The impact of body mass index on maternal and

neonatal outcomes: a retrospective study in a UK

obstetric population, 20042011
R Scott-Pillai,
a
D Spence,
a
CR Cardwell,
b
A Hunter,
c
VA Holmes
b
a
School of Nursing and Midwifery, Queens University, Belfast, UK
b
Centre for Public Health, School of Medicine, Dentistry and Biomedical
Sciences, Queens University, Belfast, UK
c
Royal Jubilee Maternity Service, Belfast Health and Social Care Trust, Belfast, UK
Correspondence: Dr V Holmes, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University, Belfast,
ICS Block B, Grosvenor Road, Belfast, BT12 6BA, UK. Email v.holmes@qub.ac.uk
Accepted 28 January 2013. Published Online 27 March 2013.
Objective To assess the prevalence of overweight and obesity, and
the impact of body mass index (BMI) on maternal and neonatal
outcomes, in a UK obstetric population.
Design Retrospective study.
Setting A tertiary referral unit in Northern Ireland.
Population A total of 30 298 singleton pregnancies over an 8-year
period, 20042011.
Methods Women were categorised according to World Health
Organization classication: underweight (BMI < 18.50 kg/m
2
);
normal weight (BMI 18.5024.99 kg/m
2
; reference group);
overweight (BMI 25.0029.99 kg/m
2
); obese class I (BMI 30.00
34.99 kg/m
2
); obese class II (BMI 3539.99 kg/m
2
); and obese
class III (BMI 40 kg/m
2
). Maternal and neonatal outcomes
were examined using logistic regression, adjusted for confounding
variables.
Main outcome measures Maternal and neonatal outcomes.
Results Compared with women of normal weight, women who
were overweight or obese class I were at signicantly increased
risk of hypertensive disorders of pregnancy (OR 1.9, 99% CI 1.7
2.3; OR 3.5, 99% CI 2.94.2); gestational diabetes mellitus
(OR 1.7, 99% CI 1.32.3; OR 3.7, 99% CI 2.85.0); induction of
labour (OR 1.2, 99% CI 1.11.3; OR 1.3, 99% CI 1.21.5);
caesarean section (OR 1.4, 99% CI 1.31.5; OR 1.8, 99% CI 1.6
2.0); postpartum haemorrhage (OR 1.4, 99% CI 1.31.5; OR 1.8,
1.62.0); and macrosomia (OR 1.5, 99% CI 1.31.6; OR 1.9,
99% CI 1.62.2), with the risks increasing for obese classes II and
III. Women in obese class III were at increased risk of preterm
delivery (OR 1.6, 99% CI 1.12.5), stillbirth (OR 3.0, 99% CI
1.09.3), postnatal stay > 5 days (OR 2.1, 99% CI 1.53.1), and
infant requiring admission to a neonatal unit (OR 1.6, 99% CI
1.02.6).
Conclusions By categorising women into overweight and obesity
subclassications (classes I III), this study clearly demonstrates
an increasing risk of adverse outcomes across BMI categories, with
women who are overweight also at signicant risk.
Keywords Body mass index, maternal and neonatal outcomes,
obesity, pregnancy.
Please cite this paper as: Scott-Pillai R, Spence D, Cardwell C, Hunter A, Holmes V. The impact of body mass index on maternal and neonatal outcomes: a
retrospective study in a UK obstetric population, 20042011. BJOG 2013;120:932939.
Introduction
Obesity has become an epidemic throughout the world.
Worldwide, obesity rates have doubled in the last 30 years,
1
with rates also increasing among pregnant women.
2,3
Maternal obesity has signicant health implications, con-
tributing to increased morbidity and mortality for both
mother and baby. A higher proportion of women who die
in pregnancy/postpartum are obese.
4,5
Antenatally, obesity increases the risk of miscarriage, ges-
tational diabetes mellitus (GDM), gestational hypertension,
thromboembolism, and pre-eclampsia.
6
Obesity is associ-
ated with poor labour outcomes, with obese women less
likely to go into labour spontaneously, more likely to have
prolonged pregnancies and have their labour induced, and
less likely to achieve a normal delivery, being at increased
risk of caesarean section.
2,713
Postnatally, obese women are
less likely to breastfeed successfully, have a longer postnatal
stay in hospital, and are at risk of postnatal infections.
710,14
Obesity is also associated with a higher risk of adverse neo-
natal outcomes, including stillbirth, congenital anomalies,
neonatal intensive care admission, and neonatal death.
2,79
DOI: 10.1111/1471-0528.12193
www.bjog.org
Maternal medicine
932 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
In addition, there are long-term consequences of obesity
in pregnancy. Obese women tend to be heavier with each
subsequent pregnancy.
15
These women are more likely to
remain obese adults, with all the associated increased risks
of obesity.
16,17
Furthermore, long-term studies demonstrate
that having an obese mother increases the risk of a child
growing up to be obese themselves.
18,19
The impact that
obesity in pregnancy has on the long-term health of society
as a whole, is therefore immeasurable.
Several UK studies have looked at adverse outcomes in
pregnancy in relation to obesity.
2,10,2025
However, none of
these studies have looked at adverse outcomes in relation
to each of the World Health Organisation (WHO) body
mass index (BMI) classications, where obesity is subdi-
vided into obese class I, II, and III (morbid obesity). The
objective of this study was to assess the prevalence of over-
weight and obesity, and to investigate the impact of rising
BMI using the WHO classication on maternal and neona-
tal outcomes.
Methods
This retrospective study used data from births between Jan-
uary 2004 and December 2011 within a tertiary referral
unit, with over 5000 births per year in Northern Ireland.
This study was designed as a clinical audit and therefore
did not require approval from a Research Ethics Commit-
tee. Local audit committee approval was obtained to use
the data routinely collected using the Northern Ireland
Maternity System (NIMATS), a computerised clinical data-
base for recording information on an individual pregnant
womens medical history and pregnancy outcomes, includ-
ing the antenatal, intranatal, and immediate postnatal
(until discharge from hospital) periods.
Anonymised data on 43 267 babies were collated with
data retrieved relating to each baby delivered within the 8-
year study period. Exclusion criteria were: births at less
than 24 weeks of gestation (n = 99); multiple pregnancies
(n = 1724); BMI recorded after 16 weeks of gestation
(n = 8986); and no BMI recorded (2160). The nal cohort
consisted of 30 298 cases (Figure 1).
Data from NIMATS were transferred into SPSS 17. The
BMIs (kg/m) were calculated from the heights and
weights measured during the antenatal booking visits.
Women were categorised using the WHO classication:
underweight (BMI < 18.50 kg/m); normal weight
(BMI 18.5024.99 kg/m; reference group); overweight
(BMI 25.0029.99 kg/m); obese class I (BMI 3034.99 kg/
m); obese class II (BMI 3539.99 kg/m); and obese class
III (BMI 40 kg/m).
26
Social deprivation scores were
calculated using the Northern Ireland Multiple Depriva-
tion Measure,
27
with women in the bottom third decile
considered to be socially deprived. Data are expressed as
frequency (n) and percentages (%) or means and standard
deviations (SDs). Logistic regression was used to calculate
odds ratios (ORs) for categorical variables, with the nor-
mal BMI group as the standard reference population. A
condence interval of 99% (99% CI) was used, and
P < 0.01 was considered signicant. All variables were
adjusted for age, parity, year of birth, social deprivation,
and smoking. In addition, induction of labour, emergency
caesarean section, elective caesarean section, and preterm
and post-term birth were adjusted for pre-gestational dia-
betes mellitus and essential hypertension; birthweight was
adjusted for gestational age and gender.
Results
An early pregnancy BMI (at 16 weeks of gestation) was
available for 93.3% of women who met other inclusion cri-
teria. Within this cohort, women were categorised as
underweight (2.8%), normal weight (52.5%), overweight
(27.8%), obese class I (11.0%), obese class II (3.9%), and
obese class III (1.9%). Demographic and clinical character-
istics are outlined in Table 1. Compared with women of
normal weight, a higher proportion of underweight women
were younger, nulliparous, unmarried, smokers, and
socially deprived. By contrast, as BMI increased, so did
maternal age and parity.
Antenatal outcomes are outlined in Table 2. The risk for
GDM increased across the overweight and obese categories,
to an OR of 8.5 (99% CI 5.712.9) for women classied as
obese class III. Likewise, the risk of hypertensive disorders
of pregnancy also increased in relation to an increase in
BMI classication, to an OR of 6.6 (99% CI 4.98.9) for
Total number in dataset
n = 43267
FINAL COHORT
n = 30298
Exclusions
Live births under 24 weeks' gestation
n = 99
Multiple births
n = 1724
Women booking after 16 weeks' gestation
n = 8986
No recorded BMI
n = 2160
Figure 1. Cohort selection.
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG 933
Impact of BMI on maternal and neonatal outcomes
women in obese class III. Only the women who were
underweight were at increased risk of anaemia (OR 1.3,
99% CI 1.01.7), and there was no statistically signicant
association between being underweight and any other ante-
natal outcome. There was no statistically signicant associa-
tion between any of the BMI categories and the following
antenatal outcomes: placenta praevia, antepartum haemor-
rhage, placental abruption, or thromboembolism.
The intranatal outcomes are outlined in Table 2. Women
who were overweight or obese were more likely to have
their labour induced, and this risk increased with each BMI
category, to an OR of 1.6 (99% CI 1.32.0) for women in
obese class III. Likewise, women who were overweight were
at increased risk of caesarean section, and this risk
increased with an increase in BMI to an OR of 2.8 (99%
CI 2.43.5) for women in obese class III. This increased
risk exists for both emergency caesarean section (OR 1.9,
99% CI 1.42.5) and elective caesarean section (OR 2.6,
99% CI 2.03.3). Conversely, overweight and obese women
were less likely to have a normal delivery or an instrumen-
tal delivery. The odds ratio for normal delivery and for
instrumental delivery decreased with an increase in BMI to
an OR of 0.5 (99% CI 0.40.6) and 0.5 (99% CI 0.30.7),
respectively, for women in obese class III. The risk of post-
partum haemorrhage (PPH) increased as BMI increased
(OR 2.7, 99% CI 2.23.4). There was no statistically signi-
cant risk of shoulder dystocia or third- or fourth-degree
perineal tear in relation to BMI.
Postnatal outcomes are included in Table 2. Women
who were overweight or obese were less likely to breastfeed,
and the OR for this variable decreased as BMI increased,
such that women who were morbidly obese had an OR of
0.4 (99% CI 0.30.5). There was an increased risk of
wound problems following caesarean section for women in
obese class II (OR 3.5, 99% CI 1.86.7) and in obese class
III (OR 6.0, 99% CI 3.012.1). Women in obese class III
were at higher risk of a postnatal stay greater than 5 days
(OR 2.1, 99% CI 1.53.1). Maternal antenatal, intranatal,
and postnatal outcomes, using a condence interval 95%,
are presented in Table S1.
Neonatal outcomes are presented in Table 3. In relation
to spontaneous preterm birth, all BMI groups were at
slightly increased risk compared with women of normal
weight; however, this was only statistically signicant for
obese class I (OR 1.3, 99% CI 1.01.6) and obese class III
(OR 1.6, 99% CI 1.12.5). When adjusted for gestational
age and gender, the underweight group was at increased
risk of delivering a baby of low birthweight (OR 1.6,
99% CI 1.02.4), with borderline signicance (P = 0.01).
However, all three obese groups were less likely to have a
baby of low birthweight (<2.5 kg), and this risk decreased
as BMI increased, such that women in obese class III had
an OR of 0.5 (99% CI 0.21.0), just below the level of sig-
nicance (P = 0.011). There was a statistically signicant
association between macrosomia (birthweight 4.0 kg)
and BMI categories. The underweight group was least likely
to deliver a macrosomic baby (OR 0.5, 99% CI 0.30.7),
whereas women in obese class III were most likely to deli-
ver a macrosomic baby (OR 3.2, 99% CI 2.44.1). The risk
of stillbirth was of borderline signicance for women in
obese class III (OR 3.0, 99% CI 1.09.3; P = 0.01). Neural
tube defects were only statistically signicant for women in
obese class II (OR 7.5, 99% CI 1.246.5). Only women in
obese class III had a statistically signicant association with
low Apgar score at 5 minutes (OR 2.0, 99% CI 1.13.6).
After adjusting for pre-gestational diabetes and preterm
delivery, the risk for admission to the neonatal unit was
still statistically signicant for the three obese groups: obese
class I, OR 1.3 (99% CI 1.11.7); obese class II, OR 1.6
(99% CI 1.22.2); and obese class III, OR 1.6 (1.02.6).
Table 1. Demographic and clinical characteristics by BMI category (kg/m
2
)
Underweight
BMI < 18.50
n = 862
Normal
BMI 18.5024.99
n = 15 908
Overweight
BMI 25.0029.99
n = 8415
Obese class I
BMI 30.0034.99
n = 3333
Obese class II
BMI 35.0039.99
n = 1194
Obese class III
BMI 40.00
n = 586
Age, mean (SD), years 26.2 (6.2) 29.7 (6.0) 30.6 (5.7) 30.4 (5.7) 30.5 (5.5) 31.1 (5.5)
Socially deprived 477 (55.3) 6096 (38.3) 3259 (38.7) 1501 (45.0) 563 (47.2) 262 (44.7)
Planned pregnancy 395 (45.8) 10 665 (67.0) 5853 (69.6) 2267 (68.0) 808 (67.7) 361 (61.6)
Married 327 (37.9) 8917 (56.1) 4903 (58.3) 1864 (55.9) 642 (53.8) 304 (51.9)
Nulliparous 511 (59.3) 7600 (47.8) 3398 (40.4) 1281 (38.4) 418 (35.0) 215 (36.7)
Smoker 274 (31.8) 3122 (19.6) 1625 (19.3) 699 (21.0) 267 (22.4) 120 (20.5)
Alcohol during pregnancy 36 (4.2) 709 (4.5) 372 (4.4) 135 (4.1) 41 (3.4) 18 (3.1)
Pre-existing diabetes 0 (0) 84 (0.5) 112 (1.3) 54 (1.6) 35 (2.9) 26 (4.4)
Essential hypertension 1 (0.1) 73 (0.5) 78 (0.9) 65 (2.0) 39 (3.3) 30 (5.1)
Data are n (%), unless otherwise indicated.
934 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
Scott-Pillai et al.
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.
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG 935
Impact of BMI on maternal and neonatal outcomes
Neonatal outcomes using a condence interval of 95% are
presented in Table S2.
Discussion
Main ndings
This large retrospective study clearly demonstrates that
being overweight or obese increases the risk of adverse
maternal and neonatal outcomes. In particular, by catego-
rising women into subclassications of obesity this study
highlights a relationship between increasing BMI (from
overweight to obese class III) and increasing risk of adverse
outcomes, including gestational diabetes mellitus (GDM),
hypertensive disorders of pregnancy, caesarean section,
macrosomia, and neonatal unit admission, with women in
the highest obesity group at risk of additional adverse out-
comes, including stillbirth, a longer postnatal stay, and
wound problems following caesarean section. Importantly,
as BMI increases women were less likely to achieve a nor-
mal delivery and were less likely to breastfeed.
Current UK guidelines recommend that women with a
BMI > 30 should be offered a glucose tolerance test ante-
natally, and that those with a BMI > 35 should have addi-
tional monitoring for pre-eclampsia.
28
In the study
reported here, obese women were at an increased risk of
GDM and hypertensive disorders of pregnancy, and this
risk increased as BMI increased, a nding consistent with
other studies.
2,7,9,1113,21,23
However, women who were
overweight were also at increased risk of hypertensive dis-
orders of pregnancy and GDM, and therefore at risk
women who are overweight or obese (class I) may not be
offered appropriate antenatal screening under the current
guidelines. Intranatally, obesity contributes to poorer out-
comes. As found in other studies, in the current study
women who were obese were more likely to have their
labour induced, were less likely to have a vaginal delivery,
and were at increased risk of PPH.
2,8,9,11,23,29,30
To the best
of the authors knowledge, no studies to date have investi-
gated the role of intranatal management on outcomes for
women who are overweight or obese, and thus further
research is now needed to elucidate the optimal intranatal
management for women who are overweight or obese.
Postnatally, in this study, women who were obese were less
likely to breastfeed successfully, which has been reported
elsewhere.
14
This has long-term implications for health, in
particular with regard to obesity, as breastfeeding has been
associated with women losing more weight postnatally, and
breastfed babies are less likely to become obese.
31,32
In terms of neonatal outcomes, maternal BMI clearly
inuenced birthweight in the current study, with women
who were underweight being more likely to deliver a baby
of low birthweight, and women in obese class III being
more likely to have a macrosomic baby. In agreement with
T
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936 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG
Scott-Pillai et al.
the recent study by Wloch et al., obesity was associated
with risk of wound infection among the population
reported here, with risk increasing with BMI category.
33
In
addition, in this study, women in obese class III were at
higher risk in relation to stillbirth, as has been demon-
strated in other larger studies.
8,34
Limitations and strengths
One of the major strengths of this study is the categorisa-
tion of women into all WHO BMI classication categories,
including the three categories of obesity. In fact, to our
knowledge, this is the only UK study to look at each sepa-
rate category of obesity, thereby enabling the observation
of a much clearer association in terms of risk and obesity
for several outcomes. Because of the relatively large cohort
in this study, it was possible to examine the outcomes for
each BMI category, be selective about the deliveries
included, and adjust for potentially confounding variables,
yet still obtain statistically signicant results for several
important outcomes. Another strength of this study is the
availability of BMIs for 93.3% of women, with BMIs
recorded in early pregnancy (before 16 weeks of gestation),
and therefore more likely to reect pre-pregnancy BMIs, in
line with current recommendations.
28
As with any study, there are some limitations. As a result
of the data available on the NIMATS database, this study
was only able to look at hypertensive disorders of preg-
nancy, rather than clearly distinguishing between conditions
such as pre-eclampsia or gestational hypertension, and thus
could not specically assess the individual risks for these
conditions. Although weight gained during pregnancy can
have an impact on risk,
17,29,35,36
the current study was
unable to adjust for pregnancy weight gain, as women were
not routinely re-weighed during pregnancy. Furthermore,
data were missing on NIMATS with regards to the ethnic
background of the women; however, Northern Ireland still
has a relatively homogenous white background population
(99.15%), so it is unlikely that ethnic background would
have been signicantly different between the groups,
27
mak-
ing this study generalisable to a largely metropolitan white
population. For outcomes where only a limited number of
cases are available, such as neural tube defects and stillbirth,
false negatives are possible, and the results should be inter-
preted with caution. Data was not available to take into
account clustering of births, and thus it is possible that a
woman may have contributed more than one birth over the
time period. Finally, it must be highlighted that although
the current study provides a comprehensive analysis of ante-
natal, intranatal, and neonatal outcomes across the BMI cat-
egories over an 8-year period, this has resulted in multiple
comparisons, and, given the large number of outcomes con-
sidered, further studies are needed to conrm the ndings.
Interpretation
This study infers that women who are obese are more likely
to require specialist medical care during their pregnancy, as
a result of the increased risks associated with obesity.
Women who were overweight or obese were less likely to
labour without medical intervention, and were more likely
to need a caesarean section, increasing the level of medical
input, with cost implications for intranatal care. Although
women in the highest BMI category were at the highest risk
for an adverse outcome, these women, as expected, repre-
sented the smallest group in this study (1.9%). The largest
at risk groups were women who were overweight or in
obese class I, representing 38.8% of the cohort studied. As
national guidelines currently focus primarily on women
within the highest BMI groups, and given resource alloca-
tion pressures within the health service, women who are
overweight or in obese class I may not receive additional
screening or management. Admittedly, these women may
not have the same level of risk as women with the highest
BMI; however, they are still at increased risk of several
adverse outcomes, as highlighted in this study. This provides
a challenge for healthcare professionals, as a substantial pro-
portion of women they care for will be at risk as a result of
being overweight or obese, yet may not be identied as such,
according to local policy and national guidelines.
In summary, being overweight or obese has a signicant
adverse impact on maternal and neonatal outcomes, with
risk increasing across BMI categories. These risks have
obvious implications for the management of these women
during their pregnancy, labour, and postnatal period. It is
important when planning care for women who are over-
weight or obese that resources are allocated appropriately
in order to minimise the risk factors for these women.
While current guidelines consider women who are obese,
women who are overweight are also at an increased risk,
and should therefore also be monitored closely during
pregnancy and delivery to ensure optimum outcomes for
women and their babies.
Disclosure of interests
None of the authors have any potential conicts of interest
to declare.
Contribution to authorship
DS and VAH conceived and designed the study, with input
from RS, AH, and CC. DS and VAH obtained audit com-
mittee approval and acquired the data. RS undertook the
analysis and interpretation of the data, with input from
CC, DS, and VAH. RS wrote the rst draft of the article.
AH provided obstetrical expertise. All authors participated
in the editing of this article and approved the nal version
for publication.
2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG 937
Impact of BMI on maternal and neonatal outcomes
Ethics approval
This study was designed as an audit, and thus did not
require ethics committee approval. Local audit committee
approval was granted. The data provided to the researchers
in this study were anonymised. No identiable data were
available to the researchers. The study was performed in an
ethical manner.
Funding
This study received no external funding.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Maternal outcomes by BMI category (kg/m
2
).
Table S2. Neonatal outcomes by BMI category (kg/m
2
).
&
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