Maternal Body Mass Index (BMI) is a critical determinant of a pregnant woman’s nutritional status and plays a significant role in maternal and fetal health outcomes. Both underweight and overweight conditions during pregnancy pose considerable risks, making maternal weight management a crucial aspect of prenatal care. Adequate weight gain during pregnancy is essential for fetal development and maternal well-being, while deviations from optimal weight gain can lead to adverse obstetric outcomes [1-3].

Globally, maternal underweight and obesity are emerging as dual public health concerns. While underweight pregnancies are often associated with Intrauterine Growth Restriction (IUGR), preterm labor, and Low Birth Weight (LBW), excessive maternal weight gain and obesity increase the risks of gestational hypertension, Gestational Diabetes Mellitus (GDM), preeclampsia, and delivery complications. Additionally, obesity has been linked to poor labor outcomes, including increased rates of cesarean sections, neonatal distress, and prolonged hospitalization [4-6].

In developing countries like India, maternal malnutrition manifests in both extremes, with a significant proportion of women being underweight due to nutritional deficiencies, while urban areas witness a rising obesity epidemic. This socioeconomic disparity results in contrasting pregnancy risks, necessitating tailored antenatal care and interventions. The World Health Organization (WHO) and the Institute of Medicine (IOM) have provided BMI-based guidelines for gestational weight gain to optimize pregnancy outcomes, but adherence remains a challenge, particularly in resource-limited settings [5-7].

Moreover, maternal BMI has long-term implications beyond pregnancy. Underweight mothers are at an increased risk of delivering Small-for-Gestational-Age (SGA) infants, who are more susceptible to developmental delays and chronic diseases later in life. Conversely, maternal obesity is associated with congenital malformations, childhood obesity, and metabolic disorders in offspring, emphasizing the intergenerational impact of maternal weight [6-9].

Given these concerns, it is imperative to evaluate the association between maternal BMI, gestational weight gain, and obstetric outcomes. This study aims to assess the influence of maternal BMI on antepartum, intrapartum, and postpartum complications while analyzing its effect on perinatal outcomes. The findings of this research will contribute to a better understanding of maternal weight-related risks, facilitating improved antenatal counseling, risk stratification, and intervention strategies to enhance maternal and neonatal health.

Study Design and Setting

This prospective observational study was conducted in the Department of Obstetrics and Gynecology at Dr. Rajendra Prasad Government Medical College, Tanda, District Kangra, Himachal Pradesh, India. Ethical approval was obtained from the Protocol Review Committee and Institutional Ethics Committee before initiating the study.

Study Duration

The study was conducted over a period of one year, from January 1, 2019, to December 31, 2019.

Study Population

Pregnant women attending the antenatal Outpatient Department (OPD) during their first trimester and meeting the inclusion criteria were recruited for the study. Informed written consent was obtained from all participants before enrollment, ensuring voluntary participation.

Inclusion and Exclusion Criteria

All pregnant women with a singleton pregnancy and their first antenatal visit before 12 weeks of gestation were eligible for the study. Women with multiple pregnancies, pre-existing medical disorders, surgical conditions, or unknown weight in the first trimester were excluded to maintain uniformity in the study population and avoid confounding variables.

Clinical Assessment and Data Collection

Each participant underwent a detailed medical history evaluation, including present and past medical complaints, menstrual and obstetric history, and relevant family history. A comprehensive general and obstetric examination was performed, and standard antenatal investigations were conducted to rule out any underlying medical disorders.

Anthropometric measurements were systematically recorded. Weight was measured in kilograms using a calibrated weighing scale, ensuring women were without shoes and in light clothing. Height was recorded in meters using a stadiometer, with participants standing barefoot, maintaining a correct posture with their heels, buttocks, shoulders, and occiput touching the wall. The Frankfurt plane was used for accurate height measurement. The Body Mass Index (BMI) was calculated using the standard formula:

BMI=Weight (kg)/ Height (m)²

Based on WHO recommendations for Asian populations, participants were categorized as follows:

• Underweight: BMI < 18.5
• Normal weight: BMI 18.5 - 22.9
• Overweight: BMI > 23.0

Gestational Age Assessment

Gestational Age (GA) was primarily determined based on the first day of the Last normal Menstrual Period (LMP). An ultrasound scan was performed at the first visit (between 10 and 13 weeks of gestation) to confirm dating. If the difference between LMP and ultrasound-derived gestational age was more than 10 days, the ultrasound scan dating was used to establish gestational age.

Outcome Measures

The study examined both maternal and neonatal outcomes associated with BMI and gestational weight gain.

Obstetric outcomes included the incidence of miscarriage, Impaired Glucose Tolerance (IGT), Gestational Diabetes Mellitus (GDM), Gestational Hypertension (GHTN), preeclampsia/eclampsia, anemia, preterm delivery, mode of delivery, and postpartum complications.

Neonatal outcomes assessed were birth weight, APGAR score at 1 and 5 minutes, NICU admission, and stillbirth. Neonates were classified based on birth weight as:

• Small for Gestational Age (SGA): Birth weight < 10th percentile

• Normal weight: 10th–90th percentile

• Large for Gestational Age (LGA): Birth weight > 90th percentile

• Low Birth Weight (LBW): < 2500g

• Macrosomia: > 4000g

Definitions of Key Obstetric Conditions

Gestational hypertension was defined according to ACOG guidelines as blood pressure ≥140/90 mmHg on two separate occasions, measured at least 6 hours apart after 20 weeks of gestation in a previously normotensive woman. Preeclampsia was diagnosed based on NICE guidelines (2015) as new-onset hypertension with proteinuria or end-organ dysfunction after 20 weeks of gestation.

GDM was defined according to WHO 1999 criteria, where an Oral Glucose Tolerance Test (OGTT) with a 75g glucose load was conducted, and a 2-hour plasma glucose level ≥140 mg/dL was considered diagnostic. Anemia was defined per WHO standards, with Hemoglobin (Hb) <11g/dL in the first and second trimesters and <10.5g/dL in the third trimester, with serum ferritin levels <12 µg/L.

Preterm delivery was defined as delivery before 37 completed weeks of gestation, while term delivery was classified as between 37 to 42 weeks of gestation. Miscarriage was defined per ACOG guidelines as a nonviable intrauterine pregnancy before 12 weeks, with an empty gestational sac or absence of fetal heart activity.

APGAR Score Assessment

Newborn well-being was assessed using the APGAR score at 1 and 5 minutes, post-birth, evaluating appearance, Pulse, Grimace, Activity, and Respiration (APGAR parameters). APGAR scores were classified as:

• Favorable outcome: APGAR score ≥7 at 5 minutes

• Unfavorable outcome: APGAR score <7 at 5 minutes

Labor and Delivery Management

Spontaneous labor was awaited in all cases unless maternal or fetal indications necessitated induction or cesarean section. Labor was induced following standard obstetric protocols when clinically indicated. Mode of delivery was recorded as spontaneous vaginal delivery, instrumental delivery, or cesarean section.

Neonatal outcomes were documented, including birth weight, NICU admissions, and APGAR scores. Babies requiring NICU admission were assessed for respiratory distress, hypoglycemia, and other complications.

Statistical Analysis

All data were recorded in Microsoft Excel 2019 and analyzed using SPSS v21.0 (IBM, USA). Categorical variables were presented as frequencies and percentages and analyzed using the Chi-square test, while continuous variables were expressed as mean ± Standard Deviation (SD). The Spearman correlation coefficient was calculated to assess associations between BMI, gestational weight gain, and obstetric outcomes. A p-value<0.05 was considered statistically significant.
 

Ethical Considerations

The study was conducted in accordance with ethical guidelines, ensuring confidentiality and anonymity of all participants. Ethical approval was obtained from the Institutional Ethics Committee before recruitment. Informed written consent was obtained from all participants, explaining the study objectives, procedures, benefits, and risks. Participants were free to withdraw at any stage without consequences.

Financial Disclosure and Conflict of Interest

This study did not receive any external funding, and no financial burden was placed on the participants. The authors declare no conflict of interest related to this research.

This study aimed to analyze the impact of maternal BMI and gestational weight gain on obstetric and neonatal outcomes. A total of 200 pregnant women were categorized into underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5-22.9 kg/m²), and overweight (BMI >23 kg/m²) groups. 

The distribution of cases based on maternal BMI, age, and parity reveals that overweight women were generally older compared to underweight and normal-weight women, with a mean age of 27.2 years compared to 25.1 years in underweight and 26.2 years in normal BMI women (p<0.0001). The majority of underweight women (57.1%) and normal-weight women (59.7%) were in the 24-28 years age group, whereas overweight women were more frequently in the 28-33 years category (40.0%). Regarding parity distribution, 60.0% of normal-weight women were primigravida, followed by 53.3% of overweight and 50.0% of underweight women. Multigravida cases were slightly higher in overweight women (46.6%) compared to normal-weight (40.0%) and underweight (50.0%) women, but this difference was not statistically significant (P = 0.060) (Table 1).

Table 1: Maternal BMI, Age, and Parity Distribution

The analysis of weight gain during pregnancy in relation to maternal BMI showed that all underweight and normal-weight women had less than the recommended weight gain, whereas 93.83% of overweight women achieved adequate weight gain (P<0.0001). The mean weight gain for underweight women was 6.7 kg, for normal BMI women it was 7.2 kg, and for overweight women, it was 8.0 kg, all significantly  lower  than   the    IOM   recommendations.

Additionally, 100% of underweight and normal-weight  women  had  inadequate  weight  gain,  whereas only 2.2% of overweight women failed to reach the recommended weight gain. Notably, no cases of excessive weight gain were recorded across all groups, highlighting that inadequate weight gain was more prevalent than excessive weight gain among the study population (Table 2).

Table 2: Maternal Weight Gain Based on IOM Recommendations

The obstetric outcomes varied significantly among the BMI groups, with preterm delivery being most common in underweight women (42.8%), followed by normal weight (13.4%) and overweight women (8.8%), with a statistically significant difference (P<0.0001). Term deliveries were highest in overweight women (90.0%), compared to 86.5% in normal weight and 57.1% in underweight women. Gestational hypertension was significantly higher in overweight women (27.7%) compared to normal weight (12.1%) and underweight women (10.7%) (P = 0.024). Preeclampsia also showed an increasing trend in overweight women (8.8%) compared to normal weight (1.2%) and underweight (7.14%), though not statistically significant (P = 0.09). IUGR was more common in underweight women (17.9%), reinforcing the impact of maternal undernutrition on fetal growth, whereas anemia was also significantly higher in underweight women (10.7%) compared to normal (4.9%) and overweight women (0%) (P = 0.016). Placenta previa, PROM, and HELLP syndrome were rare but were noted only in overweight and normal BMI women. These findings suggest that underweight women are at higher risk of preterm birth, IUGR, and anemia, whereas overweight women are more susceptible to gestational hypertension, preeclampsia, and metabolic complications (Table 3).

Table 3: Obstetric Outcomes and Antepartum Complications

The mode of delivery was significantly influenced by maternal BMI. Preterm Vaginal Delivery (PTVD) was highest in underweight women (39.3%), compared to 8.5% in normal weight and 7.8% in overweight women, making underweight status a major risk factor for preterm births (P<0.001). Instrumental deliveries were more common in overweight women (19.1%), compared to 9.8% in normal BMI women and none in underweight women (P = 0.023), suggesting that overweight women face higher labor complications requiring assisted delivery. The rate of cesarean section (LSCS) was highest in overweight women (24.7%), followed by normal BMI (23.1%) and lowest in underweight women (7.1%), though not statistically significant (P = 0.120). Labor induction was significantly more common in overweight women (40.0%) compared to 12.2% in normal weight and 25.0% in underweight women (P < 0.0001), indicating that overweight women have a higher risk of labor dysfunction requiring induction. Additionally, low birth weight (<2.5 kg) was significantly more frequent in underweight women (67.8%), compared to normal weight (18.3%) and overweight (19.2%) women, whereas macrosomia (>4 kg) was observed exclusively in overweight women (5.6%) (P = 0.049). These results reinforce the association between underweight status and low birth weight, while overweight women are at increased risk of macrosomia and operative deliveries (Table 4).

Table 4: Mode of Delivery, Neonatal Birth Weight, and Labor Induction

The APGAR score analysis showed that favorable neonatal outcomes were highest in normal weight women (95.12%), followed by overweight (92.13%) and underweight women (85.71%) (P = 0.262). Unfavorable APGAR scores (<7 at 5 min) were highest in underweight neonates (14.28%), compared to 4.87% in normal weight and 7.86% in overweight neonates. Similarly, NICU admissions were significantly higher in neonates born to underweight women (14.28%) compared to normal weight (4.87%) and overweight women (7.86%), though the difference was not statistically significant (P = 0.262). Maternal morbidity was minimal, with only one case (1.1%) observed in overweight women, while no cases were recorded in underweight or normal weight women. These findings suggest that underweight mothers are more likely to give birth to neonates with poor APGAR scores and a higher NICU admission rate, whereas overweight mothers experience slightly increased maternal morbidity (Table 5).

Table 5: APGAR Scores, NICU Admission, and Maternal Morbidity

Maternal nutritional status plays a crucial role in determining maternal and fetal well-being. Body Mass Index (BMI) is a key measure that reflects both adiposity and energy balance, influenced by ethnicity, genetics, and nutritional status. While research in developed countries primarily focuses on the adverse effects of high maternal BMI, in developing nations like India, maternal underweight remains a significant concern, contributing to poor birth outcomes (WHO, 2009 [10]. According to WHO criteria, the prevalence of obesity among pregnant women (BMI >30 kg/m²) ranges from 1.8% to 25.3% [10]. Currently, 15-20% of women start pregnancy as obese, while 20-40% exceed the recommended Gestational Weight Gain (GWG), further increasing complications (WHO, 2009; Landmann et al. [11].

In our study, 28 (14%) women were underweight, 82 (41%) were normal weight, and 90 (45%) were overweight. Similar findings were reported by Simko et al¹², where among 7122 pregnant women, 10.4% were underweight, 76.0% had normal BMI, and 8.5% were overweight. Likewise, Pongcharoen et al. [13] observed 17.2% underweight, 64.1% normal weight, and 14.3% overweight women. Other studies such as Choudhary et al. [14] and Tharihalli et al. [15] also confirm that normal BMI women constitute the majority of cases, while underweight and overweight women contribute to significant obstetric complications.

Our study showed that primigravida cases were highest among normal BMI women (60%), followed by overweight (53.3%) and underweight (50%) women. However, a higher proportion of overweight women were multigravida (46.6%), suggesting that obese women tend to have higher parity compared to underweight and normal-weight women. Similar findings were reported by Martin et al. [16], who found no significant association between parity and maternal BMI, while Calik et al. [17] reported that overweight women had higher parity compared to underweight women, who were mostly nulliparous (P = 0.05).

In our study, the mean weight gain was 6.7 kg in underweight women, 7.2 kg in normal BMI women, and 8.0 kg in overweight women, significantly lower than the IOM-recommended values [18]. Bhuyar and Dharmale [19] reported mean weight gains of 9.7 kg, 8.9 kg, and 9.4 kg, respectively, indicating variability across populations. Other studies, such as Calik et al. [17] and Papazian et al. [8], found higher mean GWG (14.8 kg in underweight, 12.6 kg in normal, and 12.2 kg in overweight women). These findings suggest that inadequate weight gain is prevalent among underweight and normal-weight women in our study, highlighting the need for early nutritional interventions.

Maternal age influences BMI, weight gain, and pregnancy outcomes. In our study, the mean age for underweight women was 25.1 years, 26.2 years for normal BMI, and 27.2 years for overweight women, with no statistically significant difference (P = 0.09). Ronnenberg et al. [20] also reported that maternal age was not significantly associated with BMI. However, Chasan-Taber et al. [21] found that women above 30 years had a higher BMI and greater weight gain exceeding IOM recommendations, which contradicts our findings.

Our study revealed that preterm delivery was significantly higher in underweight women (42.8%) compared to normal weight (13.4%) and overweight women (8.8%) (P<0.0001). Similar findings were reported by Bhuyar and Dharmale [19] where preterm delivery was 12.7% in underweight women, 12.2% in normal BMI, and 7.7% in overweight women. Bhuvaneshwari et al. [22] also observed higher preterm rates (28.5%) in underweight women compared to 2.3% in normal BMI and 6% in overweight women (P = 0.017). These findings underscore the importance of BMI in predicting gestational duration and fetal outcomes.

In our study, gestational hypertension was highest in overweight women (27.7%) compared to normal BMI (12.1%) and underweight (10.7%) (P = 0.024). Tharihalli et al. [15] and Choudhary et al. [14] also observed a significant association between higher BMI and gestational hypertension. Similarly, IUGR was significantly higher in underweight women (17.9%) (P = 0.001), consistent with findings by Verma and Shrimali [23]. Anemia was more prevalent in underweight women (10.7%), supporting studies by Kumar and Chellama [24] which linked underweight BMI to nutritional deficiencies and anemia risks.

Labor induction was significantly more common in overweight women (40%) compared to underweight (25%) and normal BMI (12.2%) (P<0.0001). Similar findings were observed by Yazdani et al. [25] and Jensen et al. [26], which found that obese women were at significantly higher risk of labor induction compared to normal and underweight women (P<0.003).

Neonatal birth weight was significantly associated with maternal BMI, with low birth weight (<2.5 kg) being most common in underweight women (67.8%) (P<0.0001). Conversely, macrosomia (>4 kg) was observed exclusively in overweight women (5.6%) (P = 0.049). Rafia Gul et al. [27] and Moussa et al. [28] found similar trends, confirming that underweight women have a higher risk of low-birth-weight infants, while overweight women are prone to macrosomia.

In our study, APGAR scores were slightly lower in underweight neonates, but the difference was not statistically significant (P = 0.26). Similar findings were reported by Papazian et al. [8] and Sekhavat et al. [29], indicating that while maternal overweight may increase neonatal distress, BMI alone does not significantly impact APGAR scores.

Our study found that NICU admissions were highest in underweight neonates (14.2%) compared to normal weight (4.87%) and overweight (7.86%) (P = 0.262). Calik et al. [17] reported similar findings, where NICU admission rates were 2.1%, 2.5%, and 5.6% in underweight, normal, and overweight neonates, respectively.

This study reinforces that maternal BMI significantly influences obstetric and neonatal outcomes. Underweight women face higher risks of preterm labor, IUGR, low birth weight, and anemia, whereas overweight women are more susceptible to gestational hypertension, preeclampsia, macrosomia, and cesarean deliveries. The findings highlight the importance of preconception BMI optimization and tailored prenatal care to improve pregnancy outcomes.

This study highlights the significant impact of maternal BMI on pregnancy outcomes, with underweight women at higher risk of anemia, IUGR, preterm delivery, and low birth weight, while overweight women face increased rates of PIH, GDM, PROM, IUGR, labor induction, and cesarean sections. As BMI naturally increases during pregnancy, monitoring Gestational Weight Gain (GWG) is essential to minimize complications. Preconception counseling, proper antenatal management, and clear guidelines on weight gain are crucial in reducing maternal and perinatal morbidity. By integrating nutritional counseling and weight management into routine antenatal care, we can optimize maternal health and ensure the best outcomes for both mother and baby.

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