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RESEARCH ARTICLE
The impact of prenatal education based on the Roy adaptation model on
gestational hypertension, adaptation to pregnancy and pregnancy outcomes
Keziban Amanak,1 Ümran Sevil,2 Zekiye Karacam3

Abstract
Objective: To analyse the impact of prenatal education on gestational hypertension, adaptation to pregnancy and
on maternal and neonatal outcomes.
Methods: The quasi-experimental case-control study was conducted at Aydin Maternity and Children's Hospital,
Aydin, Turkey, from October 2013 to July 2015, and comprised women with gestational hypertension. The sample
was randomised into education and control groups with the former receiving informative education and the latter
receiving due medical care alone. Roy Adaptation Model was used to determine the impact of prenatal education.
SPSS 20 was used for data analysis.
Results: Of the 132 subjects, 68(51.5%) were in the education group and 64(48.5%) in the control group. Post-
intervention, 11(16.2%) women in the education group and 37(57.8%)in the control group developed severe
preeclampsia. Subsequently, 44(64.7%) in the education group had no preeclampsia. The corresponding number in
the control group was 15(23.4%).
Conclusion: Education based on Roy Adaptation Model proved to be effective among pregnant women in keeping
hypertension under control.
Keywords: Adaptation, Hypertension, Roy Adaptation Model. (JPMA 69: 11; 2019)

Introduction behaviour in the four domains of adaptation. Non-adaptive

Hypertensive illnesses in pregnancy are major causes of
morbidity and mortality among mothers, foetuses and
neonates all over the world.1 The World Health Organisation
(WHO) reports that about 10% of pregnant women are
adversely affected by hypertensive illnesses and that more
than 60,000 women lose their lives because of this. 2
Moreover, the fact that preeclampsia is responsible for the
death of 500,000 neonates reveals that this disease is
considerably threatening in terms of foetal outcomes.3 In
Turkey, the incidence of hypertensive illnesses in pregnancy
is reported to range between 3.9% and 15.1%,4-7 and in
2014, it was reported that 14% of maternal deaths were
caused by hypertensive illnesses in pregnancy.8 Studies
report that the use of the Roy Adaptation Model (RAM) in
cases of education and counselling provided a positive
contribution to the process of adapting to pregnancy.9-12
RAM classifies behavioural responses in four modes
(physiological, self-concept, role function and
interdependence domains) of adaptation as adaptive or
non-adaptive. Nursing diagnoses are defined after non-
adaptive behaviour is determined and then interventions
are planned accordingly. Nursing intervention is the
education provided that addresses the non-adaptive
1,3Adnan Menderes University, Faculty of Health Sciences, 2Ege University,
Faculty of Nursing, Department of Women Health Diseases, Turkey.
Correspondence: Keziban Amanak. Email: keziban.amanak@adu.edu.tr
behaviour is responding not positively to environmental
changes. The nurse then makes another assessment to track
the effects of the intervention. If the individual develops an
adaptive behaviour, the nursing intervention is taken as
effective; if non-adaptive behaviour has developed, the
intervention is considered to have been ineffective.13,14
The current study was planned to analyse the impact of
prenatal education based on the Roy Adaptation Model
on gestational hypertension, adaptation to pregnancy
and on maternal and neonatal outcomes.
Subjects and Methods
This single-centre, randomised, quasi-experimental study
was conducted at the Gynaecology and Obstetrics Clinics of
Aydin Maternity and Children's Hospital, Aydin, Turkey, from
October 2013 to July 2015, and comprised women with
gestational hypertension. Quantitative data-collection was
employed and the hospital was selected because it was the
only maternity hospital in Aydin. Approval was obtained
from the Ege University Nursing Faculty Scientific Ethics
Committee and permission was obtained from the Aydin
Province Public Hospitals Association General Secretariat.
Written informed consent was obtained from all the
subjects. Written permission was also obtained from
Assistant Prof. Dr. Derya Tasci Beydag for the use of the Pain
self-efficacy questionnaire- Acceptance of pregnancy
subscale (PSEQ-AP).17 The study was also registered at the

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12
Australia-New Zealand Clinical Trials Registry
(ACTRN12617000225314). Using convenience sampling
method, prospective subjects were enrolled. Since there
was no study found in literature that dealt with the
standardisation of care with regard to cases with
gestational hypertension, therefore the sample size was
determined on the basis of information obtained from the
current study itself. The minimum number of individuals in
the sample was determined using G*power at a 95%
confidence interval (CI), effect size (d)=0.60, =0.05 and
power analysis= 0.80 (80%). The sample size stood at 44
women each in educational and control groups.
Those invited were pregnant women in their 20th-24th
gestational weeks, were aged 18-35 years who had received
a diagnosis of hypertension and were taking anti-
hypertensive drugs, had experienced less than four and
single pregnancies, having body mass index (BMI between
19-30, and consented to participate in the study were taking
anti-hypertensives. Excluded from the study were those
who were past their 24th gestational week, age outside the
18-35 years bracket, those who had experienced more than
four pregnancies, had a BMI outside of 19-30 bracket, and
those who did not consent to participate in the study.
Those who met the inclusion criteria were randomly
allocated into two equal groups by using a computer-
generated random number chart. For all consecutive
pregnant women, numbers were written on envelopes,
while the allocation data was entered on a separate paper
that was put into the numbered envelopes which were then
sealed. When the pregnant women met the inclusion
criteria, she signed the informed consent form and was given
her participation number. When the patient had reached the
second stage, the envelope with the participation number
on its cover was opened to reveal the randomisation.
Those who were followed up at other hospitals, or were
unable to report regular blood pressure readings were left
out (Figure-1). Demographic questionnaire, 9,15 RAM-
based semi-structured interview form, maternal and
neonatal outcomes assessment questionnaire and
gestational hypertension prognosis form were prepared
in line with the literature.14-23Prenatal Self-Evaluation
Questionnaire16 was developed to assess the adaptation
of prenatal women to pregnancy and to the role of
motherhood. The scale consists of 7 subscales and 79
items, the total tool and subscale internal consistency
coefficients varied between 0.75 and 0.92. The Turkish
version of the instrument has been tested for validity and
reliability in 2008.17 The tool has a high level of internal
consistency reliability coefficient (a =0.81), and subscales'
internal consistency reliability coefficients varied between
0.72 and 0.85. According to the item total score analysis
J Pak Med Assoc
K. Amanak, Ü. SEVIL, Z. Karacam
results for the evaluation of the tool's reliability, a value of
r=0.30-0.59 was found and no item was removed from the
tool. The tool's test-retest reliability coefficient was at a
high level (r=0.84). This study made use of the Acceptance
of Pregnancy Subscale. 17 The subscale was used to
evaluate the women's adaptation to pregnancy. The
internal consistency coefficient for the acceptance of
pregnancy subscale was 0.80. The subscale consists of 14
items. The highest possible score on this subscale is 56; the
lowest is 14. As the scores decrease, the acceptance of
pregnancy increases.15,17
The educational booklet was prepared in a manner that
encompassed the four modes of adaptation described in
RAM; physiological, self-concept, role function and
interdependence.9,12 To ensure the content validity of the
educational booklet, eight faculty members, specialised
in Obstetric and Gynaecological Nursing, were consulted.
Meetings were held with the pregnant women in the
education group four times; twice in Weeks 20-24 of
pregnancy, once in their 30th-34th weeks and on the first
and second days after the birth. At the first meeting,
introductions were made using face-to-face interviews,
consent forms were signed, and demographic
questionnaire, PSEQ-AP and RAM-based semi-structured
interview form were filled out. In addition, the pregnant
women were asked to have their blood pressure measured
and recorded once a week. Based on the data obtained from
the semi-structured interview form, the non-adaptive
behaviours according to the RAM modes of adaptation were
determined. In the second meeting, which was held one
week after the first monitoring, individual coaching was
provided on how to cope with the stimuli causing the non-
adaptive behaviour. Although the goal in this model-based
education was to diminish or eliminate the impact of the
stimuli that caused the non-adaptive behaviour, if
behaviours or stimuli could not be changed, developing a
positive perception became the objective. At the second
meeting, five sessions were held — two sessions to cover the
physiological mode, and one session each for the self-
concept, role functions and interdependence modes. The
sessions each took approximately 20-40 minutes.
Additionally, behaviour changes proposed to be achieved
until the next visit that would improve the pregnant
women's adaptation to pregnancy and to illness during
pregnancy were planned and an education booklet was
given to the women.
At the third meeting (Week 30-34 of the pregnancy), the
PSEQ-AP, the Hypertension Prognosis Form and the RAM-
based semi-structured interview forms were filled out.
Then, education was provided by means of the education
booklet on areas of adaptation where problems were
The impact of prenatal education based on the Roy adaptation model on gestational hypertension...
Figure-1: Randomisation flow chart.
experienced, after which planning was carried out for the
next meeting to facilitate behaviour changes that could
improve adaptation to pregnancy and prenatal illnesses.
In the fourth week (Day 1 and 2 after the birth), the
Gestational Hypertension Prognosis, Maternal-Neonatal
Outcomes Evaluation Forms were filled out.
The meetings with the pregnant women in the control
group were held in Weeks 20-24 and 30-34 of the
pregnancy and on the first and second days after the birth.
In the first meeting the pregnant women underwent face-
to-face interview and consent forms, as well as the
Identifying Characteristics Form and the PSEQ-AP were
filled out, after which the women were given routine care. In
addition, they were asked to have their blood pressure
measured and recorded once a week over the period of the
study. At the second meeting, the researcher filled out the
PSEQ-AP and Gestational Hypertension Prognosis Form. At
the third meeting, the Gestational Hypertension Prognosis
and the Maternal and Neonatal Outcomes Evaluation Forms
were administered. As against the control group, a
programme of education based on the Roy Adaptation
Model was provided to the education group in the second
(a week after the first monitoring) and third meetings
13
Figure-2: Study implementation steps.
(Figure-2).
SPSS 20 was used to analyse the data. Numeric data was
expressed as mean ± standard deviation (SD). Other data was
defined in the form of frequency and percentage. The
comparisons of two groups' sociodemographic and obstetric
characteristics, their gestational hypertensive illnesses in the
second and third monitoring and their neonatal outcomes
were carried out with chi-square test. Comparisons between
the two groups' obstetric characteristics' mean values, their
PSEQ-AP mean scores at the first and second monitoring,
their neonatal and maternal outcomes' mean values (normal
distribution) were carried out with independent samples t-
test. Data that did not distribute normally was analysed with
Mann-Whitney U test. The relationships between infant's
period of stay at the hospital and mother's period of stay at
the hospital were identified using Pearson correlation
analysis. The limit of significance was p<0.05 for all tests.
Results
Of the 214 women approached, 64(30%) were excluded.
The remaining 150(70%) women were divided into two
groups of 75(50%) each. Subsequently, 7(9.3%) in
education group and 11(14.6%) had to be eliminated. The
final sample size analysed was 132(62%) women;
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14 K. Amanak, Ü. SEVIL, Z. Karacam

Table-1: Sociodemographic and obstetric characteristics of the pregnant women.

Sociodemographic and Education group Control group X2 or t or Z/P

obstetric characteristics (n=68) (n=64)

Educational status, n(%)

Elementary School 51(75.0) 49(76.6) 0.422/0.810
Middle School 13(19.1) 10(15.6)
High school - University 4(5.9) 5(7.8)
Working status, n(%)
Employed 14 (20.6) 8(12.5) 1.553/0.213
Housewife 54(79.4) 56(87.5)
Rate of planned pregnancy, n(%)
First delivery mode, n(%) 58(85.3) 54(84.4) 0.022/0.883
Normal 41(69.5) 41(80.4) 1.713/0.191
Caesarean section 18(30.5) 10(19.6)
Second delivery mode, n(%)
Normal 23(63.9) 13(56.5) 0.320/0.571
Caesarean section 13(36.1) 10(43.5)
Experiencing discomfort during pregnancy, n(%) 14 (20.6) 16 (25.0) 0.365/0.546
Discomfort experienced, n(%)
Anaemia 3(21.4) 4(25.0) 2.324/0.508
Nausea-vomiting 4(28.6) 7(43.8)
Anaemia and nausea-vomiting 5(35.7) 2(12.5)
Risk of miscarriage 2(14.3) 3(18.7)
Age, Mean ± SD 26.60± 5.19 26.52± 4.83 -0.151*/0.880
Gestational week, Mean ± SD 21.29±1.43 21.38±1.41 -0.371*/0.711
Number of pregnancies, Mean ± SD 2.45±0.70 2.34±0.70 0.923/0.358
No. of live births, Mean ± SD 1.58±0.50 1.43±0.50 -1.497*/0.134
No. of living children, Mean ± SD 1.58±0.50 1.42±0.50 -1.604*/0.109
Total weight gained during pregnancy, Mean ± SD 20.26±4.60 21.45±3.86 -1.453*/0.146
*The Mann-Whitney U test was applied because normal distribution was not observed. Values are Z values.

68(51.5%) in the education group and 64(48.5%) in the
control group. The educational and employment status as
well as their planning of pregnancy of subjects in the two
groups were statistically similar (p>0.05).
In the education group, 14(20.6%) women and 16(25.0%)
in the control group stated that they had experienced
discomfort in the first monitoring (Table-1).
At the second monitoring, the difference between the
groups was statistically significant (p=0.000), with
10(14.7%) women in the education group having mild
preeclampsia compared to 2(3%) in the control group.
The rate of developing severe preeclampsia was

Table-2 Pregnant women's gestational hypertension illnesses and PSEQ-AP mean scores.

Monitoring Results Education group (n= 68) Control group (n=64) X2 or t or Z/P

Second monitoring
No preeclampsia 47(69.1) 25(39.1) 26.042/0.000
Mild preeclampsia 10(14.7) 2(3.1)
Severe preeclampsia 11(16.2) 37(57.8)
Third monitoring
No preeclampsia 44(64.7) 15(23.4) 42.587/0.000
Mild preeclampsia 11(16.2) 1(11.6)
Severe preeclampsia 13(19.1) 48(75.0)
PSEQ-AP, Mean ± SD
First monitoring 44.12±11.09 40.89±10.56 -1.447*/0.148
Second monitoring 28.57±4.79 35.45±6.32 #DIV/0!
*The Mann-Whitney U test was applied because normal distribution was not seen. Values are Z values.
PSEQ-AP:

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The impact of prenatal education based on the Roy adaptation model on gestational hypertension... 15
Table-3: Results of neonatal and maternal outcomes.

Neonatal and maternal outcomes Education group (n=68) Control group (n=64) X2 or t or Z/P

Presentation position disorder, n(%) 7(10.3) 8(12.5) 0.159/0.690

Congenital malformation, n(%) 4(5.9) 4(6.3) 0.000/1.000
RDS, n(%) 6(8.8) 9(14.1) 0.898/0.343
Neonatal hypoglycemia, n(%) 11(16.2) 15(23.4) 1.099/0.294
Neonatal hyperbilirubinemia, n(%) 6(8.8) 11(17.2) 2.056/0.152
Infant taken into intensive care, n(%) 9(13.2) 12(18.8) 0.749/0.387
Gestational week, n(%)
Weeks 34-36 3(4.4) 1(1.6) 0.199/0.655
Week 37 and above 65(95.6) 63(96.4)
Infant's head circumference, Median ±SD 34.50±0.89 34.31±0.66 1.366/0.174
Infant's length, Median ± SD 50.24±0.71 50.16±0.51 0.727/0.469
Infant's weight, Median ±SD 3533.69±274.70 3464.66±248.02 1.512/0.133
Gestational week, Median ± SD 39.26±1.23 39.08±1.01 0.949/0.345
First-minute Apgar score, Median ± SD 7.85±1.14 7.77±1.09 -0.075*/0.940
Fifth-minute Apgar score, Median ± SD 9.19±1.03 8.98±1.21 -0.942*/0.346
Infant's stay at hospital, Median ± SD 3.13±2.61 4.17±2.62 -3.538*/0.000
Mother's stay at hospital, Median ± SD 2.75±1.64 3.45±1.66 -152.75
Maternal systolic blood pressure, Median ± SD 139.29±14.51 152.83±9.04 #DIV/0!
Maternal diastolic blood pressure, Median ± SD 91.19±8.99 101.84±9.42 -5.674*/0.000
RDS: Respiratory Distress syndrome

11(16.2%) in the education group compared to 37(57.8%)
in the control group (p=0.000).
At the third monitoring, an examination, by gestational
hypertensive illnesses, of the distribution of the education
and control groups revealed that the difference between
the groups was statistically significant (p=0.000). The rate
of developing mild preeclampsia was higher in the
education group than in the control group, while the rate
of developing severe preeclampsia was less in the
education group (p=0.000). The difference between the
group with mild preeclampsia and the group with severe
preeclampsia was significant (p=0.000).
Mean PSEQ-AP score of the education group at the first
monitoring was higher than that of the control group, but
the difference was not significant (p>0.05). At the second
monitoring, the statistical difference was significant
(p=0.000) (Table-2).
The subjects in both groups were similar in terms of
presentation position anomaly, the existence of congenital
malformation, acute respiratory distress syndrome (ARDS),
existence of neonatal hypoglycaemia, neonatal
hyperbilirubinaemia, infant's admittance into intensive
care and the gestational week at birth (p>0.05 each).
Neonatal outcomes of intrauterine development
retardation, neonatal mortality, ablatio placenta were not
seen in either group but neonatal infection was observed
in only 1(1.56%) infant in the control group. Also, the only
congenital malformation observed in both groups was
neural tube defects.
The infants of women in the two groups were similar in
terms of their head circumferences, lengths, mean
weights, mean gestational week, mean scores of
appearance, pulse, grimace, activity, and respiration
(Apgar) in the first minute, and their mean Apgar score in
the fifth minute (p>0.05 each). A significant difference
between the groups was only found in terms of the
infant's average stay at the hospital (p=0.000). A positive
correlation was discovered between the infant's period of
stay at the hospital and the mother's period of stay at the
hospital (p=0.000). Similarly, the mothers in the education
group had lower levels of average stay at the hospital,
maternal systolic blood pressure averages, and maternal
diastolic blood pressure averages compared to the
mothers in the control group (p=0.000). Maternal
mortality was not observed in either group, but maternal
infection was seen in 1(1.5%) subject in the control group
(Table-3).
Discussion
In the first monitoring prior to the education in this study,
the socio-demographic and obstetric features of the
education and control groups were found to be similar, as
were their mean scores on PSEQ-AP. These findings are
important in that they reveal the homogeneity of the two
groups prior to the education.
According to the RAM, nurses focus on human and

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16
environment interactions that promote maximum human
development and well-being. People are defined as
adaptive systems able to adapt to the environment.
Therefore, nurses evaluate the adaptation status of
human beings and plan interventions directed toward
turning negative stimuli into positive responses. The
primary goal of nursing is to promote adaptation.14 In the
second and third monitoring of the subjects, the
incidence of mild and severe preeclampsia in the
education group was lower than in the control group. This
finding reveals that the RAM-based education was
effective in keeping hypertension under control in
pregnant women.
The mean PSEQ-AP score of the education group at the
first monitoring was higher than that of the control group,
but this difference was not significant. The PSEQ-AP mean
score of the education group at the second monitoring
was lower than that of the control group and this
difference was significant. It was seen in the study that the
RAM-based education enhanced the pregnant women's
levels of adaptation to pregnancy. These results point to
the effectiveness of a RAM-based education in gestational
hypertension. A similar study with pregnant women at
low risk reported that the RAM-based education
increased the women's levels of adaptation.9 Also, a study
with pregnant women reported that the PSEQ-AP mean
was 23.12±7.40.11 A further study reported that PSEQ-AP
mean was 24.0±7.9.12 Another study reported that PSEQ-
AP mean was 21.8±7.9.10 As PSEQ-AP score decreases, the
acceptance of pregnancy increases.15.17 The mean scores
of the pregnant women in both groups in this study were
higher than those reported in the literature for low-risk
pregnant women10-12 Hypertensive disorders have many
negative physiological and psychological effects on
pregnancies.
The similarity between the education and control groups
in this study in terms of presentation position anomaly,
the existence of congenital malformation, ARDS, neonatal
hypoglycaemia and hyperbilirubinaemia, the admittance
of infants into intensive care, gestational week, the head
circumference, length and weight of the infant, the
gestational week at birth, and the mean Apgar scores in
the first and fifth minutes shows that the RAM-based
education did not have an impact on neonatal outcomes.
However, the infants of the gravidae in the control group
stayed in the hospital for a longer duration due to the
medical condition of the mother. This shows that the
RAM-based education was ineffective on neonatal
outcomes. The study revealed that the RAM-based
education had a positive effect on the gravida's systolic
and diastolic blood pressure outcomes and shortened the
J Pak Med Assoc
K. Amanak, Ü. SEVIL, Z. Karacam
duration of stay in the hospital. This shows that the RAM-
based education was partially effective on neonatal
outcomes.
In terms of limitations, the study was a single-centre
research and its results are not generalisable. For this we
need to have a large multicentre trial with large sample
size. We could not do that due to unavailability of
resources.
Conclusions
RAM-based education in pregnant women was effective
in keeping hypertension under control and in enhancing
levels of adaptation to pregnancy. It was ineffective on
some neonatal outcomes and partially effective on others.
Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.
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Vol. 69, No. 1, January 2019
 Early Human Development 86 (2010) 493–497

Contents lists available at ScienceDirect

Early Human Development

j o ur nal ho mep ag e : www. elsevier. c o m /lo c ate /e ar l hum d e v

Effect of birth weight, maternal education and prenatal smoking on offspring

intelligence at school age
Kaja Rahu a, Mati Rahu a, Helle Pullmann b, Jüri Allik b,⁎
a National Institute for Health Development, The Estonian Centre of Behavioural and Health Sciences, Estonia
b Department of Psychology, University of Tartu, The Estonian Centre of Behavioural and Health Sciences, Estonia

a r t i c l e in fo abstract

Article history: To examine the combined effect of birth weight, mothers’ education and prenatal smoking on
Received 24 November 2009 psychometrically measured intelligence at school age 1,822 children born in 1992–1999 and attending the
Received in revised form 19 June 2010 first six grades from 45 schools representing all of the fifteen Estonian counties with information on birth
Accepted 21 June 2010 weight, gestational age and mother's age, marital status, education, parity and smoking in pregnancy, and
intelligence tests were studied. The scores of Raven's Standard Progressive Matrices were related to the birth
Keywords:
weight: in the normal range of birth weight (≥2500 g) every 500 g increase in birth weight was
Birth weight
accompanied by around 0.7-point increase in IQ scores. A strong association between birth weight and IQ
Intelligence
Pregnancy
remained even if gestational age and mother's age, marital status, education, place of residence, parity and
Smoking smoking during pregnancy have been taken into account. Maternal prenatal smoking was accompanied by a
Nicotine 3.3-point deficit in children's intellectual abilities. Marriage and mother's education had an independent
Socioeconomic factors positive correlation with offspring intelligence. We concluded that the statistical effect of birth weight,
maternal education and smoking in pregnancy on offspring's IQ scores was remarkable and remained even if
other factors have been taken into account.
© 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction through to early adulthood, intrauterine growth may also contribute

Low birth weight is a powerful predictor of several negative life
outcomes: poor survival, asthma, hypertension and non-insulin
dependent diabetes [1–3]. It is also documented that children with a
low birth weight (less than 2,500 g) are at risk for reduced
intelligence test scores when they have reached the school age,
even if their birth weight is corrected for gestational age [4–6].
Furthermore, more recent studies have extended the relationship
between birth weight and cognitive abilities at school age to the
normal range of birth weight as well [7–9]. A systematic review
demonstrated a consistent positive association between normal birth
weight and childhood cognitive ability, even when corrected for
confounders such as family income and parental education [10]. Birth
weight is associated with cognitive abilities through childhood and
early adulthood and does not vanish in midlife [9,11]. Although the
increase of intellectual abilities associated with the birth weight is still
small compared to the impact of other factors such as parental IQ and
education [12,13] and could explain only a small proportion of the
shared variance which is rarely larger than 3% [8], it may still have
obvious consequences at a population level. Although postnatal en-
vironment has a decisive role in the development cognitive function
⁎ Corresponding author. Department of Psychology, University of Tartu, Tiigi
78, 50410 Tartu, Estonia. Tel.: + 372 737 5905; fax: + 372 737 6152.
E-mail address: juri.allik@ut.ee (J. Allik).
to later intellectual development [14].
Association of birth weight with later intellectual development is
not necessarily causal: the child's birth weight itself can be sub-
stantially accounted for by mother's cognitive abilities [13]. Fetal size,
as a crude summary of the average level of metabolism and growth
factors, is affected by many genetic and environmental mechanisms
that serve the link between birth weight and later growth of
intellectual abilities. The significant relationship between birth weight
and childhood IQ have not been observed in all cohorts [15]
suggesting that beside intrauterine growth many other factors such
as socioeconomic position [10], mother's smoking [16] and her
intelligence [13], and postnatal head growth [17] make their
contribution to the growth of cognitive functions. These other factors
can also modulate the impact of birth weight on cognitive develop-
ment [18]. Because the exact causal mechanisms of the birth weight
influence on the child's intelligence remains largely unidentified, it is
relevant to explore a wide range of potential factors and their
interactions. For example, it is known that mother's smoking during
pregnancy may have an adverse effect on child cognitive develop-
ment. However, it is not clear whether maternal smoking has a direct
effect on child's intelligence. It is also well documented that maternal
smoking during pregnancy leads to a lowered birth weight which, in
turn, may be a factor reducing cognitive development [16,19–22].
Thus, the associations between maternal smoking during pregnancy
and poor cognitive performance in the offspring might be indirect

0378-3782/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
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494 K. Rahu et al. / Early Human Development 86 (2010) 493–497
[21–23]. The same is true concerning birth weight and it is necessary
to look for other variables that could mediate the relationship
between birth weight and intelligence.
This study is based on geographically representative sample of
Estonian children allowing studying to what extent environmental
conditions such as the degree of urbanization affect the relationship
between birth weight and intelligence. Previous studies have shown
that IQ of children who are living in an inner-cities declines relative to
suburban children during the early school years [24]. For example,
data demonstrate that residents in rural areas of Estonia may have due
to more limited access to primary health care lower level of infant
survival [25]. Similar factors can create disadvantages for prenatal
growth resulting in lower birth weight or slowing down intellectual
development.
Even though correlation between birth weight and childhood
intelligence is generally established, some factors can still confound it
[15]. Most existing data have been collected from developed and
Western countries, mainly from USA and United Kingdom but also
from Denmark, Norway, Sweden, and Israel. There are only few data
from poor or less developed countries such as China or Belarus
[26,27]. For example, it is documented that insulin resistance can
affect body weight [28]. However, the association between socioeco-
nomic position and insulin resistance is not with the same size or even
in the same direction in all countries. Among Danish children, those
with the most educated and highest earning parents had least insulin
resistance, whereas the opposite was true for children from Estonia
and Portugal [29]. Like cognitive abilities impaired glucose tolerance
and non-insulin dependent diabetes is also linked to low birth weight
[2]. Thus, it would be relevant to observe the association between
birth weight and childhood intelligence in cultures with different
socioeconomic history.
The exact nature of the relationship between the birth weight and
intelligence in school age has not established yet. Several studies have
found a parabolic relationship between birth weight and IQ: starting
from a certain values the increase of the birth weight does not lead to
the increase in mental abilities and a very heavy birth weight (over
4000 g) becomes detrimental to the growth of mental abilities [1,30–
32]. In other studies the benefit of the birth weight on intelligence
continues to increase even beyond 4000 g [7,8,14,33–36]. There is no
evidence on what conditions either of these two patterns occurs.
The aim of this study was to examine the combined effect of birth
weight, gestational age, mothers’ education, and prenatal smoking on
psychometrically measured intelligence at school age.
2. Methods
Sample
The sample was drawn from the Estonian Children Intelligence and
Personality Survey [37,38] including 45 geographically representative
schools from all of the fifteen Estonian counties (maakond), including
two largest cities – Tallinn (capital of Estonia) and Tartu, small towns
and rural areas. In this study we analyzed data of the first six grades
born in 1992–1999, all together 2,017 children. Eleven children were
excluded from further analysis because of missing IQ test results and
six were excluded due to extremely low scores which may indicate
motivational problems. We used the Estonian Medical Birth Registry,
recording all births in Estonia since January 1, 1992, as a source for
data of child (birth weight, gestational age) and mother at delivery
(age, marital status, education, parity and smoking in pregnancy).
Gestational age was determined by ultrasound examination before
21st week of pregnancy and/or by date of last menstrual period. There
were 29 participants who were twins and they were removed from
the further analysis. We also checked for diabetes – it was not
mentioned for none of mothers. Linkage was based on child's date of
birth, family name and place of residence. We failed to link 146 (7.2%)
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records; three mothers lacked information about education and/or
marital status. Finally, 1,822 children (aged 7–13 years) remained
whose data were analyzed in this study. The distribution of children
by age 7, 8, 9, 10, 11, 12 and 13 years was 1.2%, 25.9%, 26.0%, 26.5%,
2.5%, 2.6% and 15.3%, respectively.
Intelligence measure
Raven's Standard Progressive Matrices test [39] was used to
measure the intellectual abilities of the participants. Testing was
carried out 2001–2002 and 2004–2005. The test was administered
without any time limits. The raw scores of the SPM were standardized
(IQ; Mean= 100, SD= 15) across age groups based on the national
norms of the test which included this sample as a part of it. More
details of the Estonian representative normative sample are reported
elsewhere [37].
Statistical analysis
Linear regression models were used to estimate the effect of birth
weight and maternal characteristics on child's IQ score. Birth weight
was divided into six categories: b 2500, 2500–2999, 3000–3499,
3500–3999, 4000–4499, ≥4500 g. Mother's age at delivery was
calculated in full years and categorized as b 20, 20–34 and ≥
35 years. Mother's education was classified as basic/less, secondary/
secondary special, and higher professional/university; marital status
as married, cohabiting, and single/divorced; smoking in pregnancy as
yes/quitted, and no; parity as primiparas, and multiparas; gestational
age as b 37, and ≥ 37 weeks; location of the school as Tallinn, Tartu,
and other. In the model including mother's smoking in pregnancy,
additionally 46 records were removed because of missing data on
smoking.
Additionally, association between fetal growth and child's IQ score
was studied using linear regression model. Estonian population-based
gender-specific reference for birth weight for gestational age for
singleton births was used to categorize children into four groups:
b 10th percentile, 10th–50th (excl) percentile, 50th–90th (excl)
percentile, and ≥ 90th percentile [40]. Preterm births (83 cases)
were excluded from the analysis. Adjustments were made for the
same characteristics as described above.
Analyses were carried out using the Stata 10 statistical package
(StataCorp. 2007. Stata Statistical Software: Release 10. College
Station, TX: Stata Corporation.).
3. Results
The correlation coefficient between birth weight and IQ scores was
modest (r= 0.07, p=.002). The mean value of the IQ scores in
different categories of characteristics is shown in Table 1. First
remarkable finding is monotonic increase of intelligence with the
increase of birth weight (Table 2). As expected, children who were
born underweight (b 2500 g) had the lowest average IQ score.
Likewise, preterm (b 37 weeks) children scored approximately 3 IQ
points below those who were born in time, but this difference was not
statistically significant and disappeared after adjustment for birth
weight and other characteristics. Modest effect of parity on child's
intelligence (small advantage of the firstborn over later born) became
stronger and statistically significant after adjustment. There were no
signs of an optimal birth weight: 47 children with the heaviest birth
weight (≥ 4500 g) received the highest average scores in the
intelligence test. The weight-associated increase in intelligence in
the normal range of birth weight was modest by its magnitude: a
500 g increase in birth weight was related to around 0.7-point IQ
increase in gender-adjusted model (p for trend 0.02). The effect of
birth weight did not change evidently when gestational age, location
 K. Rahu et al. / Early Human Development 86 (2010) 493–497 495

Table 1
Child and maternal characteristics of the children at age 7–13 years, Estonia.

Characteristic Boys Girls

No (%) of Mean birthweight Mean IQ normalized No (%) of Mean birthweight Mean IQ normalized
children (g) by age and grade children (g) by age and grade

Total 912 (100) 3608 98.6 910 (100) 3474 101.7

Birthweight (g)
b 2500 18 (2.0) 2077 94.0 19 (2.1) 1972 91.3
2500–2999 72 (7.9) 2792 99.0 112 (12.3) 2780 99.8
3000–3499 258 (28.3) 3280 98.5 322 (35.4) 3256 100.9
3500–3999 363 (39.8) 3719 98.6 332 (36.5) 3722 102.7
4000–4499 168 (18.4) 4171 98.3 111 (12.2) 4163 104.3
≥4500 33 (3.6) 4716 102.5 14 (1.5) 4723 107.4
Birthweight for gestational age (percentile)
b 10th 65 (7.1) 2798 98.6 63 (6.9) 2694 97.6
10th–50th (excl) 336 (36.8) 3317 98.8 340 (37.4) 3181 101.1
50th–90th (excl) 405 (44.4) 3788 98.2 405 (44.5) 3658 102.6
≥90th 106 (11.6) 4345 99.7 102 (11.2) 4201 103.1
Location of the school
Tartu 207 (22.7) 3589 100.5 182 (20.0) 3519 103.8
Tallinn 149 (16.3) 3457 97.6 126 (13.8) 3406 102.3
Other 556 (61.0) 3656 98.1 602 (66.2) 3474 101.0
Mother's age (years)
b 20 117 (12.8) 3488 94.3 82 (9.0) 3413 100.0
20–34 741 (81.3) 3628 99.3 773 (84.9) 3477 102.0
≥35 54 (5.9) 3599 98.6 55 (6.0) 3522 101.0
Mother's marital status
Married 556 (61.0) 3642 98.8 551 (60.5) 3486 103.3
Cohabiting 288 (31.6) 3552 99.0 299 (32.9) 3451 99.2
Single/divorced 68 (7.5) 3570 94.9 60 (6.6) 3478 100.2
Mother's education
Basic or less 110 (12.1) 3583 93.4 111 (12.2) 3399 95.8
Secondary/secondary special 696 (76.3) 3608 98.8 664 (73.0) 3476 101.2
University/professional higher 106 (11.6) 3632 102.5 135 (14.8) 3524 109.3
Parity
0 425 (46.6) 3529 99.6 377 (41.4) 3420 102.0
≥1 487 (53.4) 3678 97.7 533 (58.6) 3512 101.6
Gestational age (weeks)
b 37 40 (4.4) 2562 96.9 43 (4.7) 2546 98.2
≥37 872 (95.6) 3656 98.7 867 (95.3) 3520 101.9
Smoking in pregnancy
Yes 39 (4.3) 3215 94.5 44 (4.8) 3393 95.0
No 852 (93.4) 3624 98.9 841 (92.4) 3477 102.2
Unknown 21 (2.3) 3720 92.8 25 (2.7) 3502 97.2

of the school, and mother's age, marital status, education, parity and
smoking during pregnancy were taken into account (Table 2).
Several characteristics of mothers had detrimental effect on their
children's mental abilities. Mothers with basic or less education, single
and divorced, and those who admitted smoking during pregnancy had
children who scored 5–6 IQ points below of the respective age norms.
The most beneficial for children's IQ was to have a married mother
with secondary or university education. Although mother's young age
(b 20 years) had a detrimental effect on her offspring intelligence, this
was mediated by other factors such as social background, parity,
gestation age, and smoking in pregnancy (see Table 2). Schoolchildren
in Tartu – a relatively small town dominated by two universities –
counted about two IQ points more than children attending schools in
the rest of Estonia. This difference was independent from mother's
education.
Mothers who admitted their smoking (N = 82) during the
pregnancy had a child who scored nearly 6 IQ points below those
mothers who reported no smoking. Even after controlling for other
characteristics under study, children whose mothers smoked during
pregnancy had about 3 points lower IQ score than those whose
mothers did not smoke.
In the analysis by fetal growth centiles, the steady increase of IQ
score was observed in the model without birth weight: children in
10th–50th percentile scored 0.6 (95% CI -2.2, 3.4) points, in 50th–90th
percentile 1.3 (-1.4, 4.1) points, and ≥ 90th percentile 2.6 (-0.6, 5.9)
points more than born small for gestational age (b 10th percentile)
children. After additional adjustment for birth weight, the increase in
points was replaced with decrease: -1.8 (-5.2, 1.7), -2.0 (-5.9, 1.9), and
-2.4 (-7.3, 2.4) points, respectively. These associations were not
statistically significant.
4. Discussion
The results of this study showed two points of considerable interest.
First, the results confirmed a consistent positive association bet-
ween normal birth weight and childhood cognitive ability, even when
corrected for some socioeconomic confounders [8–10,30]. The asso-
ciation between birth weight and childhood intelligence seems to be
robust and similar to cultures with different socioeconomic history.
Unfortunately, we had no access to all relevant socieconomic factors
(e.g. farthers’ education) but there is also no information that any of
them could play an independent role in the development of child-
hood cognitive abilities. Unlike studies which have demonstrated
detrimental effect of a very heavy birth weight (over 4000 g) on the
growth of mental abilities [1,30–32,35], this study confirmed that the
benefit of the birth weight on intelligence continues to increase even
beyond 4500 g [7,8,14,33–36], but our result is based on small
number of cases (47 children). Taking into account that in the range
from 7 to 14 years the raw SPM score increases approximately 3.6
points per year and an average SD was 8.58 [37] it is possible to
estimate that an additional 1000 g in birth weight adds to its owner
approximately 6.7 months of intellectual age. This estimate is

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496 K. Rahu et al. / Early Human Development 86 (2010) 493–497

Table 2
The effect of selected child and maternal characteristics on IQ of child at age 7–13 years, Estonia.

Characteristic Adjusted for:

Gender + Social variablesa + Parity and + Smoking

gestational age

β (95% CI) β (95% CI) β (95% CI) β (95% CI)

Gender
Boysb 0 0 0 0
Girls 3.2 (1.8, 4.5) 3.3 (1.9, 4.6) 3.4 (2.1, 4.7) 3.4 (2.1, 4.7)
Birth weight (g)
b 2500 -6.6 (-11.7, -1.5) -6.4 (-11.4, -1.4) -6.5 (-11.9, -1.1) -6.8 (-12.2, 1.5)
2500–2999b 0 0 0 0
3000–3499 0.5 (-1.9, 2.9) 0.1 (-2.2, 2.5) 0.2 (-2.3, 2.7) 0.1 (-2.4, 2.6)
3500–3999 1.4 (-0.9, 3.8) 0.9 (-1.5, 3.2) 1.1 (-1.3, 3.6) 1.1 (-1.4, 3.6)
4000–4499 1.9 (-0.8, 4.6) 1.5 (-1.2, 4.1) 1.9 (-0.9, 4.7) 1.5 (-1.3, 4.3)
≥4500 5.5 (0.8, 10.1) 5.6 (1.0, 10.2) 6.2 (1.5, 10.9) 6.3 (1.6, 10.9)
Location of the school
Tartu 0 0 0 0
Tallinn -2.3 (-4.5, -0.0) -1.7 (-3.9, 0.5) -1.8 (-4.0, 0.4) -2.0 (-4.2, 0.2)
Other -2.6 (-4.3, -0.9) -2.4 (-4.0, -0.7) -2.1 (-3.8, -0.5) -2.3 (-4.0, -0.7)
Mother's age (years)
b 20 -3.7 (-5.8, -1.5) -0.4 (-2.7, 1.9) -1.6 (-3.9, 0.8) -0.8 (-3.2, 1.6)
20–34b 0 0 0 0
≥35 -0.8 (-3.6, 2.0) -0.6 (-3.4, 2.2) 0.2 (-2.6, 3.0) 0.4 (-2.5, 3.2)
Mother's marital status
Married 3.6 (0.9, 6.2) 2.4 (-0.2, 5.1) 3.4 (0.7, 6.0) 2.8 (0.1, 5.5)
Cohabiting 1.6 (-1.2, 4.4) 1.6 (-1.1, 4.4) 2.0 (-0.7, 4.8) 1.7 (-1.0, 4.5)
Single/divorcedb 0 0 0 0
Mother's education
Basic or lessb 0 0 0 0
Secondary/secondary special 5.5 (3.4, 7.5) 5.0 (2.8, 7.1) 4.6 (2.5, 6.8) 5.0 (2.8, 7.2)
University/professional higher 11.6 (9.0, 14.2) 10.7 (7.9, 13.5) 10.4 (7.6, 13.2) 10.7 (7.8, 13.5)
Parity
0 1.2 (-0.2, 2.5) 2.6 (1.1, 4.1) 2.5 (1.0, 4.0)
≥1b 0 0 0
Gestational age (weeks)
b 37b 0 0 0
≥37 2.8 (-0.4, 6.0) -0.6 (-4.5, 3.3) -1.0 (-4.9, 2.8)
Smoking in pregnancy
Yesb 0 0
No 5.9 (2.8, 9.1) 3.3 (0.1, 6.4)

a Location of the school, mother's age, marital status and education.

b Reference category.

comparable to previous reports in which 1000 g increase in birth
weight was associated with a 4 months increase in reading scores at
7 years [41]. Matte et al. (2001) reported 6–7-point IQ increase with
a 1000-g increase in birth weight which after adjustment for
confounders reduces to 3–5-point IQ increase. There are evidences
that birth weight predicts IQ similarly in the twin samples,
considerably restricting purely genetic and shared environmental
explanations for the association [14,42]. Like previous studies the
difference between the lightest (b 2500 g) and heaviest (≥ 4500 g)
groups was approximately 10 IQ points [8,33]. Interestingly, the
birth weight appeared to be a more important factor affecting
children's intelligence than gestational age. When fetal growth and
birth weight were taken into account simultaneously, only birth
weight had a significant impact on prospective intelligence. Cross-
sectional studies generally find that firstborns score higher on
intelligence tests like SPM than did later borns [43]. Beside purely
biological explanation environmental factors (e.g. general intellec-
tual environment) apparently contribute to the intellectual superi-
ority of firstborns [44]. Expecting that disadvantages in intellectual
development of later born can be small this study found no dif-
ference in the raw SPM scores of firstborn and later born children.
However, intellectual advantage of firstborns appeared when
background variables such as mothers’ education were taken into
account. Although the current data did not allow to separate birth
order from family size it is still clear that the position among siblings
may have an independent impact on intellectual growth.
We had a reason to expect the place of living might affect IQ scores
since a previous study has shown that, at least a half century ago,
children from rural areas scored slightly lower on intelligence tests
than children grown up in large cities [45]. One reason for this dis-
advantage was shown to be intelligence and educational level of
parents. Big towns in Estonia acted as demographic siphons which
suck out from rural areas people with higher intellectual abilities [45].
However, the results of this study, being one of the first in which a
geographical representativeness of the sample was achieved, showed
higher IQ scores (independent from mother's education) in schools of
the university city, we failed to find difference between schools in the
capital city and other regions in Estonia. It remains to establish
whether equalization of urban and rural areas was caused by more
recent demographic processes or some other not fully understood
factors.
Second, although several previous studies have shown that the
association between prenatal smoking and offspring intelligence
disappears when socioeconomic factors have been taken into account
[12,16,19,23], in this study the association between maternal smoking
and child intelligence remained significant even after control for
maternal education [46–49]. This discrepancy may result from
differences in sociodemographic variation between samples but it
may be also the method effect how cognitive abilities were defined
and measured [16,50]. It is also important to remember that data
about prenatal smoking are usually based on mothers’ self-reports. It
is unlikely that the pressure to describe themselves as non-smokers is

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 K. Rahu et al. / Early Human Development 86 (2010) 493–497
identical in all socioeconomic groups [51]. It is highly probable that
many of those 46 mothers who did not report their smoking status in
pregnancy were also smokers because their offspring scored below
the respective age norm. According to the Estonian Medical Birth
Registry data only 4.5% of mothers admitted that they were smoking
during pregnancy which is much lower of smoking prevalence among
Estonian women (26%) in general [52] and cotinine-validated
smoking status among pregnant women (21%) [53]. According to
this study 20.9% of pregnant women who reported being non-
smokers had serum cotinine levels ≥ 15 ng/ml which classifies them
as current smokers. Since the nondisclosure of current smoking was
significantly more frequent among less educated women [53] the
association between prenatal smoking and offspring intelligence may
be even larger than that was actually observed.
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within sibling pairs: Findings from the Aberdeen children of the 1950s cohort.
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ages 7 to 19. J Biosoc Sci Nov 2004;36(6):735–40.
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 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
authors and reviewed by the Society of Obstetricians and
Gynaecologists of Canada (SOGC)’s Maternal-Fetal Medicine
Committee*, Family Physician Advisory Committee, and
Guideline Management and Oversight Committee; and
approved by the Board of the SOGC. Parts 1 and 2 of this
Clinical Practice Guideline supersede the original version
(#239) that was published in February 2010.
*Maternal-Fetal Medicine Committee: Hayley Bos, MD, Victoria,
BC (co-chair); Richard Brown, MD, Beaconsfield, QC; Sheryl Choo,
MD, London, ON; Venu Jain, MD, Edmonton, AB; Lisa Kuechler,
RN, Victoria, BC; Heather Martin, RM, Edmonton, AB; N. Lynne
McLeod, MD, Halifax, NS; William Mundle, MD, Windsor, ON (co-
chair);Kirsten Niles, MD, Toronto, ON; Frank Sanderson, MD,
Saint John, NB; Jennifer Walsh, MD, Calgary, AB
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-Émilie Jacob, MD, Montréal, 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
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La
Société des obstétriciens et gynécologues du Canada. Published by
Elsevier Inc. All rights reserved.
1. Pregnancy care requires maternal medical assessment
2. Team planning enhances care and reduces risks for patients
and caregivers
3. Increased awareness is needed for weight bias in obstetrics

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.

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SOGC CLINICAL PRACTICE GUIDELINE
Abstract
Objective: This guideline will review key aspects in the pregnancy care
of women with obesity. Part I will focus on pre-conception and
pregnancy care. Part II will focus on team planning for delivery and
Postpartum Care.
Intended Users: All health care providers (obstetricians, family
doctors, midwives, nurses, anaesthesiologists) who provide
pregnancy-related care to women with obesity.
Target Population: Women with obesity who are pregnant or planning
pregnancies.
Evidence: Literature was retrieved through searches of Statistics
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
mortality. Results were restricted to systematic reviews, randomized
controlled trials/controlled clinical trials, and observational studies.
There were no date or language restrictions. Searches were updated
on a regular basis and incorporated in the guideline to September
2018. Grey (unpublished) literature was identified through searching
the websites of health technology assessment and related agencies,
clinical practice guideline collections, clinical trial registries, and
national and international medical specialty societies.
Validation Methods: The content and recommendations were drafted
and agreed upon by the authors. Then the Maternal-Fetal Medicine
Committee peer reviewed the content and submitted comments for
consideration, and the Board of the Society of Obstetricians and
Gynaecologists of Canada (SOGC) approved the final draft for
publication. Areas of disagreement were discussed during
meetings, at which time consensus was reached. The level of
evidence and quality of the recommendation made were described
using the Evaluation of Evidence criteria of the Canadian Task
Force on Preventive Health Care.
Benefits, Harms, and Costs: Implementation of the recommendations
in these guidelines may increase obstetrical provider recognition of
the issues affected pregnant individuals with obesity, including
clinical prevention strategies, communication between the health
care team, the patient and family as well as equipment and human
resource planning. It is hoped that regional, provincial and federal
agencies will assist in the education and support of coordinated
care for pregnant individuals with obesity.
Guideline Update: SOGC guidelines will be automatically reviewed
5 years after publication. However, authors can propose another
review date if they feel that 5 years is too short/long based on their
expert knowledge of the subject matter.
Sponsors: This guideline was developed with resources funded by the
SOGC.
Summary Statements:
1. Maternal obesity carries both maternal and fetal risks (II-2).
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2. There are limited options for weight loss and management during
pregnancy (II-2).
3. Guidelines can assist with individualized recommendations regard-
ing maternal gestational weight gain and calorie and nutrient intake
during pregnancy (II-2).
4. Maternal obesity is a risk factor for fetal macrosomia (II-2).
5. The accuracy of fetal imaging for pregnancy dating, anatomical
assessment, and fetal weight estimates is reduced in the setting of
maternal obesity (II-2).
6. Stillbirth is more common with maternal obesity (II-1).
7. Multiple gestations carry additional risks in pregnancies complicated
by maternal obesity (II-2).
8. Weight loss surgery before pregnancy, while generally conferring
benefits to mother and fetus, also carries rare and serious morbidity
during gestation (II-1).
Recommendations:
1. Weight management strategies prior to pregnancy may include die-
tary, exercise, medical, and surgical approaches. When pursued
before pregnancy, health benefits may carry forward into future
pregnancies (III B).
2. As obesity carries many medical risks, assessment for conditions
of the cardiac, pulmonary, renal, endocrine, and skin systems, as
well as obstructive sleep apnea, is warranted in the pre-pregnancy
period (II-3 B).
3. Folic acid supplementation in the 3 months prior to conception
is warranted given the increased risks of congenital abnormali-
ties of the fetal heart and neural tube related to maternal obe-
sity (II-2 A).
4. It is recommended that both monitoring of gestational weight gain
and approaches for gestational weight gain management be for-
mally integrated into routine prenatal care (III A).
5. There is good evidence to support the role of exercise in pregnancy
(I A).
6. There is good evidence to support supplementation with folic acid
(at least 0.4 mg) and vitamin D (400 IU) during pregnancy (II-2 A).
7. Fetal macrosomia may be altered by well-controlled maternal ges-
tational weight gain (II-2 A).
8. Increased fetal surveillance for well-being is suggested in the third
trimester if the reduced fetal movements are reported, given the
increased rate of stillbirth (II-3).
9. Aspirin prophylaxis can be recommended for women with obesity
when other risk factors are present for the prevention of preeclamp-
sia (I A).
10. It is recommended that delivery be considered at 39−40 weeks
gestation for women with a body mass index of 40 kg/m2 or greater
given the increased rate of stillbirth (II-2 A).
11. Multiple gestations in women with obesity require increased sur-
veillance and may benefit from consultation with a Maternal-Fetal
Medicine consultant, especially in the setting of monochorionic
gestations (II-2 A).
12. Pregnancy after weight loss surgery may benefit from Maternal-
Fetal Medicine consultation given the potential for significant albeit
rare maternal morbidity (III B).
 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
I: Evidence obtained from at least 1 properly randomized controlled
trial
II-1: Evidence from well-designed controlled trials without
randomization
II-2: Evidence from well-designed cohort (prospective or
retrospective) or case-control studies, preferably from more than 1
centre or research group
II-3: Evidence obtained from comparisons between times or places
with or without the intervention. Dramatic results in uncontrolled
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,
descriptive studies, or reports of expert committees
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
S uccessful outcomes are possible for pregnancies affected
by maternal obesity. There are a number of considera-
tions for all obstetrical care providers, pregnant patients, and
their families (Table 1 is a key to evidence statements and
grading of recommendations). For example, there has been
an alarming increase in obesity (body mass index [BMI] >30
kg/m2) and overweight (BMI 25−29.9 kg/m2) globally; in
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.
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
including development of gestational diabetes,4−7 hyperten-
sion,4,6−8 preeclampsia,5−9 and thromboembolism.10 Women
with obesity are more likely to have increased interventions,
including induction of labour5,11 and Caesarean birth4,11
(Table 2).5−14 They have a significantly elevated risk of infant
mortality9,15−17 (Table 3).5−7,9,14−20 The perinatal risks asso-
ciated with maternal obesity include stillbirth,5,7,9,17 macroso-
mia,5−7,9,14 shoulder dystocia,7,9,14 and meconium
14
aspiration. The newborns are also more likely to require
medical intervention following delivery14 and admission to
the neonatal intensive care unit8,14 (Table 3). Children born to
mothers with obesity21 are at increased risk of obesity them-
selves, as well as associated disease states including diabetes
and cardiovascular disease.7
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Classification of Recommendationsb
A. There is good evidence to recommend the clinical preventive action.
B. There is fair evidence to recommend the clinical preventive action.
C. The existing evidence is conflicting and does not allow to make a
recommendation for or against use of the clinical preventive action;
however, other factors may influence decision making.
D. There is fair evidence to recommend against the clinical preventive
action.
E. There is good evidence to recommend against the clinical preventive
action
I. There is insufficient evidence (in quantity or quality) to make a
recommendation; however, other factors may influence decision
making.
Definition of Obesity
The most widely accepted guidelines for the classification
of obesity are produced by the World Health Organiza-
tion.19 As demonstrated in Table 4, obesity is classified as a
BMI ≥30 kg/m2. Obesity can subsequently be further clas-
sified by class I, II, and III (the term “morbidly obese” is to
be avoided).4 The published literature does not consistently
use these classifications when reporting study results, dem-
onstrating a limitation of current scientific evidence.
REFERS TO SUMMARY STATEMENT 1
PRE-CONCEPTION COUNSELLING, EVALUATION,
AND MANAGEMENT
Excess amounts of adipose tissue can impair vascular, met-
abolic, and inflammatory pathways in many organs, thereby
leading to adverse pregnancy outcomes.20 Women with
obesity should thus be informed of the benefits of weight
loss before conception, notably on reproductive function,
obstetrical outcome, and overall maternal health.22 Though
weight management strategies implemented during
pregnancy have some effect in reducing maternal and neo-
natal complications, the effect is limited. Therefore, it is
recommended that a weight-control program including
diet, exercise, and behavioral modification be encouraged
in the pre-pregnancy period.23,24 In fact, a moderate weight
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SOGC CLINICAL PRACTICE GUIDELINE

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
Hypertension 1.74−2.154,6,12 2.50−6.314−8 4.874
5
Preeclampsia 1.44 2.14−3.90 5−7,9
4.829
1.916
1.44−1.915,6
Venous thromboembolism in pregnancy 1.8012 9.7010
Placental abruption 1.408
Spontaneous miscarriage 1.678,13 1.203
Recurrent miscarriage 3.503
Hemorrhage/blood loss >500 ml 1.165 1.39−1.505,14
5
Genital tract infection 1.24 1.305
Urinary tract infection 1.175 1.39−1.905,14
5
Wound infection 1.27 2.245
Induction of labour 1.275 1.60−1.705,11
Failure to progress in labour 2.608
Caesarean birth 1.504 1.60−2.024,11 2.544
4
Emergency Caesarean birth 1.30−1.52 5−6
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
amelioration of obesity-associated metabolic disorders,
including renal function and blood sugars,25−29 and has
the potential to improve maternal as well as fetal obstetrical
outcomes.30 Proper nutritional counselling, including die-
tary changes aiming to modify BMI and ensure adequate
micronutrient intake, is suggested as optimal diet is
required for a healthy immune balance.31−33
Weight Management
Weight management strategies should address adjunctive
medical therapy or weight loss surgery when appropriate.
Pharmacotherapy can be considered in patients with a
BMI ≥30 kg/m2 or a BMI ≥27 kg/m2 with comorbid-
ities.34 In Canada, there are 2 main drug therapies: orlistat
and liraglutide 3.0 mg. Neither is approved during preg-
nancy and both should be discontinued prior to conception
when possible. Orlistat has a half-life of 2 hours and works
by blocking lipase activity, which prevents about 30% of
dietary fat from being broken down into free fatty acids
and causes it to be excreted in the feces.35 Many large stud-
ies have shown that most patients on orlistat for 1 year lost
significantly more weight than those on placebo.36−38
Between 5.8%37 and 8.5%36 of initial body weight was lost
in those without type 2 diabetes, and an average of 6.2%38
was lost in those with associated diabetes mellitus.
On the other hand, liraglutide has a half-life of 13 hours
and acts as a glucagon-like peptide-1 (GLP-1) receptor
stimulator, suppressing appetite39 and reducing gastric
emptying, which slows the digestion of nutrients and
decreases the post-prandial serum glucose load.40 Ran-
domized controlled trials entitled the Satiety and Clinical
Adiposity − Liraglutide Evidence in individuals with and

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 Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care

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
Shoulder dystocia 2.14−3.607,9,14 3.149
9
Meconium aspiration 1.64−2.87 2.859
Fetal distress 1.61−2.139 2.529
15 9,15−17
Mortality 1.25 1.37−2.70 2.44−3.419,15
Large for gestational age/macrosomia 1.575 2.365 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
Neural tube defects 1.2011
Spinal bifida 1.80−2.607,11
Congenital cardiac anomalies 1.05−1.1711,19 1.15−1.307,11,19,20 1.4418
18 19
Nervous system defects 1.15 1.44−1.65 1.8818
Omphalocele 3.307
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
5 5
Low Apgar scores 1.16 1.45
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
30.00−34.99 Obese class I 2014 demonstrating that bariatric surgery could reduce the
35.00−39.99 Obese class II risk of preeclampsia in itself by 50% (odds ratio [OR] 0.45;
≥40.00 Obese class III
95% confidence interval [CI] 0.25−0.80).64 Furthermore,
malabsorptive weight loss surgery has also been associated

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SOGC CLINICAL PRACTICE GUIDELINE
Table 5. Types of weight loss surgery and their effects
Surgery type Mechanism of action
SG Transection of the stomach, produces volume restriction46
RYGB Mechanical restriction and malabsorption through creation
of 15-mL gastric pouch43
AGB Gastric capacity restriction55,56
45
BD Gastric capacity restriction and malabsorption
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
fetuses (OR 0.46; 95% CI 0.34−0.62), though there is evi-
dence to suggest an increased risk of small for gestational
age fetuses (OR 1.93; 95% CI 1.52−2.44).64 This is likely
related to post-surgical malabsorption issues and/or poor
maternal nutrition; hence, health care providers should
consider screening for inadequate nutrition (and micronu-
trient deficiencies) and perform serial growth ultrasounds
in the third trimester.
Of note, time-to-conception interval following bariatric
surgery has been a recent subject of debate. A large popu-
lation-based study published in 2016 showed a time-to-
birth interval of less than 2 years to be associated with
increased rates of neonatal intensive care unit admissions
(12.1% vs. 17.7%; Relative Risk RR, 1.54; 95% CI 1.05
−2.25), preterm delivery (11.8% vs. 17.2%; RR, 1.48; 95%
CI 1.00−2.19), and small for gestational age status (9.2%
vs. 12.7%; RR, 1.51; 95% CI 0.94−2.42).65 Therefore, it is
suggested that patients wait a minimum of 24 months fol-
lowing bariatric surgery before trying to conceive.
Pre-pregnancy Counselling and Screening
Pre-pregnancy counselling constitutes the ideal time for
health care providers to screen the woman with obesity
for associated comorbidities, as weight loss can improve
many of these conditions.66 More particularly, obesity is
associated with an increased risk of chronic hypertension,
type 2 diabetes mellitus, dyslipidemia, cardiovascular dis-
ease, arrhythmias, stroke, osteoarthritis, non-alcoholic
fatty liver disease, chronic kidney disease, depression,
obstructive sleep apnea (OSA), and venous thromboem-
bolism.66,67 In fact, the major contributor to type 2 diabe-
tes mellitus is excess weight,68 and the degree of insulin
resistance is highest with central/abdominal obesity,
defined as a pre-pregnancy waist circumference ≥88 cm
in women.69 Hypertension occurs in approximately 40%
of individuals who have obesity,70 and blood pressure
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Excess body weight loss Likelihood of
12 months post procedure nutritional deficiencies
38%−70%47−49 Low
68%−77%50-52 High
Especially fat soluble vitamins53,54,a
41%−54%43,57,58 Lowb
57,58
66%−74% Moderate
cuffs should be properly calibrated. Spirometry has also
shown that in non-pregnant individuals with obesity, lung
volumes decrease as BMI increases, with conditions such
as asthma, obesity hypoventilation syndrome, and OSA
being more prevalent.71 OSA is characterized by repetitive
episodes of upper airway obstruction during sleep leading
to reduced airflow as well as hypoxemia, and normal
physiologic changes in pregnancy can exacerbate the con-
dition. Prevalence is not well defined, but in a prospective
study of 175 pregnant women with obesity who had in-
home portable polysomnogram studies, 15.4% were diag-
nosed with OSA.72 In a large U.S. national database study
between 1998 and 2009, women with OSA had a higher
risk of preeclampsia (OR 2.5; 95% CI 2.2−2.9), eclampsia
(OR 5.4; 95% CI 3.3−8.9), cardiomyopathy (OR 9.0;
95% CI 7.5−10.9), as well as gestational diabetes (OR
1.9; 95% CI 1.7−2.1) and were found to have a 5-fold
increased odds of dying in hospital, when adjusted for
comorbidities, age, ethnicity and socioeconomic status.73
Treatment is mainly by way of continuous positive airway
pressure.
Baseline screening where indicated could include renal
function (with screening for proteinuria and serum creati-
nine levels), liver function tests, cholesterol, triglycerides,
thyroid stimulating hormone, diabetes screen, electrocar-
diogram, pulmonary function tests if there are any respi-
ratory concerns on anamnesis/examination, OSA studies
if the patient screens positive on the Berlin question-
naire,74 and an echocardiogram to evaluate global heart
function and left ventricular function in those with a his-
tory of chronic hypertension of 5 or more years.75 Con-
sultations to appropriate specialists could also be ordered,
smoking cessation encouraged, and supplementation with
a minimum of 0.4 mg/day of folic acid (with consider-
ation of up to 5 mg as maternal obesity may be consid-
ered “high risk” in some cases) should be commenced 3
months prior to conceiving in light of an increased risk
 Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care
for neural tube defects in the obese population.76 Careful
physical examination should include evaluation of excess
adipose tissue distribution; cardiorespiratory assessment;
and screening for signs of venous thromboembolism,
abdominal hernias, pressure wounds, or intertriginous
infection.
During pre-pregnancy discussions, the patient should
also be informed of the potential pregnancy complica-
tions associated with obesity, more particularly gesta-
tional diabetes mellitus and hypertensive disorders of
pregnancy. The use of metformin to improve insulin
sensitivity in pregnancy has also been studied given its
theoretical benefit. A meta-analysis of 2 randomized tri-
als77,78 in women with obesity but without pre-existing
diabetes showed a statistically significant reduction in
maternal gestational weight gain (GWG). However, there
was no benefit regarding the development of gestational
diabetes mellitus, large for gestational age fetuses, or
adverse neonatal outcomes; as such, use of metformin
to decrease adverse pregnancy outcomes in non-diabetic
women with obesity is not recommended.79 Further-
more, as previously discussed, obesity is an independent
risk factor for gestational hypertension both with and
without proteinuria, and those with a BMI >30 kg/m2
should start taking aspirin prior to 16 weeks gestation to
prevent placentally mediated complications if additional
risk factors are present (see Table 8).80−82
REFERS TO SUMMARY STATEMENT 2 &
RECOMMEDATIONS 1, 2, AND 3
PREGNANCY CARE
Weight Management
It is well accepted that weight gain during pregnancy can
influence pregnancy outcomes, with both too much and
too little weight gain being detrimental. Excessive GWG is
associated with increased risks of gestational hypertension,
preeclampsia and diabetes, fetal overgrowth, operative
delivery, and postpartum weight retention. Inadequate
GWG is associated with fetal growth restriction.83
GWG is a dynamic process—the “right” amount of weight
gain in pregnancy should be individualized among women
with obesity. For a singleton pregnancy, the Institute of
Medicine recommends that women with a pre-pregnancy
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-
tant, with evidence showing that minimizing GWG in the
first half of pregnancy may be beneficial for women with
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obesity. There is some evidence that women with class III
obesity could gain less weight without increasing the risk of
adverse pregnancy outcomes.85 Close surveillance of fetal
growth is advised in this scenario.
Many women with obesity are unaware that excessive
GWG is a concern or that excessive GWG is associated
with pregnancy and neonatal complications.86,87 Women
want to receive this information,88,89 but studies show that
maternity care providers usually do not provide it.90
Simple strategies that may improve the achievement of
ideal GWG include setting a clear goal for GWG, deliber-
ately planning meals and snacks, decreasing sedentary
behavior, and self-weighing.91,92 Furthermore, adequate
sleep patterns have been shown to be associated with
improved GWG, and good sleep hygiene should be
encouraged.93 In addition to counselling, evidence shows
that supervised physical activity (PA) programs or person-
alized prescription/goals improve adherence to GWG tar-
gets. Evidence is mounting that intensive lifestyle
interventions can be effectively delivered using newer tech-
nologies, such as mobile phones,94 a strategy that could
decrease burden on maternity care providers.
Maternal Nutrition in Pregnancies Affected by
Obesity
Management of maternal nutrition in pregnancies compli-
cated by obesity is both complex and challenging. Ideally,
multidisciplinary care including a nutritionist should be
available to these patients. It is recognized that the majority
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
information to both care providers and expectant mothers.
Macronutrients
All fetuses need access to macronutrients (carbohydrates,
fat, and protein) to develop and grow optimally. It is gener-
ally accepted that an additional 100 kilocalories (kcal) per
day are needed in the first half of pregnancy, increasing to
300 kcal per day beyond 20 weeks gestation. For most
women with obesity, a baseline caloric intake of 2100 kcal
is sufficient in the first half of pregnancy, increasing to
2400 kcal daily after 20 weeks.95 The presence of coexist-
ing diabetes, whether diagnosed prior to pregnancy or
gestational diabetes, will require additional dietary
modifications.
Carbohydrate intake in pregnancy should focus on high-
quality, minimally processed sources in appropriate portion
sizes and constitute 40% to 55% of daily calories. Higher
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SOGC CLINICAL PRACTICE GUIDELINE
maternal intake of carbohydrates,96 specifically sugar, is
associated with unfavourable infant and child BMI peak
characteristics.97 In particular, the consumption of sugar-
sweetened beverages should be avoided.98−100
Fat intake in pregnancy should comprise 25% to 30% of
daily caloric intake, with monounsaturated fats preferred.
Saturated fat should be limited to 10% of daily caloric
intake.98
During pregnancy, women require a minimum of 60 g of
protein a day, which accounts for 20% to 25% of the daily
caloric intake. A variety of protein sources are recom-
mended, including legumes; nuts; and lean animal protein
sources, including eggs, dairy, fish, poultry, and red meat.
Women should be advised to consume 20−35 g of fiber
each day.96
Micronutrients
It is recommended that all pregnant women take a prenatal
vitamin that contains at least 400 mg of folic acid every day.101
Multivitamin use has been associated with reduced risks of
congenital anomalies and preeclampsia.102 Women with obe-
sity may be less likely to consume multivitamins before and
during pregnancy, so the importance should be reinforced by
both primary and maternity care providers.103
Folic acid supplementation is discussed in the Pre-
pregnancy Counselling and Screening section of this guide-
line. Women with obesity may benefit from an increased
dose of daily folic acid beginning at least 3 months before
pregnancy and continuing until the end of the first
trimester.104,105
Obesity is associated with lower vitamin D status, a prob-
lem that is further exacerbated in pregnancy.106 A Swedish
study has shown that 50% of pregnant women with obesity
had suboptimal vitamin D status.104 Women with pre-
pregnancy obesity should be advised to take a total daily
supplementation of 400 IU of vitamin D during pregnancy
and while breastfeeding.107
Obesity has also been reported to be associated with iron
deficiency.108 During pregnancy, it is recommended that
women with obesity have their hemoglobin, mean corpus-
cular volume, ferritin, and vitamin B12 levels assessed, with
reflex supplementation as needed.
The World Health Organization also recommends daily
supplementation with a total of 1.5−2.0 g of elemental cal-
cium a day, which is equivalent to 2.5 g of calcium
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carbonate or 4 g of calcium citrate. This recommendation
was based on reducing the risk of gestational hypertension
but may also reduce the risk of dental carries in children at
7 years of age.
Probiotics
Studies have shown that women with obesity have an
altered microbiome, compared with women of normal
weight. Probiotics have been defined as “live microorgan-
isms that, when administered in adequate amounts, confer
a health benefit on the host.”109 At the present time, there
is insufficient evidence to recommend probiotic supple-
mentation to women with obesity during pregnancy,
although the results from several large trials are anticipated
in the future.
Omega-3/Fish Oil
Inflammation, whether chronic, low grade, or metabolic, is
central to obesity-related insulin resistance. Currently, sup-
plementation with omega-3 fatty acids shows mixed effects
on inflammatory markers.110 There is insufficient evidence
to recommend omega-3 supplementation at this time.
Physical Activity
The benefits of regular physical activity during uncompli-
cated pregnancy are well documented. Ideally, women who
are pregnant and have obesity should have access to care
that promotes awareness of a healthy lifestyle and
addresses barriers to lifestyle changes and personalized sol-
utions to engaging in physical activity.111 Healthy women
with obesity who engage in regular physical activity have
improved pregnancy outcomes and healthier GWG, with-
out increasing the risk of preterm birth.112−117 Further-
more, there may be positive downstream effects on
childhood weight and health.118
Recommendations for physical activity are reviewed in
Table 6. The safety of structured walking activities has
been demonstrated in women with obesity.119 Women
with obesity who engaged in regular physical activity pre-
pregnancy should be encouraged to maintain their current
level of activity with modifications as needed, depending
on their medical status, comfort, and ability. Modest phys-
ical activity prescription can be provided for healthy, pre-
viously sedentary women with overweight and obesity,
with heart rate target zones of 102−124 beats per minute
for women aged 20 to 29 and 101−120 for women aged
30 to 39.120 Walking appears to be the most common
activity for pregnant women and has the ability to
improve aerobic capacity.119,121 Pregnant women with
overweight and obesity may have medical pre-screening
 Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care

Table 6. Physical activity recommendations for pregnant women with obesity

Review contraindications
Information review
Determine type of physical activity
Timing of initiation
Frequency of physical activity
Intensity of physical activity
Improve adherence
Adapted from Seneviratne et al.124
Screen woman with PARmed-X for Pregnancy tool to ensure she is safely able to participate in physical
activity.
Review the potential benefits of physical activity during pregnancy. Discuss risks and reasons to stop activity
and seek medical attention.
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
If previously sedentary, begin activity in early second trimester.
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
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.
Recommend keeping track of activities and/or a heart rate monitor.
Ask about physical activity at each antenatal visit, answer questions, and provide encouragement.

using the PARMed-X for Pregnancy tool122; if cleared, a
structured walking program should be recommended,
beginning in the early second trimester with 25 minutes,
adding 2 minutes per session per week until 40 minutes
per session is reached.97 Special support may be needed
for women who have back or joint pain or persistent nau-
sea and vomiting of pregnancy.123
Devices such as pedometers or Fitbits have been shown to
increase physical activity levels.125,126 In addition to the
preceding recommendation, women should be advised to
take 11 000 steps per day.127 Further recommendations on
exercise in pregnancy can be found in the latest pregnancy
guideleins by the Society of Obstetricians and Gynaecolo-
gists of Canada.128
independent effect on fetal growth. In a recent meta-analy-
sis of 16 studies, it was shown that a maternal pre-preg-
nancy BMI ≥30 kg/m2 is associated with an adjusted OR
for fetal macrosomia (birth weight ≥4.0 kg and ≥4.5 kg) of
1.93 (95% CI 1.65−2.27).131
Maternal GWG is an important modifying factor for fetal
macrosomia in women with obesity. In a prospective cohort
of euglycemic women with obesity, increasing GWG signifi-
cantly increased the risk of macrosomia (birth weight >4 kg)
and significantly correlated with umbilical cord C-peptide lev-
els (reflect insulin secretory activity of pancreatic beta
cells).132 For every kilogram increase in GWG, there was a
significant increase in risk of macrosomia, defined as birth
weight >4.0 kg, with an OR of 1.139 (95% CI 1.033−1.256).

The Impact of Maternal Obesity on Fetal Growth
Maternal obesity is often associated with fetal overgrowth,
thought to be secondary to altered glucose metabolism and
higher fetal insulin levels. Furthermore, maternal obesity
has been shown to be associated with both third trimester
placental and fetal adipocyte proliferation and storage of
lipids in the third trimester.129 A large longitudinal cohort
study of the impact of maternal obesity on fetal growth
showed that fetuses of women with obesity have higher
weights than fetuses of women without obesity as early as
32 weeks gestation.130 Prior to this point, fetal weights are
similar between the 2 groups.
It is well recognized that maternal obesity is associated with
fetal macrosomia, with newer evidence demonstrating an
In contrast to fetal overgrowth, the identification fetal
growth restriction, defined as failure of the fetus to reach
its growth potential, is challenging in women with obesity.
Because fetuses of mothers with obesity are heavier as a
group, it has been proposed that customized growth
curves may be needed to identify those fetuses at increased
risk of perinatal morbidity and mortality.133,134
Fetal Assessment in Pregnancies Affected by
Maternal Obesity
Imaging is challenging in pregnancies affected by obesity
because the quality of the ultrasound image is inversely
proportional to the depth at which the imaging is being
conducted.135 Some suggestions of optimization of scan-
ning are presented in Table 7.

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SOGC CLINICAL PRACTICE GUIDELINE
Table 7. Strategies to improve ultrasound quality in
pregnancies affected by obesity
1. Improve the signal-to-noise ratio (compound imaging, speckle-
reduction filters, pre- and post-processing, tissue harmonics).
2. Ensure the maternal bladder is full.
3. Use the umbilicus as an acoustic window.
4. Ask the patient to sit up and image above the panniculus.
5. Assist the patient into Sims position and image from flank or groin.
6. Scan transvaginally.
Establishing gestational age
The most accurate means of establishing pregnancy dating
is by transvaginal measurement of the crown−rump length
between 7 and 14 weeks gestation.136 Increased maternal
BMI has been shown to be associated with postponement
of the Estimated Date Of Delivery (EDD), with the fetus
being more likely to measure smaller by ultrasound than
the menstrual dates suggest.136,137 Accurate ascertainment
of gestational age is essential for optimizing pregnancy out-
come, particularly with respect to assessing fetal growth,
conducting aneuploidy screening, and ensuring fetal matu-
rity when timing delivery.
Prenatal screening
It has been noted that maternal obesity may increase the
odds of giving birth to an infant with trisomy 21, with a
lower likelihood of prenatal diagnosis.138−140
Failure rates for measuring the nuchal translucency
increase with maternal weight.141 Transvaginal assessment
may increase the odds of success. However, the risk esti-
mate for trisomy 21 provided by first trimester combined
screening is not affected by BMI.138
Non-invasive prenatal screening is becoming an increas-
ingly prevalent option. The risk of non-invasive prenatal
screening test failure increases with maternal weight, from
3.8% with normal weight to 24.3% with obesity, irrespec-
tive of gestational age.142
Assessing fetal anatomy
Fetuses affected by maternal obesity are more likely to
have congenital anomalies, specifically neural tube
defects (OR 1.87; 95% CI 1.62−2.15), cardiac anomalies
(OR 1.30; 95% CI 1.12−1.51), anal atresia (OR 1.48;
95% CI 1.12−1.97), and limb reduction anomalies (OR
1.34; 95% CI 1.03−1.73).143 This may be related par-
tially to the reduced odds of detecting congenital anom-
alies in the presence of maternal obesity (adjusted OR
0.77; 95% CI 0.60-0.46).144
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The likelihood of completing an adequate morphology
assessment in a single attempt is reduced with increasing
BMI, from 97.5% in women with normal BMI to 74% in
women with BMI >30 kg/m2 and 41% when BMI is >40
kg/m2.145,146 The probability of poor visualization of the
heart (37% vs. 19%) and spine (43% vs. 29%) was
increased in women with obesity compared with women of
normal weight.147 Other fetal structures that are particu-
larly difficult to image in obese women include the face,
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
7.89−215.8).148 It is recommended that the morphology
ultrasound be performed at a minimum of 20 weeks in
women with obesity. Health care providers should consider
timely referral (i.e., 1−2 weeks) for reassessment of fetal
anatomy deemed incomplete. Consideration may also be
given to assessment of fetal anatomy in the first and second
trimesters in women with obesity as an adjunct to routine
second trimester anatomy.149,150 As the majority of fetal
organs can be visualized late in the first trimester, it is pos-
sible to detect fetal anomalies in the 13−16-week
range.151,152 Considerations include availability of experi-
enced sonographers (this approach may not be available in
all centres), as well as the use of transvaginal scanning in
addition to transabdominal scanning.149,150
The quality of images can be improved in women with
obesity using the techniques presented in Table 7.135
Measuring fetal growth
Estimation of fetal weight is challenging in the setting of
maternal adiposity. Screening for fetal weight using sym-
physis fundal height measurement is not recommended
because it has not been shown to be predictive in women
with obesity.151 The increased maternal body mass is
thought to lead to falsely elevated symphysis fundal height,
which may overestimate macrosomia and underestimate
growth restriction.151
Several techniques of improving the accuracy of fetal
weight prediction have been evaluated in pregnancy.
The use of the GAP method (gestation-adjusted projection
method) has been shown to be an accurate aid in delivery
planning for women who have a BMI ≥40 kg/m2.152 This
strategy capitalizes on the concept that an ultrasound per-
formed between 340 and 366 weeks provides a more accu-
rate assessment of fetal weight than one performed at
37 weeks or later, using extrapolation to provide an
expected birth weight at term. The mean absolute percent
error of this technique ranged from 7.4% to 7.9%, in a
 Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care

population that included women with diabetes.146 As for
women of all BMI categories, the option of elective Caesar-
ean birth can then be considered for fetuses with a pro-
jected birth weight of ≥4500 g and ≥5000 g in women
with and without diabetes, respectively.153
Maternal Assessment of Fetal Well-Being
Women with obesity are more likely to present for assess-
ment for decreased fetal movement (OR 1.6; 95% CI
1.27−1.92) but do not have reduced perception of move-
ment compared with women of normal weight, according
to a recent systematic review.154,155 The authors also
found that among women with decreased fetal movement,
increased maternal body size was associated with
increased risk of stillbirth and fetal growth restriction.
Thus, additional consideration should be given to women
with obesity who report decreased fetal movement.
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
women with obesity.156 The role for non-stress tests (NSTs)
in surveillance of well-being in this population is uncertain.
In a large retrospective cohort of 2002 sonograms in 1164
pregnant women with BMI >30 kg/m2 as the only comor-
bidity, abnormalities of amniotic fluid and growth were sel-
dom made prior to 32 weeks gestation.157 Beyond
36 weeks, 7 scans (95% CI 6−8) were needed to diagnose
any abnormality of fluid (oligohydramnios or polyhydram-
nios) or growth (small or large for gestational age).157
Based on this information, it is recommended that serial
assessments of growth be conducted at 28, 32, and 36
weeks. Assessment of fetal well-being is then recom-
mended weekly from 37 weeks until delivery.
It has been shown that maternal BMI and pulsatility
index of both the umbilical artery and the maternal uter-
ine artery are positively correlated and associated with
adverse pregnancy outcomes, secondary to effects on
fetal-placental vessels.158,159 The presence of abnormal
findings, with or without co-existing medical complica-
tions (such as diabetes or hypertension), should prompt
increased fetal surveillance.
Prevention of Maternal Pregnancy Complications in
the Presence of Obesity
Because obesity is a known risk factor for gestational
hypertension/preeclampsia and gestational diabetes, con-
sideration should be given to evidence-based preventative
strategies. Optimization of GWG, diet, and physical activity
is associated with lowered risk of such complications.
Preeclampsia prevention with aspirin
Table 8 reviews the recommendations for prophylactic ace-
tylsalicylic acid (ASA) use during pregnancy, as advised by
the U.S. Preventive Task Force.160
Aspirin should be initiated after diagnosis of pregnancy
and ideally before 16 weeks gestation, taken in a low dose
(75−162 mg/day), administered at bedtime, and consid-
ered for continuation until term.161
Calcium
Evidence supports the use of calcium supplementation to
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.

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2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
SOGC CLINICAL PRACTICE GUIDELINE
recommendations for women with obesity. Women who
have an adequate dietary calcium intake should be advised
to take a supplement of 1 g of calcium daily, in addition to
the prenatal vitamin.162 Women with low dietary calcium
intake should be advised to take 1.5−2 g of calcium daily,
in addition to the prenatal vitamin.157
Gestational Diabetes Prevention: Metformin and
Myo-inositol
The use of metformin has not been shown to decrease the
risk of gestational diabetes.77,78
A number of studies have now investigated a role for
myo-inositol supplementation of women with obesity.
Myo-inositol is a precursor of insulin that has insulin sensi-
tizing effects. Daily supplementation with 2 g of myo-
inositol has been shown to reduce the risk of gestational
diabetes, by 67% compared with placebo (11.6% vs.
27.4%; OR 0.34; 95% CI 0.17−0.68) in 1 study.163,164
While preliminary data are encouraging, further study is
needed before myo-inositol supplementation can be rou-
tinely recommended.
Maternal Obesity and Stillbirth
Stillbirth is associated with maternal BMI, with a U-shaped
curve demonstrating higher risk at both low and high
BMIs. At 40 weeks, the risk of stillbirth is estimated to be
3 to 8 times higher in women with obesity >30 mg/kg2
compared with normal weight women. Multiple mecha-
nisms link obesity and stillbirth, with a notable increase in
the risk of placental disease (abnormal spiral arterial modi-
fication, placental hypertrophy) and maternal hypertension
in particular, but also fetal genetic or structural abnormali-
ties, umbilical cord abnormalities, and antepartum infec-
tions.129,165,166 A triple risk model has been proposed for
stillbirth in general that proposes an interplay of (1) mater-
nal risk factors (e.g., obesity, smoking, maternal age), (2)
fetal and placental factors (e.g., placental insufficiency, fetal
growth restriction), and (3) a stressor (e.g., veno-caval com-
pression due to maternal supine sleep position, sleep-disor-
dered breathing).167
GWG is a modifiable risk factor that can be targeted to
reduce stillbirth risk.168 As with women in lower BMI cate-
gories, suboptimal GWG (whether too much or too little)
places pregnancies at an increased risk of adverse preg-
nancy outcomes, including stillbirth.
For women with a BMI of ≥40 kg/m , it has been shown 2 multiple pregnancies complicated by maternal obesity for
that delivery before 38 weeks minimizes perinatal mortal-
ity.134 In a computational cost-effectiveness study, it was
shown that routine induction of labour at 39 weeks
1o6w3n4loa●deNdO
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sEMu2s0l19 Indonesia (eucrasia18part4@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 24,
im
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
minimizes stillbirth, Caesarean birth, and delivery-related
health care costs.169 In a hypothetical population of
100 000 term pregnancies affected by obesity where a vagi-
nal delivery is planned, routine induction of labour at 39
weeks would avoid 387 stillbirths compared with induction
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
care cost savings of $30 million.
Multiple Gestations and Maternal Obesity
Obesity and multiple gestations are both conditions that sig-
nificantly increase the risk of pregnancy complications,
including gestational diabetes and hypertension. Compared
with multiple pregnancy in women of normal weight, multiple
pregnancy in women with obesity is further adversely influ-
enced by high maternal pre-pregnancy BMI.170 Specifically,
preeclampsia is more common in women who are obese and
having multiples (OR 4.72; 95% CI 2.83−7.89), as is gesta-
tional diabetes (OR 2.19; 95% CI 1.03−4.68).171 Optimizing
GWG in this population is recommended, with the suggested
target range of 13.2−17.3 kg or 29−38 pounds.172,173
The risk of delivering prior to 34 weeks gestation is increased
in women who have obesity compared with women of nor-
mal weight (OR 1.65; 95% CI 1.10−2.48).174 Furthermore,
there is a dose-dependent increase in the risk of preterm
birth at <28, <32, and <37 weeks with increasing BMI.175
For women with a BMI ≥35 kg/m2, the corresponding risks
are 1.7%, 3.6%, and 16.4%, while for women of normal
weight, the risks are 0.6%, 1.5%, and 10.3%.171 The risk is
even higher in multiple gestations conceived through in vitro
fertilization, where the risk of delivery <32 weeks is 6.1%
and the risk of delivery <37 weeks is 11.5%.171 Based on
this information, it is recommended that pregnancy care for
multiple pregnancies include an obstetrical provider with
experience in managing maternal obesity.
Serial estimation of fetal weight by ultrasound is recom-
mended in all multiple pregnancies. There is conflicting
evidence on the effect of maternal obesity on the accuracy
of fetal weight estimation. In 1 Canadian study, the accu-
racy of fetal weight estimation for multiples was decreased
compared to normal weight women with multiples.170 In a
larger Irish study, accuracy was not adversely affected.176
There appears to be an increase in the risk of stillbirth in
same-sex but not opposite-sex multiples, suggesting an
association with monozygosity.177 Monochorionic multiple
pregnancies in mothers who have obesity may benefit
 Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care
from increased surveillance including the involvement of a
Maternal-Fetal Medicine consultant.
Pregnancy Care After Weight Loss Surgery
Pregnancies after weight loss surgery are becoming increas-
ingly common, and the risks and benefits of these proce-
dures for mother and fetus during subsequent pregnancies
are discussed earlier in this guideline. Many women experi-
ence dumping syndrome post weight loss surgery and may
not be able to tolerate glucose challenge testing during
pregnancy. Alternative approaches to diabetes evaluation
may include fasting glucose testing and assessment of
hemoglobin A1c in this setting. Additional considerations
include increased risk of gastrointestinal bleeding, severe
anemia, small bowel volvulus, obstruction, and subsequent
internal herniation.178 Given this potential complexity,
involvement of a maternal-fetal medicine consultant for
pregnancy care is suggested.
REFERS TO SUMMARY STATEMENTS 3, 4, 5, 6, 7,
AND 8 & RECOMMEDATIONS 4, 5, 6, 7, 8, 9, 10, 11,
AND 12
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nU rsiB
taR
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2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
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For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 12
Understanding Intranatal Care
through Mortality Statistics
Marjorie Tew

A fund of statistics on perinatal mortality and place of birth, reliable by any

standards, is provided by national perinatal surveys of 1958 (Butler and
Bonham, 1963) and 1970 (Chamberlain et al., 1978), which were conducted
under the aegis of the Royal College of Obstetricians and Gynaecologists, and
the official annual returns on stillbirths of the Registrar General and Office of
Population Censuses and Surveys. They make it possible to evaluate
objectively the basis for the official policy for the maternity services, the aim of
which is that all births should take place in the larger obstetric hospitals.
The proportion of births taking place in hospitals has been increasing
ever since the British College of Obstetricians was formed in 1929.
Recommendations in 1959 and 1970 by the Cranbrooke and Peel Committees,
whose most influential members were obstetricians, and in 1980 by the House
of Commons Social Services Committee, whose most influential advisers
were obstetricians, merely gave authoritative endorsement to the existing
trend.
As justification for the recommendations, obstetricians claim not simply
that the risk of death for infants and mothers is much lower in obstetric
hospitals than anywhere else, but indeed that this advantage is so great that it
should without question override any disadvantages, such as the distress it
may cause to mothers or the postnatal morbidity, physiological or psycho-
logical, which mothers or infants may suffer as a result.
To any disinterested and open-minded observer this would seem a
surprising claim, for crude mortality rates for mothers and infants have
always, with an exception which will be considered later, been much higher in
obstetric hospitals than in general practitioner maternity units (GPUs) or at
home. However, to explain this apparent paradox, obstetricians have
successfully propagated as established fact several convenient assumptions
which, on investigation, prove to be invalid.

L. Zander et al. (eds.), Pregnancy Care for the 1980s

© The Royal Society of Medicine 1984
106 Pregnanc y Care for the 1980s

EXCESS IN HOSPITAL OF BIRTHS AT HIGH RISK

One such assumption is that the excess mortality in hospital can be more than
accounted for by the fact that births there include most of those at highest risk.
However, this explanation does not survive the test of simple arithmetic, for
the mortality rate of any group of births is the sum of the contributions of its
subgroups, each of which is the product of two factors—its specific mortality
rate and the proportion of all births included in it. To test the validity of the
alleged explanatory assumption, both these factors in each subgroup have to
be quantified. If realistic figures are used, it is not arithmetically possible to
account for the actual difference observed between mortality rates in obstetric
hospitals, on the one hand, and GPUs and home, on the other.
For example, one category of risk relates to certain maternal characteristics
known during pregnancy. In the 1970 survey (Chamberlain et al., 1978) births
at each place of delivery were classified according to an antenatal prediction
score which quantified the cumulative effect of all such predicted risk factors
(Tew, 1979). Births at high and moderate risk made up 9 and 44 %,
respectively, of those in hospital, but only 3 and 30 % of those in GPUs and
home together. Overall the perinatal mortality rates (PNMR) in the low-,
moderate- and high-risk groups were in the ratio I: 1.69: 2.84. Assuming that
these ratios obtained in each place and given the actual PNMR per 1000 births
of 27.8 in hospital and 5.4 in GPU/home, the implicit specific rates for each
risk group must have been over four times higher in hospital(table 12.1). Since
the specific PNMR for low-risk births in hospital was itself much higher than
for high-risk births in GPUJhome, no excess of births at high predicted risk,
however great, could possibly explain the excess in the hospitals’ overall
PNMR.

Table 12.1. Perinatal mortality rates by predicted risk group (1970 Perinatal Survey)

Predicted Hospital GPMU/home

risk group
Proportion PNMR/1000 Proportion PNMR/1000
of births births Product of births births Product
High 0.09 53.7 4.8 0.03 12.1 0.3
Moderate 0.44 32.0 14.1 0.30 7.2 2.2
Low 0.47 18.9 8.9 0.67 4.3 2.9

All 1.00 27.8 27.8 i.oo 3.4 5.4

Similar conclusions result from a corresponding analysis of the 1970 survey

data on infant birth weight (Tew, 1981). With 9 % of births in hospital and 3 %
in GPU/home weighing 2500 g or less and with the overall PNMR for these
low-weight births 25 times that for normal-weight births, the implicit specific
PNMR in hospital in both the high-risk (220.0) and low-risk (8.8) groups
 Original Contribution

Practice of Intranatal Care and Characteristics of Mothers in a Rural

Community
*Saklain MA,1 Haque AE,2 Sarker MM3

In Bangladesh due to limited number of maternal and child health (MCH) based family planning
(FP) facilities located in rural area and other socio-economic factors, practice of intranatal care at
home is still higher than institutional based. This descriptive study was carried out with the
objective of exploring the practice of intranatal care and its associated factors in Puthia Upazilla
under Rajshahi district. Data were collected from 418 respondents residing in different villages of
Puthia Upazilla. Simple random sampling technique was adopted to select the respondents. It was
found that majority of the respondents (46.9%) were in age group 20-24 years and majority
(50.5%) respondents had home delivery and 49.5% had hospital delivery during their last child
birth. It showed that institutional delivery is higher (49.5%) than that of other parts of the country.
It indicates people became aware about the need for safe delivery, thus utilize MCH care from the
nearby health care facility. The study revealed that in case of home delivery, 92.4% literate women
was attended by trained traditional birth attendant (TBA) during their last delivery. On the other
hand among the illiterate group, it was only 6.6%. About 71% respondents told that hospital
delivery is better but 86% respondents told it is costly for them. To achieve health related
millennium development goal (MDG's) there is need to develop skilled health personnel related to
antenatal and intranatal care with giving value on socio cultural practice of intranatal care in rural
areas. Effective supervision and monitoring of the on going programme and active participation of
people can improve the MCH based FP service in rural area.

[Dinajpur Med Col J 2011 Jul; 4 (2):71-76]

Key words: Antenatal care, intranatal care, birth attendant, home delivery, hospital delivery

Introduction one quarter to one half of total death among

M ore than half a million (5,29,000)

women in the world die every year
from causes related to pregnancy and
child birth.1 Global observation shows that in
developed regions maternal mortality ratio
averages at 13 per 100000 live births; in
developing regions the figure is 440 for the
same number of live birth. Between 11 to 17
percent of maternal death happen during child
birth itself. Bangladesh is a country of 140
million people. Among them 24 million are
women aged 15 to 49 years. The number of
pregnant women at any point of time is
around 3.8 million and currently 21,000
women die every year due to causes related to
pregnancy and child birth which contribute
1. *Dr. Md. Azam Saklain, Lecturer, Department .of Pathology, Dinajpur Medical College.
2. Dr AKM Enamul Haque, Assistant Professor, Department of Community Medicine, Jessore Medical College.
the women of reproductive age group. Most
of the deliveries in rural Bangladesh are
attended by untrained TBA and relatives at
home. National figures indicate that only 13%
of the deliveries are conducted by trained
TBA or midwifes.2 With the view, for
reduction of maternal and perinatal mortality
and morbidity in recent years different
strategies were developed, these are training
of birth attendants, improvements of MCH
service, risk approach, emergency obstetric
care (EOC) and the need for community
participation an idea of a new strategy has
been evolved. The strategy is called Meeting
the Community half way.3

Dinajpur Med Col J 2011 Jul; 4(2) 71

 Original Contribution

3. Professor Dr. Md. Abdul Mukit Sarker, Department of Community Medicine, Rajshahi Medical College.
*For correspondence
In February 1987, the Safe Motherhood face interview using a designed questionnaire.
Conference was held in Nairobi, Kenya gave Data were analyzed by using SPSS programme.
rise to a global programme "Safe Motherhood Result
Initiatives". Its goal is to reduce maternal About the distribution of respondents by age,
death to at least half by 2000. Safe it was revealed from the study that the
Motherhood Initiative place special emphasis majority of the respondents [196 (46.9%)]
on the female education and improvement of were in age group 20-24 years. Another
the status of women and the need for better important age group was 25-29 years that
and more widely available maternal health constituted 32.3% of total respondents. The
services.4 proportion of respondents aged 40years and
above (0.5%) was not significant (Table I).
Now MCH and FP viewed as an essential Regarding age of the respondents it was
component of primary health care. The study calculated that the mean age was 24.35 years,
regarded as a vital step towards achieving the median 24 yrs and mode 20 yrs. SD of age of
goal to improve maternal health by reducing the women was 4.2
maternal mortality three quarters between
1990 and 2015 according to health related Table I: Age distribution of the respondents
MDG. Most of the problems suffered by the
women particularly during pregnancy and Age in years
Frequency
childbirth are preventable. This descriptive N %
15-19 35 8.4
study was carried out with the objective of
20-24 196 46.9
exploring the practice of intranatal care and 25-29 135 32.3
its associated factors in a rural community in 30-34 40 9.6
Bangladesh. 35-39 10 2.4
≥40 2 0.5
Total 418 100.0
Methods
It was a cross-sectional type of descriptive
study carried out among the mothers who
have at least one child aged one year in
different villages of Puthia Upazilla under Table II: Respondents’ educational level
Rajshahi district. Puthia Upazilla consists of
Educational status Frequency
six Unions. The respondents were selected N %
from all Unions for the present study. Sample Illiterate 52 12.4
size of the study was 418. A sampling frame Primary 154 36.8
was prepared for each Union and it included Secondary 166 39.7
all the mothers of the respective Unions who SSC 18 4.3
HSC 19 4.5
had given birth to baby in the previous year. Graduate and above 9 2.2
The researcher took help from Health Total 418 100.0
Assistant (HA) and Family Welfare Assistant
(FWA) in preparing the sampling frame for Regarding educational status of the
each Union. Simple random sampling respondents in the study area, it was revealed
technique was applied to select respondent that majority [154 (36.8%)] had primary
from each Union using the Union sampling education and 166 (39.7%) had secondary
frame.The data were collected through face to education. The literacy rate was 87.6%. The

Dinajpur Med Col J 2011 Jul; 4(2) 72

 Original Contribution

number of illiterate respondents was 52 statistically significant. (x2 = 10.16, P = 0.001,

(12.4%) (Table II). df = 1).

Table II: Respondents received ANC in last Table V: Distribution of respondents by place
pregnancy and their educational level of delivery and received ANC

Educational level Antenatal Care

Total Not
Received ANC Illiterate Literate Place of Received Total
N % N % N % delivery received
Yes 39 10.3 341 89.7 380 90.0 N % N % N %
No 13 34.2 25 65.8 38 9.1 Home 186 88.2 25 11.8 211 50.5
Total 52 12.4 366 87.6 418 100.0 Hospital 194 93.7 13 6.3 207 49.5
Total 380 90.9 38 9.1 418 100.0
x2 = 18.19 P = 0.000 df = 1
x2 = 3.920 P = 0.048 df = 1
Regarding receive of ANC in last pregnancy
and level of education of the respondents in In the context of distribution of respondents
the study area, it was revealed that most of the by received ANC and place of delivery, it was
respondents [341 (89.7%)] who received found that out of 418 respondents, 211
ANC were literate. Among the illiterate (50.5%) had home delivery and 207 (49.5%)
mothers, 39 (10.3%) went for ANC. The had hospital delivery. Compared to hospital
relationship between receive of ANC among delivery, the proportion of women was 11.8%
the women and level of education was who had home delivery did not receive ANC
statistically significant (Table III). and in case of hospital delivery majority [194
(93.7%)] women received ANC (Table V).
Table IV: Distribution of respondents by The association between received ANC by the
place of delivery and education of the mothers women and place of delivery was statistically
significant (x2 = 3.92, P = 0.048, df = 1).
Place of Educational level
Total
delivery of Illiterate Literate Table VI: Distribution of respondents by birth
last baby N % N % N % attendant at home with educational level
Home 37 17.5 174 82.5 211 50.4
delivery
Educational level
Hospital 15 7.24 192 92.7 207 49.5 Birth Total
Illiterate Literate
delivery attendant
N % N % N %
Total 52 12.44 366 87.55 418 100.0
Trained 5 7.57 61 92.42 66 31.27
x2 = 10.16 P = 0.001 df = 1
TBA
Untrained 32 22.06 113 77.93 145 68.72
About the relationship between place of TBA
delivery of respondents and education Table Total 37 17.53 174 82.46 211 100.00
IV shows that 211 (50.4% women had home
delivery. Among them 174 (82.5%) were x2 = 6.58 p < 0.05 df = 1
literate and a good number of respondents 37
(17.5%) were illiterate. 207 (49.5%) Regarding distribution of respondents by birth
respondents had hospital delivery. Most of attendant at home and education it was found
them [192 (92.7%)] were literate and a few 15 that majority of women (92.42%) who
(7.24%) were illiterate. From this study, it preferred trained TBA as their birth attendant
was found that the association between place were literate. Among illiterate women
of delivery of the women and education was majority birth attendants were untrained TBA

Dinajpur Med Col J 2011 Jul; 4(2) 73

 Original Contribution

86.48% (Table VI). In this study, relationship that the hospital service is poor in quality.
between birth attendants at home of the There is lack of medicine and hospital staffs
women and education was statistically behave improperly complained by the
significant. (x2=6.58 p < 0.05 df = 1). mothers (Table VIII).

Discussion
Table VII: Distribution of respondents by The total number of respondents was 418.
birth attendant at hospital with educational Regarding age distribution of the women in
level the study area, it was revealed that majority
(49.9%) were in the 20-24 years age group.
Educational level The mean age was 24.35 years and standard
Total
Birth attendant Illiterate Literate
N % N % N % deviation ± 4.2 and age distribution of women
Doctor 6 5.3 107 94.7 113 54.6 aged 15-49 years (Table I). In this study
Nurse 8 9.0 81 91.0 89 43.0 respondents in 20-24 years age group was
Others 1 20.0 4 80.0 5 2.4 higher because of in our country this group
Total 15 7.2 192 92.8 207 100.0 women is more fertile.
x2 = 2.243 P = 0.326 df = 2
Regarding educational status of the
respondents, it was found that proportion of
Regarding distribution of respondents by birth
literate women was higher 87.6% than that of
attendant at hospital and education, it was
other parts of the country. It does not coincide
found that majority of women [107 (94.7%)]
with our national level of literacy rate
were attended by doctor as their birth
(68.3%) in 2004.5 It is quite encouraging
attendants were literate. Among the illiterate
because education plays a vital role in a
women, in hospital delivery nurses were
society to have 'healthy mother and healthy
higher in proportion (9%) as birth attendants
baby’.
(Table VII).
Practice of intranatal care was related with
Table VIII: Distribution of reasons for not
ANC in every respect. It was revealed that out
preferring hospital delivery (n =122)
of 418, 90.9% women received ANC and
9.1% told that they did not go for ANC in last
Frequency
Reasons not prefer hospital delive ry pregnancy. It was due to fact that people were
N %
Costly 105 86 more conscious about the safe delivery and
Lack of medicine supply 23 18.8 motivational work by the family planning
Female doctor not available 41 33.6 workers was satisfactory in the study area and
Hospital service poor 25 20.4 health complex was nearer to the people.
Do not behave properly 3 2.45

Among the mothers who received ANC, most

Opinion was sought from the respondents
(89.7%) of them were literate. It indicated that
regarding hospital ‘not better for delivery’. It
literate people were more conscious about
was found that out of 122 respondents
health care and receiving ANC. The
majority (86%) respondents told it was costly
relationship between education and receive of
for them to go for delivery in the hospital. A
ANC by the pregnant women was statistically
good number of respondents (33.6%) did not
significant (x2 = 18.19, P = 0.000, df = 1) in
choose hospital for delivery due to non-
the study. (Table III).
availability of female doctors as attendants. It
was also found that 20.4% respondents told

Dinajpur Med Col J 2011 Jul; 4(2) 74


It was revealed that 90.9% respondents
received ANC and only 9.1% did not receive
ANC. Among the ANC receiver, most were
primi (95.2%). It proved that the primigravida
mothers were more conscious about their
health.
The chief objective of the study was to find
out the practice of intranatal care by the rural
women. Among the study group majority of
the respondents (50.5%) had home delivery
and rest (49.5%) of female took hospital
delivery.
There is a relationship between the place of
delivery and level of education. From the
present study it was found that among the
respondents who took hospital delivery,
92.7% were literate and 7.24% were illiterate
where as in case of home delivery. 82.5%
were literate and 17.5% were illiterate.
Relationship between two variable was
statistically significant (x2 = 10.16, P = 0.001,
df = 1) (Table IV). It contains the evidence
that home deliveries were more prevalent
among illiterate people. The educated people
prefer institutional delivery. As the level of
education progress the rate of institutional
delivery increases. In another study conducted
by Lubna Ahmed in 1995, a case study in
London on Bangladeshi immigrants showed
that out of 88, one was delivered at home and
rest 87 delivered in hospital. This report is not
mimic with the reports of present study.6
From the study, it was revealed that the
people of higher socioeconomic condition
preferred institutional delivery to home
delivery. Large number of people of this
country can not bear the expenditure of
institutional delivery. It is one of the causes of
high rate of home delivery in this country.
Unsafe home delivery is responsible for high
maternal death. So the socioeconomic
condition of the rural people to be improved.
Dinajpur Med Col J 2011 Jul; 4(2)
Original Contribution
The respondents who had their delivery at
hospital and several other institutes, almost
(93.7%) all of the women received ANC. On
the other hand compared to hospital delivery,
11.8% women had home delivery who did not
receive ANC (Table V). The relationship
between place of delivery and receive of ANC
in this study was statistically significant (x2 =
3.92, P = 0.048, df = 1). It indicated that the
pregnant women who received ANC
perceived well about the safe delivery at
hospital and thereby preferred institutional
delivery.
There is a scope to counsel the pregnant
women about need for safe delivery at
hospital during ANC visits. The high
percentage of utilization of hospital service at
the time of delivery among the ANC
recipients indicates the effectiveness and
justification of ANC for the pregnant women.
There is a strong association between level of
education and birth attendants. In case of
home delivery, 68.72% women were attended
by untrained TBA and among them 77.93%
were literate where as 31.27% women were
attended by trained TBA in which 92.42%
were literate (Table VI). The relationship
between birth attendant at home with level of
education in this study was statistically
significant (x2= 6.58, p < 0.05, df = 1).
Regarding hospital delivery, 54.6% women
were attended by doctor and large number
(94.7%) of them was educated (Table VII).
According to study it showed that educated
people were more interested to be attended by
doctor. In order to perform safe delivery and
reduce the MMR by 2015 at 1.43% people
should be motivated to report to the hospital
at the time of delivery. In developing
countries maternal mortality ratio is 20 times
higher than developed countries. The life
time risk of dying from the pregnancy related
complications for a women of developing
75
 Original Contribution

country is one in 11 compared to one in 500 6. A study on the "Attitude of pregnant

in developed countries.7 women regarding hospital delivery in a
PHC- intensified thana; NIPSOM. 1996
Conclusion 7. D. C. Dutta, Text book of obstetrics;
The objective of the present study was to Safe Motherhood, Epidemiology of
explore the practice of intranatal care and Obstetrics. Sixth edition – 599.
associated factors of mothers in a rural
community. It was revealed form the study
that out o 418 respondents, majority 50.5%
delivered their baby at home. Among them
88.2% received ANC and 82.5% were literate.
From the study 49.5% respondents who had
institutional delivery, 93.7% received ANC
and 92.7% were literate. Regarding birth
attendants at home delivery out of 211
mothers, majority (47.9%) were attended by
relatives and 28.9% by trained TBA. Trained
TBA was higher (92.4%) as birth attendant
among literate population. It indicates that
education has positive influence on taking
help from trained health personnel. Regarding
hospital delivery out of 207 respondents study
showed that educated people (94.7%) were
more conscious to be attended by doctor. It is
expensive to have delivery at hospital
mentioned by 86% women. It indicated that a
fixed amount of financial support or medicine
for the women during hospital delivery would
make them interest to go to hospital for safe
delivery.

References
1. Maternal Mortality: the Global Fact
book. The global picture. Geneva.
WHO.1991 6-10
2. Statistical pocket book of Bangladesh
2006 (BBS)
3. Emergency Obstetric care, obstetrical
and Gynecological Society of
Bangladesh. UNICEF. Sept. 1993.
4. Safe Motherhood from Advocacy to
Action. Finance and Development, issue
7, Nov 1991.
5. Statistical pocket book of Bangladesh
2006 (BBS)

Dinajpur Med Col J 2011 Jul; 4(2) 76

Dinajpur Med Col J 2011 Jul; 4(2) 77
 Postpartum Care:​An Approach
to the Fourth Trimester
Heather L. Paladine, MD, MEd, Columbia University Irving Medical Center, New York, New York
Carol E. Blenning, MD, Oregon Health and Science University School of Medicine, Portland, Oregon
Yorgos Strangas, MD, Columbia University Irving Medical Center, New York, New York

The postpartum period, defined as the 12 weeks after delivery, is an important time for a new mother and her family and can
be considered a fourth trimester. Outpatient postpartum care should be initiated within three weeks after delivery in person
or by phone, and may require multiple contacts with the patient to fully address needs and concerns. A full assessment is
recommended within 12 weeks. Care should initially focus on acute needs and risks for morbidity and mortality and then
transition to care for chronic conditions and health maintenance. Complications of pregnancy, such as hypertensive disor-
ders and gestational diabetes mellitus, affect a woman’s long-term health and require specific attention. Women diagnosed
with gestational diabetes should receive a 75-g two-hour fasting oral glucose tolerance test between four and 12 weeks
postpartum. Patients with hypertensive disorders of pregnancy should have a blood pressure check performed within seven
days of delivery. All women should have a biopsychosocial assessment (e.g., depression, intimate partner violence) screening
in the postpartum period, and preventive counseling should be offered to women at high risk. Additional patient concerns
may include urinary incontinence, constipation, breastfeeding, sexuality, and contraception. Treating these issues during the
postpartum period is important to the new mother’s immediate and long-term health. (Am Fam Physician. 2019;​100(8):​485-
491. Copyright © 2019 American Academy of Family Physicians.)

The 12 weeks after delivery, known as the postpar-
tum period or the fourth trimester, are a critical time in the
life of a mother and her infant. Maternal mortality, which
is defined as deaths that occur during pregnancy and the
first year postpartum, is highest in the first 42 days post-
partum and represents 45% of total maternal mortality.1,2
Early postpartum visits should evaluate complications from
pregnancy as well as common postpartum medical com-
plications.3-5 Subsequent care should include a full biopsy-
chosocial assessment and be tailored to individual patient
needs going forward.3 Family physicians should be aware of
the importance of social determinants of health and dispar-
ities in maternal outcomes according to race, ethnicity, and
public health insurance status.
Timing and Frequency of Postpartum Visits
Historically, physicians have performed a single postpar-
tum visit between four and six weeks after delivery to close
See related editorial on page 460.
CME This clinical content conforms to AAFP criteria for
continuing medical education (CME). See CME Quiz on
page 465.
Author disclosure:​ No relevant financial affiliations.
Patient information:​ A handout on this topic is available at
https://​family​doctor.org/recovering-from-delivery.
the prenatal care relationship.1 There is a growing consen-
sus to initiate care within the first three weeks postpartum,
and to extend the postpartum period to transition to care
of chronic conditions.6-8 The American College of Obstetri-
cians and Gynecologists (ACOG) recommends a postpar-
tum evaluation within the first three weeks after delivery
in person or by phone, with a complete biopsychosocial
assessment to be completed within 12 weeks postpartum.3
The World Health Organization recommends visits at three
days, seven to 14 days, and six weeks postpartum, inclu-
sive of newborn care.3,9 A routine pelvic examination is not
indicated unless there are patient concerns.
Postpartum Health Issues and Patient Concerns
Health issues in the postpartum period include medical
complications, patient concerns, and conditions that may
cause future health risks (Table 1).4,10-52 Family physicians
may need to continue to provide medical care for these con-
ditions beyond 12 weeks after delivery. Complications that
occur during the prenatal period may reveal areas for inter-
vention and surveillance.20,21
SECONDARY POSTPARTUM HEMORRHAGE
Secondary postpartum hemorrhage is defined as significant
vaginal bleeding that occurs beyond 24 hours postpartum.
Rates may be as high as 2%,10 and retained placental tissue
and infection are the most common causes. Women with

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TABLE 1
Postpartum Health Issues and Patient Concerns
Condition/
concern Diagnostic considerations
Secondary Ultrasonography to look for
postpartum retained placental fragments
hemorrhage10-12
Endometritis13,14 Fever with no other source, may
be accompanied by uterine ten-
derness and vaginal discharge
Thromboem- Risk is five times higher during
bolic disease15-17 postpartum period than
pregnancy
Elevated risk persists up to 12
weeks postpartum
Hypertensive Highest risk is < 48 hours after
disorders4,18,19 delivery
Recommend office visit to
check blood pressure within
7 days of delivery
Gestational 75-g, 2-hour fasting oral
diabetes glucose tolerance test 4 to 12
mellitus20-22 weeks postpartum to detect
type 2 diabetes mellitus, then
screening every 1 to 3 years
Thyroid Can have symptoms of hyper-
disorders23,24 thyroidism or hypothyroidism
Test thyroid-stimulating hor-
mone and free thyroxine
Positive thyroid-stimulating
hormone receptor antibodies
distinguish Graves disease from
postpartum thyroiditis
Postpartum Edinburgh Postnatal Depres-
depression25-29 sion Scale and Patient Health
Questionnaire-2/9 are valid
diagnostic tools for postpar-
tum depression
Intimate partner Use HARK (humiliation, afraid,
violence30,31 rape, kick) or HITS (hurt, insult,
threaten, scream) tools to evalu-
ate for intimate partner violence
POSTPARTUM CARE
Treatment considerations
Uterotonics are first-line treatment
May need uterine curettage
Antibiotics for endometritis if infection is
suspected
Usually requires intravenous antibiot-
ics, most evidence for clindamycin and
gentamicin
Avoid direct thrombin inhibitors and
direct oral anticoagulants in women who
are breastfeeding
Treat if blood pressure ≥ 150/100 mm Hg,
can use oral nifedipine or labetalol
Hospitalize if signs of end organ damage
or blood pressure ≥ 160/110 mm Hg
Recommend lifestyle changes and annual
follow-up for blood pressure and body
weight monitoring
Recommend lifestyle changes and annual
follow-up
Hyperthyroidism is transient and usually
not treated
Beta blockers can be used as needed for
symptoms
Hypothyroidism is treated with thyroid
hormone therapy
Consider counseling and medication
Consider counseling, home visits, and
parenting support
Notes
Occurs in up to 2% of women in
the postpartum period
Hemorrhage can occur up to 12
weeks postpartum
Risk factors include immediate
postpartum hemorrhage, vaginal
(vs. cesarean) delivery, and
maternal age of 35 years or older
Higher likelihood of anaerobic
infection or chlamydia in late
infections
—
Occurs in up to 10% of women
in postpartum period
Risk factor for future
cardiovascular disease, cere-
brovascular disease, and venous
thromboembolism
5% to 10% of women with gesta-
tional diabetes continue to have
type 2 diabetes after delivery
Lifetime risk of developing
type 2 diabetes is multiplied at
least eightfold after a diagnosis
of gestational diabetes
Risk increases with a higher body
mass index, more abnormal
glucose tolerance test results,
nonwhite race, and older age
Up to 10% of women develop
postpartum thyroiditis
Up to one-half of patients will be
hypothyroid at one year post-
partum, sometimes after initial
recovery of thyroid function
The American Thyroid Asso-
ciation recommends annual
screening for hypothyroidism in
women with a history of post-
partum thyroiditis
Occurs in up to 10% of women
in postpartum period
Recommend counseling to
prevent depression in high-risk
women
Prioritize patient safety, consider
referral to intimate partner vio-
lence prevention organizations
continues
 POSTPARTUM CARE
TABLE 1

Postpartum Health Issues and Patient Concerns (continued)

Condition/
concern Diagnostic considerations Treatment considerations Notes

Urinary Evaluation includes history, Bladder training, weight loss, pelvic floor More than one-fourth of
incontinence32-34 examination including cough muscle exercises effective as first-line women experience moderate or
stress test with a full bladder treatment severe urinary incontinence in
and assessment of urethral the first year postpartum
mobility, urinalysis, and mea-
surement of postvoid residual
urinary volume

Hemorrhoids and Consider effects of medica- Increased dietary fiber and water intake Constipation may affect up to
constipation35 tions and supplements such Osmotic laxatives (polyethylene glycol 17% of women in the first year
as iron [Miralax] or lactulose) recommended for postpartum
constipation
Stool softeners recommended for
hemorrhoids
May need excision or ligation for refrac-
tory hemorrhoids or grade III or higher

Breastfeeding Evaluate latch, swallow, nipple Interventions include professional sup- —

problems36-38 type and condition, and hold of port, peer support, and formal education
the infant

Postpartum Women with higher gestational Dietary changes, or diet and exercise in Increased risk of future obesity
weight retention/ weight gain, black race, and combination are effective and type 2 diabetes
metabolic risk39,40 lower socioeconomic status
are at higher risk

Sexuality 41,42 Symptoms of low postpartum
libido and reduced sexual
function likely caused by low
estrogen levels and multiple
psychosocial factors
Reassurance usually appropriate Address earlier return of sexual
Resolves over time activity with contraception to
avoid unintended closely spaced
pregnancies

Contraception41-52 — For women who are breastfeeding:​ Immediate use is not harmful to
progestin-only methods can be used the infant
immediately postpartum (e.g., etonogestrel Can improve pregnancy spacing
implant [Nexplanon], levonorgestrel-
releasing intrauterine system [Mirena],
medroxyprogesterone [Depo-Provera])
Adolescents:​begin motivational interview- Intervention during pregnancy is
ing, discussion of long-acting reversible superior to postpartum period
contraception during pregnancy
Timing:​offer progestin-only methods Earlier introduction of
immediately (no estrogen until three contraception
weeks postpartum) to all women regard-
less of lactation

Information from references 4 and 10-52.

secondary postpartum hemorrhage may need to be exam-
ined in the emergency department or hospital for prompt
evaluation, including ultrasonography to investigate for
retained placental tissue.11 Treatment may include utero-
tonic medications, uterine curettage, or antibiotic treatment
for endometritis.12
also have uterine tenderness or vaginal discharge. Late post-
partum endometritis occurs more than seven days after deliv-
ery. Risk factors include chorioamnionitis and prolonged
rupture of membranes.13 Endometritis usually requires
treatment with intravenous antibiotics, with most evidence
supporting the use of gentamicin and clindamycin.14

ENDOMETRITIS THROMBOEMBOLIC DISORDERS

Women with a fever and tachycardia during the postpartum The risk of venous thromboembolic disease, including deep
period should be evaluated for endometritis. Patients may venous thrombosis and pulmonary embolism, is five times

October 15, 2019 ◆ Volume 100, Number 8 www.aafp.org/afp American Family Physician 487
 POSTPARTUM CARE
higher during the six weeks postpartum than during preg-
nancy.17 A lesser degree of increased risk persists up to 12
weeks postpartum.5 Additional risk factors are increasing
age, cesarean delivery, postpartum hemorrhage or infec-
tion, and a history of preeclampsia.15
Patients with a history of thromboembolism should be
treated with anticoagulation for at least the first six weeks
postpartum, and potentially longer if there are other risk fac-
tors. Warfarin (Coumadin) is teratogenic during pregnancy;​
however, it is minimally excreted in breast milk and is con-
sidered safe for women who are breastfeeding. There is a lack
of data on the use of direct oral anticoagulants in breastfeed-
ing, and they are not recommended for these patients.16
HYPERTENSIVE DISORDERS
Up to 10% of women have elevated blood pressure during
pregnancy, including chronic hypertension, gestational
hypertension, and preeclampsia. Women with hypertensive
disorders of pregnancy should have a follow-up blood pres-
sure check within seven days of delivery and be evaluated
for signs or symptoms of end organ damage such as hepatic
injury or pulmonary edema.4,18 Patients with new-onset
blood pressure of 150/100 mm Hg or higher or with signs
of end organ damage should be treated with antihyperten-
sive medications. Patients with signs of end organ damage
or a blood pressure of 160/110 mm Hg or higher should be
hospitalized and treated with parenteral magnesium sul-
fate to prevent eclampsia.18 Nonsteroidal anti-inflammatory
drugs are preferred over opioid analgesia and have been
shown to be safe for women with a history of hypertension
in pregnancy.19,53,54
Women with hypertensive disorders have an increased
risk of cardiovascular events later in life.18,55,56 They also
have an elevated risk of cardiovascular disease, cerebrovas-
cular disease, and venous thromboembolic disorders, and
are at risk of these complications at an earlier age than the
general population. All patients with a history of hyperten-
sive disorders of pregnancy should be counseled on behav-
ior modification and have blood pressure and body weight
monitored at least once a year.18,55
GESTATIONAL DIABETES MELLITUS
Gestational diabetes mellitus is a significant risk factor
for the development of type 2 diabetes mellitus, hyperten-
sion, and subsequent heart disease. A woman with a his-
tory of gestational diabetes has an eight- to 20-fold risk of
developing type 2 diabetes during her lifetime.20,21 Women
with gestational diabetes should be screened for impaired
glucose tolerance with a 75-g two-hour fasting oral glu-
cose tolerance test at four to 12 weeks postpartum, and
should be evaluated for development of hypertension with
488  American Family Physician www.aafp.org/afp
blood pressure monitoring.20,53 They should continue to be
screened for diabetes every one to three years because the
risk of type 2 diabetes is elevated.21
THYROID DISORDERS
Postpartum thyroiditis can affect up to 10% of women during
the first year postpartum, with similar rates of hyperthyroid-
ism and hypothyroidism.23 Postpartum hyperthyroidism is
usually transient and does not need to be treated. Hypothy-
roidism is treated with thyroid hormone therapy. The risk
of Graves disease is also increased postpartum, and women
with a history of this disease are more likely to relapse. Pos-
itive thyroid-stimulating hormone receptor antibodies can
distinguish Graves disease from postpartum thyroiditis.
Infants of women who are breastfeeding and being treated
for thyroid disorders should be monitored for growth and
development;​however, laboratory monitoring of infants’
thyroid function is not necessary.23,24 The American Thyroid
Association recommends annual thyroid function screening
in women with a history of postpartum thyroiditis.23
POSTPARTUM DEPRESSION
Up to 10% of women will experience depression in the
first year postpartum. The U.S. Preventive Services Task
Force (USPSTF), ACOG, and American Academy of
Pediatrics recommend one or more screening examina-
tions for postpartum depression in settings where sys-
tems are in place to ensure diagnosis, treatment, and
follow-up.25-27 The American Academy of Pediatrics has spe-
cific recommendations for timing of screening at the one-,
two-, four-, and six-month well-child visits. The Patient
Health Questionnaire-2, Patient Health Questionnaire-9,
and Edinburgh Postpartum Depression Scale are appropri-
ate screening tools.
The USPSTF also recommends preventive counseling for
women at high risk of perinatal depression.28 Risk factors
include a personal or family history of depression, a history
of intimate partner violence, stressful life events including
unplanned or undesired pregnancy, poor social or financial
support, and medical complications. A previous American
Family Physician (AFP) article reviewed identification and
management of peripartum depression.29
INTIMATE PARTNER VIOLENCE
The USPSTF recommends screening women of reproductive
age for intimate partner violence with a validated screening
tool such as HARK (humiliation, afraid, rape, kick;​https://​
www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/
T1/) or HITS (hurt, insult, threaten, scream;​https://​w ww.
aafp.org/afp/2016/1015/p646.html#afp20161015p646-t2),
followed by referral to support services if indicated.30
Volume 100, Number 8 ◆ October 15, 2019
 POSTPARTUM CARE

Interventions such as counseling and home visits can reduce
intimate partner violence for women postpartum.
URINARY INCONTINENCE
In one large cohort study, 28.5% of women reported mod-
erate or severe urinary incontinence in the first year post-
partum.32 Bladder training, fluid management, body weight
loss, and pelvic floor muscle exercises improve symptoms for
all types of urinary incontinence, but studies have included
women who are perimenopausal and not postpartum.34 It is
uncertain whether pelvic floor muscle training during the
postpartum period has an effect on urinary incontinence;​
however, it does reduce postpartum urinary incontinence
by about one-third when initiated prenatally.33
HEMORRHOIDS AND CONSTIPATION
Hemorrhoids may be caused by constipation or by pushing
during the second stage of labor. Initial therapy involves
treatment for constipation.35 Up to 17% of women report
constipation in the first six weeks postpartum. Iron supple-
ments taken orally during pregnancy can be a contribut-
ing factor. First-line treatments include increased intake of
water and fiber, and osmotic laxatives such as polyethylene
glycol (Miralax) or lactulose. Patients with hemorrhoids
should also be treated with stool softeners.
BREASTFEEDING PROBLEMS
A previous AFP article addressed breastfeeding recom-
mendations and common problems.36 The USPSTF found
moderate evidence that primary care–based interventions
to increase breastfeeding are beneficial.37 Individual-level
interventions have stronger evidence of effectiveness. These
include professional support by physicians, midwives, or
lactation counselors;​peer support;​or formal education
sessions. A Cochrane review found that support by trained
personnel (e.g., medical professionals, volunteers), face-to-
face interventions, and interventions that took place over
multiple encounters were more effective.38

POSTPARTUM WEIGHT RETENTION

SORT:​KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation
Initial follow-up should be within three
weeks after delivery, in person or by
phone. A comprehensive visit should
occur within 12 weeks postpartum and
include a biopsychosocial assessment. 3,9
Women with hypertensive disorders
should have a blood pressure check
within seven days postpartum.18,19
Women with gestational diabetes
mellitus should be screened for diabetes
with a 75-g two-hour fasting oral glu-
cose tolerance test at four to 12 weeks
postpartum. 20-22
All women should be screened in the
postpartum period for depression in
settings where systems are in place
to ensure diagnosis, treatment, and
follow-up. 25
Women at high risk of perinatal
depression should receive preventive
counseling in the postpartum period. 28
USPSTF = U.S. Preventive Services Task Force.
A = consistent, good-quality patient-oriented evidence;​B = inconsistent or limited-quality
patient-oriented evidence;​ C = consensus, disease-oriented evidence, usual practice, expert
opinion, or case series. For information about the SORT evidence rating system, go to https://​
www.aafp.org/afpsort.
rating Comments
C American College of Obste-
tricians and Gynecologists
and World Health Organiza-
tion expert consensus
C Narrative reviews and expert
consensus
C Longitudinal cohort studies
and expert consensus
B USPSTF recommendation
statement
B USPSTF recommendation
statement
AND METABOLIC RISK
Although data are limited on postpar-
tum body weight retention, a National
Academy of Sciences report estimates
that most women at six months post-
partum will weigh about 11.8 pounds
(5.4 kg) more than their prepregnancy
body weight. Risk factors for higher
postpartum weight retention include
more body weight gain during preg-
nancy, black race, and lower socio-
economic status. Postpartum weight
retention is a risk factor for later met-
abolic risk including development
of obesity, higher weight in future
pregnancies, and type 2 diabetes in
women who have previously had ges-
tational diabetes.39 Counseling about
dietary modifications or dietary and
exercise modifications together are
effective in helping women lose weight
postpartum.40
SEXUALITY AND CONTRACEPTION
Libido and sexuality are common con-
cerns during the postpartum period.41
Some studies have shown that pre-
pregnancy estrogen levels may not
return for as long as one year post-
partum, particularly in women who

October 15, 2019 ◆ Volume 100, Number 8 www.aafp.org/afp American Family Physician 489
 POSTPARTUM CARE
are breastfeeding, which may contribute to a low libido.41,42
The length of time for women to wait to have intercourse
following delivery is variable;​the average is six to eight
weeks in the United States.41,42 No consistent correlation
exists between delivery complications (e.g., vaginal lacera-
tions) and a delay in resuming intercourse.41,42 Because most
patients report some type of sexual problem postpartum,42
it is important to assess patients, validate concerns, address
contributing factors, reassure when appropriate, and offer
support including counseling.
The prenatal period is the best time to discuss postpar-
tum contraception. A 2015 Cochrane review reported low-
quality evidence for the effectiveness of birth control
method education in the postpartum period;​however, a
more recent study demonstrated the effectiveness of moti-
vational interviewing resulting in a decrease in rapid repeat
pregnancy and a higher use of long-acting reversible contra-
ception in pregnant adolescents.43,44
Women who are breastfeeding may also use the lacta-
tional amenorrhea method, alone or with other forms of
contraception. The woman must be breastfeeding exclu-
sively on demand, be amenorrheic (i.e., no vaginal bleeding
after eight weeks postpartum), and have an infant younger
than six months. This method is less reliable once the infant
starts eating solid food. The failure rate is less than 2% if
these criteria are fulfilled.45,46
This article updates a previous article on this topic by Blenning
and Paladine.1
Data Sources:​ PubMed searches were done using the terms
postpartum care, secondary/late postpartum hemorrhage/
hemorrhage, postpartum endometritis, postpartum thyroid,
hypertensive disorders of pregnancy, postpartum thrombo-
embolism, postpartum mood disorders, postpartum substance
use, postpartum urinary incontinence, postpartum constipation,
postpartum hemorrhoids, breastfeeding, postpartum weight,
postpartum sexuality, postpartum contraception, maternal infant
dyad, and postpartum complications. Also searched were the
Cochrane database, Essential Evidence Plus, and recommenda-
tions from the American College of Obstetricians and Gynecol-
ogists, the Centers for Disease Control and Prevention, the U.S.
Preventive Services Task Force, and the World Health Organiza-
tion. Search dates:​July and September 2018, and June 2019.
The Authors
HEATHER L. PALADINE, MD, MEd, is the director of the New
York Presbyterian–Columbia Family Medicine Residency Pro-
gram, and an assistant professor in the Center for Family and
Community Medicine at Columbia University Irving Medical
Center, New York, NY.
CAROL E. BLENNING, MD, is an associate professor in the
Department of Family Medicine at Oregon Health and Sci-
ence University School of Medicine, Portland.
490  American Family Physician www.aafp.org/afp
YORGOS STRANGAS, MD, is an assistant professor in the
Center for Family and Community Medicine at Columbia Uni-
versity Irving Medical Center.
Address correspondence to Heather L. Paladine, MD, MEd,
610 W. 158 St., New York, NY 10032 (email:​hlp222@​gmail.
com). Reprints are not available from the authors.
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American Family Physician 491