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Our objective was to identify factors associated with recurrent preterm birth among underweight women. Maternally-linked hospital and birth certificate records of deliveries in California between — were used. Pregnancies were categorized based on outcome of the first and second birth as: We analyzed 4, women with underweight BMI in the first pregnancy. Of these, had at least one preterm birth. Among theselye Odds for first term – second preterm birth were decreased for increases in maternal age aOR: Factors associated with recurrent preterm birth were: Recurrent preterm birth among underweight women was associated with younger age, short inter-pregnancy interval, and negative or no weight change between pregnancies.
What factors are related to recurrent preterm birth among underweight women?
Each year more thanpreterm infants are born in the United States at less than 37 weeks of gestation [ 1 ]. In addition to major morbidity and mortality in the neonatal period [ 2 ], preterm birth PTB is associated with significant long-term morbidity and high economic costs for the society [ 23 ]. Although there is a known association between maternal pre-pregnancy underweight and increased risk of PTB [ 4 — 8 ], the risk factors for recurrent PTB specifically among women who have underweight BMI in their first pregnancy remain unclear.
Previous studies on recurrent PTB are done among women in all body mass index BMI categories [ 5 ] and have not specified the factors related to recurrent PTB among underweight women.
Among women in all BMI categories, the factors related to recurrent PTB include a decrease from normal to underweight prepregnancy BMI between pregnancies [ 5 ], a short inter-pregnancy interval IPIhistory of prior PTB at 28—32 weeks gestation and younger maternal age.
Identification of potentially modifiable risk factors specific to women with low BMI could help in counseling underweight women who have experienced a PTB. This is a retrospective cohort study performed using the California birth cohorts from —10, which link California birth records with Office of Statewide Health and Planning maternal and infant hospital discharge data. The datasets include maternal and pregnancy characteristics from birth certificates combined with clinical details from birth hospitalization and link multiple births to the same mother.
The dataset has been previously described in more detail [ 9 ]. Maternal demographics are based on birth certificate data. PTB was defined as a live birth occurring at less than 37 weeks of gestation. Information on gestational age at delivery was based on obstetric estimate provided on the birth certificate.
PTB was subtyped based on maternal ICDCM diagnosis and procedure codes along with birth certificate codes in a hierarchical classification. Data on maternal prepregnancy weight and height were self-reported. We restricted our analyses to women who had underweight BMI in their first pregnancy and had a singleton live birth in the subsequent pregnancy between and To establish the occurrence of recurrent PTB among women with normal BMI, we analyzed 54, women with two consecutive live births and normal BMI at the time of the first pregnancy.
To ensure correct identification of consecutive births to the same woman, we required that the maternal birth date 2454 across records and that the month and year of the preceding birth listed on the second birth certificate matched the month and year of birth recorded on the first birth certificate. Between andthere werewomen who delivered their first and second singleton live births in California.
The study population was categorized into outcome groups based on the first and the second birth as: The primary outcome of study was recurrent preterm birth and recurrent term birth was used as the reference.
Weight change between pregnancies was calculated by subtracting pre-pregnancy weight in the first pregnancy from pre-pregnancy weight in the second pregnancy. Statistical analysis was performed using SAS version 9. For multivariable models, covariates were chosen based on prior knowledge for their impact on PTB.
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Of the women with underweight BMI in their first pregnancy, 86 women 1. Characteristics of the study population by birth outcome are presented in Table 1. After excluding cases with indicated PTB from the analysis, the maternal and obstetric characteristics remained unchanged data not shown.
Among underweight women with PTB in the first pregnancy, The factors related to increased odds for recurrent PTB compared to recurrent term birth were negative or no weight change between pregnancies aOR: Factors related to outcomes of recurrent preterm birth, term birth – preterm birth and preterm birth – term birth compared to recurrent term birth among women with underweight BMI in the first pregnancy.
In multivariable modeling, odds for first term birth – second PTB were decreased for increases in maternal age adjusted odds ratio, aOR: Increased odds of first PTB with second term birth was related to inter-pregnancy intervals of less than 6 months aOR: After removing indicated PTBs from analyses, results from the multivariable modeling remained largely unchanged except the weight change between pregnancies was no longer a significant predictor for recurrent spontaneous PTB data not shown.
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In addition, after removing cases with maternal co-morbidities any pre-existing or gestational hypertension, diabetes or preeclampsia lye pregnancy 1 or pregnancy 2 the results of the multivariable modeling remained largely the same except maternal age, height and IPI were no longer significant predictors for the outcome of PTB-Term but maternal education some high school or less vs.
We analyzed almost 5, consecutive live births of women with pre-pregnancy underweight i. However, recurrence percentages between women with normal pre-pregnancy BMI, 1. 244543 examining specific 224543 related to recurrent preterm birth among women with different severity of underweight, this study adds to the existing literature that has not looked at specifically the underweight women.
In addition, our study has clinical implications for counseling underweight women who have experienced a PTB. Although several studies have shown an association between maternal prepregnancy underweight and increased risk of PTB [ 6712 ], only a few studies have investigated maternal underweight and the risk of recurrent PTB [ 58 ].
In their historical cohort of multiparous women in Utah, Simonsen et al. In another study, Whiteman et al. Neither Whiteman et al. Thus, identifying other factors related to recurrent PTB could prove valuable for prematurity prevention. In this study, we investigated the difference in pre-pregnancy weights between pregnancies and noted that no change or a negative weight change between pregnancies was associated with a significantly increased risk of recurrent PTB among underweight women.
Our finding is in line with prior studies that have demonstrated that recurrent PTB is related to less than appropriate gestational weight gain [ 8 ] and a change from normal to underweight BMI category between pregnancies [ 5 ].
That is, underweight women who do not gain weight during pregnancies are at the highest risk of recurrent PTB. Although the underlying mechanisms related to PTB among underweight women are not fully understood, factors like eating disorders [ 16 ], decreased micronutrient intake [ 17 ] and increased stress and anxiety levels [ 18 ] have been postulated to play a role.
In addition, Whiteman et al. The association leey short IPI and PTB may be associated with maternal micronutrient depletion, in particular folate depletion [ 19 ]. Interestingly, in our study a short IPI was also associated with increased risks for women whose first birth was term and second was preterm, as well as the reverse first birth preterm and second termalthough risks of 2454 IPI were highest among women with recurrent PTB and a PTB after a term birth.
It is possible that women with short IPI were unable to change their weight in between the pregnancies and remained it a higher risk because of their starting pre-pregnancy weight.
Our study has both strengths and limitations.
Because of its large size, we were able to examine consecutive live births of underweight women taking maternal underweight categories and different birth outcomes into account. In addition, the more recent cohort in our study and the population-based data employed increased the generalizability of our findings. However, we were limited to data derived from birth certificates and hospital discharge databases, which are not always reliable.
In addition, we were limited to use of self-reported 2443 and height in BMI calculations, although associations between self-reported BMI and pregnancy outcomes may be a slightly overestimated [ 20 ]. Although BMI is a simple index of weight-for-height that is commonly used to classify underweight it may not correspond to the same degree of thinness in different populations due, in part, to different body proportions.
Furthermore, although we did have self-reported data on maternal pre-pregnancy and delivery weights, we did not include gestational weight gain in the analysis because these values would have not presented a lye pregnancy weight gain which is non-linear and dependent on gestational age at delivery. It is also likely that our study was not sufficiently powered to detect differences in behavioral factors like eating disorder and we were not able to account for the effect of other rare pregnancy complications 2543 might have caused PTB.
Previously, behavioral factors including eating disorders have been shown to be poorly recorded in large population cohorts [ 21 ] and, thus, may not reflect the true occurrence of these disorders in the cohort. Finally, our large-scale study cannot identify specific mechanisms underlying the association between maternal underweight and recurrent preterm birth, but, importantly, may offer background for more specific, mechanistic studies.
In conclusion, we found that recurrent PTB among leg women was associated with younger age, IPI less than six months and negative or no weight change between pregnancies. Our results support counseling underweight women who experience PTB about the potential benefits of an adequate inter-pregnancy-interval. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
The authors report no disclosures.
National Center for Biotechnology InformationU. J Matern Fetal Neonatal Med. Author manuscript; available in PMC Sep 4. Find articles by Jonathan A Mayo. Find articles by Matthew B Wallenstein. Find articles by Jeffrey B Leyy. Find articles by Suzan L Carmichael. Find articles by David K Stevenson. Find articles by Deirdre J Lyell.
Find articles by Gary M Shaw. Author information Copyright and License information Disclaimer. See other articles in PMC that cite the published article. Introduction Each year more thanpreterm infants are born in the United States at less than 37 weeks of gestation [ 1 ]. Methods This is a retrospective cohort study performed using the California birth cohorts from —10, which link California birth records with Office of Statewide Health and Planning maternal and infant hospital discharge data.
Results Of the women with underweight BMI in their first pregnancy, 86 women 1. Open in a separate window. Weighed more at beginning of pregnancy 2 than pregnancy 1 Reference Weighed same or less at beginning of pregnancy 2 than pregnancy 1 1. Discussion We analyzed almost 5, consecutive live births of women with pre-pregnancy underweight i.
White paper on preterm birth: The global and regional toll. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Higher rates of behavioural and emotional problems at preschool age in children born moderately preterm. Maternal underweight and the risk of preterm birth and low birth weight: Changes in prepregnancy body mass index between pregnancies and risk of preterm phenotypes.
Maternal prepregnancy body mass index and risk of spontaneous preterm birth. Association of extremes of prepregnancy BMI with the clinical presentations of preterm birth.