed-X for Pregnancy tool to ensure she is safely able to participate in physical
activity.
Information review Review the potential benefits of physical activity during pregnancy. Discuss risks and reasons to stop activity
and seek medical attention.
Determine type of physical activity Walking program (though stationary cycling, water aerobics, and swimming are also acceptable and may be
preferred)
Reminder to avoid vigorous activity, activities that involve risk of falling, balance loss or abdominal trauma,
and the supine position after 16 weeks of pregnancy
Timing of initiation If previously sedentary, begin activity in early second trimester.
Frequency of physical activity If previously sedentary, begin with walking 3 days per week on non-consecutive days and increase up to
4 days per week.
Reminder to obtain 11 000 steps per day
Intensity of physical activity If previously sedentary, start at low intensity; if already active, maintain moderate-intensity activities;
low intensity: 102−124 beats/minute (20−29 years of age); 101−120 beats/minute (30−39 years of age)
Advise on the “talk test,” which is defined as being able to maintain a conversation during physical activity.
Improve adherence Recommend keeping track of activities and/or a heart rate monitor.
Ask about physical activity at each antenatal visit, answer questions, and provide encouragement.
Adapted from Seneviratne et al.124
using the PARMed-X for Pregnancy tool122; if cleared, a independent effect on fetal growth. In a recent meta-analy-
structured walking program should be recommended, sis of 16 studies, it was shown that a maternal pre-preg-
beginning in the early second trimester with 25 minutes, nancy BMI ≥30 kg/m2 is associated with an adjusted OR
adding 2 minutes per session per week until 40 minutes for fetal macrosomia (birth weight ≥4.0 kg and ≥4.5 kg) of
per session is reached.97 Special support may be needed 1.93 (95% CI 1.65−2.27).131
for women who have back or joint pain or persistent nau-
sea and vomiting of pregnancy.123 Maternal GWG is an important modifying factor for fetal
macrosomia in women with obesity. In a prospective cohort
Devices such as pedometers or Fitbits have been shown to of euglycemic women with obesity, increasing GWG signifi-
increase physical activity levels.125,126 In addition to the cantly increased the risk of macrosomia (birth weight >4 kg)
preceding recommendation, women should be advised to and significantly correlated with umbilical cord C-peptide lev-
take 11 000 steps per day.127 Further recommendations on els (reflect insulin secretory activity of pancreatic beta
exercise in pregnancy can be found in the latest pregnancy cells).132 For every kilogram increase in GWG, there was a
guideleins by the Society of Obstetricians and Gynaecolo- significant increase in risk of macrosomia, defined as birth
gists of Canada.128 weight >4.0 kg, with an OR of 1.139 (95% CI 1.033−1.256).
The Impact of Maternal Obesity on Fetal Growth In contrast to fetal overgrowth, the identification fetal
Maternal obesity is often associated with fetal overgrowth, growth restriction, defined as failure of the fetus to reach
thought to be secondary to altered glucose metabolism and its growth potential, is challenging in women with obesity.
higher fetal insulin levels. Furthermore, maternal obesity Because fetuses of mothers with obesity are heavier as a
has been shown to be associated with both third trimester group, it has been proposed that customized growth
placental and fetal adipocyte proliferation and storage of curves may be needed to identify those fetuses at increased
lipids in the third trimester.129 A large longitudinal cohort risk of perinatal morbidity and mortality.133,134
study of the impact of maternal obesity on fetal growth
showed that fetuses of women with obesity have higher Fetal Assessment in Pregnancies Affected by
weights than fetuses of women without obesity as early as Maternal Obesity
32 weeks gestation.130 Prior to this point, fetal weights are Imaging is challenging in pregnancies affected by obesity
similar between the 2 groups. because the quality of the ultrasound image is inversely
proportional to the depth at which the imaging is being
It is well recognized that maternal obesity is associated with conducted.135 Some suggestions of optimization of scan-
fetal macrosomia, with newer evidence demonstrating an ning are presented in Table 7.
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
163127,
Table 7. Strategies to improve ultrasound quality in

The likelihood of completing an adequate morphology
pregnancies affected by obesity assessment in a single attempt is reduced with increasing
BMI, from 97.5% in women with normal BMI to 74% in
1. Improve the signal-to-noise ratio (compound imaging, speckle-
reduction filters, pre- and post-processing, tissue harmonics).
women with BMI >30 kg/m2 and 41% when BMI is >40
kg/m2.145,146 The probability of poor visualization of the
2. Ensure the maternal bladder is full.
heart (37% vs. 19%) and spine (43% vs. 29%) was
3. Use the umbilicus as an acoustic window.
increased in women with obesity compared with women of
4. Ask the patient to sit up and image above the panniculus.
normal weight.147 Other fetal structures that are particu-
5. Assist the patient into Sims position and image from flank or groin. larly difficult to image in obese women include the face,
6. Scan transvaginally. genitalia, and extremities.148 The optimal gestational age to
conduct a complete anatomy ultrasound has been found to
be 22−24 weeks (93% completion rate, OR 41.3; 95% CI
Establishing gestational age
7.89−215.8).148 It is recommended that the morphology
The most accurate means of establishing pregnancy dating
ultrasound be performed at a minimum of 20 weeks in
is by transvaginal measurement of the crown−rump length
women with obesity. Health care providers should consider
between 7 and 14 weeks gestation.136 Increased maternal
timely referral (i.e., 1−2 weeks) for reassessment of fetal
BMI has been shown to be associated with postponement
anatomy deemed incomplete. Consideration may also be
of the Estimated Date Of Delivery (EDD), with the fetus
given to assessment of fetal anatomy in the first and second
being more likely to measure smaller by ultrasound than
trimesters in women with obesity as an adjunct to routine
the menstrual dates suggest.136,137 Accurate ascertainment
second trimester anatomy.149,150 As the majority of fetal
of gestational age is essential for optimizing pregnancy out-
organs can be visualized late in the first trimester, it is pos-
come, particularly with respect to assessing fetal growth,
sible to detect fetal anomalies in the 13−16-week
conducting aneuploidy screening, and ensuring fetal matu-
range.151,152 Considerations include availability of experi-
rity when timing delivery.
enced sonographers (this approach may not be available in
all centres), as well as the use of transvaginal scanning in
Prenatal screening addition to transabdominal scanning.149,150
It has been noted that maternal obesity may increase the
odds of giving birth to an infant with trisomy 21, with a The quality of images can be improved in women with
lower likelihood of prenatal diagnosis.138−140 obesity using the techniques presented in Table 7.135
Failure rates for measuring the nuchal translucency

Measuring fetal growth
increase with maternal weight.141 Transvaginal assessment
Estimation of fetal weight is challenging in the setting of
may increase the odds of success. However, the risk esti-
maternal adiposity. Screening for fetal weight using sym-
mate for trisomy 21 provided by first trimester combined
physis fundal height measurement is not recommended
screening is not affected by BMI.138
because it has not been shown to be predictive in women
Non-invasive prenatal screening is becoming an increas- with obesity.151 The increased maternal body mass is
ingly prevalent option. The risk of non-invasive prenatal thought to lead to falsely elevated symphysis fundal height,
screening test failure increases with maternal weight, from which may overestimate macrosomia and underestimate
3.8% with normal weight to 24.3% with obesity, irrespec- growth restriction.151
tive of gestational age.142
Several techniques of improving the accuracy of fetal
weight prediction have been evaluated in pregnancy.
Assessing fetal anatomy
Fetuses affected by maternal obesity are more likely to The use of the GAP method (gestation-adjusted projection
have congenital anomalies, specifically neural tube method) has been shown to be an accurate aid in delivery
defects (OR 1.87; 95% CI 1.62−2.15), cardiac anomalies planning for women who have a BMI ≥40 kg/m2.152 This
(OR 1.30; 95% CI 1.12−1.51), anal atresia (OR 1.48; strategy capitalizes on the concept that an ultrasound per-
95% CI 1.12−1.97), and limb reduction anomalies (OR formed between 340 and 366 weeks provides a more accu-
1.34; 95% CI 1.03−1.73).143 This may be related par- rate assessment of fetal weight than one performed at
tially to the reduced odds of detecting congenital anom- 37 weeks or later, using extrapolation to provide an
alies in the presence of maternal obesity (adjusted OR expected birth weight at term. The mean absolute percent
0.77; 95% CI 0.60-0.46).144 error of this technique ranged from 7.4% to 7.9%, in a
Downloaded
population that included women with diabetes.146 As for weeks. Assessment of fetal well-being is then recom-
women of all BMI categories, the option of elective Caesar- mended weekly from 37 weeks until delivery.
ean birth can then be considered for fetuses with a pro-
jected birth weight of ≥4500 g and ≥5000 g in women It has been shown that maternal BMI and pulsatility
with and without diabetes, respectively.153 index of both the umbilical artery and the maternal uter-
ine artery are positively correlated and associated with
Maternal Assessment of Fetal Well-Being adverse pregnancy outcomes, secondary to effects on
Women with obesity are more likely to present for assess- fetal-placental vessels.158,159 The presence of abnormal
ment for decreased fetal movement (OR 1.6; 95% CI findings, with or without co-existing medical complica-
1.27−1.92) but do not have reduced perception of move- tions (such as diabetes or hypertension), should prompt
ment compared with women of normal weight, according increased fetal surveillance.
to a recent systematic review.154,155 The authors also
Prevention of Maternal Pregnancy Complications in
found that among women with decreased fetal movement,
the Presence of Obesity
increased maternal body size was associated with
Because obesity is a known risk factor for gestational
increased risk of stillbirth and fetal growth restriction.
hypertension/preeclampsia and gestational diabetes, con-
Thus, additional consideration should be given to women
sideration should be given to evidence-based preventative
with obesity who report decreased fetal movement.
strategies. Optimization of GWG, diet, and physical activity
is associated with lowered risk of such complications.
Clinical Surveillance of Fetal Well-Being
Adequate external monitoring of the fetal heart rate using
both hand-held Doppler and cardiotocography is less likely in Preeclampsia prevention with aspirin
women with obesity.156 The role for non-stress tests (NSTs) Table 8 reviews the recommendations for prophylactic ace-
in surveillance of well-being in this population is uncertain. tylsalicylic acid (ASA) use during pregnancy, as advised by
the U.S. Preventive Task Force.160
In a large retrospective cohort of 2002 sonograms in 1164
pregnant women with BMI >30 kg/m2 as the only comor- Aspirin should be initiated after diagnosis of pregnancy
bidity, abnormalities of amniotic fluid and growth were sel- and ideally before 16 weeks gestation, taken in a low dose
dom made prior to 32 weeks gestation.157 Beyond (75−162 mg/day), administered at bedtime, and consid-
36 weeks, 7 scans (95% CI 6−8) were needed to diagnose ered for continuation until term.161
any abnormality of fluid (oligohydramnios or polyhydram-
nios) or growth (small or large for gestational age).157 Calcium
Based on this information, it is recommended that serial Evidence supports the use of calcium supplementation to
assessments of growth be conducted at 28, 32, and 36 prevent preeclampsia. At this time, there are no specific
Table 8. Clinical risk assessment for preeclampsia and recommendations for prophylactic acetylsalicylic acid (ASA)
Risk level Risk factors Recommendation
High History of preeclampsia, especially when accompanied by an adverse outcome Recommend low-dose aspirin if the
Multifetal gestation patient has ≥1 of these high-risk
Chronic hypertension factors.
Type 1 or 2 diabetes
Renal disease
Autoimmune disease (e.g., systemic lupus erythematosus, antiphospholipid
syndrome)
Moderate Nulliparity Consider low-dose aspirin if the
Obesity (BMI >30 kg/m2) patient has more than 2 risk factors.
Family history of preeclampsia (mother or sister)
Sociodemographic characteristics (e.g., African American race, low socioeco-
nomic status)
Age ≥35 years
Personal history factors (e.g., low birth weight or small for gestational age,
previous adverse pregnancy outcome, >10-year pregnancy interval)
Low BMI <30 kg/m2, no other risk factors Do not recommend low-dose aspirin.
BMI: body mass index.
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
163327,
recommendations for women with obesity. Women who minimizes stillbirth, Caesarean birth, and delivery-related
have an adequate dietary calcium intake should be advised health care costs.169 In a hypothetical population of
to take a supplement of 1 g of calcium daily, in addition to 100 000 term pregnancies affected by obesity where a vagi-
the prenatal vitamin.162 Women with low dietary calcium nal delivery is planned, routine induction of labour at 39
intake should be advised to take 1.5−2 g of calcium daily, weeks would avoid 387 stillbirths compared with induction
in addition to the prenatal vitamin.157 at 42 weeks. Furthermore, in the same population, elective
induction at 39 weeks compared with induction at 41
weeks would avoid 9234 Caesarean sections at a health
Gestational Diabetes Prevention: Metformin and
care cost savings of $30 million.
Myo-inositol
The use of metformin has not been shown to decrease the
risk of gestational diabetes.77,78
Multiple Gestations and Maternal Obesity
A number of studies have now investigated a role for Obesity and multiple gestations are both conditions that sig-
myo-inositol supplementation of women with obesity. nificantly increase the risk of pregnancy complications,
Myo-inositol is a precursor of insulin that has insulin sensi- including gestational diabetes and hypertension. Compared
tizing effects. Daily supplementation with 2 g of myo- with multiple pregnancy in women of normal weight, multiple
inositol has been shown to reduce the risk of gestational pregnancy in women with obesity is further adversely influ-
diabetes, by 67% compared with placebo (11.6% vs. enced by high maternal pre-pregnancy BMI.170 Specifically,
27.4%; OR 0.34; 95% CI 0.17−0.68) in 1 study.163,164 preeclampsia is more common in women who are obese and
While preliminary data are encouraging, further study is having multiples (OR 4.72; 95% CI 2.83−7.89), as is gesta-
needed before myo-inositol supplementation can be rou- tional diabetes (OR 2.19; 95% CI 1.03−4.68).171 Optimizing
tinely recommended. GWG in this population is recommended, with the suggested
target range of 13.2−17.3 kg or 29−38 pounds.172,173
Maternal Obesity and Stillbirth
Stillbirth is associated with maternal BMI, with a U-shaped The risk of delivering prior to 34 weeks gestation is increased
curve demonstrating higher risk at both low and high in women who have obesity compared with women of nor-
BMIs. At 40 weeks, the risk of stillbirth is estimated to be mal weight (OR 1.65; 95% CI 1.10−2.48).174 Furthermore,
3 to 8 times higher in women with obesity >30 mg/kg2 there is a dose-dependent increase in the risk of preterm
compared with normal weight women. Multiple mecha- birth at <28, <32, and <37 weeks with increasing BMI.175
nisms link obesity and stillbirth, with a notable increase in For women with a BMI ≥35 kg/m2, the corresponding risks
the risk of placental disease (abnormal spiral arterial modi- are 1.7%, 3.6%, and 16.4%, while for women of normal
fication, placental hypertrophy) and maternal hypertension weight, the risks are 0.6%, 1.5%, and 10.3%.171 The risk is
in particular, but also fetal genetic or structural abnormali- even higher in multiple gestations conceived through in vitro
ties, umbilical cord abnormalities, and antepartum infec- fertilization, where the risk of delivery <32 weeks is 6.1%
tions.129,165,166 A triple risk model has been proposed for and the risk of delivery <37 weeks is 11.5%.171 Based on
stillbirth in general that proposes an interplay of (1) mater- this information, it is recommended that pregnancy care for
nal risk factors (e.g., obesity, smoking, maternal age), (2) multiple pregnancies include an obstetrical provider with
fetal and placental factors (e.g., placental insufficiency, fetal experience in managing maternal obesity.
growth restriction), and (3) a stressor (e.g., veno-caval com-
pression due to maternal supine sleep position, sleep-disor- Serial estimation of fetal weight by ultrasound is recom-
dered breathing).167 mended in all multiple pregnancies. There is conflicting
evidence on the effect of maternal obesity on the accuracy
GWG is a modifiable risk factor that can be targeted to of fetal weight estimation. In 1 Canadian study, the accu-
reduce stillbirth risk.168 As with women in lower BMI cate- racy of fetal weight estimation for multiples was decreased
gories, suboptimal GWG (whether too much or too little) compared to normal weight women with multiples.170 In a
places pregnancies at an increased risk of adverse preg- larger Irish study, accuracy was not adversely affected.176
nancy outcomes, including stillbirth.
There appears to be an increase in the risk of stillbirth in
For women with a BMI of ≥40 kg/m2, it has been shown multiple pregnancies complicated by maternal obesity for
that delivery before 38 weeks minimizes perinatal mortal- same-sex but not opposite-sex multiples, suggesting an
ity.134 In a computational cost-effectiveness study, it was association with monozygosity.177 Monochorionic multiple
shown that routine induction of labour at 39 weeks pregnancies in mothers who have obesity may benefit
Downloaded
from increased surveillance including the involvement of a 10. Larsen TB, Sorensen HT, Gislum M, et al. Maternal smoking, obesity,
Maternal-Fetal Medicine consultant. and risk of venous thromboembolism during pregnancy and the
puerperium: a population-based nested case-control study. Thromb Res
2007;120:505–9.
Pregnancy Care After Weight Loss Surgery
11. Vasudevan C, Renfrew M, McGuire W. Fetal and perinatal consequences
Pregnancies after weight loss surgery are becoming increas- of maternal obesity. Arch Dis Child Fetal Neonatal Ed 2011;96:F378–82.
ingly common, and the risks and benefits of these proce-
dures for mother and fetus during subsequent pregnancies 12. Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors
of venous thrombosis: a hospital-based case-control study. J Thromb
are discussed earlier in this guideline. Many women experi- Haemost 2008;6:905–12.
ence dumping syndrome post weight loss surgery and may
13. Metwally M, Ong KJ, Ledger WL, et al. Does high body mass index
not be able to tolerate glucose challenge testing during increase the risk of miscarriage after spontaneous and assisted conception?
pregnancy. Alternative approaches to diabetes evaluation A meta-analysis of the evidence. Fertil Steril 2008;90:714–26.
may include fasting glucose testing and assessment of 14. Usha Kiran TS, Hemmadi S, Bethel J, et al. Outcome of pregnancy in a
hemoglobin A1c in this setting. Additional considerations woman with an increased body mass index. BJOG 2005;112:768–72.
include increased risk of gastrointestinal bleeding, severe 15. Johansson S, Villamor E, Altman M, et al. Maternal overweight and
anemia, small bowel volvulus, obstruction, and subsequent obesity in early pregnancy and risk of infant mortality: a population based
internal herniation.178 Given this potential complexity, cohort study in Sweden. BMJ 2014;349:g6572.
involvement of a maternal-fetal medicine consultant for 16. Shah A, Kenny L, Sands J. Maternal obesity and risk of stillbirth and
pregnancy care is suggested. neonatal death. J Matern Fetal Neonatal Med 2006;19:88.
17. Kristensen J, Vestergaard M, Wisborg K, et al. Pre-pregnancy weight and

the risk of stillbirth and neonatal death. BJOG 2005;112:403–8.
REFERS TO SUMMARY STATEMENTS 3, 4, 5, 6, 7,
18. Persson M, Cnattingius S, Villamor E, et al. Risk of major congenital
AND 8 & RECOMMEDATIONS 4, 5, 6, 7, 8, 9, 10, 11, malformations in relation to maternal overweight and obesity severity:
AND 12 cohort study of 1.2 million singletons. BMJ 2017;357:j2563.
19. World Health Organization (WHO). BMI Classification. Geneva: WHO;

2006. Available at: http://www.euro.who.int/en/health-topics/disease-
REFERENCES prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi. Accessed
May 11, 2019.
1. Government of Canada. Population by year, by province and territory. In:
The Government of Canada, editor. Ottawa: Government of Canada; 20. Ramsay JE, Ferrell WR, Crawford L, et al. Maternal obesity is associated
2017. with dysregulation of metabolic, vascular, and inflammatory pathways. J
Clin Endocrinol Metab 2002;87:4231–7.
2. Government of Canada. Body mass index, overweight or obese, self-
reported, adult, by age group and sex. In: Government of Canada, editor. 21. Gibson LY, Byrne SM, Davis EA, et al. The role of family and maternal
Ottawa: Government of Canada; 2016. factors in childhood obesity. Med J Aust 2007;186:591–5.
3. Lashen H, Fear K, Sturdee DW. Obesity is associated with increased risk 22. Moos MK, Dunlop AL, Jack BW, et al. Healthier women, healthier
of first trimester and recurrent miscarriage: matched case-control study. reproductive outcomes: recommendations for the routine care of all
Hum Reprod 2004;19:1644–6. women of reproductive age. Am J Obstet Gynecol 2008;199(6 Suppl 2):
S280–9.
4. Callaway LK, Prins JB, Chang AM, et al. The prevalence and impact of
overweight and obesity in an Australian obstetric population. Med J Aust 23. Hanson M, Barker M, Dodd JM, et al. Interventions to prevent maternal
2006;184:56–9. obesity before conception, during pregnancy, and post partum. Lancet
Diabetes Endocrinol 2017;5:65–76.
5. Sebire NJ, Jolly M, Harris JP, et al. Maternal obesity and pregnancy
outcome: a study of 287,213 pregnancies in London. Int J Obes Relat 24. Villamor E, Cnattingius S. Interpregnancy weight change and risk of
Metab Disord 2001;25:1175–82. adverse pregnancy outcomes: a population-based study. Lancet
2006;368:1164–70.
6. Gaillard R, Durmus B, Hofman A, et al. Risk factors and outcomes of
maternal obesity and excessive weight gain during pregnancy. Obesity 25. Cohen JB, Cohen DL. Cardiovascular and renal effects of weight reduction
(Silver Spring) 2013;21:1046–55. in obesity and the metabolic syndrome. Curr Hypertens Rep 2015;17:34.
7. Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on 26. Morales E, Praga M. The effect of weight loss in obesity and chronic
maternal and fetal health. Rev Obstet Gynecol 2008;1:170–8. kidney disease. Curr Hypertens Rep 2012;14:170–6.
8. Bianco AT, Smilen SW, Davis Y, et al. Pregnancy outcome and weight gain 27. Wing RR, Lang W, Wadden TA, et al. Benefits of modest weight loss in
recommendations for the morbidly obese woman. Obstet Gynecol improving cardiovascular risk factors in overweight and obese individuals
1998;91:97–102. with type 2 diabetes. Diabetes Care 2011;34:1481–6.
9. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy 28. Anderson JW, Konz EC. Obesity and disease management: effects of
outcome. Obstet Gynecol 2004;103:219–24. weight loss on comorbid conditions. Obes Res 2001;9(Suppl 4):326s–34s.
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
163527,
29. Wing RR, Koeske R, Epstein LH, et al. Long-term effects of modest 47. Karamanakos SN, Vagenas K, Kalfarentzos F, et al. Weight loss, appetite
weight loss in type II diabetic patients. Arch Intern Med 1987;147: suppression, and changes in fasting and postprandial ghrelin and peptide-
1749–53. YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a
prospective, double blind study. Ann Surg 2008;247:401–7.
30. Davies GAL, Maxwell C, McLeod L, et al. No. 239-Obesity in pregnancy.
Int J Obstet Gynaecol Can 2018;40:e630–9. 48. Bohdjalian A, Langer FB, Shakeri-Leidenmuhler S, et al. Sleeve
gastrectomy as sole and definitive bariatric procedure: 5-year results for
31. Berti C, Biesalski HK, Gartner R, et al. Micronutrients in pregnancy: weight loss and ghrelin. Obes Surg 2010;20:535–40.
current knowledge and unresolved questions. Clin Nutr 2011;30:689–
701. 49. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy
as an initial weight-loss procedure for high-risk patients with morbid
32. Steegers-Theunissen RP, Twigt J, Pestinger V, et al. The periconceptional obesity. Surg Endosc 2006;20:859–63.
period, reproduction and long-term health of offspring: the importance of
one-carbon metabolism. Hum Reprod Update 2013;19:640–55. 50. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after
laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg
33. Calder PC, Ahluwalia N, Brouns F, et al. Dietary factors and low-grade 2000;232:515–29.
inflammation in relation to overweight and obesity. Br J Nutr 2011;106
(Suppl 3):S5–78. 51. Sugerman HJ, Kellum JM, Engle KM, et al. Gastric bypass for treating
severe obesity. Am J Clin Nutr 1992;55(2 Suppl):560s–6s.
34. Lau DC, Douketis JD, Morrison KM, et al. 2006 Canadian clinical practice
guidelines on the management and prevention of obesity in adults and 52. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500
children [summary]. CMAJ 2007;176:S1–13. patients: technique and results, with 3-60 month follow-up. Obes Surg
2000;10:233–9.
35. McNeely W, Benfield P. Orlistat. Drugs 1998;56:241–9; discussion 50.
53. Poitou Bernert C, Ciangura C, Coupaye M, et al. Nutritional deficiency
36. Finer N, James WP, Kopelman PG, et al. One-year treatment of obesity: a after gastric bypass: diagnosis, prevention and treatment. Diabetes Metab
randomized, double-blind, placebo-controlled, multicentre study of 2007;33:13–24.
orlistat, a gastrointestinal lipase inhibitor. Int J Obes Relat Metab Disord
2000;24:306–13. 54. Wax JR, Pinette MG, Cartin A, et al. Female reproductive issues following
bariatric surgery. Obstet Gynecol Surv 2007;62:595–604.
37. Broom I, Wilding J, Stott P, et al. Randomised trial of the effect of orlistat
on body weight and cardiovascular disease risk profile in obese patients: 55. Tice JA, Karliner L, Walsh J, et al. Gastric banding or bypass? A systematic
UK Multimorbidity Study. Int J Clin Pract 2002;56:494–9. review comparing the two most popular bariatric procedures. Am J Med
2008;121:885–93.
38. Hollander PA, Elbein SC, Hirsch IB, et al. Role of orlistat in the treatment
of obese patients with type 2 diabetes. A 1-year randomized double-blind 56. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic
study. Diabetes Care 1998;21:1288–94. review and meta-analysis. JAMA 2004;292:1724–37.
39. Woods SC, D’Alessio DA. Central control of body weight and appetite. J 57. Hutter MM, Schirmer BD, Jones DB, et al. First report from the American
Clin Endocrinol Metab 2008;93(11 Suppl 1):S37–50. College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve
gastrectomy has morbidity and effectiveness positioned between the band
40. Delgado-Aros S, Kim DY, Burton DD, et al. Effect of GLP-1 on gastric and the bypass. Ann Surg 2011;254:410–20; discussion 20−2.
volume, emptying, maximum volume ingested, and postprandial
symptoms in humans. Am J Physiol Gastrointest Liver Physiol 2002;282: 58. Bar-Zohar D, Azem F, Klausner J, et al. Pregnancy after laparoscopic
G424–31. adjustable gastric banding: perinatal outcome is favorable also for women with
relatively high gestational weight gain. Surg Endosc 2006;20:1580–3.
41. Pi-Sunyer X, Astrup A, Fujioka K, et al. A randomized, controlled trial of
3.0 mg of liraglutide in weight management. N Engl J Med 2015;373: 59. Eerdekens A, Debeer A, Van Hoey G, et al. Maternal bariatric surgery:
11–22. adverse outcomes in neonates. Eur J Pediatr 2010;169:191–6.
42. Davies MJ, Bergenstal R, Bode B, et al. Efficacy of liraglutide for weight 60. Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric
loss among patients with type 2 diabetes: the SCALE diabetes randomized banding. Obstet Gynecol 2000;95:927–30.
clinical trial. JAMA 2015;314:687–99.
61. Badreldin N, Kuller J, Rhee E, et al. Pregnancy management after bariatric
43. American Society for Metabolic and Bariatric Surgery. Story of Obesity surgery. Obstet Gynecol Surv 2016;71:361–8.
Surgery. Available at: https://asmbs.org/resources/story-of-obesity-
surgery. Accessed on April 19, 2019. 62. Yi XY, Li QF, Zhang J, et al. A meta-analysis of maternal and fetal
outcomes of pregnancy after bariatric surgery. Int J Gynaecol Obstet
44. Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery and 2015;130:3–9.
endoluminal procedures: IFSO worldwide survey 2014. Obes Surg
2017;27:2279–89. 63. Willis K, Lieberman N, Sheiner E. Pregnancy and neonatal outcome
after bariatric surgery. Best Pract Res Clin Obstet Gynaecol
45. Abenhaim HA, Alrowaily N, Czuzoj-Shulman N, et al. Pregnancy 2015;29:133–44.
outcomes in women with bariatric surgery as compared with morbidly
obese women. J Matern Fetal Neonatal Med 2016;29:3596–601. 64. Galazis N, Docheva N, Simillis C, et al. Maternal and neonatal outcomes in
women undergoing bariatric surgery: a systematic review and meta-
46. Alvarenga ES, Lo Menzo E, Szomstein S, et al. Safety and efficacy of 1020 analysis. Eur J Obstet Gynecol Reprod Biol 2014;181:45–53.
consecutive laparoscopic sleeve gastrectomies performed as a primary
treatment modality for morbid obesity. A single-center experience from 65. Parent B, Martopullo I, Weiss NS, et al. Bariatric surgery in women of
the metabolic and bariatric surgical accreditation quality and improvement childbearing age, timing between an operation and birth, and associated
program. Surg Endosc 2016;30:2673–8. perinatal complications. JAMA Surg 2017;152:1–8.
Downloaded
66. Rueda-Clausen CF, Ogunleye AA, Sharma AM. Health benefits 85. Swank ML, Marshall NE, Caughey AB, et al. Pregnancy outcomes in the
of long-term weight-loss maintenance. Annu Rev Nutr 2015;35:475– super obese, stratified by weight gain above and below institute of
516. medicine guidelines. Obstet Gynecol 2014;124:1105–10.
67. Meldrum DR, Morris MA, Gambone JC. Obesity pandemic: causes, 86. Sui Z, Turnbull DA, Dodd JM. Overweight and obese women’s
consequences, and solutions-but do we have the will? Fertil Steril perceptions about making healthy change during pregnancy: a mixed
2017;107:833–9. method study. Matern Child Health J 2013;17:1879–87.
68. Menke A, Casagrande S, Geiss L, et al. Prevalence of and trends in 87. Shulman R, Kottke M. Impact of maternal knowledge of recommended
diabetes among adults in the United States, 1988-2012. JAMA weight gain in pregnancy on gestational weight gain. Am J Obstet Gynecol
2015;314:1021–9. 2016;214:754.e1–7.
69. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS 88. de Jersey SJ, Nicholson JM, Callaway LK, et al. An observational study of
guideline for the management of overweight and obesity in adults: a report nutrition and physical activity behaviours, knowledge, and advice in
of the American College of Cardiology/American Heart Association Task pregnancy. BMC Pregnancy Childbirth 2013;13:115.
Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol
2014;63:2985–3023. 89. Olander EK, Atkinson L. Obese women’s reasons for not attending a
weight management service during pregnancy. Acta Obstet Gynecol Scand
70. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, 2013;92:1227–30.
and obesity-related health risk factors, 2001. JAMA 2003;289:76–9.
90. Ferraro ZM, Boehm KS, Gaudet LM, et al. Counseling about gestational
71. Maxwell C, Farine D. Pregnancy and obesity. Berlin: de Gruyter BD, 2017. weight gain and healthy lifestyle during pregnancy: Canadian maternity
care providers’ self-evaluation. Int J Womens Health 2013;5:629–36.
72. Louis J, Auckley D, Miladinovic B, et al. Perinatal outcomes associated
with obstructive sleep apnea in obese pregnant women. Obstet Gynecol 91. Chuang CH, Stengel MR, Hwang SW, et al. Behaviours of overweight and
2012;120:1085–92. obese women during pregnancy who achieve and exceed recommended
gestational weight gain. Obes Res Clin Pract 2014;8:e577–83.
73. Louis JM, Mogos MF, Salemi JL, et al. Obstructive sleep apnea and severe
maternal-infant morbidity/mortality in the United States, 1998-2009. Sleep 92. Harrison CL, Teede HJ, Lombard CB. How effective is self-weighing in
2014;37:843–9. the setting of a lifestyle intervention to reduce gestational weight gain and
postpartum weight retention? Aust N Z J Obstet Gynaecol 2014;54:382–
74. Senaratna CV, Perret JL, Matheson MC, et al. Validity of the Berlin 5.
questionnaire in detecting obstructive sleep apnea: a systematic review and
meta-analysis. Sleep Med Rev 2017;36:116–24. 93. Gay CL, Richoux SE, Beebe KR, et al. Sleep disruption and duration in
late pregnancy is associated with excess gestational weight gain among
75. Ankumah NE, Sibai BM. Chronic hypertension in pregnancy: diagnosis, overweight and obese women. Birth 2017;44:173–80.
management, and outcomes. Clin Obstet Gynecol 2017;60:206–14.
94. Redman LM, Gilmore LA, Breaux J, et al. Effectiveness of SmartMoms, a
76. Wilson RD, Wilson RD, Audibert F, et al. Pre-conception folic acid and novel ehealth intervention for management of gestational weight gain:
multivitamin supplementation for the primary and secondary prevention randomized controlled pilot trial. JMIR Mhealth Uhealth 2017;5:e133.
of neural tube defects and other folic acid-sensitive congenital anomalies. J
Obstet Gynaecol Can 2015;37:534–52. 95. Mottola MF, Giroux I, Gratton R, et al. Nutrition and exercise prevent
excess weight gain in overweight pregnant women. Med Sci Sports Exerc
77. Chiswick C, Reynolds RM, Denison F, et al. Effect of metformin on 2010;42:265–72.
maternal and fetal outcomes in obese pregnant women (EMPOWaR): a
randomised, double-blind, placebo-controlled trial. Lancet Diabetes 96. Kominiarek MA, Rajan P. Nutrition recommendations in pregnancy and
Endocrinol 2015;3:778–86. lactation. Med Clin 2016;100:1199–215.
78. Syngelaki A, Nicolaides KH, Balani J, et al. Metformin versus placebo in 97. Chen LW, Aris IM, Bernard JY, et al. Associations of maternal
obese pregnant women without diabetes mellitus. N Engl J Med macronutrient intake during pregnancy with infant BMI peak
2016;374:434–43. characteristics and childhood BMI. Am J Clin Nutr 2017;105:705–13.
79. Elmaraezy A, Abushouk AI, Emara A, et al. Effect of metformin on 98. Renault KM, Carlsen EM, Norgaard K, et al. Intake of sweets, snacks and
maternal and neonatal outcomes in pregnant obese non-diabetic women: a soft drinks predicts weight gain in obese pregnant women: detailed analysis of
meta-analysis. Int J Reprod Biomed (Yazd) 2017;15:461–70. the results of a randomised controlled trial. PLoS One 2015;10:e0133041.
80. Bartsch E, Medcalf KE, Park AL, et al. Clinical risk factors for pre- 99. Leung CW, Laraia BA, Coleman-Phox K, et al. Sugary beverage and food
eclampsia determined in early pregnancy: systematic review and meta- consumption, and leukocyte telomere length maintenance in pregnant
analysis of large cohort studies. BMJ 2016;353:i1753. women. Eur J Clin Nutr 2016;70:1086–8.
81. Roberge S, Giguere Y, Villa P, et al. Early administration of low-dose 100. Cervantes-Rodriguez M, Martinez-Gomez M, Cuevas E, et al. Sugared
aspirin for the prevention of severe and mild preeclampsia: a systematic water consumption by adult offspring of mothers fed a protein-restricted
review and meta-analysis. Am J Perinatol 2012;29:551–6. diet during pregnancy results in increased offspring adiposity: the second
hit effect. Br J Nutr 2014;111:616–24.
82. D’Souza R, Kingdom J. Preeclampsia. CMAJ 2016;188:1178.
101. Wilson RD. Pre-conceptional vitamin/folic acid supplementation 2007:
83. Kapadia MZ, Park CK, Beyene J, et al. Weight loss instead of weight gain the use of folic acid in combination with a multivitamin supplement for the
within the guidelines in obese women during pregnancy: a systematic prevention of neural tube defects and other congenital anomalies. J Obstet
review and meta-analyses of maternal and infant outcomes. PLoS One Gynaecol Can 2007;29:1003–13.
2015;10:e0132650.
102. Vanderlelie J, Scott R, Shibl R, et al. First trimester multivitamin/mineral
84. Institute of Medicine. Weight gain during pregnancy: reexamining the use is associated with reduced risk of pre-eclampsia among overweight and
guidelines. Washington, DC: National Academy Press; 2009, 1–13. obese women. Matern Child Nutr 2016;12:339–48.
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
163727,
103. Masho SW, Bassyouni A, Cha S. Pre-pregnancy obesity and non-adherence 120. Davenport MH, Charlesworth S, Vanderspank D, et al. Development and
to multivitamin use: findings from the National Pregnancy Risk validation of exercise target heart rate zones for overweight and obese
Assessment Monitoring System (2009-2011). BMC Pregnancy Childbirth pregnant women. Appl Physiol Nutr Metab 2008;33:984–9.
2016;16:210.
121. McParlin C, Robson SC, Tennant PW, et al. Objectively measured physical
104. Kennedy D, Koren G. Identifying women who might benefit from higher activity during pregnancy: a study in obese and overweight women. BMC
doses of folic acid in pregnancy. Can Fam Physician 2012;58:394–7. Pregnancy Childbirth 2010;10:76.
105. Farah N, Kennedy C, Turner C, et al. Maternal obesity and pre-pregnancy 122. Canadian Society for Exercise Physiology (CSEP). PARmed-X for
folic acid supplementation. Obes Facts 2013;6:211–5. pregnancy. Ottawa: CSEP; 2015. Available at: http://www.csep.ca/
cmfiles/publications/parq/parmed-xpreg.pdf. Accessed April 19, 2019.
106. Karlsson T, Andersson L, Hussain A, et al. Lower vitamin D status in
obese compared with normal-weight women despite higher vitamin D 123. Foxcroft KF, Rowlands IJ, Byrne NM, et al. Exercise in obese pregnant
intake in early pregnancy. Clin Nutr 2015;34:892–8. women: the role of social factors, lifestyle and pregnancy symptoms. BMC
Pregnancy Childbirth 2011;11:4.
107. National Institute for Health and Care Excellence (NICE). Antenatal Care
(NICE Clinical Guideline 62). London: NICE; 2008. Available at: https:// 124. Seneviratne SN, McCowan LM, Cutfield WS, et al. Exercise in pregnancies
www.nice.org.uk/guidance/cg62 Accessed May 11, 2019. complicated by obesity: achieving benefits and overcoming barriers. Am J
Obstet Gynecol 2015;212:442–9.
108. Tijerina-Saenz A, Martinez-Garza NE, Ramirez-Lopez E, et al. Iron status
and dietary intakes of iron in normal-weight and obese young Mexican 125. Bell R, Tennant PW, McParlin C, et al. Measuring physical activity in
women. Nutr Hosp 2015;31:2412–8. pregnancy: a comparison of accelerometry and self-completion
questionnaires in overweight and obese women. Eur J Obstet Gynecol
109. World Health Organization, Food and Agricultural Orgamization of Reprod Biol 2013;170:90–5.
the United Nations. Guidelines for the Evaluation of Probiotics in
Food. London, ON: 2002. Available at: http://www.who.int/ 126. St-Laurent A, Mony M, Mathieu M, et al. Validation of the Fitbit Zip and
foodsafety/fs_management/en/probiotic_guidelines.pdf. Accessed Fitbit Flex with pregnant women in free-living conditions. J Med Eng
April 19, 2019. Technol 2018;42:259–64.
110. Khorsan R, Crawford C, Ives JA, et al. The effect of omega-3 fatty acids 127. Renault KM, Norgaard K, Nilas L, et al. The Treatment of Obese
on biomarkers of inflammation: a rapid evidence assessment of the Pregnant Women (TOP) study: a randomized controlled trial of the effect
literature. Mil Med 2014;179(11 Suppl):2–60. of physical activity intervention assessed by pedometer with or without
dietary intervention in obese pregnant women. Am J Obstet Gynecol
111. Denison FC, Weir Z, Carver H, et al. Physical activity in pregnant women 2014;210:134.e1–9.
with class III obesity: a qualitative exploration of attitudes and behaviours.
Midwifery 2015;31:1163–7. 128. Mottola MF, Davenport MH, Ruchat SM, et al. No. 367-2019 Canadian
Guideline for Physical Activity throughout Pregnancy. J Obstet Gynaecol
112. Ruiz JR, Perales M, Pelaez M, et al. Supervised exercise-based intervention Can 2018;40:1528–37.
to prevent excessive gestational weight gain: a randomized controlled trial.
Mayo Clin Proc 2013;88:1388–97. 129. Wallace JM, Horgan GW, Bhattacharya S. Placental weight and efficiency
in relation to maternal body mass index and the risk of pregnancy
113. Padmapriya N, Bernard JY, Liang S, et al. Associations of physical activity and complications in women delivering singleton babies. Placenta
sedentary behavior during pregnancy with gestational diabetes mellitus among 2012;33:611–8.
Asian women in Singapore. BMC Pregnancy Childbirth 2017;17:364.
130. Zhang C, Hediger ML, Albert PS, et al. Association of maternal obesity with
114. Barakat R, Pelaez M, Cordero Y, et al. Exercise during pregnancy protects longitudinal ultrasonographic measures of fetal growth: findings from the
against hypertension and macrosomia: randomized clinical trial. Am J NICHD fetal growth studies-singletons. JAMA Pediatr 2018;172:24–31.
Obstet Gynecol 2016;214:649.e1–8.
131. Dai RX, He XJ, Hu CL. Maternal pre-pregnancy obesity and the risk of
115. Elliott-Sale KJ, Barnett CT, Sale C. Systematic review of randomised macrosomia: a meta-analysis. Arch Gynecol Obstet 2018;297:139–45.
controlled trials on exercise interventions for weight management during
pregnancy and up to one year postpartum among normal weight, 132. Lindsay KL, Brennan L, Rath A, et al. Gestational weight gain in obese
overweight and obese women. Pregnancy Hypertens 2014;4:234. pregnancy: impact on maternal and foetal metabolic parameters and
birthweight. J Obstet Gynaecol 2018;38:60–5.
116. Garnaes KK, Morkved S, Salvesen O, et al. Exercise training and weight
gain in obese pregnant women: a randomized controlled trial (ETIP trial). 133. Lauring JR, Gupta M, Kunselman AR, et al. Identification of small for
PLoS Med 2016;13:e1002079. gestational age by population-based and customized growth charts in
newborns of obese and normal-weight primiparous women. J Matern Fetal
117. Magro-Malosso ER, Saccone G, Di Mascio D, et al. Exercise during Neonatal Med 2016;29:3570–4.
pregnancy and risk of preterm birth in overweight and obese women: a
systematic review and meta-analysis of randomized controlled trials. Acta 134. Yao R, Park BY, Foster SE, et al. The association between gestational
Obstet Gynecol Scand 2017;96:263–73. weight gain and risk of stillbirth: a population-based cohort study. Ann
Epidemiol 2017;27:638−44.e1.
118. Adamo KB, Ferraro ZM, Goldfield G, et al. The Maternal Obesity
Management (MOM) trial protocol: a lifestyle intervention during 135. Benacerraf B. The use of obstetrical ultrasound in the obese gravida.
pregnancy to minimize downstream obesity. Contemp Clin Trials Semin Perinatol 2013;37:345–7.
2013;35:87–96.
136. Bak GS, Sperling L, Kallen K, et al. Prospective population-based
119. Mottola MF. Physical activity and maternal obesity: cardiovascular cohort study of maternal obesity as a source of error in gestational
adaptations, exercise recommendations, and pregnancy outcomes. Nutr age estimation at 11-14 weeks. Acta Obstet Gynecol Scand
Rev 2013;71(Suppl 1):S31–6. 2016;95:1281–7.
Downloaded
137. Simic M, Wahlin IA, Marsal K, et al. Maternal obesity is a potential source 156. Brocato B, Lewis D, Mulekar M, et al. Obesity’s impact on
of error in mid-trimester ultrasound estimation of gestational age. intrapartum electronic fetal monitoring. J Matern Fetal Neonatal Med
Ultrasound Obstet Gynecol 2010;35:48–53. 2019;32:92–4.
138. Hildebrand E, Kallen B, Josefsson A, et al. Maternal obesity and risk of 157. Harper LM, Jauk VC, Owen J, et al. The utility of ultrasound surveillance
Down syndrome in the offspring. Prenat Diagn 2014;34:310–5. of fluid and growth in obese women. Am J Obstet Gynecol 2014;211:524.
e1–8.
139. Aagaard-Tillery KM, Flint Porter T, Malone FD, et al. Influence of
maternal BMI on genetic sonography in the FaSTER trial. Prenat Diagn 158. Sarno L, Maruotti GM, Saccone G, et al. Maternal body mass index
2010;30:14–22. influences umbilical artery Doppler velocimetry in physiologic
pregnancies. Prenat Diagn 2015;35:125–8.
140. Tsai LJ, Ho M, Pressman EK, et al. Ultrasound screening for fetal
aneuploidy using soft markers in the overweight and obese gravida. Prenat 159. Kim YH, Lee HJ, Shin JE, et al. The predictive value of the uterine artery
Diagn 2010;30:821–6. pulsatility index during the early third trimester for the occurrence of
adverse pregnancy outcomes depending on the maternal obesity. Obes Res
141. Thornburg LL, Mulconry M, Post A, et al. Fetal nuchal translucency Clin Pract 2015;9:374–81.
thickness evaluation in the overweight and obese gravida. Ultrasound
Obstet Gynecol 2009;33:665–9. 160. LeFevre ML. Low-dose aspirin use for the prevention of morbidity
and mortality from preeclampsia: U.S. Preventive Services Task
142. Yared E, Dinsmoor MJ, Endres LK, et al. Obesity increases the risk of Force recommendation statement. Ann Intern Med 2014;161:
failure of noninvasive prenatal screening regardless of gestational age. Am 819–26.
J Obstet Gynecol 2016;215:370.e1–6.
161. Magee LA, Pels A, Helewa M, et al. Diagnosis, evaluation, and
143. Stothard KJ, Tennant PW, Bell R, et al. Maternal overweight and obesity management of the hypertensive disorders of pregnancy: executive
and the risk of congenital anomalies: a systematic review and meta- summary. J Obstet Gynaecol Can 2014;36:416–38.
analysis. JAMA 2009;301:636–50.
162. Hofmeyr GJ, Lawrie TA, Atallah AN, et al. Calcium supplementation
144. Best KE, Tennant PW, Bell R, et al. Impact of maternal body mass during pregnancy for preventing hypertensive disorders and related
index on the antenatal detection of congenital anomalies. BJOG problems. Cochrane Database Syst Rev 2014:Cd001059.
2012;119:1503–11.
163. Santamaria A, Di Benedetto A, Petrella E, et al. Myo-inositol may prevent
145. Dashe JS, McIntire DD, Twickler DM. Maternal obesity limits the ultrasound gestational diabetes onset in overweight women: a randomized, controlled
evaluation of fetal anatomy. J Ultrasound Med 2009;28:1025–30. trial. J Matern Fetal Neonatal Med 2016;29(19):3234–7.
146. Maxwell C, Glanc P. Imaging and obesity: a perspective during pregnancy. 164. Matarrelli B, Vitacolonna E, D’Angelo M, et al. Effect of dietary myo-
AJR Am J Roentgenol 2011;196:311–9. inositol supplementation in pregnancy on the incidence of maternal
gestational diabetes mellitus and fetal outcomes: a randomized controlled
147. Hendler I, Blackwell SC, Treadwell MC, et al. Does advanced ultrasound trial. J Matern Fetal Neonatal Med 2013;26:967–72.
equipment improve the adequacy of ultrasound visualization of fetal
cardiac structures in the obese gravid woman? Am J Obstet Gynecol 165. Bodnar LM, Parks WT, Perkins K, et al. Maternal prepregnancy obesity
2004;190:1616–9; discussion 9−20. and cause-specific stillbirth. Am J Clin Nutr 2015;102:858–64.
148. Chung JH, Pelayo R, Hatfield TJ, et al. Limitations of the fetal anatomic 166. Avagliano L, Marconi AM, Romagnoli S, et al. Abnormal spiral arteries
survey via ultrasound in the obese obstetrical population. J Matern Fetal modification in stillbirths: the role of maternal prepregnancy body mass
Neonatal Med 2012;25:1945–9. index. J Matern Fetal Neonatal Med 2012;25:2789–92.
149. Nevo O, Brown R, Glanc P, et al. No. 352-technical update: the role of 167. Warland J, Mitchell EA. A triple risk model for unexplained late stillbirth.
early comprehensive fetal anatomy ultrasound examination. J Obstet BMC Pregnancy Childbirth 2014;14:142.
Gynaecol Can 2017;39:1203–11.
168. Bodnar LM, Siega-Riz AM, Simhan HN, et al. Severe obesity,
150. Glanc P, D’Souza R, Parrish J, et al. Should an early anatomy ultrasound gestational weight gain, and adverse birth outcomes. Am J Clin Nutr
scan be offered routinely to obese pregnant women? J Obstet Gynaecol 2010;91:1642–8.
Can 2018;40:1288–94.
169. Gill L, Holbert M. Computational model for timing of delivery in an obese
151. Sparks TN, Cheng YW, McLaughlin B, et al. Fundal height: a useful population. J Matern Fetal Neonatal Med 2018;31:469–73.
screening tool for fetal growth? J Matern Fetal Neonatal Med
2011;24:708–12. 170. Al-Obaidly S, Parrish J, Murphy KE, et al. Maternal pre-gravid body
mass index and obstetric outcomes in twin gestations. J Perinatol
152. Ahmadzia HK, Thomas SM, Dude AM, et al. Prediction of birthweight 2014;34:425–8.
from third-trimester ultrasound in morbidly obese women. Am J Obstet
Gynecol 2014;211:431.e1–7. 171. Lucovnik M, Tul N, Verdenik I, et al. Risk factors for preeclampsia in twin
pregnancies: a population-based matched case-control study. J Perinat Med
153. American College of Obstetricians and Gynecologists. Practice bulletin no. 2012;40:379–82.
173: fetal macrosomia. Obstet Gynecol 2016;128:e195.
172. Shamshirsaz AA, Haeri S, Ravangard SF, et al. Perinatal outcomes based
154. Bradford BF, Thompson JMD, Heazell AEP, et al. Understanding the on the institute of medicine guidelines for weight gain in twin pregnancies.
associations and significance of fetal movements in overweight or obese J Matern Fetal Neonatal Med 2014;27:552–6.
pregnant women: a systematic review. Acta Obstet Gynecol Scand
2018;97:13–24. 173. Luke B. Nutrition and multiple gestation. Semin Perinatol 2005;29:349–54.
155. Brown R, Higgins LE, Johnstone ED, et al. Maternal perception of fetal 174. Lucovnik M, Blickstein I, Verdenik I, et al. Maternal obesity in singleton
movements in late pregnancy is affected by type and duration of fetal versus twin gestations: a population-based matched case−control study.
movement. J Matern Fetal Neonatal Med 2016;29:2145–50. J Matern Fetal Neonatal Med 2015;28:623–5.
Indonesia fromJOGC
NOVEMBREby Elsevier
2019on March
163927,
175. Dickey RP, Xiong X, Xie Y, et al. Effect of maternal height and weight on 177. Salihu HM, Alio AP, Belogolovkin V, et al. Prepregnancy obesity and risk
risk for preterm singleton and twin births resulting from IVF in the United of stillbirth in viable twin gestations. Obesity (Silver Spring) 2010;18:
States, 2008-2010. Am J Obstet Gynecol 2013;209:349.e1–6. 1795–800.
176. Ryan HM, Morrison JJ, Breathnach FM, et al. The influence of maternal 178. Narayanan RP, Syed AA. Pregnancy following bariatric surgery-medical
body mass index on fetal weight estimation in twin pregnancy. Am J complications and management. Obes Surg 2016;26:2523–9.
Obstet Gynecol 2014;210:350.e1–6.
Downloaded

Tasya Fitri Ramadanti

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Tasya Fitri Ramadanti

Uploaded by

Copyright:

Available Formats

Best Practice & Research Clinical Obstetrics and Gynaecology 68 (2020) 109e117

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Optimal Intrapartum Care - Vol. 67 Multiple Choice Answers

2. (a) T, (b) F, (c) F, (d) F

3. (a) T, (b) F, (c) F, (d) T

7. (a) F, (b) F, (c) T, (d) T, (e) T

8. (a)T, (b) F, (c) F, (d) F, (e) F

9. (a)F, (b) F, (c) T, (d) F, (e) T

10. (a) F, (b) T, (c) F, (d) F, (e) F

11. (a) F, (b) F, (c) F, (d) T

12. (a) F, (b) F, (c) F, (d) T

13. (a) F, (b) F, (c) T, (d) F

14. (a) T, (b) F, (c) F, (d) T, (e) T

15. (a) F, (b) F, (c) F, (d) T, (e) F

16. (a) T, (b) F, (c) F, (d) T, (e) T

17. (a) F, (b) F, (c) T, (d) T, (e) F

18. (a) F, (b) T, (c) T, (d) F, (e) T

19. (a) T, (b) F, (c) F, (d) T, (e) F

20. (a) F, (b) F, (c) T, (d) T, (e) T

21. (a) T, (b) T, (c) F, (d) F, (e) F

22. (a) T, (b) F, (c) F, (d) F

23. (a) F, (b) F, (c) T, (d) F

24. (a) T, (b) F, (c) F, (d) F

25. (a) F, (b) F, (c) F, (d) T

Oxytocin is synthesized in the hypothalamus, in magnocellular neurosecretory cells of the supra-

26. (a) F, (b) F, (c) F, (d) T

27. (a) F, (b) F, (c) T, (d) F

28. (a) F, (b) F, (c) F, (d) T

Oxytocin is an induction agent and not a cervical ripening agent.

29. (a) T, (b) T, (c) T, (d) F, (e) F

30. (a) T, (b) F, (c) T, (d) T, (e) F

31. (a) T, (b) T, (c) F, (d) F, (e) T

32. (a) T, (b) F, (c) F, (d) T, (e) F

33. (a) F, (b) F, (c) T, (d) T, (e) T

34. (a) T, (b) T, (c) F, (d) T, (e) F

Midwife-led continuity-of-care models, in which a known midwife or small group of known

35. (a) F, (b) T, (c) F, (d) T, (e) T

36. (a) T, (b) T, (c) F, (d) T, (e) F

Contents lists available at ScienceDirect

Sexual & Reproductive Healthcare

Perceived barriers to utilization of antenatal care services in northern T

Introduction appropriate nutrition and recognizing complications [6]. This is

Study setting Data collection

References CA: SAGE; 2002.

Postnatal care: increasing coverage, equity, and quality

Downloaded for Fakultas Kedokteran

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/puhe

Antenatal care and skilled birth attendance in

J. Bhowmik a,*, R.K. Biswas b, M. Woldegiorgis a

article info abstract

* Corresponding author. Tel.: þ61 3 9214 8367

as a qualified carer, which was considered as the definition of

SD, standard deviation.

BDHS, Bangladesh Demographic and Health Survey; ANC, antenatal care.

CI, confidence interval.

Conclusion This research received no specific grant from any funding

No. 391, November 2019 (Replaces No. 239, February 2010)

Guideline No. 391-Pregnancy and Maternal

J Obstet Gynaecol Can 2019;41(11):1623−1640 KEY MESSAGES

INTRODUCTION Deﬁnition of Obesity

Table 3. Neonatal risks associated with maternal obesity