mother and baby risks associated with obesity in pregnancy: a systematic review of reviews 1

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Mother and baby risks associated with obesity in pregnancy: a systematic review of reviews

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Mother and baby risks associated with obesity in pregnancy: a systematic

review of reviews

Jamile Marchi1; Marie Berg2,3; Anna Dencker2,3; Ellinor K. Olander4; Cecily Begley1,2.

1School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland; 2Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;

3Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden; 4Centre for Maternal and Child Health Research, City University London, London, United Kingdom

16th Healthcare Interdisciplinary Research Conference (HIRC 2015)School of Nursing and Midwifery, Trinity College Dublin

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Acknowledgements

The systematic review was supported by funding from the University of Gothenburg’s Centre for Person-Centred Care (GPCC) and by the Brazilian Government’s Science Without Borders (SWB) scheme

There was no conflict of interest

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Presentation overview

1. Background2. Aim and research question 3. Methods4. Outcomes5. Discussion6. Strengths and Limitations7. Conclusions and recommendations

Background: some figures

Obesity during pregnancy is reaching epidemic proportions and is a growing public health issue (Berti, C. et al, 2015)

One- to two-thirds of women of reproductive age in the US and Europe are overweight or obese (Flegal, K.M et al, 1998; Flegal, K.M et al, 2010 )

Maternal obesity is linked to many different maternal and infant outcomes, including obesity in the offspring (Strauss, R.S. et al, 1999)

It had become an issue of concern for policy-makers, healthcare providers and researchers (Marchi, et al, 2015)

Direct obesity-related costs in the Republic of Ireland in 2004 were estimated at >13 million. Indirect costs were estimated at ~4 billion per year (Food Safety Authority, 2012)

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Obesity in pregnancy – Systematic Review

In preparation for my doctoral work, in 2014, I conducted a

systematic review of systematic reviews on outcomes of obesity in

pregnancy, with colleagues in Trinity College Dublin, City University London, UK, and University of Gothenburg,

Sweden.

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Systematic Review – Research question

What are the possible outcomes of obesity in pregnant women: for the mother and for the infant?

Systematic Review – Aim

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To synthesise the findings from all systematic reviews conducted on maternal obesity in order to identify the risk of adverse outcomes on mother and baby.

Systematic Review – Search strategy

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Systematic Review – Screening process

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Systematic Review: Quality assessment• AMSTAR

• Based on factors such as an a priori design, duplicate study selection and data extraction

Quality at three levels: • 8–11 is high quality • 4–7 is medium• 0–3 is low quality

(Sharif, et al, 2013)

Systematic Review: Description of the included reviews

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624 studies included in the 22 reviews: average per review =

28, range 3-70.

51 were overlapping studies 573 original studies included

in reviews

Definitions of obesity varied

Reviews conducted from 2007-14 but included studies published

between 1969 and 2014

Most reviews included studies

conducted in the US and UK and were case-control and

cohort studies

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Systematic Review: Negative outcomes found

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Systematic Review – Negative health outcomes

Gestational Diabetes Mellitus (GDM)

SR Key findings Recommendations

76 studies (after exclusion of overlapping/duplicate studies) from 02 reviews

#1 Risk of developing GDM was 4 and 9 times higher among women with obesity and severe obesity(Shu, S.Y. et al, 2007)

Screening women at risk; prevention programmes and educational activities

#2 ORs 3.76, 3.01 and 5.55 - respectively, for women with obesity, moderate obesity and morbid obesity(Torloni, M.R. et al, 2009)

Women should be informed about the risks and supported to lose weight prior to conception

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Pre-eclampsia and hypertension


54 studies(after exclusion of overlapping/duplicate studies) from 02 reviews

#1 Clear relationship: increasing BMI and risk of pre-eclampsia RRs for women with obesity and severe obesity of 2.68 and 3.43 respectively.(Wang, Z. et al, 2013)

More studies to investigate efficacy of interventions on diet and lifestyle are needed

#2 Women with obesity: 3–10 times higher chances of having pre-eclampsia and 4.5–8.7 times of developing gestational hypertension (Salihu, H.M. et al, 2012)

Further studies to investigate causes and to develop interventions are needed

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Mode of birth SR Key findings Recommendations


#1 Caesarean section (CS), unadjusted ORs:BMI ≥30, 2.05 (1.86–2.27) andBMI ≥35, 2.89 (2.28–3.79) (Chu, S.Y. et al, 2007)

More studies are needed

#2 Increased odds in women with obesity of having instrumentalvaginal births (OR 1.17, 95% CI 1.13–1.21) (Heslehurst, N. et al, 2008)

Interventions to prevent maternal obesity and use of guidelines to the care of pregnant women with high BMI

#3 Increased rates of CS and instrumental vaginal birth (Poobalan, A.S. et al 2009)

More studies investigating GWG restriction are needed

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Surgical site Infection (SSI)



#1 A significant associationbetween obesity and SSI was found only in 2 studies only.(Lakhan, P. et al 2010)

Further research is needed

#2 12 studies out of 13 found an association between SSI and obesity(Anderson, V. et al 2013)

Post-discharge wound assessments by community midwives are needed

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Mental Health


62 studies

#1 Women with obesity had elevated odds for the development of both antenataland postnatal depression (Amir, L.H. 2007)


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Preterm birth



#1 Women with BMI ≥35 kg2 had a 33% higher risk of preterm birth(Torloni, M.R. et al, 2009)

More research is needed

#2 Obesity and morbid obesity was linked to birth before <37 weeks(Heslehurst, N. et al 2008)

More research is needed

#3 Risk of a preterm birth (<33 weeks) was 1.49 and 2.02 for obese and very obese women (BMI ≥34.9 to ≥40 kg m−2) (McDonald, S.D. et al, 2010)

PTB should be considered in women with overweight and obesity

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Infant birth weight



#1 Pre-pregnancy obesity decreased the risk of low birth weight (LBW) (<10th centile) and increased the risk of large-for gestational-age (>90th centile) (Yu, Z. 2013)

Educational sessions with women who are overweight or obese are needed to reduce pre-pregnancy BMI

#2 LBW (<2,500 g), RR: BMI 30–34.9, 0.63 (0.34–1.19); BMI ≥34.9 to ≥40, 0.81 (0.42–1.53)(McDonald, S.D. et al, 2010)

Obesity in women is not necessarily protective against having LBW

#3 Maternal obesity was linked to high birth weight and to lower risk of low birth weight(Heslehurst, N. et al 2008)

Public health interventions are needed to prevent and manage obesity in pregnancy

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Systematic Review – Gestational Diabetes Mellitus (GDM)Fetal defects and congenital anomalies


14 studies(after exclusion of overlap./duplicate studies) from 03 reviews

#1 NTD; anencephaly; spina bifida; cardiovascular and septal anomaly; cleft palate; cleft lip and palate; anorectal atresia; hydrocephaly; limb reduction. A significantly lower prevalence ofGastroschisis among obese mothers (Stothard, K.J. et al 2009)

Intervention for raised pre-pregnancy BMI


#2 Neither of the two studies showed any increased risk of fetal alcohol syndrome in babies of mothers with obesity (Van Lieshout, R.J. 2011)

Intervention - pre-pregnancy BMI and GWG

#3 2 out of 3 relevant studies showed a significant association for anorectal anomalies in the fetus of mothers with obesity (Zwink, N. et al 2011)


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Fetal death/ miscarriage/ stillbirth



#1 Obesity associated with higher RR for stillbirth and fetal death (Aune, D. et al, 2014)

Weight management guidelines to help women who are planning pregnancy

#2 Stillbirth, adjusted OR: BMI ≥30, 1.6 (Flenady, V. et al, 2011)

Weight management and awareness of pre-pregnancy and pregnancy disorders

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Fetal death/ miscarriage/ stillbirth



#3 Miscarriage, pooled OR: 1.31 BMI ≥28 or BMI ≥30

Obesity also linked to stillbirth (Boots, C. 2011)

More studies are required in order to confirm this possible association

#4 Stillbirth, OR:BMI ≥30, 2.07 (1.59–2.74) (Chu, S.Y. 2007)

Women with obesity who are planning pregnancy should be encouraged to lose weight first

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Miscellaneous outcomes


49 studies #1 Some of the findings suggested increased risk for: induced labour, use of oxytocin augmentation and higher incidence of failure to progress in labour; babies needed neonatal intensive care more often, and had higher rates of fetal compromise and meconium stained liquor; longer duration of hospital stay in women and higher hospital costs(Heslehurst, N. et al 2008)

Public health interventions to prevent maternal obesity

Guidelines for the care of women with higher BMI

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Breastfeeding SR Key findings Recommendations


#1 7 out of 15 studies found that women with obesity breastfed for a shorter durationThey were also less likely to initiate breastfeeding (Amir, L.H. 2007)

More qualitative studies from women’s perspectives are needed

#2 Women with obesity were less likely to initiate breastfeeding. An increase in early cessation of breastfeeding (Turcksin, R. 2012)

Education for healthcare professionals and for women with BMI >30 (counselling and assistance)

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Systematic Review– Strengths and Limitations

Strengths

• It was not possible to perform meta-analysis because of the heterogeneity of the reviews and overlapping of studies

• The outcomes were limited to compare with normal weight women only

• Grey literature was not used

• Focus was on obesity – however gestational weight gain is also an issue that could exacerbate those negative outcomes

Limitations

• First review of reviews on the risks of maternal obesity for the mother and infant

• Amount and quality of studies that were found, resumed and critically discussed

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Conclusion and recommendation

It is very clear that obesity negatively affects outcomes for mothers and babies

Increased hospital/medical costs due to all adverse outcomes

More qualitative and quantitative studies in this area are required, as well as updated systematic reviews

Need for national programmes to help women before and during pregnancy

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THANK YOU!!

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ReferencesAmir LH, Donath S. A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth 2007; 7: 9.

Anderson V, Chaboyer W, Gillespie B. The relationship between obesity and surgical site infections in women undergoing caesarean sections: an integrative review. Midwifery 2013; 29: 1331–1338.

Aune D, Saugstad OD, Henriksen T, Tonstad S. Maternal body mass index and the risk of fetal death, stillbirth, and infant mortality: a systematic review and meta-analysis. JAMA 2014; 311: 1536–1546.

Berti C, Cetin I, Agostoni C et al. Pregnancy and infants’ outcome: nutritional and metabolic implications. Crit Rev Food Sci Nutr 2014; Mar 14 [Epub ahead of print]. doi: 10.1080/10408398.2012.745477.

Boots C, Stephenson MD. Does obesity increase the risk of miscarriage in spontaneous conception: a systematic review. Semin Reprod Med 2011; 29: 507–513.

Chu SY, Callaghan WM, Kim SY et al. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care 2007; 30:2070–2076 (a)

Chu SY, Kim SY, Lau J et al. Maternal obesity and risk of stillbirth: a metaanalysis. Am J Obstet Gynecol 2007; 197: 223–228 (b).

Examining Nutrition Surveillance on the island of Ireland, 2012

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ReferencesFlegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960–1994. Int J Obes Relat Metab Disord 1998; 22: 39–47.

Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010; 303: 235–241.

Flenady V, Koopmans L, Middleton P et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011; 377: 1331–1340.

Heslehurst N, Simpson H, Ells LJ et al. The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis. Obes Rev 2008; 9: 635–683.

Lakhan P, Doherty J, Jones M, Clements A. A systematic review of maternal intrinsic risk factors associated with surgical site infection following Caesarean sections. Healthc Infect 2010; 15: 35–41.

Marchi, J., Berg, M., Dencker, A., Olander, E. K. and Begley, C. (2015), Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews. Obesity Reviews, 16: 621–638. doi: 10.1111/obr.12288

McDonald SD, Han Z, Mulla S, Beyene J. Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and meta-analyses. BMJ 2010; 341: c3428.

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ReferencesPoobalan AS, Aucott LS, Gurung T, Smith WCS, Bhattacharya S. Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women – systematic review and meta-analysis of cohort studies. Obes Rev 2009; 10: 28–35.

Salihu HM, De La Cruz C, Rahman S, August EM. Does maternal obesity cause preeclampsia? A systematic review of the evidence. Minerva Ginecol 2012; 64: 259–280.

Sharif, Mohammad O., et al. "Systematic reviews explained: AMSTAR—how to tell the good from the bad and the ugly." Oral Health Dent Manag 12.1 (2013): 9-16.

Stothard KJ, Tennant PWG, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 2009; 301: 636–650.

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Torloni MR, Betran AP, Daher S et al. Maternal BMI and preterm birth: a systematic review of the literature with metaanalysis. J Matern Fetal Neonatal Med 2009; 22: 957–970 (a).

Torloni MR, Betran AP, Horta BL et al. Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis. Obes Rev 2009; 10: 194–203 (b)

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References

Turcksin R, Bel S, Galjaard S, Devlieger R. Maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review. Matern Child Nutr 2012; 10: 166–183.

Van Lieshout RJ, Taylor VH, Boyle MH. Prepregnancy and pregnancy obesity and neurodevelopmental outcomes in offspring: a systematic review. Obes Rev 2011; 12: e548–e559.

Wang Z, Wang P, Liu H et al. Maternal adiposity as an independent risk factor for pre-eclampsia: a meta-analysis of prospective cohort studies. Obes Rev 2013; 14: 508–521.

Yu Z, Han S, Zhu J, Sun X, Ji C, Guo X. Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta-analysis. PLoS ONE 2013; 8: e61627.

Zwink N, Jenetzky E, Brenner H. Parental risk factors and anorectal malformations: systematic review and meta-analysis. Orphanet J Rare Dis 2011; 6: 25.

mother and baby risks associated with obesity in pregnancy: a systematic review of reviews 1

Documents

systematic review negative

systematic review aim8

maternal obesity

possible outcomes of

included reviews12624

city university london

direct obesityrelated

infant outcomes