Evidence Report/Technology Assessment 

Number 168 

Outcomes of Maternal Weight Gain 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0016 

Prepared by: 

RTI International–University of North Carolina Evidence-based Practice Center 

Research Triangle Park, North Carolina 

Investigators 

Meera Viswanathan, Ph.D. 

Anna Maria Siega-Riz, Ph.D., R.D. 

Merry-K Moos, R.N, F.N.P., M.P.H. 

Andrea Deierlein, M.S., M.P.H. 

Sunni Mumford, S.M. 

Julie Knaack, M.P.H., R.D., L.D.N. 

Patricia Thieda, M.S. 

Linda J. Lux, M.P.A. 

Kathleen N. Lohr, Ph.D. 

AHRQ Publication No. 08-E009 

May 2008
ii

This report is based on research conducted by the RTI–UNC Evidence-based Practice Center 

(EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD 

(Contract No. 290-02-0016). The findings and conclusions in this document are those of the 

author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. 

No statement in this report should be construed as an official position of AHRQ or of the U.S. 

Department of Health and Human Services. 

The information in this report is intended to help clinicians, employers, policymakers, and others 

make informed decisions about the provision of health care services. This report is intended as a 

reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for the development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 
iii

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

Viswanathan M, Siega-Riz AM, Moos M-K, Deierlein A, Mumford S, Knaack J, Thieda P, Lux 

LJ, Lohr KN. Outcomes of Maternal Weight Gain, Evidence Report/Technology Assessment No. 

168. (Prepared by RTI International–University of North Carolina Evidence-based Practice 

Center under Contract No. 290-02-0016.) AHRQ Publication No. 08-E009. Rockville, MD: 

Agency for Healthcare Research and Quality. May 2008. 

No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock options, expert testimony, grants or patents received or 

pending, or royalties) that conflict with material presented in this report. 
iv

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and new 

health care technologies. The EPCs systematically review the relevant scientific literature on 

topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to 

developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. 

Director 

Agency for Healthcare Research and Quality 

Jean Slutsky, P.A., M.S.P.H. 

Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality 

 Beth Collins Sharp, Ph.D., R.N. 

 Director, EPC Program 

 Agency for Healthcare Research and Quality 

Carmen Kelly, Pharm.D., R.Ph. 

EPC Program Task Order Officer 

Agency for Healthcare Research and Quality 
v

Structured Abstract 

Objectives. The RTI International–University of North Carolina at Chapel Hill Evidence-based 

Practice Center (RTI-UNC EPC) systematically reviewed evidence on outcomes of gestational 

weight gain and their confounders and effect modifiers, outcomes of weight gain within or 

outside the 1990 Institute of Medicine (IOM) guidelines, risks and benefits of weight gain 

recommendations, and anthropometric measures of weight gain. 

Data Sources. We searched MEDLINE®, Cochrane Collaboration resources, Cumulative Index 

to Nursing & Allied Health Literature, and Embase. 

Review Methods. We included studies published in English from 1990 through October 2007. 

We excluded studies with low sample size (based on study design: case series < 100 subjects and 

cohorts < 40 subjects). 

Results. Overall, strong evidence supported an association between gestational weight gains and 

the following outcomes: preterm birth, total birthweight, low birthweight (<2,500 g), 

macrosomia, large-for-gestational-age (LGA) infants, and small-for-gestational-age (SGA) 

infants; moderate evidence supported an association for cesarean delivery and intermediate-term 

weight retention (3 months to 3 years postpartum). The studies reviewed provided strong 

evidence for the independent association of pregravid weight status and outcomes, moderate 

evidence for age and parity, and weak evidence for race. 

Regarding outcomes of weight gain within or outside 1990 IOM guidelines, moderate to 

strong evidence suggests an association between weight gain below IOM recommendations and 

preterm birth, low birthweight, SGA birthweights, and failure to initiate breastfeeding, and 

strong evidence for the association between weight gain above IOM recommendations and high 

birthweight, macrosomia, and LGA birthweights. Moderate evidence supports an association 

between weight gain above IOM guidelines and cesarean delivery and postpartum weight 

retention in the short, intermediate, and long term. 

Included research is inadequate for objective assessments of the range of harms and benefits 

of providing all women, irrespective of age, race or ethnicity, or pregravid body mass index 

(BMI), with the same recommendation for weight gain in pregnancy. 

Conclusions. Gestational weight gain is associated with some infant and maternal outcomes. 

One weight gain recommendation for all women is not supported by the evidence identified in 

this review. To understand fully the impact of gestational weight gain on short- and long-term 

outcomes for women and their offspring will require that researchers use consistent definitions of 

weight gain during pregnancy, better address confounders in their analyses, improve study 

designs and statistical models, and conduct studies with longer followup. 
vii 

Contents 

Executive Summary.........................................................................................................................1

Evidence Report.............................................................................................................................9 

Chapter 1. Introduction ..................................................................................................................11

Background............................................................................................................................... 11

Weight Gain Recommendations in the United States............................................................11

Gestational Weight Gain Patterns in the United States .........................................................12

Key Questions and Analytic Framework.................................................................................. 12

Key Questions........................................................................................................................12

Analytic Framework for Outcomes of Maternal Weight Gain ................................................. 13

Production of This Evidence Report......................................................................................... 15

Organization of This Evidence Report ..................................................................................15

Technical Expert Panel (TEP) ...............................................................................................15

Uses of This Report .................................................................................................................. 16

Chapter 2. Methods........................................................................................................................17

Literature Review Methods....................................................................................................... 17

Inclusion and Exclusion Criteria............................................................................................17

Literature Search and Retrieval Process ................................................................................18

Literature Synthesis .................................................................................................................. 20

Development of Evidence Tables and Data Abstraction Process..........................................20

Quality Rating of Individual Studies .....................................................................................20

Strength of Available Evidence .............................................................................................23

External Peer Review................................................................................................................ 23

Chapter 3. Results ..........................................................................................................................25

KQ 1: Outcomes of Gestational Weight Gain .......................................................................... 25

Maternal Antepartum Outcomes............................................................................................25

Maternal Intrapartum Outcomes............................................................................................36

Birth Outcomes ......................................................................................................................58

Infant Outcomes...................................................................................................................105

Child Outcomes ...................................................................................................................112

Short- and Long-term Maternal Outcomes..........................................................................115

KQ 3: Outcomes of Weight Gain Within or Outside IOM Recommendations ...................... 123

Maternal Antepartum Outcomes..........................................................................................123

Maternal Intrapartum Outcomes..........................................................................................128

Birth Outcomes ....................................................................................................................131

Infant Outcomes...................................................................................................................160

Child Outcomes ...................................................................................................................161

Short- and Long-term Maternal Outcomes..........................................................................162

KQ 5: Anthropometrics of Weight Measurement................................................................... 173
viii 

Chapter 4. Discussion ..................................................................................................................175

Outcomes of Maternal Weight Gain (KQ 1 and KQ 3) .......................................................... 176

Maternal Antepartum Outcomes..........................................................................................177

Maternal Intrapartum Outcomes..........................................................................................178

Birth Outcomes ....................................................................................................................182

Infant Outcomes...................................................................................................................187

Child Outcomes ...................................................................................................................190

Short- and Long-term Maternal Outcomes..........................................................................191

KQ 2: Confounders and Effect Modifiers of Outcomes of Maternal Weight Gain................ 194

Age.......................................................................................................................................194

Race and Ethnicity ...............................................................................................................196

Pregravid Weight or Body Mass Index................................................................................198

Parity....................................................................................................................................201

KQ 4: Risks and Benefits of Gestational Weight Gain Recommendations............................ 202

Findings Relative to Benefits and Harms of Different Recommendations Based on Race.203

Findings Relative to Benefits and Harms of Different Recommendations Based on Age ..205

Findings Relative to Benefits and Harms of Different Recommendations from the IOM ..206

Conclusions Regarding the Harms and Benefits of Uniform Recommendations for All 

Women.................................................................................................................................207

KQ 5: Anthropometrics of Weight Measurement During Pregnancy .................................... 207

Limitations .............................................................................................................................. 209

Limitations of the Evidence Base ........................................................................................209

Limitations of the Review....................................................................................................209

Future Research Directions..................................................................................................... 210

References....................................................................................................................................213

Figures 

Figure 1. Outcomes of gestational weight gain for singleton pregnancies: conceptual 

framework....................................................................................................................14

Figure 2. Disposition of articles for gestational weight gain ......................................................19 

Tables 

Table 1. Inclusion/exclusion criteria for gestational weight gain ..............................................17

Table 2. MEDLINE® search strategy and unduplicated results for February 2007..................18

Table 3. Scoring algorithm for subdomains and overall quality rating for individual studies ..21

Table 4. Gestational weight gain and abnormal glucose control ...............................................27

Table 5. Gestational weight gain and pregnancy-induced hypertension ...................................31

Table 6. Gestational weight gain and induction of labor ...........................................................38

Table 7. Gestational weight gain and length of labor ................................................................40

Table 8. Gestational weight gain and mode of delivery ............................................................42

Table 9. Gestational weight gain and shoulder dystocia............................................................55

Table 10. Gestational weight gain and preterm birth...................................................................58

Table 11. Total gestational weight gain (categorical) and infant birthweight .............................67
ix 

Table 12. Total gestational weight gain (continuous) and infant birthweight .............................69

Table 13. Continuous gestational weight gain by trimester and infant birthweight ....................74

Table 14. Net and proportional gestational weight gain and infant birthweight..........................75

Table 15. Total gestational weight gain and low birthweight (LBW) .........................................76

Table 16. Other gestational weight gain measures and LBW......................................................80

Table 17. Gestational weight gain and macrosomia > 4,500 g....................................................82

Table 18. Gestational weight gain and macrosomia > 4,000g.....................................................84

Table 19. Gestational weight gain and LGA................................................................................87

Table 20. Gestational weight gain and LGA by BMI status........................................................91

Table 21. Gestational weight gain and SGA................................................................................93

Table 22. Gestational weight gain and SGA by BMI status ........................................................98

Table 23. Gestational weight gain and Apgar scores.................................................................104

Table 24. Gestational weight gain and perinatal mortality ........................................................106

Table 25. Gestational Weight Gain and Other Infant Growth Measures...................................110

Table 26. Gestational weight gain and childhood weight status................................................113

Table 27. Gestational weight gain and postpartum weight retention.........................................115

Table 28. Weight change relative to IOM thresholds and gestational diabetes mellitus...........124

Table 29. Weight change relative to IOM thresholds and preeclampsia ...................................126

Table 30. Weight change relative to IOM thresholds and cesarean delivery ............................128

Table 31. Weight change relative to IOM thresholds and preterm birth (< 37 weeks) .............131

Table 32. Weight change relative to IOM thresholds and birthweight......................................135

Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g)............141

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant 

 weight....................................................................................................................147

Table 35. Weight change relative to IOM thresholds and small-for-gestational-age ................155

Table 36. Weight change relative to IOM thresholds and Apgar scores ...................................159

Table 37. Weight change relative to IOM thresholds and breastfeeding...................................163

Table 38. Weight change relative to IOM thresholds and short-term weight retention.............166

Table 39. Weight change relative to IOM thresholds and weight retention during the first 

 year postpartum.....................................................................................................168

Table 40. Weight change relative to IOM thresholds and long-term weight retention .............171

Table 41. Strength of evidence: maternal antepartum outcomes of gestational weight gain.....177

Table 42. Strength of evidence: maternal intrapartum outcomes of gestational weight gain....179

Table 43. Strength of evidence: birth outcomes of gestational weight gain..............................183

Table 44. Strength of evidence: infant outcomes of gestational weight gain ............................188

Table 45. Strength of evidence: child outcomes of gestational weight gain..............................190

Table 46. Strength of evidence: maternal outcomes of gestational weight gain........................191

Table 47. Age, gestational weight gain, and outcomes..............................................................196

Table 48. Race and ethnicity, gestational weight gain, and outcomes.......................................197

Table 49. Pregravid body mass index, gestational weight gain, and outcomes.........................199

Table 50. Parity, gestational weight gain and outcomes...........................................................201

Table 51. Adiposity measurements and use in pregnancy.........................................................208
x 

Appendixes 

Appendix A: Exact Search Strings 

Appendix B: Sample data abstraction forms 

Appendix C: Evidence tables 

Appendix D: List of Excluded Studies 

Appendix E: Peer Reviewers 

Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
1 

Executive Summary 

Introduction 

This systematic review of outcomes of gestational weight gain, often referred to as maternal 

weight gain, is motivated by several trends in perinatal health that are of great public health 

concern. Women are increasingly gaining weight during pregnancy beyond the thresholds set 

forth by the Institute of Medicine (IOM); increases are pronounced among overweight and obese 

women; obesity levels among women of childbearing ages are rising dramatically; and 

pregnancy complications associated with excess gestational weight gain such as large-forgestational-age babies and cesarean delivery have increased in prevalence. These trends point to 

the need for assessment of the guidelines to address optimal weight gain for all women during 

pregnancy. 

The RTI International–University of North Carolina at Chapel Hill Evidence-based Practice 

Center (RTI-UNC EPC) conducted a systematic review of the literature to review the evidence 

on influence of gestational weight gain on various outcomes. We systematically assessed the 

evidence for five key questions (KQs): 

KQ 1. What is the evidence that either total weight gain or rate of weight gain during pregnancy 

is associated with (1) birth outcomes, (2) infant health outcomes, and (3) maternal health 

outcomes? Does any evidence suggest that either total weight gain or rate of weight gain 

is a causal factor in infant or maternal health outcomes? 

KQ 2. What are the confounders and effect modifiers for the association between gestational 

weight gain (overall and patterns) and birth outcomes? Based on the findings in KQ 1, do 

these confounders and effect modifiers themselves contribute to antepartum or 

postpartum complications or to longer-term maternal and fetal complications, including 

development of adult obesity? 

KQ 3. What is the evidence that weight gains above or below thresholds defined in the 1990 

IOM body mass index (BMI) guidelines or weight loss in pregnancy contribute to 

antepartum or postpartum complications or longer-term maternal and fetal 

complications? How do these relationships vary by sociodemographic characteristics 

(i.e., race and age)? 

KQ 4. What are the harms or benefits of offering the same weight gain recommendations to all 

pregnant women, irrespective of age and body weight considerations (e.g., pregravid 

weight, actual body weight at a particular time point, or optimal body weight)? 

KQ 5. What are the anthropometric tools for determining adiposity and their appropriateness for 

the pregnancy state? What are the risks and benefits of measuring adiposity for 

(1) clinical management of weight gain during pregnancy and (2) evaluation of the 

relationship between weight gain and outcomes of pregnancy? 

Methods 

We searched MEDLINE®, Cochrane Collaboration resources, Cumulative Index to Nursing 

& Allied Health Literature, and Embase. We dually reviewed each study against a priori 
2 

inclusion/exclusion criteria. For included articles, a primary reviewer abstracted data directly 

into evidence tables; a second senior reviewer confirmed accuracy. We included 150 studies in 

English, published from 1990 through October 2007. We excluded studies with low sample size 

(cases series < 100 and cohorts < 40) or failure to control for pregravid weight. We rated 

individual studies for quality, based on the assessment of nine domains of quality: background, 

sample selection, specification of exposure, specification of outcome, soundness of information, 

followup, analysis comparability, analysis of outcome, and interpretation. In assessing the 

strength of evidence for each outcome as strong, moderate, weak, or absent, we incorporated the 

quality of the studies in addition to consistency and volume of the evidence. 

Results 

KQ 1 and KQ 3: Outcomes of Gestational Weight Gain 

KQ 1 asks about outcomes of gestational weight gain for infants and for mothers; more than 

30 outcomes were specified as being of interest. KQ 1 also asks what evidence exists to 

demonstrate causality. Nearly all the studies in this review are observational studies; therefore, 

generally this evidence base cannot demonstrate a causal link between gestational weight gain 

and outcomes. The analysis of outcomes related to weight gains in relationship to IOM 

recommendations (KQ 3) classified outcomes into six categories as with KQ 1: maternal 

antepartum outcomes, maternal intrapartum outcomes, birth outcomes (neonatal outcomes at the 

time of birth), infant outcomes (<1 year), child outcomes (≥ 1 year), and short- and long-term 

maternal outcomes. To enable synthesis and help identify gaps in the evidence, we combined 

discussion of the findings for KQ1 and KQ3 and focus below on outcomes for which the 

evidence is either strong or moderate. 

Maternal intrapartum outcomes. We examined the literature for 11 maternal and 

intrapartum outcomes. For one of these—cesarean delivery—the evidence was of moderate 

strength. For all other outcomes, evidence was weak. 

Cesarean delivery. Of the 21 studies identified in KQ 1 (14 fair, 7 poor), all but 4 showed 

some degree of association between higher weight gain and cesarean delivery; the evidence was 

moderate. The association appeared to be stronger among overweight and obese women. 

Nine studies (8 fair, 1 poor) examined the association between gestational weight gain 

classified by the IOM guidelines and cesarean delivery (KQ 3). These studies suggest moderate 

evidence for increased risk of cesarean for weight gain above IOM recommendations for 

underweight and normal weight women, and weak inconsistent evidence for obese or morbidly 

obese women. 

Overall, the majority of studies suggested an association between weight gain and cesarean 

delivery. Our findings of a higher risk of cesarean for overweight and obese women, coupled 

with the lack of significance of weight gain above IOM recommendations among obese or 

morbidly obese women, suggests that underlying health risks (such as increased risks of 

abnormal glucose tolerance) associated with high pregravid weight are likely confounders in the 

relationship between gestational weight gain and cesarean delivery. 

Birth outcomes. The knowledge base about the association between gestational weight gain 

and birth outcomes is, on the whole, stronger than the knowledge base for any other set of 

outcomes with moderate to strong evidence for low gestational weight gain and preterm birth, 

low birthweight, and small-for-gestational-age (SGA) birthweights, and strong evidence for the 
3 

association between high weight gain and high birthweight, macrosomia, and large-forgestational-age (LGA). 

Preterm birth. Strong evidence from 12 studies (2 good, 7 fair, 3 poor) suggests that both low 

and high weight gains result in an increased risk of premature birth (KQ 1). Despite little 

consistency in terms of adjustment for covariates, definition of preterm birth (with or without 

premature rupture of membranes), and the methods used to define and categorize gestational 

weight gain, eight of nine studies reported at least one significant association between low 

gestational weight gain and preterm birth; four of five studies focused on high gestational weight 

gain (as defined in each study) reported at least one significant association between gestational 

weight gain and preterm birth. 

Among the studies that examined preterm birth using categories of gestational weight gain 

(i.e., low, adequate, and high), seven of eight reported a significant increased risk of preterm 

birth with low gestational weight gain and four of five reported a significant increased risk with 

high gestational weight gain. In general, low rates of weight gain were ≤ 0.37 kg per week and 

high rates of weight gain were > 0.52 kg per week throughout gestation. 

 Four studies, all of fair quality, reported on the association between rate of gestational 

weight gain according to the IOM guidelines and preterm birth (KQ 3). Despite inconsistencies 

in the definitions and timing of rate of weight gain calculations, the four studies are consistent in 

showing increased risks of preterm birth for underweight and normal-weight women who have a 

low rate of gain. 

Overall, the majority of studies found a consistent effect of low gestational weight gain on 

preterm birth, and a less consistent effect of high gestational weight gain on preterm birth. The 

association for low gestational weight gain holds whether total weight gain or rate of weight gain 

is used as the relevant exposure of interest. 

Birthweight. Evidence from 25 studies (4 good, 12 fair, 9 poor) provided strong evidence that 

gestational weight gain is associated with infant birthweight (KQ 1). This relationship held true 

for various measures of gestational weight gain. Evidence from seven studies reported that 

birthweight increased between 16.7 and 22.6 g for every 1 kg increase in weight gain. Two 

studies reported values by BMI status, suggesting that the effect of increased gestational weight 

gain on infant birthweight was more pronounced at lower BMI levels. Three studies examined 

the effect of weight gain by trimester on infant birthweight. All three studies were consistent in 

demonstrating the least effect of gestational weight gain in the third trimester. Two of three 

studies that used similar definitions of trimester found that a 1-kg increase in gestational weight 

gain during the first trimester was associated with 18-31 g increases in birthweight, whereas 

during the second trimester, such gains were associated with increases of 26-32.8 g, and 

increases of 7-17 g during the third trimester. 

10 articles (1 good, 8 fair, and 1 poor) from nine databases provide strong evidence that 

weight gain below IOM recommendations is associated with lower birthweights (KQ 3). Seven 

studies found an association between high weight gains and higher birthweights, particularly for 

underweight and normal-weight women. 

Overall, we found strong evidence in support of an association between gestational weight 

gain and birthweight. Low gestational weight gain is associated with lower birthweights across 

all pregravid weight status groups whereas high gestational weight gain resulting in higher 

birthweight appears to be limited to underweight and normal-weight women. 

Low birthweight (LBW). Thirteen studies (one good, nine fair, three poor) provided strong 

evidence that low weight gain increases the risks of LBW (KQ 1). 
4 

Ten studies published in twelve articles (two good, seven fair, and three poor) provided 

strong, consistent evidence of an association between weight gain below the IOM guidelines and 

LBW for only underweight and normal-weight women (KQ 3).

Overall we found strong evidence for an association between low gestational weight gain and 

low birthweight. The evidence appears to be stronger among women of underweight and normalweight pregravid status than among overweight and obese women.

Macrosomia. Eleven of 12 studies (1 good, 9 fair, 1 poor) provided strong evidence that high 

gestational weight gain is associated with greater risks of macrosomia (KQ 1). The relationship 

between high gestational weight gain and macrosomia held despite variations in definition of 

macrosomia (> 4,500 g or > 4,000 g). Generally, the highest weight gains were associated with 

the highest risks of macrosomia. 

Seven studies examined the association between gestational weight gain categorized 

according to the IOM and macrosomia defined as either > 4,000 g or > 4,500 g (2 good, 1 poor, 

the remaining fair) (KQ 3). These studies suggest moderate evidence for the association between 

weight gains above the IOM recommendations and macrosomia for overweight and obese 

women. 

Overall, moderate to strong evidence suggests that high weight gains are associated with 

macrosomia. 

Large-for-gestational-age (LGA). Fourteen studies (one good, eight fair, five poor) with 

varying definitions of weight gain and LGA were consistent in demonstrating an association 

between high gestational weight gain and LGA; we graded the evidence for this association as 

strong (KQ 1). This association held whether LGA was defined as birthweight greater than the 

90th percentile, or as birthweight more than two standard deviations above the mean. Whether 

BMI modifies this relationship is unclear. 

Eight articles examined gestational weight gain according to the IOM and LGA (2 good, 5 

fair, 1 poor) (KQ 3). These studies provided strong evidence that high weight gains are 

associated with an increased risk of LGA infants. Weight gains below IOM guidelines, by 

contrast, were protective against LGA in only four studies (moderate evidence). 

Overall, we found strong evidence of the association between high gestational weight gain 

and LGA despite differences in the definition of LGA. 

Small-for-gestational-age (SGA). Twenty publications (1 good, 12 fair, and 7 poor) provided 

strong evidence that women in the lowest weight gain categories had higher percentages of SGA 

infants and were at increased risk of delivering an SGA infant, despite differences across studies 

in the definition of weight gain and SGA (KQ 1). In general, the risk of SGA among women with 

low weight gain decreased as BMI increased. 

Ten articles (three good, one poor, and the rest fair) examined the association between 

gestational weight gain categorized according to the IOM guidelines on SGA (KQ 3). The 

evidence is strong that SGA is associated with weight gains below the IOM guidelines. Weight 

gains above the IOM were associated with a lower risk of SGA in four out of six studies 

suggesting a moderate degree of evidence. 

Overall, we found strong evidence for an association between low gestational weight gain 

and the risk of having an SGA infant. 

Maternal short- and long-term outcomes. The literature covered eight maternal outcomes. 

Of these, the evidence is moderate for only intermediate-term (3 months to 3 years postpartum) 

postpartum weight retention (PPWR) for both KQ 1 and KQ 3. In addition, we found moderate 

strength of evidence to support the association between gestational weight gain and breastfeeding 
5 

initiation, short-term PPWR (≤ 11 weeks postpartum) and long-term PPWR (> 3 years 

postpartum). The evidence for all other outcomes (breastfeeding duration, fat accrual, 

interpregnancy weight retention, and premenpausal breast cancer) was weak (except for 

lactation, for which no literature was available at all). 

Breastfeeding initiation. Three studies, published in four articles, all fair, examined the 

association of weight gain in relation to the IOM guidelines and breastfeeding (KQ 3) and 

provide moderate evidence of an association between weight gains below the IOM guidelines 

and lower likelihood of breastfeeding initiation. 

Short-term PPWR (≤ 11 weeks). Four studies (all fair) provide moderate evidence that weight 

gains exceeding IOM guidelines (KQ 3) were associated with PPWR measured at or before 11 

weeks postpartum. 

Intermediate PPWR (3 months to 3 years). Five studies (one good, three fair, and one poor) 

provide moderate evidence for an association between gestational weight gain and intermediate 

PPWR (KQ 1). 

Six studies (five fair and one poor) examined the association between weight gain 

categorized according to the IOM and intermediate-term PPWR (KQ3). They consistently 

indicated that women who gained above the IOM recommendations retained more weight than 

those who gained within the guidelines (moderate strength of evidence). They provided only 

weak evidence about any association when weight gains were below IOM guidelines. 

Overall, we found moderate evidence for an association between high gestational weight 

gains and intermediate PPWR. 

Long-term postpartum weight retention (>3 years). Three fair studies provided moderate 

evidence of an association between high gestational weight gain, defined according to the IOM 

(KQ 3), and weight retention later in life, but the magnitude of weight retained was small. 

Other outcomes. We found no moderate or strong evidence for maternal antepartum 

outcomes (hyperemesis, abnormal glucose metabolism, hypertensive disorders, gallstones, and 

maternal discomforts of pregnancy), infant outcomes (neonatal hypoglycemia, neonatal distress, 

hyperbilirubinemia, neonatal hospitalization, other infant morbidity, infant BMI, and other infant 

growth characteristics), or childhood health outcomes (childhood obesity and childhood 

hospitalization). 

KQ 2: Confounders and Effect Modifiers of Gestational Weight Gain 

KQ 2 asks about the confounders and effect modifiers relevant for examining any 

associations between gestational weight gain (overall and patterns) and birth outcomes; it also 

asks about the extent to which these confounders and effect modifiers themselves contribute to 

outcomes. As reported in our results and discussion for KQ 1, the types of confounders and 

effect modifiers vary considerably by the type of outcome being considered. Little consistency 

exists within the body of evidence for each outcome on which confounders are to be included, 

and even less consistency exists on their definition. 

Given the large variations in the overall body of evidence on the confounders and effect 

modifiers, our discussion of KQ 2 is limited to outcomes with moderate or strong evidence of 

association with gestational weight gain. These are preterm birth, mode of delivery, birthweight, 

low birthweight, macrosomia, LGA infants, SGA infants, and intermediate-term PPWR. 

Because age, race and ethnicity, and pregravid weight status are key considerations in the 

1990 IOM weight gain recommendations, we further limit our discussion of KQ 2 to the 

consideration of these key variables. We additionally consider parity. The included studies 
6 

defined these four variables in highly variable fashion. Finally, because KQ 2 asks about the 

independent association between confounders and effect modifiers, we considered results only 

from multivariate analyses for confounders and effect modifiers that included gestational weight 

gain as a predictor of the outcome. These studies together provide strong evidence of the 

independent association of pregravid weight status on outcomes, moderate evidence on age and 

parity, and weak evidence, largely because of insufficient data, on the effect of race. 

KQ 4: Benefits and Harms of Gestational Weight Gain 

Recommendations 

Research is inadequate to permit objective assessment of harms and benefits of providing all 

women, irrespective of age, race or ethnicity, or pregravid BMI, with the same recommendation 

for weight gain in pregnancy. The majority of the studies present evidence suggesting that one 

recommendation for all women would be disadvantageous, but the findings are not consistent 

and do not fully explore harms. Most studies limited their analyses to short-term outcomes 

related to the pregnancy, the intrapartum, and the neonatal period. A full examination of harms 

would require long-term, rigorously designed studies to determine unexpected consequences of 

specific recommendations; we found no such investigations. 

KQ 5: Anthropometrics of Gestational Weight Gain 

Our review required that included studies estimated adiposity using body weight or BMI. Ten 

studies collected data using other anthropometric measurements and incorporated them into 

varying body composition equations or models to estimate body fat. 

These measurements included bioelectrical impedance analysis, dual energy X-ray 

absorptiometry, body circumferences, total body water, total body potassium, magnetic 

resonance imaging, and underwater weighing. Collectively, these studies do not provide 

sufficient evidence to judge whether alternate methods of weight measurement are more 

informative or predictive of infant and maternal outcomes than standard body weight (including 

BMI) and height measurements. 

Discussion 

We found strong evidence to support the association between gestational weight gains and 

preterm birth, birthweight, macrosomia, LGA, SGA, low birthweight, and preterm birth. 

Moderate evidence supported the association between gestational weight gain and breastfeeding 

initiation, mode of delivery, and PPWR. 

As reported in our results and discussion for KQ 1, the types of confounders and effect 

modifiers vary considerably by the type of outcome being considered. Little consistency exists 

within the body of evidence for each outcome on which confounders are to be included, and even 

less consistency exists on their definition. The studies reviewed provide strong evidence for the 

independent association of pregravid weight status and outcomes, moderate evidence for age and 

parity, and weak evidence for race and ethnicity. 

Existing research is inadequate to permit objective assessments of the range of harms and 

benefits of providing all women, irrespective of age, race or ethnicity, or pregravid BMI, with 

the same recommendation for weight gain in pregnancy. 
7 

Clear clinical recommendations based on this systematic review will be challenging to 

formulate because of major shortcomings in the body of research investigating gestational weight 

gain and pregnancy outcomes. The research is almost all observational; it lacks uniformity of 

definitions, methodologies, and analyses. To understand fully the impact of gestational weight 

gain on the short- and long-term outcomes for women and their offspring will require that 

researchers use consistent definitions of gestational weight gain and the outcomes, describe the 

criteria used to assess confounding in their analysis, use statistical methods that allow for the 

evaluation of more than one outcome at a time, make improvements in study design to allow 

better collection of weight and weight gain data, and follow women and infants for longer 

periods. 
Evidence Report 
11 

Chapter 1. Introduction 

This systematic review of outcomes of maternal weight gain, often referred to as gestational 

weight gain,*

 is motivated by several trends in perinatal health that are of great public health 

concern. First, since 1990, women have increasingly gained weight during pregnancy beyond the 

thresholds set forth by the Institute of Medicine (IOM);1

 these increases are pronounced among 

overweight and obese women.2-4 Second, overweight and obesity levels among women of 

childbearing ages are rising dramatically5-8 as are the levels among preschool children.9

 Third, 

pregnancy complications associated with excess weight such as gestational diabetes and largefor-gestational-age babies10 and cesarean delivery11 have increased in prevalence. These trends, 

coupled with the limitations of the current guidelines, point to the need for assessment of the 

guidelines to address optimal weight gain for all women during pregnancy. 

Background 

Weight Gain Recommendations in the United States 

Ideal weight gain during pregnancy has long been debated. Gestational (formerly maternal) 

weight gain includes the products of conception, which include the fetus and placenta, and 

increases in maternal fat stores, plasma volume, and uterine and breast tissue. Because pregnancy 

is the only common clinical situation when the provider has at least two patients, the mother and 

the fetus(es), balancing the amount of weight gain needed to optimize the size of the baby 

without jeopardizing the health of the mother both in the short and long term is essential. The 

balance has proven challenging. 

In the 1930s, the recommendation to all pregnant women, irrespective of pregravid weight 

status, was 6.8 kg (~ 15 pounds). This recommendation to restrict weight gains to decrease the 

risk of pregnancy complications continued until 1970; it stemmed largely from the observation 

that increased maternal weight gains were positively related to higher birthweights.12 In 1970, 

however, the IOM determined that restriction of weight gain was likely to be harmful with 

respect to birthweight; subsequently, weight gain recommendations were eased from less than 20 

pounds throughout pregnancy to a range of 20 to 27 pounds.13

Over the next two decades, accumulating research suggested that one guideline was unlikely 

to benefit all women and their fetuses. This recognition led an IOM committee to issue 

guidelines that offered standardized guidance to providers and to the general public based on a 

woman’s pregravid weight status.1

 The recommendations were weight gains of (a) 28 to 40 

pounds for women with low body mass index (BMI), defined as < 19.8; (b) 25 to 35 pounds for 

women with normal BMI (19.8-26); and (c) 15 to 25 pounds for women with high BMI (> 26.0-

29.0). Further, the recommendations included a weight gain of at least 15 pounds for obese 

women (BMI > 29), weight gain in the upper end of the recommended range for adolescents and 

black women, and weight gain in the lower end of the recommended range for short women 

(< 157 centimeters [cm] or 62 inches). 

These recommendations were the first to account for pregravid weight status and to 

encourage obese women to gain weight during pregnancy in recognition of the needs of the fetus. 

 

*

 Hereafter in this report, we refer to gestational weight gain for consistency across the text and to clarify that we focus on weight 

gained during gestation as the exposure of interest.
12 

They also addressed patterns of weight gain by providing guidance on the ideal amount to be 

gained in the first trimester and rates of weight gain in the second and third trimesters. These 

recommendations tended to focus on the prevention of low birthweight deliveries rather than the 

impact on maternal obesity and related health outcomes. 

In 1996, an expert panel assembled by the Maternal and Child Health Bureau of the US 

Health Resources and Services Administration reexamined these recommendations. At the time, 

the panel decided that revisions were unnecessary. They found, however, that the evidence to 

date suggested that the recommendations for higher weight gains by black women and 

adolescents and lower weight gains for women of short stature were not well supported; they 

concluded that these subpopulations should be advised to stay within the IOM’s recommended 

weight range specific for their pregravid BMI.14 

Gestational Weight Gain Patterns in the United States 

Since the 1990 IOM recommendations appeared, several studies have documented the 

proportion of women meeting the guidelines. In a 1998 study of more than 120,000 women, only 

34 percent gained weight within the recommended ranges.15 Specifically, the proportion of 

women gaining more than the recommended range increased over the time span from 42 percent 

to 44 percent. The figures for women gaining less than the recommended amount remained 

relatively stable over time (23 percent to 22 percent). Other studies reporting on various 

subpopulations since the 1990 report found that only 30 percent to 40 percent of women gained 

weight within the recommended ranges.4,16-25 Although the IOM recommendations have been in 

existence for almost 2 decades, between 35 percent and 60 percent of pregnant women reported 

receiving no advice from their providers about appropriate pregnancy weight gain.26,27 Pregnant 

women who reported being advised about the appropriate amount of weight to gain during 

pregnancy were more likely to gain within the recommended range than women who did not 

report receiving such advice.28,29 This association is based on a handful of studies; moreover, 

most had been conducted before or soon after the revised IOM guidelines were made 

public.26,28,29

Persistent nonadherence to weight gain guidelines and the wide variability in the amount of 

weight gained during pregnancy has served as the impetus for much research on predictors of the 

adequacy of gestational weight gain. This body of work suggests that a multifactorial model may 

be at play.27,30,31 The bulk of research in this area has emphasized the importance of pregravid 

weight status, parity, height, race or ethnicity, age, age at menarche, physical activity, and 

psychosocial stress.27,30-33 Although such investigations are important, even more basic is an 

understanding of the short- and long-term benefits and risks of gestational weight gain for the 

mother, the fetus, and the child. This systematic evidence review was undertaken to fully explore 

what has been learned about the impact of gestational weight gain since the IOM 

recommendations were released in 1990. 

Key Questions and Analytic Framework 

Key Questions 

Increases in the body weight of women of childbearing ages combined with a rising trend in 

weight gain during pregnancy outside the IOM recommendations have raised concerns about the 
13 

1990 IOM recommendations. Of particular interest is assembling and evaluating evidence 

linking gestational weight gain and birth, infant, and maternal health outcomes. 

To accomplish this, the Agency for Healthcare Research and Quality (AHRQ) commissioned 

the RTI International–University of North Carolina Evidence-based Practice Center (RTI-UNC 

EPC) to complete this systematic review. The partner for this work was the American Dietetic 

Association. The EPC received and revised key questions (KQs) after discussions with internal 

technical staff, AHRQ staff, an American Dietetic Association representative, and our Technical 

Expert Panel (TEP, see below). The final KQs are as follows: 

KQ 1. What is the evidence that either total weight gain or rate of weight gain during pregnancy 

is associated with (1) birth outcomes, (2) infant health outcomes, and (3) maternal health 

outcomes? Does any evidence suggest that either total weight gain or rate of weight gain 

is a causal factor in infant or maternal health outcomes? 

KQ 2. What are the confounders and effect modifiers for the association between maternal 

weight gain (overall and patterns) and birth outcomes? Based on the findings in KQ 1, do 

these confounders and effect modifiers themselves contribute to antepartum or 

postpartum complications or to longer-term maternal and fetal complications, including 

development of adult obesity? 

KQ 3. What is the evidence that weight gains above or below thresholds defined in the 1990 

Institute of Medicine BMI Guidelines or weight loss in pregnancy contribute to 

antepartum or postpartum complications or longer-term maternal and fetal 

complications? How do these relationships vary by sociodemographic characteristics 

(i.e., race and age)? 

KQ 4. What are the harms or benefits of offering the same weight gain recommendations to all 

pregnant women, irrespective of age and body weight considerations (e.g., pregravid 

weight, actual body weight at a particular time point, or optimal body weight)? 

KQ 5. What are the anthropometric tools for determining adiposity and their appropriateness for 

the pregnancy state? What are the risks and benefits of measuring adiposity for 

(1) clinical management of weight gain during pregnancy and (2) evaluation of the 

relationship between weight gain and outcomes of pregnancy? 

Analytic Framework for Outcomes of Maternal Weight Gain 

The analytic framework adopted from the 1990 IOM report shown in Figure 1 (i.e., the 

conceptual model developed to guide this systematic review) summarizes the critical topics 

addressed by this report and their links to the key questions. KQs 1 and 3 focus on identifying 

and evaluating evidence. KQ 5 attempts to explore the practicality and clinical utility of methods 

to assess maternal fat accrual (often thought to be the causative agent for many of the adverse 

outcomes).34 KQs 2 and 4 are essentially derivative of information obtained for KQs 1 and 3. 
14 

Figure 1. Outcomes of gestational weight gain for singleton pregnancies: conceptual framework 

Confounders and Effect Modifiers

- Age

- Race

- Pregravid BMI

- Health status: preexisting conditions and pregnancy complications 

(i.e., GDM, anemia)

- Genetic

- History of restrained eating

- Sociodemographic

- Psychosocial (stress, anxiety, depression, attitudes, body image)

- Smoking

- Substance abuse

- Prenatal care

- Pregnancy intendedness

- Weight gain recommendations

Energy intake 

(composition of 

the diet) Energy balance

Energy 

expenditure

(physical 

activity)

Maternal weight gain 

- fetus

- placenta

- amniotic fluid

- increased maternal fat 

stores, uterine weight, breast 

tissue, and plasma volume

- Maternal antenatal and 

intrapartum outcomes

- Birth outcomes

- Infant health outcomes

- Child health outcomes

- Maternal postpartum outcomes 

(short- and long-term)

KQ2

KQ1 KQ3

Anthropometric tools to 

measure adiposity during 

pregnancy

KQ5

(KQ4)

Modified from the Institute of Medicine (IOM) 1990 report Nutrition during Pregnancy. Part I, Weight Gain1

BMI, body mass index; GDM, gestational diabetes mellitus; KQ, key question. 

The KQs are noted on the relevant arrows connecting the main boxes or within boxes, as 

appropriate. Our conceptual framework recognizes that energy balance, which is a result of 
15 

dietary intake and energy expenditure, directly influences maternal weight gain. We note, 

however, that this systematic review focuses on outcomes of weight gain during pregnancy, not 

on the predictors of that weight gain. As a result, we do not directly address strategies to reduce 

or modify maternal weight gain. Furthermore, this field of research consists predominantly of 

observational studies, which by their nature do not prove causality and, at most, provide 

evidence on a temporal sequence of events. The majority of the studies included in this 

systematic review are observational in nature. For that reason, we do not infer causality between 

gestational weight gain and health outcomes and instead focus on the strength of association. 

Production of This Evidence Report 

Organization of This Evidence Report 

Chapter 2 describes our methods, including our search strategies and inclusion/exclusion 

criteria; we also document our approach to grading the quality of articles and rating the strength 

of evidence. We conducted extensive systematic literature searches and appraisal of evidence for 

included articles only for KQs 1, 3, and 5. In Chapter 3, we report the results of literature 

searches and synthesis of retained articles for KQs 1, 2, 3, and 5. Chapter 4 presents our 

conclusions and discusses KQ 4 in detail; it also offers our recommendations for future research. 

References and included studies follow Chapter 4. Appendixes include a detailed description 

of our search strings (Appendix A),†

 data collection forms (Appendix B), detailed evidence 

tables (Appendix C), excluded studies (Appendix D), and acknowledgments (Appendix E). 

Technical Expert Panel (TEP) 

We identified six technical experts in nutrition, nursing, obstetrics, and family medicine to 

provide assistance throughout the project (Appendix E); one was a member of the American 

Dietetic Association. The TEP contributed to AHRQ’s broader goals of (1) creating and 

maintaining science partnerships as well as public-private partnerships and (2) meeting the needs 

of an array of potential customers and users of its products. Thus, the TEP was both an additional 

resource and a sounding board during the project. 

To ensure robust, scientifically relevant work, we called on the TEP to provide reactions to 

work in progress and advice on substantive issues or possibly overlooked areas of research. 

Specifically, TEP members participated in conference calls and discussions through e-mail to: 

• refine the analytic framework and key questions at the beginning of the project; 

• discuss the preliminary assessment of the literature, including inclusion/exclusion 

criteria; and 

• provide input on the information and categories included in evidence tables. 

Because of their extensive knowledge of the literature, including numerous articles authored 

by TEP members themselves, and their active involvement in professional societies and as 

practitioners in the field, we also asked TEP members to participate in the external peer review 

of the draft report. 

 

†

 Appendixes and evidence tables cited in this report are provided electronically at

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
16 

Uses of This Report 

This evidence report addresses the key questions outlined above using methods described in 

Chapter 2 to conduct a systematic review of published literature. We anticipate that the report 

will be of value to all women’s health care providers, including the American Dietetic 

Association, the American College of Obstetricians and Gynecologists, the American College of 

Nurse Midwives, the Association of Women’s Health, Obstetric and Neonatal Nurses, the 

American Society of Reproductive Medicine, and other groups concerned with health outcomes 

during childbearing and beyond, such as the American Academy of Family Physicians and the 

American Academy of Nurse Practitioners, and the American Academy of Pediatrics. This report 

can bring practitioners up to date about the current state of evidence, and it provides an 

assessment of the quality of studies that aim to determine the outcomes of maternal weight gain. 

The report will be of use to various parts of the US Department of Health and Human 

Services, including the National Institutes of Health, Centers for Disease Control and Prevention, 

Centers for Medicare & Medicaid Services, and Health Resources and Services Administration, 

and the US Department of Agriculture; all these agencies have offices or bureaus devoted to 

women’s health issues. We also anticipate that it will be of use to private sector organizations 

concerned with women’s health, such as Our Bodies Ourselves, the National Women’s Health 

Network, and the National Black Women’s Health Imperative. In addition, this review will be of 

use to the Institute of Medicine in proposed revisions to the national guidelines. 

Researchers can obtain a concise analysis of the current state of knowledge in this field. They 

will be poised to pursue further investigations that are needed to understand the causal links 

between maternal weight gain and health outcomes for mother and baby, clarify risk factors, 

develop prevention strategies, and optimize guidelines offered to women.
17 

Chapter 2. Methods 

In this chapter, we document the procedures that the RTI International–University of North 

Carolina Evidence-based Practice Center (RTI–UNC EPC) used to develop this comprehensive 

evidence report on outcomes of maternal weight gain. The team was led by a senior health 

services researcher (Meera Viswanathan, PhD, Study Director), a senior epidemiologist (Anna 

Maria Siega-Riz, PhD, RD, Scientific Director), and a senior nurse-researcher (Merry-K Moos, 

FNP, MPH, co-Scientific Director). 

We first describe our strategy for identifying articles relevant to our five key questions 

(KQs), our inclusion and exclusion criteria, and the process we used to abstract relevant 

information from the eligible articles and generate our evidence tables. We also discuss our 

criteria for grading the quality of individual articles and for rating the strength of the evidence as 

a whole. Finally, we explain the peer-review process. 

Literature Review Methods 

Inclusion and Exclusion Criteria 

Our inclusion and exclusion criteria are documented in Table 1. As noted in Chapter 1, this 

systematic review focuses on outcomes of maternal weight gain with respect to the 1990 

recommendations from the Institute of Medicine (IOM).1 Largely for that reason, we limited our 

searches to articles published in 1990 and thereafter. We also restricted our searches to 

developed countries so that we could have data generally relevant for maternal weight gain and 

health outcomes in the United States. 

Table 1. Inclusion/exclusion criteria for gestational weight gain 

Category Criteria 

Study population Women of any age with singleton pregnancies 

Study settings and 

geography 

KQ 1, KQ 2, KQ 4: Developed nations: United States, Canada, Western Europe, Japan, Australia, 

New Zealand 

KQ 3: United States 

KQ 5: All countries 

Time period January 1990 through October 2007 

Publication 

languages 

English only 

Admissible 

evidence (study 

design and other 

criteria) 

Admissible designs

• Controlled trials (n ≥ 40), nonrandomized controlled trials (n ≥ 40), systematic reviews, metaanalyses, prospective trials with historical controls (n ≥ 40), prospective or retrospective 

observational cohort studies (n ≥ 40), and medium to large case series (n ≥ 100) 

Other criteria 

• Original research studies must provide sufficient detail regarding methods and results to 

enable use and adjustment of the data and results. 

• Relevant outcomes must be abstractable from data presented in the papers. 

• Sample sizes must be appropriate for the study question addressed in the paper; single case 

reports or small case series (fewer than 100 subjects) are excluded. 

• For KQ 1, 2, 3, and 4: prepregnancy body mass index (BMI) or weight must be accounted for 

in the relationship between maternal weight gain and outcome. 

• Studies limited to women with preexisting health conditions only are excluded. 
18 

We excluded studies that (1) were published in languages other than English (given the 

available time and resources); (2) did not report information pertinent to the key clinical 

questions; (3) had fewer than 40 subjects for randomized controlled trials (RCTs) or 

nonrandomized cohorts with comparisons or fewer than 100 subjects for case series; and (4) 

were not original studies. 

For KQ 1, 2, 3, and 4, we required that the reported association between maternal weight 

gain and health outcomes accounted for prepregnancy body mass index (BMI) or weight, either 

through stratified univariate analysis or multivariate analysis. 

Literature Search and Retrieval Process 

Databases. We used multifaceted search strategies to include current and valid research on 

the KQs, which we applied to four standard electronic databases—MEDLINE®, Cochrane 

Collaboration resources, Cumulative Index to Nursing and Allied Health Literature (CINAHL), 

and Embase. We also hand-searched the reference lists of relevant articles to make sure that we 

did not miss any relevant studies. We consulted with our Technical Expert Panel (TEP) about 

any studies or trials that are currently under way or that may not yet be published. 

Search terms. Based on the inclusion/exclusion criteria above, we generated a list of 

Medical Subject Heading (MeSH) search terms (Table 2 and Appendix A).*

 Our TEP also 

reviewed these terms to ensure that we were not missing any critical areas, and this list 

represents our collective decisions as to the MeSH terms used for all searches. 

Table 2. MEDLINE® search strategy and unduplicated results for February 2007 

Search Terms Search Results 

#2 Search "Weight Gain"[MeSH] 13,220 

#5 Search pregnancy [MeSH] 577,647 

#6 Search #2 AND #5 1,808 

#7 Search gestational weight gain 1,725 

#8 Search #6 OR #7 3,023 

#9 Search #6 OR #7 Limits: English, Humans 1,696 

#15 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Outcome and Process 

Assessment (Health Care)"[MeSH] OR "Pregnancy Outcome"[MeSH]) OR 

"Reproductive History"[MeSH] OR "birth outcomes" OR "infant health outcomes" OR 

"maternal health outcomes” Limits: English, Humans 

332,914 

#16 Search #9 AND #15 Limits: English, Humans 474 

#19 Search ("Counseling"[MeSH] OR "Directive Counseling"[MeSH]) 23,091 

#20 Search #9 AND #19 12 

#25 Search "Body Weights and Measures"[MeSH] 279,399 

#26 Search #9 AND #25 1,044 

#29 Search "Anthropometry"[MeSH] 71,849 

#30 Search #26 AND #29 359 

 

*

 Appendixes and evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
19 

Our searches in MEDLINE® produced 715 unduplicated records. Searches in other 

databases yielded in 190 new records from CINAHL and 4 from Embase. Similar searches in 

Cochrane did not produce any new citations. Following an update on October 3, 2007, and 

additional searches for KQ 5, we ultimately identified 1,082 unduplicated records. In addition, 

peer reviews suggested 3 new citations that met our inclusion criteria. 

Figure 2 presents the yield and results from our searches, which we conducted from February 

through October 3, 2007. Beginning with a yield of 1,085 articles, we retained 150 articles that 

we determined were relevant to address our KQs and met our inclusion/exclusion criteria (Table 

1). We reviewed titles and abstracts of the articles against the basic inclusion criteria above; we 

retained relevant articles, all published after our search cutoff date of January 1990, and used 

them as appropriate in the discussion in Chapter 4. 

Figure 2. Disposition of articles for gestational weight gain 
20 

Article selection process. Once we had identified articles through the electronic database 

searches, review articles, and reference lists, we examined abstracts of articles to determine 

whether studies met our criteria. Each abstract was independently, dually reviewed for inclusion 

or exclusion, using an Abstract Review Form (Appendix B).* If one reviewer concluded that the 

article should be included in the review, we retained it. 

Of this entire group of 1,085 articles, 479 required full review. For the full article review, one 

team member read each article and decided whether it met our inclusion criteria, using a Full 

Text Inclusion/Exclusion Form (Appendix B). Reasons for article exclusion are listed in 

Appendix D. 

Literature Synthesis 

Development of Evidence Tables and Data Abstraction Process 

The senior staff who conducted this systematic review jointly developed the evidence tables. 

We designed the tables to provide sufficient information to enable readers to understand the 

studies and to determine their quality; we gave particular emphasis to essential information 

related to our KQs. We based the format of our evidence tables on successful designs that we 

have used for prior systematic reviews. 

We trained abstractors by having them abstract several articles into evidence tables and then 

reconvening as a group to discuss the utility of the table design. The abstractors repeated this 

process through several iterations until they decided that the tables included the appropriate 

categories for gathering the information contained in the articles. 

Three junior epidemiologists (Sunni Mumford, SM; Andrea Deierlein, MS, MPH; and Julie 

K. Knaack, MPH, RD, LDN) shared the task of initially entering information into the evidence 

tables. Senior staff reviewed the articles and edited all initial table entries for accuracy, 

completeness, and consistency. Abstractors reconciled all disagreements concerning the 

information reported in the evidence tables. The full research team met regularly during the 

article abstraction period and discussed global issues related to the data abstraction process. 

The final evidence tables are presented in their entirety in Appendix C.Studies are presented 

in the evidence tables alphabetically by the last name of the first author. A list of abbreviations 

and acronyms used in the tables appears at the beginning of that appendix. 

Quality Rating of Individual Studies 

The evidence for this systematic review is based almost entirely on observational studies. 

This fact presents a challenge for rating individual studies. Quality rating forms for RCTs have 

been validated and in use for several years; a similarly well-validated form for observational 

studies does not exist. 

Thus, as a parallel effort, we developed a form to rate observational studies.35 This form, 

which can be used to rate the quality of a variety of observational studies, was based on a review 

of more than 90 AHRQ systematic reviews that included observational studies; we supplemented 

this review with other key articles identifying domains and scales.36,37 We structured the resultant 

 

*

 Appendixes and evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
21 

form largely on the basis of the domains and subdomains suggested by Deeks and colleagues;36

we then adapted it for use in this systematic review (Appendix B).*

 

The form currently includes review of nine key domains: background, sample selection, 

specification of exposure, specification of outcome, soundness of information, followup, analysis 

comparability, analysis of outcome, and interpretation. Each of these domains was further 

evaluated on aspects of quality of the study design or reporting that would influence the reader’s 

perception of internal validity of the journal article (Table 3). We note that variations in reporting 

could result in different scores for studies drawing from the same sample. 

Table 3. Scoring algorithm for subdomains and overall quality rating for individual studies 

Definition and Scoring Algorithm Rating 

Score algorithm for background (presented in the context of previous research, hypothesis clearly

described)

• Both elements present Good 

• Neither present Poor 

• One of two elements present Fair 

Score algorithm for sample definition (explicitly stated inclusion/exclusion criteria, uniform 

application of criteria, clear description of recruitment strategy, clear description of characteristics of 

the participants, power analysis or some other basis noted for determining the adequacy of study 

sample size)

• > Three elements present Good 

• < Two elements present Poor 

• Two or three elements present Fair 

Score algorithm for exposure (clear definition of weight gain, check for plausibility of pregravid 

weight, clear explanation of actions taken on outliers)

• All three elements present or clearly defined Good 

• Poor definition of weight gain Poor 

• Moderate or very clear definition of weight gain, one or more other elements 

present 

Fair 

Score algorithm for outcome (clear description of primary outcomes)

• All essential details described Good 

• Few or no essential details described Poor 

• Some essential details described Fair 

Score algorithm for soundness of information (quality of source of information on exposure, 

confounders, and outcome)

• Good for all three Good 

• Poor on source of information for exposure Poor 

• Any other score Fair 

 

*

 Appendixes and evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
22 

Table 3. Scoring algorithm for subdomains and overall quality rating for individual studies (continued) 

Definition and Scoring Algorithm Rating 

Score algorithm for followup (adequate reporting of reasons for loss to followup)

• Retrospective or prospective study with clear reporting on loss to followup Good 

• Prospective study, no reporting on followup Poor 

• Retrospective study with no reporting on loss to followup Fair 

Score algorithm for analysis comparability (comparability of cohorts through design, reasonable 

choice of control variables, clear description of confounders, adequate adjustment for confounders)

• All elements present Good 

• Inadequate adjustment for confounding Poor 

• Any other score Fair 

Score algorithm for analysis outcome (withdrawals, lost to followup, and missing data adequately 

accounted for in the analysis, and appropriate statistical methods used) 

• Both elements clearly present Good 

• Neither element present Poor 

• Any other score Fair 

Score algorithm for interpretation (results interpreted appropriately based on study design and 

statistics, clinically useful, appropriate presentation, presented in the context of prior research, and 

conclusion supported by results) 

• All elements clearly present Good 

• Conclusions not supported by results Poor 

• Any other score Fair 

Score algorithm for overall quality

• 5 or more good ratings and no poor ratings on subdomains Good 

• 3 or more poor ratings on subdomains Poor 

• <5 good ratings and <3 poor ratings on subdomains; 5 or more good ratings and 

any poor ratings 

Fair 

As described in Table 3, we combined these elements to generate overall scores. We set the 

default as fair and then focused on the threshold required for good and poor studies; the 

algorithm is also described in Table 3. Fair studies, therefore, include studies that were 

predominantly fair (four to nine fair ratings on domains) and could not be rated either good 

(fewer than five good ratings for subdomains) or poor (fewer than three poor ratings for 

subdomains). Studies with more than five good ratings for domains that also received one or two 

poor ratings were downgraded to fair quality. 

Key methodological concerns in this literature relate to the source of information on weight 

gain and the timing of measurement of weight gain. Studies that relied solely on self-reported 

pregravid and final pregnancy weights suffer from well-documented issues of recall bias. In 

addition, women tend to misreport their weight, and this bias varies by weight status38 and 

ethnicity.39 The timing of weight measurement (for pregravid weight and final weight) can vary 

depending on the design of the study; when unreported, the total weight gain during pregnancy 

cannot be assumed to be collected at similar time points for all women within the study, resulting 

in further bias. Our rating algorithm, therefore, paid special attention to the source of data on 

gestational weight gain and the timing of measurement. Studies that relied solely on recalled 
23 

prepregnancy and total pregnancy weight were rated poor on that domain, but if they defined 

their gestational weight variable clearly (providing details on the timing of measurement for 

pregravid and final weight measurements) and either checked for the biological plausibility of 

pregravid weight status or explained how outliers were dealt with, they could receive an overall 

fair rating (assuming that they received fewer than three poor ratings overall). 

Strength of Available Evidence 

Our scheme follows the criteria applied in an earlier RTI-UNC EPC systematic review of 

systems for rating the strength of a body of evidence.40 That system has three domains: quality of 

the research (as evaluated by the quality rating algorithm described above), quantity of studies 

(including number of studies and adequacy of the sample size), and consistency of findings. Two 

senior staff members assigned grades by consensus. 

We graded the body of literature for each KQ and present those ratings as part of the 

discussion in Chapter 4. The possible grades in our scheme are as follows: 

I. Strong: The evidence is from studies of sound design (good quality); results are both 

clinically important and consistent with minor exceptions at most; results are free from 

serious doubts about generalizability, bias, or flaws in research design. Studies with 

negative results have sufficiently large samples to have adequate statistical power. 

II. Moderate: The evidence is from studies of sound design (good quality), but some 

uncertainty remains because of inconsistencies or concern about generalizability, bias, 

research design flaws, or adequate sample size. Alternatively, the evidence is consistent 

but derives from studies of weaker design (fair quality). 

III. Weak: The evidence is from a limited number of studies of weaker design (fair or poor 

quality). Studies with strong design (good quality) either have not been done or are 

inconclusive. 

IV. No evidence: No published literature. 

External Peer Review 

As is customary for all evidence reports and systematic reviews done for AHRQ, the RTIUNC EPC requested review of this report from a wide array of individual outside experts in the 

field, including our TEP, and from relevant professional societies and public organizations. 

AHRQ also requested review from its own staff. We sent 20 invitations for peer review: 6 TEP 

members, 6 relevant organizations, and 8 individual experts. Reviewers included clinicians (e.g., 

obstetrics and gynecology, women’s health/general health), representatives of federal agencies, 

advocacy groups, and potential users of the report. 

We charged peer reviewers with commenting on the content, structure, and format of the 

evidence report, providing additional relevant citations, and pointing out issues related to how 

we had conceptualized and defined the topic and KQs. We also asked them to complete a peer 

review checklist. We received comments from 11 of the invited peer reviewers in addition to 

comments from AHRQ staff. The individuals listed in Appendix E*

 gave us permission to 

 

*

 Appendixes and evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
24 

acknowledge their review of the draft. We compiled all comments and addressed each one 

individually, revising the text as appropriate. 
25

Chapter 3. Results 

This chapter presents the results of our evidence review for the following four key questions 

(KQs): KQ 1, outcomes of gestational weight gain; KQ 3, outcomes of gestational weight gain 

within or outside the recommendations of the Institute of Medicine (IOM); and KQ 5, 

anthropometrics of gestational weight gain. 

We note that KQ 2, on modifiers of outcomes, is derivative of KQ 1. KQ 4, on 

recommendations for weight gain, is derivative of KQ 3. Because we framed KQ 2 and KQ4 as 

synthesis questions, we cover them in Chapter 4. 

Appendix C*

 provides the detailed evidence tables for KQs 1, 3, and 5. Our summary tables 

below feature groups of studies addressing each outcome; we present these text tables only when 

we have three or more studies pertaining to that particular outcome. These tables are organized 

by quality (good, then fair, then poor), and then alphabetically. 

The summary tables generally provide information to identify the study (author and date),

sample size, study quality, definition of gestational weight gain, definition of outcome, results, 

and confounders and effect modifiers. Unless otherwise noted, we use the metrics (e.g., grams, 

kilograms, pounds) that each study article used; we did not recalculate measures into the same 

metric. 

KQ 1: Outcomes of Gestational Weight Gain 

We present outcomes in the physiological order, beginning with maternal antepartum and 

intrapartum outcomes, then birth outcomes (neonatal outcomes at the time of birth), infant 

outcomes (<1 year), child outcomes (≥ 1 year), and finally maternal short- and long-term 

outcomes. Evidence Tables 1-35 (Appendix C) include studies relevant for KQ 1, listed 

alphabetically by author. For each outcome, we describe study characteristics and then report an 

overview of results, followed by detailed results. When meaningful, we present results separately 

for varied measures of gestational weight gain (categorical measures of weight gain, rate of 

weight gain, total weight gain, and other). For some bodies of evidence, variations in the 

definition of the outcome and inconsistencies in the direction of effect may suggest that an 

overall assessment of the effect is more meaningful than separate assessments of outcomes 

associated with each measure of gestational weight gain. Summary tables and text include 

information on the confounders and effect modifiers accounted for in each study. 

Maternal Antepartum Outcomes 

Maternal discomforts of pregnancy. 

Study characteristics. Five studies (Evidence Table 1) investigated the relationship between 

weight gain and diverse maternal discomforts of pregnancy: a composite of pregnancy 

discomforts,41 physical energy and fatigue,42 stretch marks,43,44 and heartburn.45 

Overview of results. Two fair41,42 and three poor studies43-45 found no differences for women 

who gained an excessive amount of weight compared to those who did not, irrespective of body 

mass index (BMI) group,42 a higher frequency of symptoms from midpregnancy through the 36th 

 

*

 Appendixes and evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
26

week of gestation,46 no association between gestational weight gain and heartburn in gestation,45

and some increased risk of stretch marks with increased weight gain.43,44

Detailed results. A prospective cohort study in Sweden examined symptoms across 

pregnancy and attempted to document the prevalence and frequency of 27 pregnancy symptoms 

while controlling for biomedical factors.41 A cohort of 476 nulliparous women was assessed six 

times during gestation (gestational ages of 10, 12, 20, 28, 32, and 36 weeks). The investigators 

sought to determine the prevalence of various symptoms in pregnancy and to explore whether 

psychosocial variables are explanatory while controlling for possible confounding variables such 

as medical risk, smoking, and weight gain. Pregravid BMIs were calculated from self-reported 

weight information and women were weighed when they arrived at the hospital to give birth. 

Total weight gain was associated with a higher frequency of symptoms from midpregnancy 

through the 36th week of gestation. Reflecting on their findings, the researchers recommend that 

weight gain be included in future studies exploring the etiology of symptoms during pregnancy. 

A secondary analysis of data collected in a US prospective cohort study investigated the 

relationship of prepregnancy weight and gestational weight gain on levels of physical energy and 

physical symptoms collected through a series of questionnaires that had been administered in 

patient homes in early, mid, and late pregnancy.42 All weight data were self-reported. The 

researchers found no differences in the number of physical symptoms or level of physical energy 

reported by women who gained an excessive amount of weight compared with those who did 

not, irrespective of BMI group. Women whose weight gain was greater than the IOM guidelines 

reported a lower level of functional status in the third trimester than women whose weight gain 

was within the guidelines (P = 0.014). Women participating in this study were 30.9 years of age 

on average, married, English-speaking, and of low medical risk. No confounders or effect 

modifiers were accounted for in the analysis. 

The one study (rated poor quality) that investigated the determinants of heartburn in 

pregnancy undertook a cross-sectional study in the United Kingdom of 602 women of different 

gestational lengths who self-reported their pregravid weight and completed a questionnaire.45

The analysis, which considered age, race, parity, and pregravid BMI, found that weight gain in 

pregnancy was not a risk factor for heartburn in gestation. 

Two studies (both rated poor quality) reported on the relationship between stretch marks 

(striae gravidarum) and weight gain.43,44 One was a small retrospective cohort (N = 48) recruited 

from one private and one teaching hospital in the United States.43 Mean total weight gain was 

significantly greater in women with abdominal striae than women without stretch marks 

(P < .05) but the analysis did not account for any confounders or effect modifiers. The other 

study reported on a cross-sectional sample of 324 primiparous women who were assessed within 

48 hours of giving birth in Great Britain.44 Logistic regression analysis found maternal age, BMI, 

weight gain, and neonatal birthweight to be independently associated with striae. Weight gain 

was a weakly significant risk factor (OR, 1.08; 95% CI, 1.02-1.14). 

Hyperemesis. 

Study characteristics. A retrospective cohort study compared the experiences of 1,270 

women who had an antepartum admission before 24 weeks of gestation for hyperemesis with 

those of 154,821 women who experienced no antepartum admission related to vomiting 

(Evidence Table 2).47 Baseline weight and weight gain were abstracted from the Nova Scotia 

Atlee Perinatal Database, but the authors did not explain how the weights entered into the 

database were assessed. 
27

Overview of results. One poor study found a correlation between increasing likelihood of 

total gestational weight gain of < 7 kg with increasing numbers of antenatal admissions for 

hyperemesis.47

Detailed results. The study, undertaken to determine the relationship between hyperemesis 

and a variety of outcomes, used the number of antenatal admissions as a marker for severity of 

disease. The study found a correlation between increasing likelihood of total gestational weight 

gain of < 7 kg with increasing numbers of antenatal admissions. Many potential confounders 

were incorporated into the analysis including previous pregnancy experiences, psychiatric 

disorders, pregravid weight, and preexisting medical diseases. Weight gain information, 

however, was missing for approximately 17 percent of the cohort. 

Abnormal glucose metabolism. 

Study characteristics. Eleven studies specifically investigated the relationship between 

weight gain in pregnancy and the development of abnormal glucose metabolism (Evidence Table 

3, Table 4).3,48-57 Of these, four were done outside the United States.49,50,52,53 Numerous 

inconsistencies in methodology and definitions, such as differences in criteria used for the 

diagnosis of gestational diabetes mellitus (GDM), preclude clear summations regarding the 

research. 

Table 4. Gestational weight gain and abnormal glucose control 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and Effect 

Modifiers Included in 

Analysis 

Kieffer et al., 

200648

US Michigan 

federally qualified 

community health 

center 

1,041 Latinas 

 

All BMIs 

Good 

Pregravid weight: 

Self-report; if 

unknown 

calculated from wt 

at ≤ 10 wks 

gestation 

Total weight gain: 

Computed from 

last weight 

recorded within 7 

days delivery 

Note: study aim to 

determine 

relationship of 

anthropometric and 

metabolic variables 

on infant outcomes 

Women with GDM had 

significantly lower 

average weight gain than 

those without GDM but 

weight gain was not 

significantly related to 

glucose category 

Parity, pregravid BMI, 

weight gain 

Saldana et al., 

20063

US North Carolina 

prenatal study 

2,254 

All BMIs 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Calculated on 

prenatal 

measurement to 

end of second 

trimester 

Weight gain ratio 

(observed/recommended)

IGT OR (95% CI) 

0.9 (0.7-1.1) 

GDM OR (95% CI) 

1.2 (0.9-1.4) 

Race, maternal age, 

gestation age of weight 

measurement 

AA, African American; ACOG, American College of Obstetrics and Gynecology; BMI, body mass index; CHC, community health center; CI, 

confidence interval; G, group; GA, gestational age; GDM, gestational diabetes mellitus; GIP, gastric inhibitory polypeptide; IGT, impaired 

glucose tolerance; IOM, Institute of Medicine; NS, not significant; OR, odds ratio; PNV, prenatal visit. 
28

Table 4. Gestatiornal weight gain and abnormal glucose control (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and Effect 

Modifiers Included in 

Analysis 

Edwards et al., 

199655

US Minnesota, 

births at specific 

medical center 

1,343 divided 

between 

obese women 

(BMI > 29) 

matched to 

nonobese (BMI 

19.8-26.0) 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Last prenatal 

assessment 

Pregravid wt 19.8-

26.0 BMI: 

G1: < 11.5 kg gain 

G2: 11.6-16 kg gain 

G3: > 16 kg gain 

Pregravid wt > 29 kg 

G4: lost/gained 

nothing 

G5: 0.5-6.5 kg gain 

G6: 7-11.5 kg gain 

G7: 12-16 kg gain 

G8: >16 kg gain 

Incidence gestational 

diabetes: 

G1: 2.3% 

G2: 3.3% 

G3: 2.9% 

(P = .759) 

G4: 13.3% 

G5: 24.3% 

G6: 11.9% 

G7: 16.7% 

G8: 17.3% 

(P = .554) 

Maternal age, parity, race, 

prenatal smoking, prenatal 

alcohol use, prenatal illicit 

drug use, pregravid 

health, weight and 

adequacy of prenatal care

Hackmon, et al., 

200757

US inner city 

population 

75 

All BMIs 

Fair 

Pregravid weight: 

How determined 

not described 

Weight gain: 

Weight at 24-28 

weeks end point 

for calculations 

 There was no difference 

in maternal weight gain 

during early pregnancy 

between patients with 

abnormal versus normal 

GCT values (mean±SD of 

4.13±3.2 and 4.16±1.67, 

respectively). 

Gravidity, parity, ethnicity, 

BMI 

Kieffer et al., 

200156

US Detroit health 

care system 

1,334 AA and 

Hispanic 

All BMIs 

Fair 

Pregravid weight: 

Self-report or, if 

unknown, weight 

assessment in 1st 

10 wks gestation 

Total weight gain: 

How determined 

not described 

Wt gain to 28 wk GA:

Latinas: 

G1: < 14 lbs gain 

G2: 14-28 lbs gain 

(reference) 

G3: >28 lbs gain 

AAs: 

G4: < 14 lbs gain 

G5: 14-28 lbs gain 

G6: > 28 lbs gain 

Multiple logistic 

regression analyses 

revealed statistically 

significant risk factors for 

GDM included increasing 

weight gain during first 28 

wks of gestation 

Age, family history 

diabetes, parity, BMI, 

weight gain first 28 weeks, 

ethnicity 

Murakami et al., 

200552

Japan hospital 

data 

633 

All BMIs 

Fair 

Pregravid weight: 

Self-report on first 

visit 

Total weight gain: 

Measured on 

admission for birth 

G1: < 8.5 kg gain 

G2: 8.5-12.5 kg gain 

G3: >12.5 kg gain 

AOR (95% CI) gestational 

diabetes 

G1: 5.14 (0.97-27.20) 

G2: Reference 

G3: 3.91 (0.61-24.73) 

Maternal age, parity, 

smoking, weight gain, 

gestational weeks; 

pregravid BMI 
29

Table 4. Gestational weight gain and abnormal glucose control (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and Effect 

Modifiers Included in 

Analysis 

Thorsdottir, et al., 

200253

Iceland University 

Hospital 

615 

BMI: 19.5-25.5 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Maternity records 

(no specifics 

offered) 

G1: <11.5 kg gain 

G2: 11.5-16.0 kg gain 

G3: 16.1-20.0 kg gain 

G4: >20 kg gain 

Incidence 

gestational 

diabetes 

G1: 2.9% 

G2: 0 

G3: 0 

G4: 0 

(P = .015) 

Age, parity, height, 

gestational age 

Bianco, et al., 

199854

US New York 

Medical Center 

Database 

11,840 

Nonobese (BMI 

19-27) and 

Morbidly obese 

(BMI > 35) ages 

20-34 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Computed from 

measured weight 

within 4 weeks of 

delivery 

Reported only for BMI > 35: 

G1: weight loss or no gain 

G2: 1-15 lb gain 

G3: 16-25 lb gain 

G4: 26-35 lb gain 

G5: > 35 lb gain 

Incidence GDM: 

G1: 15.7% 

G2: 15.0% 

G3: 14.4% 

G4: 13.4% 

G5: 12.5% 

(P = NS) 

Race, parity, clinic 

service, substance abuse, 

and preexisting medical 

conditions 

Brennand et al., 

200549 

Quebec, Canada, 

First Nation’s 

People (Cree) 

603 

All BMIs ≥18.5 

Poor 

Pregravid weight: 

Measured weight 

≤14 wk GA used 

as proxy 

Total weight: 

Last recorded 

weight within 4 

wks of giving birth 

G1: “Low weight gain” 

G2: “Acceptable weight 

gain” 

G3: “Excessive weight gain”

All categories per Canadian 

Guidelines 

Incidence GDM: 

G1: 38.6% 

G2: 27.3% 

G3: 19.3% 

(P = 0.011) 

Incidence IGT: 

G1: 12.0% 

G2: 15.2% 

G3: 7.9% 

(P = 0.249) 

None reported 

Kabiru and 

Raynor, 200451

US Atlanta public 

hospital database 

5,131 

All BMIs ≥ 20 

Poor 

Pregravid weight: 

First prenatal visit 

Total weight gain: 

Computed on 

weight at 

admission for birth 

BMI < 25 first assessment: 

G1: no change BMI 

category 

G2: increase 1 category 

G3: increase > 1 category 

BMI ≥ 25 first assessment: 

G4: no change BMI 

category 

G5: increase 1 category 

G6: increase >1 category 

Incidence 

gestational 

diabetes 

G1: 0.5% 

G2: 1.5% 

G3: 3.7% 

(P = .005) 

G4: 1.0% 

G5: 3.3% 

G6: 1.9% 

(P = .005) 

Pregravid weight 
30

Table 4. Gestational weight gain and abnormal glucose control (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and Effect 

Modifiers Included in 

Analysis 

Seghieri et al., 

200550

Italy Outpatient 

Diabetes Unit 

1,880 

All BMIs 

Poor 

Pregravid weight: 

How determined 

not described 

Total weight gain: 

How determined 

not described 

 Weight gain as 

predictor of GDM OR 

(95% CI) 

1.024 (0.974-1.077) 

(P = NS) 

Parity, age, pregestational 

BMI, weight gain, family 

history diabetes 

The diagnostic algorithm for assigning the diagnosis of GDM in most asymptomatic women 

begins with administration and interpretation of a 1-hour glucose challenge test; those women 

who have a glucose level following the challenge above a specified level then receive a 3-hour 

glucose tolerance test (GTT). Abnormalities in the GTT results are considered diagnostic of 

GDM. The set point for determining if the glucose challenge test is abnormal is not universally 

agreed upon. Therefore, more women in one setting may be tested for disease than in another 

setting, not because of an increased prevalence of disease but because of differing definitions of 

abnormal. In addition, impaired glucose tolerance (IGT) is not clearly defined. Women with an 

abnormal glucose challenge test who subsequently have a normal GTT are sometimes identified 

as having IGT; more commonly, women who have one abnormal value in their GTT are 

designated as having IGT. The lack of standardization in the criteria necessary to be considered 

to have IGT and GDM hampers the body of research exploring the relationship between weight 

gain and abnormal glucose tolerance in pregnancy. Further hampering understanding of the 

relationship is that GDM is generally diagnosed around 28 weeks of gestation and is treated, in 

part, by dietary counseling and efforts to control weight gain. Similar attention is not directed 

toward women without this diagnosis. Therefore, using total weight gain as a predictor of disease 

or as a comparison point to a population without the diagnosis is likely to result in 

methodologically flawed conclusions. 

Overview of results. Four studies (1 good,3

 2 fair,55,56 1 poor51) found that greater weight 

gains in pregnancy were positively associated with abnormal glucose tolerance. Three studies (1 

good quality,48 1 fair,53 1 poor49) found that women having lower than average weight gains had 

higher likelihood of GDM. Finally, four studies (2 poor,50,54 1 fair52,53,57) found no significant 

association. 

Detailed results. Whether total weight gain or the distribution of the gain across trimester or 

weeks of pregnancy predicts development of GDM is unclear from the articles we reviewed. As 

previously noted, treatment of the condition can alter total weight gain. Three studies3,56,57

analyzed the association between weight gain in the first two trimesters of pregnancy and the 

diagnosis of GDM. A good-quality study reported that a weight gain ratio at the end of the 

second trimester of pregnancy that was greater than the IOM recommendations correlated with 

abnormalities of glucose metabolism.3

 A fair study found no correlation between weight gain in 

the first 24 to 28 weeks of gestation and an abnormal glucose challenge test, the first step in the 
31

testing process to identify GDM.57 A third study assessed to be of fair quality reported that 

weight gain in the first 28 weeks of gestation was a significant predictor of the diagnosis of 

GDM (OR, 1.02; 95% CI, 1.004-1.042; P = 0.015) for their total sample of 987 black and Latina 

women but that total weight gain was not.56 The OR for black women was the same (1.02; 95% 

CI, 1.002-1.044; P = 0.30). However, the range of weight gain included in the reference category 

was large (14-28 pounds) especially given that nearly 50 percent of the sample entered into the 

reported pregnancies with BMIs > 26.0. 

Overall, family history of diabetes,50,56 maternal age,3,50,56 parity,50 and BMI3,50,56,57 were 

found to be more predictive of abnormal glucose metabolism than gestational weight gain in the 

research we reviewed.

Maternal hypertensive disorder. 

Study characteristics. Twelve studies investigated the relationship between weight gain and 

pregnancy-induced hypertensive disorders (Evidence Table 4, Table 5).4,25,49,51-55,58-61 Six of the 

studies were conducted outside the United States;49,52,53,58,59,61 six studied US cohorts.4,25,51,54,55,60

While all of these studies reported on blood pressures that became elevated during gestation, the 

criteria for diagnosing gestational hypertension (also called pregnancy-induced hypertension) 

and preeclampsia were often poorly defined; in addition, criteria for the various diagnoses lacked 

consistency between studies. 

Table 5. Gestational weight gain and pregnancy-induced hypertension 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Cedergren, 200658

Swedish Medical 

Birth Registry 

245,526 

All BMIs 

Fair 

Pregravid weight: 

Self-report; if 

unknown 

“standardized 

measurement” 

used 

Total weight gain: 

Computed on 

weight at 

presentation for 

delivery 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI > 35 

Preeclampsia by BMI for 

weight gain < 8 kg (reference 

gain 8-16 kg). 

OR (95% CI): 

G1: 0.90 (0.55-1.48) 

G2: 0.73 (0.61-0.89) 

G3: 0.64 (0.54-0.76) 

G4: 0.52 (0.42-0.62) 

G5: 0.63 (0.51-0.79) 

Preeclampsia by BMI for 

weight gain >16 kg (reference 

weight gain 8-16 kg): 

Odds ratios (95% CI) 

G1: 2.23 (1.83-2.71) 

G2: 2.31 (2.15-2.49) 

G3: 1.88 (1.72-2.06) 

G4: 1.65 (1.43-1.92) 

G5: 1.50 (1.17-1.92) 

Age, parity, 

smoking in early 

pregnancy, year of 

birth 

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; G, group; GA, gestational age; HTN, hypertension; kg, kilogram; lb, 

pounds; NS, not significant; OGTT, oral glucose tolerance test; OR, odds ratio; PIH, pregnancy-induced hypertension; USA, United States of 

America; wt, weight; wts, weights. 
32

Table 5. Gestational weight gain and pregnancy-induced hypertension (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

DeVader, et al., 

200725

USA Missouri, birth 

certificate data 

94,696 

BMI: 19.8-26.0 

Fair 

Pregravid weight: 

Noted on prenatal 

record or reported 

at postpartum stay 

Total weight gain: 

As stated on birth 

certificate data. 

Specifics not 

provided 

G1: Weight gain < 25 lbs

G2: Weight gain 25-35 

lbs 

G3: Gained > 35 lbs 

AOR for preeclampsia (95% 

CI) 

G1: 0.56 (0.49-0.64) 

G2: 1 

G3: 1.88 (1.74-2.04) 

Maternal age, 

race/ethnicity, 

education, 

Medicaid status, 

tobacco and 

alcohol use, 

maternal height, 

adequacy of 

prenatal care, 

child’s sex, child’s 

birth year 

Edwards et 

al.,199655

USA Minnesota, 

births at specific 

medical center 

1,343 divided 

between obese 

women (BMI > 29) 

matched to 

nonobese (BMI 

19.8-26.0) 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Last prenatal 

assessment 

Pregravid wt 19.8-26.0 

BMI: 

G1: < 11.5 kg gain 

G2: 11.6-16 kg gain 

G3: > 16 kg gain 

Pregravid wt > 29 kg 

G4: lost/gained nothing 

G5: 0.5-6.5 kg gain 

G6: 7-11.5 kg gain 

G7: 12-16 kg gain 

G8: > 16 kg gain 

Preeclampsia: 

G1: 2.8% 

G2: 2.9% 

G3: 6.6% 

(P = .048) 

G4:10.7% 

G5: 7.7% 

G6: 8.3% 

G7: 7.9% 

G8: 16.5% 

(P = .076) 

Gestational HTN: 

G1: 2.3% 

G2: 3.8% 

G3: 3.3% 

(P = .607) 

G4: 9.3% 

G5: 8.3% 

G6: 11.3% 

G7: 10.3% 

G8: 9.0% 

(P = .832) 

Maternal age, 

parity, race, 

prenatal smoking, 

prenatal alcohol 

use, prenatal illicit 

drug use, 

pregravid health, 

weight and 

adequacy of 

prenatal care 

Kiel et al., 20074

USA Missouri, birth 

certificate data 

120,251 

BMIs ≥ 30.0 

Fair 

Total weight gain: 

As stated on birth 

certificate data. 

Specifics not 

provided 

Analysis done by each 

class of obesity and 

weight changes in 

gestation including: 

weight loss ≥ 10 lbs; 

weight loss 2-9 lbs; no 

weight change; gain 2-9 

lbs; gain 10-14 lbs; gain 

15-25 lbs; gain 26-35 

lbs; gain > 35 lbs 

Data all presented in graph 

form: 

Using a gain of 15-25 pounds 

as reference for each obesity 

class, OR of preeclampsia 

lower with less weight gain 

and higher with more weight 

gain 

Age, education, 

poverty (defined 

as participation 

in one or more 

subsidized 

programs) tobacco 

use, parity, 

chronic 

hypertension 
33

Table 5. Gestational weight gain and pregnancy-induced hypertension (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Murakami et al., 

200552

Japan hospital data 

633 

All BMIs 

Fair 

Pregravid weight: 

Self-reported at 

first visit 

Total weight gain: 

Measured on 

admission for birth 

G1: < 8.5 kg gain 

G2: 8.5-12.5 kg gain 

G3: >12.5 kg gain 

Estimated OR (95% CI) 

preeclampsia 

G1: 0.74 (0.37-1.48) 

G2: 1 

G3: 0.57 (0.24-1.32) 

Maternal age, 

parity, smoking, 

weight gain, 

gestational weeks; 

pregravid BMI 

Ogunyemi et al., 

1998,60

USA, rural Alabama 

582 

All BMIs 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Weight at last 

prenatal visit 

G1: “low weight gain” 

G2: “normal weight gain”

G3: “high weight gain” 

Incidence preeclampsia: 

G1: 10% 

G2: 7% 

G3: 19% 

(P = < .01) 

Age, parity, 

pregravid BMI, 

tobacco use, 

hypertension 

Thorsdottir, et al., 

200253

Iceland, university 

hospital 

615 

BMI: 19.5-25.5 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Maternity records 

(no specifics 

offered) 

G1: <11.5 kg gain 

G2: 11.5-16.0 kg gain 

G3: 16.1-20.0 kg gain 

G4: > 20 kg gain 

% gestational HTN 

G1: 1.5% 

G2: 4.6% 

G3: 5.1% 

G4: 9.2% 

(P = 0.026) 

% preeclampsia 

G1: 1.4% 

G2: 2.3% 

G3: 5.4% 

G4: 4.4% 

(P = 0.262) 

Age, parity, height, 

gestational age 

Bianco, et al., 

199854

USA, New York 

Medical Center 

Database 

11,840 

Nonobese 

(BMI 19-27) and 

morbidly obese 

(BMI > 35) ages 

20-34 

Poor 

Pregravid weight: 

Self-reported 

Total weight gain: 

Computed on 

measured weight 

within 4 weeks of 

delivery 

Reported only for BMI > 

35: 

G1: weight loss or no 

gain 

G2: 1-15 lb gain 

G3: 16-25 lb gain 

G4: 26-35 lb gain 

G5: > 35 lb gain 

Incidence PIH 

G1: 11.8% 

G2: 13.7% 

G3: 13.7% 

G4: 12.4% 

G5: 21.3% 

(P = NS) 

Race, parity, clinic 

service, substance 

abuse, and 

preexisting 

medical conditions
34

Table 5. Gestational weight gain and pregnancy-induced hypertension (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Brennand et al., 

200549 

Quebec, Canada, 

First Nation’s 

People (Cree) 

603 

BMI ≥ 18.5 

Poor 

Pregravid weight: 

Measured weight 

≤ 14 wk GA used 

as proxy 

Total weight gain: 

Computed on last 

recorded weight 

within 4 wks of 

giving birth 

G1: “Low weight gain” 

G2: “Acceptable weight 

gain” 

G3: “Excessive weight 

gain” 

All categories per 

Canadian 

Guidelines 

HTN disorders 

G1: 7.3% 

G2: 12.5% 

G3: 19.3% 

(P = 0.051) 

PIH: 

G1: 3.7% 

G2: 6.3% 

G3: 4.4% 

(P = 0.698) 

Preeclampsia 

G1: 3.7% 

G2: 6.3% 

G3: 14.9% 

(P = 0.013) 

None reported 

Jensen et al., 

200559

Danish medical 

centers 

481 

BMI ≥ 30 

Poor 

Pregravid weight: 

Self-reported 

Total weight gain: 

Details not 

provided 

G1: < 5 kg gain 

G2: 5.0-9.9 kg gain 

G3: 10.0-14.9 kg gain 

G4: ≥ 15.0 kg gain 

OR (95% CI) gestational HTN 

G1: 1 

G2: 2.1 (0.8-5.7) 

G3: 3.6 (1.3-9.8) 

G4: 4.8 (1.7-13.1) 

(P = 0.001) 

Results of 2 hour 

OGTT, age, 

pregravid BMI, 

gestational age, 

parity, smoking, 

ethnicity, and site 

of prenatal care 

Kabiru and Raynor, 

200451

USA Atlanta, public 

hospital database 

5,131 

BMI ≥20 

Poor 

Pregravid weight: 

First prenatal visit 

Total weight gain: 

Computed on 

weight at 

admission for birth 

BMI < 25 first 

assessment: 

G1: no change BMI 

category 

G2: increase 1 category 

G3: increase > 1 

category 

BMI ≥ 25 first 

assessment: 

G4: no change BMI 

category 

G5: increase 1 category 

G6: increase > 1 

category 

Incidence preeclampsia 

G1: 1.9% 

G2: 3.2% 

G3: 1.6% 

(P = .203) 

G4: 2.8% 

G5: 3.7% 

G6: 3.7% 

(P = .002) 

Pregravid weight 

Wataba et al., 

200661

Japanese medical 

center 

21,718 

All BMIs 

Poor

Total weight gain: 

Computed by 

delivery weight less 

pregravid weight 

(no details on how 

assessed) divided 

by gestational age 

Separate analyses done 

for low, medium and high 

pregravid weight groups 

by following intervals of 

kg/week gain: 

< 0.15: 

0.15-.20; 0.20-.25; 0.25-

.30; 0.30-.35; 0.35-40; 

>0.40 

No clear trends for 

preeclampsia or severe 

preeclampsia by pregravid 

weight status and kg/week 

weight gains. AOR generally 

crossed 1.0 or had wide 

confidence intervals. 
35

Overview of results. The vast majority of the studies (7 fair,4,25,53,55,58-60 3 poor,49,51,61) found 

that increasing weight gain was associated with increasing likelihood of a pregnancy-induced 

hypertensive disorder. Two studies, one fair52 and one poor,54 did not support this association. 

Detailed results. Six studies specifically examined the impact of weight gain on the 

development of pregnancy-induced hypertension in women classified as obese by their pregravid 

weight status.4,49,54,55,58,59 A prospective cohort study from Sweden examined the relationship of 

weight gain by pregravid BMI on pregnancy outcomes for 245,526 women who delivered term 

infants between 1994 and 2002.58 When compared to a reference gain of 8-16 kg, the researchers 

found that gains of less than 8 kg were protective against the development of preeclampsia for all 

pregravid BMI categories. The finding was not significant, however, for those with BMIs < 20. 

Gaining more than 16 kg increased the likelihood of developing preeclampsia, especially for 

women who entered pregnancy with lower BMIs. The greatest increased risk was for women 

entering pregnancy at a BMI of 20 to 24.9 (OR, 2.31; CI, 2.15-2.49); the lowest increased risk 

was for women who entered pregnancy at a BMI ≥ 35 (OR, 1.50; CI, 1.17-1.92). 

One US retrospective cohort study studied 771 women with BMIs of 30 or greater matched 

by race or ethnicity, delivery date, age categories, and parity categories with women of normal 

pregravid BMIs (19.8-26.0).55 For women of normal weight, as weight increased the prevalence 

of preeclampsia steadily increased (P =.048) but increasing weight was not associated with the 

prevalence of gestational hypertension. For obese women, weight gain and the development of 

either gestational hypertension or preeclampsia were not significantly associated. 

In a retrospective cohort study of 603 Cree women in Canada (rated poor quality), Brennand 

et al.49 found that overweight and obese women had a significant unadjusted OR of 2.25 to 4.25 

times higher, respectively, than normal weight women for pregnancy-induced hypertension and 

1.25 to 3.45 times higher for preeclampsia. 

Three retrospective cohorts were limited to women who entered pregnancy with BMIs 

≥ 30.4,54,59 In a study of 481 Danish women, the authors, using < 5 kg as the reference weight 

gain, found a statistically significant trend for development of pregnancy-associated 

hypertension with increasing weight (P = 0.0001).59 A US study examined birth certificate data 

for 120,251 obese women classified according to the 1998 National Institute of Health obesity 

classes.4 The researchers found that the amount of weight gain associated with minimal risk for 

preeclampsia differed by class of obesity but that, in all classes, a gain of less than 15 pounds 

was protective. The third study (rated poor quality) specifically investigated pregnancy and 

neonatal risks associated with BMIs > 35 in 527 morbidly obese women.54 Although these 

women were more likely to experience obstetrical complications than a control population (BMIs 

19-27), gestational weight gain did not affect the complication rate. 

One other study did not support the association between weight gain and pregnancy-induced 

hypertension.52 In this study, 633 Japanese women who gave birth to a singleton infant at 24-42 

weeks of gestational age were studied. Pregravid BMI categories were those defined by the IOM. 

At the time of the study (2005) the Japan Society of Obstetrics and Gynecology did not have a 

recent guideline for weight gain during pregnancy; as a result, researchers used the frequency 

distributions from their population to set quartiles regarding weight gain and then set the 

parameters for insufficient and excessive gains accordingly. In this study, insufficient gain was 

defined as less than 8.5 kg and excessive gain as 12.5 kg. Finding no significant influence on 

weight gain and various perinatal outcomes of the mother or infant, the research team used other 

cut-off points and was still unable to find an appropriate criterion for predicting risk. The authors 

stated that their sample size was not sufficient to prove a lack of significance. Of note, the mean 
36

pregravid BMI of the sample was 20.9 ± 2.8 and the mean weight gain was 10.5 kg ± 3.4. While 

this study was assessed to be of fair quality, it has little, if any, generalizability to the United 

States because our population of childbearing women is more racially and ethnically diverse and 

have a higher mean BMI. 

Gallstones. 

Study characteristics. Two studies reported on the relationship between weight gain in 

pregnancy and cholelithiasis (gallstones)62,63(Evidence Table 5).

Overview of results. Two studies (1 poor62 and 1 fair63) suggest a potential relationship 

between weight gain and cholelithiasis. 

Detailed results. One study reported on weight and the development of gallstones in a 

prospective study of 128 northern plains Native American and white women in 2004.63 Nine 

independent variables including BMI, prenatal weight gain, prenatal physical activity, dietary fat, 

iron supplementation, age, parity, history of gallbladder disease, and serum cholesterol were 

analyzed. Weight assessments during pregnancy were carefully collected; how pregravid weights 

were determined is not specifically stated. Gestational weight gain had a nonsignificant, partial 

correlation of 0.09 and a beta coefficient of 0.13. A case-control study (rated poor quality), using 

data abstracted from birth certificates, reported on 6,211 women from the state of Washington 

who had a gallstone-related diagnosis at delivery or in the first year postpartum between 1987 

and 2001.62 Four controls were randomly selected for each case and matched for year of 

delivery. Multiple logistic regression found an inverse relationship between gestational weight 

gain and gallbladder disease. The OR per kg was. 0.98 (95% CI, 0.97-0.99; P = < 0.001). 

Maternal age, race, BMI based on self-reported pregravid weight, GDM, and infant gestational 

age were accounted for in the analysis. 

Maternal Intrapartum Outcomes 

Premature rupture of membranes (PROM). 

Study characteristics. Investigators explored the relationship of gestational weight gain and 

the risks for premature rupture of membranes (PROM) in two studies (Evidence Table 6).64,65

One involved a total of 1,176 women who had experienced preterm delivery, defined as gestation 

≤ 36 weeks, with PROM (n = 220), preterm delivery without PROM (n = 184), full-term delivery 

with PROM, defined as gestation ≥ 37 weeks, with at least 3 hours of PROM before the onset of 

labor, (n = 184), and 588 controls. Women were recruited following delivery at two academic 

medical centers in the United States.64 In another study,65 the investigators analyzed data for 

62,167 women enrolled in the Danish National Birth Cohort who had pregravid weight and total 

weight gain recorded in the registry. They assessed the impact of obesity and gestational weight 

gain on the risk of various subtypes of preterm birth, including PROM. Pregravid weight and 

gestational gains were self-reported.

Overview of results. Two fair studies64,65 suggest that low weight gain (< 21 pounds) or low 

rate of weight gain (< 275 g per week) is associated with a higher risk of PROM for full-term 

pregnancies and preterm pregnancies.

Results for categorical measures of weight gain. A retrospective case-control study,64

published in 1992, found that weight gain below the reference category of 21 pounds to 30 

pounds significantly increased the risk of preterm delivery with PROM while weight gain above 

the reference category significantly reduced the risk of PROM. Similar trends were noted for 

full-term PROM. However, they were statistically significant only for gestational weight gain of 

31 to 40 pounds when compared with women who gained 21 to 30 pounds (OR,0.56; 95% CI, 
37

0.33-0.94). Many potential confounders and effect modifiers were included in the analyses, 

including diet quality, BMI, age, race, parity, gestational iron supplementation, various medical 

conditions such as chlamydia that are considered risks for PROM, and smoking. The authors did 

not say if they adjusted for gestational age as a continuous variable. All variables, including 

pregravid weight and total weight gain, were assessed through a questionnaire administered to 

most of the subjects within 72 hours of giving birth. 

Results for rate of weight gain. In the Danish cohort study, women with a weekly weight gain 

of less than 275 grams per week had an adjusted hazards ratio for PROM of 1.5 (95% CI, 1.2-

1.7) compared with women gaining between 276 grams and 675 grams weekly. When compared 

with women with BMIs of 18.5 to 24.9, those with either low (< 18.5) or high (> 30) BMIs had 

significantly higher rates of preterm delivery with PROM. The authors adjusted for prepregnancy 

BMI, weight gain, parity, mother’s age, socio-occupational status, and lifestyle exposures in 

early pregnancy including smoking and alcohol exposure.65

Preterm labor. 

Study characteristics. One poor study (Evidence Table 7) examined the relationship between 

gestational weight gain and preterm labor.66 Preterm labor was not defined. This study, set in the 

United States, examined data from 11,505 women at the Boston Hospital for Women. The study 

defined gestational weight gain as pounds gained per week (≤ 0.4, 0.41 to 0.65, 0.66 to 0.9, and > 

0.9).

Overview of results. One poor study suggested that weight gain below 0.65 to 0.9 pounds per 

week significantly increased the risk of preterm labor.66

Results. After controlling for an extensive list of confounders and effect modifiers (race, 

height, prepregnancy weight, infant sex, maternal age, education, health insurance, marital status, 

planned pregnancy, parity, previous induced or spontaneous abortion, previous stillbirth, uterine 

exposure to diethylstilbestrol, incompetent cervix, uterine anomaly, maternal morbidity, 

substance abuse, caffeine use, and prenatal care), the study found that weight below the reference 

range of 0.66 to 0.9 pounds per week significantly increased the risk of premature labor (AOR 

for 0.41-0.65 pounds per week: 1.7, 95% CI, 1.3-2.1; AOR for ≥ 0.4 pounds per week: 3.0; 95% 

CI, 2.2-4.2). Weight gain above 0.9 pounds per week did not have a significant effect on 

premature labor.

Postterm pregnancy. Study characteristics. One study58 used data from 245,526 pregnancies 

identified through the Swedish Medical Birth Registry (Evidence Table 8). 

Overview of results. One fair study found no evidence of association between gestational 

weight gain and postterm gestation.58

Results. The author examined the effects of low (< 8 kg) and high weight gain (> 16 kg), 

compared with the effect of average weight gain (8-16 kg), on deliveries at > 41 weeks of 

gestation across strata of maternal pregravid BMI strata. After adjusting estimates for maternal 

age, parity, smoking in early pregnancy, and year of birth, no significant associations emerged 

between gestational weight gain and postterm gestational age. The study suggests that low or 

high gestational weight gain has no effect on postterm gestation. 

Induction of labor. 

Study characteristics. Five studies examined the relationship between gestational weight gain 

and labor induction (Table 6, Evidence Table 9) Of these, three were set in the United 

States,25,51,67 one in Denmark,59 and one in Finland.68 Of these five studies, three were of poor 

quality.51,59,68 Three examined induction of labor59,67,68 and two examined failed induction of 

labor (defined as a birth that required a cesarean delivery despite induction of labor).25,51 One of 
38

five studies was limited to obese, glucose-tolerant women,67 and one to women of normal 

weight;25 the other studies included women with a range of pregravid BMI. Each of the five 

studies defined gestational weight gain differently. Three used categories of gestational weight 

gain, with different cutpoints.25,59,67 One stratified its sample by weight gain categories, 

comparing women with normal prepregnancy weight and weight gain during pregnancy with 

those with abnormal weight gain during pregnancy, defined as ≥ 20 kg or ≤ 5 kg during 

pregnancy; the study did not specify the prepregnancy weight status of women in these 

“abnormal” weight gain categories.68 Another study characterized weight gain as change in BMI 

class between prepregnancy weight and weight at delivery.51 The study defined BMI categories 

as follows: normal, BMI 20 to 24.9; overweight, BMI 25 to 29.9; obese I, BMI 30 to 34.9; obese 

II, BMI 35 to 39.9; morbid obesity, BMI ≥ 40.51

Table 6. Gestational weight gain and induction of labor 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

DeVader et al., 

200725

USA, birth certificate 

data 

94,696 

Normal weight only 

Fair 

Pregravid weight: 

Medical record: 

If missing, obtained 

from mother during 

postpartum hospital 

stay 

Total weight gain: 

Obstetrical records 

G1: < 30 lbs 

G2: 30-35 lbs 

G3: > 35 lbs 

AOR for failed induction 

of labor vs. other birth 

outcomes 

G1: 0.68 

(95% CI, 0.59-0.78) 

G2: 1.0 

G3: 1.51 

(95% CI, 1.39-1.64) 

Maternal age, 

maternal race or 

ethnicity, maternal 

education, Medicaid 

status, tobacco use, 

alcohol use, 

maternal height, 

prior pregnancy, 

adequacy of 

prenatal care, 

child’s sex, and 

child’s birth year 

Graves et al., 

200667

USA, midwifery 

practices 

1,500 

All weights/BMI 

Fair 

Pregravid weight: 

Actual prepregnant 

weight or early first 

trimester weight 

documented in 

medical records 

Total weight gain: 

Last prenatal 

assessment 

≤ 45 pounds vs. > 45 

pounds 

OR induction of labor for 

> 45 lb: 1.5 (95% CI, 

1.0-2.4) 

Maternal BMI, infant 

birthweight, and 

gestational age at 

delivery 

Ekblad and 

Grenman, 199268 

Finland, hospital 

357 

Normal weight only 

Poor 

Pregravid weight: 

Data from records, 

unclear if selfreported 

Total weight gain: 

Last prenatal 

assessment 

G1: weight gain ≤ 5 kg 

G2: weight gain ≥ 20 kg 

G3: reference (normal 

prepregnancy weight 

and normal weight gain 

[undefined]) 

Percentage induced 

G1: 23% 

G2: 43% 

G3: 24 

P < 0.05 for G2 vs. G3 

NA 

AOR, adjusted odds ratio; BMI, body mass index; G, group; GWG: gestational weight gain; OGTT, oral glucose tolerance test. 
39

Table 6. Gestational weight gain and induction of labor (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Jensen et al., 

200559

Denmark, university 

hospitals 

481 

Obese only 

Poor 

Pregravid weight: 

Records or selfreport of pregravid 

BMI 

Total weight gain: 

Last prenatal 

assessment 

G1: < 5.0 kg 

G2: GWG 5.0-9.9 kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15 kg 

OR for induction of labor 

G1: 1.0 

G2: 2.7 

(95% CI, 1.3-5.7) 

G3: 2.8 

(95% CI, 1.3-5.9) 

G4: 3.7 

(95% CI, 1.7-8.0) 

P for trend = 0.002 

Age, pregravid BMI, 

2 hour OGTT result, 

smoking, 

gestational age 

Kabiru and Raynor, 

200451

USA, hospital 

5,131 

All BMIs > 20 

Poor 

Pregravid weight: 

Weight at first 

prenatal visit 

Total weight gain: 

Weight at admission 

for birth

G1: normal BMI, no 

change in BMI between 

first prenatal visit and 

delivery 

G2: normal BMI, 1 

category increase in BMI 

between first prenatal 

visit and delivery 

G3: normal BMI, > 1 

category increase in BMI 

between first prenatal 

visit and delivery 

G4: overweight BMI, no 

change in BMI between 

first prenatal visit and 

delivery 

G5: overweight BMI, 1 

category increase in BMI 

between first prenatal 

visit and delivery 

G6: overweight BMI, > 1 

category increase in BMI 

between first prenatal 

visit and delivery 

Percent failed induction 

of labor 

G1: 4.7 

G2: 9.2 

G3: 15.9 

P < 0.001 

G4: 7.9 

G5: 10.3 

G6: 14.6 

P < 0.001 

NA 

Overview of results. Two fair25,67 and three poor51,59,68 studies examined the association of 

increased gestational weight gain and labor induction59,67,68 or failure of labor induction,25,51 and 

found a risk of labor induction or failure of induction with increased gestational weight gain. 

Results. The three studies that looked at induction of labor found a statistically significant 

increase in the risk of labor induction with increases in gestational weight gain.59,67,68 The 

magnitude of the effect across all three studies cannot be summarized because of differences in 

the definition of weight gain and in the nature of confounders controlled for in the analysis. Both 

studies examining failed induction of labor found a significant association between gestational 

weight gain and increase in the risk of failed induction compared with all other delivery 

routes.25,51
40

Length of labor. 

Study characteristics. Three cohort studies, set in Finland and the United States, examined 

the association between gestational weight gain and labor (Table 7, Evidence Table 10).68-70 Two 

studies focused on length of labor,68,69 one on labor abnormalities.70 The definition of gestational 

weight gain differed across studies. One study examined an overall increase in weight of > 25 

percent or ≤ 25 percent for women with normal pregravid weight (90-120 percent of normal 

weight for height based on Metropolitan Life Insurance Company Table for 1983).69 Another 

reported on categories of gestational weight gain (< 16 pounds, 16-25 pounds, 26-35 pounds, and 

> 35 pounds) for pregravid BMI categories defined by the IOM.70 The third study, of poor 

quality, stratified its sample by weight gain categories, comparing women with normal 

prepregnancy weight and weight gain during pregnancy with those with abnormal weight gain (≥

20 kg, or ≤ 5 kg) during pregnancy; the study did not specify the prepregnancy weight status of 

women in these “abnormal” weight gain categories.68

Table 7. Gestational weight gain and length of labor 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Johnson et al., 

199270 

USA, prenatal 

clinics 

3,191 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report collected 

at first antepartal visit 

Total weight gain: 

Last prenatal visit 

G1: total weight gain 

< 16 pounds 

G2: total weight gain 

16-25 pounds 

G3: total weight gain 

26-35 pounds 

G4: total weight gain 

> 35 pounds 

Elevated odds of labor 

abnormalities only in the 

group gaining > 35 pounds 

compared with women 

gaining < 16 pounds; not 

significant when adjusted 

for confounders 

Trend analysis showed risk 

of labor abnormalities with 

increased weight gain, a 

difference in 10 lb. 

corresponds to OR=2 (P< 

0.0001) after adjusting for 

BMI, patient care (private 

vs. nonprivate), parity, 

infant sex, hypertension, 

and macrosomia 

Prepregnancy weight 

quartile, height 

(tertile), BMI 

category, 

race/ethnicity, marital 

status, private 

physician, parity, 

infant sex, maternal 

age, hypertension, 

and birthweight 

Purfield and Morin, 

199469

USA, Tertiary care 

medical center 

104 

Normal weight 

women only 

Fair 

Pregravid weight: 

Self-report as noted in 

medical chart 

Total weight gain: 

Weight at admission 

to hospital for birth 

G1: prepregnant 

weight increased by 

25% or less 

G2: prepregnant 

weight increased by 

more than 25% 

Normal weight 

primigravidas with a low risk 

pregnancy who gained an 

excessive amount of weight 

had a longer mean length of 

second stage labor than 

women who gained less 

weight 

Minutes of length of second 

stage in minutes by weight 

groups (SD): 

G1: 72.42 (46.69) 

G2: 93.28 (52.87) 

t = -2.05 P = 0.02 

NA 

BMI, body mass index; G, group; SD, standard deviation. 
41

Table 7. Gestational weight gain and length of labor (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Ekblad and 

Grenman, 199268

Finland, hospital 

357 

Normal weight only 

Poor

Pregravid weight: 

Data from records, 

unclear if selfreported 

Total weight gain: 

Last clinically 

measured weight 

prior to delivery

G1: weight gain ≤ 5 

kg 

G2: weight gain ≥ 20 

kg 

G3: reference 

(normal 

prepregnancy weight 

and normal weight 

gain [undefined])

Labor pattern - I stage 

(minutes± SD) 

G1: 333±208 

G2: 374±208 

G3: 346±188 

Labor pattern - II stage 

(minutes) 

G1: 15±18) P < 0.05 

compared to reference 

category 

G2: 27±25 

G3: 21±18 

Labor pattern - III stage 

(minutes) 

G1: 13±13 

G2: 13±11 

G3: 12±12

NA

Overview of results. Two of three studies (2 fair,69,70 1 poor68) suggested that higher weight 

gain among normal weight women of normal weight was associated with longer labor.68,69

Results. The two studies that examined length of labor demonstrated significantly longer 

second stage of labor for women with high weight gain, based on samples of 35768 and 10469

respectively. Neither study controlled for confounders or effect modifiers. 

The study that reported on labor abnormalities found higher odds of labor abnormalities for 

women gaining > 35 pounds compared with women gaining < 16 pounds. These odds lost 

statistical significance when adjusted for confounders. In a trend analysis, the study found a 

higher risk of labor abnormalities with increased weight gain, suggesting that a difference of 10 

pounds corresponds to an OR of 2 (P < 0.0001) after adjusting for BMI, patient care (private vs. 

nonprivate), parity, infant sex, hypertension, and macrosomia.70

Mode of delivery. 

Study characteristics. Twenty-one cohort studies reported on the relationship between 

gestational weight gain and mode of delivery (Table 8, Evidence Table 11).4,25,49,51,52,54,58,59,61,67-78

Thirteen studies were set in the United States,4,25,51,54,67,69-71,73-77 three in Canada,49,53,72,78 two in 

Japan,52,61 one in Sweden,58 one in Denmark,59 and one in Finland.68
42

Table 8. Gestational weight gain and mode of delivery 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Cedergren, 200658 

Sweden, Medical 

Birth Registry 

245,526 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report; if unknown, 

standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Total weight gain: 

Measured when 

woman entered 

delivery unit 

Weight gain < 8 kg, 8-

16 kg, and > 16 kg for 

each BMI class below 

G1: BMI< 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

AOR for weight gain < 8 kg for 

cesarean section compared 

with weight gain 8-16 kg (95% 

CI) 

G1: 1.07 (0.89-1.29) 

G2: 0.98 (0.92-1.05) 

G3: 0.88 (0.82-0.95) 

G4: 0.81 (0.73-0.90) 

G5: 0.75 (0.66-0.87) 

AOR for weight gain > 16 kg 

for cesarean section 

compared with weight gain 8-

16 kg (95% CI) 

G1: 1.29 (1.17-1.43) 

G2: 1.24 (1.19-1.29) 

G3: 1.23 (1.17-1.30) 

G4: 1.22 (1.10-1.35) 

G5: 1.27 (1.05-1.52) 

AOR for weight gain < 8 kg for 

instrumental delivery 

compared with weight gain 8-

16 kg (95% CI) 

G1: 0.89 (0.71-1.11) 

G2: 0.88 (0.80-0.96) 

G3: 0.85 (0.76-0.95) 

G4: 0.75 (0.63-0.88) 

G5: 0.83 (0.65-1.03) 

AOR for weight gain > 16 kg 

for instrumental delivery 

compared with weight gain 8-

16 kg (95% CI) 

G1: 1.28 (1.15-1.43) 

G2: 1.19 (1.14-1.25) 

G3: 1.14 (1.06-1.23) 

G4: 1.09 (0.93-1.27) 

G5: 1.04 (0.77-1.40) 

Maternal age, 

parity, smoking in 

early pregnancy, 

and year of birth 

Chen et al., 200473

USA, private practice 

3,355 

All weights/BMI 

Fair 

Pregravid weight: 

Weight taken at first 

prenatal visit if 

presented before 20 

weeks; if after 20 

weeks, self report 

Total weight gain: 

Last clinically 

measured weight prior 

to delivery 

Gestational weight 

gain in lbs 

Progression of AOR of 

cesarean delivery weight gain 

(for every 5 lbs): 1.094 (1.074-

1.115) 

BMI, maternal 

height, maternal 

age, pregnancy 

weight gain, 

gestational age at 

delivery, and fetal 

birthweight 

AOR, adjusted odds ratio; BMI, body mass index; G, group; GDM, gestational diabetes mellitus; kg, kilogram; lbs, pounds; LGA, large-forgestational-age; SGA, small-for-gestational-age. 
43

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

DeVader et al., 200725

USA, birth certificate 

data 

94,696 

Normal weight only 

Fair 

Pregravid weight: 

Medical record; if 

missing, obtained 

from mother during 

postpartum hospital 

stay 

Total weight gain: 

Obstetrical records 

G1: < 30 lbs 

G2: 30-35 lbs 

G3: > 35 lbs 

AOR for cesarean (95% CI): 

G1: 0.82 (0.78-0.87) 

G2: 1.0 

G3: 1.35 (1.29-1.40) 

AOR for instrumental (95% 

CI): G1: 0.97 (0.90-1.04) 

G2: 1.0 

G3: 1.03 (0.97-1.08) 

Maternal age, 

maternal race or 

ethnicity, maternal 

education, Medicaid 

status, tobacco use, 

alcohol use, 

maternal height, 

prior pregnancy, 

adequacy of 

prenatal care, 

child’s sex, and 

child’s birth year 

Graves et al., 200667

USA, midwifery 

practices 

1,500 

All weights/BMI 

Fair 

Pregravid weight: 

Actual prepregnant 

weight or early first 

trimester weight 

documented in 

medical records 

Total weight gain: 

Last prenatal 

assessment 

≤ 45 lbs vs. > 45 lbs Greater weight gain in 

pregnancy was not associated 

significantly with route of 

delivery 

Prepregnancy BMI 

category, total 

prenatal weight gain 

category, induction 

of labor, newborn 

birthweight ≥ 4,000 

g, gestational age > 

41 weeks, and 

race/ethnicity 

Jain et al. 200777

USA, birth certificate 

records and 

Pregnancy Risk 

Assessment 

Monitoring System 

7,661 

All weights/BMI 

Fair 

Pregravid weight: 

Not stated 

Total weight gain: 

Birth certificate 

G1: WG ≤ 15 lbs 

G2: WG 15-24 lbs 

G3: WG 25-35 lbs 

G4: WG ≥ 35 lbs 

AOR for primiparous cesarean 

delivery (from model including 

interaction term for 

overweight/obese + > 25 lbs 

weight gain) 

G1: 0.95 (0.59-1.52) 

G2: 1.0 (ref) 

G3: 1.10 (0.76-1.60) 

G4: 1.62 (1.10-2.39) 

AOR for multiparous cesarean 

delivery (from model including 

interaction term for 

overweight/obese + > 25 lbs 

weight gain) 

G1: 1.11 (0.60-2.04) 

G2: 1.0 (ref) 

G3: 1.08 (0.63-1.85) 

G4: 1.95 (1.02-3.72) 

Maternal age, 

pregravid BMI, 

parity, education, 

race/ethnicity, 

US/foreign origin, 

interaction terms for 

pregravid BMI and 

weight gain 

Johnson et al., 199270

USA, prenatal clinics 

3,191 

All weights/BMI 

Fair 

Pregravid weight: 

Self report collected at 

first antepartal visit 

Total weight gain: 

Last prenatal visit 

G1: total weight gain < 

16 lbs 

G2: total weight gain 

16-25 lbs 

G3: total weight gain 

26-35 lbs 

G4: total weight gain 

> 35 lbs 

AOR for unscheduled 

cesarean (95% CI) 

G1: 1.0 

G2: 0.95 (0.6-1.5) 

G3: 1.3 (0.86-1.95) 

G4: 1.95 (1.32- 2.87) 

Prepregnancy 

weight quartile, 

height (tertile), BMI 

category, private 

physician (yes/no), 

maternal age, 

parity, birthweight, 

diabetes, 

hypertension, and 

maternal education 
44

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Joseph et al., 200372

Nova Scotia Atlee 

Perinatal Database 

100,259 

All weights/BMI 

Fair 

Pregravid weight: 

Data taken from 

standardized forms 

and hospital medical 

records - no mention of 

self report 

Total weight gain: 

Not explained by 

authors - data taken 

from maternity records 

G1: < 5 kg 

G2: 5-9 kg 

G3: 10-14 kg 

G4: 15-19 kg 

G5: ≥ 20 kg 

AOR for cesarean delivery 

(95% CI) 

G1: 1.10 (1.00-1.20) 

G2: 1.04 (0.99-1.10) 

G3: 1.00 

G4: 1.09 (1.05-1.14) 

G5: 1.41 (1.35,-1.47) 

Age, parity, 

prepregnancy 

weight, smoking, 

pregnancy 

(singleton or 

multiple), 

hypertension, 

diabetes, previous 

fetal death, 

induction, epidural, 

physician type, time 

Kiel et al., 20074

USA, birth registry

120,170 

Obese women only 

Fair 

Pregravid weight: 

Self report from data 

on birth certificate 

Total weight gain: 

Abstracted from 

medical chart 

All obese women 

G1: Loss 10 lbs or 

more 

G1: Loss 2-9 lbs 

G1: No change 

G1: Gain 2-9 lbs 

G1: Gain 10-14 lbs 

G1: Gain 15-25 lbs 

G1: Gain 25-35 lbs 

Compared with women who 

gained 15-25 lbs during their 

pregnancies, those who 

gained less weight had 

significantly lower odds of 

preeclampsia, cesarean 

delivery, and LGA births, but 

higher odds for SGA births 

Magnitude differed by obesity 

classification, even after 

adjusting for known or 

suspected confounders 

Age, race, parity, 

education, poverty 

(enrollment in 

Medicaid, WIC, 

food stamp 

programs), tobacco 

use, chronic 

hypertension 

Murakami et al., 

200552

Japan, hospital 

633 

All weights/BMI 

Fair 

Pregravid weight: 

Self report at first visit 

to clinic 

Total weight gain: 

Based on last clinically 

measured weight prior 

to delivery 

G1: < 8.5 kg 

G2: 8.5-12.5 kg 

G3: > 12.5 kg 

AOR for cesarean delivery 

(95% CI) 

G1: 1.08 (0.56-2.07) 

G2: 1.00 

G3: 1.23 (0.61-2.48) 

Maternal age, 

parity, smoking, 

prepregnancy BMI, 

and gestational age 

(weeks) 
45

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Purfield and Morin, 

199569

USA, Tertiary care 

medical center 

104 

Normal weight 

women only 

Fair 

Pregravid weight: 

Self report as noted in 

medical chart 

Total weight gain: 

Weight at admission to 

hospital for birth 

G1: prepregnant 

weight increased by 

25% or less 

G2: prepregnant 

weight increased by 

more than 25% 

Higher rate of vacuum 

extraction and cesarean 

delivery and lower rate of 

spontaneous vaginal delivery 

with excessive weight gain 

No difference in forceps 

delivery and vaginal delivery 

by weight gain status 

Vaginal delivery 

G1: n = 27 

G2: n = 9 

Vacuum extraction 

G1: n = 14 

G2: n = 25 

low forceps 

G1: n = 8 

G2: n = 8 

Cesarean section 

G1: n = 3 

G2: n = 10 

χ2 = 15.87, P = 0.001 for all 4 

modes of delivery by weight 

groups 

NA 

Rosenberg et al., 

200571

USA, vital statistics 

data 

329,988 

All weights/ no BMI 

Fair 

Pregravid weight: 

Self report on birth 

certificate 

Total weight gain: 

Weight data on birth 

file 

< 41 vs. ≥ 41 pounds AOR for primary cesarean 

(95% CI): 1.38 (1.34-1.41) 

Age, parity, GDM, 

pregnancy-induced 

hypertension, 

preeclampsia, 

prepregnancy 

weight, chronic 

diabetes, chronic 

hypertension, 

marital status, 

maternal education, 

mother's birthplace, 

prenatal care payer, 

social risk, trimester 

prenatal care began
46

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Shepard et al., 199875

USA, obstetrical 

practices 

2,301 

All weights/BMI 

Fair 

Pregravid weight: 

Self report before 15 

weeks of gestation 

Total weight gain: 

Self report of weight at 

delivery 

Proportional weight 

gain (total weight gain/ 

prepregnancy weight) 

and absolute weight 

gain 

G1: Proportional Gain: 

Adjusted Relative Risk (95% 

CI) 

G2: Absolute Gain: 

Adjusted RR (95% CI) 

Underweight (< 19.4), 

≤ median 

G1: 1.00 

G2: 1.00 

Underweight (< 19.4), 

> median 

G1: 2.08 (0.86-5.04) 

G2: 1.20 (0.56-2.59) 

Low-Average (19.5-22.4), 

≤ median 

G1: 1.62 (0.90-3.67) 

G2: 1.00 (0.54-1.84) 

Low-Average (19.5-22.4), 

> median 

G1: 2.35 (1.06-5.21) 

G2: 1.62 (0.94-3.02) 

High-Average (22.5-28.4), 

≤ median 

G1: 2.78 (1.26-6.12) 

G2: 1.80 (1.01-3.21) 

High-Average (22.5-28.4), 

> median 

G1: 3.06 (1.40-6.73) 

G2: 2.02 (1.14-3.57) 

Obese (> 28.5), ≤ median 

G1: 3.25 (1.40-7.54) 

G2: 2.13 (1.12-4.08) 

Obese (> 28.5), > median 

G1: 2.69 (1.18-6.16) 

G2: 1.65 (0.90-3.03) 

Preeclampsia, 

gestational 

diabetes, placental 

problems, fetal 

distress, 

macrosomia, 

induction, maternal 

age and height, 

parity, ethnicity, and 

marital status 
47

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Sherrard et al., 200778

Canada, hospital 

database 

63,390 

All BMIs 

Fair 

Pregravid weight: 

Self report 

Total weight gain: 

Self report or 

measured 

Rate of weight gain 

(kg/wk) 

G1: Low (≤0.17) 

G2: Normal (0.18-

0.50) 

G3: High (>0.50) 

AOR for unlabored cesarean, 

primary 

G1: 0.79 (0.59-1.05) 

G2: 1.00 (ref) 

G3: 1.03 (0.64-1.64) 

AOR for labored cesarean, 

primary 

G1: 0.77 (0.68-0.86) 

G2: 1.00 (ref) 

G3: 1.40 (1.23-1.60) 

AOR for unlabored cesarean, 

repeat 

G1: 0.91 (0.76-1.09) 

G2: 1.00 (ref) 

G3: 1.38 (1.04-1.83) 

AOR for labored cesarean, 

repeat 

G1: 0.79 (0.54-1.15) 

G2: 1.00 (ref) 

G3: 1.22 (0.72-2.09) 

BMI, gestational 

diabetes, 

pregnancy-induced 

hypertension, 

macrosomia, 

socioeconomic 

factors, parity, and 

maternal age 

Witter et al., 199576

USA,obstetric 

database at major 

medical center 

4,346 

All weights/BMI 

Fair 

Pregravid weight: 

Self report, unclear at 

what timepoint 

Total weight gain: 

Weight recorded at last 

prenatal visit 

Pregnancy weight 

gain (kg) 

AOR for cesarean (95% CI): 

1.04 (1.02-1.05) 

Age, pregravid BMI, 

height, at least one 

previous viable 

pregnancy, 

diagnosis of 

preeclampsia 

during the current 

pregnancy, 

previous cesarean 

delivery 

Bianco et al., 199854

USA, major medical 

center 

11,926 

BMI OF 27 and 34 

are excluded from 

analysis 

Poor 

Pregravid weight: 

Unclear 

Total weight gain: 

Weight from before 36 

weeks gestation or not 

within 4 weeks of 

delivery 

Maternal weight gain 

outcomes by BMI 

presented for morbidly 

obese women only, 

N: 613 

G1: 0 or weight loss 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Cesarean % 

G1: 25.8% 

G2: 26.8% 

G3: 28.8% 

G4: 35.0% 

G5: 33.8% (P = NS) 

NA 
48

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Brennand et al., 

200549

Canada, medical 

records 

603 

All weights/BMI 

Poor 

Pregravid weight: 

Routine prenatal care 

medical records, 

measured within 14 

weeks of gestation 

Total weight gain: 

Based on last clinically 

measured weight prior 

to delivery: within 4 

weeks of birth 

Primigravid women 

(maternal weight gain 

outcomes by BMI 

presented only for 

obese women) 

Primigravid women 

(maternal weight gain 

outcomes by BMI 

presented only for 

obese women) 

G1: Obese - low 

weight gain (< 7 kg) 

G2: Obese - 

acceptable weight 

gain (7-11.5 kg) 

G3: Obese - 

excessive weight gain 

(> 11.5 kg) 

G4: Total 

Cesarean section (%) 

G1: 25.3 

G2: 23.5 

G3: 23.7 

χ2 P = 0.952 

G4: 24.1 

NA 

Ekblad and Grenman, 

199268

Finland, hospital 

357 

Normal weight only 

Poor 

Pregravid weight: 

Data from records, 

unclear if self reported 

Total weight gain: 

Routine prenatal care 

or maternity records 

based on last clinically 

measured weight prior 

to delivery 

G1: weight gain ≤ 5 kg

G2: weight gain ≥ 20 

kg 

G3: reference (normal 

prepregnancy weight 

and normal weight 

gain [undefined]) 

Normal vaginal delivery (%) 

G1: 90 P < 0.05 compared to 

reference category 

G2: 64 

G3: 71 

Forceps or vacuum delivery 

(%) 

G1: 3 

G2: 13 

G3: 5 

Breech (%) 

G1: 1 

G2: 0 

G3: 2 

Cesarean section - elective% 

G1: 3 

G2: 5 

G3: 13 

Cesarean section - 

emergency% 

G1: 3 

G2: 18 

G3: 9 

NA 
49

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Jensen et al., 200559

Denmark, university 

hospitals 

481 

Obese only 

Poor 

Pregravid weight: 

Records or self report 

of pregravid BMI 

Total weight gain: 

Last prenatal 

assessment 

G1: GWG 5.0-9.9 kg 

G2: GWG 10.0-14.9 

kg 

G3: GWG ≥ 15 kg 

OR for cesarean delivery 

(95% CI) 

G1: 1.0 

G2: 2.4 (1.1-5.3) 

G3: 3.0 (1.4-6.4) 

G4: 3.6 (1.6-7.8) 

P for trend=0.002 

2-h OGTT result, 

maternal 

age, prepregnancy 

BMI, gestational 

age (continuous 

variables), parity, 

smoking, ethnic 

background, and 

clinical center 

(categorical 

variables 

Kabiru and Raynor, 

200451

USA, hospital 

5,131 

All BM’s > 20I 

Poor 

Pregravid weight: 

First prenatal visit 

Total weight gain: 

Weight at admission 

for birth 

Primary cesarean 

G1: normal BMI, no 

change in BMI 

between first prenatal 

visit and delivery 

G2: normal BMI, 1 

category increase in 

BMI between first 

prenatal visit and 

delivery 

G3: normal BMI, > 1 

category increase in 

BMI between first 

prenatal visit and 

delivery 

G4: overweight BMI, 

no change in BMI 

between first prenatal 

visit and delivery 

G5: overweight BMI, 1 

category increase in 

BMI between first 

prenatal visit and 

delivery 

G6: overweight BMI, 

> 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

Operative vaginal delivery 

G1: 11.4 

G2: 12.4 

G3: 12.2 P = 0.837 

G4: 8.4 

G5: 11.4 

G6: 17.3 P < 0.001 

Cesarean delivery rate for 

failure to progress 

G1: 2.5 

G2: 6.5 

G3: 10.2 P = 0.203 

G4: 3.5 

G5: 6.9 

G6: 10.2 P = 0.002 

Pregravid BMI, 

none other 
50

Table 8. Gestational weight gain and mode of delivery (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Wataba et al., 200661

Japan, academic 

medical center 

21,718 

All weights/BMI 

Poor 

Pregravid weight: 

Unreported 

Total weight gain: 

From hospital 

database/ register 

Rate of weight gain, 

categorized differently 

across different BMI 

groups 

For nulliparous, low BMI 

women: 

Higher risk of cesarean 

delivery for women with weight 

gain ≥ 0.4 kg/week (AOR: 2.30 

[95% CI, 1.06-4.98] compared 

with women gaining 0.25-0.3 

kg/week) 

For nulliparous, medium BMI 

women: 

Higher risk of cesarean 

delivery for women with weight 

gain ≥ 0.4 kg/week (AOR: 1.61 

[95% CI, 1.21-2.14] compared 

with women gaining 0.25-0.3 

kg/week) and for women with 

weight gain 0.35-0.4 kg/week 

(AOR: 1.68 [95% CI, 1.22-

2.30] compared with women 

gaining 0.25-0.3 kg/week) 

For nulliparous, high BMI 

women: 

No increased risk 

For parous, medium BMI 

women: 

Higher risk of cesarean 

delivery for women with weight 

gain 0.25-0.3 kg/week (AOR: 

1.49 [95% CI, 1.09-2.04] 

compared with women gaining 

0.20-0.25 kg/week) 

No data presented on 

cesarean delivery for other 

BMI groups for parous women 

Parity, baseline BMI

Young et al., 200274

USA, private practice 

3,375 

All weights/BMI 

Poor 

Pregravid weight: 

Self reported 

Total weight gain: 

Based on last clinically 

measured weight prior 

to delivery 

G1: < 30 lbs 

G2: 30-35 lbs 

G3: > 35 lbs 

Increase in overall cesarean 

delivery rate with increased 

weight gain was significant at 

all BMI levels 

BMI 

All 21 studies examined cesarean delivery as an outcome. Five examined instrumental 

delivery in addition to cesarean delivery.25,51,58,68,69 Eight studies reported on cesarean delivery 

without providing further definition.4,25,49,54,58,59,74,76 The studies that offered some detail varied 
51

in their definition; these studies defined cesarean delivery as failure to progress,51 unscheduled 

cesarean,67,70 cesarean including elective and emergency,52 elective cesarean and emergency 

cesarean,61,68 cephalopelvic disproportion/failure to progress, fetal distress, breech, and other 

indications,73cesarean delivery for cephalic presentation,77 and cesarean delivery for singleton 

cephalic presentation separately analyzed for primary and repeat cesareans, with and without 

labor.78 A key consideration in assessing the risk of cesarean delivery is the route of previous 

delivery; with the declining prevalence of vaginal birth after cesarean (VBAC), a history of prior 

cesarean delivery is likely to result in cesareans for all subsequent pregnancies. Studies that fail 

to account for prior route of delivery cannot therefore control for its confounding effect. Eleven 

studies did not take into account prior route of delivery.4,25,49,52,54,58,59,61,67,68,70

Definitions of gestational weight gain also varied greatly. Some studies used categorical 

definitions designed to identify high weight gain alone,67,71 weight gain across a spectrum of 

gain,4,25,49,52,54,58,59,70,72,74,77 continuous weight gain,73,76 rate of weight gain,61,78 and weight gain 

in relation to pregravid weight.51,68,69,75

Overview of results. Across the 14 fair4,25,52,58,67,69-73,75-78and 7 poor49,51,54,59,61,68,74 studies that 

examined gestational weight gain as a predictor of route of delivery, only four (2 poor) failed to 

show an effect of gestational weight gain on route of delivery.49,52,54,67 The remainder 

demonstrated higher risks of cesarean delivery associated with gestational weight gain, with 

some evidence suggesting more pronounced risks associated with high pregravid BMI status. 

Notably, only 10 studies controlled for route of previous delivery. Of these, five controlled for 

co-morbidities that could have been significant confounders for route of delivery.71,72,75,76,78 One 

study explicitly examined the interactions between weight gain and pregravid weight; it did not 

find any significant effect.77

Results across BMI categories for categorical measures of weight gain. Fifteen studies 

considered weight gain across a range of pregravid weight categories. Of these, two fair studies 

defined gestational weight gain as a categorical variable (≤ 45 pounds vs. > 45 pounds,67 and 

< 41 vs. ≥ 41 pounds71). One of these two studies, limited to primary cesarean, found a 

significant association between weight gain and cesarean delivery (AOR, 1.38; 95% CI, 1.34-

1.41).71 This study found pregravid BMI, diabetes, and hypertension to also be strong predictors 

of cesarean delivery. The other, which did not control for route of previous delivery, did not find 

any association between gestational weight gain and route of delivery.67 

Six studies defined gestational weight gain in categories that allowed for the identification of 

both low and high weight gain, across a spectrum of pregravid weight categories;52,58,70,72,74 of 

these, one was rated poor quality74 and the remainder fair. One study showed no difference in 

cesarean delivery by weight gain category.52 All others showed some patterns of association with 

higher levels of weight gain, although the magnitude of the effect varied.58,70,72,74 Three studies 

found similar thresholds for the rise in risk of cesarean delivery, namely, weight gains in excess 

of 15 kg72or greater than 35 pounds.70,77 One study looked at both relatively low weight gain (< 8 

kg) and relatively high weight gain (> 16 kg) in comparison with weight gain of 8 to 16 kg.58

The study found no statistically significant risk of cesarean delivery for low or normal BMI 

categories but significantly higher risk with higher weight gain for overweight, obese, and 

morbidly obese women.58 One study examined the effects of pregravid weight, gestational 

weight gain, and the interaction between the two as predictors of cesarean delivery for 

primiparous and multiparous women (defined in two different ways). The study found that 

pregravid overweight or obese status as well as weight gain over 35 pounds are associated with 

the risk of cesarean delivery for primiparous women, but no significant effect of the interaction 
52

between weight gain and pregravid weight. The study did not find consistently significant effects 

of these variables on cesarean delivery for multiparous women; the previous route of delivery, a 

likely confounder, was not controlled in these analyses.

Results across BMI categories for rate of weight gain. Two studies, one rated fair78 and the 

other poor,61 examined the rate of weight gain across a range of pregravid weight categories. The 

fair study separately examined the risks of primary and repeat cesarean, with and without labor 

in models that accounted for gestational diabetes, pregnancy-induced hypertension, macrosomia, 

socioeconomic factors, parity, or maternal age. The study found that a high rate of weight gain 

(> 0.5 kg/week) significantly increased the risk of a labored primary cesarean, while a low rate of 

weight gain (≤ 0.17 kg/week) significantly reduced the risk, compared with an average rate of 

weight gain (0.18-0.50 kg/week). High rate of weight gain significantly increased the risk of 

unlabored repeat cesareans. The rate of weight gain during pregnancy did not predict the risk of 

primary unlabored cesarean or repeat labored cesarean. In contrast, pregravid overweight and 

obese status was a significant risk factor for all types of cesarean delivery. The poor study 

examined associations between cesarean delivery and rates of weekly weight gain (seven 

categories), categorized differently across different BMI groups (three groups) and parity (two 

categories), resulting in 42 comparisons.61 As with the fair study, a subset of results were 

significant, suggesting that for nulliparous women with low or medium BMI, high rates of 

weight gain increased the risks of cesarean delivery. Specifically, the study found: 

• among nulliparous, low-BMI women, a higher risk of elective cesarean delivery for 

women with weight gain ≥ 0.4 kg per week (AOR: 2.30 [1.06-4.98]) than for women 

gaining between 0.25 and 0.3 kg per week. 

• among nulliparous, medium-BMI women, a higher risk of elective cesarean delivery 

o for women with weight gain ≥ 0.4 kg per week (AOR: 1.61 [1.21-2.14]) than for 

women gaining 0.25 to 0.3 kg per week and 

o for women with weight gain of 0.35 to 0.4 kg per week (AOR: 1.68 [1.22-2.30]) than 

for women gaining 0.25-0.3 kg per week. 

The study examined risk of emergency (rather than elective) cesarean for high BMI nulliparous 

women and failed to find an association with gestational weight gain rates. 

In examining outcomes for parous women, with a single exception—a higher risk of cesarean 

delivery for women with weight gain 0.25-0.3 kg/wk (AOR, 1.49 [1.09-2.04]) than for women 

gaining 0.20 to 0.25 kg/week—the poor study did not find statistically significant effects for rate 

of weight gain on cesarean delivery for parous, medium-BMI women. No data were presented on 

cesarean delivery (emergency or elective) for low or high BMI groups for parous women. 

Results across BMI categories for continuous measures of weight gain. Of the 15 studies that 

considered a range of pregravid weight categories, two fair studies modeled gestational weight 

gain as a continuous variable.73,76 Both found significantly higher risks of cesarean delivery with 

increasing weight. One study identified the progression of AOR of cesarean delivery weight gain 

for every 5 pounds of gestational weight gain to be 1.094 (95% CI, 1.074-1.115).73 The second 

study calculated the attributable risk for cesarean delivery of gaining more than 16 kg to be 6.9 

percent.76 Both studies account for route of previous delivery. 

Results across BMI categories for other measures of weight gain. Of these same 15 studies, 

three (1 fair,75 and 2 poor51,53,68) defined gestational weight gain as a function of pregravid 

weight.51,68,75 Two of three studies controlled for previous route of delivery by limiting their 
53

sample to primary cesareans. The fair study used underweight women who gained less than the 

median for proportional weight gain (total weight gain/prepregnancy weight) as the referent.75

This study found higher risks of cesarean delivery for all other categories, although risks were 

statistically significant only for women in the high and obese BMI category in all weight gain 

categories and women in the average BMI category who gained less than the median 

proportional weight gain. One poor-quality study characterized weight gain as change in BMI 

class between prepregnancy weight and at delivery. BMI categories were defined as follows: 

normal, BMI 20 to 24.9; overweight, BMI 25 to 29.9; obese I, BMI 30 to 34.9; obese II, BMI 35 

to 39.9; morbid obesity, BMI ≥ 40.51 This study found no statistically significant association 

between weight gain and cesarean delivery among normal-BMI women but did find a positive 

association for high-BMI women. The extent to which these results corroborate findings from the 

fair study is hard to determine given the differences in the reference category, but both studies 

imply that increased risks of cesarean are pronounced among overweight and obese women. A 

third study, also of poor quality, examined differences in route of delivery between women with 

normal prepregnancy weight and weight gain during pregnancy with those with abnormal weight 

gain (≥ 20 kg or ≤ 5 kg) during pregnancy; the study did not specify the prepregnancy weight 

status of women in these “abnormal” weight gain categories.68 Unlike the other two studies in 

this category, the rates for cesarean delivery were not statistically significantly different across 

groups. The study did find a statistically significant higher rate of normal vaginal delivery for 

low weight gain women compared with the reference category of normal prepregnancy weight 

and weight gain. Notably, this study did not control for route of previous delivery.

Results within BMI categories for other measures of weight gain. Two studies were limited 

to women of normal BMI.25,69 Both suggested an increase in the risk of cesarean delivery with 

increasing weight gain, defined in one study as 25 percent gain over prepregnancy weight,69 and 

in the other as a weight gain > 35 pounds as compared with a weight gain of 30 to 35 pounds. 

Weight gain of < 30 pounds was associated with a lower risk of cesarean delivery, suggesting a 

linear increase in the risk of cesarean delivery with weight gain for women of normal weight. 

One of the two studies controlled for previous cesarean delivery by limiting its sample to 

primigravidas.69

Four studies limited their analysis to obese women or morbidly obese women.4,49,54,59 Of 

these, two studies (both rated poor quality) suggested no difference in cesarean delivery 

outcomes by gestational weight gain.49,54 Neither accounted for route of previous delivery. 

The other two studies suggested that the risk of cesarean delivery increased with higher 

levels of weight gain for obese and morbidly obese women.4,59 One poor study suggested that 

risk increases with higher levels of weight gain.59 Compared with the risk of cesarean delivery 

for women gaining < 5 kg, the results were as follows: AOR of cesarean delivery for women 

gaining 5 to 9.9 kg, 2.4 (95% CI, 1.1-5.3); AOR for women gaining 10 to 14.9 kg, 3.0 (95% CI, 

1.4-6.4); and AOR for women gaining ≥ 15 kg, 3.6 (95% CI, 1.6-7.8).59 The other study 

suggested that women who had lower weight gain than women who gained 15 to 25 pounds had 

lower risks of cesarean delivery, but the magnitude of the association varied by obesity 

classification.4

 Overall, across a range of outcomes the study suggested that minimal risk may 

correspond to a weight gain of 10 to 25 pounds for class I obese women (BMI 30-34.9), a weight 

gain of 0 to 9 pounds for class II obese women (BMI 35-39.9), and a weight loss of 0 to 9 

pounds for class III obese women (BMI > 40). Neither of these studies controlled for route of 

previous delivery.
54

Results for instrumental delivery. Five studies examined instrumental delivery in addition to 

cesarean delivery.25,51,58,68,69 Two found no association.25,68 Of the remaining studies, one found a 

higher risk of instrumental delivery with increased weight gain only for normal BMI and 

overweight women,58 and a second found this only for overweight women.51 A third study, 

limited to women of normal weight, examined differences in the rate of vacuum extraction and 

forceps delivery by amount of weight gain; it found a higher rate of vacuum extraction with 

excessive weight gain but no difference in rate of forceps delivery.69

Results controlling for confounding. Studies varied in their adjustment for confounding 

factors. Seven studies controlled for route of previous delivery by limiting their sample to 

primary cesarean51,71,72,75 or primigravidas.69,73,74 Three studies included multigravidas but 

accounted for previous cesarean delivery in the analysis.76-78 The remaining 11 studies did not 

control for route of previous delivery.4,25,49,52,54,58,59,61,67,68,70

Of the 10 studies that controlled for route of previous delivery, five studies examined 

underlying health risks (e.g., preeclampsia, pregnancy-induced hypertension) as predictors of 

cesarean delivery; all five found these health factors to be significantly associated with risks of 

cesarean delivery.71,72,75,76,78

Vaginal birth after cesarean. 

Study characteristics. One US cohort study (rated poor quality) examined the effect of 

weight gain on the success of vaginal birth after cesarean (VBAC) (Evidence Table 12).79

Overview of results. A single poor study found that gestational weight gain of 40 pounds or 

more increased the risk of VBAC failure.

Results. Women who gained more than 40 pounds during pregnancy were less likely to have 

VBAC success than women who gained 40 pounds or less (OR, 0.65; 95% CI, 0.42-0.98). This 

study controlled for previous normal spontaneous vaginal delivery, previous VBAC, diabetes, 

induction, birthweight > 4,000 g, recurrent indication, one layer closure, pregnancy 

complications, and BMI, but it failed to account for age or parity. The study suggested that 

pregravid BMI was also a predictor of VBAC success, with lower pregravid BMI being 

predictive of success.

Vaginal lacerations. 

Study characteristics. Two cohort studies examined vaginal lacerations (Evidence Table 

13).51,68 One US study (rated poor quality) examined the incidence of third- or fourth-degree 

lacerations among women.51 Weight gain was characterized as change in BMI class between 

prepregnancy weight and weight at delivery. BMI categories were defined as follows: normal, 

BMI 20 to 24.9; overweight, BMI 25 to 29.9; obese I, BMI 30 to 34.9; obese II, BMI 35 to 39.9; 

morbid obesity, BMI ≥ 40. The second study (described earlier, also rated poor quality) was set 

in Finland.68 It examined the rate of vaginal repairs for women with normal prepregnancy weight 

and weight gain during pregnancy and for those with abnormal weight gain (≥ 20 kg, or ≤ 5 kg) 

during pregnancy.68

Overview of results. Two studies, both of poor quality, did not report consistent results on the 

effects of gestational weight gain on vaginal lacerations. 

Results. The US study found no differences in the incidence of third- and fourth-degree 

lacerations among women who were overweight before pregnancy.51 It did find a statistically 

significant difference among normal weight women; the incidence of lacerations rose from 24 

percent for women with no change in BMI category to 29.3 percent for women gaining enough 

to change weight status by one BMI category and to 31.7 percent for women who gained enough 

to change weight status by more than one BMI category. The Finnish study found no statistical 
55

differences between study and control mothers in the rate of repair of second- or third-degree 

lacerations.68 Neither study controlled for any variable other than pregravid BMI. 

Shoulder dystocia. 

Study characteristics. Three studies, set in Ireland,80 the United States,51 and Finland,68

examined the effect of gestational weight gain on shoulder dystocia (Table 9, Evidence Table 

14). The Irish study, a case-control investigation (rated poor) comparing cesarean delivery for 

shoulder dystocia with cephalic vaginal term deliveries, distinguished between two groups of 

gestational weight gain (< 12 kg and ≥ 12 kg).80 The Finnish study (described earlier and rated 

poor quality), stratified its sample by weight gain categories, comparing women with normal 

prepregnancy weight and weight gain during pregnancy with those with abnormal weight gain (≥

20 kg or ≤ 5 kg) during pregnancy.68 The US case-control study (also rated poor quality), 

stratified its sample between normal and overweight BMI categories and examined the effect of 

change in BMI class between prepregnancy weight and weight at delivery. The Irish study 

defined shoulder dystocia to include mild, moderate, and severe cases;80 the other two studies did 

not define their outcome variable.51,68 

Table 9. Gestational weight gain and shoulder dystocia 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Ekblad and 

Grenman, 199268 

Finland, hospital 

357 

Normal weight only 

Poor 

Pregravid weight: 

Data from records, 

unclear if self reported 

Total weight gain: 

Last clinically measured 

weight prior to delivery 

G1: weight gain ≤ 5 kg 

G2: weight gain ≥ 20 kg 

G3: reference (normal 

prepregnancy weight and 

normal weight gain 

[undefined]) 

Shoulder dystocia% 

G1: 3 

G2: 2 

G3: 0.6 

NA 

Geary et al., 199580

Ireland, hospital 

363 

All weights/BMI 

Poor 

Pregravid weight: 

First prenatal visit 

Total weight gain: 

Not described

Weight gain < 12 kg and 

≥ 12 kg for cases 

shoulder dystocia and 

controls 

G1: Cases with shoulder 

dystocia 

G2: Controls 

Maternal weight 

gain < 12 kg 

G1: 59.1% 

G2: 74.1% 

OR 2.0 (1.6-2.2) 

Parity 

Previous birth 

≥ 4,000 g 

BMI, body mass index; g, gram; G, group; kg, kilogram; N, number; OR, odds ratio. 
56

Table 9. Gestational weight gain and shoulder dystocia (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Kabiru and Raynor, 

200451

USA, hospital 

5,131 

All weights/BMI 

Poor 

Pregravid weight: 

First prenatal visit 

Total weight gain: 

Weight at admission for 

birth

G1: normal BMI, no 

change in BMI between 

first prenatal visit and 

delivery 

G2: normal BMI, 1 

category increase in BMI 

between first prenatal 

visit and delivery 

G3: normal BMI, > 1 

category increase in BMI 

between first prenatal 

visit and delivery 

G4: overweight BMI, no 

change in BMI between 

first prenatal visit and 

delivery 

G5: overweight BMI, 1 

category increase in BMI 

between first prenatal 

visit and delivery 

G6: overweight BMI, > 1 

category increase in BMI 

between first prenatal 

visit and delivery 

Shoulder dystocia% 

G1: 0.5 

G2: 1.4 

G3: 1.1 

P = 0.278 for 

associations within 

normal BMI 

categories 

G4: 1.0 

G5: 1.8 

G6: 1.9 

P = 0.357 for 

associations within 

overweight BMI 

categories 

NA

Overview of results. Only one80 of three poor studies found a positive association between 

gestational weight gain and shoulder dystocia.

Results. The three studies found rates of shoulder dystocia ranging from 0.6 percent to 1.4 

percent.51,68,80 Two studies reported no statistically significant differences in rates of shoulder 

dystocia between weight gain groups.51,68 The Irish case-control investigation found that higher 

gestational weight gain during pregnancy was a significant predictor of shoulder dystocia (OR, 

2.0; 95% CI, 1.6-2.2; P = 0.015). The authors calculated positive predictive value percentages 

from the study group and applied them to the total hospital population of singleton vaginal 

deliveries without shoulder dystocia over the same time period. These results suggest a positive 

predictive value of 1 percent for shoulder dystocia when gestational weight gain is 12 kg or 

greater. 

The Irish study accounted for a subset of confounders and effect modifiers other than 

pregravid BMI.80 Multiparity and birth of a previous heavy baby were significant and 

independent determinants for shoulder dystocia, in addition to gestational weight gain. However, 

the investigators noted that each predictor individually accounted for less than 2 percent of the 

positive predictive value for shoulder dystocia, and all three put together accounted for less than 

3 percent. 

Cephalopelvic disproportion. 

Study characteristics. Two US cohort studies examined the association between gestational 

weight gain and cephalopelvic disproportion (CPD) (Evidence Table 15).25,74 One study, using 

Missouri birth certificate data, defined CPD as the condition when the size, presentation, or 
57

position of the fetal head to the maternal pelvis prevented cervical dilation or descent of the fetal 

head.25 This study controlled for a range of demographic confounders but not for maternal health 

characteristics.25 The other study (rated poor quality) defined CPD among primiparous women as 

little or no progress over a 2- to 4-hour period, with contractions documented to be adequate and 

cervix dilated to at least 3 cm or preferably 4 cm. However, if the delivering physician defined 

the indication as CPD, the decision was accepted without chart review, despite the definitions 

listed earlier.74 

Both studies defined weight gain in categories: < 30 pounds, 30 to 35 pounds, and > 35 

pounds. The study using birth certificate data limited inclusion to normal weight women 

(pregravid BMI 19.8-26.0);25 the other study examined the association between gestational 

weight gain and CPD across four pregravid BMI categories: < 20, 20 to 25, 25 to 30, and > 30.

Overview of results. Both studies (1 fair25 and 1 poor74) showed that, for normal-weight 

women, the risk of CPD rose with higher gestational weight gain

Results. The fair study reported an AOR of 1.58 (95% CI, 1.44-1.75) for women gaining > 35 

pounds compared with women gaining 25 to 30 pounds, after adjusting for maternal age, 

maternal race or ethnicity, maternal education, Medicaid status, tobacco use, alcohol use, 

maternal height, prior pregnancy, adequacy of prenatal care, child’s sex, and child’s birth year.25

The poor study showed similar results, with an unadjusted OR of CPD of 1.85 (95% CI, 1.63-

2.06) for normal-weight women gaining > 35 pounds compared with women gaining < 30 

pounds. This study also showed an increased risk of CPD for underweight women gaining > 35 

pounds compared with women gaining < 30 pounds (unadjusted OR: 3.8; 95% CI, 3-4.6). The 

relationship between weight gain and CPD was not statistically significant at higher pregravid 

BMI levels.74

Complications of labor and delivery. 

Study characteristics. Two retrospective cohort studies, one from Iceland53 and the other 

from the United States,81 evaluated the impact of gestational weight gain on complications of 

labor and delivery (Evidence Table 16). 

Overview of results. Two studies, of fair53 and poor81 quality respectively found conflicting 

evidence on the risks of complications. One failed to find statistically significant results;53 the 

other reported that gestational weight gain of more than 40 pounds increased the risk for the 

previously listed complications by 40 percent.81

Results. The fair study from Iceland analyzed the quartiles of total weight gain in women 

with normal pregravid BMIs (19.5-25.5) to determine the impact of weight gain on labor and 

delivery processes.53 After adjusting for age, height, parity, gestational length, and birthweight, 

they found that weight gain of 11.5 to 16.0 kg was associated with the highest likelihood of a 

normal vaginal delivery, defined to include no shoulder dystocia and no asphyxia, and the least 

likelihood of operative procedures including cesarean delivery and forceps- or vacuum-assisted 

deliveries. The findings of this study, however, were not statistically significant. 

The poor US study enrolled 493 women at 37 or more weeks of gestational age to determine 

the relationship between various lifestyle choices and complications in term pregnancy.81

Complications included dystocia, postpartum hemorrhage, retained placenta, fetal and neonatal 

distress, and pregnancy-induced hypertension. All complications were grouped together for the 

analysis. Smoking had a protective effect against complications, but entering pregnancy with 

excess weight for height and gaining more than 40 pounds during gestation both predicted 

complications. A gestational weight gain of more than 40 pounds increased the risk for the 

previously listed complications by 40 percent. 
58

Birth Outcomes 

Preterm birth. 

Study characteristics. Twelve studies (Table 10, Evidence Table 17) examined the 

relationship between weight gain and birth outcomes.23,59,65,71,82-89 These include eight cohort 

studies,59,65,82-86,89 two case-control studies,87,88 and two cross-sectional studies.23,71 The majority 

of the studies defined preterm birth as delivery occurring prior to 37 weeks of gestation; the one 

exception defined it as delivery between 24 and 35 weeks of gestation.87 Each study defined 

weight gain differently. Two studies examined associations of weight gain with early and late 

preterm birth,23,65 and two studies examined associations across subtypes of preterm delivery.65,84 

Table 10. Gestational weight gain and preterm birth 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Kramer et al., 

199588

Canada, University 

Hospitals 

396 

All weight/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Gestational weight gain 

categories (kg/wk): 

G1: < 0.27 

G2: ≥ 0.27 

AOR (95% CI) for cases with 

preterm delivery versus controls 

G1: 1.56 (0.94-2.58) 

G2: 1.00 (reference) 

Parity, marital 

status, language, 

age, education, 

matched on 

smoking history 

Siega-Riz et al., 

199684 

USA, Public Health 

Clinics (California) 

7,589 

All weight/BMI 

Good 

Pregravid weight: 

Self-reported 

Total weight gain: 

Measured 

Categories of 3rd 

trimester weekly weight 

gain rates (kg/week): 

G1: Inadequate 

(Underweight, < 0.34; 

Normal weight, < 0.35; 

Overweight/ Obese, 

< 0.30) 

G2: Adequate 

(Underweight, > 0.34; 

Normal, > 0.35; 

Overweight/Obese, 

> 0.30) 

AOR (95% CI) for rate of preterm 

birth: 

G1: 1.91 (1.40-2.61) 

G2: 1.00 (reference) 

AOR (95% CI) for rate of preterm 

labor: 

G1:1.75 (1.15-2.64) 

G2: 1.00 (reference) 

AOR (95% CI) for rate of 

PPROM: 

G1: 2.70 (1.35-5.42) 

G2: 1.00 (reference) 

Iron status, parity 

combined with 

maternal age, 

ethnicity, 

hypertension 

(chronic or 

pregnancy 

induced), smoking 

status, week 

prenatal care 

began 

Carmichael et 

al.,199782 

USA, University 

Hospital (California) 

7,259 

Nonobese 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Maternity Records 

Total gestational weight 

gain (continuous) 

Linear regression analysis of 

gestational age (days) as 

dependent variable and 

gestational weight gain (kg) as 

independent variable: Regression 

coefficient = 0.51; t-statistic = 

13.1; P < 0.001 

AOR (95% CI) of spontaneous 

preterm birth/ kg increase in total 

weight gain: 0.84 (0.82-0.87) 

BMI, maternal age, 

infant sex 

cigarettes per day 

maternal height, 

parity, race, 

pattern of gain 

derived from 

quadratic curves 

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; HR, hazards ratio; kg, kilogram; n, number; OR, odds ratio; PPROM, 

preterm premature rupture of amniotic membranes; RD, risk difference; USA, United States of America; wk, week. 
59

Table 10. Gestational weight gain and preterm birth (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Dietz et al., 200623 

USA, Pregnancy 

Risk Assessment 

Monitoring System 

113,019 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Birth Certificates 

Categories of mean rate of 

gestational weight gain 

(kg/wk) during second and 

third trimesters stratified by 

pregravid BMI and type of 

preterm birth (very preterm, 

20-31 weeks; moderate 

preterm, 32-36 weeks): 

G1: < 0.12 

G2: 0.12-0.22 

G3: 0.23-0.68 

G4: 0.69-0.79 

G5: > 0.79 

In general, in comparison to 

women with normal BMI in 

G3: underweight women in 

G1- G5 and normal weight 

women in G1, G2, and G5 

were at increased risk of 

very preterm births (AOR: 

1.5-9.8). Underweight 

women in G1-G3 and G5 

and normal women in G1, 

G2, and G5 were at 

increased risk moderate 

preterm births (AOR: 1.4-

3.1). Overweight and obese 

women in G1 and G5 were 

at increased risk of very 

preterm birth (AOR: 2.3-

2.5) but had no elevated 

risk of moderate preterm 

birth. Very obese women 

with G1, G4, G5 had 

increased risks of very 

preterm births (AOR: 2.1-

2.8) and with G4 had 

increased risks of moderate 

preterm birth (AOR: 1.3) 

Race, Medicaid 

recipient, parity, 

marital status 

Nohr et al., 200765

Danish National 

Birth Cohort 

16,167 

All weight/BMI 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Self-reported 

Rate of gestational weight 

gain (g/wk) for women with 

early preterm birth (22-33 

weeks) with PPROM : 

G1: < 275 

G2: 276-675 

G3: ≥ 676 

Rate of gestational weight 

gain (g/wk) for women with 

early preterm birth (22-33 

weeks) without PPROM : 

G4: < 275 

G5: 276-675 

G6: ≥ 676 

Rate of gestational weight 

gain (g/wk) for women with 

late preterm birth (34-36 

weeks) with PPROM: 

G7: < 275 

G8: 276-675 

G9: ≥ 676 

HR (95% CI): 

G1: 2.1 (1.5-3.0) 

G2: 1.0 (ref) 

G3: 1.2 (0.8-1.8) 

HR (95% CI): 

G4: 1.9 (1.3-2.6) 

G5: 1.0 (ref) 

G6: 1.9 (1.3-2.6) 

HR (95% CI): 

G7: 1.3 (1.0-1.6) 

G8: 1.0 (ref) 

G9: 1.2 (1.0-1.5) 

HR (95% CI): 

G10: 1.0(0.9-1.2) 

G11: 1.0(ref) 

G12: 1.0 (0.9-1.2) 

Pregravid BMI, 

age, height, parity, 

socio-occupational 

status, smoking 

alcohol 

consumption 
60

Table 10. Gestational weight gain and preterm birth (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Nohr et al., 200765

(continued) 

 Rate of gestational weight 

gain (g/wk) for women with 

late preterm birth (34-36 

weeks) without PPROM: 

G10: < 275 

G11: 276-675 

G12: ≥ 676 

 

Rosenberg et al., 

200571 

USA, New York City 

birth files 

329,988 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Categories of total 

gestational weight gain 

(lbs): 

G1: <41 

G2: ≥ 41 

AOR (95% CI) for Preterm 

Birth: 

G1: 1.00 (reference) 

G2: 0.54 (0.52-0.57) 

Pregravid weight, 

chronic diabetes, 

GDM, chronic 

hypertension, PIH 

preeclampsia, 

maternal age 

marital status 

maternal education 

maternal 

birthplace, prenatal 

care payer, social 

risk, parity, 

trimester that 

prenatal care 

began 

Schieve, et al., 

199986

USA, Pregnancy 

Nutrition 

Surveillance System 

(PNSS) 

266,172 

All weight/BMI 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Self-reported 

Rate of weight gain 

(kg/week) in percentiles 

stratified by Low, Average, 

High, and Obese pregravid 

BMI: 

G1: 5th,0.10 

G2: 10th, 0.16 

G3: 25th,0.26 

G4: 50th,0.35 

G5: 75th, 0.46 

G6: 90th, 0.57 

G7: 95th, 0.65 

Reference category of rate 

of weight gain: 0.35-<0.46 

kg/wk 

RD of preterm birth varied 

by prepregnant BMI and 

gestational weight gain. 

Overall, women gaining 

0.26-0.46 kg/wk had the 

lowest RD of preterm birth. 

The highest RD occurred 

for women gaining the least 

and most amount of weight, 

irrespective of prepregnant 

BMI; however, the highest 

RD of preterm births were 

among women of low BMI 

None 

Stotland et al., 

200685

USA, University 

Hospital (California) 

15,101 

Underweight/Normal 

BMI 

Fair 

Pregravid weight: 

Medical Charts 

Total weight gain: 

Medical Charts 

Categories of rate of 

gestational weight gain 

(kg/wk): 

G1: < 0.27 

G2: 0.27 to 0.52 

G3: > 0.52 

AOR (95% CI) for preterm 

delivery < 37 weeks: 

G1: 2.6 (2.1-3.2) 

G2: 1.0 (reference) 

G3: 1.0 (0.8-1.2) 

AOR (95% CI) for preterm 

delivery < 34 weeks: 

G1: 3.0 (2.0-4.8) 

G2: 1.0 (ref) 

Race, age 

pregravid BMI, 

year of delivery, 

parity, previous 

preterm birth, 

number of days 

between last 

weighing and 

delivery, smoking 
61

Table 10. Gestational weight gain and preterm birth (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Wen et al., 199089

USA, University 

Hospital (Alabama) 

17,149 

All weight/BMI 

 

Fair 

Pregravid weight: 

Measured at first 

prenatal visit 

Total weight gain: 

Medical records 

Rate of weight gain (kg/wk) 

after 20 weeks gestation 

G1: < 0.24 

G2: 0.24-0.57 

G3: 0.58-0.74 

G4: ≥0.75 

AOR for preterm birth: 

G1: 1.52 (P < 0.05) 

G2: 1.11 (NS) 

G3: 1.00 (ref) 

G4: 1.71 (P < 0.05) 

Race, parity, infant 

sex, marital status, 

education, age, 

previous preterm 

delivery, smoking, 

alcohol 

consumption, drug 

use, height, 

pregravid weight 

Jensen et al., 

200559 

Denmark, University 

hospital centers 

481 

Obese 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Hospital records 

Total gestational weight 

gain categories (kg): 

G1: < 5.0 

G2: 5.0-9.9 

G3: 10.0-14.9 

G4: > 15.0 

Percent (%) preterm 

delivery by weight gain 

categories: 

G1: 6.5 

G2: 6.0 

G3: 4.6 

G4: 2.5 

P for trend = 0.11 

NA 

Spinillo et al., 

199887

Italy, University 

Hospital 

690 

All weight/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Medical records 

G1: Prepregnancy 

BMI ≤ 19.5 and 2nd/3rd 

trimester weight gain ≤ 0.37 

kg/wk 

G2: Prepregnancy 

BMI>19.5 and 2nd/3rd 

trimester weight gain ≤ 0.37 

kg/wk 

G3: Prepregnancy BMI ≤ 48 

kg and 2nd/3rd trimester 

weight gain ≤ 0.37 kg/wk 

G4: Prepregnancy BMI > 48 

kg and 2nd/3rd trimester 

weight gain ≤ 0.37 kg/wk 

AOR (95% CI) for cases 

with spontaneous preterm 

delivery versus controls: 

G1: 5.63 (2.35-13.8) 

G2: 2.45 (1.60-3.75) 

P = 0.06 for interaction 

between G1 and G2 

G3: 5.29 (1.45-20.90) 

G4: 2.42 (1.65-3.55) 

P = 0.21 for interaction 

between G3 and G4 

Pregravid BMI, 

pregravid weight, 

height, age, parity, 

smoking, social 

class education, 

infant sex 
62

Table 10. Gestational weight gain and preterm birth (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Velonakis et 

al.,199783

France, Hospital 

2040 

All weight/BMI 

Poor 

Pregravid weight: 

Self-reported 

Total weight gain: 

Measured 

Total gestational weight 

gain (continuous) 

Regression analysis with 

gestational age (weeks) as 

the dependent variable and 

net gestational weight gain 

as the independent 

variable: 

Β = 0.191 (SE, 0.06) 

P = 0.001 

Age, race, 

gravidity, previous 

diseases, parity, 

abortions, marital 

status, pathology 

of index 

pregnancy, infant 

sex, height 

pregravid weight, 

job classification, 

alcohol, smoking, 

APGAR score, 

duration of 

pregnancy 

Overview of results. Taken collectively, the results of these two good,84,88 seven 

fair,23,65,71,82,85,86,89 and three poor53,59,83,87studies suggest an association between preterm birth 

and both low and high rates of weight gain and with low total weight gain, with one study 

reporting a 16 percent decrease in preterm birth associated with a 1 kg increase in maternal 

weight. The cut points for low and high weight gains and the severity of the risks of preterm 

birth associated with them differ by pregravid BMI. In general, low rates of weight gain were 

≤0.37 kg per week and high rates of gain were > 0.52 kg per week throughout gestation, with the 

greatest risks found among underweight women. However, as pregravid BMI increases, the risk 

of preterm birth decreases for women gaining in the lower range of the low rate of weight gain 

and increases for women gaining in the lower range of the high rate of weight gain, such that the 

range of adequate rates of weight gain is shifted down for heavier women compared to their 

lighter counterparts. Some evidence also suggests that low rate of weight gain is associated with 

greater risks of early preterm birth as well as preterm birth due to premature rupture of the 

amniotic membranes. 

Detailed results from categorical measures of total rate of weight gain. Four studies used 

categorical definitions of rate of weight gain averaged for the entire length of gestation;85,86,88,89

one study was rated good88 and the others rated fair.85,86,89 In the good study,88 a rate of weight 

gain of < 0.27 kg per week was not associated with preterm birth (OR, 1.56; 95% CI, 0.94-2.58). 

Among the fair studies, all three studies found evidence of an association between low rate of 

weight gain and preterm birth, and two studies found evidence of an association between high 

rate of weight gain and preterm birth.86,89 

One study used a retrospective, US-hospital-based cohort of deliveries from 1976 to 2001 to 

examine the association of preterm birth and gestational weight gain by maternal race or 

ethnicity.85 Weight gain was categorized into three groups based on rate of weight gain: < 0.27 

kg per week, 0.27-0.52 kg per week, and > 0.52 kg per week. Within the entire cohort and across 

four racial or ethnic groups (white, black, Latina, and Asian), the highest percentages of preterm 

birth occurred among women gaining < 0.27 kg per week. The adjusted odds of spontaneous 

preterm birth were 2.5 times higher in women with rates of weight gain < 0.27 kg per week than 
63

in women gaining 0.27 to 0.52 kg per week. The adjusted odds ratios for this association were 

statistically significant across the different racial or ethnic groups, ranging from 2.1 (95% CI, 

1.4-3.1) for white women to 3.6 (95% CI, 2.2-6.0) for black women. No association between 

spontaneous preterm birth and rate of weight gain > 0.52 kg per week (relative to a weight gain 

of 0.27 to 0.52 kg per week) was seen either within the entire cohort or across the racial or ethnic 

groups. 

Another study, conducted in a population of young, primarily black, disadvantaged women, 

found statistically significant higher odds of preterm delivery among women gaining < 0.24 kg 

per week and > 0.74 kg per week than among women gaining 0.58 to 0.74 kg per week.89 

The final study used data collected from women participating in US federally funded prenatal 

public health programs via the Pregnancy Nutrition Surveillance System (PNSS).86 Gestational 

weight gain was defined as rates of weight gain and net weight gain (kg/week) and categorized 

by the percentile distributions based on the total sample. Women with rates of weight gain 

between 0.35 and 0.46 kg per wk (the 50th through the 74th percentiles) were used as the 

reference for risk difference calculations. In general, the risk of preterm birth was highest among 

women with the smallest and greatest rates of weight gain, < 0.10 kg per week and ≥ 0.65 kg per 

week, respectively. The lowest risks of preterm delivery occurred among women gaining 

between 0.26 and 0.46 kg per week (the 25th through the 74th percentiles). Preterm risk 

differences did vary by maternal pregravid BMI status. An increased risk of preterm birth was 

associated with rates of weight gain for the following pregravid BMI categories: 

• pregravid BMI < 19.8: < 0.26 kg per week; 

• pregravid BMI of 19.8 to 26.0: < 0.26 kg per week and > 0.65 kg per week; 

• pregravid BMI of 26.1 to 29.0: < 0.10 kg per week and > 0.65 kg per week; and 

• pregravid BMI > 29.0: ≥ 0.57 kg per week. 

The results were similar when rates of weight gain per week excluded the first 14 weeks of 

gestation. 

Results from categorical measures of trimester rate of weight gain. Four studies used 

categorical definitions of rate of gestational weight gain measured during specific trimesters of 

pregnancy.23,65,84,87 All of the studies found evidence for an association between preterm birth 

and low rate of weight gain and two studies found evidence for an association between preterm 

birth and high rate of weight gain. 

One study of good quality used a cohort of mainly Hispanic women recruited from public 

health clinics to examine the association between preterm birth and rate of weight gain during 

the third trimester.84 Women with preterm deliveries had significantly lower rates of third 

trimester weight gain than women with term deliveries, 0.50 (standard error of mean [SEM]: 

0.02) kg per week versus 0.53 (SEM: 0.004) kg per week, respectively (P < 0.05). The odds of 

preterm birth were 1.91 (95% CI, 1.40-2.61) times greater among women with inadequate third 

trimester weight gains (defined as a rate of weight gain less than the 25th percentile of gain in 

each pregravid weight status: 0.34 kg/week, underweight; 0.35 kg/week, normal weight; 0.30 

kg/week, overweight and obese) than among women with adequate rates of weight gain. When 

data were stratified by the type of preterm delivery, women with inadequate weight gains were 

1.75 (95% CI, 1.15-2.64) times more likely to have preterm delivery resulting from preterm labor 

and 2.70 (95% CI, 1.32-5.42) times more likely to have preterm delivery resulting from preterm 
64

premature rupture of the amniotic membranes (PPROM) than women with adequate rates of 

weight gain. 

One study, rated fair quality, used data from the Danish National Birth Cohort to assess the 

impact of gestational weight gain on early (22-33 weeks), late (34-36 weeks), and all (22-36 

weeks) preterm births with PPROM, without PPROM, and with medical inducement.65

Gestational weight gain was categorized as low (< 275 g/week), medium (275-675 g/week), and 

high (> 675 g/week) based on two self-reported measurements recorded at least 6 weeks apart 

between 12 and 37 weeks of gestation. Women with medium rates of weight gain were used as 

the reference. Overall, low rates of weight gain were significantly associated with an increased 

risk of early spontaneous preterm birth with and without PPROM and with all spontaneous 

preterm births with PPROM, adjusted odds ratios ranged from 1.5 to 2.1. High rates of weight 

gain were significantly associated with an increased risk of early spontaneous preterm births 

without PPROM (AOR, 1.9; 95% CI, 1.3-2.6) and early, late, and all medically induced early 

preterm births. However, when women with obesity-related diseases and abruptio placenta were 

excluded, the associations for medically induced preterm births were no longer significant. 

Another fair quality study used information collected for the Pregnancy Risk Assessment 

Monitoring System (PRAMS) to examine the effect of rate of weight gain during the second and 

third trimesters on preterm birth.23 These investigators stratified women by prepregnancy BMI 

status and examined the risk of preterm birth in two categories: moderate length of gestation (32-

36 weeks) and very short length of gestation (20 to 31 weeks). Second and third trimester rate of 

weight gain was categorized, in kg per week, as follows: < 0.12, 0.12-0.22, 0.23-0.68, 0.69-0.79, 

and > 0.79; the investigators also used five pregravid BMI groups: underweight (< 19.8), normal 

weight (19.8-26.0), overweight (26.1-28.9), obese (29.0-34.9), and very obese (≥ 35.0). Women 

of normal weight with rates of weight gain of 0.23 to 0.68 kg per week were used as the 

reference for analyses. After adjusting for covariates and excluding women with diabetes, 

hypertension, or small-for-gestational-age (SGA) infants, significant associations (AOR range, 

1.3-3.1) were reported between moderate preterm birth and rates of weight gain as follows: 

< 0.69 and > 0.79 kg per week among underweight women; < 0.23 and > 0.79 kg per week 

among normal weight women; and 0.69 to 0.79 kg per week among obese and very obese 

women. Significant associations (AOR range, 1.5-9.8) were reported between very preterm birth 

and rates of weight gain as follows: all weight gain categories among underweight women; < 

0.23 and > 0.79 kg per week among normal weight women; < 0.12 and > 0.79 kg per week 

among overweight and obese women; and < 0.12 and > 0.68 kg per week among very obese 

women. In general, the greatest odds were found among underweight women and in the extreme 

weight gain categories. 

Results from a poor study87 were consistent with those of the other studies and revealed an 

overall increased odds of preterm birth (between 24 and 35 weeks’ gestation) with gestational 

weight gain ≤ 0.37 kg per week in the second and third trimesters; however, the odds were 

greater among women with pregravid BMI ≤ 19.5 compared to those with BMI >19.5. 

Results from categorical measures of total weight gain. Two studies,59,71 one rated fair and 

the other poor, used categories of total weight gain. In the fair study, data from the New York 

City birth file from 1999 through 2001 was used to examine the odds of preterm birth associated 

with different levels of gestational weight gain.71 After adjusting for covariates, the investigators 

determined that the odds of preterm birth were significantly decreased (OR, 0.54; 95% CI, 0.52-

0.57) among women who gained at least 41 pounds compared with women who gained less than 

41 pounds. Results from the poor study,59 which used a population of obese women, showed the 
65

highest proportion of preterm birth among those with the lowest gestational weight gain (< 5.0 

kg). 

Results from continuous measures of weight gain. The remaining two studies, one rated fair 

and the other poor, used gestational weight gain as a continuous measure.82,83 Both studies 

reported a significant increase in length of gestation for a 1 kg increase in total gestational weight 

gain. 

In the fair study,82 simple regression techniques were used to develop a variable for pattern of 

weight gain that reflected the variation between a woman’s pattern of weight gain and a linear 

pattern of weight gain.82 Deviations in the pattern of weight gain, such as pronounced speeding 

up or slowing down of weight gain later in gestation, from an average pattern of weight gain 

were associated with decreased gestational age and increased risk of spontaneous preterm birth. 

A 1- kg increase in total gestational weight gain was associated with 0.51 day’s increase in 

gestational age (P < 0.001). The odds of spontaneous preterm birth were decreased by 16 percent 

for each 1- kg increase in total gestational weight gain (OR, 0.84; 95% CI, 0.82-0.87; P < 0.001). 

Birthweight. 

Study characteristics. Twenty-five studies examined the association between gestational 

weight gain and infant birthweight (Evidence Table 18).48,54,55,59,68,70,75,83,90-106 These studies 

consisted of various groups of women, in many different countries. Nine studies were completed 

outside the United States, in Canada,105 France,83,92 Italy,91,100 Denmark,59 Norway and 

Sweden,99 Finland,68 and Austria.93 

One study observed the association for adolescent mothers.95 The association was also 

evaluated for mothers with gestational diabetes mellitus (GDM),100 mothers who had a positive 

diabetic screen but normal glucose tolerance levels,91 and obese glucose-tolerant women.59

Seventeen studies adjusted their analyses for multiple confounders, including maternal age, BMI, 

smoking, glucose levels, race, marital status, and parity.48,55,59,70,75,90-93,97-103,105

Overview of results. The results for four good,48,98,103,106 12 fair,55,65,70,75,92,93,97,99-102,104,105 and 

nine poor54,59,68,83,90,91,94-96 studies consistently demonstrate an association between higher 

gestational weight gain and birthweight. 

Results from categorical measures of weight gain. Eight studies analyzed the relationship 

between weight gain and birthweight by categorizing gestational weight gain 

(Table 11).54,59,68,94,95,99,101,106 One study was rated to be of good quality,106 two of fair 

quality,99,101 and five of poor quality.54,59,68,94,95 These studies suggest a positive association 

between gestational weight gain and infant birthweight. 

A U.S. study rated of good quality found that higher values for maternal weight near term, 

categorized by the percentage of standard weight-for-height, were associated with higher 

birthweight for black and Hispanic mothers.106 Specifically, black mothers > 135 percent of 

standard weight for height gave birth to infants that weighed on average 512 g more than infants 

born to black mothers < 100 percent of standard weight for height. Hispanic mothers > 135 

percent of standard weight for height gave birth to infants that weighed on average 338 g more 

than infants born to Hispanic mothers < 100 percent of standard weight for height. 

In one Scandinavian study (fair quality), estimated birthweights decreased by 131 g for 

women who gained less than 11 kg and increased by 164 g for women who gained more than 17 

kg, as compared with estimated birthweights for women gaining between 11 and 17 kg.99 A fairquality US study examined patterns of weight gain and infant birthweight in a population of 

white nonobese women.101 Low weight gain by trimester was defined as having weight gain less 

than the 25th percentile. Infants of mothers with low weight gain in all three trimesters had 
66

weighed 248.1 g less, on average, than infants of mothers in other groups. Low weight gain for 

the first trimester was associated with a decrease in birthweight of 133 g; low weight gain for the 

second and third trimesters was associated with an 88.5 g decrease in birthweight. 
67

Table 11. Total gestational weight gain (categorical) and infant birthweight 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hickey et al., 

1990106

United States, 

prenatal clinics 

325 

All weight/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Infant BW for groups 

defined by maternal weight 

near term (% of standard 

weight-for-height) 

G1: > 135%, Black 

G2: > 135%, Hispanic 

G3: 120-135%, Black 

G4: 120-135%, Hispanic 

G5: 110-119%, Black 

G6: 110-119%, Hispanic 

G7: 100-109%, Black 

G8: 100-109%, Hispanic 

G9: < 100%, Black 

G10: < 100%, Hispanic 

G1: 3,325 g ± 460 

G2: 3,543 g ± 410 

G3: 3,200 g ± 389 

G4: 3,381 g ± 385 

G5: 3,157 g ± 373 

G6: 3,282 g ± 400 

G7: 3,025 g ± 494 

G8: 3,154 g ± 375 

G9: 2,813 g ± 289 

G10: 3,205 g ± 472 

N/A 

Abrams et al., 

1995101

USA, university 

hospital 

4,420 

Nonobese 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

G1: Infant BW among 

nonobese women 

3,485.8 g ± 523.1 Maternal age, 

parity, pregravid 

BMI, height, 

smoking, infant 

sex, difference 

in weeks 

between the 

last measured 

weight and 

delivery 

Zaren et al., 199799

Norway and 

Sweden, university 

hospitals 

1,099 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

β is estimated change in 

infant BW (g) 

G1: GWG ≤ 11 kg: 

G2: GWG ≥ 17 kg: 

G1: β = -131 (P = 0.0001) 

G2: β = 164 (P = 0.0001) 

Maternal age, 

height, 

pregravid 

weight, smoking

Bianco et al., 199854

USA, medical center 

613 

Morbidly obese (BMI 

> 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Infant BW for GWG: 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

G1: 3,302 

G2: 3,192 

G3: 3,337 

G4: 3,506 

G5: 3,453 

(P < 0.05) 

N/A 

β unstandardized coefficient from multiple regression; BMI, body mass index; BW, birthweight; cm, centimeters; g, grams; GWG,gestational 

weight gain; kg, kilogram; lbs, pounds; SC, standardized coefficient; N/A, not applicable; NR, not reported; RCT, randomized controlled trial; 

SD, standard deviation 
68

Table 11. Total gestational weight gain (categorical) and infant birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Cherry et al., 199395

USA, hospital 

RCT 

599 

All weights/BMI 

Poor 

Pregravid weight: 

Measured by study 

investigators 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Infant BW by Quartiles of 

weight gain 

Quartiles defined as weekly 

weight gain in g per cm 

height 

G1: Quartile 1 (≤ 1.87g) 

G2: Quartile 2 (1.88-2.68g) 

G3: Quartile 3 (2.69-3.58g) 

G4: Quartile 4 (≥ 3.59g) 

G1: 2,829 g 

G2: 2,990 g 

G3: 3,112 g 

G4: 3,189 g 

N/A 

Ekblad and 

Grenman, 199268

Finland, hospital 

357 

Prepregnancy 

weight 20% over or 

under ideal body 

weight for height 

and normal weight 

Poor 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Infant BW by group 

G1: Normal prepregnancy 

weight and normal weight 

gain 

G2: Weight gain ≤5 kg 

G3: Weight gain ≥20 kg 

G1: 3,538 g ± 535 

G2: 3,284 g ± 880 

G3: 3,803 g ± 538 

(P < 0.005 compared to 

G1) 

N/A 

Jensen et al., 200559

Denmark, university 

hospitals 

481 

Obese 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Infant BW for groups 

defined by GWG 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9 kg 

G3: GWG 10-14.9 kg 

G4: GWG ≥ 15.0 kg 

G1: 3,456 g ± 620 

G2: 3,624 g ±675 

G3: 3,757 g ± 582 

G4: 3,784 g ± 597 

P < 0.0001 

N/A 

Shapiro et al., 

200094

USA, community 

hospital 

159 

All weight/BMI 

Poor 

Pregravid weight: 

Routine prenatal 

care 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Infant BW for groups 

defined by BMI and weight 

gain 

G1: Low BMI (< 25), Low 

gain (< 35lbs) 

G2: Low BMI (< 25), High 

gain (> 35lbs) 

G3: High BMI (> 25), Low 

gain (< 35lbs) 

G4: High BMI (> 25), High 

gain (> 35lbs) 

G1: 3,363 g 

G2: 3,636 g 

G3: 3,565 g 

G4: 3,774 g 

N/A 
69

The five poor-quality studies also found that increases in gestational weight gain resulted in 

larger infant birthweights.54,59,68,94,95 This trend held among studies of obese glucose-tolerant 

women,59 Finnish women,68 and adolescent mothers.94,95 One study stratified by maternal BMI 

and found that among women with low BMI (< 25) those that gained > 35 lbs had infants that 

were, on average, 273 g heavier than infants born to women gaining < 35 lbs. Among women 

with high BMI (> 25), women that gained > 35 lbs had infants that were, on average, 209 g 

heavier than infants born to women who gained < 35 lbs. One study among morbidly obese 

women (BMI > 35) found a similar trend, although it was inconsistent at the extremes of weight 

gain. Specifically, the following infant birthweights were found for each of the gestational 

weight gain categories: weight loss or 0 lbs, 3,302 g; 1-15 lbs, 3,192 g; 16-25 lbs, 3,337 g; 26-35 

lbs, 3,506 g; >35 lbs, 3,453 g. 

Results for continuous total weight gain. Fourteen studies (Table 12) evaluated the 

relationship between continuous total weight gain and birthweight using linear regression 

techniques to determine the effect of every 1 kg increase in weight gain.48,55,59,90,92,93,96,98,100-105

Of these studies, three48,98,103 were rated of good quality, eight55,92,93,100-102,104,105 of fair quality, 

and three59,90,96 of poor quality. Seven studies of good and fair quality reported that birthweight 

increased between 16.7 and 22.6 g for every 1 kg increase in weight gain.48,93,98,101-103,105 Three 

poor-quality studies reported that birthweight increased between 18.4 and 44.3 g for every 1 kg 

increase in weight gain.59,90,96

Table 12. Total gestational weight gain (continuous) and infant birthweight 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Brown et al., 200298

USA, primary care 

clinics 

389 

All weight/BMI 

Good 

Pregravid weight: 

Measured by study 

investigators 

Total weight gain: 

Collected by study 

investigators 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain 

G1: β = 20 g 

(P < 0.0001) 

Maternal age, 

parity, pregravid 

BMI, height, infant 

sex, gestational 

age 

Groff et al., 1997103

USA, multispecialty 

clinics 

341 

All weights/BMI 

Good 

Pregravid weight: 

Self-report 82% 

First prenatal visit 

18% 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

G1: Increase in birthweight 

per 1 lb increase in total 

pregnancy weight gain 

G1: β = 10.1g ± 1.76 

(P ≤ 0.001) 

Pregravid BMI, 

infant sex, smoking

AGA, Appropriate for gestational age; β, unstandardized coefficient from multiple regression; BMI, body mass index; g, gram; GDM, gestational 

diabetes mellitus; kg, kilogram; lb, pound; LGA, large-for-gestational-age; NR, not reported 
70

Table 12. Total gestational weight gain (continuous) and infant birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Kieffer et al., 200648

USA, community 

health center 

1,041 

All weights/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain 

G1: β = 19.7 g ± 2.8 

(P < 0.01) 

Parity, pregravid 

BMI, height, 1-hour 

glucose value, 

gestational age 

Abrams et al., 

1995101

USA, university 

hospital 

4,420 

Nonobese 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain 

G1: β = 22.6 g 

(P < 0.001) 

Maternal age, 

parity, pregravid 

BMI, height, 

smoking, infant 

sex, gestational 

age 

Butte et al., 200397

USA, US Agriculture 

Research Service 

Children’s Nutrition 

Research Center 

63 

All weights/BMI 

Fair 

Pregravid weight: 

Measured by study 

investigators 

Total weight gain: 

Measured by study 

investigators 

G1: Correlation coefficient 

G2: Variability in birthweight 

accounted for by gestational 

age, pregravid weight, and 

total pregnancy weight gain 

G1: 0.28 

G2: 37.9% 

Maternal race, 

pregravid BMI, 

gestational age 

Edwards et al., 

199655

USA, hospital 

1,443 

Normal and obese 

BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain for 

obese women 

G2: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain for 

normal weight women 

G1: β = 11 g ± 2 

(P ≤ 0.001) 

G2: β = 15 g ± 2 

(P ≤ 0.001) 

Maternal age, 

parity, pregravid 

BMI, pregnancyinduced 

hypertension, 

adequacy of 

prenatal care, 

alcohol use, drug 

use, smoking, 

gestational age 
71

Table 12. Total gestational weight gain (continuous) and infant birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Guihard-Costa et al., 

200492

France, hospital 

database 

13,972 

All weights/BMI 

Fair 

Pregravid weight: 

Routine prenatal care 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Standardized 

coefficient for effect of 

pregnancy weight gain on 

infant birthweight. 

Standardized coefficients 

are regression coefficients 

calculated as if all of the 

independent variables had 

a variance of 1 

G1: SC = 0.199 Maternal age, 

parity, pregravid 

BMI, height 

Hediger et al., 

1994102

USA, setting not 

stated 

608 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain 

G1: β = 16.7 g ± 2.5 

(P = 0.001) 

Maternal age, 

maternal 

race/ethnicity, 

parity, pregravid 

weight, height, 

gestational age, 

prior poor 

outcome, fat loss, 

pregravid weight: 

 low weight, fat 

accretion, smoking, 

infant sex 

Kirchengast and 

Hartmann, 200393

Austria, university 

hospital 

8,011 

All weights/BMI 

Fair 

Pregravid weight: 

Estimated from 

measured weight at 

first prenatal visit 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain 

G1: β = 17.32 (14.62, 

20.03) 

Maternal age, age 

at menarche, 

pregravid weight, 

height, distantia 

cristarum 

Luke et al., 1996104

USA, clinic 

487 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

Increase in birthweight per 

1 kg increase in total 

pregnancy weight gain for 

BMI categories: 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

G1: β = 44.9 g ±6.8 

(P < 0.01) 

G2: β = 22.9 g ± 3.9 

(P < 0.01) 

G3: β = 11.9 g ± 5.2 

(P < 0.05) 

Maternal age, 

parity, black 

ethnicity, smoking, 

gestational age, 

infant sex 
72

Table 12. Total gestational weight gain (continuous) and infant birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Muscati et al., 

1996105

Canada, public 

health department 

371 

All weight/BMI 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Collected by study 

investigators 

G1: Increase in birthweight 

per 1 kg increase in total 

weight gain up to week 20 

G1: β = 22 g ± 6 

(P < 0.01) 

Parity, pregravid 

standard weight, 

pregravid excess 

weight, birth 

length, infant sex 

Pezzarossa et al., 

1996100

Italy, not stated 

192 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

Increase in birthweight per 

1 kg increase in total 

pregnancy weight gain for: 

G1: Controls (normal 

glucose tolerance) 

G2: GDM 

G1: β = 27.8 g 

(P = 0.0001) 

G2: β = 39.5 

(P = 0.0001) 

Pregravid BMI, 

fasting plasma 

glucose 

Di Cianni et al., 

200491

Italy, diabetes clinic 

180 

All weights/BMI 

Poor 

Pregravid weight: 

Not reported 

Total weight gain: 

Collected by study 

investigators 

 F statistic = 3.16, 

P = 0.08 

Pregravid BMI, 

maternal 

triglycerides, 

plasma glucose 

Jensen et al., 200559

Denmark, university 

hospitals 

481 

Obese 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain 

G1: β = 18.4 g 

(P < 0.001) 

Maternal age, 

pregravid BMI, 

smoking, 

gestational age, 

result of 2-hour 

oral glucose 

tolerance test 

Paauw et al., 200590

USA, hospital 

351 

All weights/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

G1: Increase in birthweight 

per 1 kg increase in total 

pregnancy weight gain 

G1: β = 21.0 g Maternal race, 

pregravid weight, 

marital status, 

smoking, 

gestational age 
73

Table 12. Total gestational weight gain (continuous) and infant birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Springer et al., 

199296

USA, university 

hospital 

107 

All weights/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in birthweight 

per 1 lb increase in total 

pregnancy weight gain 

G1: β = 20.1g Maternal age, 

pregravid weight, 

length of gestation, 

smoking, weight 

gain at 20 weeks 

Two studies of fair quality reported these values by BMI status.55,104 One found that 1 kg 

increases in weight gain among normal-weight women were associated with a 15 g increase in 

infant birthweight and, among obese women, an 11 g increase in infant birthweight.55 The other 

study reported, for each 1 kg increase in gestational weight gain, a 44.9 g increase in birthweight 

for underweight women, a 22.9 g increase for women of normal weight, and an 11.9 g increase 

for overweight women.104 

In the one fairquality study that stratified by GDM, the association of total weight gain and 

infant birthweight was stronger among mothers with GDM than among women not diagnosed 

with GDM.100 Specifically, 1 kg increases in weight gain raised infant birthweight by 27.8 g 

among nondiabetic mothers and by 39.5 g among mothers with GDM. 

Several studies reported statistically significant correlations between gestational weight gain 

and infant birthweight. Correlation coefficients between birthweight and total weight gain ranged 

from 0.22 to 0.28 in two fair-quality studies.97,105 A poor-quality study among obese, glucosetolerant women reported a nonsignificant correlation value of r2 = 0.062.91

Results for continuous total weight gain by trimester. Three studies reported on the effects of 

gestational weight gain, by trimester, on infant birthweights (Table 13).98,101,105 One US study 

(rated good quality) reported that weight gain during the first trimester was associated with a 31 

g increase in birthweight per kg of gestational weight gain. Comparable gains in infant 

birthweight for each kg of gestational weight gain in the second and third trimesters were 26 g 

and 7 g.98 This study also found that infant birthweight decreased by 211 g among mothers who 

lost weight during the first trimester.98 

A Canadian study of fair quality found similar results: for each 1 kg increase in weight gain 

up to week 20, birthweight increased by 22 g; increases from week 21 to 30 increased 

birthweight by 31 g; and weight gain from week 31 to term increased birthweight by 12 g.105

Lastly, another US study of fair quality reported an 18 g increase in birthweight for each 

kilogram gained by the mother in the first trimester. Corresponding increases in the second and 

third trimesters were 32.8 g and 17.0 g, respectively.101
74

Table 13. Continuous gestational weight gain by trimester and infant birthweight 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Brown et al., 200298

USA, primary care 

clinics 

389 

All weight/BMI 

Good 

Pregravid weight: 

Measured by study 

investigators 

Total weight gain: 

Collected by study 

investigators 

G1: Increase in 

birthweight per 1 kg 

increase in first 

trimester weight gain 

G2: Increase in 

birthweight per 1 kg 

increase in second 

trimester weight gain 

G3: Increase in 

birthweight per 1 kg 

increase in third 

trimester weight gain 

G1: β = 31 g 

(P < 0.0007) 

G2: β = 26 g 

(P < 0.007) 

G3: β = 7 g 

(P < 0.40) 

Maternal age, parity, 

pregravid BMI, 

height, infant sex, 

gestational age 

Abrams et al., 1995101

USA, university 

hospital 

4,420 

Nonobese 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Increase in 

birthweight per 1 kg 

increase in first 

trimester weight gain 

G2: Increase in 

birthweight per 1 kg 

increase in second 

trimester weight gain 

G3: Increase in 

birthweight per 1 kg 

increase in third 

trimester weight gain 

G1: β = 18.0 g ± 2.4 

(P < 0.001) 

G2: β = 32.8 g ± 2.8 

(P < 0.001) 

G3: β = 17.0 g ± 2.9 

(P < 0.001) 

Maternal age, parity, 

pregravid BMI, 

height, smoking, 

infant sex, 

gestational age 

Muscati et al., 1996105

Canada, public health 

department 

371 

All weight/BMI 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Collected by study 

investigators 

G1: Increase in 

birthweight per 1 kg 

increase in total 

weight gain from 

weeks 21 to 30 

G2: Increase in 

birthweight per 1 kg 

increase in total 

weight gain from 

weeks 31 to term 

G1: β = 31 g ± 7 

(P < 0.001) 

G2: β = 12 g ± 6 

(P < 0.05) 

Parity, pregravid 

standard weight, 

pregravid excess 

weight, birth length, 

infant sex 

β, unstandardized coefficient from multiple regression; BMI, body mass index; g, gram; kg, kilogram; lbs, pounds. 

Results from other measures of weight gain (net weight gain and proportional weight gain). 

Four studies examined the associations between infant birthweight and various other measures of 

gestational weight gain. Three studies (1 rated poor quality) of net weight gain (total gestational 

weight gain minus infant birthweight) showed that infant birthweight increased as net gestational 

weight gain increased (Table 14).70,83,104 In one study, for every 1 kg increase in net weight gain, 

birthweight rose by 15.4 g.70 In another, which examined differences by BMI status, increases of 

1 kg in net weight gain raised infant birthweight as follows: for underweight women, 41.9 g; for 

women of normal weight, 19.2 g; and for obese women, 9.1 g.104 Each kilogram of net weight 

gain associated with an increase of 111.2 g in birthweight in another study.83 
75

Table 14. Net and proportional gestational weight gain and infant birthweight 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Johnson et al., 

199270

USA, prenatal 

clinics 

3,191 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

G1: Increase in 

birthweight per 1 lb 

increase in net 

pregnancy weight gain

G1: β = 15.4 g ± 2.2 

(P < 0.0001) 

Maternal race, parity, 

pregravid BMI, height, 

pregravid weight, 

marital status, 

education, 

tobacco/alcohol/drug 

use, pregnancy-induced 

hypertension, 

gestational age, 

macrosomia, infant sex 

Luke et al., 1996104

USA, clinic 

487 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Increase in birthweight 

per 1 kg increase in 

net pregnancy weight 

gain for BMI 

categories: 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

G1: β = 41.9 g ± 7.5 

(P < 0.01) 

G2: β = 19.2 g ± 3.9 

(P < 0.01) 

G3: β = 9.1 g ± 5.3 

Maternal age, parity, 

black ethnicity, smoking, 

gestational age, infant 

sex 

Shepard 199875

USA, obstetrical 

practices in New 

Haven, CT 

2,301 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Infant birthweight for 

mothers with: 

G1: Low average BMI 

(19.5 to 22.4), 

proportional weight 

gained > median 

G2: Low average BMI 

(19.5 to 22.4), gained 

< median 

G3: High average BMI 

(22.5 to 28.5), gained 

> median 

G4: High average BMI 

(22.5 to 28.5), gained 

< median 

G5: Obese (> 28.5 

BMI), gained > median

G6: Obese (> 28.5 

BMI), gained < median

G1: 3,231 g 

G2: 3,553 g 

G3: 3,395 g 

G4: 3,620 g 

G5: 3,685 g 

G6: 3,453 g 

N/A 

Velonakis et al., 

199783

France, hospital 

2,040 

All weights/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

G1: Increase in 

birthweight for net 

pregnancy weight gain

G1: β = 111.17 g ± 12.94 

(P = 0.000) 

Maternal age, parity, 

pathology of 

previous/current 

pregnancy, previous 

diseases, reproductive 

history, marital status, 

employment, infant sex, 

height, weight, smoking, 

alcohol use, APGAR 

score, gestational age, 

nationality 

β, unstandardized coefficient from multiple regression; BMI, body mass index; C-section, cesarean section; g, gram; kg, kilogram; lbs, pounds; 

N/A, not applicable. 
76

The fourth study, which considered proportional gestational weight gain (total gestational 

weight gain divided by pregravid weight) found that for mothers with BMIs of 19.5 to 22.4, 

those who gained above the median proportional gestational weight gain had infants who were 

322 g heavier than the infants of mothers who gained below the median. 

Similar results were found for mothers with BMIs of 22.4 to 28.5: those who gained above 

the median gave birth to infants who were 225 g heavier. Finally, for women with BMIs above 

28.5, the increase in birthweight was 232 g.75 

Low birthweight. 

Study characteristics. Thirteen studies examined the effect of gestational weight gain on low 

birthweight (LBW) (Evidence Table 19).2,4,52,54,70,71,75,93,95,106-109 LBW is defined as infant 

birthweight < 2,500 g. Overall, the risk of LBW decreased as gestational weight gain increased. 

In general, risks for LBW began to decrease for gestational weight gains above 25 to 30 pounds. 

In 11 of these studies, the analyses were adjusted for multiple confounders, including maternal 

age, pregravid BMI, smoking, alcohol use, gestational age, parity, race, marital status, maternal 

education, pregnancy complications, and infant sex.2,4,52,70,71,75,93,106-109

Overview of results. Ten studies considered the relationship between LBW and total 

gestational weight gain (Table 15).2,4,52,54,71,93,106-109 One of these studies was rated good 

quality,106 seven of fair quality,2,4,52,71,93,107,108 and two of poor quality.54,109 In general, as 

gestational weight gain increased, LBW decreased. 

Table 15. Total gestational weight gain and low birthweight (LBW) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hickey et al., 1990106

United States, prenatal 

clinics 

325 

All weights/BMI 

Good

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records

G1: Percent BW < 3,000, Low 

weight gain < 120% of standard 

G2: Percent BW ≥ 3,000, Low 

weight gain < 120% of standard 

G3: Percent BW < 3,000, 

Acceptable weight gain ≥ 120% 

of standard 

G4: Percent BW ≥ 3,000, 

Acceptable weight gain ≥ 120% 

of standard

G1: 38.2 

G2: 61.8 

G3: 22.1 

G4: 77.9 

N/A

Cogswell et al., 19942

USA, Pregnancy 

Nutrition Surveillance 

System 

53,541 

Normal/Overweight/ 

Obese 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report

ORs and 95% CI, for LBW by 

GWG and prepregnancy BMI 

G1: Normal BMI, GWG < 15 lbs 

G2: Normal BMI, GWG ≥ 40 lbs 

G3: Normal BMI, GWG 25-29 lbs 

(Reference for normal BMI) 

G4: Overweight BMI, GWG 30-34 

lbs 

G5: Overweight BMI, GWG 35-39

G6: Overweight BMI, GWG ≥40 

lbs 

G7: Overweight BMI, GWG 15-19 

lbs (Reference for overweight 

BMI)

G1: 2.1 (1.6-2.6) 

G2: 0.5 (0.4-0.6) 

G3: 1.0 

G4: 0.5 (0.3-0.8) 

G5: 0.6 (0.3-1.1) 

G6: 0.4 (0.3-0.7) 

G7: 1.0

Maternal age, 

maternal race, 

height, smoking, 

infant sex, 

gestational age

BMI, body mass index; BW, birthweight; CI, confidence interval; GDM, gestational diabetes mellitus; GWG, gestational weight gain; kg, 

kilogram; lbs, pounds; LBW, low birthweight; N/A, not applicable; OR, odds ratio. 
77

Table 15. Total gestational weight gain and low birthweight (LBW) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Desjardins and 

Hardwick, 1999107

Canada, Healthiest 

Babies Possible 

Program 

1,892 

All weights/BMI 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Home visitor's scale

G1: OR and 95% CI, for 

LBW and inadequate 

weight gain (defined by 

dietician)

G1: 1.15 (0.78-1.67) Gestational age, 

adolescence, 

pregravid 

underweight, 

number of 

Healthiest Baby 

Possible visits 

Kiel et al., 20074

USA, birth certificate 

registry 

120,251 

Obese 

Fair

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal 

care or maternity 

records

G1: Odds of LBW for 

weight gain > 25 lbs 

G2: OR of LBW for weight 

gain < 15 lbs 

G3: Reference Weight gain 

15-25 lbs

G1: Odds of LBW 

are lower for women 

in this group 

G2: Odds of LBW 

are higher for 

women in this group 

Numerical value for 

ORs not reported in 

study

Maternal age, 

maternal race, 

maternal 

education, poverty, 

smoking, parity, 

chronic 

hypertension

Kirchengast and 

Hartmann 200393

Austria, university 

hospital 

8,011 

All weights/BMI 

Fair

Pregravid weight: 

Estimated from 

measured weight at 

first prenatal visit 

Total weight gain: 

Routine prenatal 

care or maternity 

records

G1: OR and 95% CI, for 

LBW

G1: 0.90 (0.85-0.95) Maternal age, 

pregravid weight, 

height, distantia 

cristarum

Murakami et al., 

200452

Japan, hospital 

633 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

OR and 95% CI, for LBW 

G1: GWG < 8.5 kg 

G2: GWG 8.5-12.5 kg 

G3: GWG > 12.5 kg 

G1: 1.26 (0.57-2.75) 

G2: Reference 

G3: 0.62 (0.24-1.62) 

Maternal age, 

parity, pregravid 

BMI, smoking, 

gestational age 
78

Table 15. Total gestational weight gain and low birthweight (LBW) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Rosenberg et al., 

200571

USA, vital statistics 

data 

329,988 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

OR and 95% CI, for LBW 

G1: GWG ≥ 41 lbs 

G2: GWG < 41 lbs 

G1: 0.41 (0.39-

0.43) 

G2: Reference 

Maternal age, 

parity, GDM, 

pregnancy-induced 

hypertension, 

preeclampsia, 

pregravid weight, 

chronic diabetes, 

chronic 

hypertension, 

marital status, 

maternal education, 

mother’s birthplace, 

prenatal care payer, 

social risk, trimester 

prenatal care began

Zhou and Olsen, 

1997108

Denmark, two 

communities 

7,122 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

OR and 95% CI, for LBW for 

GWG categories by BMI 

G1: GWG < 11 kg, 

Underweight (Reference) 

G2: GWG < 11 kg, Normal 

weight 

G3: GWG < 11 kg, Overweight 

G4: GWG 12-15 kg, 

Underweight 

G5: GWG 12-15 kg, Normal 

weight 

G6: GWG 12-15 kg, 

Overweight 

G7: GWG ≥16 kg, Underweight

G8: GWG ≥16 kg, Normal 

weight 

G9: GWG ≥16 kg, Overweight 

G1: 1.0 

G2: 0.9 (0.5-1.5) 

G3: 0.8 (0.3-2.0) 

G4: 0.5 (0.2-1.0) 

G5: 0.8 (0.4-1.5) 

G6: 0.9 (0.2-3.8) 

G7: 0.3 (0.1-1.0) 

G8: 0.4 (0.2-0.8) 

G9: 0.0 (0.0-2,500) 

Maternal age, 

parity, alcohol, no 

diabetes, term 

delivery, smoking, 

infant sex, 

gestational age 

Bianco et al., 199854

USA, medical center 

613 

Morbidly obese 

(BMI > 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

% LBW for GWG: 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

G1: 2 

G2: 11.1 

G3: 8.3 

G4: 5.2 

G5: 3.8 

N/A 
79

Table 15. Total gestational weight gain and low birthweight (LBW) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Lasker et al., 2005109

USA, hospital 

5,528 

All weights/BMI 

Poor 

Pregravid weight: 

Not stated 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

OR and 95% CI, for LBW 

G1: GWG < 10 lbs 

G2: GWG > 30 lbs 

G3: GWG 21-30 lbs 

(Reference) 

G1: 2.43 (1.45-4.05) 

G2: 0.63 (0.47-0.85) 

G3: 1.00 

Maternal age, 

maternal race, 

marital status, 

prenatal care, prior 

term births, prior 

abortions, prior 

preterm births, BMI 

at delivery, 

preeclampsia, 

bleeding, smoking, 

multiple births, 

premature birth, 

congenital anomaly, 

incompetent cervix, 

smoking 

Three studies evaluated measures of gestational weight gain other than total gestational 

weight gain (Table 16).70,75,95 Two70,75 studies were of fair quality and one95 was of poor quality. 

These studies suggest reduced risk of LBW in association with increases in net, proportional, or 

other measures of change in weight gain. 

Results for total gestational weight gain and LBW. Results taken from a figure from a goodquality study of low-income black and Hispanic women showed the trend of decreasing LBW as 

maternal weight near term compared to the standard weight-for-height increased.106A 

population-based cohort study in New York City reported a protective effect for LBW (OR, 0.41; 

95% CI, 0.39-0.43) for women who gained more than 41 pounds compared with women who 

gained less than 41 pounds.71 A study in Denmark found that the risk of LBW was significantly 

reduced only for underweight women gaining at least 12 kg when compared to underweight 

women gaining less than 11 kg (OR, 0.5; 95% CI, 0.2-1.0).108 A study in Austria93 found that the 

odds ratio of LBW was 0.9 (95% CI, 0.85-0.95) for each 1 kg increase in gestational weight gain. 

A study among obese women also found that the risk of having a LBW infant was increased for 

low gestational weight gains.4 

Among low-income women the effect of weight gain varied by pregravid BMI;2 only among 

women of average weight was there a consistent decrease in LBW risk as gestational weight gain 

increased from < 15 pounds to ≥ 40 pounds. Mothers of average weight who gained less than 15 

pounds had an OR for delivering an LBW infant of 2.1 (95% CI, 1.6-2.6). The odds of LBW 

were substantially lower for women who gained more than 40 pounds (OR, 0.5; 95% CI, 0.4-

0.6). There was no reduction in the percentage of LBW infants for weight gains above 30 to 34 

pounds for overweight women, and for weight gains above 15 to 19 pounds for obese women. 

For overweight women gaining 30 to 34 pounds, the OR was 0.5 (95% CI, 0.3-0.8). The poorquality studies showed results in the same general direction.54,109
80

Table 16. Other gestational weight gain measures and LBW 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Johnson et al., 

199270

USA, prenatal 

clinics 

3,191 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

OR and 95% CI, for LBW 

G1: Net WG < 14.9 lbs 

(Reference) 

G2: Net WG 14.9-23.5 lbs 

G3: Net WG 24-33 lbs 

G4: Net WG > 33 lbs 

G1: 1.0 (Reference) 

G2: 0.51 (0.27-0.98) 

G3: 0.54 (0.28-1.04) 

G4: 0.38 (0.2-0.8) 

Maternal race, parity, 

pregravid BMI, height, 

pregravid weight, 

marital status, 

education, 

tobacco/alcohol/drug 

use, pregnancyinduced hypertension, 

gestational age, 

macrosomia, infant sex

Shepard 199875

USA, obstetrical 

practices in New 

Haven, CT 

2,301 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

%LBW 

G1: Proportional WG < median, 

underweight (BMI < 19.4) 

G2: Proportional WG < median, 

obese (BMI > 28.5) 

G3: Proportional WG > median, 

underweight (BMI < 19.4) 

G4: Proportional WG > median, 

Low-average BMI (19.5-22.4) 

G5: Proportional WG > median, 

High-average BMI (22.5-28.5) 

G6: Proportional WG > median, 

obese (BMI > 28.5) 

G1: 3.5% 

G2: 7.4% 

G3: 2.1% 

G4: 2.8% 

G5: 2.1% 

G6: 4.6% 

N/A 

Cherry et al., 

199395

USA, hospital 

599 

All weights/BMI 

Poor 

Pregravid weight: 

Measured by study 

investigators 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

%LBW for each shifting of EW 

category. 

Light: < 90% EW 

Normal: 90 to 110% of EW 

Heavy: > 110% EW 

G1: Heavy to normal 

G2: Normal to light 

G3: Normal to heavy 

G4: Light to normal 

G1: 5% 

G2: 32% 

G3: 3.1% 

G4: 2.7% 

N/A 

BMI, body mass index, CI, confidence interval; EW, expected weight; lb, pound; LBW, low birthweight; N/A, not applicable; OR, odds ratio; 

WG, weight gain 

Two fair-quality studies did not find a statistically significant association between total 

gestational weight gain and LBW, although the point estimates were in the expected 

direction.52,107 Among a cohort of Japanese women,52 for weight gain < 8.5 kg, the adjusted OR 

of LBW was 1.26 (95% CI, 0.57-2.75) and for weight gain > 12.5 kg, it was 0.62 (95% CI, 0.24-

1.62), when these groups were compared with women gaining between 8.5 and 12.5 kg. Another 

study found that inadequate weight gain was associated with an OR for LBW of 1.15 (95% CI, 

0.78-1.67);107 in this study, a dietitian determined inadequate weight gain status (exact criteria 

were not reported). 

Results for net, proportional, or other measures of change in weight gain and LBW. One 

study looked at the relationship between net weight gain (total gestational weight gain minus 

infant birthweight) and the risk of LBW; the risk decreased as net weight gain increased.70 Odds 
81

ratios reported are in comparison with women gaining < 14.9 pounds. For mothers gaining > 33 

pounds, the OR was 0.38 (95% CI, 0.2-0.8); for women gaining 24 to 33 pounds, the OR was 

0.54 (95% CI, 0.28-1.04); and for women gaining 14.9 to 23.5 pounds, the OR was 0.51 (95% 

CI, 0.27-0.98) The association between risk of LBW infants and proportional weight gain (total 

gestational weight gain divided by pregravid weight) above and below the median was also 

evaluated in relation to BMI status.75 Obese women had a higher percentage of LBW infants than 

underweight women. The risk of LBW was even higher for women gaining less than the median. 

A study of adolescent mothers (rated poor quality) showed similar effects. Mothers who 

shifted to lower weight classes during pregnancy were more likely to have LBW babies, and 

mothers who progressed to higher weight classes had lower percentages of LBW.95

Macrosomia. 

Study characteristics. Twelve studies examined the influence of gestational weight gain on 

macrosomia in their infants (Evidence Table 20).2,4,49,59,70,77,93,108,110-113 Studies did not define 

macrosomia consistently. Four studies defined macrosomia as birthweight > 4,500 g.2,108,110,113

Seven of the remaining eight studies defined macrosomia as birthweight > 4,000 

g.4,59,70,77,93,111,112 One study applied both definitions.49 One110 study was rated to be of good 

quality, nine2,4,70,77,93,108,111-113 of fair quality, and two49,59 of poor quality.

Overview of results. In four studies (all fair2,108,110,113) defining macrosomia as birth > 4,500 g 

and seven (6 fair4,70,77,93,111,112 and 1 poor59) studies defining macrosomia as birthweight > 4000 

g, the highest weight gains were demonstrated to be associated with macrosomia. A single poor 

study failed to show a significant association, using either definition of macrosomia.49

Detailed results. In four of the studies in which macrosomia was defined as birthweight 

> 4,500 g,2,108,110,113 the highest weight gains were associated with increased risk of macrosomia 

(Table 17). These four studies adjusted for multiple confounders such as age, BMI, race, parity, 

glucose levels, placental weight, smoking status, gestational age, and infant sex.2,108,110,113 A 

nested case-control study (rated good quality), using women gaining 0.22 to 0.31 kg per week as 

the reference group, found that women with the highest rates of pregnancy weight gain (0.40 to 

1.03 kg/week) were at increased risk for macrosomia (OR,2.23; 95% CI, 1.54-3.22) and that 

women with the lowest rates (-0.26 to 0.21 kg/week) were at decreased risk (OR,0.52; 95% CI, 

0.34-0.79).110 Results were similar when considering rates of weight gain only before 24 to 28 

weeks of gestation. 

A fair-quality study in Denmark also showed increased risk of macrosomia at the highest 

weight gains, with the highest risks among overweight and obese women.108 However, the 

confidence intervals from this study are very imprecise. A fair-quality study in Norway showed 

similar results, with increasing ORs as weight gain increased. Women with weight gain in the 

fourth quartile, as compared to weight gain in the first quartile, had the highest OR of 4.3 (95% 

CI, 1.9-9.8).113
82

Table 17. Gestational weight gain and macrosomia > 4,500 g 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Hedderson et al., 

2006110

USA, Kaiser 

Permanente Medical 

Care Program 

45,245 

All weights/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

ORs and 95% CI, for 

macrosomia based on rate 

of weight gain 

Rate of gain kg/wk: 

G1: -0.26 to 0.21 

G2: 0.22 to 0.31 

(Reference) 

G3: 0.32 to 0.39 

G4: 0.40 to 1.03 

G1: 0.52 (0.34-0.79) 

G2: 1.00 

G3: 0.99 (0.67-1.47) 

G4: 2.23 (1.54-3.22) 

Maternal age, 

maternal 

race/ethnicity, 

parity, pregravid 

BMI, screening 

glucose value, 

gestational age 

Clausen et al., 2005113

Norway, university 

hospital 

2050 

All weights/BMI 

Fair 

Pregravid weight: 

Routine prenatal 

care 

Total weight gain: 

Routine prenatal 

care of maternity 

records 

ORs and 95% CIs for 

macrosomia 

G1: WG, Quartile 1 

(Reference) 

G2: WG, Quartile 2 

G3: WG, Quartile 3 

G4: WG, Quartile 4 

G1: 1.0 

G2: 2.1 (0.8-5.1) 

G3: 3.5 (1.5-8.0) 

G4: 4.3 (1.9-9.8) 

Maternal age, 

parity, smoking, 

placental weight, 

gestational 

diabetes, first 

trimester BMI 

Cogswell et al., 19942

USA, Pregnancy 

Nutrition Surveillance 

System 

53,541 

Normal/Overweight/ 

Obese 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

ORs and 95% CIs for 

macrosomia by GWG and 

prepregnancy BMI 

G1: Normal BMI, GWG 25-

29 lbs (Reference for 

normal BMI) 

G2: Normal BMI, GWG 35-

39 lbs 

G3: Normal BMI, GWG ≥ 40 

lbs 

G4: Overweight BMI, GWG 

15-19 lbs (Reference for 

overweight BMI) 

G5: Overweight BMI, GWG 

≥ 40 lbs 

G6: Obese, GWG 15-19 lbs 

(Reference for obese GMI) 

G7: Obese BMI, GWG 30-

34 lbs 

G8: Obese BMI, GWG 35-

39 lbs 

G9: Obese BMI, GWG ≥ 40 

lbs 

G1: 1.0 

G2: 1.5 (1.0-2.3) 

G3: 3.3 (2.3-4.7) 

G4: 1.0 

G5: 4.0 (1.6-10.1) 

G6: 1.0 

G7: 1.9 (1.3-2.9) 

G8: 2.1 (1.3-3.2) 

G9: 2.3 (1.6-3.3) 

Maternal age, 

maternal race, 

height, smoking, 

infant sex, 

gestational age 

BMI, body mass index; CI, confidence interval; GWG,gestational weight gain; kg, kilogram; kg/wk, kilogram per week; N/A, not applicable; OR, 

odds ratio; wk, week. 
83

Table 17. Gestational weight gain and macrosomia > 4,500 g (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Zhou and Olsen, 

1997108

Denmark, two 

communities 

7,122 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

OR and 95% CI, for 

macrosomia by GWG 

categories and BMI 

G1: GWG < 11 kg, 

underweight (Reference) 

G2: GWG < 11 kg, normal 

weight 

G3: GWG < 11 kg, 

overweight 

G4: GWG 12-15 kg, 

underweight, 

G5: GWG 12-15 kg, normal 

weight 

G6: GWG 12-15 kg, 

overweight 

G7: GWG ≥ 16 kg, 

underweight 

G8: GWG ≥ 16 kg, normal 

weight 

G9: GWG ≥ 16 kg, 

overweight 

G1: 1.0 

G2: 52.8 (0.3-22.9) 

G3: 9.7 (1.2-81.8) 

G4: 0.0 (0.0-7x105) 

G5: 6.8 (0.9-51) 

G6: 27.1 (3.3-220) 

G7: 6.1 (0.7-52.5) 

G8: 15.7 (2.2-114) 

G9: 45.6 (6.0-349) 

Maternal age, 

parity, alcohol, no 

diabetes, term 

delivery, smoking, 

infant sex, 

gestational age 

Brennand et al., 200549

Canada, medical 

records 

603 

Normal/Overweight/ 

Obese 

Poor 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

% Macrosomia among 

obese women only 

G1: Low WG, < 7 kg 

G2: Acceptable WG, 7-11.5 

kg 

G3: Excessive WG, > 11.5 

kg 

G1: 16.9% 

G2: 15.3% 

G3: 18.4% 

(P = 0.834) 

N/A 

Among low-income women enrolled in the Supplemental Food Program for Women, Infants, 

and Children (WIC), a fair-quality US study reported significant associations between weight 

gain and macrosomia only for women gaining more than 30 to 34 pounds when compared with 

women gaining 25 to 29 pounds for women of normal weight or with women gaining 5 to 19 

pounds for overweight and obese women.2

 For average-weight women, the OR was 1.5 (95% CI, 

1.0-2.3), for those gaining 35 to 39 pounds and 3.3 (95% CI, 2.3-4.7) for women gaining 40 

pounds or more. Overweight women also had high risks for macrosomia, but only at weight 

gains of 40 pounds or more (OR, 4.0; 95% CI, 1.6-10.1). The OR among obese women gaining 

30 to 34 pounds was 1.9 (95% CI, 1.3-2.9). Similar results were found for obese women gaining 

more than 35 pounds with odds ratios ranging from 2.1 to 2.3. 

In a US study of Cree women (rated poor quality), weight gain among obese women was not 

significantly associated with macrosomia.49

Of the eight studies that considered macrosomia as > 4,000 g, seven found a significant 

association between gestational weight gain and macrosomia (Table 18).4,59,70,77,93,111,112 In 
84

general, the highest weight gains were associated with an increased risk of macrosomia. 

Six4,70,77,93,111,112 of these studies were rated of fair quality, and one59 of poor quality. These 

studies were adjusted for multiple confounders including maternal age, race, education, parity, 

height, pregravid weight, pregravid BMI, distantia cristarum, length of gestation, glucose levels, 

smoking status, and infant sex. 

Table 18. Gestational weight gain and macrosomia > 4,000g 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Bergmann et al., 

2003112

Germany, Berlin 

Perinatal Registry 

206,308 

All weights/BMI 

Fair 

Pregravid weight: 

Not stated 

Total weight gain: 

Not stated 

ORs and 95% CIs of 

macrosomia 

G1: WG < 10 kg 

(Reference) 

G2: WG 10-16 kg 

G3: WG ≥ 16 kg 

G1: 1.0 

G2: 1.85 (1.77-1.93) 

G3: 3.37 (3.22-3.53) 

Pregravid BMI, height, 

parity, smoking, 

diabetes, postterm 

delivery 

Jain et al., 200777

USA, birth 

certificate records 

and Pregnancy 

Risk Assessment 

Monitoring 

System 

7,661 

All weights/BMI 

Fair 

Pregravid weight: 

Not stated 

Total weight gain: 

Birth certificate 

ORs and 95% CIs for 

macrosomia 

G1: WG ≤ 15 lbs 

G2: WG 15-24 lbs 

G3: WG 25-35 lbs 

G4: WG ≥ 35 lbs 

G1: 0.49 (0.30-0.82) 

G2: 1.0 

G3: 1.17 (0.82-1.65) 

G4: 2.83 (2.04-3.92) 

Maternal age, pregravid 

BMI, parity, education, 

race/ethnicity, 

US/foreign origin 

Johnson et al., 

199270

USA, prenatal 

clinics 

3,191 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

OR and 95% CI, for 

macrosomia 

G1: Net WG < 14.9 lbs 

(Reference) 

G2: Net WG 14.9-23.5 lbs

G3: Net WG 24-33 lbs 

G4: Net WG > 33 lbs 

G1: 1.0 

G2: 1.20 (0.83-1.75) 

G3: 1.77 (1.24-2.52) 

G5: 2.86 (2.02-4.02) 

Maternal race, parity, 

pregravid BMI, height, 

pregravid weight, 

marital status, 

education, 

tobacco/alcohol/drug 

use, pregnancy-induced 

hypertension, 

gestational age, 

macrosomia, infant sex 

BMI, body mass index; CI, confidence interval; GA, gestational age; GWG, gestational weight gain; lbs, pounds; OGTT, oral glucose tolerance 

test; OR, odds ratio; WG, weight gain. 
85

Table 18. Gestational weight gain and macrosomia > 4,000g (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Kiel et al., 20074

USA, birth 

certificate registry 

120,251 

Obese 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Odds of macrosomia 

for WG > 25 lbs 

G2: OR of macrosomia 

for WG < 15 lbs 

G3: Reference WG 15-25 

lbs 

G1: Odds of 

Macrosomia are 

higher for women in 

this group 

G2: Odds of 

Macrosomia are 

lower for women in 

this group 

Numerical value for 

ORs not reported in 

study 

Maternal age, maternal 

race, maternal 

education, poverty, 

smoking, parity, chronic 

hypertension 

Kirchengast and 

Hartmann 200393

Austria, university 

hospital 

8,011 

All weights/BMI 

Fair 

Pregravid weight: 

Estimated from 

measured weight at 

first prenatal visit 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: OR and 95% CI, for 

Macrosomia 

G1: 1.07 (1.05-1.10) Maternal age, pregravid 

weight, height, distantia 

cristarum 

Takimoto et al., 

2006111

Japan, obstetric 

units 

112,257 

All weights/BMI 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs and 95% CI, for 

macrosomia 

G1: Total GWG < 25th 

percentile for GA 

G2: Total GWG 25-49th 

percentile for GA 

G3: Total GWG 50-74th 

percentile for GA 

(Reference) 

G4: Total GWG 75-89th 

percentile for GA 

G5: Total GWG ≥90th 

percentile for GA 

G1: 0.31 (0.20,-0.47) 

G2: 0.49 (0.34-0.70) 

G3: 1.0 

G4: 1.62 (1.24-2.12) 

G5: 2.41 (1.83-3.17) 

Maternal age, parity, 

pregravid weight, 

gestational age, infant 

sex 

Brennand et al., 

200549

Canada, medical 

records 

603 

Normal/Overweight/Obese 

Poor 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal care 

or maternity records 

% Macrosomia among 

obese women only 

G1: Low WG, < 7 kg 

G2: Acceptable WG, 7-

11.5 kg 

G3: Excessive WG, 

> 11.5 kg 

G1: 47.0% 

G2: 42.9% 

G3: 54.4% 

(P = 0.234) 

N/A 
86

Table 18. Gestational weight gain and macrosomia > 4,000g (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Jensen et al., 

200559

Denmark, 

university 

hospitals 

481 

Obese 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs and 95% CIs for 

Macrosomia 

G1: GWG < 5.0 kg 

(Reference) 

G2: GWG 5.0-9.9 kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0 kg 

G1: 1.0 

G2: 1.8 (0.8-3.8) 

G3: 2.2 (1.0-4.7) 

G4: 4.0 (1.8-9.0) 

Maternal age, pregravid 

BMI, gestational age, 2-

hour OGTT, parity, 

smoking, ethnicity, 

clinical center 

Among the fair-quality studies of gestational weight gain on macrosomia, ORs for this 

association were between 2.41 and 3.37 for the highest weight gains when compared to weight 

gains within the normal range.70,77,111,112 Among a cohort of Japanese women (fair-quality study), 

the group with total weight gain above the 90th percentile for gestational age had an OR for 

macrosomia of 2.41 (95% CI, 1.83-3.17) relative to the group in the 50th to 74th percentile.111

The effect was reduced for total weight gain based on percentile for gestational age for the lower 

percentile ranges. A fair-quality US study looked at the association between net weight gain 

(total gestational weight gain minus infant birthweight) and macrosomia.70 With women gaining 

< 14.9 pounds as the reference group, the strongest effect was noted among women gaining > 33 

pounds (OR, 2.86; 95% CI, 2.02-4.02), followed by women gaining 24 to 33 pounds (OR, 1.77; 

95% CI, 1.24-2.52); no significant effect was observed for women gaining 14.9 to 23.5 pounds. 

A fair-quality study in Germany found a higher risk of macrosomia for women gaining more 

than 16 kg as compared to women gaining less than 10 kg (OR, 3.37; 95% CI, 3.22-3.53).112

Similar results were noted in a fair-quality US study where weight gains above 35 pounds (as 

compared to weight gains of 15 to 25 pounds) were associated with an OR for macrosomia of 

2.83 (95% CI, 2.04-3.92).77 A fair-quality study in Austria found that for each 1 kg increase in 

gestational weight gain, the OR for macrosomia was 1.07 (95% CI, 1.05-1.10).93 Of the poorquality studies, one found results in a similar direction.59 One poor-quality study among obese 

Cree women found that the percent macrosomia did not differ between weight gain groups.49 

Size based on gestational age. 

Study characteristics. Twenty-five articles from 23 studies examined the association between 

gestational weight gain and large-for-gestational-age (LGA) and small-for-gestational-age (SGA) 

infants.4,51,58,59,61,66,68,89,95,100,105,108,111,114-123 These investigators used various definitions to 

classify both LGA and SGA infants. Some defined LGA as birthweight greater than the 90th 

percentile or more than 2 standard deviations (SD) above the mean. Some defined SGA as 

birthweight less than the 10th (or 15th) percentile or more than 2 (or 1.5) SD below the mean. 

Of the 14 articles addressing LGA (Evidence Table 21),4,54,58,59,61,68,100,105,115,116,118,120-122 two 

defined LGA using the > 2 SD criterion.58,120 Ten used the commonly applied 90th percentile 

definition;4,54,59,61,100,105,115,116,118,121 one study evaluated multiple percentiles;68 and one defined 
87

LGA as fetal growth ratio (FGR) > 1.15.122 FGR is the ratio of the observed birthweight at a 

given gestational age to the mean birthweight at a given gestational age for a certain fetal growth 

distribution. 

SGA definitions varied considerably as well: birthweight < 10th percentile; < 2 (or 1.5) SD 

below the mean; FGR < 0.85; or a combination of birthweight and percentile of placenta weight. 

If a study used a definition other than birthweight < 10th percentile, the specific criterion used 

will be noted in the text below. In general, the lowest weight gains were associated with 

increased risks for SGA. 

Overview of results for LGA. Among the studies that did not use BMI status (Table 19), 

six100,105,115,118,121,122 were rated of fair quality and four54,59,68,120 of poor quality. All reported 

lower risks of LGA with lower gestational weight gain. Studies that stratify by BMI status 

present greater challenges to synthesis. Two studies (1 good116 and 1 fair58) examined a range of 

BMI categories, and found inconsistent results: one reported that the estimates of LGA did not 

differ greatly across BMI categories116 while the other reported that high weight gain (> 16 kg) 

was strongly associated with LGA, and this association was most pronounced in the lowest BMI 

categories. A fair-quality study of obese women4

 observed lower odds of LGA among women 

who gained less than the reference group (15-25 pounds) and higher odds of LGA among women 

who gained more the reference group. A poor-quality study among Japanese women found that 

nulliparous women in the highest weight gain category (> 0.40 kg/week) had ORs for LGA of 

2.25 (95% CI, 1.03-4.94) for low BMI women and 2.58 (95% CI, 1.71-3.89) for medium BMI 

women.61

Table 19. Gestational weight gain and LGA 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Bo et al., 2003115

Italy, university clinic 

700 

All weights/BMI 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Not collected

G1: OR and 95% CI, 

for LGA for each 1 kg 

increase in GWG

G1: 1.08 (1.03-1.12) Maternal age, 

pregravid BMI, 

smoking, 

gestational 

hyperglycaemia

Kitajima et al., 2001121

Japan, university 

hospital 

146 

All weights/BMI 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records

G1: OR and 95% CI, 

for LGA for each 1 kg 

increase in GWG

G1: 1.08 (0.81-1.44) Pregravid BMI, 

maternal plasma 

glucose levels, 

gestational age, 

infant sex

BMI, body mass index; CI, confidence interval; g, grams; GDM, gestational diabetes mellitus; GWG: gestational weight gain; kg, kilogram; lbs, 

pounds; LGA, large-for-gestational-age; N/A, not applicable; NS, non-significant; OR, odds ratio; SD: standard deviation; USCF, University of 

Southern California at San Francisco; WG, weight gain. 
88

Table 19. Gestational weight gain and LGA (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Kramer et al., 1990122

Canada, university 

hospital 

8,719 

All weights/BMI 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records

G1: OR and 95% CI, 

for LGA for each 5 kg 

decrease in net 

gestational WG

G1: 0.73 (0.68-0.79) Pregravid weight, 

infant sex, smoking, 

parity, maternal 

diabetes, height, 

previous LBW 

infant, severe 

pregnancy-induced 

hypertension

Muscati et al., 1996105

Canada, public health 

department 

371 

All weight/BMI 

Fair

Pregravid weight: 

Medical records 

Total weight gain: 

Collected by study 

investigators

G1: OR for LGA per 1 

kg increase in WG up 

to week 20 

G2: OR for LGA per 1 

kg increase in WG 

from weeks 21 to 30 

G3: OR for LGA per 1 

kg increase in WG 

from weeks 31 to term

G1: 1.17 (P < 0.001) 

G2: 1.16 (P < 0.01) 

G3: 1.02 (P = NS)

Parity, pregravid 

standard weight, 

pregravid excess 

weight, birth length, 

infant sex

Parker and Abrams, 

1992118

USA, hospital 

6,690 

All weights/BMI 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records

ORs and 95% CIs of 

LGA for high WG 

G1: Compared to 

UCSF Cohort 25-75th 

percentile of WG 

G2: Compared to 

UCSF 10-90th 

percentile of WG 

G1: 1.89 (1.51-2.37) 

G2: 1.87 (1.39-2.52)

Maternal age, 

maternal race, 

parity, gestational 

age, smoking, 

pregravid BMI, 

height

Pezzarossa et al., 

1996100

Italy, not stated 

192 

All weights/BMI 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records

Relative risks for LGA 

G1: GWG < 9 kg 

G2: GWG 9-14 kg

G1: Relative risks for 

LGA similar between 

non-diabetic and GDM 

groups 

G2: GDM group has 2 

times higher risk that 

non-diabetics 

Numerical results not 

reported.

Pregravid BMI, 

fasting plasma 

glucose 

Bianco et al., 199854

USA, medical center 

613 

Morbidly obese 

(BMI > 35) 

Poor

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records

% LGA for GWG: 

G1: Weight loss or 0 

lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs

G1: 12.0 

G2: 11.8 

G3: 18.8 

G4: 25.8 

G5: 23.8 

(P < 0.01)

N/A
89

Table 19. Gestational weight gain and LGA (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Ekblad and Grenman, 

199268

Finland, hospital 

357 

Prepregnancy weight 

20% over or under ideal 

body weight for height 

and normal weight 

Poor

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal 

care or maternity 

records

Infant BW by group 

Infant weight 

percentile for mothers 

with normal pregravid 

weight and normal 

weight gain 

G1: < 2.5% 

G2: 2.5-10% 

G3: 10-50% 

G4: 50-90% 

G5: 90-97.5% 

G6: > 97.5% 

Infant weight 

percentile for mothers 

with weight gain ≤5 kg

G7: < 2.5% 

G8: 2.5-10% 

G9: 10-50% 

G10: 50-90% 

G11: 90-97.5% 

G12: > 97.5% 

Infant weight 

percentile for mothers 

with weight gain ≥20 

kg 

G13: < 2.5% 

G14: 2.5-10% 

G15: 10-50% 

G16: 50-90% 

G17: 90-97.5% 

G18: > 97.5%

G1: 1% 

G2: 6% 

G3: 35% 

G4: 43% 

G5: 13% 

G6: 2% 

 

G7: 3% 

G8: 14% 

G9: 32% 

G10: 34% 

G11: 14% 

G12: 3% 

G13: 0% 

G14: 2% 

G15: 42% 

G16: 29% 

G17: 20% 

G18: 7%

N/A

Jensen et al., 200559

Denmark, university 

hospitals 

481 

Obese 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

ORs and 95% CIs for 

LGA 

G1: GWG < 5.0 kg 

(Reference) 

G2: GWG 5.0-9.9 kg 

G3: GWG 10.0-14.9 

kg 

G4: GWG ≥ 15.0 kg 

G1: 1.0 

G2: 2.4 (1.1-5.3) 

G3: 2.1 (1.1-4.8) 

G4: 4.7 (2-11) 

Maternal age, 

pregravid BMI, 

gestational age, 2 

hour OGTT, parity, 

smoking, ethnicity, 

clinical center 

Sunehag et al., 1991120

Italy, prenatal clinics 

133 

All weights/BMI 

Poor 

Pregravid weight: 

Not stated 

Total weight gain: 

Not stated 

G1: Association 

between LGA and 

GWG > 18 kg 

G1: χ2

 = 8.2 

(P < 0.005) 

N/A 
90

Detailed results. Among the studies that did not use BMI status (Table 19), three fair-quality 

studies that evaluated the impact of a 1 kg increase in weight gain produced similar 

results.105,115,121 For Italian women, the OR of having an LGA infant was 1.08 (95% CI, 1.03-

1.12).115 For nondiabetic Japanese women with a positive diabetic screen, the OR was 1.08 (95% 

CI, 0.81-1.44).121 The third study evaluated this relationship separately for weight gain by time: 

up to week 20, from week 21 to week 30, and from week 31 to term. It found ORs of 1.17, 1.16, 

and 1.02 (non-significant), respectively.105 The OR for weeks 31 to term was not significant. In 

other words, the odds of giving birth to an LGA infant tends to increase for each 1 kg increase in 

gestational weight gain during the first and second trimester. 

Two fair-quality studies100,118 considered the association between categorical weight gain and 

LGA. In a US study,118 women with the highest weight gains were at increased risk for LGA 

(OR,1.89; 95% CI, 1.51-2.37) relative to women in the 25th to 75th percentile of weight gain and 

to women in the 10th to 90th percentile (OR. 1.87; 95% CI, 1.39- 2.52). In a study involving 

mothers with GDM,100 the risks for LGA were similar for weight gains up to 9 kg. However, for 

weight gains of 9 to 14 kg, the risk of LGA for mothers with GDM was two times that for 

nondiabetic mothers. 

In a study that defined LGA as FGR > 1.15,122 the OR for having an LGA infant given a 5 kg 

decrease in net gestational weight gain (total gestational weight gain minus infant birthweight) 

was 0.73 (95% CI, 0.68-0.79). This result is consistent with other studies reporting that the odds 

of LGA drops with lower gains in maternal weight. 

The poor-quality studies showed similar results. LGA was significantly related to the highest 

weight gains among studies of GDM mothers,120 obese glucose-tolerant mothers,59 and morbidly 

obese mothers.54 A Finnish study68 noted that women gaining ≥ 20 kg were more likely to have 

babies in the higher weight gain percentile categories, but these differences were not 

significantly different. 

Four studies stratified results by BMI status (Table 20).4,58,61,116 In a good-quality US study, 

the estimates of LGA did not differ greatly across BMI categories.116 The ORs of LGA for rate 

of weight gain of 50 g per week were as follows: among underweight women, 1.25 (95% CI, 

1.11-1.41); among women of normal weight, 1.14 (95% CI, 1.08-1.20); and among overweight 

and obese women, 1.14 (95% CI, 1.07-1.20). In a fair-quality study based on the Swedish birth 

registry,58 high weight gain (> 16 kg) was strongly associated with LGA, and this association 

was most pronounced in the lowest BMI categories. In comparison with the risk of LGA among 

women with weight gain between 8 and 16 kg (the reference group), adjusted ORs by BMI 

categories were as follows: BMI < 20, 3.26 (95% CI, 2.76-3.86); BMI ≥ 35, 1.54 (95% CI, 1.24-

1.90). 
91

Table 20. Gestational weight gain and LGA by BMI status 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Caulfield et al., 1998116

USA, hospital obstetric 

database 

3,870 

All weights/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

ORs and 95% CIs for 

LGA per 50g/wk 

increase in rate of 

weight gain by BMI 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

G1: 1.25 (1.11-1.41) 

G2: 1.14 (1.08,-1.20) 

G3: 1.13 (1.07-1.20) 

Maternal age, race, 

parity, pregravid 

BMI, height, 

hypertension, 

provider type, 

smoking, infant sex 

Cedergren, 200658

Sweden, Medical Birth 

Registry 

245,526 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

ORs and 95% CIs for 

LGA (> 2 SD above the 

mean) 

Weight gain < 8 kg 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

Weight gain > 16 kg 

G6: BMI < 20 

G7: BMI 20-24.9 

G8: BMI 25-29.9 

G9: BMI 30-34.9 

G10: BMI ≥ 35 

Weight gain 8-16 kg 

(Reference) 

G1: 0.43 (0.24-0.75) 

G2: 0.53 (0.47-0.61) 

G3: 0.48 (0.43-0.53) 

G4: 0.66 (0.59-0.75) 

G5: 0.54 (0.46-0.63) 

G6: 3.26 (2.76-3.86) 

G7: 2.73 (2.60-2.88) 

G8: 2.14 (2.01-2.28) 

G9: 2.24 (2.00-2.51) 

G10: 1.54 (1.24-1.90) 

Maternal age, 

parity, smoking, 

year of birth 

Kiel et al., 20074

USA, birth certificate 

registry 

120,251 

Obese 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

G1: Odds of LGA for 

weight gain > 25lbs 

G2: OR of LGA for 

weight gain < 15lbs 

G3: Reference weight 

gain 15-25 lbs 

G1: Odds of LGA are 

higher for women in this 

group 

G2: Odds of LGA are 

lower for women in this 

group 

Numerical value for ORs 

not reported in study 

Maternal age, 

maternal race, 

maternal education, 

poverty, smoking, 

parity, chronic 

hypertension 

BMI, body mass index; CI, confidence interval; g, grams; g/wk, gram per week; kg/wk, kilogram per week; LGA, large for gestational age; OR, 

odds ratio; SD, standard deviation; WG, weight gain. 
92

Table 20. Gestational weight gain and LGA by BMI status (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Wataba et al., 200661

Japan, academic 

medical center 

21,718 

All weights/BMI 

Poor 

Pregravid weight: 

Not stated 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

ORs and 95% CIs for 

LGA 

Nulliparous 

G1: Low BMI (< 18), 

WG > 0.40 kg/wk 

G2: Medium BMI (18-

23.9), WG 0.20-0.25 

kg/wk 

G3: WG 0.25-0.30 

kg/wk (Reference) 

G4: Medium BMI, WG 

0.30-0.35 kg/wk 

G5: Medium BMI, WG 

0.35-0.40 kg/wk 

G6: Medium BMI, WG 

> 0.40 kg/wk 

Parous 

G7: Low BMI (< 18), 

WG > 0.40 kg/wk 

G8: WG 0.20-0.25 

kg/wk (Reference for 

low/med BMI) 

G9: Medium BMI (18-

23.9), WG 0.25-0.30 

kg/wk 

G10: Medium BMI, WG 

0.30-0.35 kg/wk 

G11: Medium BMI, WG 

0.35-0.40 kg/wk 

G12: Medium BMI, WG 

> 0.40 kg/wk 

G13: High BMI (≥24), 

WG 0.15-0.20 kg/wk 

G14: WG ≥ 0.30 kg/wk 

(Reference for high 

BMI) 

G1: 2.25 (1.03-4.94) 

G2: 1.41 (1.31-1.76) 

G3: 1.0 

G4: 1.76 (1.38-2.23) 

G5: 2.34 (1.77-3.10) 

G6: 2.58 (1.71-3.89) 

G7: 2.16 (0.63-/7.44) 

G8: 1.0 

G9: 1.48 (1.15-2.33) 

G10: 1.64 (1.18-2.27) 

G11: 2.23 (1.51-3.31) 

G12: 3.94 (2.56-6.03) 

G13: 2.27 (1.31-3.95) 

G14: 1.0 

Preeclampsia, Csection, 1-minute 

Apgar score < 4 

In a fair-quality study of obese women,4 lower odds of LGA were observed among women 

who gained less than the reference group (15-25 pounds) and higher odds of LGA were observed 

among women who gained more the reference group. Minimal risk for LGA was observed at 

weight gains of 10 to 25 pounds for class I obese women (BMI 30-34.9), at gains of 0 to 9 

pounds for class II obese women (BMI 35-39.9), and at gains of 0 to 9 pounds for class II obese 

women (BMI ≥ 40). A poor-quality study among Japanese women found that nulliparous women 

in the highest weight gain category (> 0.40 kg/week) had ORs for LGA of 2.25 (95% CI, 1.03- 

4.94) for low BMI women and 2.58 (95% CI, 1.71-3.89) for medium BMI women.61

Eleven studies4,58,59,61,100,105,115,116,118,121,122 adjusted for potential confounders including age, 

pregravid BMI, glucose levels, smoking status, parity, and gestational age.
93

Overview of results for SGA. Twenty studies examined the relationship between gestational 

weight gain and SGA (Evidence Table 22).4,51,54,58,59,61,66,68,89,95,105,108,111,114,116,118,119,122-124 One 

study was of good quality,116 twelve of fair quality,19,24,53,69,72,76,79,83,85,89-91 and seven of poor 

quality.11,14,20,22,29,31,59 SGA births as a percentage of all births tended to be highest for the lowest 

weight gains. 

Detailed results for SGA. As with LGA results, we discuss results relating to the simple 

association between weight gain and risk for SGA separately (Table 21) from those that also take 

BMI status into account (Table 22). Among indigent US women (fair-quality study),89 the 

percentage of SGA infants was 9.9 among women gaining < 0.24 kg per week, and 5.7 among 

the group gaining ≥ 0.75 kg per week. Similar results were observed among a cohort of Japanese 

women (fair-quality study),111 which defined SGA as birthweight < 1.5 SD below the mean. The 

percentage of SGA infants ranged from 10.9 percent in the lowest weight gain group (< 25th 

percentile of weight gain) to 3.1 percent in the highest weight gain group (≥ 90th percentile of 

weight gain). Another fair-quality US study observed an increased incidence of SGA at low 

weight gains; the incidence among obese women with low weight gain was two times that 

among obese women with normal weight gain.118 Similar results were obtained in a poor-quality 

study of morbidly obese women.54

Table 21. Gestational weight gain and SGA 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Parker and Abrams, 

1992118

USA, hospital 

6,690 

All weights/BMI 

Fair

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records

ORs and 95% CIs 

of SGA for low 

WG 

G1: Compared to 

UCSF Cohort 25-

75th percentile of 

WG 

G2: Compared to 

UCSF 10-90th 

percentile of WG 

G1: 2.06 (1.62-2.63) 

G2: 1.82 (1.35-2.47))

Maternal age, 

maternal race, 

parity, gestational 

age, smoking, 

pregravid BMI, 

height

Cheng et al., 2004124

USA, birth certificate 

registry 

14,114 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Not stated 

OR and 95% CI, 

for SGA 

G1: WG < 0.2 

kg/wk 

G2: WG ≥ 0.2 

kg/wk (Reference)

G1: 1.9 (1.8-2.2) 

G2: 1.0 

Maternal age, 

education, 

Medicaid status, 

pregravid BMI, 

smoking, previous 

SGA, adequacy of 

prenatal care, 

maternal cardiac 

disease, 

preeclampsia, year 

of birth of second 

infant 

BMI, body mass index; CI, confidence interval; EW, expected weight; FGR, fetal growth ratio; G, group; GWG, gestational weight gain; kg, 

kilogram; kg/wk, kilogram per week; lb, pound; NS, non-significant; OR, odds ratio; SGA, small-for-gestational-age; WG, weight gain. 
94

Table 21. Gestational weight gain and SGA (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Cnattingius et al., 

1998123

Sweden, Medical 

birth register 

167,750 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs and 95% CIs 

for SGA 

G1: WG < 0.25 

kg/wk 

G2:WG 0.25-0.34 

kg/wk 

G3: WG 0.35-0.44 

kg/wk 

G4: ≥ 0.45 kg/wk 

(Reference) 

G1: 3.0 (2.5-3.5) 

G2: 1.9 (1.6-2.2) 

G3: 1.3 (1.1-1.5) 

G4: 1.0 

Maternal age, 

parity, pregravid 

BMI, height, 

education, mother 

living with father, 

smoking 

Dawes and 

Grudzinskas, 1991119

UK, hospital 

1,092 

All weights/BMI 

Fair 

Pregravid weight: 

Measured at first 

prenatal visit 

Total weight gain: 

Routine prenatal care 

or maternity records 

Average weekly 

weight gain < 0.20 

kg as a predictor 

of SGA 

G1: Sensitivity 

G2: Specificity 

G1: 12.9% 

G2: 91.3% 

Maternal age, 

parity, pregravid 

BMI, weight, 

smoking, 

gestational age 

Kiel et al., 20074

USA, birth certificate 

registry 

120,251 

Obese 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: Odds of SGA 

for weight gain > 

25lbs 

G2: OR of SGA for 

weight gain < 15 

lbs 

G3: Reference 

Weight gain 15-25 

lbs 

G1: Odds of SGA are 

lower for women in this 

group 

G2: Odds of SGA are 

higher for women in this 

group 

Numerical value for ORs 

not reported in study 

Maternal age, 

maternal race, 

maternal 

education, poverty, 

smoking, parity, 

chronic 

hypertension 

Kramer et al., 

1990122

Canada, university 

hospital 

8,719 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

G1: OR and 95% 

CI, for SGA for 

each 5 kg 

decrease in net 

gestational WG 

G1: 1.32 (1.20-1.44) Pregravid weight, 

infant sex, 

smoking, parity, 

maternal diabetes, 

height, previous 

LBW infant, severe 

pregnancyinduced 

hypertension 
95

Table 21. Gestational weight gain and SGA (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Muscati et al., 

1996105

Canada, public 

health department 

371 

All weight/BMI 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Collected by study 

investigators 

G1: OR for SGA 

per 1 kg increase 

in WG up to week 

20 

G2: OR for SGA 

per 1 kg increase 

in WG from weeks 

21 to 30 

G3: OR for SGA 

per 1 kg increase 

in WG from weeks 

31 to term 

G1: 0.93 (P = NS) 

G2: 0.85 (P < 0.01) 

G3: 0.89 (P < 0.01) 

Parity, pregravid 

standard weight, 

pregravid excess 

weight, birth 

length, infant sex 

Steward and Moser, 

2004114

USA, vital statistics 

data 

2,933 

All weights/BMI 

Fair 

Pregravid weight: 

Not stated 

Total weight gain: 

Self-report 

G1: OR and 95% 

CI, for SGA 

defined as FGR 

< 0.85 

G1: 0.98 (0.97-0.98) Maternal age, 

race, education, 

marital status, 

pregravid weight, 

adequacy of 

prenatal care, 

smoking, infant 

sex 

Takimoto et al., 

2006111

Japan, obstetric units 

112,257 

All weights/BMI 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs and 95% CI, 

for SGA 

G1: Total GWG 

< 25th percentile 

for GA 

G2: Total GWG 

25-49th percentile 

for GA 

G3: Total GWG 

50-74th percentile 

for GA 

(Reference) 

G4: Total GWG 

75-89th percentile 

for GA 

G5: Total GWG 

≥90th percentile 

for GA 

G1: 2.87 (2.56-3.21) 

G2: 1.49 (1.35-1.66) 

G3: 1.0 

G4: 0.55 (0.55-0.72) 

G5: 0.45 (0.45-0.63) 

Maternal age, 

parity, pregravid 

weight, gestational 

age, infant sex 
96

Table 21. Gestational weight gain and SGA (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Wen et al., 199089

USA, hospital 

Cohort 

17,149 

Fair 

Pregravid weight: 

Measured at first 

prenatal visit 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs for SGA 

G1: GWG < 0.24 

kg/wk 

G2: GWG 0.24-

0.57 kg/wk 

G3: GWG 0.58-

0.74 kg/wk 

(Reference) 

G4: GWG ≥ 0.75 

kg/wk 

G1: 2.24 (P < 0.05) 

G2: 1.55 (P < 0.05) 

G3: 1.0 

G4: 1.25 (NS) 

Maternal age, 

race, parity, 

marital status, 

education, 

previous preterm 

delivery, alcohol 

use, drug use, 

maternal height, 

maternal weight, 

smoking, infant 

sex 

Bianco et al., 199854

USA, medical center 

613 

Morbidly obese (BMI 

> 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

% SGA for GWG: 

G1: Weight loss or 

0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

G1: 4 

G2: 3.9 

G3: 5.6 

G4: 3.1 

G5: 3.8 

N/A 

Cherry et al., 199395

USA, hospital 

599 

All weights/BMI 

Poor 

Pregravid weight: 

Measured by study 

investigators 

Total weight gain: 

Routine prenatal care 

or maternity records 

%SGA for each 

shifting of EW 

category. 

Light: < 90% EW 

Normal: 90 to 

110% of EW 

Heavy: > 110% 

EW 

G1: Normal to 

Heavy 

G2: Light to 

Normal 

G3: Heavy to 

Heavy 

G4: Normal to 

Normal 

G5: Light to Light 

G6: Heavy to 

Normal 

G7: Normal to 

Light 

G1: 22% 

G2: 39% 

G3: 38% 

G4: 41% 

G5: 62% 

G6: 60% 

G7: 65% 

N/A 
97

Table 21. Gestational weight gain and SGA (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Ekblad and 

Grenman, 199268

Finland, hospital 

357 

Prepregnancy weight 

20% over or under 

ideal body weight for 

height and normal 

weight 

Poor 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal care 

or maternity records 

Infant BW by 

group 

Infant weight 

percentile for 

mothers with 

normal 

prepregnancy 

weight and normal 

weight gain 

G1: < 2.5% 

G2: 2.5-10% 

G3: 10-50% 

G4: 50-90% 

G5: 90-97.5% 

G6: > 97.5% 

Infant weight 

percentile for 

mothers with 

weight gain ≤5 kg 

G7: < 2.5% 

G8: 2.5-10% 

G9: 10-50% 

G10: 50-90% 

G11: 90-97.5% 

G12: > 97.5% 

Infant weight 

percentile for 

mothers with 

weight gain ≥20 kg

G13: < 2.5% 

G14: 2.5-10% 

G15: 10-50% 

G16: 50-90% 

G17: 90-97.5% 

G18: > 97.5% 

G1: 1% 

G2: 6% 

G3: 35% 

G4: 43% 

G5: 13% 

G6: 2% 

 

G7: 3% 

G8: 14% 

G9: 32% 

G10: 34% 

G11: 14% 

G12: 3% 

G13: 0% 

G14: 2% 

G15: 42% 

G16: 29% 

G17: 20% 

G18: 7% 

N/A 

Jensen et al., 200559

Denmark, university 

hospitals 

481 

Obese 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

Rates of SGA 

G1: GWG < 5.0 kg 

(Reference) 

G2: GWG 5.0-9.9 

kg 

G3: GWG 10.0-

14.9 kg 

G4: GWG ≥ 15.0 

kg 

No significant difference 

in rates of SGA by 

maternal weight gain 

group. Numerical results 

not reported in article. 

Maternal age, 

pregravid BMI, 

gestational age, 2 

hour OGTT, parity, 

smoking, ethnicity, 

clinical center 
98

Table 21. Gestational weight gain and SGA (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Lang et al., 199666

USA, hospital 

11,505 

All weights/BMI 

Poor 

Pregravid weight: 

Not stated 

Total weight gain: 

Not stated 

ORs and 95% CIs 

for SGA 

G1: WG ≤ 0.40 

lbs/wk 

G2: WG 0.40-0.65 

lbs/wk 

G3: WG 0.65-0.90 

lbs/wk (Reference)

G4: WG > 0.90 

lbs/wk 

G1: 2.8 (2.2-3.6) 

G2: 1.6 (1.4-1.9) 

G3: 1.0 (Reference) 

G4: 0.6 (0.5-0.7) 

Maternal age, 

race, parity, 

height, pregravid 

weight, maternal 

education, health 

insurance, planned 

pregnancy, 

previous induced 

abortion, previous 

spontaneous 

abortion, previous 

still birth, maternal 

morbidity, caffeine 

intake, marijuana, 

prenatal care, 

smoking, infant 

sex 

Table 22. Gestational weight gain and SGA by BMI status 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Caulfield et al., 

1998116

USA, hospital obstetric 

database 

3,870 

All weights/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs and 95% CIs for SGA 

per 50g/wk increase in rate 

of weight gain by BMI 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

G1: 0.87 (0.78-0.97) 

G2: 0.90 (0.84-0.96) 

G3: 0.93 (0.86-1.01) 

Maternal age, 

race, parity, 

pregravid BMI, 

height, 

hypertension, 

provider type, 

smoking, infant 

sex 

BMI, body mass index; cat, category; CI, confidence interval; G, group; g, gram; kg, kilogram; kg/wk, kilogram per week; lbs, pounds; med, 

medium; OR, odds ratio; SD, standard deviation; SGA, small-for-gestational-age. 
99

Table 22. Gestational weight gain and SGA by BMI status (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Cedergren, 200658

Sweden, Medical Birth 

Registry 

245,526 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs and 95% CIs for SGA 

(< 2 SD below the mean) 

Weight gain < 8 kg 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

Weight gain > 16 kg 

G6: BMI < 20 

G7: BMI 20-24.9 

G8: BMI 25-29.9 

G9: BMI 30-34.9 

G10: BMI ≥ 35 

Weight gain 8-16 kg 

(Reference) 

G1: 2.35 (1.92-2.88) 

G2: 1.99 (1.77-2.23) 

G3: 1.75 (1.48-2.07) 

G4: 1.68 (1.26-2.25) 

G5: 1.71 (1.03-2.85) 

G6: 0.50 (0.41-0.61) 

G7: 0.50 (0.45-0.56) 

G8: 0.57 (0.47-0.68) 

G9: 0.61 (0.40-0.93) 

G10: 0.50 (0.20-1.24) 

Maternal age, 

parity, smoking, 

year of birth 

Cheng et al., 2004124

USA, birth certificate 

registry 

14,114 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Not stated 

95% CIs of SGA for low 

weight gain (< 0.2 kg/wk) 

by BMI 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

G4: Obese 

G1: (1.2-2.4) 

G2: (1.9-2.7) 

G3: (1.6-2.9) 

G4: (1.4-2.1) 

Maternal age, 

education, 

Medicaid status, 

pregravid BMI, 

smoking, 

previous SGA, 

adequacy of 

prenatal care, 

maternal cardiac 

disease, 

preeclampsia, 

year of birth of 

second infant 

Zhou and Olsen, 

1997108

Denmark, two 

communities 

Cohort 

7,122 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal care 

or maternity records 

% Growth retardation 

(birthweight < 3,000g and 

placental weight > 490g) 

by weight gain category 

and BMI 

Weight gain < 11 kg 

G1: Underweight 

(Reference) 

G2: Normal 

G3: Overweight 

Weight gain 12-15 kg 

G4: Underweight 

G5: Normal 

G6: Overweight 

Weight gain > 16 kg 

G7: Underweight 

G8: Normal 

G9: Overweight 

G1: 1.0 

G2: 0.6 (0.4-0.8) 

G3: 0.6 (0.4-1.1) 

G4: 0.3 (0.2-0.5) 

G5: 0.4 (0.3-0.6) 

G6: 0.4 (0.1-1.0) 

G7: 0.3 (0.2-0.5) 

G8: 0.2 (0.1-0.3) 

G9: 0.2 (0.1-0.6) 

Maternal age, 

parity, alcohol, 

diabetes, term 

delivery, 

smoking, 

gestational age, 

infant sex 
100

Table 22. Gestational weight gain and SGA by BMI status (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Kabiru and Raynor, 

200451

USA, hospital 

5,131 

All weights/BMI 

Poor 

Pregravid weight: 

Measured at first 

prenatal visit 

Total weight gain: 

Routine prenatal care 

or maternity records 

% SGA 

G1: No change in BMI 

category 

G2: 1 category increase in 

BMI 

G3: > 1 category increase 

in BMI 

% SGA among overweight 

G4: No change in BMI 

category 

G5: 1 category increase in 

BMI 

G6: > 1 category increase 

in BMI 

G1: 19.5% 

G2: 13.5% 

G3: 9.5% 

G4: 14.2% 

G5: 9.9% 

G6: 11.5% 

N/A 

Wataba et al., 200661

Japan, academic 

medical center 

21,718 

All weights/BMI 

Poor 

Pregravid weight: 

Not stated 

Total weight gain: 

Routine prenatal care 

or maternity records 

ORs and 95% CIs for SGA 

Parous, Low BMI (< 18) 

G1: WG < 0.15 kg/wk 

G2: WG 0.15-0.20 kg/wk 

G3: WG 0.20-0.25 kg/wk 

G4: WG 0.25-0.30 kg/wk 

(Reference 

Parous, Medium BMI (18-

23.9) 

G5: WG < 0.15 kg/wk 

G6: WG 0.15-0.20 kg/wk 

G7: WG 0.20-0.25 kg/wk 

(Reference) 

Parous, High BMI (> 24) 

G8: WG < 0.15 kg/wk 

G9: WG 0.15-0.20 kg/wk 

(Reference) 

Nulliparous, Low BMI (< 18)

G10: WG < 0.15 kg/wk 

G11: WG 0.15-0.20 kg/wk 

G12: WG 0.20-0.25 kg/wk 

G13: WG 0.25-0.30 kg/wk 

(Reference 

Nulliparous, Medium BMI 

(18-23.9) 

G14: WG < 0.15 kg/wk 

G15: WG 0.15-0.20 kg/wk 

G16: WG 0.20-0.25 kg/wk 

G17: WG 0.25-0.30 

(Reference) 

G1: 5.42 (2.86-10.27) 

G2: 2.78 (1.53-5.06) 

G3: 1.39 (0.82-2.42) 

G4: 1.0 

G5: 2.21 (1.67-2.93) 

G6: 1.68 (1.23-2.07) 

G7: 1.0 

G8: 2.82 (1.17-6.78) 

G9: 1.0 

G10: 6.20 (2.72-14.09) 

G11: 2.58 (1.14-5.87) 

G12: 2.46 (1.19-5.08) 

G13: 1.0 

G14: 2.64 (1.88-3.71) 

G15: 1.60 (1.15-2.23) 

G16: 1.39 (1.03-1.87) 

G17: 1.0 

G18: 7.06 (2.11-23.61) 

G19: 1.0 

Preeclampsia, 

C-section, 1-

minute Apgar 

score < 4 
101

Table 22. Gestational weight gain and SGA by BMI status (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Wataba et al., 200661

(continued) 

 Nulliparous, High BMI 

(> 24) 

G18: WG < 0.05 kg/wk 

G19: WG 0.15-0.20 kg/wk 

(Reference) 

 

Six fair-quality studies24,53,76,83,90,91 evaluated the ORs for SGA and found that the lowest 

weight gains (as compared to normal weight gains) were associated with ORs between 1.82 and 

3.0. Among indigent US women,89 the risk of SGA was highest for mothers in the lowest weight 

gain category (< 0.24 kg/week) when compared with women gaining 0.58 to 0.74 kg per week 

(OR2.24; P < 0.05). A weaker association was observed for women gaining 0.24 to 0.57 kg per 

week (OR1.55; P < 0.05). A US study noted earlier also found that women with the lowest 

weight gains had an OR for an SGA infant of 2.06 (95% CI, 1.62-2.63) when compared with 

women gaining between the 25th and 75th percentile, and an OR of 1.82 (95% CI, 1.35-2.47) 

when compared with women gaining between the 10th and 90th percentiles.118 A US study found 

that the OR of SGA in a second pregnancy was 1.9 (95% CI, 1.8-2.2) for weight gains less than 

0.2 kg/wk as compared to weight gains greater than 0.2 kg/wk.124 The study of Japanese women 

noted earlier defined SGA as birthweight < 1.5 SD below the mean and gestational weight gain 

according to percentiles.111 Among women in the two lowest weight gain categories (very low 

and low) the ORs of SGA were 2.87 (95% CI, 2.56-3.21) and 1.49 (95% CI, 1.35-1.66), 

respectively, when compared with women in the moderate weight gain category. In addition, a 

significant protective effect was observed for the two highest weight gain categories. One study, 

using data from the Swedish Medical Birth Registry, observed higher rates of SGA (here defined 

as < 2 SD below the mean) among the lowest weight gain groups.123 Specifically, women 

gaining < 0.25 kg per week had an OR of 3.0 (95% CI, 2.5-3.5) when compared with women 

gaining ≥ 0.45 kg per week. The ORs decreased as gestational weight gain category dropped. 

Similar results were found in a study of obese women.4

Among white nonsmokers in Canada (fair-quality study),105 for each 1 kg increase in weight 

gain up to week 20, the OR of an SGA infant was 0.93 (not significant); for weight gain from 

weeks 21 to 30, it was 0.85 (P < 0.01); and for weight gain from week 31 to term, it was 0.89 

(P < 0.01). In other words, increases in weight gain from weeks 21 to term lowered a woman’s 

risk of an SGA infant. A fair-quality study of the predictors of SGA found that average weekly 

weight gain < 0.20 kg had 12.9 percent sensitivity and 91.3 percent specificity.119

Two fair-quality studies defined growth restriction using FGR, with SGA specified as an 

FGR < 0.85.79,89 In general, increases in weight gain were associated with lower risks of SGA. 

Specifically, one study found an OR of 0.98 (95% CI, 0.97-0.98) for each 1 kg increase in total 

gestational weight gain.114 Another study found an OR of 1.32 (95% CI, 1.20-1.44) for each 5 kg 

decrease in net gestational weight gain (total gestational weight gain minus infant 

birthweight).122 
102

In a poor US study,66 using women gaining 0.65 to 0.9 pounds per week as the reference 

group, women gaining ≤ 0.40 pounds per week had an OR for an SGA infant of 2.8 (95% CI, 

2.2-3.6), and women gaining 0.4 to 0.65 pounds per week an OR of 1.6 (95% CI, 1.4-1.9). In this 

study, however, women gaining > 0.9 pounds per week also experienced a significant protective 

effect against SGA (OR, 0.6; 95% CI, 0.5-0.7). 

The results from three14,20,31 poor-quality studies did not find statistically significant results. 

One study was among Finnish women,68 one defined SGA as birthweight < 2 SD below the 

mean,59 and one study was among morbidly obese women.54 A study among adolescents (also 

rated poor) looked at the proportion of infants who gained less than the median weight (instead 

of the 10th percentile).95 Mothers who shifted to higher weight classes had fewer infants who fell 

below the median for intrauterine growth; women who did not maintain their weight and shifted 

to lower weight classes were more likely to have infants below the median for intrauterine 

growth. 

Six studies presented stratified analyses by BMI (Table 22).11,19,22,72,81,91 In general, the risk 

of SGA among women with low weight gain decreased as BMI increased. 

A US database study (rated good quality) found that increasing rates of weight gain were 

associated with reduced risk of an SGA infant, with the risk decreasing with increasing BMI.116

Specifically, the ORs of SGA for each 50 g per week increase in maternal weight were as 

follows: 0.87 (95% CI, 0.78-0.97) for underweight mothers; 0.90 (95% CI, 0.84-0.96) for 

mothers of normal weight; and 0.93 (95% CI, 0.86-1.01) for overweight and obese women. In 

the Swedish birth registry study (rated fair quality), the risk of SGA was higher in the low weight 

gain group (< 8 kg), but the risk decreased with increasing BMI.58 Using women gaining 

between 8 and 16 kg as the reference group, these researchers reported that the OR for delivering 

an SGA infant for women with low weight gain (< 8 kg) was 1.71 (95% CI, 1.03-2.85) among 

women with a BMI ≥ 35; it was 2.35 (95% CI, 1.92-2.88) among women with a BMI < 20. 

Women gaining > 16 kg were at decreased risk for delivering an SGA infant, with the risk being 

similar between all BMI categories. 

Among nondiabetic women in Denmark (fair-quality study) for whom SGA was defined as 

birthweight < 3,000 g despite placenta weight being above the 66th percentile (491 g), women 

who gained more than 16 kg were at lower risk of delivering an SGA infant; this risk was the 

same regardless of BMI status.108 The risk of SGA decreased with increasing weight gain, and it 

also tended to decrease as BMI increased. In a US study, 95% CIs of the OR of SGA for low 

weight gain (< 0.2 kg/wk) compared to weight gain >0.2 kg/wk, were similar across BMI 

categories: underweight (95% CI, 1.2-2.4), normal weight (95% CI, 1.9-2.7), overweight (95% 

CI, 1.6-2.9), obese (95% CI, 1.4-2.1).124

A poor-quality study of the effect of changing BMI categories found that excessive weight 

gain (defined in various ways depending on BMI) was associated with lower rates of SGA for 

two groups of women: normal weight (excessive gain, > 35 pounds; P = 0.016) and overweight 

(excessive gain, > 25 pounds; P = 0.003); this association did not hold for obese women.51 A 

study among Japanese women (also poor quality) found high risks for SGA among nulliparous 

women with low BMI (< 18) and low rates of weight gain (< 0.15 kg/week).61 

Sixteen of these studies adjusted for multiple confounding factors such as age, pregravid 

BMI, smoking, glucose levels, parity, race, gestational age, marital status, height, education, and 

sex of infant.19,20,22,24,29,53,69,72,76,79,81,83,85,89-91
103

Apgar scores. 

Study characteristics. Four studies, set in Sweden,58 the United States,33,92 and Japan,61

examined the effect of gestational weight gain on Apgar scores (Evidence Table 23, Table 23). 

Apgar scores, calculated on the basis of five criteria (appearance, pulse, grimace, activity, 

respiration), range from 0 to 10. Three were cohort studies; the fourth was a case-control study 

examining outcomes of macrosomic infants (≥ 4,000 g) and normal-weight babies (2,500-3,999 

g).125

Overview of results. These four studies, three rated fair19,33,92 and one poor,61 did not provide 

consistent evidence on the direction or trend of effect. These studies inconsistently controlled for 

confounders. None controlled for a range of maternal pregnancy complications that could 

account for low Apgar scores.

Detailed results. Three studies examined 1-minute or 5-minute Apgar scores at two levels: 

> 7 or ≥ 7. Two found no association between gestational weight gain and Apgar scores.19,92 The 

third found increased ORs for gestational weight gain, after adjusting for prepregnancy weight 

quartile, height (tertile), BMI category, race, parity, hypertension, and other variables entered by 

stepwise regression model, but the authors provided no further details on the magnitude of the 

effect.70 

One poor-quality study examined associations between 1-minute Apgar scores > 4 and rates 

of weekly weight gain (7 categories), categorized differently across different BMI groups (3 

groups) and parity (2 categories), resulting in 42 comparisons.61 Two comparisons were 

statistically significant: (1) higher risk for low Apgar scores for nulliparous women with low 

BMI and lower-than-median weight gain for their peer group; and (2) higher risk for parous 

women with medium BMI with higher-than-median weight gain for their peer group. 
104

Table 23. Gestational weight gain and Apgar scores 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis

Cedergren, 200658 

Sweden, Medical 

Birth Registry 

245,526 

All weights/BMI 

Fair 

Pregravid weight: 

Self report, if unknown, 

standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Total weight gain: 

Measured when 

woman entered 

delivery unit 

Weight gain < 8 kg, 

8-16 kg, and >16 kg 

for each BMI class 

below 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥35 

No association 

between low weight 

gain and Apgar score 

(< 7), despite BMI of 

mother 

BMI, maternal age, 

parity, smoking in 

early pregnancy, year 

of birth 

Johnson et al., 

199270 

USA, prenatal clinics 

3,191 

All weights/BMI 

Fair 

Pregravid weight: 

Self report collected at 

first antepartal visit 

Total weight gain: 

Last prenatal visit 

G1: total weight gain 

< 16 lb 

G2: total weight gain 

16-25 lb 

G3: total weight gain 

26-35 lb 

G4: total weight gain 

> 35 lb 

Increased OR for 

gestational weight gain 

on 1-minute and 5-

minute Apgar score 

≤ 7, persists after 

adjusting (no further 

details provided) 

Prepregnancy weight 

quartile, height 

(tertile), BMI category, 

race, parity, 

hypertension, other 

variables entered by 

stepwise regression 

model 

AOR, adjusted odds ratio; BMI, body mass index; kg/wk, kilogram per week.
105

Table 23. Gestational weight gain and Apgar scores (continued) 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results

Confounders and 

Effect Modifiers 

Included in Analysis

Nixon et al., 1998125

USA, county nursemidwifery services 

2,228 

All weights (IOM) 

Fair 

Pregravid weight: 

Routine data forms, 

self report collected 

at first prenatal visit 

Total weight gain: 

Routine data forms, 

prenatal care or 

maternity records 

prior to delivery 

Continuous weight 

gain measure Gestational weight gain was 

not a predictor of Apgar 

scores < 7 

Age, parity, BMI 

Wataba et al., 

200661

Japan, academic 

medical center 

21,718 

All weights/BMI 

Poor 

Pregravid weight: 

Hospital database/ 

register 

Total weight gain: 

Hospital database/ 

record 

Rate of weight gain, 

categorized 

differently across 

different BMI groups 

AOR for 1 min Apgar scores 

< 4 for nulliparous women 

with low BMI, weekly weight 

gain < 15 kg/wk, compared 

with women gaining 0.25-0.3 

kg/wk: 12.24 (2.04-73.43) 

AOR for 1 min Apgar scores 

< 4 for parous women with 

medium BMI, weekly weight 

gain 0.35-0.4 kg/wk 

compared with women 

gaining 0.2-0.25 kg/wk: 2.21 

(1.08-4.53) 

No other relationships were 

significant 

Parity, baseline 

BMI 

Infant Outcomes 

Perinatal mortality. 

Study characteristics. Three studies, two set in the United States93,94 and one in Denmark,126

looked at the association between maternal weight gain and mortality, defined in one study as 

stillbirth126 and in two others as perinatal mortality (neonatal plus fetal deaths)93,94 (Table 24, 

Evidence Table 24). All three studies used different definitions of maternal weight gain: 

• weight gain per week;126 

• optimal weight gain127 defined as 36 to 40 pounds for underweight women, 31 to 40 

pounds for women of ideal prepregnancy weight, and 26 to 30 pounds for overweight 

women, based on associations between maternal prepregnancy weight, height, weight 

gain, and adverse perinatal outcomes; and 

• low weight gain (< 0.8 kg per week).128

Overview of results. One of these studies was rated poor quality128 and the others were rated 

fair. These studies suggest a protective effect of gestational weight gain on perinatal mortality 

but not on stillbirth. 
106

Table 24. Gestational weight gain and perinatal mortality 

Author, Date 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Bracero and Byrne, 

1997127

USA, hospital 

20,971 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report at first 

prenatal visit 

Total weight gain: 

Last prenatal 

assessment 

G1: Suboptimal 

weight gain 

G2: Optimal weight 

gain 

Perinatal mortality% 

G1: 0.6 

G2: 0.2 

P < 0.0001 

NA 

Nohr et al., 2005126

Denmark, National 

Birth Cohort 

54,505 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report of prepregnancy weight at 

first telephone interview 

between 9 and 24 

weeks weeks 

Total weight gain: 

Average weekly 

increase between self 

reported weights in first 

and second pregnancy 

interviews for women 

who provided a first 

interview between 9-24 

weeks, those who 

provided a second 

interview between 26 

and 38 completed 

weeks of gestation, and 

those who had at least 

6 weeks between 2 

interviews 

Weight per week for 

BMI groups 

(underweight < 18.5; 

18.5 ≤ normal weight 

< 25; 25 ≤

overweight < 30; and 

obese ≥ 30) 

Weight gain in 

pregnancy was not 

significantly associated 

with the risk of stillbirth 

for any BMI groups. 

AOR adjusted for 

age, height, parity, 

socio-occupational 

status, physical 

exercise, smoking, 

alcohol and coffee 

consumption 

Naeye, 1990128

USA, hospitals 

affiliated with medical 

schools 

56,857 

All weights/BMI 

Poor

Pregravid weight: 

Self-report at first 

antenatal care visit 

Total weight gain: 

Data from medical 

records after first 

trimester 

Low weight gain 

defined as < 0.8 

kg/week after the 

first trimester for 

pregravid BMI 

groups below: 

G1: BMI < 20 

G2: BMI 20-24 

G3: BMI 25-30 

G4: BMI > 30 

Attributable risk 

estimates for perinatal 

death for low pregnancy 

weight gain 

G1: 0.03 

(95% CI, 0.02-0.05) 

G2: 0.02 

(95% CI, 0.01-0.03) 

G3: 0.01 

(95% CI, 0.00-0.02) 

G4: 0.00 

Age 35-40, 

diabetes mellitus, 

hypertensive 

disorders, black, 

preterm birth, major 

congenital 

malformations, 

twins, neonatal 

respiratory distress 

syndrome 

AOR, adjusted odds ratio; BMI, body mass index; G, group; kg, kilogram. 

Results for categorical measures of weight gain. Both studies that focused on optimal or low 

weight gain found a protective effect of weight gain on infant mortality, but variations in the 

definition of maternal weight gain and the outcome do not allow quantification of the magnitude 

of the effect.93,94
107

Results for rate of weight gain. The study that examined associations between weight gained 

per week and stillbirth found no effect of weight gain on stillbirth within groups defined by 

BMI.126 It found increased risks of stillbirth with pregravid obesity and overweight status. This 

association between higher pregravid weight and stillbirth persisted after the investigators 

excluded women with obesity-related diseases (diabetes, preeclampsia, and other hypertensive 

disorders). Within this subset of women without obesity-related diseases (n = 39,187), the AOR 

for stillbirth related to an increased weight of 100 g per week was 0.94 (95% CI, 0.87-1.03). 

Neonatal distress. 

Study characteristics. A Swedish study examined the effects of gestational weight gain on 

fetal distress (equivalent to International Classification of Diseases [ICD] 9–codes 768.2–4; and 

ICD 10–codes P20.0, P20.1, and P20.9) using medical birth registry data from 245,526 singleton, 

term pregnancies over a 9-year period. (Evidence Table 25).58 Women were grouped by BMI 

status into three gestational weight gain categories: < 8 kg (low), 8 to 16 kg, and >16 kg (high). 

Overview of results. The results of this fair study show that after adjusting for maternal age, 

parity, smoking in early pregnancy, and year of birth, the authors reported that fetal distress was 

not significantly associated with low weight gain despite the BMI of the mother. Overweight and 

morbidly obese women with excessive weight gain did have an increased risk for fetal distress.

Detailed results. Compared with women with gestational weight gain of 8-16 kg, the OR for 

fetal distress among women gaining 16 kg or more was 2.15 (95% CI, 1.10-4.20) for women 

with BMI > 35 and 1.31 (95% CI, 1.05-1.53) for women with BMI 25-29.9. 

Neonatal hypoglycemia. 

Study characteristics. Two studies examined the effect of gestational weight gain on neonatal 

hypoglycemia (Evidence Table 26).75,96 One was a retrospective cohort study of 20,465 

women;129 the other110 was a retrospective case-control study using data from 45,245 singleton, 

live births from a US prepaid group practice health plan. The studies categorized gestational 

weight gain differently; one examined gestational weight gain as a dichotomous variable based 

on extremes of weight gain (< 7 kg and >18 kg),129 and the other used maternal rate of weight 

gain (total pregnancy weight gain minus infant birthweight divided by weeks of gestation when 

the last weight was measured) in kg per week.110 Hypoglycemia was defined by ICD codes129 or 

as at least one plasma glucose test result < 40 mg/dL.110 

In the case-control study,110 babies were identified as cases if they had the following 

complications: macrosomia (birthweight > 4,500 g), hypoglycemia (at least one plasma glucose 

< 40 mg/dL), or hyperbilirubinemia (at least one total serum bilirubin of 20 mg/dL or more). In 

general, hypoglycemic cases tended to be infants whose mothers were younger, nonwhite, and 

less educated than mothers of controls. More women with a prepregnancy BMI >29.0 appeared 

among the cases (22.9 percent) than the controls (17.6 percent).

Overview of results. The results of these studies (1 good110 and 1 fair129) suggest that 

gestational weight gain is associated with the risk of infant hypoglycemia.

Results. In the case-control study (rated good quality),110 after adjusting for age, raceethnicity, parity, plasma screening value, and gestational age at last weight measured, the authors 

found that women who gained in the highest bracket of weight gain per week (more than 0.40 

kg/week) had a increased risk of delivering an infant with hypoglycemia (AOR, 1.94; 95% CI, 

1.33-2.82) than women gaining 0.22 to 0.31 kg per week. 

Findings from the retrospective cohort study were similar.129 After controlling for several 

confounders, the authors found that weight gain of more than 18 kg was associated with 

hypoglycemia (AOR, 1.67; 95% CI, 1.13-2.46) when compared with weight gain of 11.5 to 16.0 

kg. 
108

Hyperbilirubinemia. 

Study characteristics. The retrospective case-control study described above also examined 

the effect of gestational weight gain on infant hyperbilirubinemia (Evidence Table 27).110

Overview of results. One good study110 suggested that increased gestational weight gain is 

associated with a higher risk of hyperbilirubinemia.

Detailed results. Compared with controls, the hyperbilirubinemia case group had more 

Asians (20.1 percent vs. 8.1 percent) and tended to be born at a gestational age < 37 weeks. 

Compared with women gaining 0.22 to 0.31 kg per week, women who gained in the highest 

bracket of weight gain/week (more than 0.40 kg/week) had an increased risk of delivering an 

infant with hyperbilirubinemia (AOR, 1.94; 95% CI, 1.33-2.82). 

Neonatal hospitalization. 

Study characteristics. One study investigated the influence of gestational weight gain on 

perinatal outcomes, including hospitalization of infant (Evidence Table 28).12 Using a hospitalbased, retrospective cohort study design, the authors studied 633 women who delivered live, 

singleton babies in Japan between 24 and 42 weeks’ gestation. Mean age of the women was 29.1 

and most were nulliparas. Most of the women gained between 8.5 and 12.5 kg (mean, 10.5 kg) 

during their pregnancy. Gestational weight gain was collected from maternity records and was 

based on last weight taken at the hospital prior to delivery. 

Overview of results. One fair study suggested that infants of women who gained less than 8.5 

kg during their pregnancy were 60 percent more likely to require hospitalization.12 

Detailed results. Overall, 13.3 percent had babies with complications requiring 

hospitalization, excluding admissions for phototherapy necessitated by neonatal jaundice. After 

adjusting for maternal age, parity, smoking, prepregnancy BMI, and gestational age, the authors 

did not find a significant relationship between gestational weight gain of less than 8.5 kg (AOR, 

1.60; 95% CI, 0.88-2.88) or weight gain greater than 12.5 kg (AOR, 0.93; 95% CI, 0.46-1.88) 

and hospitalization of infant. 

Other infant morbidity. 

Study characteristics. Two studies addressed other neonatal morbidity in association with 

gestational weight gain (Evidence Table 29); one was the large cohort study noted above,129and 

the other used a case-control design.130 Both studies relied on self-reported prepregnancy 

weights. Total weight gained during pregnancy was ascertained from prenatal records129 and 

women’s self-report.130 The studies differed on how gestational weight gain was categorized: the 

cohort study categorized gestational weight gain according to both the IOM recommendations 

(i.e., the woman was below, within, or above the IOM thresholds) and by extremes of weight 

gain (< 7 kg, > 15 kg); the case-control study defined gestational weight gain as a continuous 

variable. 

Overview of results. One fair study reported that gestational weight gain less than 7 kg was 

associated with neonatal seizure.129 Another fair study reported no significant association 

between infant leukemia and weight gain during pregnancy.130

Detailed results. The cohort study looked at the relationship between gestational weight gain 

and several adverse neonatal outcomes (birth trauma, 5-minute Apgar score < 7, need for assisted 

ventilation, SGA, LGA, umbilical cord arterial pH < 7.1, umbilical cord arterial base excess 

< 10, admission to the neonatal intensive care unit [NICU], admission to the special-care nursery 

[a step-down unit], neonatal infection, seizure, hypoglycemia, polycythemia, jaundice, 

meconium aspiration syndrome, respiratory distress or tachypnea, anemia, birth asphyxia, and 

perinatal death).129 The authors controlled for maternal age, race, parity, smoking, pregravid 

BMI, date of delivery, pregnancy-induced hypertension, mode of delivery, length of first stage of 

labor, length of second stage of labor, gestational age, and birthweight. Using weight gain of 
109

11.5 to 16 kg as a reference, the authors reported that gestational weight gain less than 7 kg was 

associated with neonatal seizure (AOR, 10.66; 95% CI, 2.17-52.36). Gestational weight gain >18 

kg was associated with assisted ventilation (AOR, 1.52; 95% CI, 1.16-2.00), seizure (AOR, 6.19; 

95% CI, 1.32-28.96), polycythemia (AOR, 1.59; 95% CI, 1.13-2.22), and meconium aspiration 

syndrome (AOR, 1.86; 95% CI, 1.13-3.05). 

The case-control study130 examined the association between maternal reproductive history, 

including gestational weight gain, and the risk of infant leukemia in 240 cases, defined as infant 

leukemia diagnosed at < 1 year of age, and 255 controls matched to cases by year of birth. 

Infants with infant leukemia were significantly (P < 0.003) less likely to be white (79.5 percent 

vs. 85.5 percent) and more likely to be Hispanic (10.5 percent vs. 3.5 percent) than controls. 

After adjusting for sex, race or ethnicity, maternal education, and prepregnancy BMI, the authors 

found no significant association between infant leukemia and weight gain during pregnancy. 

Infant BMI. 

Study characteristics. Two older studies examined the influence of gestational weight gain 

on the offspring’s BMI (Evidence Table 30). One cohort study comprised 8,719 singleton, liveborn infants from a hospital in Montreal, Canada, from 1980 to 1986.122 Of these mothers, 48 

percent were primiparas, 90 percent were married, and 87 percent had started prenatal care in the 

first trimester. The infant’s weight and length at birth was used to calculate BMI. Weight gain 

was expressed as total weight gain minus the weight of the infant at birth. The second study 

enrolled 119 term GDM and 143 term control mother-infant dyads from a hospital in Rhode 

Island in 1982.131 The mothers were all screened for gestational diabetes using a universal screen 

approach between 24 and 28 weeks’ gestation. Anthropometric measurements on the infants 

were done by study staff on the second day of life; weight and height was used to calculate 

infants’ BMI. Total gestational weight gain was defined as measured weight at last prenatal visit 

(within one week of delivery) minus self-reported pregravid weight.

Results. The Canadian study reported that net gestational weight gain was weakly but 

significantly correlated with infant’s BMI (r =.04, P < 0.01).122 In multivariate analysis, net 

gestational weight gain did not meet the criterion threshold for remaining in the stepwise 

regression.122 

In the US study, total gestational weight gain was significantly correlated with infant’s BMI 

(r =.22, P = 0.01).131 In multivariable regression analysis done separately for mothers with GDM 

and controls, total gestational weight gain significantly predicted infant’s BMI such that a 1 kg 

increase in weight gain was associated with a 0.06 and 0.05 increase in BMI for GDM and 

control infants, respectively, after controlling for pregravid BMI and glucose values. The 

difference between the results of these two studies lies in the fact that once the weight of the 

infant is removed from total weight gain, an important product of conception is missing from the 

measure of weight gain and thus the strength of the association is reduced.131

Other infant growth characteristics. 

Study characteristics. Six studies examined the association between gestational weight gain 

and various other infant growth characteristics (Evidence Table 31, Table 25).31,56,57,62,82,89 
110

Table 25. Gestational Weight Gain and Other Infant Growth Measures 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Brown et al., 200298

USA, primary care 

clinics 

389 

All weight/BMI 

Good 

Pregravid weight: 

Measured by study 

investigators 

Total weight gain: 

Collected by study 

investigators 

G1: Increase in 

ponderal index per 1 

kg increase in first 

trimester weight gain 

G2: Increase in 

ponderal index per 1 

kg increase in second 

trimester weight gain 

G3: Increase in 

Ponderal Index per 1 

kg increase in third 

trimester weight gain 

G1: β = 0.21 

(P < 0.0003) 

G2: β = 0.05 PI 

(P < 0.4) 

G3: β = 0.12 

(P < 0.03) 

Maternal age, 

parity, pregravid 

BMI, height, infant 

sex, gestational 

age 

Guihard-Costa et al., 

200492

France, hospital 

database 

13,972 

All weights/BMI 

Fair 

Pregravid weight: 

Routine prenatal 

care 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

G1: SC for effect of 

GWG on crown-heel 

length 

G2: SC for effect of 

GWG on head 

circumference 

G3: SC for effect of 

GWG on subscapular 

skinfold thickness 

SCs are regression 

coefficients calculated 

as if all of the 

independent variables 

had a variance of 1 

G1: SC 0.142 

G2: SC 0.120 

G3: SC 0.146 

Maternal age, 

parity, pregravid 

BMI, height 

Kirchengast and 

Hartmann 200393

Austria, university 

hospital 

8,011 

All weights/BMI 

Fair 

Pregravid weight: 

Estimated from 

measured weight 

at first prenatal 

visit 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Change in infant size 

characteristics per 1 

kg increase in GWG 

G1: Birth length (cm) 

G2: Head 

circumference (cm) 

G3: Acromial 

circumference (cm) 

G4: Diameter 

frontoccipitalis (cm) 

G1: β = 0.55 (0.43-0.68) 

G2: β = 0.33 (0.23-0.42) 

G3: β = 0.47 (0.39-0.55) 

G4: β = 0.12 (0.07-0.18) 

Maternal age, age 

at menarche, 

pregravid weight, 

height, distantia 

cristarum 

β, unstandardized coefficient from multiple regression; BMI, body mass index; cm, centimeters; g, gram; GWG, gestational 

weight gain; kg, kilogram; SC, standardized coefficient; SGA, small-for-gestational-age. 
111

Table 25. Gestational Weight Gain and Other Infant Growth Measures (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Kramer et al., 1990122

Canada, university 

hospital 

8,719 

All weights/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Correlation coefficients 

between GWG and: 

G1: Length 

G2: Head circumference

G3: BMI 

G4: Ponderal Index 

G5: Weight/Head 

circumference 

Net gestational weight 

gain was associated with 

correlation coefficients of 

-0.04 for length, -0.01 for 

head circumference, 

0.04 for BMI, 0.04 for 

Ponderal Index, and 

0.01 for weight/head 

circumference. Results 

were significant 

(P < 0.01) for length, 

BMI, and Ponderal Index

G1: -0.04 

(P < 0.01) 

G2: -0.01 

G3: 0.04 

(P < 0.01) 

G4: 0.04 

(P < 0.01) 

G5: 0.01 

Pregravid weight, 

infant sex, smoking, 

parity, maternal 

diabetes, height, 

previous LBW 

infant, severe 

pregnancy-induced 

hypertension 

Shepard et al., 1996117

Norway and Sweden, 

multicenter study 

369 

All weights/BMI 

Fair 

Pregravid weight: 

Medical records 

Total weight gain: 

Measured at 3 

study time periods 

Increase in mean 

abdominal fetal growth 

rate (mm/day) per 5% 

increase in proportional 

weight gain in this 

period: 

G1: Weeks 17-25 

G2: Weeks 25-33 

G3: Weeks 33-37 

G1: β = 0.35 (P = 0.49) 

G2: β = 0.88 (P = 0.02) 

G3: β = 1.53 (P = 0.02) 

Maternal age, 

pregravid BMI, 

previous SGA, 

infant sex 

Ekblad and Grenman, 

199268

Finland, hospital 

357 

Prepregnancy weight 

20% over or under 

ideal body weight for 

height and normal 

weight 

Poor 

Pregravid weight: 

Medical records 

Total weight gain: 

Routine prenatal 

care or maternity 

records 

Mean symphysis-fundus 

height: 

G1: Weight gain ≤ 5 kg 

G2: Weight gain 5-20 kg 

G3: Weight gain ≥ 20 kg 

G1: 30.8 cm ± 4.0 

G2: 32.8 cm ± 3.4 

G3: 35.0 cm ± 3.9 

N/A 

Overview of results. The evidence from one good,98 three fair,14,56,57,82 and one poor study68

suggest that gestational weight gain is associated with various measures of infant growth 

characteristics. A single fair study failed to find an association between gestational weight gain 

and infant proportionality.122
112

Detailed results. One good-quality study analyzed the relationship between weight gain (total 

and by trimester) and ponderal index (PI, a way of characterizing the relationship of height to 

mass for an individual).98 Each kilogram of weight gained in the first and third trimesters 

significantly increased the PI: first trimester, an estimated 0.21 units; third trimester, by 0.12 

units. Second trimester weight gain was not associated with newborn PI. The authors adjusted 

their models for gestational age, sex, parity, maternal height, maternal age, and pregravid BMI. 

A retrospective cohort study (rated fair quality) conducted in France examined predictors of 

various infant growth measures,92 using standardized coefficients (SC) from stepwise regression 

models. SCs are regression coefficients calculated as if all of the independent variables had a 

variance of 1. Pregnancy weight gain had a significant influence on birthweight (SC 0.199), 

crown-heel length (SC 0.142), head circumference (SC 0.120), and subscapular skinfold 

thickness (SC 0.146). 

One fair-quality study examined proportional weight gain in relation to fetal growth rate in 

millimeters (mm) per day, calculated by averaging three ultrasound measurements of the sagital 

and transverse diameters of the fetal abdomen in three study time periods.117 Increases in 

proportional weight gain during the second period (weeks 25 to 33) and third period (weeks 33 to 

37), but not the first period (weeks 17 to 25) were significantly associated with significant 

increases in fetal growth. These results were adjusted for age, BMI, smoking, history of 

delivering an SGA infant, and infant sex. 

Infant body proportionality was studied in a Canadian population (rated fair quality) with 

validated gestational ages.122 Proportionality was evaluated using z transformations of crownheel length, head circumference, BMI, PI, and birthweight/head circumference. Net gestational 

weight gain was associated with correlation coefficients of -0.04 for length, 0.04 for BMI, and 

0.04 for PI (all P < 0.01). ORs of low and high PI for each 5 kg decrease in net gestational 

weight gain were not significant. 

A fair-quality study conducted in Austria found that for each 1 kg increase in total gestational 

weight gain, birth length increased by 0.55 cm (95% CI, 0.43-0.68), head circumference 

increased by 0.33 cm (95% CI, 0.23-0.42), acromial circumference increased by 0.47 cm (95% 

CI, 0.39-0.55), and diameter frontoccipitalis increased by 0.12 cm (95% CI, 0.07-0.18).93 This 

study adjusted for maternal age, age at menarche, pregravid weight, height, and distantia 

cristarum. 

Finally, a poor-quality retrospective cohort study conducted in Finland examined the 

relationship between weight gain and symphysis-fundus (SF) height.68 SF height did not differ 

significantly between weight gain groups at 24 weeks, but higher gestational weight gains were 

associated with longer SF height. 

Child Outcomes 

Childhood weight status. 

Study characteristics. Four studies, using different definitions of outcomes, examined the 

long-term effect of gestational weight gain on children’s weight status (Evidence Table 32).99-102

Three studies enrolled the subjects at birth and then followed them through various end points; 

up to 15 months postpartum,132 3 years of age,24 and 2 and 5 years for the Avon longitudinal 

study of pregnancy and childhood (ALSPAC) in England.133 All three included only singleton 

births. One was conducted using a national representative sample from 1979 that followed the 

children of mothers who were born in 1984, 1986, 1988, and 1990 for up to 12 years.134
113

Overview of results. Due to the different definitions of the outcomes, the results from three 

fair100-102 and one poor99,102 studies are mixed for an association between gestational weight gain 

and childhood weight status. 

Detailed results. In the ALSPAC study (rated fair), which used as its outcome “catch up 

growth” from birth to 2 years of age (for definition see Table 26), bivariate analysis suggested 

that children who showed catch-up growth were no different in the amount of weight that their 

mothers gained during pregnancy than children who showed no change or those who had catchdown growth. No adjustments were made for confounding. 

In another fair study that reported on the effect of total weight gain and net weight gain 

(excluding infant birthweight),24 child BMI percentiles at age 3 were grouped as follows: below 

50th (referent category), 50th to 84th, 85th to 94th, and 95th or higher. Gestational weight gain 

was associated with a BMI of ≥ 95 percentile in both bivariate and multivariate analysis; a 5 kg 

increase in weight gain was associated with a 52 percent increase in risk of obesity in the 

offspring. Gestational weight gain was also associated with BMI z score. Similar associations 

were found when using net weight gain as the exposure. 

Table 26. Gestational weight gain and childhood weight status 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Li et al., 2007134

USA, National 

Longitudinal 

Survey of youth 

1979 Child and 

Young Adult file 

1,739 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Maternal 

weight gain 

categories 

(kg): 

G1: < 15 lbs 

G2: 15-24 lbs 

G3: 25-34 lbs 

G4: 35-44 lbs 

G5: > 45 lbs 

AOR (95% CI) for early onset overweight 

(early onset of overweight 

that persisted throughout childhood) 

compared with normal (low 

probability of overweight throughout 

childhood and was 

characterized as the never overweight 

class) 

G5: 1.7 (1.0-2.9) 

G3: 1.0 (reference) 

Other AOR for weight gain categories for 

early onset overweight not significant 

compared with weight gain 25-34 lbs 

No association between maternal weight 

gain and risk of late onset overweight 

(moderately high probability of overweight 

at age 2 years, low probability of overweight 

at age 4 and 6 years, but growing 

probability of overweight after age 8 years) 

Infant sex, race, 

birth order, 

gestational age, 

birthweight, 

breastfeeding, 

pregravid BMI, 

maternal age, 

maternal 

education, family 

income 

Oken et al., 

200724

USA, HMO 

1,044 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal 

weight gain, 5 

kg increments 

AOR (95%CI) BMI≥95th percentile vs 

BMI<50th percentile associated with a 5 kg 

increase in gestational weight gain: 

1.52 (1.19-1.94) 

Child BMI z-score at age 3 years for AOR 

listed above (95% CI): 

0.11 (0.05, 0.17) 

Smoking, race, 

household 

income, marital 

status, glucose 

tolerance, 

gestation length, 

breastfeeding 

duration, child’s 

sex 

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; G, group; HMO, health maintenance organization; kg, 

kilogram; lbs, pounds; USA, United States of America; vs, versus. 
114

Table 26. Gestational weight gain and childhood weight status (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Ong et al., 2000133

UK, Avon 

longitudinal study 

of pregnancy and 

childhood 

848 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Obstetric records 

Maternal weight 

gain, 

continuous 

measure 

Children were grouped into three 

growth categories (catch-up, no 

change, and catch-down) based on a 

gain in weight (SD score > 0.67 for 

catch-up; SD score < 0.67 for catchdown. 

Maternal weight gain was not a 

significant predictor of catch-up 

growth between 0 and 2 years 

NA 

Sowan et al., 

2000132

USA, NIH-funded 

Infant Growth 

Study 

630 

All weight/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Maternal weight 

gain, 5 lb. 

increments 

AOR (95%CI) for infant obesity (BMI> 

gender and age specific 84th 

percentile based on Infant Growth 

Study population norms) at 1, 4, 7, 

and 10 months: NS 

AOR (95%CI) for obesity at 14 

months: .8 (0.7-1.0) 

Maternal age, 

nonpregnant weight, 

smoking, marital 

status, father living in 

home, family stress, 

grandmother living in 

home, 

socioeconomic 

status, gender, race, 

infant BMI at birth, 

infant BMI from 

previous study 

month 

The one poor study that examined BMI ≥ 85th percentile at ages less than 14 months did not 

find any association with gestational weight gain.132 However, the nationally representative study 

did find an association for early onset of overweight associated with weight gains ≥ 20.43 kg 

(≥ 45 lbs) but not later on in life.134

The US study (rated poor quality) determined, using multivariable logistic regression models, 

that gestational weight gain was a significant predictor of infant obesity at 1 and 14 months of 

age.132 The odds of obesity rose 10 percent at 1 month for every 5-pound increase in weight gain 

adjusting for parental and household variables, sex of the infant, and ethnicity (OR, 1.1; 95% CI, 

1.0-1.2). At 14 months the association was reversed; the odds of obesity was decreased by 20 

percent for every 5-pound increase in gestational weight gain (OR, 0.8; 95% CI, 0.7-1.0), 

adjusting for several variables include birth BMI and BMI from the previous study month.

Childhood hospitalization. 

Study characteristics. One study, a cohort of children (N = 11,980) born to mothers attending 

midwifery centers in Denmark from April 1984 to 1987, examined the effect of maternal 

prenatal lifestyle factors on children’s hospitalizations with infectious diseases (Evidence Table 

33).135 After excluding stillbirths, multiple births, and children with congenital malformations, 

the authors followed 10,440 newborns from 6 months to 12 years. Information on prenatal 

factors was self-reported by the mother via a questionnaire. Weight gain, calculated as the 

difference between the self-reported pregravid weight and the weight measured at the time of 

delivery obtained from the medical records, was categorized as < 10, 10 to 12, 13 to 15, and ≥ 16 

kg. Outcome data on hospitalizations related to infections were obtained from registry 

information based on ICD codes. 
115

Overview of results. One fair study suggested that weight gain > 13 kg only for women who 

were underweight before pregnancy (BMI < 18) was associated with an increased risk of 

childhood hospitalization for infectious diseases.135

Detailed results. The crude incidence rate ratios (IRR) for the effect of weight gain on 

hospitalizations were nonsignificant compared with weight gains of 13 to 15 kg: < 10 kg, 0.99; 

10 to 12 kg, 0.93; and > 16 kg, 1.01). When maternal pregravid weight status was stratified as 

BMI < 18 and BMI ≥ 18, weight gain greater than 13 kg among women with a pregravid BMI 

< 18 increased the risk of hospitalizations compared with women with higher BMI and gaining 

similar weight (IRR, 1.42; 95% CI, 1.09-1.86). This model adjusted for maternal and paternal 

age, social group, marital status, number of siblings, and maternal smoking during pregnancy. 

Short- and Long-term Maternal Outcomes 

Lactation. We found no evidence on the effect of gestational weight gain (not defined by 

IOM definitions) on lactation that accounted for pregravid weight. We present results for studies 

relying on IOM definitions of weight gain under KQ 3.

Postpartum weight retention. 

Study characteristics. Twelve articles from 10 study populations examine the relationship 

between gestational weight gain and postpartum weight retention (Evidence Table 34, Table 

27).105,136-146 Six articles used data collected within 1-year postpartum;105,140-143,145 four used 

long-term follow-up data of greater than 1 year postpartum;136,142,144,146 and three used 

interpregnancy interval data.137-139

Table 27. Gestational weight gain and postpartum weight retention 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Callaway et al., 

2007146

Australia, 

University Hospital 

3,572 

All weight/BMI 

Good 

Pregravid weight: 

Self report 

Total weight gain: 

Obstetric records/ 

maternal 

questionnaires

G1: Gestational weight 

gain ≤ 15 kg 

G2: Gestational weight 

gain >15 kg 

G1: Mean change (95% 

CI) in BMI at 21 years 

postpartum: 5.06 kg/m2

(4.85-5.27) 

G2: Mean change (95% 

CI) in BMI at 21 years 

postpartum: 6.40 kg/m2

(6.19-6.61) 

P < 0.001 

G2 was associated with a 

mean change in BMI over 

21 years of 0.19 kg/m2

(95%CI: 0.16-0.22) 

Baseline income, 

secondary school 

completion, 

ethnicity, maternal 

age at birth, parity, 

birthweight, 

gestational age, 

infant sex, maternal 

smoking during 

pregnancy, smoking 

at 21 years, 

sedentary lifestyle at 

21 years, baseline 

maternal BMI, 

hypertensive 

disorders during 

pregnancy

AGA, average gestational age; ANCOVA, analyses of covariances; β, unstandardized regression coefficient; B, standardized 

regression coefficient; kg, kilogram; SD, standard deviation; SE, standard error; SEM, standard error of the mean; UK, United 

Kingdom. 
116

Table 27. Gestational weight gain and postpartum weight retention (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Harris et al., 

1999144 

UK, Antenatal Care 

Project 

74 

All weight/BMI 

Good 

Pregravid weight: 

Measured at first 

trimester prenatal 

visit 

Total weight gain: 

Self report 

Continuous maternal 

weight gain, kg 

ANCOVA model with 

weight (kg) at 2.5 years 

postpartum as dependent 

variable and maternal 

weight gain (kg) as 

independent variable: 

B = -0.031 

β = -0.029 

SEM = 0.120 

P = 0.796 

Marital status, 

increased 

dissatisfaction with 

body, increased 

access to food, 

increased energy 

intake, decreased 

activity, smoking 

status, maternal 

age, duration of 

followup, pregravid 

BMI, parity, 

gestational age at 

booking, parental 

obesity, social 

support

Harris et al., 

1997137

UK, Hospital 

523 

All weight/BMI 

Fair 

Pregravid weight: 

Measured within 13 

weeks’ gestation 

Total weight gain: 

Measured 

Gestational weight gain 

during previous 

pregnancy (kg), 

continuous 

ANCOVA model for 

interpregnancy weight 

change (kg), defined as 

the difference between 

weight at start of index 

pregnancy and weight at 

start of previous 

pregnancy: 

B = 0.262 

β = 0.227 

SEM = 0.52 

P < 0.001 

Marital status, 

smoking status, 

alcohol, parity, age, 

socioeconomic 

status, nulliparous 

BMI, birthweight, 

gestational age at 

start of previous 

pregnancy, 

gestational age at 

start of index 

pregnancy, 

gestational age at 

start of first 

pregnancy, 

interpregnancy 

interval, gestational 

age at delivery

Harris et al., 

1997138

UK, Hospital 

243 

All weight/BMI 

Fair 

Pregravid weight: 

Measured within 13 

weeks’ gestation 

Total weight gain: 

Measured 

Gestational weight gain 

during first pregnancy as 

a continuous measure 

(kg) 

ANCOVA model for 

interpregnancy weight 

change (kg), defined as 

the difference between 

weight at start of first 

pregnancy and weight at 

start of the second 

pregnancy: 

B = 0.176 

β = 0.169 

SEM = 0.070 

P < 0.013 

Marital status, 

lactation, smoking 

status, alcohol, 

height, nulliparous 

BMI, birthweight, 

gestational age at 

start of previous 

pregnancy, 

terminations 

between pregnancy, 

interpregnancy 

interval
117

Table 27. Gestational weight gain and postpartum weight retention (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hunt et al., 1995139 

USA, populationbased family history 

database (Utah) and 

participants of an 

obesity study 

221 

All weight/BMI 

Morbidly obese 

Fair 

Pregravid weight: 

Self-report 

(validated by 

hospital records if 

available) 

Total weight gain: 

Self-report 

(validated by 

hospital records if 

available) 

G1: Population-based 

sample 

G2: Morbidly obese 

women who were 

normal weight at age 

20-24 years or prior to 

first pregnancy 

Regression of current 

weight on total number of 

pregnancies showed a 

1.3 kg/pregnancy increase 

in current weight 

(P = 0.03) with no 

difference between G1 

and G2 (P = 0.60) 

Gestational weight gain 

was significantly greater in 

G2 than G1 for the first 

pregnancy only (P < 0.05) 

G2 had a net weight 

retention after the first 

pregnancy of 4.0 kg 

greater than G1 at 6 

weeks postpartum 

G2 averaged 1.6 kg/ 

pregnancy greater weight 

retention than G1 for 

additional pregnancies 

Weight at ages 20 to

24, current age 

Linne et al., 2004142

Sweden, Stockholm 

Pregnancy and 

Weight 

Development Study 

563 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Medical Records 

Gestational weight gain 

as a continuous variable 

(kg): 

G1: Pregravid BMI ≤ 25 

G2: Pregravid BMI > 25 

G2 had significantly 

greater weights at 

prepregnancy, delivery, 1 

year postpartum, and 15 

years postpartum 

compared to G1 

(P < 0.001); however, G2 

did not have a higher risk 

of postpartum retention 

than G1

Alcohol use, 

smoking, number of 

pregnancies since 

index child, 

employment area

Linne et al., 2003136 

Sweden, Stockholm 

Pregnancy and 

Women's Nutrition 

Study 

563 

Normal 

weight/overweight 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Medical records 

G1: Women with normal 

BMI (20-25) at 

prepregnancy and 15 

years postpartum 

G2: Women with normal 

BMI at prepregnancy 

who had overweight BMI 

(> 25) at 15 years 

postpartum 

G1: Mean (SD) maternal 

weight gain, 13.6 (3.7) kg 

G2: Mean (SD) maternal 

weight gain, 15.4 (4.4) kg 

t-Test: P<0.001 

None 
118

Table 27. Gestational weight gain and postpartum weight retention (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Muscati et al., 

1996105

Canada, Prenatal 

Nutrition Counseling 

Program 

371 

All weight/BMI 

Fair 

Pregravid weight: 

Physicians’ records 

Total weight gain: 

Measured 

G1: Weight gain ≤ week 

20 (kg) 

G2: Weight gain weeks 

21-30 (kg) 

G3: Weight gain weeks 

31- term 

G4: Total weight gain 

≤ 12 kg 

G5: Total weight gain 

> 12 kg 

Regression model of 

weight retention (kg) at 6 

weeks postpartum as the 

dependent variable and 

G1-G5 as independent 

variables: 

G1: β = 0.86 (SE: 0.05) 

P< 0.001 

G2: β = 0.68 (SE: 0.07) 

P< 0.001 

G3: β = 0.49 (SE: 0.07) 

P < 0.001 

G4: β = 0.58 (0.13) 

P=NR 

G5: β = 0.77 (0.04) 

P=NR 

Among women with AGA 

infants, women with 6 

week postpartum weights 

greater than the median 

value (6.2kg, underweight; 

5.7kg, normal weight; 

3.1kg, overweight) had 

significantly greater total 

weight gains and weight 

gains during the first 20 

weeks’ gestation 

compared to women with 6 

week postpartum weights 

of the median value or 

lower

Standard weight for 

height (based on 

1983 Metropolitan 

Life Insurance 

Tables), pregravid 

weight above 

standard (difference 

between actual 

weight and standard 

weight), parity, 

gestational age, 

infant sex

Ohlin et al., 1990145 

Sweden, maternity 

clinics 

1423 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Maternity records 

Gestational weight gain 

as a continuous variable 

(kg) 

Regression model for 

weight change (kg), 

defined as the difference 

between prepregnancy 

and 1 year postpartum 

weights: 

B = 0.32 

P< 0.001 

Lactation score, 

age, prepregnancy 

BMI, parity
119

Table 27. Gestational weight gain and postpartum weight retention (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Soltani et al., 

2000143 

UK, Hospital 

77 

All weight/BMI 

Fair 

Pregravid weight: 

Measured at 13 

weeks’ gestation 

Total weight gain: 

Measured 

Pregravid weight 

G1: Normal weight 

G2: Underweight 

G3: Overweight 

G4: Obese 

G1: Patterns of changes in 

body weight (kg) and fat 

mass follow a monotonous 

trend; body weight and 

fatness increased during 

gestation, decreased 

substantially at 6 weeks 

postpartum, and then 

stayed the same or slightly 

decreased until 6 months 

postpartum 

G2: Showed similar 

pattern to G1. 

G3: Divergent pattern of 

weight gains and losses; 

body fat mass changes 

show a very scattered 

pattern 

G4: Divergent pattern of 

both weight and fat mass 

gains and losses; heavier 

and greater fat masses at 

6 months postpartum 

compared to 13 weeks 

gestation; significantly 

lower fat mass loss and 

greater skinfold thickness 

gain between 36 weeks 

gestation and 6 months 

postpartum compared to 

normal weight women 

(P < 0.05) 

None 

Walker et al., 

2004141 

USA, Austin New 

Mothers Study 

382 

All weight/BMI 

Fair 

Pregravid weight: 

Self report 

Total weight gain: 

Self report 

Continuous gestational 

weight gain (kg) 

Each kg of gestational 

weight gain was 

associated with 0.314 

kg/m2

 of postpartum BMI 

(P < 0.001)

Ethnicity, time, 

interaction of 

ethnicity and time, 

pregravid BMI, 

weight-related 

distress, energy 

intake
120

Table 27. Gestational weight gain and postpartum weight retention (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Parham et al., 

1990140 

USA, prenatal clinics 

serving low income 

women 

158 

All weight/BMI 

Poor 

Pregravid weight: 

Self report 

Total weight gain: 

Measured 

Gestational weight gain 

for population in tertiles, 

mean (se): 

G1: 3.7 (2.9) 

G2: 9.4 (1.3) 

G3: 16.0 (3.7)

Change in BMI category 

between prepregnancy 

and 1-3months 

postpartum: 

G1, G2: 83% No change; 

7% Desirable change (i.e. 

underweight women 

becoming normal weight); 

10% Undesirable change 

(~5% had an increase in 

BMI category and ~5% 

had a decrease in BMI 

category) 

G3: 42% no change; 19% 

desirable change; 39% 

undesirable change (all 

increases in BMI category)

None 

Overview of results. The results of the two good144,147 and eight105,136-143,145 fair studies 

reviewed in this section suggest that gestational weight gain is positively associated with weight 

retention within 1 year postpartum105,141,145 and with interpregnancy weight gains.137-139 There is 

evidence to suggest that pattern of weight gain influences weight retention; a higher percentage 

of weight gained within the first 20 weeks of gestation is retained at 6 weeks postpartum 

compared to weight gains later in pregnancy.105 Additionally, weight retention differs across 

pregravid BMI strata,138,143 with overweight and obese women retaining more weight compared 

to normal weight women. Postpartum weight retention seems to be especially problematic for 

obese women, who may be at risk for increases in fat mass and central adiposity in the 

postpartum period.143 In the long term, the effect of gestational weight gain on weight retention 

is less conclusive; two studies144,146 found little to no association between gestational weight gain 

and weight at 2.5 and 21 years after the index pregnancy and one study136 found that women who 

became overweight at 15 years follow-up had higher gestational weight gains compared to 

women who remained normal weight. 

Results for less than 1-year postpartum. Three cohort studies, two rated105,143 and the other 

rated poor,140 examined the association between weight gain and weight retention prior to 1-year 

postpartum. 

One study used a population of low-income white women to examine the influence of total 

gestational weight gain and partial weight gains, categorized as weight gain ≤ 20 weeks, 21-30 

weeks, and 31 weeks to term, on postpartum weight retention at 6 weeks.105 Each kilogram of 

gestational weight gain at ≤ 20 weeks, 21-30 weeks, and 31 weeks to term was significantly 

(P < 0.001) associated with an increase of 0.86 (±0.05), 0.68 (±0.07), and 0.49 (±0.07) kg at 6 

weeks postpartum, respectively. Pregravid weight status, defined as underweight, normal weight, 

and overweight, was based on 1983 Metropolitan Life Insurance Table weight-for-height values. 

The mean gestational weight gains for women with < median postpartum weight retention 

(median values of postpartum weight retention were 5.7 kg for underweight, 6.2 kg for normal 

weight, and 3.1 kg for overweight women) were 13.3, 13.2, and 9.6 kg for underweight, normal 
121

weight, and overweight women, respectively. In contrast, the mean weight gains for women 

≥ median postpartum weight retention were 19.6, 20.2, and 19.1 kg, respectively (P < 0.001). 

Similar significant differences were seen for mean partial weight gains between women with 

postpartum weight retention < median and ≥ median values (P < 0.05- P < 0.001), with the 

greatest weight gain differences seen within 20 weeks of gestation. Gestational weight gain of 12 

kg was associated with 2.5 kg of postpartum weight retention; regression analyses for weight 

gains of ≤12 kg and >12 kg were associated with 0.58 (SE: 0.13) and 0.77 (SE: 0.04) kg of 

postpartum weight retention per kg of weight gain, respectively. 

Another study measured body weight, body fat mass (kg), and skinfold thickness (sum of 

five skinfold thicknesses) from 13 weeks of gestation through 6 months postpartum.143 BMI 

categories at 13 weeks’ gestation were defined using the IOM BMI classifications. Patterns in 

changes of body weight and fat mass across the study period were described for each BMI 

category. Among normal-weight women, the patterns of changes in both body weight and fat 

mass follow a monotonic trend; body weight and fatness increased during gestation, decreased 

substantially at 6 weeks postpartum, and then stayed the same or slightly decreased until 6 

months postpartum. Overweight women show a divergent pattern of weight gains and losses; 

women with the highest weight gains and losses at 6 months postpartum were in this group. 

Body fat mass changes showed a very scattered pattern. Obese women also show a divergent 

pattern of both weight and fat mass gains and losses; however, the majority of obese women are 

heavier and have greater fat masses at 6 months postpartum compared to 13 weeks’ gestation. 

Compared with normal-weight women, obese women have significant (P < 0.05) increases in 

total skinfold thickness between 36 weeks’ gestation and 6 months postpartum and in waist to 

hip ratio between 6 weeks’ and 6 months postpartum. 

Results from the poor study were consistent.140 Among the women within the upper tertile 

for gestational weight gains (mean 16.0 ± 3.7 kg), approximately 39 percent had an increase in 

BMI category at 1 to 3 months postpartum compared to only 5 percent among women within the 

lower and middle tertiles for gestational weight gains (mean 3.7 ± 2.9 kg and 9.4 ± 1.3 kg, 

respectively). 

Postpartum weight retention at 1 year. Three publications (2 studies), all rated fair quality, 

measured weight retention at 1 year postpartum.141,142,145 One study using data from a low 

income, racially/ethnically diverse population reported that a 1 kg increase in gestational weight 

gain was associated with an increase of 0.314 kg/m2

 in BMI at 1 year postpartum.141 Two articles 

based on data from the Stockholm Pregnancy and Weight Development Study examined the 

association between gestational weight gain and weight retention at 1 year postpartum.142,145 In 

one article, a 1 kg increase in total gestational weight gain was associated with a 0.32 kg increase 

in weight at 1 year postpartum (P < 0.001), which explained 12.7 percent of the variation in the 

change in weight from prepregnancy to 1 year postpartum (P < 0.001).145 The other article 

examined body weight at prepregnancy, delivery, 1 year followup, and 15 years followup in 

women with normal (BMI 20-25) and overweight (BMI > 25) pregravid BMI.142 Women who 

were overweight before pregnancy were significantly heavier at each time point (P < 0.001); 

however, there were no significant differences between normal-weight women and overweight 

women in the amount of weight retained from prepregnancy to 6 months and 1 year postpartum. 

Postpartum weight retention in the medium term. One good-quality study144 found no 

association between gestational weight gain and weight retention at two and half years 

postpartum in a small cohort of women with low antenatal risks enrolled in the Antenatal Care 

Project (United Kingdom). 

Long-term postpartum weight retention. Three publications (2 studies) measured long-term 

weight retention. One good-quality study in a cohort of Australian women examined the 
122

association between gestational weight gain, dichotomized as ≤ 15 kg and > 15 kg, and weight 

retention at 21 years after the index pregnancy.146 Excessive weight gain during pregnancy (> 15 

kg) was associated with a mean change in BMI of 0.19 kg/m2 (95% CI, 0.16-0.22). 

Two articles, both rated fair, from the Stockholm Pregnancy and Weight Development Study 

examined the effects of gestational weight gain on weight retention at 15 years postpartum.136,142

At 15 years follow-up, women who had been overweight (BMI > 25) before pregnancy were 

heavier than women who had been of normal weight (BMI 20-25) before pregnancy.142 The 

difference in the weight increases from prepregnancy to 15 years follow-up between overweight 

and normal-weight women were not significant (7.7 ± 7.0 kg and 6.2 ± 12.1 kg, respectively; 

P = 0.36).142 Among women with normal pregravid weight, those who remained at a normal 

weight at 15 years follow-up had significantly lower gestational weight gains than women who 

were overweight at 15 years follow-up (13.6 ± 3.7 kg and 15.4 ± 4.4 kg, respectively; 

P < 0.001).136

Interpregnancy weight retention. Three studies, all rated fair quality, examined the 

association between gestational weight gain and interpregnancy weight retention.137-139 Two 

cohort studies used data collected from women attending a city hospital in England..137,138 In one, 

gestational weight gain during a previous pregnancy was associated with a 0.262 kg increase 

(standard error of the mean [SEM], 0.052; P < 0.001) in weight between the index pregnancy 

and the previous pregnancy.137 In the other, gestational weight gain was associated with a 0.176 

kg increase (SEM, 0.074; P = 0.001) in weight from the beginning of the index pregnancy to the 

beginning of the second pregnancy.138 Prepregnancy BMI and interpregnancy weight gain were 

independently associated, suggesting that women who had gained the most weight between 

pregnancies were more likely to have been overweight before their first pregnancy than women 

who gained less between pregnancies. 

A cross-sectional study examined the effect of weight gain (self-reported) from multiple 

pregnancies on the development of morbid obesity in a group of morbidly obese women, who 

were not morbidly obese prior to their first pregnancy, and population-based controls.139 The 

mean gestational weight gain and net weight retention for all pregnancies was 14.2 kg and 5.7 

kg, respectively, for women who became morbidly obese, and 12.5 kg and 3.4 kg, respectively, 

for the controls. Women who became morbidly obese gained significantly more weight during 

their first pregnancy than controls (16.4 kg vs. 12.6 kg, respectively; P < 0.05), and they retained 

significantly more weight after their first and second pregnancies than controls (7.1 kg and 5.9 

kg vs. 3.1 kg and 2.9 kg, respectively; P < 0.05). After adjusting for pregravid weight at ages 20 

to 24 years, the authors determined that each pregnancy was associated with a 1.3 kg increase in 

current weight (P = 0.03), with no significant difference between the slopes of women who 

became obese and controls (1.6 kg/pregnancy and 1.0 kg/pregnancy, respectively; P = 0.6). 

Premenopausal breast cancer. 

Study characteristics. One study examined the effect of pregnancy weight gain on a woman’s 

risk of developing premenopausal breast cancer (Evidence Table 35).148 The study was a nested 

case-control study within a cohort of 22,610 Finnish women with a mean age of 40 during 1990 

and 1993. Women self-reported their breast cancer status, and their current weight, highest 

nonpregnancy weight, weight at age 20, and weight gain during any pregnancy in one of four 

categories (< 10, 10-15, 16-20, and > 20 kg). A total of 114 women had identified themselves as 

having premenopausal breast cancer; of these, 98 women had provided information on year of 

birth, had been pregnant, and had their cancer diagnosed after a pregnancy. Four controls for 

each case from the cohort were selected matched by age and type of intrauterine device. 

Overview of results. The fair study suggested that gestational weight gain and premenopausal 

breast cancer are not associated.148
123

Detailed results. ORs for breast cancer by gestational weight gain category were close to null 

and nonsignificant in both crude and adjusted models (age, education, family history of breast 

cancer, and change in BMI) using the < 10 kg category as the reference: ORs were 0.8 (0.44, 

1.47), 1.0 (0.47, 2.04), and 0.8 (0.27, 2.13) for weight categories 10-15 kg, 16-20 kg, and > 20 

kg, respectively. 

KQ 3: Outcomes of Weight Gain Within or Outside IOM 

Recommendations 

Although the KQ 3 issues are similar to those addressed in KQ 1, the focus here is on 

analyses that directly apply the categories of weight gain during pregnancy that the IOM laid out 

in its 1990 document.1

 The recommendations specific to BMI weight status groups and certain 

sociodemographic or physical characteristics are as follows: 

• 28 to 40 pounds for women with low BMI (<19.8); 

• 25 to 35 pounds for women with normal BMI (19.8-26); 

• 15 to 25 pounds for women high BMI (> 26.0-29.0); 

• weight gain of at least 15 pounds for obese women (BMI > 29); 

• weight gain in the upper end of the recommended range for adolescents and black 

women; and 

• weight gain in the lower end of the recommended range for short women (< 157 

centimeters, or approximately 62 inches). 

We present KQ 3 results similar to the presentation for KQ 1. We examine, first, maternal 

antenatal outcomes and then intrapartum outcomes; we then consider birth outcomes, infant 

outcomes, and child outcomes; and, finally, we cover maternal short- and long-term outcomes. 

When we have three or more studies dealing with the same topic (i.e., outcome), we present 

information in summary tables; otherwise, detailed information on these articles will be found in 

the relevant evidence tables in Appendix E.†

 For all outcomes, we first describe the studies (main 

study characteristics only); we then provide an overview of the results (for topics with more than 

one study), followed by a more detailed discussion of relevant studies. 

We rated studies for quality as good, fair, or poor (as explained in Chapter 2). All studies are 

reported in summary tables (including quality grades), and they are presented in order by quality 

rating. The text focuses on studies of good and fair quality, in that order; the vast majority are 

fair quality, so studies for which no quality grade is specified can be assumed to be of fair 

quality. We only briefly summarize poor studies. Generally, if studies deal with more than one 

outcome, we describe the study once and refer back as needed. 

Maternal Antepartum Outcomes 

Gestational diabetes mellitus. 

Study characteristics. Four studies examined the relationship between weight gain according 

to the IOM guidelines and GDM (Evidence Table 36, Table 28).3,53-55 Two studies were done 

 

†

 Appendixes and evidence tables cited in this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/admaternal/admaternalapp.pdf. 
124

specifically among obese women;54,55 two included women of normal weight;53,55 and one 

included women of various pregravid weight categories.3

 

Table 28. Weight change relative to IOM thresholds and gestational diabetes mellitus 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Saldana et al., 20063 

USA, hospital 

952 

All weight/BMI 

Good

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

G1: Normal 

glucose 

tolerance 

G2: Impaired 

glucose 

tolerance 

G3: Gestational 

diabetes 

mellitus 

BMI IOM 

Mean (SE) weight gain ratio 

(defined as obeserved weight 

gain/IOM recommended weight 

gain): 

G1: 1.43 (0.04) 

G2: 1.48 (0.21) 

G3: 1.88 (0.15) 

P < 0.05 

AOR (95% CI) for weight gain 

ratio: 

G1: 1.0 (reference) 

G3: 1.2 (0.9-1.4) 

Race, age, 

gestational 

age 

Edwards et al., 199655 

USA, Hospital 

1,443 

Normal/obese 

weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Obese BMI > 

29 (kg): 

G1: Lost 

weight/no 

change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal weight 

BMI 19.8-26 

G6: < 11.5 

G7: 11.5-16 

G8: > 16 

Gestational diabetes, % 

G1: 13.3 

G2: 24.3 

G3: 11.9 

G4: 16.7 

G5: 17.3 

P for linear trend (G1-G5) = 

0.554 

G6: 2.3 

G7: 3.3 

G8: 2.9 

P for linear trend (G6-G8) = 

0.759 

None 

Thorsdottir 200253 

Iceland, hospital 

records 

614 

Normal weight/BMI 

19.5-25.5 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Maternity records 

Maternal 

weight gain 

categories (kg):

G1: < 11.5 

G2: 11.5-16.0 

G3: 16.1-20.0 

G4: > 20.0 

Gestational diabetes, % 

G1: 2.9 

G2: 0 

G3: 0 

G4: 0 

P for trend < 0.015 

None 

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; g, gram; GDM, gestational diabetes mellitus; IOM, 

Institute of Medicine; kg, kilogram; NS, not sufficient; SE, standard error; USA, United States of America. 
125

Table 28. Weight change relative to IOM thresholds and gestational diabetes mellitus (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Bianco et al., 199854 

USA, medical center 

11,926 

Nonobese (BMI 19-27) 

and morbidly obese 

(BMI > 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal 

weight gain 

categories 

among 

morbidly obese 

(BMI > 35): 

G1: Weight 

loss/no change

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Distribution of GDM, %: 

G1: 15.7 

G2: 15.0 

G3: 14.4 

G4: 13.4 

G5: 12.5 

P = NS 

Race, parity, clinic 

service, substance 

abuse, preexisting 

medical condition 

Overview of results. No definitive evidence from four studies (1 good,3 2 fair,53,55 1 poor54) 

exists of an association between high weight gain and risk of developing GDM because of 

methodological problems with most studies addressing this topic. 

Detailed results. Obese women, independent of weight gain, had increased risks of 

developing GDM in three studies (1 of good quality,3 1 of poor quality54). Overweight women in 

the one good study that included them also had an increased risk for GDM.3

 All studies used 

weight gain at the time of delivery, which included the weight gained after the diagnosis of 

GDM. This measure of weight gain is biased since, once the diagnosis of GDM is made, weight 

gain is closely monitored and controlled through treatment. 

One good study evaluated weight gain up to the time of GDM diagnosis in both white and 

black women.3 The authors calculated the ratio of weight gain that expressed the amount of 

weight a woman gained to the amount she was expected to gain according to the IOM guidelines 

until the time of diabetes testing (that is, accounting for gestational length). Women who 

developed GDM had higher weight gain ratios than did women with normal glucose tolerance. In 

multivariable analysis, weight gain ratio was not significantly associated with developing GDM. 

However, among overweight women, a higher weight gain ratio was predictive of impaired 

glucose tolerance and this effect was stronger for white women (data not shown in table). 

Two studies (1 poor-quality54) examined total weight gain and GDM risk in obese women; 

neither found any association (using bivariate analyses) with weight gains either above or below 

the IOM guidelines.54,55 

Two studies reported findings for women of normal weight.53,55 One had too few women 

who developed GDM across the weight gain groups to permit analyses,53 and the other found no 

association.55

Hypertension. 

Study characteristics. One poor study compared the effect of total weight gain on the risk of 

developing pregnancy-induced hypertension among morbidly obese women and nonobese 

women using data from Mount Sinai Medical Center from 1988 to 1995 (Evidence Table 37).54

Results. In bivariate analysis, this study found no association between weight gains below or 

above the IOM guidelines and pregnancy-induced hypertension. 
126

Preeclampsia. 

Study characteristics. The association between gestational weight gain and preeclampsia was 

examined in four articles (2 from the same database) of fair quality (Evidence Table 38, Table 

29).4,25,53,55 Two studies included obese women;4,55 three included women of normal 

weight.25,53,55

Table 29. Weight change relative to IOM thresholds and preeclampsia 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Devader et al., 200725 

USA, birth certificate 

data 

94,696 

Normal weight/BMI 

19.8-26 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight 

gain categories 

(lbs): 

G1: < 25 

G2: 25-35 

G3: > 35 

AOR (95% CI) for 

preeclampsia: 

G1: 0.56 (0.49-0.64) 

G2: 1.00 (reference) 

G3: 1.88 (1.74-2.04) 

Age, race, 

education, income, 

alcohol use, height, 

prior pregnancy, 

inadequate 

prenatal care use, 

smoking, child's 

gender, birth year 

Edwards et al., 199655 

USA, Hospital 

1,443 

Normal/ Obese 

weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Obese BMI > 29 

(kg): 

G1: Lost weight/ 

no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal weight BMI 

19.8-26: 

G6: < 11.5 

G7: 11.5-16.0 

G8: > 16.0 

Preeclampsia 

G1: 10.7 

G2: 7.7 

G3: 8.3 

G4: 7.9 

G5: 16.5 

P for linear trend (for G1-

G5) = 0.076 

G6: 2.8 

G7: 2.9 

G8: 6.6 

P for linear trend (for G6-

G8) = 0.048 

None 

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; g, gram; kg, kilogram; lbs, pounds; USA, United 

States of America. 
127

Table 29. Weight change relative to IOM thresholds and preeclampsia (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Kiel et al., 20074 

USA, Hospital 

120,170 

Obese BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Medical record 

Maternal weight 

gain categories 

stratified by 

prepregnancy 

obesity status, 

Obese Class I 

(BMI 30–34.9), 

Obese Class II 

(BMI 35–39.9), 

Obese Class III 

(BMI ≥ 40): 

G1: ≤ -10lbs 

G2: -2 to -9 lbs 

G3: No change 

G4: 2-9 lbs 

G5: 10-14 lbs 

G6: 15-25 lbs 

G7: 26-35 lbs 

G8: > 35 lbs 

For Obese Class I: OR 

(95% CI) for preeclampsia 

were significantly lower 

(< 1.00, G6 was 

reference) for G2-G5 and 

significantly higher for G7-

G8. 

For Obese Class II: OR 

(95% CI) for preeclampsia 

were significantly greater 

(> 1.00, G6 was 

reference) for G1 and G3- 

G5 and significantly lower 

for G8. 

For Obese Class III: OR 

(95% CI) for preeclampsia 

were significantly greater 

(> 1.00, G6 was 

reference) for G1-G3 and 

G5 and significantly lower 

for G7-G8 

Age, race, parity, 

education, poverty 

(enrollment in 

Medicaid, WIC, food 

stamp programs), 

tobacco use, chronic 

hypertension 

Thorsdottir et al., 

200253

Iceland, hospital 

records 

614 

Normal weight/BMI 

19.5-25.5 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Maternity record 

Maternal weight 

gain categories 

(kg): 

G1: < 11.5 

G2: 11.5-16.0 

G3: 16.1-20.0 

G4: > 20.0 

Preeclampsia,% 

G1: 1.4 

G2: 2.3 

G3: 5.4 

G4: 4.4 

P for trend = 0.262 

None 

Overview of results. The evidence of an association between high weight gains and increased 

risk of preeclampsia is inconclusive. 

Detailed results. Among obese women, preeclampsia risk increased with gains greater than 

25 pounds and decreased with gains lower than 15 pounds in one study.4 Another study reported 

no association, but it had not conducted multivariate analyses for this outcome.55 

Among women of normal weight, one study found no association between preeclampsia and 

gains either below or above the IOM levels.53 In two other studies, the risk of preeclampsia rose 

as weight gains above the IOM recommendations increased;25,55 it dropped with weight gains 

below IOM thresholds in one of these studies.25 
128

Maternal Intrapartum Outcomes 

Cesarean delivery. 

Study characteristics. Nine articles examined the effect on cesarean delivery of weight gain 

classified according to the IOM guidelines (Evidence Table 39, Table 30).4,25,53-55,77,118,149,150

These studies were all rated fair except for one poor study.54 Two articles were based on the 

same birth certificate data from Missouri;4,25 three used US hospital databases;55,118,149 one used 

data from a US midwifery practice;150 one used a random selection of normal-weight pregnant 

women in Iceland;53 and one used data from the US Pregnancy Risk Assessment Monitoring 

System (PRAMS).77 

Overview of results. For underweight and normal-weight women, some evidence may 

suggest an increased risk of cesarean delivery for weight gains above IOM recommendations; 

evidence for obese or morbidly obese women is inconsistent. 

Detailed results. Two studies that examined women across a range of BMI categories found 

increased risks of cesarean delivery for weight gains exceeding IOM guidelines and these results 

were consistent in all pregravid weight categories (AORs of 1.6 and 2.0).149,150 

Table 30. Weight change relative to IOM thresholds and cesarean delivery 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Devader et al., 

200725 

USA-Missouri, 

birth certificate 

data 

94,696 

Normal weight 

BMI 19.8-26 

Fair 

Pregravid weight: 

Self-Report 

Total weight gain: 

As reported on birth 

certificate 

G1: Gained less than 

25 lbs 

G2: Gained 25-35 lbs 

G3: Gained more 

than 35 lbs 

AOR for cesarean delivery 

(additionally controlled for LGA 

and cephalopelvic 

disproportion) 

G1: 0.82 (0.78–0.87) 

G2: 1.0 

G3: 1.35 (1.29–1.40) 

Age, race, 

education, income, 

alcohol use, 

height, prior 

pregnancy, 

inadequate 

prenatal care use, 

smoking, child's 

gender, birth year 

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; G, group; GDM, gestational diabetes mellitus; IOM, 

Institute of Medicine; lb(s), pound(s); LGA, large for gestational age; OR, odds ratio; PRAMS, Pregnancy Risk Assessment 

Monitoring System; USA, United States of America; WIC, The Special Supplemental Nutrition Program for Women, Infants, 

and Children. 
129

Table 30. Weight change relative to IOM thresholds and cesarean delivery (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Edwards et al., 

199655 

USA, hospital 

1,443 

Normal BMI 19.8-

26 

Obese BMI > 29 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Prenatal records 

Obese 

G1: wt loss or 0 lbs 

G2: 1-14 lbs 

G3: 15-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Normal weight 

G1: < 25 lbs 

G2: 25-35 lbs 

G3: > 35 lbs 

Obese 

G1: 30.7% 

G2: 21.6% 

G3: 23.8% 

G4: 26.2% 

G5: 30.1% 

Normal wt 

G1: 5.7% 

G2: 12.1% 

G3: 8.6% 

No significant difference in 

rates of cesarean delivery by 

IOM weight gain categories for 

normal weight or obese women 

Obese women AOR = 3.2 (2.3-

4.4) for cesarean delivery 

Age, parity, 

pregravid BMI, 

GDM, pregnancyinduced 

hypertension, 

prenatal 

adequacy, alcohol 

use, drug use, 

smoking, 

gestational age 

Jain et al., 200777

USA, PRAMS 

7,661 

All weight/BMIs 

(using IOM 

definitions) 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Self-reported 

G1: ≤ 15 lbs 

G2: 16 - < 25 lbs 

G3: 25 - < 35 lbs 

G4: ≥ 35 lbs 

G5: interaction term 

overwt/obese and 

gaining 25-35 

Primipara (AOR, 95% CI) 

G5: 0.71 (0.43-1.19) 

Multipara 

G5: 0.77 (1.37-1.59) 

Pregravid BMI, 

parity 

Kaiser and Kirby, 

2001150 

USA, university 

nurse-midwifery 

system 

1,881 

All wt/BMI (using 

IOM definitions) 

Fair 

Pregravid BMI: 

Self-reported 

Total weight gain: 

Measured at last 

prenatal visit 

G1: Below IOM 

G2: Within IOM 

G3: Above IOM 

Crude OR 95% CI 

G1: 0.82 (0.49-1.36) 

G3:1.0 (0.62-1.63) 

AOR for weight gain above 

IOM recommendations: 

2.04 (95% CI 1.02-4.05) 

Age, race, pregravid 

BMI, preeclampsia, 

height, previous live 

births, failure to 

progress, breech 

presentation, 

placental abruption, 

fetal bradycardia, 

primigravidity, 

birthweight 

Kiel et al., 20074

USA-Missouri, 

birth certificate 

120,170 

Obese BMI > 30 

Fair 

Pregravid BMI: 

Self-reported 

Total weight gain: 

Birth certificate 

G1: Wt loss > 10 lbs 

G2: Wt loss 2-9 lbs 

G3: No change 

G4: 2-9 lbs 

G5: 10-14 lbs 

G6: 15-25 lbs 

G7: 26-35 lbs 

G8: > 35 lbs 

For all three classes of 

obese women, risks of 

cesarean delivery rise 

above an OR of 1 when 

weight gain exceeds 25 

pounds 

Age, race, parity, 

education, poverty 

(enrollment in 

medicaid, WIC, food 

stamp programs), 

tobacco use, 

chronic 

hypertension 
130

Table 30. Weight change relative to IOM thresholds and cesarean delivery (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Parker and 

Abrams, 1992118 

USA, hospital data 

base 

6,690 

All wt/BMI (using 

IOM definitions) 

Fair 

Pregravid weight: 

Self reported 

Total weight gain: 

Measured weight in 

prenatal record 

G1: Below IOM 

G2: Above IOM 

AOR for all women weight 

gain > IOM (G2) = 1.48 

(1.25-1.76) 

For overweight women, 

there was no significant 

association between 

cesarean delivery and 

weight gain (AOR = 0.71 

(0.40-1.26) 

For nonoverweight women, 

the association between 

cesarean delivery and 

weight gain was 1.45 (1.21-

1.73) 

Age, race, parity, 

pregravid BMI, 

height, maternal 

high and low weight 

gain, smoking, 

gestational age, 

birthweight 

Stotland et al., 

2004149

USA, university 

hospital 

9,788 

All wt/BMI 

Fair 

Pregravid weight: 

No details reported 

Total weight gain: 

No details reported, 

possibly measured 

weight in prenatal 

records 

G1: Below IOM 

G2: Above IOM 

AOR with birthweight in 

model 

G1: 0.99 (0.82-1.19) 

G2 :1.40 (1.22-1.59) 

BMI < 19.8 G1 = 0.96 

(0.67-1.37); G2 = 1.93 

(1.45-2.53) 

BMI 19.8-26 G1 = 1.04 

(0.81-1.33); G2 = 1.26 

(1.06-1.50) 

BMI > 26 G1 = 0.74 (0.38-

1.44); G2 = 1.21 (0.83-1.78) 

Age, race, pregravid 

BMI, year of 

delivery, smoking, 

gestational age, 

birthweight, infant 

sex 

Thorsdottir et al., 

200253 

Iceland, hospital 

records 

614 

Normal wt/BMI 

19.5-25.5 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Measured weight in 

prenatal records 

G1 < 11.5 kg 

G2 11.5-16 kg 

G3 16.1-20 kg 

G4 > 20 kg 

G1: 17.4% 

G2: 9.5% 

G3: 12.9% 

G4: 13.1% 

No significant differences in 

cesarean delivery rates by 

IOM weight gain categories 

in normal weight women 

Age, parity, height, 

gestational age, 

birthweight 

Bianco et al., 

199854

USA, hospital 

11,926 

Nonobese BMI 19 

to 27 /morbidly 

obese BMI > 35 

Poor 

Pregravid weight: 

Perinatal data base 

Total weight gain: 

Perinatal data base 

G1: wt loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

G1: 25.5% 

G2: 26.8% 

G3: 28.8% 

G4: 35.0% 

G5: 33.8% 

No significant difference 

among morbidly obese 

women by weight gain 

categories 

OR for cesarean comparing 

morbidly to nonobese = 2.3 

(1.9-2.8) 

Macrosomia 
131

The six studies stratified by pregravid weight status produced mixed results. Of the articles in 

this category, five considered women of normal weight.25,53,55,118,149 Of these five studies, two53,55

reported no association with weight gains above the IOM guidelines and three found a moderate 

association between cesarean delivery and weight gain above IOM recommendations25,118,149

Four studies (1 of poor quality54) examined these issues among overweight and obese 

women.54,55,118,149 They reported no association between weight gain and risk of cesarean 

delivery. For underweight women, two studies reported a moderate to strong association between 

weight gain above IOM recommendations and risk for cesarean delivery;118,149 for nonobese 

women, one of these studies reported a moderate association.118 Three studies reported that the 

risk of cesarean delivery was higher for obese or morbidly obese women than for nonobese 

women.54,55,150 One study suggested that these risks increase within classes of obesity with gains 

greater than 25 pounds.4

 

The one study that examined the interaction between weight gain of 25-34 pounds and 

pregravid overweight or obese status did find a significant effect for multiparous women but not 

primiparous.77 

Birth Outcomes 

Preterm birth. 

Study characteristics. Four studies, all rated fair, reported on the association between weight 

gain according to the IOM guidelines and preterm birth defined as < 37 completed weeks of 

gestation (Evidence Table 40, Table 31).22,85,151,152 One study reported on total weight gain.22 All 

four reported on the rate of weight gain or pattern.22,85,151,152

Table 31. Weight change relative to IOM thresholds and preterm birth (< 37 weeks) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Hickey et al., 

1995151 

USA, university 

prenatal clinics 

1,518 

Under/normal wt 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Prenatal records 

G1: Low rate of weight 

gain in first trimesterunderweight (BMI 

< 19.8) & < 2.3 kg and 

normal weight (BMI 

19.8-26) & < 1.6 kg 

G2: Low rate of weight 

gain in second 

trimester (Underwt & 

< 0.38 kg/wk or normal 

wt & < 0.37 kg/wk) 

G3: Low rate of weight 

gain in third trimester 

(Underwt & < 0.38 

kg/wk or normal wt & 

< 0.37 kg/wk) 

OR (95% CI) for spontaneous 

preterm 

G1: 1.27 (0.7-2.3) 

G2: 1.23 (0.7-2.18) 

G3: 2.46 (1.53-3.92) 

Pattern of weight gain 

G1 only: 2.94 (0.73-11.98) 

G2 only: 1.08 (0.1-11.23) 

G3 only: 11.54 (2.93-45.28) 

G1 & G2: 4.89 (0.85-28.14) 

G1 & G3: 4.49 (0.96-20.96) 

G2 & G3: 7.37 (1.66-32.76) 

All trimesters: 4.18 (0.75-23.35) 

Age, race, 

pregravid BMI, 

height, alcohol 

use, history of 

previous infant 

less than 2,750 

g, number of 

days between 

last weight 

observation 

and delivery, 

smoking, infant 

sex 

Af Am, African American; AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; DOB, date of birth; G, 

group; IOM, Institute of Medicine; kg/wk, kilograms per week; OR, odds ratio; wt: weight; PTB, pre-term birth; USA, United 

States of America; wk, week; wt, weight. 
132

Table 31. Weight change relative to IOM thresholds and preterm birth (< 37 weeks) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Schieve et al., 

2000152

USA, nationally 

representative 

1988 births 

3,511 

All wt/BMI 

Low BMI < 19.8 

Average BMI 

19.8-26 

High BMI > 26 

Fair 

Pregravid weight: 

Self-reported 

baseline 

Weight gain: 

Rate of measured 

weight between 14 

and 28 wks 

gestation 

G1: Low < 0.5 

less/week; 

G2: Average 

0.5-1.5 lb/week 

G3: High > 1.5 

lb/week 

AOR for preterm birth 

Low BMI: G1 = 6.7 (1.1-40.6) 

Low BMI: G2 = 0.8 (0.4-1.4) 

Low BMI: G3 = 1.0 (0.4-2.6) 

Average BMI: G1 = 3.6 (1.6-8.0) 

Average BMI: G2 (Reference) 

Average BMI: G3 = 1.0 (0.6-1.9) 

High BMI: G1 = 1.6 (0.7-3.5) 

High BMI: G2 = 1.1 (0.6-2.1) 

High BMI: G3 = 0.1 (0.03-0.6) 

Age, race, 

parity, marital 

status, 

education, 

smoking 

Siega-Riz et al., 

199422 

USA, public 

health clinics 

5,854 

All wt/BMI (using 

IOM definitions) 

Fair 

Pregravid weight: 

self reported 

Total weight Gain: 

Prenatal records 

Total weight 

gain expressed 

as a ratio of 

observed: 

expected based 

on the IOM 

recommendation for a 

given 

gestational age.

Adequacy of weight gain in the third 

trimester was predictive of preterm birth 

- the data suggested a threshold effect 

for all weight status groups with a 

marked decrease in risk at 90-110% of 

the IOM recommendation 

With the rate of weight gain less than 

60% of the IOM value, women in all four 

groups had more than double the risk of 

delivering preterm, which was 

statistically significant for all but the 

obese category. 

Excessive rate of weight gain was 

signficantly associated with a preterm 

birth only for women of normal 

prepregnancy weight status at a value 

greater than 200% of the IOM value 

Pregravid BMI, 

gestational age
133

Table 31. Weight change relative to IOM thresholds and preterm birth (< 37 weeks) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Stotland et al., 

200685

USA, academic 

medical center 

15,101 

Underweight BMI 

< 19.8 and normal 

weight BMI 19.8-

26 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

prenatal records 

G1: low rate of 

weight gain 

< .27 kg/wk 

G2: ref 0.27-

0.52 kg/wk 

G3: high rate of 

weight gain > 

0.52 kg/wk 

Crude OR of spontaneous preterm birth 

G1: 2.6 (95% CI 2.1–3.2) 

G3: 1.0 (95% CI 0.8–1.2) 

AOR of spontaneous preterm birth 

G1: 2.5 (95% CI 2.0–3.1) 

G3: 1.0 (95% CI 0.8–1.3) 

No differences in results by parity 

combined with history of preterm birth 

Slightly higher risks for Af Am and high 

wt gain close to sign for Af Am 

Age, race, 

parity, 

pregravid BMI, 

history of 

previous PTB, 

year of 

delivery, 

number of days 

between last 

weighing and 

DOB, smoking 

Overview of results. Despite inconsistencies in the definitions of rate of weight gain and the 

timing of its calculation, the four studies are consistent in showing increased risks of preterm 

birth for underweight and normal-weight women, thereby providing evidence of some 

association between weight gain below IOM recommendations and preterm birth. Evidence 

about any association between weight gain above IOM recommendations and preterm birth is 

inconclusive. 

Detailed results on total weight gain. The single study on total weight gain, set in the United 

States, included only singleton live births with no pregnancy complications among 

predominantly Hispanic women (80 percent) using information reported on the medical record.22

Total weight gain was defined as weight at last prenatal visit minus self-reported pregravid 

weight (which was checked for biological plausibility). To analyze observed weight gains in 

light of the IOM recommendations, the authors created an “expected total weight gain” variable 

using the amount of weight gain a woman was supposed to gain according to the IOM guidelines 

when her last weight was measured and then calculated a ratio of observed to expected weight 

gain. Ratios greater than 1 indicate that the women gained more weight than expected; ratios less 

than 1 indicate that they gained less weight than expected. For all but obese women, the pattern 

of risk of preterm birth was U-shaped. The lowest risk of preterm birth was observed for all 

women with weight gain ratios between 1.10 and 1.40. 

Results on rate of weight gain for all women. In the two studies that examined rate of weight 

gain among women in all BMI groupings,22,152 the US study described above found that 

inadequate or excessive weight gain in the first or second trimester using the IOM definitions 

was not associated with preterm birth.22 By contrast, adequacy in the third trimester was 

predictive of risk of preterm birth; ratios of observed/expected between .90 and 1.10 were 

associated with decreased risk. A ratio of < 0.60 was significantly associated with a doubling of 

the risk of preterm birth for women of all but the obese weight groups. Among normal-weight 

women, a ratio > 2.0 was significantly associated with a preterm birth. 

The other study was conducted in a nationally represented sample of all singleton live births 

in the US from 1988.152 This study used common definitions of rate of weight gain (mapping to 

IOM categories for underweight women): low (< 0.5 lb/week), average (0.5 to 1.5 lb/week), and 
134

high > 1.5 lb/week) for all BMI groups. The authors calculated rate of weight gain in a 

regression model using measured prenatal weights from 14 to 28 weeks of gestation. Among 

women of normal weight, low weight gain was statistically significantly associated with an 

increased risk (approximately fourfold) of preterm delivery compared with women in this same 

category who had average weight gain. This finding held true when medically indicated preterm 

deliveries were excluded, when women with pregnancy complications were excluded, and when 

models were adjusted for confounders listed in Table 31. Among underweight women, a low rate 

of weight gain was statistically significantly associated with the risk of preterm birth when the 

same exclusions and model adjustments were made. In models with these same exclusions and 

adjustments, however, for women with a BMI ≤ 26, high weight gain was not associated with 

significant changes in the risk of preterm birth and for women with a BMI > 26, high weight gain 

was associated with lower risk of preterm birth. 

Detailed results on rate of weight gain for normal or underweight women. Two studies 

examined the effect of rate of weight gain on spontaneous preterm birth among only underweight 

and normal-weight women.85,151 In one US study, the authors calculated the rate of weight gain 

over the entire pregnancy using weight at time of delivery minus self-reported pregravid weight 

divided by gestational age at delivery (minus 2 weeks because gestational age was based on last 

menstrual period).85 Low rate of weight gain during pregnancy, defined as < 0.27 kg per week, 

was statistically significantly associated with spontaneous preterm birth in both crude and 

adjusted analyses. High rate of weight gain, defined as > 0.52 kg per week, was not associated 

with risk of preterm birth. These findings were similar when the models were stratified by 

ethnicity, parity, and history of preterm birth, and adjusted for the confounders listed. 

In another US study, total weight gain in the first trimester was defined as measured weight 

at 10 to 13 weeks minus self-reported pregravid weight; second and third trimester rates of 

weight gain were based on measured weights during the trimester.151 Low weight gain in the first 

or second trimester alone was not associated with spontaneous preterm birth. By contrast, low 

third-trimester weight gain was statistically significantly associated with spontaneous preterm 

birth. The combination of low second- and third-trimester rate of weight gain was also 

statistically significantly associated with spontaneous preterm birth. All analyses controlled for 

several confounders listed in Table 31. 

Birthweight. 

Study characteristics. Ten studies from nine databases examined the association between 

weight gain defined by IOM guidelines and birthweight (Evidence Table 41, Table 

32).20,54,60,104,153-158 Three studies were done in only black women;60,153,154 two stratified by 

race;20,155,156 two were done in adolescents;153,154 one came from a cohort of 233 women enrolled 

in the WIC program in Iowa;157 and one used a perinatal database from a medical center in New 

York.54 
135

Table 32. Weight change relative to IOM thresholds and birthweight 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Nielsen 2006153

USA, prenatal 

clinics 

African-Americans 

only 

815 

All weight/BMIs 

Good 

Pregravid weight: 

Self-reported 

Total weight gain: 

Prenatal records, 

measured 

G1: < IOM 

G2: lower half IOM 

range 

G3: Upper half 

IOM range 

G4: > IOM 

Adjusted birthweight 

BMI < 19.8 

G1: 2,986 g 

G2: 3,167 g 

G3: 3,198 g 

G4: 3,277 g 

All significantly different from 

each other except G2 & G3 

BMI 19.8-26 

G1: 3,018 g 

G2: 3,166 g 

G3: 3,255 g 

G4: 3,318 g 

All significantly different from 

each other 

BMI > 26 

G1: 3,127 g 

G2: 3,351 g 

G3: 3,384 g 

G4: 3,434 g 

G1 significantly different from 

the others, G2,G3 & G4 not 

significantly different from each 

other 

Parity, pregravid 

BMI, 

preeclampsia, 

time between last 

weight measure 

and delivery, 

height, smoking, 

infant sex 

&, and; AOR, adjusted odds ratio; birthwt, birthweight; BMI, body mass index; G, group; g, gram; GDM, gestational diabetes 

mellitus; IOM, Institute of Medicine; kg/wk, kilogram per week; NR, not/none reported; OR, odds ratio; underwt, underweight; 

USA, United States of America; WIC, The Special Supplemental Nutrition Program for Women, Infants, and Children.
136

Table 32. Weight change relative to IOM thresholds and birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hickey et al., 

199720 

USA, public 

health programs 

5,198 

All wt/BMI (using 

IOM definitions) 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Measured weightsprenatal records 

G1: Below IOM 

range 

G2: Lower end of 

IOM range 

G3: Upper end of 

IOM range 

G4: Gain above 

IOM range 

BMI < 19.8 

G1: 

Black: 2,840 

White: 3,002 

G2: 

Black: 2,995 

White: 3,151 

G3: 

Black: 3,017 

White: 3,200 

G4: 

Black: 3,163 

White: 3,353 

BMI 19.8-26.0 

G1: 

Black: 3,052 

White: 3,176 

G2: 

Black: 3,105 

White: 3,199 

G3: 

Black: 3,180 

White: 3,307 

G4: 

Black: 3,228 

White: 3,389 

BMI > 26.0 

G1: 

Black: 3,126 

White: 3,385 

G2: 

Black: 3,192 

White: 3,376 

G3: 

Black: 3,312 

White: 3,402 

G4: 

Black: 3,300 

White: 3,504 

Age, education, 

height, street 

drugs, alcohol 

use, time between 

last prenatal 

weight observation 

and delivery, 

smoking, 

gestational age, 

infant sex 
137

Table 32. Weight change relative to IOM thresholds and birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hickey et al., 

1996155

USA, prenatal 

clinics 

415 

Under & Normal 

weight 

Fair 

Pregravid BMI: 

Self-reported 

Total weight gain: 

Prenatal records 

G1: First trimester 

< 2.6 kg for 

underwt (BMI 

< 19.8) & < 1.6 kg 

for normal wt (BMI 

19.8-26) 

G2: Second 

trimester 

< 0.38 kg/wk for 

underwt & < 0.37 

kg/wk for normal 

wt 

G3: < 0.38 kg/wk 

for underwt & 

< 0.37 kg/wk for 

normal wt 

Association of low trimester 

gain with birthwt 

G1: all women -18 g P = .65 

Black -15 g P = .76 

White -42 g P = .53 

G2: All women -166g 

P = < .001 

Black -164 g P = .005 

White -158 g P = .05 

G3: All women -111g P = .008 

Black -77 g P = .14 

White -194 g P = .004 

No association with low weight 

gain in only the first or second 

trimester. 

G3: All -164 g P = .01 

Black -80 g P = .38 

White -300 g P = .005 

Association with low weight 

gain during more than one 

trimester 

G1 & G2: All -236 g P = .01 

Black -265 g P = .04 

White -169 g P = .25 

G1 & G3: No significant diff 

G2 & G3: All -206 g P = .01 

Black -178 g P = .08 

White -268 g P = .06 

G1, G2 & G3: All -284 g 

P = .002 

Black -252 g P = .03 

White -379 g P = .008 

Age, race, 

pregravid BMI, 

height, alcohol 

use, third trimester 

number of weeks 

between last 

weight observation 

and delivery, 

history of previous 

infant < 2,750 g, 

smoking, 

gestational age, 

infant sex 

Hickey et al., 

1993156

USA, prenatal 

clinics 

1,168 

All weight/BMIs 

Fair 

Pregravid BMI: 

Self-reported 

Total weight gain: 

Prenatal records 

BMI ≤ 29 

G1: gain < range 

G2: gain in the 

range 

G3: gain > range 

BMI > 29 

G4: gain < 6.0 kg 

G5: gain > 6.0 kg 

Adjusted Birthwt 

BMI ≤ 29 

G1: 

Black: 3,027 

White: 3,246 

G2: 

Black: 3,177 

White: 3,233 

G3: 

Black: 3,293 

White: 3,523 

Maternal height, 

education, parity, 

marital status, 

smoking, alcohol 

use, hypertension, 

GDM, gestational 

age at delivery, 

socioeconomic 

status, time 

between last 

weight and 

delivery 
138

Table 32. Weight change relative to IOM thresholds and birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hickey et al., 

1993156

(continued) 

 BMI > 29 

G4: 

Black: 3,214 

White: 3,500 

G5: 

Black: 3,553 

White: 3,596 

Luke et al., 

1996104 

USA, clinic 

487 

All weight/BMIs 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Prenatal records, 

measured 

G1: Gain < IOM 

G2: gain equal to 

IOM 

G3: gain > IOM 

Adjusted birthweight 

G1: 

BMI < 19.8 2,873 g* 

BMI 19.8-26.0 3,157 g* 

BMI > 26 3,138 g 

G2: 

BMI < 19.8 3,190 g 

BMI 19.8-26 3,298 g 

BMI > 26 3,338 g 

G3: 

BMI < 19.8 3,489 g* 

BMI 19.8-26 3,494 g* 

BMI > 26 3,347 g 

* significantly different from 

gains within range within each 

BMI grouping 

Maternal age, 

parity, black 

ethnicity, smoking, 

gestational 

duration, fetal sex 

May, 2007157

USA, WIC clinic 

233 

All weight/BMI 

Fair 

Pregravid weight: 

Self reported 

Total gestational weight 

gain: 

Self-reported 

G1: Below IOM 

G2: Greater IOM 

Betas from multiple linear 

regression 

G1: -162 g 

G2: -153 g 

Maternal BMI, 

smoking, 

gestational age at 

delivery 

Ogunyemi et al., 

199860

USA, Hospital 

582 

All weight/BMIs 

(using IOM 

definitions) 

Fair 

Pregravid weight: 

Self-reported 

Total gestational weight 

gain: 

Prenatal records, 

measured 

G1: Low < IOM 

G2: Normal = IOM 

G3: High > IOM 

Birthweight 

G1: 3,029 

G2: 3,210 

G3: 3,283 (P < 0.01) 

NR 
139

Table 32. Weight change relative to IOM thresholds and birthweight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Scholl et al., 

1995158 

USA Camden 

Study 

274 

Normal weight 

BMI 19.8-26 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Prenatal records, 

measured 

Rate between 20-

36 wks 

G1: low rate < 0.34 

kg/wk 

G2: moderate rate 

0.34-0.68 kg/wk 

G3: Excessive rate 

> 0.68 kg/wk 

Birthweight (g): 

G1: 3,049 (56.94) P < 0.05, low 

vs. moderate plus excessive 

weight gain 

G2: 3,208 (36.33) 

G3: 3,191 (49.46) 

NR 

Stevens-Simon 

and McAnarney, 

1992154 

USA AfricanAmerican 

adolescent 

maternity 

program 

141 

All BMI 

Fair 

Pregravid weight: 

Self-reported 

Total weight gain: 

Prenatal records, 

measured 

G1: slow < 0.23 

kg/wk 

G2: average 0.23-4

kg/wk 

G3: rapid > 0.4 

kg/wk 

Birthweight (g): 

G1: 2,745 (694) 

G2: 3,097 (457) 

G3: 3,351 (482) P < 0.0001 

No difference in pregravid by 

weight gain groups 

NR 

Bianco et al., 

199854

USA, medical 

center 

11,926 

Nonobese (BMI 

19-27) and 

morbidly obese 

(BMI > 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight 

gain categories 

among morbidly 

obese : 

G1: Weight loss/no 

change 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

G1: 3,302 g 

G2: 3,192 g 

G3: 3,337 g 

G4: 3,506 g 

G5: 3,453 g 

P = < 0.05 

NR 

Overview of results. Overall, these studies (1 good,153 8 fair,20,60,104,154-157 and 1 poor54) 

support an association between weight gains less than the IOM guidelines and lower birthweight; 

such an association appears to be stronger when the rate of weight gain is the relevant factor. 

There is also evidence of an association for gains above the guidelines and higher birthweight 

but less so when rate of weight gain is the relevant factor. 

Detailed results for total weight gain. Seven articles examined total weight gain; one was 

good,153 one was poor quality,54 and the remainder were fair.20,60,104,156,157 The study of women in 

the WIC program found that weight gains both below and above the IOM guidelines were 

associated with lower birthweights (162 g and 153 g, respectively).157 One study found that 

women who were underweight or normal weight and who gained above the IOM guidelines had 
140

higher birthweights; women who gained below the guidelines had lower birthweights than those 

who gained within them.104 The association of higher birthweight with higher weight gain was 

also found among morbidly obese women in one poor study that failed to adjust for any 

confounders.54

Studies that stratified by race20,156or that included only one race60,153 found, overall, that 

black women gaining above the IOM guidelines experienced significantly higher birthweights (a 

range of 73 g to 330 g) than those who gained less weight.20,60,153,156 Among white women,20,156

weight gain above the IOM guidelines was also associated with higher birthweights for those 

with a BMI ≤ 2920,156 but not > 29 in one study.156 This increase in birthweight was close to 200 

g.20,156 In three of these studies,20,153,156 the analyses were adjusted for multiple confounders 

listed in Table 32. 

One good study conducted among black adolescents that examined total weight gain found 

infant birthweights to be lower among those who gained less than the IOM recommendations 

than among those who gained within or above the guidelines;153 infant birthweights did not differ 

between those who gained within and those who gained above the thresholds.

Detailed results for rate of weight gain. Three fair-quality studies examined rate of weight 

gain as the exposure of interest with respect to birthweight.154,155,158 The one including only 

adolescents found that mothers who gained < 0.23 kg per week had infants with a mean 

birthweight of 2,745 g; this birthweight was lower than for infants of mothers who gained 0.23 to 

0.4 kg per week (3,097 g) and for those who gained > 0.4 kg per week (3,351 g).154 

One study examined rate of weight gain only among normal-weight women from the ages of 

12 to 29 from black, white, and Hispanic groups.158 The authors used a rate of weight gain 

between 20 to 36 weeks and defined low as < 0.34 kg per week, moderate as 0.34 to 0.68 kg per 

week, and excessive as > 0.68 kg per week. Controlling for several confounders, the 

investigators found that women with low rates of weight gain had infants of statistically 

significantly lower birthweights than did women with higher rates of weight gain. Birthweights 

did not differ between those who gained at excessive and moderate rates. 

The other rate of weight gain study involved both white and black women with a BMI ≤ 26 

and a mean age of 25.155 Their analyses used mothers who gained more than the IOM guidelines 

as the reference group. Mothers who gained low levels of weight (< 0.38 kg per week for 

underweight or < 0.37 kg per week for normal weight) in the second trimester had infants who 

weighed 166 g less than infants from the reference group; mothers who gained low levels of 

weight in the third trimester had infants who weighed 111 g less than those in the reference 

group. When all women were included in the analyses, the effect seen in the third trimester was 

statistically significant; however, when analyses were stratified by race, it was significant only 

for white women. 

In addition, this study showed that pattern of weight gain was important. Low total weight 

gain in the first trimester combined with low rate of gain in the second was associated with an 

infant who weighed 236 g less than those whose mothers gained more weight. This finding 

appeared to be statistically significant for all women and for black women when analyses were 

stratified by race. Low rate of weight gain in the second and third trimesters was associated with 

a 206 g deficit in weight of the infant. Low rate of weight gain in all three trimesters was 

associated with the greatest deficit, 284 g. 

Low birthweight. 

Study characteristics. Twelve articles (from 10 databases) examined low birthweight (LBW, 

defined as < 2,500 g) (Evidence Table 42, Table 33).2,20,54,55,60,127,154,159-163 Two articles reported 

on data from the Pregnancy Nutrition Surveillance System (PNSS) from either eight2

 or nine 

states;160 two used a single hospital database.55,159 Two studies used PRAMS data.162,163 
141

Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hellerstedt et al., 

1997159 

USA, hospital 

1,343 

Normal/obese BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories stratified by 

pregravid BMI and smoking 

status: 

Obese (BMI > 29.0): 

G1: Smokers, < IOM 

G2: Smokers, within IOM 

G3: Smokers, > IOM 

G4: Nonsmokers, < IOM 

G5: Nonsmokers, within IOM 

G6: Nonsmokers, > IOM 

Normal weight (BMI 19.8-

26.0): 

G7: Smokers, < IOM 

G8: Smokers, within IOM 

G9: Smokers, > IOM 

G10: Nonsmokers, < IOM 

G11: Nonsmokers, within 

IOM 

G12: Nonsmokers, > IOM 

Obese: 

G13: Lost/no gain 

G14: 0.5-6.5 kg 

G15: 7-11.5 kg 

G16: 12-16 kg 

G17: > 16 kg 

Normal weight: 

G18: < 11.5 kg 

G19: 11.5-16 kg 

G20: > 16 kg 

G1: 17.3% 

G2: 10.0% 

G3: 12.3% 

G4: 10.5% 

G5: 7.8% 

G6: 2.6% 

G7: 17.5% 

G8: 3.5% 

G9: 3.6% 

G10: 12.4% 

G11: 6.0% 

G12: 5.3% 

G13: 16.0% 

G14: 11.1% 

G15: 8.3% 

G16: 4.0% 

G17: 6.0% 

P = 0.003 for G13-G17 

G18: 14.2% 

G19: 5.4% 

G20: 4.9% 

P = 0.001 for G18-G20 

For obese women, 

compared to nonsmokers 

who gained 7-11.5 kg, 

smokers who gained < 7 

kg were at significantly 

higher risk of LBW: 

AOR: 7.7 (95% CI, 1.5-

40.0) 

Maternal age, 

pregravid BMI, 

infant sex, race, 

parity, prenatal 

alcohol use, 

prenatal illicit drug 

use, adequacy of 

prenatal care, 

gestational 

hypertension, 

GDM, gestational 

age 

Schieve et al., 

1998160 

USA, Pregnancy 

Nutrition 

Surveillance 

System (WIC 

clinics) 

Pregravid weight: 

Self-report 

Total weight gain: 

Self report 

Maternal weight gain 

categories stratified by 

pregravid BMI (IOM 

underweight, normal weight, 

overweight, and obese) and 

race (non-Hispanic white, 

non-Hispanic black, and 

Hispanic) 

Within every BMI-race 

ethnicity stratum, the 

odds of delivering a LBW 

infant tended to decrease 

as weight gain increased. 

This trend was 

statistically significant for 

all strata; however, the 

Age, height, 

education, 

trimester of the 

special 

supplemental 

nutrition program 

for WIC 

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; G, group; g, gram; GDM, gestational diabetes; IOM, 

Institute of Medicine; kg, kilogram; lbs, pounds; LBW, low birthweight; MLBW, moderately low birthweight; NICU, neonatal 

intensive care unit; USA, United States of America; VLWB, very low birthweight; WIC, The Special Supplemental Nutrition 

Program for Women, Infants, and Children.
142

Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Schieve et al., 

1998160 (continued) 

173,006 

All weight/BMI 

Good 

 G1: ≥ 10 lbs below IOM 

G2: 1-9 lbs below IOM 

G3: Lower half of IOM 

G4: Upper half of IOM 

G5: 1-9 lbs above IOM 

G6: ≥ 10 lbs above IOM 

trend diminished with 

increasing BMI. Women 

with underweight and 

normal weight BMI in G2 

were 1.1–2.8 times more 

likely to deliver a LBW 

infant than women in G3; 

women in G1 were 1.8 –

3.2 times more likely to 

deliver a LBW infant 

compared to G3. 

Bracero and Byrne, 

1998127 

USA, hospital, 

Brooklyn, NY 

20,971 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories: 

G1: Maternal weight gain 

under the IOM guidelines 

G2: Maternal weight gain 

within the IOM guidelines 

G3: Maternal weight gain 

over the IOM guidelines 

G4: Optimal weight gain (36-

40 lbs for BMI < 19.8; 31-40 

lbs for BMI 19.8-26.0; 26-30 

lbs for BMI > 26.0) 

G5: Suboptimal weight gain 

(< 36 lbs for BMI < 19.8; < 31 

lbs for BMI 19.8-26.0; < 26 

lbs for BMI > 26.0) 

G1: 10.1% 

G2: 3.3% 

G3: 2.5% (P < 0.001 

comparing G1-G3) 

G4: 4.9% 

G5: 1.8% (P < 0.001 vs. 

G4) 

Not applicable 

Cogswell et al., 

19952

USA, Pregnancy 

Nutrition 

Surveillance 

System 

53,541 

Normal/ 

Overweight/Obese 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Maternal weight gain 

categories (lbs) stratified by 

pregravid BMI: 

Normal weight (BMI 19.8-

26.0): 

G1: < 15 

G2: 15-19 

G3: 20-24 

G4: 25-29 

G5: 30-34 

G6: 35-39 

G7: ≥ 40 

AOR (95% CI) for low 

birthweight: 

G1: 2.1 (1.6-2.6) 

G2: 1.4 (1.1-1.8) 

G3: 1.0 (0.8-1.3) 

G4: 1.0 (reference) 

G5: 0.8 (0.6-1.0) 

G6: 0.6 (0.5-0.8) 

G7: 0.5 (0.4-0.6) 

G8: 1.1 (0.7-1.9) 

G9: 1.0 (reference) 

G10: 0.7 (0.4-1.2) 

G11: 0.8 (0.5-1.4) 

G12: 0.5 (0.3-0.8) 

G13: 0.6 (0.3-1.1) 

G14: 0.4 (0.3-0.7) 

Age, race, height, 

smoking, 

gestational age, 

infant sex 
143

Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Cogswell et al., 

19942

 (continued) 

 Overweight (BMI > 26.0-

29.0): 

G8: < 15 

G9: 15-19 

G10: 20-24 

G11: 25-29 

G12: 30-34 

G13: 35-39 

G14: ≥ 40 

Obese (BMI > 29.0): 

G15: < 15 

G16: 15-19 

G17: 20-24 

G18: 25-29 

G19: 30-34 

G20: 35-39 

G21: ≥ 40 

G15: 1.5 (0.9-2.4) 

G16: 1.0 (reference) 

G17: 0.9 (0.5-1.6) 

G18: 1.3 (0.8-2.3) 

G19: 0.9 (0.5-1.7) 

G20: 1.0 (0.5-1.8) 

G21: 0.9 (0.5-1.5) 

Edwards et al., 

199655 

USA, Hospital 

1,443 

Normal/Obese 

weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories (kg) 

Obese BMI > 29: 

G1: Lost weight/no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal BMI 19.8-26: 

G6: < 11.5 kg 

G7: 11.5-16 

G8: > 16 kg 

G1:12.8% 

G2: 8.9% 

G3: 7.9% 

G4: 6.8% 

G5: 8.7% 

P (for G1-G5) = 0.405 

G6: 8.5% 

G7: 5.6% 

G8: 8.9% 

P (for G6-G8) = 0.183 

AOR (95% CI) for 

birthweight < 2,500 g 

among obese women 

(BMI > 29.0): 

G3: 1.0 (reference) 

G1: 4.2 (0.9-19.6) 

Age, parity, 

pregravid BMI, 

GDM, pregnancyinduced 

hypertension, 

prenatal 

adequacy, alcohol 

use, drug use, 

smoking, 

gestational age 

Hickey et al., 

199720 

USA, public health 

programs 

5,198 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories stratified by race: 

Black Women: 

G1: Below range (< 12.5kg 

for BMI< 19.8; < 13.9kg for 

BMI 19.8-26.0; < 7.0kg for 

BMI > 26.0) 

G2: In lower range (12.5-

15.2kg for BMI< 19.8; 11.5-

13.8kg for BMI 19.8-26.0; 

7.0-9.2kg for BMI > 26.0) 

G3: In upper range (15.3-

18kg for BMI< 19.8; 13.9-

16.0kg for BMI 19.8-26.0; 

9.3-11.5kg for BMI > 26.0) 

AOR (95% CI) 

G1: 2.6 (1.2-5.6) 

G2: 1.0 (reference) 

G3: 1.2 (0.4-3.3) 

G4: 1.4 (0.6-3.6) 

G5: 1.5 (0.8-2.6) 

G6: 1.0 (reference) 

G7: 0.4 (0.2-0.9) 

G8: 0.7 (0.3-1.2) 

Age, education, 

height, drug use, 

alcohol use, time 

between last 

prenatal weight 

observation and 

delivery, smoking, 

gestational age, 

infant sex 
144

Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hickey et al., 

199720 (continued) 

 G4: Above range (> 18kg for 

BMI < 19.8; > 16.0kg for BMI 

19.8-26.0; > 11.5kg for BMI 

> 26.0) 

White Women: 

G5: Below range 

G6: In lower range 

G7: In upper range 

G8: Above range 

 

Ogunyemi et al., 

199960

USA, Hospital 

582 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI IOM 

AOR (95% CI) for very 

low birthweight: 

G1: 1.8 (0.6-4.7) 

G2: 1.1 (0.4-4.7) 

G3: 1.0 (Reference) 

Age, parity, 

pregravid BMI, 

preeclampsia, 

cesarean delivery, 

previous cesarean, 

tobacco use, 

previous fetal 

death, 

hypertension, 

asthma, previous 

LBW, vomiting, 

NICU 

Stevens-Simon 

and McAnarney, 

1992154 

USA, adolescent 

maternity program 

141 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories (kg/wk): 

G1: < 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Distribution of LBW, %: 

G1: 21.4 

G2: 10.6 

G3: 4.3 

P = NS 

Not applicable 

Strauss and Dietz, 

1999161 

USA, National 

Collaborative 

Perinatal Project 

and the Child 

Health and 

Development 

Study 

10,756 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories stratified by 

pregravid BMI: 

BMI < 20.0: 

G1: Low 1st trimester gain 

(< 0.1kg/wk) 

G2: Low 2nd trimester gain 

(< 0.3kg/wk) 

G3: Low 3rd trimester gain 

(< 0.3kg/wk) 

BMI 20.0-25.0: 

G4: Low 1st trimester gain 

G5: Low 2nd trimester gain 

G6: Low 3rd trimester gain 

BMI > 25.0: 

G7: Low 1st trimester gain 

G8: Low 2nd trimester gain 

G9: Low 3rd trimester gain 

AOR (95% CI) for < 

2,500g: 

G1: 0.88 (0.50-1.57) 

G2: 2.68 (1.46-4.94) 

G3: 2.07 (1.22-3.51) 

G4: 1.31 (0.88-1.95) 

G5: 1.92 (1.29-2.87) 

G6: 2.12 (1.48-3.04) 

G7: 1.02 (0.50-2.08) 

G8: 1.88 (1.03-3.43) 

G9: 1.53 (0.86-2.74) 

Reference group-normal 

rate of weight gain in the 

trimester 

Race, GDM, 

toxemia, smoking 
145

Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Bianco et al., 

199854 

USA, medical 

center 

11,926 

Nonobese (BMI 19-

27) and morbidly 

obese (BMI > 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories among morbidly 

obese (BMI> 35): 

G1: Weight loss/no change 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Distribution of LBW,%: 

G1: 2.0 

G2: 11.1 

G3: 8.3 

G4: 5.2 

G5: 3.8 

P = NS 

Race, parity, clinic 

service, substance 

abuse, preexisting 

medical condition 

Hulsey et al., 

2005162 

USA, birth 

certificates linked 

to PRAMS data 

87,293 

All weight/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Birth certificate 

Pregravid BMI and 

gestational weight gain 

categories: 

G1: BMI < 19.8 and < IOM 

G2: BMI 19.8-26.0 and 

< IOM 

G3: BMI 19.8-26.0 and within 

IOM 

G4: BMI 26.1-29.0 and 

< IOM 

G5: BMI > 29.0 and < IOM 

G6: BMI > 29.0 and within 

IOM 

AOR (95% CI) for very 

low birthweight (500-

1,499g): 

G1: 2.06 (1.26-2.87) 

G2: 1.82 (1.22-2.29) 

G3: 1.00 (reference) 

G4: 2.05 (0.90-4.44) 

G5: 1.25 (0.61-1.61) 

G6: 1.74 (1.23-2.42) 

AOR (95% CI) for 

moderately low 

birthweight (1500-2499 

g): 

G1: 4.83 (2.98-7.83) 

G2: 1.77 (1.23-2.60) 

G3: 1.00 (reference) 

G4: 0.28 (0.11-1.83) 

G5: 1.09 (0.67-2.13) 

Ethnicity, 

intendedness of 

pregnancy, 

Medicaid status, 

WIC status, 

prenatal care, 

diabetes, 

hypertension 

Nida et al., 1996163

USA PRAMS 

No sample size 

All weight/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

G1: < IOM 

G2: within IOM 

G3: > IOM 

BMI < 19.8 

G1: 10.2% 

G2: 6% 

G3: 4.7 

BMI 19.8-25 

G1: 8.4% 

G2: 3.9% 

G3: 4.5% 

BMI > 26 

G1: 6.1% 

G2: 3.8% 

G3: 5.1% 

No statistical testing was 

performed 

Pregravid BMI 
146

Overview of results. Evidence from twelve articles (2 good,159,160 7 fair,2,20,55,60,77,127,154,161 and 

3 poor54,162,163) supports an association between weight gain less than the IOM guidelines and 

LBW for both underweight and normal-weight women; evidence is less conclusive about any 

association for women with higher body weight. 

Detailed results for total weight gain. In the nine-state PNSS study,160 analyses for normal 

and overweight women stratified by race showed a statistically significant decreased risk of 

LBW with higher gains. Among underweight women, a protective effect against LBW was seen 

with higher gains in whites and Hispanic and an increased risk was associated with low weight 

gains (>10 lbs <IOM threshold) across all the race groups. Similarly, among obese women of all 

race groups, low weight gains (> 10 pounds below the IOM threshold) were associated with 

higher risk of LBW.160 

In the eight-state PNNS study,2

 for women of normal weight, the odds for LBW were 

elevated and statistically significant when their weight gains were below 19 pounds compared 

with women whose weight gains were in the recommended range. For overweight and obese 

women, weight gains below the IOM guidelines were not associated with LBW infants. This was 

also shown in the study by Edwards et al.55 

Weight gains above the IOM guidelines starting at > 35 pounds were protective against 

having a LBW infant for normal-weight women,2 and starting at ≥ 40 pounds for overweight 

women, but higher weight gains were not protective for obese women. 

Two studies showed almost double the odds of LBW among black women who delivered at 

term but had weight gain below the IOM range;20,60 this finding was statistically significant in 

only one (good) study.20 The OR among white women was 1.5 (not significant).20

The only association seen among obese women was among smokers who gained less than the 

IOM guidelines.159 These women had an eightfold increased risk of having an LBW infant 

compared with obese nonsmokers who gained adequately.159

One study performed bivariate analysis between the IOM categories of weight gain and LBW 

infants.127 It demonstrated a statistically higher prevalence of LBW among mothers who gained 

less than the IOM guidelines than among mothers who gained within or more than the 

guidelines. 

Detailed results for rate of weight gain. Two studies examined the effect of the rate of weight 

gain on LBW.154,161 One among black adolescents found no differences in the prevalence of 

LBW by rate-of-weight-gain group.154 The other included only term births, used data from the 

National Collaborative Perinatal Project and the Child Health and Development Study, and 

examined total weight gain in the first trimester and rates in the second and third trimesters.161

Low rate of weight gain in the second and third trimesters was associated with an increased risk 

of term LBW or intrauterine growth restriction (IUGR) in both data sets. This association held 

for all weight status groups except women with a BMI > 25 when the analysis was stratified by 

pregravid BMI and adjusted for multiple confounders. 

Fetal growth (large for gestational age or macrosomia). 

Study characteristics. We identified 15 studies that examined the association between weight 

gain categorized according to the IOM guidelines on LGA4,25,54,116,118,129,154,159 or 

macrosomia2,53,55,110,160,164,165 (Evidence Tables 43 and 44, Table 34). Five studies used data from 

a hospital database;54,55,116,118,129,159 three were cohort studies.53,154,164 One study used data from a 

health maintenance organization;110 one used a prenatal clinic database;153 one used state birth 

certificate data;4,25 one used the Pregnancy Nutrition Surveillance System;2,160 and one used 

controls from a multicenter study of birth defects.165 
147

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight 

Author, Year 

Country, 

Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

LGA as > 90th percentile of birthweight for gestational age 

Caulfield et al., 

1998116

USA, university 

hospital 

3,870 

All weight/BMI 

Good 

Pregravid weight: 

Self report 

Total weight gain: 

Measured 

G1: Underweight, BMI < 19.8 

G2: Normal weight, BMI 19.8-

26.0 

G3: Overweight, BMI > 26.0 

Black women: 

G4: No weight gain < IOM 

G5: No weight gain > IOM 

White women: 

G6: No weight gain < IOM 

G7: No weight gain > IOM 

AOR (95% CI) for LGA and rate 

of weight gain (per 50 g/wk): 

G1: 1.25 (1.11-1.41) 

G2: 1.14 (1.08-1.20) 

G3: 1.13 (1.07-1.20) 

Expected absolute change (as % 

of baseline) in incidence of LGA 

associated with modifiable risk 

factor (G4-G7): 

G4: +1.28 (+26) 

G5: -0.77 (-16) 

G6: +2.58 (+17) 

G7: -2.87 (-19) 

Age, race, 

parity, 

pregravid BMI, 

height, 

hypertension, 

provider type, 

smoking, 

female infant 

Hellerstedt et 

al., 1997159 

USA, medical 

center 

1,343 

Normal/obese 

BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain categories 

stratified by pregravid BMI and 

smoking status: 

Obese (BMI > 29.0): 

G1: Smokers, < IOM 

G2: Smokers, within IOM 

G3: Smokers, > IOM 

G4: Nonsmokers, < IOM 

G5: Nonsmokers, within IOM 

G6: Nonsmokers, > IOM 

Normal weight (BMI 19.8-26.0): 

G7:Smokers, < IOM 

G8: Smokers within IOM 

G9:Smokers,> IOM 

G10: Nonsmokers < IOM 

G11: Nonsmokers, within IOM 

G12: Nonsmokers, > IOM 

Obese: 

G13: Lost/no gain 

G14: 0.5-6.5 kg 

G15: 7-11.5 kg 

G16: 12-16 kg 

G17: > 16 kg 

Normal weight: 

G18: < 11.5 kg 

G19: 11.5-16 kg 

G20: > 16 kg 

Frequencies of LGA,%: 

G1: 5.3 

G2: 10.0 

G3: 12.3 

G4: 12.2 

G5: 11.7 

G6: 22.2 

G7: 0 

G8: 1.8 

G9: 9.1 

G10: 4.4 

G11: 8.1 

G12: 14.3 

G13: 9.3 

G14: 10.5 

G15: 11.3 

G16: 17.5 

G17: 21.8 

P = 0.001 for G13-G17 

G18: 2.8 

G19: 6.7 

G20: 13.1 

P < 0.001 for G18-G20 

Compared with infants of obese 

nonsmokers who gained 7-

11.5kg, the only group at 

significantly higher risk of LGA 

was non smokers who gained 

> 11.5kg: AOR: 2.3 (95% CI, 1.2-

4.5) 

Maternal age, 

pregravid BMI, 

infant sex, 

race, parity, 

prenatal 

alcohol use, 

prenatal illicit 

drug use, 

adequacy of 

prenatal care, 

gestational 

hypertension, 

GDM, 

gestational age

AOR: adjusted odds ratio; BMI, body mass index; CI, confidence interval; G, group; g, gram; GDM: gestational diabetes; IOM, Institute of 

Medicine; kg/wk, kilogram per week; lbs, pounds; LBW, low birthweight; NICU, neonatal intensive care unit; PRAMS, Pregnancy Risk 

Assessment Monitoring System; USA, United States of America; WIC, The Special Supplemental Nutrition Program for Women, Infants, and 

Children.
148

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued) 

Author, Year 

Country, 

Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Devader et al., 

200725 

USA, birth 

certificate data 

94,696 

Normal 

weight/BMI 

19.8-26 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain categories:

G1: < 25 lbs 

G2: 25-35 lbs 

G3: > 35 lbs 

AOR (95% CI) for LGA: 

G1: 0.40 (0.37-0.44) 

G2: 1.00 (reference) 

G3: 2.43 (2.30-2.56) 

Age, race, 

education, 

income, alcohol 

use, height, prior 

pregnancy, 

inadequate 

prenatal care use, 

smoking, child's 

gender, birth year

Kiel et al., 

20074

 

USA, birth 

registry 

120,170 

Obese BMI 

> 30 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Medical record 

Maternal weight gain categories 

stratified by prepregnancy 

obesity status, Obese Class 

I(BMI 30–34.9), Obese Class II 

(BMI 35–39.9), Obese Class III 

(> = BMI 40): 

G1: ≤ -10 lbs 

G2: -2 to -9 lbs 

G3: No change 

G4: 2-9 lbs 

G5: 10-14 lbs 

G6: 15-25 lbs 

G7: 26-35 lbs 

G8: > 35 lbs 

For Obese Class I: OR (95% 

CI) for LGA were significantly 

lower (< 1.00, G6 was 

reference) for G1- G5 and 

significantly higher for G7-

G8. 

For Obese Class II: OR (95% 

CI) for LGA were significantly 

lower (< 1.00, G6 was 

reference) for G1- G5 and 

significantly higher for G7-

G8. 

For Obese Class III:OR (95% 

CI) for LGA were significantly 

lower (< 1.00, G6 was 

reference) for G1- G4 and 

significantly higher for G7-G8 

Age, race, parity, 

education, 

poverty 

(enrollment in 

Medicaid, WIC, 

food stamp 

programs), 

tobacco use, 

chronic 

hypertension 

Parker and 

Abrams, 

1992118 

USA, hospital 

USA, Hospital 

database 

(California) 

6,690 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain categories:

G1: < IOM range 

G2: Within IOM range 

G3: > IOM 

BMI IOM 

AOR (95% CI) for LGA: 

G3: 1.92 (1.52-2.43) 

G2: 1.00 (reference) 

Incidence of LGA in 

nonobese women,%: 

G1: 3.25 

G2: 6.14 

G3: 13.11 

Incidence of LGA in obese 

women,%: 

G1: 5.88 

G2: 17.53 

Age, race, parity, 

pregravid BMI, 

height, maternal 

high and low 

weight gain, 

smoking, 

gestational age, 

birthweight 
149

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued) 

Author, Year 

Country, 

Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Stevens-Simon 

and 

McAnarney, 

1992154 

USA, 

adolescent 

maternity 

program 

141 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain categories 

(kg/wk): 

G1:< 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Distribution of LGA,%: 

G1: 3.6 

G2: 4.5 

G3: 12.8 

P = NS 

NA 

Stotland et al., 

2006129 

USA, university 

hospital 

20,465 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Prenatal record 

Maternal weight gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: weight gain < 7kg 

G5: weight gain > 18kg 

BMI IOM 

Unadjusted Rates of LGA: 

G1: 3.85 P< 0.001 vs. G2 

G2: 6.62 

G3:13.76 P< 0.001 vs. G2 

G4: 5.26 

G5: 14.60 P< 0.05 vs. G2 

AOR (95% CI) for LGA: 

G1: 0.58 (0.47-0.72) 

G2: 1.00 (reference) 

G3: 1.98 (1.74-2.25) 

G4: 0.50 (0.33-0.78) 

G5: 2.28 (2.00-2.62) 

Age, race, parity, 

pregravid BMI, 

pregnancyinduced 

hypertension, 

date of delivery, 

mode of delivery, 

length of first and 

second stage of 

labor, smoking, 

gestational age, 

birthweight 

Bianco et al., 

199854

USA, Medical 

Center 

11,926 

Nonobese (BMI 

19-27) and 

morbidly obese 

(BMI > 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain categories 

among morbidly obese (BMI > 

35): 

G1: Weight loss/no change 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Distribution of LGA,%: 

G1: 12.0 

G2: 11.8 

G3: 18.8 

G4: 25.8 

G5: 23.8 

P < 0.01 

Race, parity, 

clinic service, 

substance abuse, 

preexisting 

medical condition
150

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued) 

Author, Year 

Country, 

Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

LGA as birthweight > 4,500 gm 275 

Hedderson et 

al., 2006110 

USA, Kaiser 

Permanente 

Medical Care 

Program 

45,245 

All weight/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI IOM 

% Distribution of maternal 

weight gain categories 

among women with 

macrosomia: 

G1: 4.0 

G2: 16.3 

G3: 79.7 P < 0.05 (compared 

to controls) 

AOR (95% CI) for 

macrosomia: 

G1: 0.38 (0.20-0.70) 

G2: 1.00 reference 

G3: 3.05 (2.19-4.26) 

OR (95% CI) for 

macrosomia: 

Underweight women (BMI 

< 19.8) 

G2: 1.00 (reference) 

G3: 2.70 (0.83-8.61) 

Normal weight women(BMI 

19.8-26.0) 

G2: 1.00 (reference) 

G3: 3.60 (2.27-5.83) 

Overweight/obese women 

(BMI > 26.0) 

G2: 1.00 (reference) 

G3: 2.00 (1.14-3.47) 

Age, race, 

parity, pregravid 

BMI, screening 

glucose value 

from 1 hour after 

the 50g oral 

glucose 

challenge test, 

difference 

between age at 

delivery and 

gestational age 

at last weight 

measured 

Schieve et al., 

1998160 

USA 

Pregnancy 

Nutrition 

Surveillance 

System - data 

from WIC 

clinics 

173,006 

All weight/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Self report 

Maternal weight gain categories 

stratified by pregravid BMI (IOMunderweight, normal weight, 

overweight, and obese) and race 

(non-Hispanic white, nonHispanic black, and Hispanic): 

G1: ≥ 10 lbs below IOM 

G2: 1-9 lbs below IOM 

G3: Lower half of IOM 

G4: Upper half of IOM 

G5: 1-9 lbs above IOM 

G6 ≥ 10 lbs above IOM 

Within every BMI-race 

ethnicity stratum, the odds of 

delivering a > 4,500g infant 

tended to increase as weight 

gain increased. This trend 

was statistically significant for 

all strata; however, the trend 

diminished with decreasing 

BMI. Women in G6 were 

2.2–10.8 times more likely to 

deliver a > 4,500 g infant 

compared to women in G3, 

irrespective of BMI status. 

Age, height, 

education, 

trimester of the 

Special 

Supplemental 

Nutrition 

Program for 

WIC 
151

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued) 

Author, Year 

Country, 

Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Cogswell et al., 

19952

USA, 

Pregnancy 

Nutrition 

Surveillance 

System 

53,541 

Normal/ 

Overweight/ 

Obese 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Maternal weight gain categories 

(lbs) stratified by pregravid BMI: 

Normal weight (BMI 19.8-26.0): 

G1: < 15 

G2: 15-19 

G3: 20-24 

G4: 25-29 

G5: 30-34 

G6: 35-39 

G7: ≥= 40 

Overweight (BMI > 26.0-29.0): 

G8: < 15 

G9: 15-19 

G10: 20-24 

G11: 25-29 

G12: 30-34 

G13: 35-39 

G14: ≥ 40 

Obese (BMI > 29.0): 

G15: < 15 

G16: 15-19 

G17: 20-24 

G18: 25-29 

G19: 30-34 

G20: 35-39 

G21: ≥ 40 

AOR (95% CI) for high 

birthweight: 

G1: 1.0 (0.5-2.0) 

G2: 0.4 (0.2-1.0) 

G3: 0.6 (0.3-1.1) 

G4: 1.0 (reference) 

G5: 1.1 (0.7-1.8) 

G6: 1.5 (1.0-2.3) 

G7: 3.3 (2.3-4.7) 

G8: 0.8 (0.2-2.6) 

G9: 1.0 (reference) 

G10: 1.1 (0.4-3.5) 

G11: 2.1 (0.8-5.7) 

G12: 2.4 (0.9-6.4) 

G13: 1.6 (0.6-4.6) 

G14: 4.0 (1.6-10.1) 

G15:0.7 (0.5-1.1) 

G16: 1.0 (reference) 

G17: 1.1 (0.7-1.7) 

G18: 1.3 (0.8-2.0) 

G19: 1.9 (1.3-2.9) 

G20: 2.1 (1.3-3.2) 

G21: 2.3 (1.6-3.3) 

Age, race, 

height, smoking, 

gestational age, 

sex of infant 

Thorsdottir 

200253 

Iceland, 

Hospital 

records 

614 

Normal 

weight/BMI 

19.5-25.5 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Maternity records 

Maternal weight gain categories: 

G1: < 11.5 kg 

G2: 11.5-16.0 kg 

G3: 16.1-20.0 kg 

G4: > 20.0 kg 

G5: 12.5-15.5 kg 

G6: > 17.8-20.8 kg 

Birthweight > 4,500g,% 

G1: 4.3 

G2: 4.1 (P< 0.05 between 

groups) 

G3: 9.1 (P< 0.05 between 

groups) 

G4: 10.2 (P< 0.05 between 

groups) 

P for trend< 0.015 

RR (95% CI) for > 4,500g: 

G5: 1.00 (reference) 

G6: 3.54 (1.26-9.97) 

Age, parity, 

height, 

gestational age, 

birthweight 
152

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and Effect 

Modifiers Included in 

Analysis 

LGA as birthweight > 4,000 gm 

Edwards et al., 

199655 

USA, Hospital 

1,443 

Normal/Obese 

weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories (kg) Obese > 29: 

G1: Lost weight/no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal BMI 19.8-26 

G6: < 11.5kg 

G7: 11.5-16 

G8: > 16kg 

Birthweight ≥

4,000g,%: 

G1:12.0 

G2: 12.5 

G3: 13.3 

G4: 15.4 

G5: 24.4 

P (for G1-G5) 

= 0.026 

G6: 5.7 

G7: 6.6 

G8: 16.9 

P (for G6-G8) 

< 0.001 

AOR (95% CI) for 

birthweight ≥ 4,000 

g among obese 

women (BMI > 

29.0): 

G3: 1.0 (reference) 

G8: 2.8 (1.4-5.6) 

AOR (95% CI) for 

birthweight ≥ 4,000g 

among normal 

weight women (BMI 

19.8-26.0): 

G7: 1.0 (reference) 

G8: 2.4 (1.3-4.7) 

Age, parity, pregravid 

BMI, GDM, pregnancyinduced hypertension, 

prenatal adequacy, 

alcohol use, drug use, 

smoking, gestational age 

Rode et al., 2007164

Denmark Smokefree Newborn 

Study, University 

Hospital 

2,248 

All weight/BMI 

Fair 

Pregravid weight: 

Self report 

Total weight gain: 

Self report 

Maternal weight gain 

categories stratified by 

pregravid BMI status: 

BMI less than 19.8 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI 19.8–26.0 

G4: < IOM 

G5: Within IOM 

G6: > IOM 

BMI 26.1–29.0 

G7: < IOM 

G8: Within IOM 

G9: > IOM 

AOR (95% CI) for 

birthweight ≥

4,000g: 

G1: 0.8 (0.4-1.6) 

G2: 1.0 (reference) 

G3: 1.7 (0.8-3.6) 

G4: 0.7 (0.5-0.999) 

G5: 1.0 (reference) 

G6: 1.9 (1.5-2.5) 

G7: 0.6 (0.1-3.1) 

G8: 1.0 (reference) 

G9: 1.8 (0.8-3.9) 

G10: 0.8 (0.4-1.7) 

G11: 1.0 (reference) 

G12: 0.9 (0.4-2.0) 

Preeclampsia, caffeine 

consumption, gestational 

age, smoking 
153

Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis 

Rode et al., 

2007164

(continued) 

 BMI greater than 29.0 

G10: < IOM 

G11: Within IOM 

G12: > IOM 

 

Kabali et al., 

2007165

USA,/Canada, 

Pediatric practice 

815 

All weight/BMI 

Poor 

Pregravid weight: 

Self-report 

Total weight: 

Self-report 

G1: < IOM 

G2: within IOM 

G3: > IOM 

BMI IOM 

AOR 

G1: 1.0 (0.4, 1.9) 

G2: ref 

G3: 1.5 (0.7, 2.5) 

Combined effect with BMI OR 

(AOR similar but not all could 

be calculated) 

Underweight/G1: 0.7 (0.2, 3.3) 

Underweight/G2: 1.0 (0.3, 3.5) 

Underweight/ G3: 1.7 (0.4, 6.4) 

Normal/G1: 0.7 (0.3, 1.8) 

Normal/G2 Ref 

Normal/ G3: 1.1 (0.5, 2.3) 

Overweight/G1: 1.2 (0.4, 3.8) 

Overweight/G2: 0.8 (0,2, 2.7) 

Overweight/G3: 2.4 (1.2, 4.8) 

Maternal age, marital 

status, race/ethnicity, 

family income, years of 

education, smoking, 

alcohol, sex of child, 

parity, gestational age 

Overview of results for LGA infant weight. Eight studies defined LGA as > 90 percentile of 

birthweight for gestational age (Table 34).4,25,54,116,118,129,154,159 The majority of these studies, of 

which two were rated good,116,159 one poor54 and the remainder fair,4,25,118,129,154 showed a 

consistent association between weight gains above the IOM guidelines and LGA for women of 

all weight status groups. Four articles examined LGA defined as > 4,500 g;2,53,110,160 two were 

good quality,110,160 two were fair.2,53 They also showed a consistent association. When 

macrosomia or high birthweight was the outcome, results were less consistent (1 poor quality,165

2 fair-rated studies55,164). 

Detailed results for LGA infant weight. One study reported the risk of LGA among women of 

all weight status groups129 and another among nonobese women (BMI < 30).118 In both studies, 

the risk for LGA was nearly doubled for women who gained above the IOM guidelines. For 

women who gained below the IOM guidelines, the risk for LGA was decreased by close to 40 

percent.129 

For women of normal pregravid weight, the odds of LGA estimated from an adjusted model 

found a nonsignificant increased risk of having an LGA infant.55In another study, the risk was 

twofold higher and statistically significant for women gaining more than IOM 

recommendations.25 This same study found that the odds of LGA was decreased by more than 60 

percent with gains below the IOM guidelines for normal-weight women. 

Among obese women, the risk of LGA was 2.3 times greater for nonsmokers gaining in 

excess of the IOM guidelines, but this was not true among obese smokers.55,159 In a study that 

grouped women into classes of obesity,4 the odds of LGA increased with weight gains above 25 

pounds for all classes of obesity. 
154

Two studies examined the impact of rate of weight gain according to the IOM guidelines on 

having an LGA infant.116,154 One good study defined the rate of weight gain in increments of 50 

g per week.116 The AORs associated with having an LGA infant for each increment were as 

follows: 1.25 for normal-weight women, 1.14 for overweight women, and 1.13 for obese women. 

Using these AORs, the authors calculated the expected change in the incidence of LGA if weight 

gains remained within the IOM guidelines. These changes were -0.77 percent for black women 

and -2.87 percent for white women; baseline LGA incidence rates were 4.8 percent and 14.8 

percent, respectively. The other study investigated rate of weight gain among black adolescents 

with no difference in pregravid weight status.154 In bivariate analysis the prevalence of LGA did 

not differ between mothers who were slow weight gainers (< 0.23 kg/week) or rapid weight 

gainers (> 0.4 kg/week) and mothers who were average weight gainers (0.23 to 0.4 kg/week). 

With respect to LGA defined as > 4,500 g, the one study reporting risk estimates for women 

of all weight groups found that weight gain above the IOM guidelines was associated with a 

threefold increased risk of LGA after adjustment for various confounders.110 Women who gained 

less than the recommendation were 62 percent less likely to have an LGA infant than women 

who gained within the recommended range. 

Analyses for normal-weight women showed a threefold increased risk of LGA with weight 

gains above the IOM guidelines110 or at > 40 pounds2,53 after adjusting for multiple confounders. 

Overweight and obese women who gained more than the IOM guidelines had twice the risk of 

having an LGA infant in one study,110 and in another study,2

 they did not have a significantly 

increased risk until weight gains exceeded 40 pounds for overweight women (AOR, 4.0; 95% CI, 

1.6-10.1) and 30 pounds for obese women (AOR ranged from 1.9 to 2.3). 

Low weight gains were not significantly associated with LGA risk in any of these 

studies.2,53,110,160 In one study that stratified results by weight status and race across all BMI and 

racial groups,160 the risk of LGA was significantly higher with total weight gains 10 pounds more 

than the IOM recommendation. Weight gains below the IOM guidelines were protective only 

among white women across all BMI weight status groups. 

Detailed results for high birthweight or macrosomia. Three studies (1 poor-quality165) 

defined high birthweight or macrosomia as > 4,000 g.55,164 All stratified results by pregravid 

weight status. For normal-weight women, those who gained more than the IOM guidelines were 

at a statistically significant increased risk in the two studies of fair quality.55,164 Normal-weight 

women who gained below the guidelines were at decreased risk in one study.164 For obese 

women, one study found no difference in the risk of macrosomia with weight gains either above 

or below the IOM guidelines;164 the other found that those who gained above the IOM guidelines 

had 2.8 times the risk for a macrosomic infant relative to those who gained within the 

recommended range.55 For underweight and overweight women, weight gains above or below 

the IOM guidelines were not associated with delivering a macrosomic infant,164 although women 

with weight gains above the guidelines appeared to have a slightly increased risk. 

Fetal growth (small for gestational age). 

Study characteristics. Ten articles examined the association of gaining weight according to 

the IOM guidelines and having an SGA infant (Evidence Table 45, Table 

35).4,25,54,55,116,118,129,153,154,159 Two studies were conducted among black adolescents.153,154 The 

majority used hospital databases54,55,116,118,129,153,159 or clinic databases153 as the source of their 

information; one study (2 articles) used birth certificate information;4,25 and one was a cohort 

study.154 All studies used a definition of < 10th percentile to define SGA, but reference 

populations differed across these studies. 
155

Table 35. Weight change relative to IOM thresholds and small-for-gestational-age 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Caulfield et al., 

1998116

USA, University 

Hospital 

3,870 

All weight/BMI 

Good 

Pregravid weight: 

Self report 

Total weight gain: 

Measured 

G1: Underweight, BMI 

< 19.8 

G2: Normal weight, BMI 

19.8-26.0 

G3: Overweight, BMI 

> 26.0 

Black women: 

G4: No weight gain < IOM 

G5: No weight gain > IOM 

White women: 

G6: No weight gain < IOM 

G7: No weight gain > IOM 

AOR (95% CI) for SGA and 

rate of weight gain (per 50 

g/wk): 

G1: 0.87 (0.78-0.97) 

G2: 0.90 (0.84-0.96) 

G3: 0.93 (0.86-1.01) 

Expected absolute change (as 

% of baseline) in Incidence of 

SGA associated with 

modifiable risk factors (G4-

G7): 

G4: -1.17 (-16) 

G5: +0.97 (+13) 

G6: -0.44 (-11) 

G7: +0.60 (+15) 

Age, race, 

parity, 

pregravid BMI, 

height, 

hypertension, 

provider type, 

smoking, 

female infant 

Hellerstedt et al., 

1997159 

USA, medical 

center 

1,343 

Normal/obese BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories stratified by 

pregravid BMI and 

smoking status: 

Obese (BMI > 29.0): 

G1: Smokers, < IOM 

G2: Smokers, within IOM 

G3: Smokers, > IOM 

G4: Nonsmokers, < IOM 

G5: Nonsmokers, within 

IOM 

G6: Nonsmokers, > IOM 

Normal weight (BMI 19.8-

26.0): 

G7: Smokers, < IOM 

G8: Smokers, within IOM 

G9: Smokers, > IOM 

G10: Nonsmokers, < IOM 

G11: Nonsmokers, within 

IOM 

G12: Nonsmokers, > IOM 

Frequencies of SGA,%: 

G1: 13.3 

G2: 10.0 

G3: 7.7 

G4: 5.5 

G5: 4.7 

G6: 3.6 

G7: 28.6 

G8: 10.9 

G9: 3.6 

G10: 8.9 

G11: 6.5 

G12: 6.4 

G13: 10.7 

G14: 6.6 

G15: 6.0 

G16: 4.0 

G17: 5.3 

P = 0.115 for G13-G17 

G18: 15.9 

G19: 7.5 

G20: 5.7 

P = 0.001 for G18-G20 

Maternal age, 

pregravid BMI, 

infant sex, 

race, parity, 

prenatal 

alcohol use, 

prenatal illicit 

drug use, 

adequacy of 

prenatal care, 

gestational 

hypertension, 

GDM, 

gestational age

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; G, group; GDM, gestational diabetes mellitus; kg, 

kilogram; IOM, Institute of Medicine; NS, not sufficient; OR, odds ratio; PIH, pregnancy-induced hypertension; SGA, small for 

gestational age; USA, United States of America; WIC, The Special Supplemental Nutrition Program for Women, Infants, and 

Children.
156

Table 35. Weight change relative to IOM thresholds and small-for-gestational-age (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Hellerstedt et al., 

1997159 (continued) 

 Obese: 

G13: Lost/no gain 

G14: 0.5-6.5 kg 

G15: 7-11.5 kg 

G16: 12-16 kg 

G17: > 16 kg 

Normal weight: 

G18: < 11.5 kg 

G19: 11.5-16 kg 

G20: > 16 kg 

For obese women, compared to 

nonsmokers who gained 7-11.5 

kg, smokers who gained < 7 kg 

were at significantly higher risk of 

SGA OR: 3.2 (95% CI, 1.1-10.1) 

For normal weight women, 

compared to nonsmokers who 

gained 11.5-16 kg, smokers who 

gained < 11.5 kg were at 

significantly higher risk of SGA 

OR: 4.3 (95% CI, 1.8-10.3) 

Nielsen et al., 

2006153

USA, hospitals 

(African American 

adolescents) 

815 

All weight/BMI 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

G4: < IOM 

G5: Lower half of IOM 

G6: Upper half of IOM 

G7: > IOM 

SGA,%: 

G1: 22.3 

G2: 15.6 

G3: 11.5 

P < 0.01 for G1-G3 

AOR (95% CI) for SGA: 

G4: 2.31 (1.22-4.37) 

G5: 1.00 (reference) 

G6: 0.88 (0.41-1.89) 

G7: 0.68 (0.34-1.35) 

P < 0.01 for G4-G7 

Parity, 

pregravid BMI, 

time between 

last weight 

measure and 

delivery, height

Devader et al., 

200725

USA, birth 

certificate data 

94,696 

Normal weight/BMI 

19.8-26 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories (lbs): 

G1: < 25 

G2: 25-35 

G3: > 35 

AOR (95% CI) for SGA: 

G1: 2.14 (2.01-2.27) 

G2: 1.0 (reference) 

G3: 0.48 (0.45-0.50) 

Age, race, 

education, 

income, 

alcohol use, 

height, prior 

pregnancy, 

inadequate 

prenatal care 

use, smoking, 

child's gender, 

birth year 
157

Table 35. Weight change relative to IOM thresholds and small-for-gestational-age (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Edwards et al., 

199655 

USA, hospital 

1,443 

Normal/Obese 

weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Obese BMI > 29 (kg): 

G1: Lost weight/no change

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal weight 19.8-26 

G6: < 11.5 

G7: 11.5-16 

G8: > 16 

% SGA for obese: 

G1: 10.7% 

G2: 6.6% 

G3: 6.0% 

G4: 4.0% 

G5: 5.3% 

P = 0.11 

For normal weight: 

G6: 15.9% 

G7: 7.5% 

G8: 5.7% 

P = 0.001 

AOR (95% CI) 

Obese: 

G1 vs. G3 2.9 (1.1-8.4) 

Normal weight: 

G6 vs. G7 1.7 (0.9-3.4) 

Age, parity, 

pregravid BMI, 

GDM, PIH, 

prenatal 

adequacy, 

alcohol use, 

drug use, 

smoking, 

gestational age

Kiel et al., 20074 

USA, birth registry 

120,170 

Obese BMI > 30 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Medical record 

Maternal weight gain 

categories stratified by 

prepregnancy obesity 

status, Obese Class I (BMI 

30–34.9), Obese Class II 

(BMI 35–39.9), Obese 

Class III (BMI ≥ 40): 

G1: ≤ -10 lbs 

G2: -2 to -9 lbs 

G3: No change 

G4: 2-9 lbs 

G5: 10-14 lbs 

G6: 15-25 lbs 

G7: 26-35 lbs 

G8: > 35 lbs 

For Obese Class I: AOR (95% 

CI) for SGA were significantly 

greater (> 1.00, G6 was 

reference) for G1- G5 and 

significantly lower for G7-G8. 

For Obese Class II: AOR 

(95% CI) for SGA were 

significantly greater (> 1.00, 

G6 was reference) for G1- G5 

and significantly lower for G7-

G8 

For Obese Class III: AOR 

(95% CI) for SGA were 

significantly greater (> 1.00, 

G6 was reference) for G1 and 

G3 and significantly lower for 

G7-G8 

Age, race, 

parity, 

education, 

poverty 

(enrollment in 

Medicaid, WIC, 

food stamp 

programs), 

tobacco use, 

chronic 

hypertension 

Parker and 

Abrams, 1992118 

USA, hospital 

(California) 

6,690 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI IOM 

AOR (95% CI) for SGA: 

G1: 1.78 (1.39-2.27) 

G2: 1.00 (reference) 

Incidence of SGA in 

nonobese women,%: 

G1: 3.25 

G2: 6.14 

G3: 13.11 

Incidence of SGA in obese 

women,%: 

G1: 11.76 

G2: 3.09 

Age, race, 

parity, 

pregravid BMI, 

height, 

maternal high 

and low weight 

gain, smoking, 

gestational 

age, 

birthweight 
158

Table 35. Weight change relative to IOM thresholds and small-for-gestational-age (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Stevens-Simon and 

McAnarney, 

1992154 

USA, adolescent 

maternity program 

141 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories (kg/wk): 

G1: < 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Distribution of SGA, %: 

G1: 7.1 

G2: 9.1 

G3: 2.1 

P = NS 

None 

Stotland et al., 

2006129 

USA, university 

hospital 

20,465 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Prenatal record 

Maternal weight gain 

categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: < 7 kg 

G5: > 18 kg 

Unadjusted rates of SGA: 

G1: 11.74 P< 0.001 vs. G2 

G2: 7.05 

G3: 3.70 P< 0.001 vs. G2 

G4: 13.99 P< 0.05 vs. G2 

G5: 3.87 P< 0.05 vs. G2 

AOR (95% CI) for SGA: 

G1: 1.66 (1.44-1.92) 

G2: 1.00 (reference) 

G3: 0.51 (0.44-0.59) 

G4: 2.26 (1.76-2.90) 

G5: 0.50 (0.42-0.60) 

Age, race, 

parity, 

pregravid BMI, 

PIH, date of 

delivery, mode 

of delivery, 

length of first 

and second 

stages of labor, 

smoking, 

gestational 

age, 

birthweight 

Bianco et al., 

199854

USA, medical 

center 

11,926 

Nonobese (BMI 19-

27) and morbidly 

obese (BMI > 35) 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight gain 

categories among morbidly 

obese (BMI > 35): 

G1: Weight loss/no change

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Distribution of SGA,%: 

G1: 4.0 

G2: 3.9 

G3: 5.6 

G4: 3.1 

G5: 3.8 

P = No testing due to small 

numbers in each cell 

Race, parity, 

clinic service, 

substance 

abuse, 

preexisting 

medical 

condition 

Overview of results for SGA infant weight. Evidence from 10 studies (3 good,116,153,159 6 

fair,4,25,55,118,129,154 one poor54) supports an association between weight gains below the 

recommended IOM guidelines and the risk of having an SGA infant. 

Detailed results of SGA infant weight. With respect to gaining less than the IOM guidelines, 

two studies found statistically significant higher odds for women giving birth to an SGA infant 

across all pregravid BMI categories.118,129 One of these studies also examined the odds for 

excessive weight gain, which was statistically significantly protective.129 

Among normal-weight women, two studies found that excessive weight gain decreased the 

SGA risk by half, whereas inadequate weight gain doubled the SGA risk.25,55 Among obese 

women, those who gained below the IOM guidelines were at nearly three times the risk of 
159

having an SGA infant55,118,159 compared with those who gained within the recommended range. 

In the one study that was able to examine classes of obesity (Class I, BMI 30.0 –34.9; Class II, 

BMI 35.0 –39; and Class III, BMI ≥ 40), the risk of SGA increased for all classes in a linear 

fashion as weight gain fell below the IOM recommendation of at least 15 to 25 pounds.4

 

The good study conducted among black adolescents that examined total weight gain153 found 

an increased odds for SGA associated with gaining less than the IOM guidelines compared with 

gaining at the lower half of the guidelines (AOR, 2.31; 95% CI, 1.22-4.37) and no significantly 

protective effect with weight gains in the upper half or greater than the IOM. 

Two studies examined the rate of weight gain.116,154 One, among black adolescents,154 found 

no difference in the prevalence of SGA among rate of weight gain categories (slow, < 0.23 

kg/week; average, 0.23 to 0.40 kg/week; and rapid, > 0.4 kg/week). In the other study, after 

adjustment for multiple confounders, increasing rates of weight gain were associated with a 

reduced risk of SGA.116 This study calculated the expected change in the incidence of SGA by 

preventing inadequate weight gain to be -1.17 percent and -0.44 percent for black and white 

women, respectively. 

Apgar Scores. 

Study characteristics. Three studies, all rated fair quality, dealt with Apgar scores (Evidence 

Table 46; Table 36).125,129,154

Table 36. Weight change relative to IOM thresholds and Apgar scores 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Nixon et al., 1998125 

USA, county nursemidwifery services

2,228 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Data records 

Gestational 

weight gain 

categorized by 

IOM 

recommendations

BMI IOM 

Maternal weight gain by IOM 

guidelines was not not a signigicant 

predictor of Apgar scores (detailsnone reported) 

None 

Stevens-Simon and 

McAnarney, 1992154 

USA, adolescent 

maternity program 

141 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight 

gain categories 

(kg/wk): 

G1: < 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Distribution of 1-minute Apgar score 

≤ 4,%: 

G1: 25.0 

G2: 4.5 

G3: 14.9 

P = 0.02 for G1 vs. G2 or G3 

Distribution of 5-minute Apgar score 

≤ 4,%: 

G1: 3.5 

G2: 0 

G3: 0 

P = NS 

None 

BMI, body mass index; G, group; IOM, Institute of Medicine; kg/wk, kilogram per week; NS, not significant; USA, United 

States of America. 
160

Table 36. Weight change relative to IOM thresholds and Apgar scores (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Stotland et al., 

2006129 

USA, university 

hospital 

20,465 

All weight/BMI 

(using IOM 

definitions) 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Prenatal records 

Maternal weight 

gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: < 7 kg 

G5: > 18 kg 

Unadjusted rates of 5-minute Apgar 

score < 7: 

G1: 1.94 

G2: 1.58 

G3: 2.14 (P< 0.05, G3 vs. G2) 

G4: 2.39 

G5: 2.16 (P< 0.05, G5 vs. G2) 

AOR (95% CI) for 5-minute Apgar 

score < 7: 

G1: 1.18 (0.84-1.66) 

G2: 1.00 (reference) 

G3: 1.33 (1.01-1.76) 

G4: 1.29 (0.70-2.39) 

G5: 1.30 (0.95-1.77) 

Age, race, parity, 

pregravid BMI, 

pregnancy-induced 

hypertension, date 

of delivery, mode of 

delivery, length of 

first and second 

stage of labor, 

smoking, 

gestational age, 

birthweight 

Overview of results. Three fair studies provide insufficient evidence to support an association 

between weight gain and low Apgar scores. 

Detailed Results on Apgar Scores. Three studies included investigation of Apgar scores and 

adherence to the IOM recommendations.125,129,154 In one study,129 total weight gain above the 

IOM guidelines increased the risk of having a 5-minute Apgar score of < 7 by 33 percent 

(AOR,1.33; 95% CI, 1.01- 1.76), whereas a weight gain below the IOM guidelines was not 

associated with a low 5-minute Apgar score (AOR, 1.18; 95% CI, 0.84-1.66). Another study125

found no effect of maternal weight gain with the outcome defined as a 1-minute Apgar score of < 

7. The third study154 was conducted among black adolescents and found a slow rate of weight 

gain (< 0.23 kg/week) to be associated with a 1-minute Apgar score of ≤ 4 compared to higher 

rates of weight gain (> 0.23 kg/week). 

Infant Outcomes 

Perinatal mortality. 

Study characteristics. One US study of a hospital database examined perinatal mortality 

(Evidence Table 47).127 The study included overall perinatal mortality and adverse perinatal 

outcome, which was defined as an infant death between delivery and discharge, delivery before 

37 completed weeks of gestation, LBW, or stillbirth.127

Overview of results. One fair study did not conduct multivariable modeling using the IOM 

cutpoints, and therefore provides weak evidence on the association between weight gain and 

perinatal mortality.127

Detailed results. The authors reported, using only bivariate analysis, that infants of mothers 

who gained below the IOM recommendations had a significantly higher proportion of adverse 

perinatal outcomes (14 percent) and perinatal mortality (1.1 percent) than the infants whose 

mothers gained within or above the recommendations (8.5 percent and 0.4 percent respectively; 

P < 0.001 for all comparisons). 
161

Infant hypoglycemia. 

Study characteristics. Two studies from hospital databases examined hypoglycemia in the 

infant (Evidence Table 48).110,129 One study had many other outcomes such as birth trauma, 

admission to the special care nursery, neonatal infection, seizure, polycythemia, meconium 

aspiration syndrome, respiratory distress syndrome, and a hospital stay of 5 and 10 days.129

Overview of results. Two studies, of good110 and fair quality,129 respectively, found moderate 

evidence that high maternal weight gain is associated with an increased risk of neonatal 

hypoglycemia for weight gain above IOM recommendations and were consistent in 

demonstrating a lack of association between weight gain below IOM recommendations and 

neonatal hypoglycemia. 

Detailed results. Two studies included infant hypoglycemia as an outcome of interest.110,129

The good study used a case-control design for women who delivered singletons at Kaiser 

Permanente Medical Center from 1996 to 1998.110 Cases (N = 328) were defined as infants with 

plasma glucose < 40 mg/dl; controls were infants born to women with no GDM. Cases had a 

significantly higher odds of having mothers who gained more than the IOM guidelines (AOR, 

1.38; 95% CI, 1.01-1.89); weight gains below the IOM were not associated with infant 

hypoglycemia. 

Stratification by race (in the good study) showed that among infants born to non-Hispanic 

white women, a pregnancy weight gain below the IOM guidelines was significantly associated 

with a decreased odds of hypoglycemia (OR, 0.39; 95% CI, 0.18-0.84); among infants born to 

women of minority groups (undefined), weight gain below the IOM guidelines was significantly 

associated with an increased risk of hypoglycemia (OR, 1.69; 95% CI, 1.08-2.64).110 This study 

also stratified by pregravid BMI and did not find any significant effect that suggested the effect 

of weight gain varied by pregravid BMI. 

The second study reported that women who gained above the IOM guidelines were 

significantly more likely to have an infant with hypoglycemia (AOR, 1.52; 95% CI, 1.06-2.16)129

but that women with weight gain below the guidelines had no such association. This study found 

significant associations only for weight gains above the IOM and the following outcomes: infant 

seizure (AOR, 6.5; 95% CI, 1.43-29.65), polycythemia (AOR, 1.44; 95% CI, 1.06-1.94), and 

meconium aspiration (AOR; 1.79, 95% CI, 1.12-2.86). Data were adjusted for maternal race, 

prepregnancy BMI, parity, age, gestational hypertension, smoking, gestational age at delivery, 

model of delivery, length of each stage of labor, and birthweight. 

NICU admissions. 

Study characteristics. Two studies, rated fair, dealt with admission to the neonatal intensive 

care unit (NICU); (Evidence Table 49).129,154 One study was a cohort of black adolescents.154

Overview of results. Two fair studies using different measures of weight gain provided weak 

inconsistent evidence on neonatal hospitalization. 

Detailed results on admission to NICU. One study found that decreased risk of NICU 

admission was significantly associated with weight gain below IOM guidelines (AOR, 0.66; 95% 

CI, 0.46-0.96) but not with weight gains above the IOM guidelines (AOR, 1.03; 95% CI, 0.79-

1.35).129 In the other study, among black adolescents a slow rate of weight gain (< 0.23 kg/week) 

was significantly associated with NICU admission (P = 0.01).154 

Child Outcomes 

Childhood weight status. Study characteristics. Only one study of fair quality was found24

that examined weight gain according to the IOM and childhood weight status (Evidence Table 

50). This study involved 1,585 women from a single HMO in Boston who were part of 
162

pregnancy study and then enrolled in a follow-up study. A total of 1,110 children completed a 

visit at age 3, at which time study staff measured their weight and height; maternal weight and 

pregravid weight status were obtained via questionnaire. This study did not specify singletononly births, but it did note that preterm births and infants weighing < 2,500 kg were excluded 

because of their different growth trajectories in the first year of life. Maternal weight gain was 

calculated as the difference between weight measured near delivery obtained from the prenatal 

record and self-reported pregravid weight. The study reported on the effect of total weight gain, 

net weight gain (excluding infant birthweight) and weight gain classified by IOM guidelines. 

Child BMI percentiles were grouped as follows: below 50th (referent category), 50th to 84th, 

85th to 94th, and 95th or higher. 

Results. Using children born to women who gained inadequately as the referent, children 

born to women who gained adequately or excessively had higher odds of being in higher 

percentile categories. The AORs for children born to women who gained adequately were as 

follows: 50th to 84th percentile, 1.85 (1.17-2.92); 85th to 94th percentile, 2.09 (1.12-3.92), and 

95th percentile and above, 3.77 (1.38-10.27). AORs for children born to mothers who gained 

excessively were similar: respectively, 1.84 (1.17-2.88), 2.03 (1.11-3.72) and 4.35 (1.69-11.24) 

Both models adjusted for maternal pregravid BMI, prenatal smoking, race/ethnicity, household 

income, martial status, glucose tolerance, paternal BMI, gestational length, and child’s sex. 

Short- and Long-term Maternal Outcomes 

Lactation performance. 

Study characteristics. Three studies (four articles) reported on the effects of weight gain on 

lactation performance (Evidence Table 51, Table 37).166-169 One study was done using the Danish 

National Birth Cohort;166 another study (2 articles) used a US hospital database for years 1988 to 

1997;168,169 and the third used data from the US Pediatric Nutrition Surveillance System and the 

Pregnancy Nutrition Surveillance System.167 Lactation performance was defined as initiated 

breastfeeding,167,168 duration of any breastfeeding,166-168 and exclusive breastfeeding.166,168,169

Weight gain was defined as the difference between weight at delivery and self-reported 

pregravid weight168,169 or was based simply on self-reported total weight gain.166,167 The two US 

studies used total weight gain as categorical variables corresponding to the IOM guidelines;167-169

the Danish study used categories corresponding to the following cutpoints: < 8 kg, 8 to 15.9 kg 

(the reference group), and ≥ 16 kg.166 
163

Table 37. Weight change relative to IOM thresholds and breastfeeding 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Baker et al., 

2007166

Denmark-National 

Birth 

37,459 

All wt/BMI 

Under wt BMI 

< 18.5 

Normal BMI 18.5-

24.9 

Overweight BMI 

25-29 

Obese BMI ≥ 30 

Fair 

Pregravid weight: 

Prepregnant weight 

Self reported 

Total weight gain: 

Self-reported 

G1: < 8 kg 

G2: 8-15.9 kg 

G3: ≥ 16 kg 

Overall higher risk of 

terminating full or any 

breastfeeding with higher 

pregravid BMI. 

Unadjusted RR full BF G1: 

1.13 (95% 1.08-1.18) G3: 

1.05 (1.03-1.08). 

Any BF 

G1: RR 1.16 (1.11-1.22) 

G3: 1.05 (1.03-1.08). 

GWG not a predictor of full or 

any when BMI was in the 

model. 

BMI 

Li et al., 2003167

USA WIC clinics 

51,329 

All wt/BMI (using 

IOM definitions) 

Fair 

Pregravid weight: 

Prepregnant weight 

Self reported 

Total weight gain: 

Self-reported 

G1: < IOM 

G2: within IOM 

G3: > IOM 

Adjusted OR for failure to 

initiate BF by BMI: 

Under, normal and 

overweight G1: groups had a 

significant increased odds of 

failure to initiate BF compared 

to G2: within BMI strata. 

Obese women regardless of 

weight gain had increased 

odds of failure to initiate 

compared to normal wt G2. 

Adjusted mean duration of BF 

(P < 0.01)* 

G1: 12.9 wk* 

G2: 13.6 wk (ref) 

G3: 12.8 wk* 

Age, race, parity, 

pregravid BMI, 

maternal education, 

marital status, 

prenatal care, 

poverty-income 

ratio, gestational 

weight gain, 

smoking, gestational 

age, birthweight 

BF, breastfeeding; BMI, body mass index; G, group; IOM, Institute of Medicine; OR, odds ratio; overwt, over weight; PCAP, 

Prenatal Care Assistance Program; RR, relative risk; wt, weight; WIC, The Special Supplemental Nutrition Program for Women, 

Infants, and Children.
164

Table 37. Weight change relative to IOM thresholds and breastfeeding (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) Definition of Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Rasmussen et al., 

2002168 

Hilson et al., 

2006169 

USA, hospital 

2,494 

All wt/BMI (using 

IOM definitions) 

Fair 

Pregravid weight: 

Prepregnant weight 

Self reported 

Total weight gain: 

Prenatal records 

G1: < IOM 

G2: within IOM 

G3: > IOM 

OR unsuccessful initiation of 

BF (normal wt G2: ref) 

Underweight no significant diff 

Normal wt G3: 1.66 (1.05-

2.63) 

Overwt no significant diff 

Obese G3: 2.89 (1.78-4.69) 

Hazard OR discontinuing 

exclusive BF 

(normal wt G2: ref) 

Underwt G3: 1.39 (1.01-1.92) 

Normal wt-no signif 

differences 

Overwt G3: 1.27 (1.03-1.56) 

Obese 

G1: 1.37 (1.01-1.84) 

G2: 1.50 (1.11-2.03) 

G3: 1.78 (1.48-2.14) 

Hazard OR discontinuing any 

BF 

(normal wt G2: ref) 

Underwt-no sign difference 

Normal wt-no sign difference 

Overwt- no sign difference 

Obese G2: 1.57 (1.14-2.18), 

G3: 1.99 (1.64-2.43) 

Age, parity, 

participation in 

WIC/PCAP, type of 

delivery, mother 

attended college, 

smoking 

Overview of results. These studies (all fair quality) support an association between weight 

gains below the IOM guidelines and lower likelihood of breastfeeding initiation; they also 

suggest a shorter duration of exclusive breastfeeding among obese women. They provide only 

inconsistent evidence of an association between weight gain in relation to the IOM guidelines 

and initiation of breastfeeding. 

Detailed results on breastfeeding initiation. Obese women, regardless of weight gain, had 

higher odds of never initiating breastfeeding than women of normal weight in one US study.167

For women who were underweight or of normal weight, greater weight gain was associated with 

a lower odds of never initiating breastfeeding; for overweight and obese women, there was no 

such association.167 Finally, for all three categories of women classified by BMI, weight gain 

below the IOM guidelines (as compared with weight gain within the guidelines) was associated 

with higher odds of never initiating breastfeeding. 

The second study (2 articles) examined initiation of breastfeeding at 4 days postpartum 

among women who intended to breastfeed.168,169 Compared with normal-weight women who 

gained within the IOM guidelines, normal-weight women who gained more than the IOM 

guidelines and obese women regardless of weight gain had significantly higher odds of not 

breastfeeding.168Among obese women, unsuccessful initiation of breastfeeding was limited to 

those who gained more than IOM guidelines169 compared with normal-weight women who 
165

gained within the guidelines. This study also reported a nonsignificant tendency of failing to 

initiate breastfeeding successfully with weight gain less than the IOM guidelines. 

Detailed results on duration of exclusive breastfeeding. The two studies (three articles) 

examining the length of exclusive breastfeeding all showed statistically significant shorter 

durations among obese women.166,168,169 The association between weight gain and duration of 

full breastfeeding did not differ by BMI status in two studies.166,169

US women who gained above the IOM guidelines had a statistically significant shorter 

median duration of exclusive breastfeeding than women who gained within the guidelines 

according to multivariate models.169 For those who gained above the guidelines, the median 

duration of exclusive breastfeeding was 1 week shorter for underweight and overweight women 

and 3 weeks shorter for obese women. 

In the Danish study,166 weight gain was a statistically significant predictor of full 

breastfeeding at 1, 16, and 20 weeks postpartum. In unadjusted models, both low weight gain 

(< 8 kg) and high weight gain (≥ 16 kg) were associated with early termination of full 

breastfeeding Once the authors adjusted for pregravid BMI, however, this association was no 

longer significant. 

Detailed results on duration of any breastfeeding. Shorter duration of any breastfeeding was 

associated with maternal obesity.166,167,169 

In the two US studies, gaining weight above the IOM guidelines was associated with shorter 

duration of any breastfeeding (in the range of 1 to 2.5 weeks less) in bivariate and multivariate 

analysis.167,169 In one study, gaining weight below the IOM guidelines was also associated with 

shorter length of any breastfeeding (~1 week).167 

In the Danish study, weight gain was a statistically significant predictor of terminating any 

breastfeeding at 16 and 20 weeks postpartum but not at 1 week.166 In unadjusted models, both 

low and high weight gains were associated with early termination of any breastfeeding. Once 

models were adjusted for pregravid BMI, this finding was no longer significant. 

Fat retention. 

Study characteristics. Two studies in the United States examined differences in the amount 

of fat retained in the postpartum period by IOM categories of weight gain (Evidence Table 

52).16,97 One study reported on 63 pregnant women (17 underweight, 34 normal weight, 12 

overweight/obese) from a convenience sample of 124 nonsmoking women ages 18 to 40.97 The 

study conducted body composition measurements using dual-energy x-ray absorptiometry both 

before and after pregnancy and weighed the women before, during, and after pregnancy. The 

second study was conducted among a convenience sample of 196 nonsmoking women between 

19 and 36 years recruited from three prenatal clinics. These investigators used self-reported 

pregravid weight and conducted body composition measurements starting at 12 to 16 weeks of 

gestation, at 37 weeks, and/or at 2 to 4 weeks postpartum with hydrodensitometry (underwater 

weighing) and deuterium dilution volume.16 Total body bone mineral was measured at 2 to 4 

weeks postpartum using dual-energy absorptiometery. They applied a four-compartment model 

(incorporating measurements of total body water, body density, body weight, and bone mineral 

content) to estimate total body fat. 

Overview of results. Evidence from two fair studies suggests that fat retention was higher 

among women whose weight gains exceeded IOM guidelines. 

Detailed results. In one study, fat retention was significantly higher among women who 

gained above the IOM guidelines (5.3 kg) than among women who gained within (2.3 kg) or 

below (-0.5kg).97 In the second study, changes in body fat from 14 to 37 weeks of gestation 

stratified by pregravid BMI showed that women who gained below the IOM guidelines had the 

lowest amount of fat gain; those within an intermediate level and those above had the highest fat 
166

gain.16 The investigators did not report significance tests. Among obese women who gained 

within the IOM guidelines, the percentage of body fat change (-0.6 kg) was significantly lower 

than among other BMI groups who also gained within the recommendations (6.0 kg for 

underweight, 3.8 kg for normal weight, and 2.8 kg for overweight women). 

Short-term weight retention. 

Study characteristics. Four studies examined weight gain and weight retention in the short 

term104,154,158,170 (Evidence Table 53, Table 38). Three studies reported on results at 6 weeks 

postpartum.154,158,170 All used a cohort design involving mostly low-income women; two 

included Hispanic, black, and white women,158,170 and the third included only black 

adolescents.154 One study used total weight gain as the exposure;170 two examined the rate of 

weight gain.154,158 A fourth study examined the possible association 2 days after term delivery 

(37 to 43 weeks’ gestation).104 

Table 38. Weight change relative to IOM thresholds and short-term weight retention 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Luke et al., 

1996104 

USA, clinic 

487 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight 

gain < IOM 

recommendations:

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

Maternal weight 

gain within IOM 

recommendations:

G4: BMI < 19.8 

G5: BMI 19.8-26.0 

G6: BMI > 26.0 

Maternal weight 

gain > IOM 

recommendations:

G7: BMI < 19.8 

G8: BMI 19.8-26.0 

G9: BMI > 26.0 

Mean (SEM) retained weight (defined as 

2-day postpartum weight minus 

pregravid weight, kg): 

G1: 3.2 (0.5) P < 0.05 compared to G4 

G2: 0.8 (0.4) P < 0.05 compared to G5 

G3: -5.0 (0.7) P < 0.05 compared to G6 

G4: 8.2 (0.7) 

G5: 7.0 (0.4) 

G6: 1.4 (0.8) 

G7: 15.5 (0.9) P < 0.05 compared to G4 

G8: 12.9 (0.4) P < 0.05 compared to G5 

G9: 9.5 (0.5) P < 0.05 compared to G6 

Age, parity, 

race, smoking, 

gestation 

duration, fetal 

sex 

Scholl et al., 

1995158 

USA Camden 

Study 

274 

Normal weight/BMI 

19.8-26 

Fair 

Pregravid weight: 

Self report 

Total weight gain: 

Measured 

Maternal weight 

gain categories 

(kg/wk): 

G1: ≤ 0.34 

G2: > 0.34-0.68 

G3: > 0.68 

Mean (SEM) change in weight (kg) from 

pregravid to 6 weeks postpartum: 

G1: 3.1 (0.80) 

G2: 3.9 (0.51) 

G3: 9.4 (0.70) P < 0.001, G3 vs. G1,G2 

Age, parity, 

race, height, 

lactation 

status, 

smoking 

B,beta; BMI, body mass index; CI, confidence interval; G, group; IOM, Institute of Medicine; kg, kilogram; kg/wk, kilogram per 

week; SD, standard deviation; SE, standard error; SEM, standard error of mean. 
167

Table 38. Weight change relative to IOM thresholds and short-term weight retention (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders 

and Effect 

Modifiers 

Included in 

Analysis 

Stevens-Simon 

and McAnarney, 

1992154 

USA, adolescent 

maternity program 

141 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight 

gain categories 

(kg/wk): 

G1:< 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Short term weight retention (2-11 weeks 

postpartum), total kg: 

G1: -1.7 (SD 2.9) 

G2: 2.9 (SD 2.9) 

G3: 9.6 (SD 5.6) 

P < 0.0001 

AOR (95% CI) for subsequent maternal 

obesity (> 120% ideal weight for height): 

G3: 190.94 (7.55-4,779.02) 

Age, pregravid 

BMI, level of 

physical 

activity, timing 

of first prenatal 

and 

postpartum 

visits 

substance 

use, body 

habitus 

Walker et al., 

2004170 

USA, Austin New 

Mothers Study 

419 

All weight/BMI 

(using IOM 

definitions) 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Maternal weight 

gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Mean (SD) weight (kg) retained at 6 

weeks postpartum: 

G1: -0.34 (3.44) 

G2: 3.86 (3.45) 

G3: 10.55 (6.14) 

P = 0.000 

% Women who attained pregravid 

weight at 6 weeks postpartum: 

G1: 48.8 

G2: 14.3 

G3: 2.3 

Correlation of gestational weight gain, 

excluding infant weight, (continuous 

variable) and weight retained at 6 weeks 

postpartum: r = 0.90 P = 0.000 

Multiple regression analysis predicted a 

mean increase in retained weight of 0.88 

kg for each 1 kg increase in maternal 

weight gain (B = 0.88, SE = 0.02, 

P = 0.000) 

Race, parity, 

pregravid BMI, 

gestational 

weight gain, 

gestational 

age 

Overview of results. Evidence from four fair studies supports an association between weight 

gain in excess of the IOM recommendations and higher weight retention in the immediate 

postpartum period.104,154,158,170

Detailed results. In one study, women who gained more than recommended levels retained, 

at 6 weeks, statistically significantly more weight than women who gained within or below IOM 

guidelines.170 The 2-day post-delivery analyses, stratified by pregravid BMI, showed that for 

each BMI grouping, women who gained above the IOM guidelines retained statistically 

significantly more weight than women who gained within the guidelines; women who gained 

below the IOM guidelines retained significantly less than those who gained within them.104 

Two studies examined the rate of weight gain. One defined < 0.23 kg per week as slow 

weight gain and > 0.4 kg per week as rapid,154 and the other defined low as < 0.34 kg per week 

and excessive as > 0.68 kg week.158 In both studies, the amount of weight retained was highest 

among women who had an excessive rate of weight gain compared with women who had lower 

rates.154,158
168

Weight retention during the first year postpartum. 

Study characteristics. Six studies examined the effect of weight gain according to IOM 

classifications on weight retained during the first year postpartum (Evidence Table 54, Table 

39).158,171-175 Five studies were from the United States, and one was from Sweden.171 Five used a 

cohort design;158,171,172,174,175 one US study was done in a representative sample of births.173 

Table 39. Weight change relative to IOM thresholds and weight retention during the first year postpartum 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Amorim et al., 

2007171 

Sweden, hospital 

483 

All weight/BMI 

Fair 

Pregravid weight: 

Self-report 

Total weight gain: 

Obstetric records 

Maternal weight 

gain categories: 

< IOM 

Within IOM 

> IOM 

A mixed ANOVA with one repeated 

measures factor (weight before 

pregnancy, 6 months, 1, and 15 years) 

and one between-subjects factor 

(< IOM, within IOM, > IOM) showed a 

main effect of time [F (9.024) = 113.7, 

P = 0.000] and a significant time group 

interaction [F(6,12) = 77.23, P = 0.000] 

The weight of women who gained 

excessive during pregnancy was 

significantly greater at each time-point 

[main effect of group: F (10.55) = 

870.0, P = 0.000] 

Pregravid BMI 

Rooney et al., 

2002174 

USA, hospital 

540 

All weight/BMI 

Fair 

Pregravid weight: 

Measured at first 

visit 

Total weight gain: 

Measured 

Maternal weight 

gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI IOM 

Average weight change between 

prepregnancy and 6 months 

postpartum (kg): 

G1: -0.61 

G2: 1.8 

G3: 4.2 

P = 0.01 

Regression coefficient (95% CI) for 

weight at 6 months postpartum: 

G1: -1.53 (-3.36–0.30) 

G2: Reference 

G3: 1.24 (-0.63–3.11) 

Duration of 

breastfeeding, 

postpartum aerobic 

exercise, weight 

loss by 6 months 

ANOVA, analysis of variance; BMI, body mass index; CI, confidence interval; G, group; kg, kilogram; kg/wk, kilogram per 

week; SE, standard error. 
169

Table 39. Weight change relative to IOM thresholds and weight retention during the first year postpartum 

(continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Scholl et al., 

1995158 

USA, Camden 

Study 

274 

Normal 

weight/BMI 19.8-

26 

Fair 

Pregravid weight: 

Self report 

Total weight gain: 

Measured 

Maternal weight 

gain categories 

(kg/wk): 

G1: ≤ 0.34 

G2: > 0.34-0.68 

G3: > 0.68 

Mean (SEM) change in weight (kg) 

from pregravid to 6 months postpartum: 

G1: 3.2 (0.95) 

G2: 3.8 (0.61) 

G3: 7.9 (0.83) P < 0.001, G3 vs. G1, 

G2 

Mean (SEM) change in weight (kg) 

from 6 weeks to 6 months postpartum: 

G1: 0.13 (0.64) 

G2: -0.05 (0.41) 

G3: -1.48 (0.56) P < 0.05, G3 vs. G1, 

G2 

AOR (95% CI) for becoming 

overweight (BMI > 26.0) at 6 months 

postpartum: 

G1, G2: 1.0 (reference) 

G3: 2.89 (1.36-6.00) 

Age, race, parity, 

pregravid BMI, 

lactation, height, 

smoking 

Walker, 1996172

USA, mail survey 

88 

Underweight/ 

Normal/ 

Overweight (using 

IOM definitions) 

Fair 

Pregravid weight: 

Self report 

Total weight gain: 

Self report 

Maternal weight 

gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Mean weight retention at 6 months 

postpartum, lbs: 

G1: 0.4 

G2: 3.7 

G3: 13.5 

P < 0.001 

Maternal weight gain was significantly 

related to weight at 6 months 

postpartum: r = 0.60, P < 0.001 

Mean weight retention at 18 months 

postpartum, lbs: 

G1, G2: 0.7 

G3: 11.0 

P < 0.01 

Maternal weight gain was significantly 

related to weight at 18 months 

postpartum: r = 0.49, P < 0.001 

Mode of delivery, 

infant sex, 

breastfeeding, 

infant birthweight, 

pregravid BMI 
170

Table 39. Weight change relative to IOM thresholds and weight retention during the first year postpartum 

(continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in 

Analysis 

Olson 2002175

USA, hospital and 

primary care clinic 

system 

622 

All weight/BMI 

Fair 

Pregravid weight: 

Measured during 

first trimester 

Total weight gain: 

Measured 

Maternal weight 

gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: Interaction 

for > IOM and 

income ≤ 185% 

federal poverty 

line 

Regression coefficient (SE) for weight 

change from early pregnancy to 1 year 

postpartum (kg): 

G1: -1.50 (0.62) P = 0.016 

G2: reference 

G3: 0.32 (0.65) P = 0.621 

G4: 3.41 (0.91) P < 0.001 

AOR (95% CI) for major weight gain 

(≥ 10 lbs) at 1 year postpartum: 

G1: 0.33 (0.13-0.83) 

G2: 1.00 (reference) 

G3: 1.47 (0.73-2.94) 

G4: 3.23 (1.25-9.08) 

Compared to normal-weight women 

(BMI 19.8-26.0) in G2, normal weight, 

overweight (BMI 26.1-29.0) and obese 

(BMI > 29.0) women in G3 retained 

significantly more weight at 1 year 

postpartum (all P < 0.01) 

Exercise, food 

intake, 

breastfeeding, 

pregravid BMI, age, 

marital status, 

income, postpartum 

month that weight 

was measured 

Keppel 1993173

USA, 1988 

National Maternal 

and Infant Health 

Survey 

2,944 

Non obese/BMI 

< 29 

Poor 

Pregravid weight: 

Self-report 

Total weight gain: 

Self-report 

Categories of 

amount of 

weight retained 

(lbs) at 10-18 

months 

postpartum: 

G1: Lost weight 

G2: 0-3 

G3: 4-8 

G4: 9-13 

G5: ≥ 14 

The percent distribution of women in 

G1-G5 stratified by maternal weight 

gain categories showed that both black 

and white women who gained < IOM or 

within the IOM guidelines retained less 

weight (10-18 months postpartum) than 

women who gained > IOM 

recommendations. Irrespective of 

maternal weight gain, black women 

retained more weight than white 

women 

None 

Overview of results. The evidence from five fair studies158,171,172,174,175 and one poor study173

supports an association between excessive weight gain and weight retention within the first year 

postpartum. 

Detailed results. Regardless of when postpartum weight was measured—at 6158,171,172,174 or at 

10 to 18 months171,173,175—women who gained above the IOM recommendations retained more 

weight than those who gained within them. Women who gained below recommendations did not 

always retain less weight than those who gained within them, according to one fair158 and one 

poor study.173 In the poor study, which stratified results by race, this pattern of weight retention 

by weight gain held true for white and black women.173 One study calculated women had 

statistically significant odds of becoming overweight at 6 months given rates of weight gain 

above IOM guidelines.158 

Another study used a mixed ANOVA with a one-repeated-measure factor (time of the weight 

measurement: before pregnancy, 6 months, 1 year, and 15 years after) and one between-subject 

factor (below, within, above the IOM guidelines).171 The weight of women who gained 
171

excessively during pregnancy was statistically significantly higher at each time point adjusted for 

pregravid BMI. 

Long-term weight retention. 

Study characteristics. Four articles from three databases examined weight retention after 

several years171,174,176 or until the second pregnancy177(Evidence Table 55, Table 40). One study 

(2 articles) was in a US medical center in Wisconsin,174,176 one was done in another US 

hospital;177 and one was conducted in Sweden.171 Three studies were rated fair quality; one was 

rated good.177

Table 40. Weight change relative to IOM thresholds and long-term weight retention 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis

Gunderson, 

2000177

USA, hospital 

1,300 

All weight/BMI 

(using IOM 

definitions) 

Good 

Pregravid weight: 

Self-report 

Total weight gain: 

Measured 

Maternal weight 

gain categories: 

G1: < IOM/ within 

IOM 

G2: > IOM 

AOR (95% CI) for becoming 

overweight between baseline 

(pregravid weight at start of index 

pregnancy) and start of second 

study pregnancy (median interval 

time = 1.5 years): 

G1: Reference 

G2: 2.95 (1.67-5.24) 

Smoking, PIH, 

education, parity, 

marital status, age at 

menarche, interval to 

first birth 

Rooney, 2005176

USA, hospital 

484 

All weight/BMI 

Fair 

Pregravid weight: 

Measured at first 

prenatal visit 

Total weight gain: 

Measured 

Categories of 

maternal weight 

gain: 

G1: < IOM 

G2: within IOM 

G3: > IOM 

Multivariable regression 

coefficient (95% CI) for BMI at 15 

years postpartum: 

G1: -0.57 (-0.57-1.21) 

G2: reference 

G3: 1.69 (0.79-2.58) 

Multivariable regression 

coefficient (95% CI) for change in 

weight between baseline and 15 

years postpartum: 

G1: 0.43 (-1.87-2.73) 

G2: reference 

G3: 4.19 (1.88-6.51) 

Marital status at 

delivery, change in 

marital status, current 

parity, insurance 

status at delivery, 

current insurance 

status, baseline BMI, 

weight gain at index 

pregnancy, retained 

weight at 6 months 

postpartum, 

participation in 

postpartum aerobic 

exercise, duration of 

breastfeeding 

Amorim et al., 

2007171 

Sweden, hospital 

483 

Pregravid weight: 

Self-report 

Total weight gain: 

Obstetric records 

Maternal weight 

gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Mean (SD) change in weight at 

15 years postpartum, kg: 

G1: 6.2 (6.8) 

G2: 6.7 (6.8) 

G3: 10.3 (8.5) 

P = 0.000 

Education, lactation, 

weight retention at 6 

months postpartum, 

weight gain between 

6 months and 1 year 

postpartum, 

pregravid BMI 

AOR, adjusted odds ratio; B, beta; BMI, body mass index; CI, confidence interval; G, group; IOM, Institute of Medicine; PHI, 

pregnancy-induced hypertension; SD, standard deviation; USA, United States of America. 
172

Table 40. Weight change relative to IOM thresholds and long-term weight retention (continued) 

Author, Year 

Country, Setting 

Sample Size 

Baseline BMI 

Quality 

Pregravid Weight 

(How Measured) 

Total Weight Gain 

(How Measured) 

Definition of 

Groups Results 

Confounders and 

Effect Modifiers 

Included in Analysis

Amorim et al., 

2007171

(continued) 

All weight/BMI 

(using IOM 

definitions) 

Fair 

 Mean (SD) BMI at 15 years 

postpartum: 

G1: 23.5 (3.7) 

G2: 23.6 (3.0) 

G3: 25.9 (3.9) 

P = 0.000 

Multiple regression coefficient, B 

(95% CI) for 15 year BMI status: 

G1: 0.01 (-0.56-0.59) 

G2: Reference 

G3: 0.72 (0.15-1.30) 

P = 0.033 

Multiple regression coefficient 

(95% CI) for change in BMI status 

between pregravid and 15 years 

postpartum: 

G1: 0.02 (-0.56-0.59) 

G2: Reference 

G3: 0.68 (0.11-1.24) 

P = 0.042 

Rooney et al., 

2002174 

USA, hospital 

540 

All weight/BMI 

(using IOM 

definitions) 

Fair 

Pregravid weight: 

Measured at first visit 

Total weight gain: 

Measured 

Maternal weight 

gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Average weight change between 

prepregnancy and ~8.5 years 

postpartum (kg): 

G1: 4.1 

G2: 6.5 

G3: 8.4 

P = 0.01 

Regression coefficients (95% CI) 

for BMI at ~8.5 years postpartum: 

G1: -3.86 (-5.56 - -2.16) 

G2: Reference 

G3: -0.70 (-2.13-0.74) 

Duration of 

breastfeeding, 

postpartum aerobic 

exercise, weight loss 

by 6 months 

Overview of results. Evidence from one good article177 and three fair articles171,174,176

supports an association between excessive weight gain and higher weights later in life.

Detailed results. The results for the Sweden study were reported above.171 In the Wisconsin 

study, the average amount of weight retained at a mean of 8.5 years later was statistically 

significantly higher among women who gained more than recommended guidelines than among 

women who gained within or below guidelines.174,176 In the regression model predicting longterm weight (at 8.5 years and 14.7 years), weight gain during pregnancy was a significant 

predictor of weight retention. 

In the other US study, the incidence of overweight at the second pregnancy was statistically 

significantly higher among women who had gained above the IOM in the prior pregnancy than 

among those who gained within or below IOM recommendations.177 The adjusted odds of 

becoming overweight between baseline and the start of the second pregnancy was nearly 

threefold for women gaining above recommendations. 
173

KQ 5: Anthropometrics of Weight Measurement 

Nearly all of the 150 studies included in this review estimated adiposity using body weight or 

BMI. Ten studies collected data from other anthropometric measurements and incorporated them 

into varying body composition equations or models to estimate body fat (Evidence Table 

56).16,97,102,115,143,178-182 These measurements included bioelectrical impedance analysis (BIA),178

dual energy X-ray absorptiometry (DEXA, formerly referred to as DXA),16,97,180 skinfold 

thicknesses,102,143,180 circumferences (arm, thigh, radius, upper chest, chest, elbow, waist, upper 

iliac, wrist, knee, calf, and ankle),102,115,143,178,180 total body water,16,97,178,180 total body nitrogen,97

total body potassium,97 magnetic resonance imaging (MRI),179,181 and underwater 

weighing.16,97,180 Studies that used DEXA or MRI methods16,97,179,180 recorded measurements 

only during the postpartum period. 

Collectively, these studies do not provide sufficient evidence to judge whether alternate 

methods of weight measurement are more informative or predictive of infant and maternal 

outcomes than standard body weight and height measurements. 
175

Chapter 4. Discussion 

This chapter discusses our findings for five key questions (KQs) relating to outcomes of 

gestational weight gain, modifiers and confounders of outcomes of weight gain, outcomes of 

weight gain within or outside Institute of Medicine (IOM) recommendations, risks and benefits 

of recommendations, and anthropometric measures of weight gain. 

We note in this discussion both the quality of individual studies (good, fair, or poor, as 

explained in Chapter 2) and the strength of the evidence for each question or subquestion (also 

described in Chapter 2) and defined below. As noted in Chapter 2, the quality of each study is 

based on the summary assessment of quality on nine key domains: background, sample selection, 

specification of exposure, specification of outcome, soundness of information, followup, analysis 

comparability, analysis of outcome, and interpretation. 

The strength of evidence for each outcome incorporates the quality of the studies and the 

consistency and volume of the evidence. To reiterate, the levels of strength of evidence are as 

follows: 

I. Strong: The evidence is from studies of strong design; results are both clinically 

important and consistent with minor exceptions at most; results are free from serious 

doubts about generalizability, bias, or flaws in research design. Studies with negative 

results have sufficiently large samples to have adequate statistical power. 

II. Moderate: The evidence is from studies of strong design, but some uncertainty remains 

because of inconsistencies or concern about generalizability, bias, research design flaws, 

or adequate sample size. Alternatively, the evidence is consistent but derives from studies 

of weaker design. 

III. Weak: The evidence is from a limited number of studies of weaker design. Studies with 

strong design either have not been done or are inconclusive. 

IV. No evidence: No published literature. 

In this first part of this chapter, we discuss chiefly the outcomes with strong or moderate 

strength of evidence. The tables present outcomes in the order of strength of evidence and then 

by the outcomes as presented in Chapter 3. We caution that the levels of evidence assigned to the 

outcomes below reflect associations, not causality, given the preponderance of observational 

studies in this literature. 

For greater synthesis, we first combine our discussion of outcomes for KQ 1 (outcomes of 

gestational weight gain, broadly defined) and KQ 3 (outcomes of gestational weight defined by 

IOM cutpoints). We then take up KQ 2 (modifiers and confounders of gestational weight gain), 

KQ 4 (risks and benefits of gestational weight gain recommendations), and KQ 5 

(anthropometrics of weight measurement during pregnancy). When results are described as 

significant, we mean statistically significant. We conclude the chapter by examining the 

limitations of this review and the evidence base and then presenting our recommendations for 

future research. 
176

Outcomes of Maternal Weight Gain (KQ 1 and KQ 3) 

KQ 1 asks about outcomes of gestational weight gain for infants and for mothers; we had 

specified more than 30 outcomes as being of interest. We present outcomes of gestational weight 

gain for each of these categories of outcomes, classified in six categories: maternal antepartum 

outcomes, maternal intrapartum outcomes, birth outcomes, infant outcomes, child outcomes, and 

short- and long-term maternal outcomes. We focus chiefly on outcomes for which the evidence 

is either strong or moderate. 

KQ 1 also asks what evidence exists to demonstrate causality. Nearly all the studies in this 

review are observational studies; therefore, generally this evidence base cannot demonstrate a 

causal link between gestational weight gain and outcomes. Moreover, observational studies that 

do not control for confounding or possible explanatory factors cannot be used to comment on 

causality. These research questions thus require the inclusion and assessment of observational 

studies for making policy decisions, and decisionmakers will need to take into account the 

limitations of the evidence base. 

Our analysis of outcomes related to weight gains in relationship to recommendations of the 

Institute of Medicine (KQ 3) classified outcomes into six categories as with KQ 1. KQ 3 also 

asks about the outcomes of weight loss. Weight loss is not considered appropriate during 

pregnancy for any weight status. Few studies collected or analyzed these data in a manner that 

allowed compilation and synthesis. 

To enable synthesis and help identify gaps in the evidence, we have combined the discussion 

of the findings for KQ 1 and KQ3, by outcomes. The levels of evidence assigned below account 

for consistency, directionality, and quality for associations between gestational weight gain and 

the outcome. The following tables provide a summary assessment of the outcome and its strength 

of evidence for KQ 1 and KQ3: maternal antepartum outcomes, Table 41; maternal intrapartum 

outcomes, Table 42; birth outcomes, Table 43; infant outcomes, Table 44; child outcomes, Table 

45; and maternal short- and long-term outcomes, Table 46. 

Across all 36 outcomes that we examined for KQ 1, only eight outcomes had strong or 

moderate strength of evidence. Specifically, we found 

• no strong or moderate evidence for maternal antepartum outcomes; 

• moderate evidence only for cesarean delivery among maternal intrapartum outcomes; 

• moderate or strong evidence for several birth outcomes: preterm birth, birthweight, low 

birthweight, macrosomia, large-for-gestational-age (LGA), and small-for-gestational-age 

(SGA); 

• no strong or moderate evidence for infant outcomes; 

• no strong or moderate evidence for child outcomes; and 

• moderate evidence for intermediate-term postpartum weight retention among short- and 

long-term maternal outcomes. 

For KQ 3, we found strong or moderate strength of evidence for 11 outcomes: the 8 

identified for KQ 1 and moderate evidence for breastfeeding, short-term postpartum weight 

retention, and long-term postpartum weight retention. 
177

Maternal Antepartum Outcomes 

We examined the literature for five maternal antepartum outcomes (Table 41). For all, 

evidence was weak. 

Table 41. Strength of evidence: maternal antepartum outcomes of gestational weight gain 

Outcome 

Source of 

evidence 

Strength of 

evidence Number and quality of studies 

Maternal discomforts of pregnancy KQ 1 Weak 2 fair41,42 and 3 poor studies43-45

 KQ 3 No evidence 

Hyperemesis KQ 1 Weak 1 poor47

 KQ 3 No evidence 

Abnormal glucose metabolism KQ 1 Weak 2 good,3,48 5 fair52,57,

55,56,53, 4 poor49-51,54

 KQ 3 Weak 1 good,3 2 fair,53,55 1 poor54 

Hypertensive disorders KQ 1 Weak 8 fair,4,25,52,53,55,58-60 4 poor,49,51,54,61

 KQ 3 Weak 4 fair,4,25,53,55 1 poor54 

Gallstones KQ 1 Weak 1 fair, 1 poor62,63

 KQ 3 No evidence 

Maternal discomforts of pregnancy. 

Results from KQ 1. Five studies (2 fair41,42 and 3 poor studies43-45) provided weak evidence 

on a variety of discomforts of pregnancy: heartburn,45 physical symptoms or level of physical 

energy,42 stretch marks,43,44 and overall symptoms.41 A study on physical symptoms and level of 

physical energy found no differences for women who gained an excessive amount of weight 

compared to those who did not, irrespective of BMI group.42 A study on overall symptoms found 

that total weight gain was associated with a higher frequency of symptoms from mid-pregnancy 

through the 36th week of gestation.41 Both studies of development of striae gravidarum43,44 and 

the heartburn study45 were rated poor quality, so no conclusions can be drawn about any 

relationship between gestational weight gain and these outcomes. 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Hyperemesis. 

Results from KQ 1. One study of poor quality provided weak evidence that total gestational 

weight gain of < 7 kg is associated with an antepartum admission related to hyperemesis.47 This 

study had a high number of cases with missing values on gestational weight gain (17 percent of 

the cohort). 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Abnormal glucose metabolism. 

Results from KQ 1. Eleven studies (2 good,3,48 5 fair,52,53,55-57 and 4 poor49-51,54) provided 

weak evidence on the relationship between weight gain in pregnancy and the development of 

abnormal glucose metabolism.3,48-57 Although 11 studies is a sizeable number of articles, the 

inconsistencies in methodology and definition across them (i.e., lack of standardization) are too 

substantial to permit clear summation of the research or to warrant any stronger grading than 

weak. The major shortcoming was inconsistent diagnostic criteria. 
178

Four studies found that greater weight gains in pregnancy were positively associated with 

abnormal glucose tolerance;3,51,55,56 three (2 good, 1 poor) found that women having lower-thanaverage weight gains had a higher likelihood of gestational diabetes mellitus (GDM),48,49,53 and 

four articles found no significant association.50,52,54,57 Family history of diabetes,50,56 maternal 

age,3,50,56 parity,50 and body mass index (BMI)3,50,56,57 were more predictive of abnormal glucose 

metabolism than gestational weight gain in the research we reviewed. 

Results from KQ 3. Four studies (1 good,3

 2 fair,53,55 and 1 poor54) examined the relationship 

of the IOM guidelines and abnormal glucose metabolism. These studies offered weak evidence 

of an association largely because all except one used total gestational weight gain as the 

exposure variable rather than weight gain until the time of diagnosis. Because treating women 

with GDM includes dietary counseling and efforts to control weight gain, the use of total weight 

gain as a predictor of GDM is likely to be a biased indicator. 

Synthesis of results. Inconsistent diagnostic criteria and biases in the definition of weight gain 

result in a weak body of evidence from which we cannot draw conclusions about the association 

between gestational weight gain and GDM. 

Maternal hypertensive disorders. 

Results from KQ 1. Twelve studies (2 fair,4,25,52,53,55,58-60 4 poor,49,51,54,61) provided weak 

evidence on the association between prenatal weight gain and the development of pregnancyinduced hypertension.4,25,49,51-55,58-61 Of these 12 studies, 10 reported a relationship between 

increasing weight and the likelihood of pregnancy-induced hypertension;4,25,49,51,53,55,58-61 2 found 

no effect. One potential explanation for the relationship between weight and gestational 

hypertension, particularly preeclampsia, is that the condition is marked by edema, which often 

presents as rapidly increasing weight before delivery. Consequently, the association observed in 

the majority of the studies may represent the disease state itself, rather than any marker of 

implied causation. 

Results from KQ 3. When we examined maternal hypertensive disorders by IOM guidelines, 

three fair studies (4 articles)4,25,53,55 and one poor study54 provided weak evidence of an 

association relating to pregnancy-induced hypertension. 

Synthesis of results. In summary, largely because weight gain is a marker of edema, which is 

a hallmark of preeclampsia, and because of analytical flaws, the available evidence provides only 

weak evidence of a relationship between gestational weight gain and the development of 

pregnancy-induced hypertension. 

Gallstones. 

Results from KQ 1. Two studies (2 poor62 and 1 fair63) provided weak evidence suggesting a 

potential relationship between weight gain and cholelithiasis. 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Maternal Intrapartum Outcomes 

In all, we examined the literature for 11 maternal and intrapartum outcomes (Table 42). For 

one of these—cesarean delivery—the evidence was of moderate strength. For all other outcomes, 

evidence was weak. 
179

Table 42. Strength of evidence: maternal intrapartum outcomes of gestational weight gain 

Outcome 

Source of 

evidence Strength of Evidence 

Number and Quality of 

Studies 

Premature rupture of 

membranes 

KQ 1 Weak 2 Fair64,65

 KQ 3 No evidence 

Preterm labor KQ 1 Weak 1 Poor66

 KQ 3 No evidence 

Postterm pregnancy KQ 1 Weak 1 Fair58

 KQ 1 Weak 1 Fair58

 KQ 3 No evidence 

Induction of labor KQ 1 Weak 2 Fair,25,67 

3 Poor51,59,68 

 KQ 3 No evidence 

Length of labor KQ 1 Weak 2 Fair,69,70 

1 Poor68 

 KQ 3 No evidence 

Mode of delivery KQ 1 Moderate for cesarean delivery; 

Weak for instrumental delivery 

14 Fair,4,25,52,58,67,69-73,75-78 

7 Poor49,51,54,59,61,68,74 

 KQ 3 Moderate evidence for increased risk of 

cesarean for weight gain above IOM 

recommendations for underweight and 

normal weight women 

Weak inconsistent evidence for weight gain 

above IOM recommendations for obese or 

morbidly obese women 

8 Fair,4,25,53,55,77,118,149,150 

1 Poor54 

Vaginal birth after cesarean KQ 1 Weak 1 Poor79

 KQ 3 No evidence 

Vaginal lacerations KQ 1 Weak 2 Poor51,68

 KQ 3 No evidence 

Shoulder dystocia KQ 1 Weak 3 Poor51,68,80

 KQ 3 No evidence 

Cephalopelvic disproportion KQ 1 Weak 1 Fair,25 

1 Poor74

 KQ 3 No evidence 

Complications of labor and 

delivery 

KQ 1 Weak 1 Fair,53 

1 Poor81 

 KQ 3 No evidence 

Premature rupture of membrane. 

Results from KQ 1. Two fair studies provided weak evidence that low weight gain (< 21 

pounds) or low rate of weight gain (< 275 g per week) is associated with a higher risk of 

premature rupture of membrane for full-term pregnancies and preterm pregnancies.64,65 One 

study provided weak evidence that high weight gain (> 40 pounds) is also associated with a 

higher risk of premature rupture of membranes of full-term pregnancies.64 
180

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Preterm labor. 

Results from KQ 1. One poor study yielded weak evidence that weight gain below 0.65 to 0.9 

pounds per week significantly increased the risk of premature labor.66 Compared with the risk for 

premature labor for women gaining 0.66 to 0.9 pounds per week, the risk was nearly doubled for 

women gaining 0.41 to 0.65 pounds per week and nearly tripled for women gaining 0.4 pounds 

per week or less. Weight gain above 0.9 pounds per week had no significant effect on premature 

labor. 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations.

Postterm pregnancy. 

Results from KQ 1. One fair study (weak evidence) showed no effect of either low or high 

gestational weight gain on postterm pregnancy.58

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Induction of labor. Five studies (2 fair,25,67 3 poor51,59,68) examined the association of 

increased gestational weight gain and labor induction59,67,68 or failure of labor induction.25,51

These studies provided weak evidence of an association between higher risk of labor induction or 

failure of induction and higher weight gain. We cannot summarize the magnitude of the effect 

because of differences in the definition of weight gain and in the nature of confounders 

controlled for in the analyses; however, the association was statistically significant in different 

pregravid BMI categories. No study controlled for maternal health characteristics that might lead 

to labor induction. 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Length of labor. 

Results from KQ 1. Three studies (2 fair,69,70 1 poor68) provided weak evidence on the 

association between gestational weight gain and length of labor; two studies yielded weak 

evidence that higher weight gain among women of normal weight was associated with longer 

labor.68,69 These studies inconsistently controlled for confounding factors. A single study that 

controlled for a subset of confounders provided weak evidence that increased weight gain was 

associated with labor abnormalities.183

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Mode of delivery. 

Results from KQ 1. Of the 21 studies (14 fair,4,25,52,58,67,69-73,75-78 7 poor49,51,54,59,61,68,74) that 

examined mode of delivery, all but 4 showed some degree of association between higher weight 

gain and cesarean delivery; the strength of evidence was moderate.4,25,49,51,52,54,58,59,61,67-76 Only 

four studies49,52,54,67 failed to show any relationship between gestational weight gain and mode of 

delivery, specifically cesarean delivery. 

Ten studies controlled for route of previous delivery. Of these, five controlled for 

comorbidities that could have been significant confounders for route of delivery; all found an 

increased risk of cesarean delivery with increased weight gain.71,72,75,76,78 The association 

appeared to be stronger among overweight and obese women. The evidence is limited by 

variations in the definition of gestational weight gain and in the definition of cesarean delivery 
181

and by the failure in many studies to account for previous route of delivery or underlying health 

risks. As other reviews suggest, indications for cesarean delivery are driven by underlying 

maternal health risks184 that may be associated with pregravid BMI and weight gain. 

Of the five studies that examined risks of instrumental delivery,25,51,58,68,69 three suggested a 

higher risk of instrumental delivery with increasing weight.25,68,69 This evidence base was graded 

weak because it is limited by variations in definition of the outcome and lack of control for 

confounding. 

Results from KQ 3. Nine studies (8 fair,4,25,53,55,118,148,149 1 poor54) examined the association 

between gestational weight gain classified by the IOM guidelines and cesarean delivery. These 

studies yielded moderate evidence for increased risk of cesarean delivery for weight gain above 

IOM recommendations for underweight and normal-weight women; they offered weak, 

inconsistent evidence for obese or morbidly obese women. 

The various studies showed the following main findings with respect to cesarean delivery: 

higher risk with weight gains in excess of IOM recommendations across all pregravid weight 

groups (2 studies);149,150 higher risk with weight gain in excess of IOM recommendations among 

nonobese women as a group (1 study);118 higher risk with weight gain above IOM 

recommendations for normal-weight women (325,118,149 of 5 studies25,53,55,118,149); and higher risk 

with weight gain above IOM recommendations for underweight women (2 studies).118,149 

Studies on obese or morbidly obese women were inconsistent. Two suggested no higher risk 

with weight gain above IOM recommendations,54,55 one suggested a higher risk,149 and a fourth 

suggested higher risks with weight gain in excess of 25 pounds.4

 One study examining the 

interaction between pregravid overweight or obese status and weight gain above IOM 

recommendations failed to find a significant effect for either primiparous or multiparous women 

when the interaction term was defined as pregravid overweight or obese status and weight gain 

of 25-34 pounds.77 When the interaction term was redefined as pregravid overweight or obese 

status and weight gain greater than 25 pounds, the study found a significant effect only for 

multiparous women. 

Synthesis of results. The majority of studies suggested an association between gestational 

weight gain and cesarean delivery. This association appeared to be stronger for overweight and 

obese women. When studies examined the risk of cesarean delivery with respect to IOM 

recommendations, they were relatively more consistent in demonstrating higher risks for weight 

gain above IOM recommendations for underweight and normal-weight women, but they were 

inconsistent in demonstrating increased risks of cesarean delivery for weight gain above IOM 

recommendations for obese and morbidly obese women. Our findings of a higher risk of 

cesarean for overweight and obese women, coupled with the lack of significance of weight gain 

above IOM recommendations for obese and morbidly obese women, suggest that underlying 

health risks (such as increased risks of abnormal glucose tolerance) associated with high 

pregravid weight are likely confounders in the relationship between gestational weight gain and 

cesarean delivery. 

Vaginal birth after cesarean. 

Results from KQ 1. One poor study provided weak evidence that gestational weight gain of 

40 pounds or more increased the risk of vaginal birth after cesarean (VBAC) failure.79

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Vaginal lacerations. 
182

Results from KQ 1. Two studies, both rated poor quality, provided weak, inconsistent 

evidence on the effect of weight gain and vaginal lacerations (incidence of third- or fourthdegree vaginal lacerations or the need for repairs).51,68

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Shoulder dystocia. 

Results from KQ 1. Evidence from three poor studies provided weak evidence on the 

association of gestational weight gain and shoulder dystocia.51,68,80 One study suggested a 

positive association, but the positive predictive value of high weight gain on shoulder dystocia 

was only 1 percent. A model of shoulder dystocia that included other predictors, such as 

multiparity and previous heavy baby, had a total positive predictive value of less than 3 percent. 

Thus, shoulder dystocia is largely an unpredictable outcome. 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Cephalopelvic disproportion. 

Results from KQ 1. Two studies (1 fair,25 1 poor74) provided weak evidence of an association 

between higher gestational weight gain and cephalopelvic disproportion (CPD) among normalweight women. Variability in the definition of CPD and the failure to account for underlying 

maternal health characteristics weaken the reported association. The poor study failed to identify 

an association between weight gain and CPD at higher pregravid BMI levels.74

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Other complications of labor and delivery. 

Results from KQ 1. Two studies (1 fair,53 1 poor81) provided weak, conflicting evidence on 

labor and delivery complications. One study failed to find statistically significant results; the 

other reported that weight gain of more than 40 pounds increased the risk for complications by 

40 percent. 

The degree of impact was difficult to assess because the studies defined the outcome broadly 

and differently and used different cutpoints to assign weight gain categories. The outcome, 

complications, was treated as a dichotomous variable, and analyses were not specific to any one 

intrapartum or neonatal problem; thus, making meaningful clinical recommendations is 

impossible. 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Birth Outcomes 

The knowledge base about the association between gestational weight gain and birth 

outcomes is, on the whole, stronger than the knowledge base for any other set of outcomes. The 

relative strength of this body of evidence is unsurprising because the IOM committee based its 

recommendations on optimizing birthweight and fetal growth; the body of research thereafter 

was focused on testing these outcomes. 

Five outcomes—preterm birth, birthweight, low birthweight, and large-for-gestational-age 

(LGA) and small-for-gestational-age (SGA) birthweights—all have strong bodies of evidence 

(Table 43). The outcome of macrosomia was graded moderate strength of evidence; Apgar 

scores had only weak strength of evidence. 
183

Table 43. Strength of evidence: birth outcomes of gestational weight gain 

Outcome 

Source of 

Evidence Strength of Evidence Number and Quality of Studies 

Preterm birth KQ 1 Strong 2 Good,84,88 

7 Fair,23,65,71,82,85,86,89 

3 Poor59,83,87

 KQ 3 Strong for association with weight gain below 

IOM recommendations; 

Weak inconsistent for association with 

weight gain above IOM recommendations 

4 Fair22,85,151,152

Birthweight KQ 1 Strong 4 Good,48,98,103,106

12 Fair,55,70,75,92,93,97,99-102,104,105 

9 Poor54,59,68,83,90,91,94-96

 KQ 3 Strong for association between low gains 

and low birthweight 

Moderate for association between high gains 

and high birthweight only for underweight 

and normal-weight women 

1 Good,153 

8 Fair,20,60,104,154-158 

1 Poor54

Low birthweight KQ 1 Strong 1 Good,106 

9 Fair,2,4,52,70,71,75,93,107,108 

3 Poor54,95,109

 KQ 3 Strong for association between low gains 

and low birthweight for underweight and 

normal weight mothers; weak for lack of 

association between low gain and low 

birthweight for overweight and obese women 

2 Good,159,160 

7 Fair,2,20,55,60,127,154,161 

3 Poor54,162,163

Macrosomia KQ 1 Strong 1 Good,110 

9 Fair,2,4,70,77,93,108,111-113 

2 Poor49,59

 KQ 3 Moderate only for overweight and obese 

women 

2 Good,110,160 

4 Fair,2,53,55,164 

1 Poor165

Large-forgestational-age KQ 1 Strong 1 Good,116 

8 Fair,4,58,100,105,115,118,121,122 

5 Poor54,59,61,68,120

 KQ 3 Strong for association between high gains 

and LGA infants, and moderate for protective 

effect of low gains and LGA infants 

2 Good,116,159 

5 Fair,4,25,118,129,154 

1 Poor54 

Small-forgestational-age KQ 1 Strong 1 Good,116 

12 Fair,4,58,89,105,108,111,114,118,119,122-124

7 Poor51,54,59,61,66,68,95

 KQ 3 Strong for the association between low gains 

and SGA infants 

3 Good,116,153,159 

6 fair,4,25,55,118,129,154 

1 Poor54 

Apgar scores KQ 1 Weak 3 Fair, 1 Poor58,61,70,125

 KQ 3 Weak 3 Fair125,129,154

Preterm birth. 

Results from KQ 1. Strong evidence from 12 studies (2 good,84,88 7 fair,23,65,71,82,85,86,89 3 

poor59,83,87) suggested that weight gains at either end of the spectrum result in a higher risk of 

premature birth. Overall, the majority of studies adjusted for sociodemographic characteristics 
184

and risk factors of preterm birth, including maternal age, smoking status, alcohol consumption, 

race, marital status, socioeconomic status, and education. Not all studies measured maternal 

history of obstetric complications. These studies displayed little consistency in terms of 

adjustment for covariates, inclusion/exclusion of different types of preterm births, and the 

methods used to define and categorize gestational weight gain. Nevertheless, the results 

collectively suggested that weight gain is associated with length of gestation82,83 and that low 

weight gain71,82 and low rate of weight gain23,65,82,84-87,89 predict preterm birth. 

Among the nine studies that categorized gestational weight gain and reported effect 

estimates,23,65,71,84-89 eight reported at least one significant association between low gestational 

weight gain (as defined in the study) and preterm birth.23,65,71,84-87,89 Of five studies focused on 

high gestational weight gain (as defined in the study),23,65,85,86,89 four reported at least one 

significant association between gestational weight gain and preterm birth.23,65,86,89 

Across the eight studies that considered low rate of weight gain,23,65,84-89 the rates varied 

below a cutpoint of 0.37 kg per week; nonetheless, seven consistently showed a higher risk of 

preterm birth with a low rate of weight gain.23,65,84-87,89 Across the five studies that considered 

high rate of weight gain,23,65,85,86,89 high rates varied above a cutpoint of 0.52 kg per week; four 

studies consistently showed a higher risk of preterm birth with a high rate of weight gain.23,65,86,89 

The association between risk of preterm birth and gestational weight gain may differ by 

maternal pregravid weight status. In three studies that stratified by pregravid BMI status,23,86,87

underweight women tended to have higher risks of preterm birth at low rates of weight 

gain,23,86,87 but obese women tended to have higher risks of preterm birth at high rates of weight 

gain.23,86 One study found no association between the risk of preterm birth and gestational weight 

gain.85 

Results from KQ 3. Four studies, all of fair quality, reported on the association between rate 

of gestational weight gain according to the IOM guidelines and preterm birth.22,85,151,152 Despite 

inconsistencies in the definitions of rate of weight gain and the timing of its calculation, the four 

studies are consistent in showing increased risks of preterm birth for underweight and normalweight women, thereby providing strong evidence of an association between weight gain below 

IOM recommendations and preterm birth. Specifically, two studies found that weight gain below 

IOM recommendations is associated with a higher risk of preterm birth across all pregravid BMI 

categories;22,85 two studies found this effect for normal-weight women and underweight 

women.151,152 Two studies, one including all pregravid weight status,22 and another limited to 

normal-weight and underweight women,151 reported an association only for low weight gain 

during the third trimester and preterm birth.22,151 

These studies also provided weak, inconsistent evidence of the association between weight 

gain above IOM recommendations and preterm birth. One study suggested increased risks of 

preterm birth with high weight gain for normal-weight women22 one suggested no increased risk 

for underweight and normal-weight women, but a protective effect of high weight gain for high 

BMI women;152 and one suggested no increased risks at all.85 

Synthesis of results. The majority of studies found an effect of low gestational weight gain on 

preterm birth. High gestational weight gain was less consistently associated with this outcome. 

The association for low weight gain held whether investigators used total weight gain or rate of 

weight gain as the relevant exposure of interest; it also held despite differences in confounders 

that were controlled for across the studies. Evidence also supported a stronger association 

between low gestational weight gain and preterm birth for underweight women than for any 

other category of pregravid weight status.
185

Birthweight. 

Results from KQ 1. Evidence from 25 studies (4 good,48,98,103,106 12 fair,55,70,75,92,93,97,99-

102,104,105 9 poor54,59,68,83,90,91,94-96) provided strong evidence that gestational weight gain is 

associated with infant birthweight. This relationship held true for various measures of gestational 

weight gain (categorical measures, total weight gain, net weight gain, proportional weight gain, 

and weight gain by trimester). 

Seven studies48,93,98,101-103,105 reported that birthweight increased between 16.7 g and 22.6 g 

for every 1-kg increase in gestational weight gain. Two studies55,104 reported values by BMI 

status,55,104 suggesting that the effect of increased gestational weight gain on infant birthweight 

was more pronounced at lower BMI levels. 

Three studies examined the effect of weight gain by trimester on infant birthweight.98,101,105

They were consistent in demonstrating that weight gain in the third trimester had the least effect. 

Two studies that used similar definitions of trimester found that a 1-kg increase in gestational 

weight gain during the first trimester was associated with 18- to 31-g increases in birthweight. 

By contrast, a 1-kg increase during the second trimester or during the third trimester was 

associated with, respectively, 26- to 32.8-g and 7- to 17-g increases in infant birthweight.98,101 

Results from KQ 3. 10 articles from nine databases (1 good,153 8 fair,20,60,104,154-158 and 1 

poor54) examined the association between gestational weight gain defined by IOM guidelines and 

birthweight. Overall, these articles provided strong evidence that weight gain below IOM 

recommendations is associated with lower birthweights. All the studies found an association 

between low weight gain and lower birthweight despite various methods of characterizing 

gestational weight gain (total, rate, or by trimester). 

The evidence that higher weight gains were associated with higher birthweights is moderate 

because of the inconsistency across the studies. All but one study examined this association.155

Seven found an association between high weight gains and higher birthweights,20,54,60,104,153,154,156

and two found no association;157,158 however, the study populations differed by race and 

pregravid weight status. We found moderate evidence for three findings: infants of black women 

had significantly higher birthweights (73 to 330 g);20,60,153,156 infants of white women with a BMI 

less than 29 had higher birthweights (~200 g);156 and infants of underweight and normal-weight 

women had higher birthweights with higher weight gains, but this was not true for overweight 

and obese women.104,153

Synthesis of results. We found strong evidence in support of an association between 

gestational weight gain and birthweight. Low gestational weight gain is associated with lower 

birthweights across all pregravid weight status groups. High gestational weight gain resulting in 

higher birthweight appears to be limited to underweight and normal-weight women. 

Low birthweight (< 2,500 grams). 

Results from KQ1. Thirteen studies (1 good,106 9 fair,2,4,52,70,71,75,93,107,108 3 poor54,95,109) 

provided strong evidence that low weight gain increases the risks of low birthweight 

(LBW).2,4,52,54,71,93,106-109 Only two fair studies did not find a statistically significant association 

between total gestational weight gain and LBW, although their point estimates were in the 

expected direction.52,107 Variations in the definition of gestational weight gain and specification 

of weight increase category make it challenging to infer the magnitude of risk at different levels 

of gestational weight gain. 

Results from KQ 3. Twelve articles from 10 databases articles (2 good,159,160

7 fair,2,20,55,60,127,154,161 and 3 poor54,162,163) examined the association between weight gain and low 

birthweight. These studies provided strong, consistent evidence of an association between weight 
186

gain below the IOM guidelines and LBW for underweight and normal-weight women. They 

suggest no association between weight gain below IOM recommendations and LBW for 

overweight and obese women, but the strength of evidence is weak.2,55

Synthesis of results. Overall, we found strong evidence for an association between low 

gestational weight gain and low birthweight. The evidence appears to be stronger among women 

who, before pregnancy, had been underweight or of normal weight than among women who had 

been overweight or obese; this is especially true when gestational weight gain is a categorical 

variable (low, medium, high). Despite variations in controlling for confounding and the 

definition of gestational weight gain, studies were consistent in defining low birthweight as 

< 2,500 g and in their direction of the outcome.

Macrosomia. 

Results from KQ1. Eleven of 12 studies (1 good,110 9 fair,2,4,70,77,93,108,111-113 1 poor59) 

provided strong evidence that high gestational weight gain is associated with greater risks of 

macrosomia.2,4,59,70,77,93,108,110-113 One poor study did not support the association.49 The 

relationship between high gestational weight gain and macrosomia held despite variations in 

definition of macrosomia (> 4,500 g2,108,110,113 or > 4,000 g4,59,70,77,93,111,112). Generally, the 

highest weight gains were associated with the highest risks of macrosomia. 

Results from KQ3. Seven studies examined the association between gestational weight gain 

categorized according to the IOM and macrosomia defined as either > 4,000 g or > 4,500 g (2 

good,110,160 1 poor,165 and the remaining fair2,53,55,164). These studies yielded moderate evidence of 

an association between weight gains above the IOM recommendations and macrosomia. The 

association differed by pregravid weight status and how weight categories above the IOM 

recommendations were defined. We found a consistent effect of weight gains above IOM 

recommendations among normal-weight women on macrosomia in five of seven 

studies.53,55,110,160,164 By contrast, no significant effect was seen among underweight women in 

three of four studies, although the point estimates were elevated suggesting an increased risk of 

macrosomia with excessive weight gains.110,164,165 Among overweight women and obese women, 

five out of seven studies found an association,53,55,110,160,165 one found the association only with 

very high weight gains well above the IOM recommendations,2 and one found no association.164

Synthesis of results. Moderate to strong evidence suggests that high weight gains are 

associated with macrosomia. This evidence has some inconsistencies in the findings attributable 

to variations in definitions of both macrosomia and gestational weight gain categories. The 

evidence suggests no effect of high gestational weight gain for underweight women on 

macrosomia. 

Size based on gestational age: large for gestational age (LGA). 

Results from KQ1. Fourteen studies (1 good,116 8 fair,4,58,100,105,115,118,121,122 5 poor54,59,61,68,120) 

with varying definitions of weight gain and LGA were consistent in demonstrating an association 

between high gestational weight gain and LGA; we graded the evidence for this association as 

strong. This association held whether LGA was defined as birthweight greater than the 90th 

percentile or as birthweight more than two standard deviations above the mean. Whether BMI 

modifies this relationship is unclear. 

Results from KQ3. Eight articles examined gestational weight gain according to IOM 

guidelines and LGA (2 good,116,159 5 fair,4,25,118,129,154 and 1 poor54). These studies provided 

strong evidence that high weight gains are associated with an increased risk of LGA infants. 

Only one study failed to find an association.154 Weight gains below IOM guidelines, by contrast, 

were protective against LGA in only four studies (moderate evidence).4,25,129,159 
187

Synthesis of results. The increased risk of LGA was consistently seen in women with higher 

absolute weight gains and in women with gains in excess of the IOM recommendations. The 

body of literature is large and the evidence is strong for this association despite differences in the 

definition of LGA and factors that were controlled for confounding. 

Size based on gestational age: small for gestational age (SGA). 

Results from KQ1. Twenty publications (1 good,116 12 fair,4,58,89,105,108,111,114,118,119,122-124 and 7 

poor51,54,59,61,66,68,95) provided strong evidence that women in the lowest weight gain categories 

had higher percentages of SGA infants and were at increased risk of delivering an SGA infant, 

despite differences across studies in the definition of weight gain and SGA. In general, the risk of 

SGA among women with low weight gain decreased as BMI increased. 

Results from KQ3. Ten articles examined the association between weight gain categorized 

according to the IOM guidelines and SGA (3 good,116,153,159 1 poor,54 and the rest 

fair4,25,55,118,129,154) and yielded strong evidence of an association.between SGA and weight gains 

below IOM guidelines. Only two studies did not find any evidence of an association.54,154 Weight 

gains above the IOM were protective of SGA in four studies4,25,129,159 of six, suggesting a 

moderate degree of evidence; two did not find an effect.116,153. 

Synthesis of results. Overall, a large body of literature yielded strong evidence for an 

association between low gestational weight gain and the risk of having an SGA infant. This 

association is seen whether weight gain is examined in categories or in absolute terms and 

despite some inconsistencies in what variables were controlled for in the analysis. 

Apgar scores. 

Results from KQ 1. Four studies (3 fair,58,70,125 1 poor study61) provided weak evidence on the 

effect of gestational weight gain on Apgar scores. Two studies (1 fair, 1 poor) suggested some 

association between weight gain and Apgar scores, but the results were not consistent in the 

direction or trend of effect; the other two did not report any such association. 

Results from KQ 3. Three fair studies provided weak evidence on any association between 

weight gain according to IOM guidelines and Apgar scores.125,129,154

Synthesis of results. Together these studies do not provide consistent evidence on the 

association between gestational weight gain and Apgar scores. 

Infant Outcomes 

We reviewed eight infant outcomes and found weak evidence for all outcomes (Table 44). 
188

Table 44. Strength of evidence: infant outcomes of gestational weight gain 

Outcome 

Source of 

Evidence 

Strength of 

Evidence Number and Quality of Studies 

Perinatal mortality KQ 1 Weak 2 fair,126,127 1 poor128

 KQ 3 Weak 1 fair127

Neonatal hypoglycemia KQ 1 Weak 1 good,110 1 fair129

 KQ 3 Weak 1 good,110 1 fair129 

Neonatal distress KQ 1 Weak 1 fair58

 KQ 3 No evidence 

Hyperbilirubinemia KQ 1 Weak 1 good110

 KQ 3 No evidence 

Neonatal hospitalization KQ 1 Weak 1 fair52 

 KQ 3 Weak 2 fair129,154

Other infant morbidity KQ 1 Weak 2 fair129,130

 KQ 3 No evidence 

Infant BMI KQ 1 Weak 2 fair122,131

 KQ 3 No evidence 

Other infant growth 

characteristics 

KQ 1 Weak 1 good,98 4 fair,92,93,117,122 1 poor68 

 KQ 3 No evidence 

Perinatal mortality. 

Results from KQ 1. Three studies (2 fair,126,127 1 poor128) with samples ranging from 20,000 

to 50,000 women provide weak evidence that low gestational weight gain is associated with a 

higher risk of perinatal mortality or stillbirth.126-128 The poor study reported that higher BMI is 

associated with a higher risk of stillbirth, suggesting a nonlinear relationship between weight 

gain and stillbirth.128 No study controlled for maternal health characteristics that might lead to 

perinatal mortality. 

Results from KQ 3. One fair study on overall perinatal mortality reported a significantly 

higher proportion of perinatal mortality (1.1 percent) among infants of mothers who gained 

below the IOM recommendations than the infants whose mothers gained within or above the 

recommendations. This work, however, did no multivariable modeling using the IOM cutpoints, 

so it yielded only weak evidence.127

Synthesis of results. Together, these results provided weak evidence of an association 

between low gestational weight gain and perinatal mortality. 

Neonatal hypoglycemia. 

Results from KQ 1. Two studies (1 good,110 1 fair129) suggested that high gestational weight 

gain (> 18 kg) or a high rate of weight gain (> 0.4 kg/week) is associated with an increased risk 

of infant hypoglycemia. The two studies only incompletely adjusted for confounding variables, 

however. 

Results from KQ 3. The same two studies found that high gestational weight gain is 

associated with an increased risk of neonatal hypoglycemia for weight gain above IOM 

recommendations. They were consistent in demonstrating a lack of association between weight 

gain below IOM recommendations and neonatal hypoglycemia. 
189

Synthesis of results. Together, these results provided weak evidence of an association 

between low gestational weight gain and neonatal hypoglycemia 

Neonatal distress. 

Results from KQ 1. One fair study provided weak evidence of a lack of association between 

low weight gain and fetal distress.58

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Hyperbilirubinemia. 

Results from KQ 1. One good study yielded weak evidence that women who gained in the 

highest bracket of weight gain per week (more than 0.40 kg/week) during pregnancy had a nearly 

doubled odds ratio of delivering an infant with hyperbilirubinemia when compared with women 

gaining between 0.22 kg and 0.31 kg per week.110 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Hospitalization. One fair study provided weak evidence that infants of women who gained 

less than 8.5 kg during their pregnancy were more likely to require hospitalization than infants 

born to women who gained the reference amount of 8.5 to 12.5 kg during pregnancy.52 The study 

controlled for maternal age, parity, smoking, prepregnancy BMI, and gestational age but not for 

other maternal health characteristics. 

Results from KQ 3. Two fair studies using different measures of weight gain provided weak, 

inconsistent evidence on neonatal hospitalization. In one, decreased risk of admission to a 

neonatal intensive care unit (NICU) was significantly associated with weight gain below IOM 

guidelines but not with weight gains above the IOM guidelines.129 In the other study among 

black adolescents, risk of NICU admission was significantly associated with a slow rate of 

weight gain (< 0.23 kg/week).154 

Synthesis of results. Together, these studies provide weak, inconsistent evidence on the 

relationship between gestational weight gain and neonatal hospitalization. 

Other infant morbidity. 

Results from KQ 1. Two fair studies provided weak evidence on other neonatal and infant 

morbidity outcomes.129,130 In one study, weight gain less than 7 kg was significantly associated 

with neonatal seizure.129 In addition, gestational weight gain greater than 18 kg was significantly 

associated with assisted ventilation, seizure, polycythemia, and meconium aspiration syndrome. 

Another study found no significant association between infant leukemia and weight gain during 

pregnancy after adjusting for sex, race, maternal education, and prepregnancy BMI.130

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Infant BMI. 

Results from KQ 1. Two fair studies provide weak, inconsistent evidence on the influence of 

weight gain on infant BMI.122,131 Any possible association may be attenuated, however, when the 

weight of the infant is removed from total weight gain. 

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Other infant growth characteristics. 

Results from KQ 1. Five of six studies (1 good,98 4 fair,92,93,117,122 1 poor68) provided weak 

evidence that gestational weight gain is associated with various other infant growth 

characteristics. Gestational weight gain increased birth length, head circumference, acromial 
190

circumference, and diameter frontoccipitalis93 and crown-heel length and subscapular skinfold 

thickness.92 Proportional weight gain after 25 weeks of gestation increased fetal growth;117

higher gestational weight gains were associated with longer symphysis-fundus height.68 Weight 

gained in the first and third trimester, but not the second trimester, was associated with ponderal 

index.98 A fair study on infant body proportionality failed to find any association between 

gestational weight gain and the outcome.122

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Child Outcomes 

Only two child outcomes were covered by literature included in this review: childhood 

weight status and childhood hospitalization (Table 45). The strength of evidence is weak for 

both. 

Table 45. Strength of evidence: child outcomes of gestational weight gain 

Outcomes 

Source of 

evidence 

Strength of 

Evidence Number and Quality of Studies 

Childhood weight status KQ 1 Weak 3 fair,24,133,134 1 poor132 

 KQ 3 Weak 1 fair24

Childhood hospitalization for 

infectious diseases 

KQ 1 Weak 1 fair135

 KQ 3 No evidence 

Childhood weight status. 

Results from KQ 1. Four studies (3 fair24,133,134 and 1 poor132) examined the long-term effect 

of gestational weight gain on the offspring’s weight status, but they differed in definitions of the 

outcomes and timing of measurements. They provided weak, inconsistent evidence of this 

possible association: three studies showed no effect for childhood weight status at 14 or 24 

months132,133 or much later in life;134 one reported an increased risk early in infancy;134 and one 

reported an increased risk at 3 years.24

Results from KQ 3. One fair study examined weight gain according to the IOM 

recommendations and childhood weight status.24 Children born to women who gained adequately 

or excessively had higher odds of being in 50th to 84th, 85th to 94th, and 95th or higher BMI 

percentile categories than did children born to women who gained inadequately.

Synthesis of results. The evidence of an association between gestational weight gain and 

childhood weight status is weak because of the limited number of studies and variations in 

definition of gestational weight gain during pregnancy. Additionally, variations in the age at 

which child outcomes were measured make comparisons across studies challenging. Studies do 

not adequately address the potentially lessening role of gestational weight gain on childhood 

weight status as the importance of child’s dietary behavior and physical activity rises. 

Childhood hospitalization for infectious diseases. 

Results from KQ 1. One fair study examined the effect of gestational weight gain on 

childhood hospitalization for infectious diseases.135 It provided weak evidence of an effect of 

weight gains greater than 13 kg only among women who had been underweight before 

pregnancy (BMI < 18). 
191

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 

Short- and Long-term Maternal Outcomes 

The literature covered eight maternal outcomes (Table 46). Of these, evidence for both KQ 1 

and KQ 3 is moderate for intermediate-term postpartum weight retention. In addition, we found 

moderate strength of evidence to support the association between weight gain and breastfeeding 

initiation, short-term postpartum weight retention, and long-term postpartum weight retention. 

The evidence for every other outcome (breastfeeding duration, fat accrual, interpregnancy weight 

retention, and premenpausal breast cancer) was weak. 

Table 46. Strength of evidence: maternal outcomes of gestational weight gain 

Outcomes 

Source of 

Evidence Strength of Evidence 

Number and Quality of 

Studies 

Lactation KQ 1 No evidence 

 KQ 3 Breastfeeding initiation: 

Moderate for gains below guidelines 

Exclusive breastfeeding duration: 

Weak 

Any breastfeeding duration: 

Weak 

3 fair studies (4 articles), 

3 fair166-169

Fat accrual KQ 1 No evidence 

 KQ 3 Weak 2 fair16,97

Short-term weight 

retention (11 weeks or 

less) 

KQ 1 Weak 1 fair105

 KQ 3 Moderate 4 fair104,154,158,170 

Intermediate term weight 

retention (3 months to 3 

years) 

KQ 1 Moderate 1 good,144 

3 fair,141,143,145 

1 poor140

 KQ 3 Moderate for weight retention for gains 

within or above guidelines 

Weak for weight retention for gains below 

guidelines 

2 fair,171,172,174 

2 poor158,173

Inter-pregnancy weight 

retention 

KQ 1 Weak 3 fair137-139 

 KQ 3 Weak 1 good177

Long-term weight 

retention (>3 years) 

KQ 1 Weak 1 good,146 

1 fair (2 articles)136,142

 KQ 3 Moderate 3 fair,171,174,176 

Premenopausal breast 

cancer 

KQ 1 Weak 1 fair148

 KQ 3 No evidence 

Lactation. 

Results from KQ 1. We found no evidence on the effect of weight gain (total or rate of weight 

gain as a continuous variable) on lactation that accounted for pregravid weight. 
192

Results from KQ 3. Three fair studies, published in four articles,166-169 examined the 

association of weight gain in relation to the IOM guidelines and breastfeeding. Evidence for an 

association between weight gains below the guidelines and lower likelihood of breastfeeding 

initiation is moderate. 

For duration of exclusive breastfeeding, the studies offered moderate evidence of a shorter 

duration of exclusive breastfeeding for women with pregravid obese status.166,168,169 They offered 

only weak evidence for associations with weight gain; one reported shorter duration with higher 

gains169 and another reported no association.185 

Three studies provide moderate evidence that suggests the length of any breastfeeding among 

obese women.166,168,169 The studies provided only weak evidence that gestational weight gain is 

associated with the duration of any breastfeeding. Two studies reported that gaining weight 

above the IOM guidelines was associated with shorter duration,167,169 but another reported no 

association after adjustments for confounding by BMI.166 

Overall, few studies examined the relationship between gestational weight gain and lactation. 

Comparison across studies is problematic because of the various definitions of breastfeeding. 

There appears to be a moderate association between pregravid weight status and breastfeeding; 

obese women appear to have a lower likelihood of initiating and continuing breastfeeding, 

regardless of weight gain. 

Maternal fat accrual and retention postpartum. 

Results from KQ 1. We found no evidence on the effect of gestational weight gain on 

maternal fat accrual and retention postpartum that accounted for pregravid weight. 

Results from KQ 3. Two fair studies examined differences in the amount of fat retained in the 

postpartum period by categories of IOM weight gain.16,97 Both suggested that higher weight 

gains were associated with more fat accrual postpartum, but the evidence is weak because of the 

low number of studies, their limited generalizability, and small sample sizes. 

Short-term (≤ 11 weeks postpartum) postpartum weight retention. 

Results from KQ1. One fair study provided weak evidence for an association between 

gestational weight gain and short-term postpartum weight retention (measured at 6 weeks 

postpartum).105 

Results from KQ3. Four studies (all fair104,154,158,170) provided moderate, consistent evidence 

that weight gains (defined as total weight gain or rate of weight gain) exceeding IOM guidelines 

were associated with greater weight retention measured at or before 11 weeks postpartum. 

Synthesis of results. Overall, the studies on weight retention measured within 11 weeks 

postpartum all showed a consistent effect that higher gestational weight gains are associated with 

higher weight retention. 

 Intermediate-term (3 months up to 3 years postpartum) postpartum weight retention. 

Results from KQ1. Five studies (1 good,144 3 fair,141,143,145 and 1 poor140) provide moderate 

evidence for an association between gestational weight gain and weight retention between 3 

months and 3 years postpartum. 

Results from KQ3. Six studies (5 fair158,171,172,174,175 and 1 poor173) examined the association 

between weight gain categorized according to IOM guidelines and weight retention within 3 

years postpartum. They yielded moderate, consistent evidence that women who gained above the 

IOM recommendations retained more weight than those who gained within them. They provided 

only weak evidence about any association when weight gains were below IOM guidelines. 

Synthesis of results. Overall, the evidence is moderate for an association between high 

gestational weight gains (despite variations in definitions) and weight retention in the 
193

intermediate term. However, the lack of consistent adjustment for covariates, particularly for 

factors influencing weight development over time such as physical activity and diet, means that 

this summary assessment must be interpreted cautiously. 

Long-term (> 3 years postpartum) postpartum weight retention. 

Results from KQ1. Two studies (1 good146 and 1 fair [2 articles]136,142) provided weak 

evidence on the association between gestational weight gain and long-term postpartum weight 

retention. The one good study found no association for higher weight gains at 21 years after 

delivery.146

Results from KQ3. Three fair studies examined the association between gestational weight 

gain according to the IOM guidelines and weight retention several years after delivery.171,174,176

They yielded moderate, consistent evidence that higher weight gains were associated with weight 

retention later in life, but the magnitude of weight retained was small. 

Synthesis of results. Overall, the evidence is weak to moderate for an association between 

high gestational weight gains and long-term weight retention. Once again, the lack of consistent 

adjustment for covariates, particularly on factors influencing weight development over time such 

as physical activity and diet, make a summary assessment of the influence of gestational weight 

gain on long-term postpartum weight retention challenging; our results must be interpreted with 

caution. 

Interpregnancy weight retention. 

Results from KQ1. Three studies, all rated fair quality, provide weak evidence for an 

association between gestational weight gain and interpregnancy weight retention.137-139 Two 

studies reported positive associations between gestational weight gain in an index pregnancy and 

an increase in weight from the beginning of the index pregnancy to the beginning of the 

following pregnancy.137,138 Another study found no evidence for an association between 

gestational weight gain across multiple pregnancies and the development of morbid obesity;139

however, women who became morbidly obese gained significantly more weight during their first 

pregnancy and retained significantly more weight after their first and second pregnancies than 

did controls. 

Results from KQ3. One good study examined gestational weight gain according to the IOM 

guidelines and weight retention until the second pregnancy.177 The incidence of overweight at the 

second pregnancy was significantly higher among women who had gained above IOM 

recommendations in the prior pregnancy than among those who gained within or below IOM 

recommendations.177 The adjusted odds of becoming overweight between baseline and the start 

of the second pregnancy was nearly threefold for women gaining above recommendations. We 

rate this evidence as weak due to the limited number of studies conducted. 

Synthesis of results. Overall, evidence for an association between gestational weight gain and 

interpartum weight retention up to the next pregnancy is weak. 

Premenopausal breast cancer. 

Results from KQ 1. One fair study provided weak evidence that gestational weight gain and 

premenopausal breast cancer are not associated.148

Results from KQ 3. We found no evidence from studies examining outcomes of weight gain 

categorized by IOM recommendations. 
194

KQ 2: Confounders and Effect Modifiers of Outcomes of 

Maternal Weight Gain 

KQ 2 asks about the confounders and effect modifiers relevant for examining any 

associations between weight gain (overall and patterns) and birth outcomes; it also asks about the 

extent to which these confounders and effect modifiers themselves contribute to outcomes. As 

reported in our results and discussion for KQ 1, the types of confounders and effect modifiers 

vary considerably by the type of outcome being considered. Moreover, as demonstrated in our 

summary tables for KQ 1, little consistency exists within the body of evidence for each outcome 

on which confounders are to be included, and even less consistency exists on their definition. 

Given the large variations in the overall body of evidence on the confounders and effect 

modifiers, our discussion on KQ 2 is limited to outcomes with either moderate or strong 

evidence of association with weight gain (as identified for KQ 1). These are preterm birth, 

cesarean delivery, birthweight, low birthweight, macrosomia, LGA infants, SGA infants, and 

intermediate postpartum weight retention (3 months to 3 years). 

Because age, race and ethnicity, and pregravid weight status are key considerations in the 

1990 IOM weight gain recommendations, we limit our discussion of KQ 2 to the consideration 

of these three key variables. In addition, we consider the independent effect of parity on health 

outcomes. All four variables are defined in highly variable fashion across the included studies. 

The discussion below represents general trends for these variables. 

Finally, because KQ 2 asks about the independent association between confounders and 

effect modifiers, we consider results only from multivariate analyses for confounders and effect 

modifiers that included weight gain during pregnancy as a predictor of the outcome. Several 

studies controlled for age, race and ethnicity, pregravid weight status, and parity, but they did not 

have abstractable results; the summary findings below are therefore a subset of relevant 

evidence. These studies together provide strong evidence of the independent association of 

pregravid weight status on outcomes, moderate evidence on the effects of age and parity, and 

weak evidence, largely because of insufficient data, on the effect of race. 

Age 

Several studies controlled for age in multivariate analysis but did not present their results in 

the published data. In general, the studies that presented findings for age suggested increasing 

risks for cesarean delivery and preterm birth as age rises. Key highlights of the evidence are 

presented below; Table 47 offers further details. 

• Of five studies of preterm birth,82,87-89 three (2 fair,82,89 1 poor87) suggested higher risks of 

preterm birth with increased age; two (1 good,88 1 poor83) suggested no effect of age. 

• Five fair studies on cesarean delivery72,73,76-78 suggested a higher risk of cesarean delivery 

with increased age. The risk was generally true for both primary and repeat cesareans,77,78

except for repeat labored cesareans, in the only study that examined the association for 

that particular subgroup.78

• Of six studies concerning birthweight,83,93,98,99,101,102 three (1 good,98 2 fair93,99) suggested 

that higher ages are associated with increased birthweight; three (2 fair,101,102 1 poor83) 

suggested no effect of age. 
195

• Two studies were available on low birthweight defined as < 2500 g.107,109 One fair study 

reported no effect of mothers’ being adolescents,107 and one poor study reported a higher 

risk for women ages 40 years and older than for women ages 20 to 29 years.109

• Two fair studies reported no association between age and macrosomia;70,77 two fair 

studies reported an increased risk of macrosomia with increased maternal age.93,112

• Three studies were available on SGA.66,89,124 One fair study reported higher risks of 

intrauterine growth retardation (IUGR) for women older than 25 years89 than for women 

20 to 25 years; the other two (1 fair,124 1 poor66) reported no association between age and 

SGA. 

• Of three studies about intermediate weight retention,141,144,145 two fair studies reported 

higher risk with increased age;141,145one good study reported no increased risk.144
196

Table 47. Age, gestational weight gain, and outcomes 

Outcome 

Citations Addressing 

Effect of Age Effect of Age 

Preterm birth 582,83,87-89 of 

1223,59,65,66,71,82-89 Higher risks of preterm birth with increased age82Among women with prepregnancy weight < 48 kg, higher risk of preterm 

birth for women < 21 years than for women ≥ 21 years87 

Higher risks of preterm delivery for women < 17 and > 25 than for 20-

2589

No significant association between gestational age and age categories 

(16-19, 20-24, 25-29, 30-34, 35-45)83

No significant association between preterm birth and age categories (< 

20, 21-35, ≥35 years)88

Cesarean 

delivery 

572,73,76-78 of 

214,25,49,51,52,54,58,59,61,67-78 Higher risk of primary cesarean for women > 30 years than for women 

20-29 years; lower risk for women < 20 years than for women 20-29 

years72

Increased risk of cesarean delivery with increased age73,76

Increased risk of cesarean delivery with age ≥ 30 years compared with 

20-24 years for primiparous and multiparous cesarean delivery; no 

significant association for other age groups77

Higher risk of primary cesarean delivery, with or without labor, for 

women ≥ 35 years than for women 20-34 years; higher risk of repeat 

cesarean without labor for women ≥ 35 years than for women < 35 

years; no increased risk of repeat cesarean with labor for women age 

≥ 35 compared with women < 35; lower risk of primary cesarean with 

labor for women < 20 years than for women 20-34 years78

Birthweight 683,93,98,99,101,102 of 

2548,54,55,59,68,70,75,83,90-106 Increased birthweight associated with higher age93,98Lower birthweight for women < 25 years than for women 25-29 years, 

no significant association for age > 29 years99

No significant association between birthweight and age83,101,102

Low 

birthweight 

(specifically 

< 2,500 g) 

2107,109 of 

132,4,52,54,70,71,75,93,95,106-109 Higher risk of LBW for women ≥40 than for women 20-29, no significant 

association for women 30-29 years compared with women 20-29 

years109

No significant association between LBW and adolescence107

Macrosomia 470,77,93,112 of 

122,4,49,59,70,77,93,108,110-113 Increased risk of macrosomia with higher age93,112No significant association by age70,77

Large-forgestationalage (LGA) 0 of 

144,54,58,59,61,68,100,105,115,116,1

18,120-122

No abstractable data 

Small-forgestationalage (SGA) 366,89,124 of 

204,51,54,58,59,61,66,68,89,95,105, 

108,111,114,116,118,119,122-124

Higher risks of IUGR for women > 25 than for women 20-2589

No significant association between SGA birth and age66,124

Intermediate 

postpartum 

weight 

retention 

(PPWR) 

3141,144,145 of 5140,141,143-145 Higher PPWR with higher age141,145

No significant association between postpartum weight retention and 

age144

IUGR, intrauterine growth retardation; kg, kilogram; LBW, low birthweight; PPWR, postpartum weight retention; SGA, smallfor-gestational-age. 

Race and Ethnicity 

Studies from relatively homogenous populations did not examine the effect of race or 

ethnicity, so the body of evidence on the independent effect of these variables was limited. These 

studies suggested that black women, in comparison with white women, have higher risks of 
197

preterm birth and SGA and lower risks of LGA and macrosomia. Highlights of the evidence are 

presented below, with details in Table 48. 

Table 48. Race and ethnicity, gestational weight gain, and outcomes 

Outcome 

Citations Addressing 

Effect of Race and 

Ethnicity Effect of Race and Ethnicity 

Preterm 

birth 

282,85 of 1223,59,65,71,82-89 Significantly higher risks of preterm birth for blacks compared with 

whites, significantly lower risks of preterm birth for Asians compared 

with whites, no differences for Hispanics compared with whites82,106

Among blacks, both low and high gain were associated with 

spontaneous preterm birth, although for high gain the statistical 

significance was borderline; among Asians, there was a nonstatistically 

significant inverse association between high gain and spontaneous 

preterm birth; among whites and Latinas, low gain was associated with 

a significantly higher risk of preterm birth but not high gain85

Cesarean 

delivery 

177 of 

214,25,49,51,52,54,58,59,61,67-78 No significant association between race/ethnicity and primiparous or 

multiparous cesarean delivery77

Birthweight 394,102,106 of 

2548,54,55,59,68,70,75,83,90-106 Lower birthweight for infants of black women than for infants of white 

women; no significant association for Puerto Rican ancestry compared 

with white ancestry102

No effect of race and ethnicity on birthweight94,106

LBW 2106,109 of 

132,4,52,54,70,71,75,93,95,106-109 LBW babies more likely among black than Hispanic women106LBW babies more likely among black women and Hispanic women than 

white women109

Macrosomia 270,77 of 

122,4,49,59,70,77,93,108,110-113

Lower risk of macrosomia for black women than for white women70

Lower risk of macrosomia for foreign-born Asian non-Hispanic women 

than for native-born white non-Hispanic women; lower risk of 

macrosomia for Hispanic women, whether native or foreign-born, than 

for native-born white non-Hispanics; lower risk of macrosomia for 

Hispanic women, whether native or foreign-born, than for native-born 

white non-Hispanics; lower risk of macrosomia for native-born black 

non-Hispanic women than for native-born white non-Hispanic wwomen; 

no significant associations for foreign-born white or black non-Hispanic 

women or native-born Asian non-Hispanic women77

LGA 1116 of 

144,54,58,59,61,68,100,105,115,116, 

118,120-122

Lower risk of LGA for black women with BMI 19.8-26 or BMI > 26 than 

white women at the same BMI levels; no significant association for race 

at BMI < 19.8116

SGA 366,114,116 of 

204,51,54,58,59,61,66,68,89,95,105, 

108,111,114,116,118,119,122-124

Lower risk of SGA for black women with BMI 19.8-26 than white women 

at the same BMI level; no significant associations for race at BMI < 19.8 

or BMI > 26116

Higher risk of SGA infants among black women and women of other 

races than white women66

Higher risk of IUGR among black women than white women; lower risk 

of IUGR among Asian women than white women114

Intermediate 

PPWR 

1141 of 5140,141,143-145 Risk of weight retention higher for black and Hispanic than white 

women141

BMI, body mass index; IUGR, intra-uterine growth retardation; LBW, low birthweight; LGA, large-for-gestational-age; PPWR, 

postpartum weight retention; SGA, small-for-gestational-age. 

• Two fair studies suggested higher risks of preterm birth for black women than for white 

women.82,85 One study suggested that among blacks, both high weight gain and low 

weight gain predicted preterm birth, but that among women of other races and ethnicities, 

low weight gain alone increased the risk of preterm birth.85
198

• One fair study showed no significant association between race or ethnicity and 

primiparous or multiparous cesarean delivery.77

• One fair study reported an effect of race and ethnicity showing lower infant birthweight 

for black women than white women; it reported no significant association for women of 

Puerto Rican ancestry.102 Two other studies (1 good,106 1 poor94) showed no effect of race 

and ethnicity. 

• Two studies (1 good,166 1 poor109) reported a higher risk of LBW infants among black 

women than among white women.106,109 One reported a higher risk of LBW babies 

among Hispanic women than among white women.109

• Two fair studies showed a lower risk of macrosomia for black women than for white 

women;70,77 one reported a lower risk for Hispanic women than for white women.77

• One good study reported that black women of normal weight were less likely to have 

LGA babies than white women of normal weight.116

• Three studies (1 good,116 1 fair,114 1 poor66) showed higher risks for either SGA66,116 or 

IUGR114 for black women than for white women; one study showed lower risks for Asian 

women than white women.114

• One study fair reported that black and Hispanic women retained more weight than white 

women.141

Pregravid Weight or Body Mass Index 

Our search strategy required that included studies have controlled for pregravid weight 

status; as a result, the evidence on pregravid weight status is strongest. These studies generally 

demonstrated a strong independent effect of pregravid weight status on all but one of the 

outcomes for which we found moderate or strong evidence (preterm birth, cesarean delivery, 

birthweight, low birthweight, macrosomia, LGA infants, SGA infants, and intermediate 

postpartum weight retention [3 months to 3 years]). The exception was postpartum weight 

retention, for which the studies showed inconsistent results. Key highlights are presented below, 

with more details in Table 49: 

• Seven studies (2 good,84,88 and 5 fair65,71,82,86,89) reported a higher risk of preterm birth 

with lower pregravid weight status; one poor study showed no statistically significant 

relationship between pregravid weight and gestational age.83

• Ten fair studies reported showing a higher risk of cesarean delivery with higher pregravid 

weight status.52,67,70-73,75-78
199

Table 49. Pregravid body mass index, gestational weight gain, and outcomes 

Outcome 

Citations Addressing 

Effect of Body Mass 

Index Effect of Body Mass Index 

Preterm 

birth 

865,71,82-84,86,88,89 of 

1223,59,65,71,82-89 Higher risks of preterm birth with baseline weight lower than reference 

pregravid weight of 100-149 pounds; no increased risks with higher than 

reference weight71

Lower risks with increased BMI82

Higher risks with decreased BMI86 

Higher risks with BMI less than normal range (< 19.8-26)84,88

Higher risks with pregravid weight < 73 kg than with ≥ 85 kg89

Higher risks of preterm birth with obesity (pregravid BMI > 30)65 

No significant association between pregravid weight and gestational age 

Cesarean 

delivery 

1052,67,70-73,75-78 of 

214,25,49,51,52,54,58,59,61,67-78 Higher risk of cesarean delivery with higher BMI70,73,76Higher risks of cesarean delivery with higher pregravid weight75 

Higher risks of primary cesarean with pregravid weight higher than 100–149 

pounds; no increased risks with lower than reference weight71

Higher risks of unplanned cesarean with obesity than nonobese weight 

categories67

Higher risk of cesarean with pregravid BMI > 25 than with BMI 18.5-25;no 

increased risk for BMI < 18.552

Higher risk of primary cesarean delivery for pregravid weight ≥ 70 kg than 

with 60-69 kg; no significant association with other pregravid weights72

Higher risks of primiparous cesarean delivery with pregravid overweight and 

obese status than with normal weight; higher risk of multiparous cesarean 

delivery with obese status than with normal weight; no significant 

association for overweight women compared with normal-weight women for 

multiparous cesarean delivery77

Higher risk of primary cesarean, with or without labor, and repeat cesarean, 

with or without labor, for pregravid overweight or obese status than for 

normal weight; lower risk of primary cesarean with labor for underweight 

women than for normal weight women; no significant association between 

underweight status and either primary cesarean without labor or repeat 

cesarean with or without labor78

Birthweight 1248,83,91,93,94,96,98-102,105 of 

2548,54,55,59,68,70,75,83,90-106 Higher birthweight associated with higher pregravid weight48,83,91,93,96,98,101 Birthweight lower for prepregancy weight < 55 kg than for prepregnancy 

weight 56-66 kg; birthweight higher with prepregnancy weight > 66 kg99

Higher birthweight with higher pregravid weight-for-height (using 

Metropolitan Life Insurance tables)105

No significant association between birthweight and obesity100

No difference in birthweight by pregravid BMI groups94

No significant association between birthweight and low pregravid BMI102

LBW 82,52,70,71,93,107-109 of 

132,4,52,54,70,71,75,93,95,106-109 Higher risks of LBW with pregravid weight less than 100–149 pounds, 

significantly decreased risks with higher than reference weight71 

Higher risk of LBW with pregravid BMI < 18.5 than with BMI 18.5-25; no 

significant association for BMI > 2552

Lower risk of LBW with increasing pregravid weight2,93

Lower risk of LBW with increasing BMI70

Lower risk of LBW with BMI > 30 than with BMI 25-29, no significant 

association for women with BMI < 25109

No significant association between LBW and BMI for women gaining < 11 kg 

(no direct comparisons for other weight gain categories)108

No significant association between LBW and pregravid underweight 

status107

BMI, body mass index; IUGR, intra-uterine growth retardation; kg, kilogram; LBW, low birthweight; PPWR, postpartum weight 

retention; SGA, small for gestational age. 
200

Table 49. Pregravid body mass index, gestational weight gain, and outcomes (continued) 

Outcome 

Citations Addressing 

Effect of Body Mass Index Effect of Body Mass Index 

Macrosomia 72,70,83,93,108,112,113 of 

122,4,49,59,70,77,93,108,110-113 Increased risk of macrosomia with higher pregravid weight93,112Increased risk of macrosomia with pregravid BMI 19.8-26 compared with 

BMI < 19.870

Higher risk of macrosomia with first trimester BMI > 25 than with < 20; no 

higher risk with BMI 20-25 compared with BMI < 20113

Higher risk of macrosomia with pregravid BMI > 26 than with BMI < 19.8 

for women gaining < 11 kg; no higher risk for women with BMI 19.8-26 

(no direct comparisons for other weight gain categories)108

Higher rates of macrosomia with higher pregravid weight2

Higher risk of macrosomia with pregravid overweight or obese status 

than with normal weight77

LGA 4100,105,121,122 of 

144,54,58,59,61,68,100,105,115,116, 

118,120-122

Higher rates of LGA with higher pregravid BMI100

Higher rates of LGA with higher pregravid weight-for-height (using 

Metropolitan Life Insurance tables)105

Lower risk of LGA with lower prepregnancy weight122

No significant association between pregravid BMI (per 1 kg/meter2 

ncrement) and LGA121

SGA 966,89,105,108,114,119,122-124 of 

204,51,54,58,59,61,66,68,89,95,105, 

108,111,114,116,118,119,122-124

Higher risks of SGA with pregravid weight < 73 kg than with ≥ 85 kg89

Higher risk of growth retardation with BMI < 19.8 than with BMI 19.8-26 

for women gaining < 11 kg; no significantly increased risk of growth 

retardation with BMI > 26 compared with BMI < 19.8 for women gaining 

< 11 kg (no direct comparisons for other weight gain categories)108

Lower risk of SGA with higher pregravid weight-for-height (using 

Metropolitan Life Insurance tables)105

Lower risk of SGA with pregravid BMI higher than 19.9 compared with 

BMI ≤ 19.9123

Higher risk of SGA with pregravid BMI < 20 than with BMI ≥ 20119

Higher risks of SGA with pregravid weight < 100 pounds than with 

pregravid weight 126-160 pounds, lower risk of SGA with pregravid 

weight 160 pounds than with pregravid weight 126-160 pounds66

Higher risks of SGA with pregravid underweight status than with normal 

weight; lower risks of SGA wth pregravid overweight or obese status 

than with normal weight124

Higher risk of IUGR with lower prepregnancy weight122

Lower risk of IUGR with higher pregravid weight114

PPWR 3141,144,145 of 5140,141,143-145 Increased risk of PPWR with higher pregravid weight141,144,145

No significant association between pregravid weight and PPWR144,145

• Of 12 studies,48,83,91,93,94,96,98-102,105 nine (2 good,48,98 4 fair,93,99,101,105 3 poor83,91,96) 

demonstrated higher birthweight with higher pregravid weight status; three (2 fair,100,102 1 

poor94) suggested no association. 

• Of eight studies,2,52,70,71,93,107-109 six (5 fair,2,52,70,71,93 1 poor109) reported lower risks of 

LBW with higher pregravid weight status; two fair studies suggested no association.107,108

• Seven (6 fair,2,70,93,108,112,113 1 poor83) studies reported a higher risk of macrosomia with 

higher pregravid weight (overweight or obese compared with normal weight). 

• Of four studies,100,105,121,122 three fair studies reported a higher risk of LGA with higher 

pregravid weight status;100,105,122 one fair study found no significant association.121

• Nine studies reported lower risks of either SGA (5 fair,89,105,119,123,124 1 poor66) or IUGR 

(3 fair studies)108,114,122 with higher pregravid weight status. 
201

• Of three studies,141,144,145 one fair study suggested a higher risk of postpartum weight 

retention with higher pregravid weight status;141 two (1 good,144 1 fair145) showed no 

association. 

Parity 

Studies did not always examine or report on the independent effect of parity on health 

outcomes, but the few that did showed consistent effects of increased risks of cesarean delivery 

and SGA with nulliparity and reduced risks of weight retention for primiparous women. 

Multiparous women have larger (heavier) babies, lower risks of low birthweight babies, and 

higher risks of LGA or macrosomia. Key highlights are presented below, with more details in 

Table 50: 

• Five (1 good,88 2 fair,82,89 2 poor83,87) studies suggested no association between parity and 

preterm birth. 

• Four fair studies suggested higher risks of cesarean delivery with nulliparity.67,70,72,76

• Eight (2 good,48,98 5 fair,70,92,101,102,105 1 poor83) studies reported a higher birthweight with 

higher parity. 

• Two studies (1 fair,70 1 poor109) reported lower risks of low birthweight with higher 

parity. 

• Three fair studies suggested a higher risk of macrosomia with higher parity.70,77,112

• Two of three studies (1 good,116 1 fair122) suggested a higher risk of LGA with higher 

parity;116,122one fair study suggested no association between LGA and parity.115

• Three studies (1 good,116 1 fair,89 1 poor66) suggested greater risks of SGA66,116 or IUGR 

with nulliparity.89

• One fair study reported that primiparous women were more likely to retain weight at 1 

year postpartum than multiparous women.141

Table 50. Parity, gestational weight gain and outcomes 

Outcome 

Citations Addressing Effect of 

Parity Effect of Parity 

Preterm birth 582,83,87-89 of 1223,59,65,71,72,82-89 Lower gestational age with parity ≥ 5 compared with nulliparous; no 

significant association for other parities83 

No significant association between preterm birth and parity82,87-89

Cesarean 

delivery 

467,70,72,76 of 

214,25,49,51,52,54,58,59,61,67-78 Higher risk of cesarean delivery with nulliparity67,70Higher risk of cesarean delivery for nulliparity compared with parity 

= 1; no increased risk of cesarean with parity > 1 compared with 

parity =172

Lower risk of cesarean with having had at least one viable 

pregnancy76

BMI, body mass index; IUGR, intra-uterine growth retardation; kg, kilogram; LBW, low birthweight; LGA, large-forgestational-age; PPWR, postpartum weight retention; SGA, small for gestational age. 
202

Table 50. Parity, gestational weight gain and outcomes (continued) 

Outcome Citations Addressing Effect of Parity Effect of parity 

Birthweight 848,70,83,92,98,101,102,105 of 

2548,54,55,59,68,70,75,83,90-106 Higher birthweight associated with higher 

parity48,70,83,92,98,101,102,105

Low 

birthweight 

270,109 of 

132,4,52,54,70,71,75,93,95,106-109 Lower risk of LBW with increased parity70Lower risk of LBW with 3 or more term live births than with 1 

or 2 live births; higher risk of LBW with no term live births 

than with 1 or 2109

Macrosomia 370,77,112 of 

122,4,49,59,70,77,93,108,110-113 Higher risk of macrosomia with multiparity than with 

nulliparity70,112

Higher risk of macrosomia with nulliparity compared with 

parity ≥ 2, no significant risks of macrosomia with parity = 1 

compared with parity ≥ 277

LGA 3115,116,122 of 

144,54,58,59,61,68,100,105,115,116,118,120-122 Higher risks of LGA with multiparity for all BMI categories116Higher risks of LGA with multiparity122

No significant association between LGA and parity115

SGA 366,89,116 of 

204,51,54,58,59,61,66,68,89,95,105,108,111,114,116, 

118,119,122-124

Increased risk of IUGR for parity = 1 than with parity = 2; no 

increased risk of IUGR for parity ≥ 3 than with parity = 289

Lower risk of SGA with multiparity for normal BMI women; no 

significant association between SGA and multiparity for 

underweight and overweight women116 

Higher risk of SGA with nulliparity than multiparity66

Intermediate 

PPWR 

1141 of 

5140,141,143-145 Lower risk of PPWR for primiparous women than multiparous 

women141

KQ 4: Risks and Benefits of Gestational Weight Gain 

Recommendations 

Despite conducting a systematic review of 150 studies identified by numerous search 

strategies, we did not uncover any clear exposition of the harms and benefits of offering the same 

weight gain recommendations to all women, irrespective of race or ethnicity, age, or pregravid 

BMI. 

Although most studies controlled for various demographics variables in their analyses, few 

were specifically undertaken to understand the impact of the IOM recommendations on 

subpopulations. We did uncover a few studies that specifically investigated differential response 

to weight gain by pregravid BMI relative to numerous outcomes, but generally this evidence was 

not conclusive. Outcomes differentially affected by weight gain included the following: 

• Labor induction (2 fair studies;3,67 2 poor studies59,68) 

• Cesarean delivery (9 fair studies;4,25,58,69-73,75,76 5 poor studies51,59,61,68,74) 

• Preterm birth (2 fair studies;23,86 1 poor study87) 

• Low birthweight(1 fair;2

 1 poor162 study) 

• Large-for-gestational age(2 fair studies25,129) 

• Macrosomia (2 fair studies55,164) and 

• Postpartum weight retention (3 fair studies138,140,143). 

This differential response suggests that one recommendation for all women, irrespective of 

BMI, cannot be justified by the studies we reviewed. This conclusion is not as robust as it might 
203

seem, however, because nearly the entire database comprises observational studies; this fact 

renders the findings suggestive but not definitive. Further undermining our ability to state clearly 

whether any harms or benefits accrue to having a single recommendation for all women is that 

the quality ratings assigned to the studies were rarely “good” and that a nontrivial share of the 

articles were of poor quality and should be discounted in terms of arriving at overall grades of 

the strength of evidence. A common deficiency was that investigators did not control adequately 

for potential confounders and effect modifiers in their analyses. As noted throughout Chapter 3, 

inadequate attention to confounders undermines our ability to interpret the findings of much of 

the research we reviewed. 

The IOM recommendations state that black women and teenagers should gain at the upper 

end of the recommendations; several researchers aimed to investigate whether weight gains 

differentially affect the outcomes for adolescents and black women. Assessing this research is 

important in determining the harms and benefits of one recommendation for all women. 

Findings Relative to Benefits and Harms of Different 

Recommendations Based on Race 

The IOM guidelines recommended that black women gain at the upper end of recommended 

ranges; the aim was to influence differences in mean birthweights between blacks and whites and 

decrease the risks of low or suboptimal birthweights among black infants. Five studies, four 

good.20,116,156,160 and one fair,85 specifically aimed to compare the impact of the IOM guidelines 

on infants born to black and white women. 

Three of these studies20,116,160 did not produce evidence supporting benefits of black women 

gaining at the upper limit of the IOM recommendations. In one of the good studies,116

researchers studied 3,870 women who gave birth to singleton infants at 28 or more weeks of 

gestation between 1987 and 1989. They found that the relationship between weight gain and 

either SGA infants or LGA infants did not differ by maternal race for any BMI category. 

Although racial differences seemed to arise in the occurrence of SGA and LGA infants, these 

differences were mediated by pregravid BMI rather than weight gain during pregnancy. The 

researchers concluded that encouraging black women to gain at the upper end of the 

recommended range is unlikely to produce measurable reductions in SGA births; they noted, 

however, that benefits may accrue from recommending lowered weight gain recommendations 

for average and overweight white women with respect to the prevalence of LGA infants. 

In another good study,160 investigators reported on data from the Pregnancy Nutrition 

Surveillance System for nine states. The study involved self-reported pregravid weight, total 

weight gain, and infant birthweight data on 173,066 women who delivered between 39 and 41 

weeks’ gestational age. Adjusted odds ratios (ORs) showed that both black and white women 

who entered pregnancy with a low BMI had a statistically greater likelihood of having an LBW 

infant if they gained 10 pounds or less than the IOM recommendations than did women who 

gained within the lower half of the recommendations. The investigators did not control for 

maternal complications and underlying diseases. Within all of the BMI-race strata, mean 

birthweight rose as weight gain increased. The study was unable to find consistent evidence to 

support benefits of counseling black women to gain at a rate different than that for other women; 

the researchers concluded that their analysis did not support the IOM recommendation that black 

women gain at the upper ends of the ranges. 
204

The third study, which yielded no support for differential recommendations based on race, 

examined outcomes for 5,918 low-income women.20 The researchers revealed that adjusted mean 

birthweights were higher for white women with normal pregravid BMIs gaining in the upper half 

of the recommended ranges but not for black women with normal pregravid BMIs. They also 

found through logistic regression analyses that prenatal weight gain in the upper compared with 

the lower half of the recommended ranges was significantly associated with a decreased OR for 

low birthweight among white women but not for black women. In addition to its large size, the 

study has several strengths that included the exclusion of women with a variety of confounding 

characteristics, such as adolescents less than 18 years old and maternal risk factors for poor 

pregnancy outcomes. The researchers also excluded all women whose last prenatal weight 

assessment was greater than 3 weeks before delivery. The study lacked data on parity, however, 

and gestational age was not based on ultrasound verifications. Additionally, fewer black women 

than white women were included in the analyses, which may have limited the researchers’ ability 

to detect the impact of weight gain on outcomes. Findings from the study led the researchers to 

conclude that their data do not support differential recommendations. 

An earlier study by the same lead author had concluded that the IOM recommendation that 

black women gain at the upper end of the recommended ranges is valid.156 In this study, they 

analyzed birth outcomes for 1,168 multiparous low-income women who were at risk for 

delivering an SGA infant. When weight gain was less than 6 kg, black women with a pregravid 

BMI > 29 delivered twice as many growth-restricted infants as did white women with 

comparable BMIs; when, however, weight gain exceeded 6 kg, obese black women delivered 

one-third as many growth-restricted infants as obese white women. After adjusting for numerous 

potentially confounding and intervening variables, black women in each pregravid category 

delivered increasingly larger infants if they met or exceeded the IOM recommendations; this 

relationship effect was absent in white women. The authors concluded, therefore, that their 

findings supported the IOM recommendations regarding weight gain guidance for black women. 

This study lacked generalizability to all black women, however, because the study population 

was specifically chosen based on its risks for giving birth to growth-restricted infants. 

The fifth study that specifically aimed to explore the interaction of weight gain and race on 

infant outcomes analyzed data from 15,101 births to white, black, Latina, and Asian women who 

entered pregnancy with normal or underweight BMIs.85 For most subgroups, weight gain beyond 

0.27 kg per week was not associated with decreasing risks for spontaneous preterm births. 

However, both low and high weight gains were associated with significantly increased risks of 

spontaneous preterm birth in black women who had experienced a previous preterm birth and 

who entered pregnancy with a low or normal BMI. The authors concluded that determining 

whether race or ethnicity modifies the relationship between weight gain and prematurity requires 

further exploration. 

In summary, the harms and benefits of providing women of all racial and ethnic subgroups 

with the same weight gain recommendations cannot be determined from existing research. 

Undoubtedly, various factors in addition to weight gain are likely to be responsible for 

differences between white and black women in both mean birthweights and the prevalence of 

low birthweight infants.20 As Hickey and colleagues note, more important than race may be 

social, economic, environmental, nutritional, cultural, lifestyle, medical and other factors for 

which race is a surrogate.20
205

Findings Relative to Benefits and Harms of Different 

Recommendations Based on Age 

Few studies specifically aimed to understand differences in the impact of weight gain 

recommendations on women in various age categories. Four studies purposefully investigated 

adolescents (1 good,153 2 fair,154,186 and 1 poor95); according to the IOM, they should gain at the 

upper ranges of the BMI-specific recommendations. 

Researchers for the one study rated good analyzed data for 815 black adolescents who, at the 

time of conceiving their infants, were less than 18 years old.153 Birthweight outcomes markedly 

improved in teens from all BMI groups when their weight gain increased from below to within 

the lower half of the IOM recommended range; additional benefits from gains in the upper half 

of the recommended ranges were modest or equivocal. A limitation of this study was that 

prepregnancy weight was self-reported; whether the reliability of self-reported weights in teens is 

equivalent to self-reported weights in older women is not known. 

One fair study also reported results that question whether encouraging adolescents to gain in 

the upper ranges of the recommendations confers any advantages.186 This study specifically 

examined whether adolescents require greater prenatal weight gains than nonadolescents to 

deliver infants of comparable weight. The study population was 423 women between the ages of 

14 and 25 who received care in a health maintenance organization. The study, published in 1991, 

did not specifically reference the IOM recommendations but, rather, used a weight gain of 11 to 

12 kg as the optimal level. Both the adolescents and the young adults had a total weight gain of 

approximately 3 kg over the optimal level and delivered similar weight infants. Despite the 

relatively high weight gains, 28 percent of the adolescents and 31 percent of the nonadolescents 

had infants determined to be in the optimal weight range of 3,500 to 3,999 g. Maternal weight 

gain, gestational age, parity, and cigarette use during pregnancy were significant predictors of 

infant birthweight in the regression analysis. Analysis of subjects who were primiparous, 

nonsmokers, had a gestational age greater than 37 weeks at delivery, and who entered prenatal 

care in the first trimester revealed that mean monthly weight gain, total pregnancy weight gain, 

and infant birthweights were similar between the young adult and adolescent mothers. The 

authors concluded that pregnant adolescents are not at biological risk of delivering underweight 

infants and that adolescents do not appear to require a greater weight gain than young adults to 

deliver similar weight babies. 

Another fair study undertook a prospective, longitudinal assessment to investigate the 

advantages and disadvantages of large weight gain among pregnant adolescents. The study 

involved 141 low-income black women ages 12 through 19. The subjects were classified 

according to their average rate of weekly weight gain as either slow, average, or rapid gainers. 

The rate of weight gain did not influence the prevalence of maternal glucose intolerance, 

pregnancy-induced hypertension, or cesarean delivery; larger weight gains were associated with 

larger infants. 

One study did not meet inclusion criteria but we note it because it provides a provocative 

argument that weight gain recommendations based on adult BMI categories may not be 

sufficiently specific to yield optimal maternal and neonatal outcomes for childbearing 

adolescents.187 This study, which included only descriptive statistics and no multivariate 

analyses, compared the pregnancy experience of adolescents when assigned to IOM categories 

for BMI status with the experience when they were assigned to BMI growth curve percentiles set 

forth by the Centers for Disease Control and Prevention (CDC). Fewer adolescents were 
206

classified as underweight by the CDC BMI percentiles than by the IOM categories; thus, the 

CDC percentiles mean that fewer adolescents will be encouraged to gain extra pounds in 

pregnancy to compensate for low BMI. The author postulated that application of the IOM 

recommendations to teens results in recommendations for weight gain that are higher than 

necessary for healthy pregnancy outcomes and sets young women up for excess weight retention. 

Findings Relative to Benefits and Harms of Different 

Recommendations from the IOM 

Options to the IOM weight gain recommendations were specifically explored in three studies 

(1 good;188 2 fair4,127). These studies offered optimal weight gain ranges, based on their findings 

that differ from the IOM recommendations. 

In a fair study, one research team set out to determine optimal weight gain in a singleton 

pregnancy.127 Using a retrospective cohort of 20,971 singleton pregnancies delivered in a 

primarily low-risk population between 1987 and 1993, the researchers reported that the best 

perinatal outcomes for all women, except those with BMIs in the obese range, occurred with 

higher weight gains than current IOM recommendations. The optimal gain was determined to be 

between 36 and 40 pounds; among obese women, the best outcomes occurred when women 

gained less than 36 pounds. These conclusions considered outcomes only for the infant without 

balancing the potential impact of such recommendations on prenatal and intrapartum 

complications for the mother or her long-term obesity risks. 

Another study offered specific suggestions for women by obesity class defined by the 

National Institutes of Health (NIH).4

 The authors, investigating the relationship between weight 

gain and preeclampsia, cesarean delivery, and LGA and SGA infants, reported that the following 

weight gains were associated with minimal risks for these outcomes: (a) class I obese women, 

weight gain of 10 to 25 pounds; (b) class II obese women, weight gain of 0 to 9 pounds; and (c) 

class III, obese women weight loss of 0 to 9 pounds. As noted earlier, this study failed to account 

for confounders and effect modifiers. A recent good study analyzed data from 298,648 singleton 

pregnancies registered in the Swedish Medical Birth Registry to recommend optimal weight 

gains by BMI class.188 Analyzing the ORs of various adverse maternal and perinatal outcomes, 

the researchers determined that the optimal weight gains were as follows: (a) for women entering 

pregnancy with a BMI < 20, 9 to 22 pounds (4-10 kg); (b) for women with a BMI of 20 to 24.9, 

5 to 22 pounds (2-10 kg); for women with BMIs of 25 to 29.9, less than 20 pounds (< 9 kg); and 

(d) for women with a BMI ≥ 30, less than 13 pounds (< 6 kg). Like most studies in this review, it 

limited its exploration to short-term outcomes related to the pregnancy, the intrapartum, and the 

neonatal period. 

The most compelling evidence to determine the harms and benefits of the IOM 

recommendations compared with those of other recommendations would come from 

experimental studies. The IOM recommendations have become the de facto standard of care, 

however, and so investigators have neither an incentive nor an ethically strong position to test 

alternatives. 
207

Conclusions Regarding the Harms and Benefits of Uniform 

Recommendations for All Women 

In conclusion, existing research is inadequate to assess objectively the range of harms and 

benefits of providing all women, irrespective of age, race or ethnicity, or pregravid BMI with the 

same recommendation for weight gain in pregnancy. The majority of the studies presented 

evidence suggesting that one recommendation for all women would be disadvantageous, but 

findings were not consistent; moreover, these studies typically did not fully explore harms. Most 

of the studies in this review limited their analyses to short-term outcomes related to the 

pregnancy, the intrapartum, and the neonatal period. A full examination of harms would require 

longitudinal cohorts to determine long-term and unexpected consequences of specific 

recommendations. 

A major impediment in understanding the harms or benefits of offering the same weight gain 

recommendations to all women is the lack of any information about how that advice might have 

been proffered. That is, the research we included did not reveal studies that investigated the 

processes of offering advice or the behavioral determinants for women acting on advice that is 

offered. 

KQ 5: Anthropometrics of Weight Measurement During 

Pregnancy 

Clinicians and researchers can use several anthropometric tools to determine adiposity (body 

fat). They include height and weight (to derive BMI); skinfold thicknesses, measured with 

calipers at various regions of the body, such as the arms, legs, and abdomen; circumferences, 

measured with measuring tape at various regions of the body, such as the arms, hips, and waist; 

bioelectrical impedance analysis (BIA); ultrasound; isotope dilution (to assess total body water); 

total body potassium; dual energy x-ray absorptiometry (DEXA); underwater or hydrostatic 

weighing (to measure body density); computerized tomography (CT); and magnetic resonance 

imaging (MRI). 

The majority of these tools are appropriate for measuring adiposity in the pregnancy state 

(Table 51). The exceptions are CT and DEXA, which involve x-ray energies, and BIA, which 

has been used in pregnant women; however, its appropriateness is questionable because it 

involves sending a weak electrical current through the body. 

Because body fat cannot be measured directly, researchers can incorporate values obtained 

from these tools into various equations to estimate percent body fat or body fat mass. These 

methods have been evaluated in two fair-quality studies.16,180 The equations and models, such as 

the four-compartment model, are based on assumptions of the relationships between aspects of 

body composition that can and cannot be measured. The more assumptions that a model relies 

on, the less likely it is to be accurate, especially when those assumptions are for large body 

components, such as water and bone.180 The four-compartment model, which incorporates 

measurements of total body water, body density, body weight, and bone mineral content, has 

been shown to be a more accurate approach to estimating body fat16,180 than other equations 

using skinfolds and circumferences. 
208

Table 51. Adiposity measurements and use in pregnancy 

Adiposity Measurement Used During Pregnancy? 

Weight Yes 

Body mass index (BMI) Yes 

Skinfold thicknesses Yes 

Circumferences Yes 

Hydrostatic weighing Yes 

Dual energy x-ray absorptiometry 

(DEXA) 

No 

Bioelectrical impedance analysis (BIA) Yes 

Isotope dilution Yes 

Total body potassium Yes 

Total body nitrogen Yes 

Computed tomography (CT) No 

Magnetic resonance imaging (MRI) Yes 

Ultrasound Yes 

An obstacle in trying to assess body composition during pregnancy is that body components 

(e.g., water, lean mass, fat) are constantly changing throughout gestation; moreover, some 

measurements may not be able to distinguish individual components. For example, increased 

fluid retention and subcutaneous fat deposition during pregnancy may result in greater skinfold 

thickness estimates. If body fat or body density estimates are derived from equations using 

skinfold thicknesses, then body fat will be overestimated.180 Additionally, anthropometric 

equations may be based on reference data collected in nonpregnant women or in those who are in 

early pregnancy and therefore involve inaccurate assumptions of changes occurring throughout 

pregnancy. 

The lack of research on anthropometric changes throughout pregnancy and the postpartum 

period using measurements other than body weight and BMI is notable. Furthermore, only 

limited information is available about the methodology, validity, comparability, and, in some 

cases, safety of these measurements during pregnancy. Although ultrasound techniques are used 

throughout pregnancy and have been validated for measuring visceral fat, they are seldom used 

for measuring maternal adiposity. Similarly, MRI may be an effective tool to estimate adiposity; 

however, machinery is not readily available and is expensive to operate, therefore limiting its use 

in research settings. In contrast, measurements such as skinfold thicknesses or circumferences 

are inexpensive and easy to collect in the clinical setting, but whether they are as or more 

informative or predictive of infant and maternal outcomes than standard body weight and height 

measurements remains unclear. These types of measurements also require training and 

standardized methods (e.g., where tape measures or calipers are placed and how measurements 

are made); these requirements, especially if not met, may yield less precise and reproducible 

measurements than more expensive and sophisticated methods. 
209

Limitations 

Limitations of the Evidence Base 

Source of information on weight gain. The lack of attention to the validity of self-reported 

weight and weight gain is a key limitation of this evidence base. Studies typically relied on selfreport for pregravid weight; a substantial proportion relied on self-report for weight gain as well. 

Women often misreport their weight, and this bias varies by weight status. One study found 

underreporting of BMI (kg/m2) by 0.8 and an understated prevalence of overweight or obesity 

(BMI > 25) in the range of 3 percent to 5 percent for non-Hispanic black and white women and 

up to 16 percent for Mexican-American women.39 Among obese women of reproductive age, 50 

percent underreported their weight by more than 5 pounds.38 When studies use self-reports for 

both pregravid weight and weight gain during pregnancy, the bias is likely compounded. 

Timing of measurement of gestational weight gain. Related to the issue of estimating the 

measurement error in the calculation of gestational weight gain is the timing of weight 

measurement during pregnancy relative to gestational age. Few women are weighed at the time 

of delivery; thus, their weight at the last prenatal visit varies by gestational age. Adjusting for the 

timing in gestation is critical in assessing adequacy of weight gain. 

Studies fail to account for gestational age for other outcomes of interest as well. GDM is 

customarily diagnosed at about 26 to 28 weeks’ gestation; for that reason, weight gain up to the 

time of the GDM diagnosis is the critical exposure period, not total weight gain during 

pregnancy. With outcomes such as preeclampsia, the timing of measurement is critical because 

increased weight gain that may be attributable to edema may be related to the disease process 

itself. 

Studies that examine the effect of weight gain by trimesters of pregnancy but that fail to 

account for gestational age at the first weight measurement also suffer from likely misestimation 

of the true amount of weight gained early in pregnancy. Results from such studies may be biased 

as a result. 

Appropriate adjustment for confounding. The evidence base is also limited by variations 

in the specific confounders and effect modifiers that investigators included or controlled for in 

their analyses. Omission of important confounders and effect modifiers, especially complications 

of pregnancy that are associated with changes in maternal weight postpartum, intrapartum 

complications, or birthweight, limit the interpretability and utility of the evidence. Furthermore, 

using the studies that did account for confounders and effect modifiers is hampered by the lack 

of consistent definition and inclusion of key variables. 

These deficiencies together appreciably limit the consistency and validity of the evidence. As 

a result, we found very few outcomes for which we were able to attribute at least a moderate 

strength of association, despite the relatively large body of evidence that we examined. 

Limitations of the Review 

We limited our search to articles published in English, primarily for reasons of time and 

resources. We also excluded case reports and case series with fewer than 100 women. Given the 

deficiencies of much of the work we did include, however, we do not believe that these 

exclusions would have provided much, if any, additional useful information. We did examine 
210

work from numerous developed countries, so our review does reach beyond the United States 

and potentially beyond English-speaking countries. 

For similar time and resource reasons, we did not conduct dual independent, blinded review 

of articles for inclusion or abstraction of information into evidence tables. Instead, one reviewer 

performed the initial review, and a second reviewer examined that input and recommended 

changes or corrections when needed. These two reviewers reconciled any differences by 

consensus discussion. These procedures are generally in accord with the usual procedures for the 

RTI-UNC Evidence-based Practice Center. To enable us to address any systematic bias in our 

work that the above approach may have introduced, however, we did apply dual independent 

review for assessing the quality of individual articles and grading the strength of evidence. 

The paucity of “similar” articles, for populations, patient characteristics, settings, and 

outcomes measured, precluded any efforts to pool findings statistically.

Future Research Directions 

The gold standard of a randomized controlled trial will never be appropriate to determine the 

impact of different levels of weight gain by women of varying pregravid weights relative to their 

own health, the health of their pregnancy, and the health of the offspring. Therefore, 

observational studies are necessary to determine associations. Although our systematic review 

included large numbers of studies that took advantage of large databases and longitudinal data 

that allowed investigation of the influence of weight gain on short- and long-term outcomes, it 

yielded very little in the way of consistent findings because the body of research lacks 

methodological rigor, precision, and directionality. 

Major shortcomings in the existing research include the lack of uniformity in definitions of 

the exposure and outcomes, lack of structured and transparent approaches for assessing 

confounders and effect modification, lack of power to detect meaningful differences, and 

inadequate approaches for assessing multiple outcomes related to gestational weight gain for the 

mother and child. Many studies also failed to provide a conceptual model that accounted for 

physiological processes. A comprehensive conceptual model with biological underpinnings 

would have allowed for the identification of preexisting maternal conditions that could confound 

the relationship between weight gain during pregnancy and outcomes such as gestational 

diabetes, pregnancy-induced hypertension, and newborn weight. 

Another major shortcoming of the existing research is that many of the retrospective cohorts 

reported on populations preceding the obesity epidemic in this country. In addition, the IOM 

recommendations are imprecise with respect to overweight and obese women. The obese 

population deserves special attention because they are likely to enter pregnancy with numerous 

coexisting conditions or problems; they are also more likely to develop complications in 

pregnancy such as gestational diabetes, pregnancy-induced hypertension, preeclampsia, and 

delivery by cesarean section. 

To address methodological issues future studies should: 

• State when and how baseline pregravid weight and height are determined; 

• When weight is self-reported, check for biological plausibility; 

• State when and how weight gain is determined; 

• Specify when and how postpartum weight is determined; 
211

• Report on how outliers in pregravid weight, gestational weight gain, postpartum weight, 

and maternal height are handled; 

• Standardize definitions regarding rates of weight gain, adequacy of rate of weight gain, 

and total weight gain; 

• Standardize definitions of key confounders and effect modifiers, with more attention 

directed to disease states that affect both weight gain and pregnancy and neonatal 

outcomes; and 

• Use more specific categories of BMI status for women categorized as obese (for example, 

using NIH categories such as obese class I, II, and III). 

Most of the reviewed studies relied on self-reported pregravid weight and argued that this is 

an acceptable surrogate for prepregnancy measurement because it has been demonstrated in 

some populations to be reliable. That reliability needs to be studied for women of varying 

pregravid weights; it also needs to be studied relative to when it is asked in gestation (e.g., early 

first trimester, second trimester, or at delivery). Without a thorough understanding of the 

reliability of self-reported weights in and beyond pregnancy for all women and for 

subpopulations of women by age, BMI, and race or ethnicity, calculations for total weight gain 

may well lead researchers to conclusions supported by the data but not by actual weight changes. 

Such errors in calculations could easily lead to erroneous or missed associations. Thus, studies 

that assess the magnitude of this error are urgently needed. 

We identified the following areas for further studies: 

• Exploration of whether women receive accurate weight gain guidance by their prenatal 

clinicians; whether clinicians have the knowledge, attitudes, and skills necessary to 

provide appropriate weight gain guidance 

• The knowledge, attitudes, and self-efficacy of women regarding gestational weight gain 

• The impact of weight gain on lactation performance in order to differentiate biologic and 

psychologic reasons for discontinuation of breastfeeding 

• The impact of age (younger and older) on the relationship of weight gain and pregnancy 

outcomes 

• The impact of menarchal age on the relationship of weight gain and pregnancy outcomes 

• The impact of parity on the relationship of weight gain and pregnancy outcomes 

• Genetic influences of the relationship between weight gain and pregnancy outcomes 

• The effect, over time, of gestational weight gain on women’s health status 

• The interaction of stature and weight gain 

• Tests of the reliability of self-reported weights in pregnancy by age, parity, and BMI 

• The impact of total weight gain vs. rate of weight gain vs. timing of weight gain on 

pregnancy outcomes 

• Tests of the use of direct measurements of body fat prior to and during pregnancy as well 

as in the postpartum period 

• Preferred anthropometric measurements for predicting outcomes of interest 

• The effect of gestational weight gain on infant (beyond birthweight) and childhood 

outcomes 

• Determination of optimal weight gains for obese women 
212

In addition, more research is needed to evaluate the long-term impact of specific amounts of 

weight gain. This research will require significant funding because following longitudinal 

cohorts is crucial. Scandinavian countries report on longitudinal cohorts, but findings from these 

studies lack reasonable generalizability to the United States, which has a far more diverse 

population, a different prevalence of obesity, possibly different norms about the acceptability of 

obesity, and a different structure for health care delivery. 

Finally, we emphasize the need for the use of far better research methods than the existing 

body of evidence reflects. Clearly the field has improved over time in the use of analytical 

approaches; more recent studies have taken into consideration some of the flaws in previous 

work. Investigators should make use of checklists to improve the quality of reporting of 

observational studies, such as STROBE,189 to ensure that the design and conduct of their work 

meets contemporary standards for publication. 
213

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18 months after childbirth: a pilot study. J 

Obstet Gynecol Neonat Nurs. 1996;25(1):39-

48. 

173. Keppel KG, Taffel SM. Pregnancy-related 

weight gain and retention: implications of the 

1990 Institute of Medicine guidelines. Am J 

Pub Health.83(8):1100-3. 

174. Rooney BL, Schauberger CW. Excess 

pregnancy weight gain and long-term obesity: 

one decade later. Obstet Gynecol. 2002 

Aug;100(2):245-52. 

175. Olson CM, Strawderman MS, Hinton PS, 

Pearson TA. Gestational weight gain and 

postpartum behaviors associated with weight 

change from early pregnancy to 1 y 

postpartum. Int J Obes Relat Metab Disord. 

2003 Jan;27(1):117-27. 

176. Rooney BL, Schauberger CW, Mathiason 

MA. Impact of perinatal weight change on 

long-term obesity and obesity-related 

illnesses. Obstet Gynecol. 2005;106(6):1349-

56. 

177. Gunderson EP, Abrams B, Selvin S. The 

relative importance of gestational gain and 

maternal characteristics associated with the 

risk of becoming overweight after pregnancy. 

Int J Obes Relat Metab Disord. 2000 

Dec;24(12):1660-8. 

178. Larciprete G, Valensise H, Vasapollo B, 

Altomare F, Sorge R, Casalino B, et al. Body 

composition during normal pregnancy: 

reference ranges. Acta Diabetol. 2003 Oct;40 

Suppl 1:S225-32. 

179. Sohlstrom A, Wahlund LO, Forsum E. Total 

body fat and its distribution during human 

reproduction as assessed by magnetic 

resonance imaging. Basic Life Sci. 

1993;60:181-4. 

180. Paxton A, Lederman SA, Heymsfield SB, 

Wang J, Thornton JC, Pierson RN, Jr. 

Anthropometric equations for studying body 

fat in pregnant women. Am J Clin Nutr. 1998 

Jan;67(1):104-10. 

181. Jovanovic-Peterson L, Crues J, Durak E, 

Peterson CM. Magnetic resonance imaging in 

pregnancies complicated by gestational 

diabetes predicts infant birthweight ratio and 

neonatal morbidity. Am J Perinatol. 1993 

Nov;10(6):432-7. 

182. Bartha JL, Marin-Segura P, GonzalezGonzalez NL, Wagner F, Aguilar-Diosdado 

M, Hervias-Vivancos B. Ultrasound 

evaluation of visceral fat and metabolic risk 

factors during early pregnancy. Obesity 

(Silver Spring). 2007 Sep;15(9):2233-9. 

183. Williamson DF, Madans J, Anda RF, 

Kleinman JC, Giovino GA, Byers T. Smoking 

cessation and severity of weight gain in a 

national cohort. N Engl J Med. 1991 Mar 

14;324(11):739-45. 

184. Viswanathan M, Visco AG, Hartmann K, 

Wechter ME, Gartlehner G, Wu JM, et al. 

Cesarean delivery on maternal request. Evid 

Rep Technol Assess (Full Rep). 2006 

Mar(133):1-138. 

185. Carpenter MW, Sady SP, Sady MA, Haydon 

B, Coustan DR, Thompson PD. Effect of 

maternal weight gain during pregnancy on 

exercise performance. J Appl Physiol. 1990 

Mar;68(3):1173-6. 
223

186. Johnston CS, Christopher FS, Kandell LA. 

Pregnancy weight gain in adolescents and 

young adults. J Am Coll Nutr. 1991 

Jun;10(3):185-9. 

187. Groth S. Are the Institute of Medicine 

recommendations for gestational weight gain 

appropriate for adolescents? J Obstet Gynecol 

Neonatal Nurs. 2007 Jan-Feb;36(1):21-7. 

188. Cedergren MI. Optimal gestational weight 

gain for body mass index categories. Obstet 

Gynecol. 2007 Oct;110(4):759-64. 

189. von Elm E, Altman DG, Egger M, Pocock SJ, 

Gotzsche PC, Vandenbroucke JP. The 

Strengthening the Reporting of Observational 

Studies in Epidemiology (STROBE) 

statement: guidelines for reporting 

observational studies. J Clin Epidemiol. 2008 

Apr;61(4):344-9. 
Appendixes
Search Strategy 

Focused Search 1: November 2006 

#3 Search "Weight Gain"[MeSH] 12977

#7 Search "Pregnancy"[MeSH] OR "Postpartum Period"[MeSH] 583182

#9 Search #3 AND #7 1939

#10 Search gestational weight gain 1694

#11 Search #9 OR #10 3130

#12 Search #9 OR #10 Limits: English, Humans 1681

#15 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Pregnancy 

Outcome"[MeSH]) OR "Outcome and Process Assessment (Health 

Care)"[MeSH] Limits: English, Humans 

287919

#16 Search #12 AND #15 Limits: English, Humans 297

#17 Search "Pregnancy Outcome"[MeSH]) Limits: English, Humans 19056

#18 Search #12 AND #17 Limits: English, Humans 255

#19 Search ("Weight Gain/ethnology"[MeSH] OR "Weight 

Gain/genetics"[MeSH]) Limits: English, Humans 

97

#20 Search #12 AND #19 Limits: English, Humans 21

#22 Search "Socioeconomic Factors"[MeSH] Limits: English, Humans 154168

#23 Search #12 AND #22 Limits: English, Humans 183

#27 Search "Body Weight"[MeSH] OR "Body Mass Index"[MeSH] Limits: 

English, Humans 

125469

#28 Search #12 AND #27 Limits: English, Humans 1438

#29 Search #28 AND #15 Limits: English, Humans 257

#31 Search "Obesity"[MeSH] Limits: English, Humans 49340

#32 Search "Obesity"[MeSH] Limits: All Adult: 19+ years, English, 

Female, Humans 

22784

#33 Search #32 AND #12 Limits: All Adult: 19+ years, English, Female, 

Humans 

131

#36 Search #9 OR #10 Limits: English, Publication Date from 1990, 

Humans 

1453

#38 Search "United States"[MeSH] Limits: English, Publication Date from 

1990, Humans 

364130

#39 Search #38 AND #36 Limits: English, Publication Date from 1990, 

Humans 

135
#42 Search iom 682

#43 Search #42 AND #12 19

#45 Search #43 OR #39 Limits: English, Publication Date from 1990, 

Humans 

150

#47 Search ("Counseling"[MeSH] OR "Directive Counseling"[MeSH]) 

Limits: English, Publication Date from 1990, Humans 

11733

#48 Search #47 AND #12 Limits: English, Publication Date from 1990, 

Humans 

13

#53 Search "Body Weights and Measures/instrumentation"[MeSH] Limits: 

English, Publication Date from 1990, Humans 

13

#54 Search Body Weights and Measures[MeSH] 275772

#55 Search #12 AND #54 1030

#66 Search Anthropometry [mh] 70445

#67 Search #55 AND #66 350

KQ1: OUTCOMES 

#3 Search "Weight Gain"[MeSH] 12977

#7 Search "Pregnancy"[MeSH] OR "Postpartum Period"[MeSH] 583182

#9 Search #3 AND #7 1939

#10 Search gestational weight gain 1694

#11 Search #9 OR #10 3130

#12 Search #9 OR #10 Limits: English, Humans 1681

#15 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Pregnancy 

Outcome"[MeSH]) OR "Outcome and Process Assessment (Health 

Care)"[MeSH] Limits: English, Humans 

287919

#16 Search #12 AND #15 Limits: English, Humans 297

#17 Search "Pregnancy Outcome"[MeSH]) Limits: English, Humans 19056

#18 Search #12 AND #17 Limits: English, Humans 255

 

KQ2: SES 

#19 Search ("Weight Gain/ethnology"[MeSH] OR "Weight 

Gain/genetics"[MeSH]) Limits: English, Humans 

97

#20 Search #12 AND #19 Limits: English, Humans 21

#22 Search "Socioeconomic Factors"[MeSH] Limits: English, Humans 154168

#23 Search #12 AND #22 Limits: English, Humans 183
KQ3: IOM Guidelines 

#27 Search "Body Weight"[MeSH] OR "Body Mass Index"[MeSH] Limits: 

English, Humans 

125469

#28 Search #12 AND #27 Limits: English, Humans 1438

#29 Search #28 AND #15 Limits: English, Humans 257

#31 Search "Obesity"[MeSH] Limits: English, Humans 49340

#32 Search "Obesity"[MeSH] Limits: All Adult: 19+ years, English, 

Female, Humans 

22784

#33 Search #32 AND #12 Limits: All Adult: 19+ years, English, Female, 

Humans 

131

#36 Search #9 OR #10 Limits: English, Publication Date from 1990, 

Humans 

1453

#38 Search "United States"[MeSH] Limits: English, Publication Date from 

1990, Humans 

364130

#39 Search #38 AND #36 Limits: English, Publication Date from 1990, 

Humans 

135

#42 Search iom 682

#43 Search #42 AND #12 19

#45 Search #43 OR #39 Limits: English, Publication Date from 1990, 

Humans 

150

KQ4: Recommendations 

#47 Search ("Counseling"[MeSH] OR "Directive Counseling"[MeSH]) 

Limits: English, Publication Date from 1990, Humans 

11733

#48 Search #47 AND #12 Limits: English, Publication Date from 1990, 

Humans 

13

KQ5: Tools 

#53 Search "Body Weights and Measures/instrumentation"[MeSH] Limits: 

English, Publication Date from 1990, Humans 

13

#54 Search Body Weights and Measures[MeSH] 275772

#55 Search #12 AND #54 1030

#66 Search Anthropometry [mh] 70445

#67 Search #55 AND #66 350
Focused Search 2: February 2007 

#2 Search "Weight Gain"[MeSH] = 13220 

#5 Search pregnancy [mesh] = 577647 

#6 Search #2 AND #5 = 1808 

#7 Search gestational weight gain = 1725 

#8 Search #6 OR #7 = 3023 

#9 Search #6 OR #7 Limits: English, Humans = 1696 

#15 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Outcome and Process 

Assessment (Health Care)"[MeSH] OR "Pregnancy Outcome"[MeSH]) OR 

"Reproductive History"[MeSH] OR "birth outcomes" OR "infant health outcomes" 

OR "maternal health outcomes Limits: English, Humans = 332914 

#16 Search #9 AND #15 Limits: English, Humans = 474 

#19 Search ("Counseling"[MeSH] OR "Directive Counseling"[MeSH]) = 23091 

#20 Search #9 AND #19 = 12 

#25 Search "Body Weights and Measures"[MeSH] = 279399 

#26 Search #9 AND #25 = 1044 

#29 Search "Anthropometry"[MeSH] = 71849 

#30 Search #26 AND #29 = 359 

CINAHL 

DE= Weight gain – in pregnancy = 253 

63 duplicates 

190 new records 

COCHRANE = 4 records, already in database 

EMBASE = 18 records, 8 new 

Total unduplicated database = 913 
Focused Search 3: March 2007 

Same search as Focused Search 1 using Cochrane, CINAHL 

Focused Search 4: June 2007 

#1 Search pregnancy 620141 

#2 Search height OR weight OR BMI OR "body mass index" OR skinfolds 

OR circumferences OR BIA OR "body impedance analyzer" OR 

ultrasound OR DEXA OR UWW OR "underwater weighing" OR "BOD 

POD" OR CT OR MRI 

1369412 

#3 Search #1 AND #2 103432 

#4 Search #1 AND #2 Limits: Humans, English 66133 

#5 Search #1 AND #2 Limits: Publication Date from 1990, Humans, English, 

All Adult: 19+ years 

24044 

#6 Search BMI OR "body mass index" OR skinfolds OR circumferences OR 

BIA OR "body impedance analyzer" OR ultrasound OR DEXA OR 

UWW OR "underwater weighing" OR "BOD POD" OR CT OR MRI 

Limits: Publication Date from 1990, Humans, English, All Adult: 19+ 

years 

247723 

#7 Search #5 AND #6 Limits: Publication Date from 1990, Humans, English, 

All Adult: 19+ years 

15336 

________________________________________________________________________ 

#4 Search ("Pregnancy/physiology"[Majr]) AND ("Weight Gain"[Mesh]) 379 

#7 Search ("Adipose Tissue/anatomy and histology"[Mesh]) 14707 

#8 Search #4 AND #7 14 

#9 Search ("Pregnancy/physiology"[Majr]) AND ("Weight Gain"[Mesh]) 

Limits: Publication Date from 1990, Humans, English, All Adult: 19+ years 

148 
Focused Search 5: October 2007 

#1 Search "Weight Gain"[MeSH] AND pregnancy [mesh] 1889 

#2 Search gestational weight gain 1812 

#3 Search #1 OR #2 3160 

#4 Search #1 OR #2 Limits: added to PubMed in the last 1 year, Humans, 

English 

98 

#5 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Outcome and 

Process Assessment (Health Care)"[MeSH] OR "Pregnancy 

Outcome"[MeSH]) OR "Reproductive History"[MeSH] OR "birth 

outcomes" OR "infant health outcomes" OR "maternal health outcomes" 

395351 

#6 Search #4 AND #5 26 

#7 Search ("Counseling"[MeSH] OR "Directive Counseling"[MeSH]) 23918 

#8 Search #4 AND #7 1 

#9 Search "Body Weights and Measures"[MeSH] 

AND"Anthropometry"[MeSH] 

42873 

#10 Search #4 AND #9 34 

#11 Search ("Pregnancy/physiology"[Majr]) AND ("Weight Gain"[Mesh]) 

AND ("Adipose Tissue/anatomy and histology"[Mesh]) 

14 

#12 Search ("Pregnancy/physiology"[Majr]) AND ("Weight Gain"[Mesh]) 

AND ("Adipose Tissue/anatomy and histology"[Mesh]) Limits: added to 

PubMed in the last 1 year, Humans, English 

0 

CINAHL 

DE= Weight gain – in pregnancy = 36 

Duplicates = 18 

new records = 18 

COCHRANE = 1 records 

EMBASE = 5 records 

Duplicates = 1 

New records = 4 

58 new records 

Total unduplicated database = 1024 
B-1

Appendix B. Sample Data Collection Forms
Systematic Review of Maternal Weight Gain

Abstract Review Form 

First Author, Year: ______________ Endnote:_________ 

Abstractor Initials: ______________ 

Primary Inclusion/Exclusion Criteria 

1. Original research 

 (Exclude editorials, commentaries, letters 

to editor, reviews, etc.) 

Yes No Cannot 

Determine 

2. Study published between January 1990 and 

February 2007 

Yes No Cannot 

Determine 

3. Study published in English Yes No Cannot 

Determine 

4. Is this study located in a developed nation? 

 (US, Canada, Western Europe, Japan, New 

Zealand, Australia) 

Yes No Cannot 

Determine 

5. Eligible Study type 

 (Include RCTs, cohorts with comparisons, and 

case-controls with N40, case-series with 

N100) 

a. ___RCT (N =_____) 

b. ___Cohorts with comparison (N =_____) 

c. ___Case-control (N =_____) 

d. ___Case series (N =_____) 

Yes No Cannot 

Determine 

 

6. Applies to research topic 

 (if not select one of the following 

reasons): 

a. ___Basic science 

b. ___ Not “maternal weight gain” 

Yes No Cannot 

Determine 

7. Entirely or mostly singleton births Yes 

No 

(100% 

multifetal)

Cannot 

Determine 

Retain for (include meta-analyses and systematic reviews here as appropriate): 

 _____BACKGROUND/DISCUSSION 

 _____REVIEW OF REFERENCES 

_____Other 

COMMENTS:
Reviewing

Reviewing at Level 1

SRS has detected that you may be not need to fill this form out. It has already been completed by 2 users and is currently being worked on 

by 0 other users. It only needs to be reviewed by 2 users therefore your input may be redundant. 

Click here to skip to the next one

Refid: 1, Birenbaum, H. J., M. A. Pane, S. M. Helou and K. P. Starr, Comparison of a restricted transfusion schedule with erythropoietin therapy versus 

a restricted transfusion schedule alone in very low birth weight premature infants, South Med J, 99(10), 2006, p. 1059-62

State: Excluded, Level: 1

Abstract Review

Keywords:

Anemia, Neonatal/blood/ prevention & control 

Increase Font Size

Decrease Font Size

Abstract:

OBJECTIVE: Erythropoietin (EPO) is commonly used in 

very low birth weight neonates to minimize blood 

transfusions during hospitalization. Data are limited 

comparing the use of EPO along with a restricted 

transfusion schedule versus a restricted transfusion 

schedule alone. We compared the effects of a restricted 

transfusion schedule with EPO versus a restricted 

transfusion schedule alone during two consecutive 6-

month periods. METHODS: In period I, infants born at <30 

weeks gestational age (GA) or <1,500 g birth weight (BW)

were treated prophylactically for six weeks with EPO 1,000 

U/kg/wk in three divided doses and blood transfusions 

were given using a restricted transfusion schedule. This 

was the called the EPO Group. In period II, a restricted 

transfusion schedule was utilized, but EPO was not 

administered. This constituted the No EPO Group. No 

other changes in clinical practice were introduced in either 

period. RESULTS: There were 30 neonates in the EPO 

Group and 20 in the No EPO Group. There were no 

significant differences in sex, race, mean birth weight 

(1,074 +/- 283 versus 965 +/- 330 g), mean gestational age 

(28.9 +/- 2.96 versus 27.8 +/- 2.86 wks), 5 minute Apgar 

score (7.8 +/- 1.2 versus 7.6 +/- 1.1), or mean hematocrit 

(48.2% +/- 6.05 versus 48.6% +/- 6.31) at admission. 

There were no significant differences in the total number of 

transfusions between the two periods. In the EPO Group, 

8/30 patients received 27 transfusions. Six transfusions 

violated guidelines based on hematocrit level. EPO was 

discontinued in three infants secondary to treatmentrelated neutropenia. There were two deaths unassociated 

with EPO treatment. Excluding deaths, 6 patients received 

16 transfusions. In the No EPO Group, 8/20 patients 

received 13 transfusions. Two transfusions violated 

guidelines based on hematocrit. There were three deaths 

and one patient transfer. Excluding these four patients, 6 

infants received 11 transfusions (P < or = 1.) Among 

survivors, there were no significant differences in mean 

total length of stay (49.3 +/- 22.7 versus 53.2 +/- 26.4 d), 

mean discharge weight (2,144 +/- 405 versus 2,358 +/- 458 

g), or average weight gain/d (20.7 +/- 5.44 versus 22.6 +/-

6.81 g), between the two groups respectively, nor were 

there significant differences when all babies were included 

in the analysis. There was a significant difference in mean 

hematocrit at discharge, respectively, (38.3% +/- 6.84 

31 4% +/ 6 26 P 0 003) i i

Submit Data

1. Original research (no review articles, editorials, letters to the editor or commentaries)? 

nmlkji Yes

nmlkj No

nmlkj Cannot determine

Clear Selection

2. Study published after January 1, 1990? 

nmlkji Yes

nmlkj No

nmlkj Cannot determine

Clear Selection

3. Study published in English? 

nmlkj Yes

nmlkj No

nmlkji Cannot determine

Clear Selection

4. Study conducted in a developed nation? (for example- US, Canada, western Europe, 

Japan, New Zealand, Australia) 

nmlkj Yes

nmlkj No- if not then where?

nmlkji Cannot determine

Clear Selection

5. Study design is one of the following: 

nmlkj RCT

nmlkji Cohort studies N => 40

nmlkj Case control with N => 40

nmlkj Case series N => 100

nmlkj Cross sectional N => 100

nmlkj None of the above- so exclude

None of the above- but include (please provide 

explanation)

nmlkj

nmlkj Cannot determine

Clear Selection

6. Entirely or mostly singleton births? 

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nmlkj Yes

nmlkj No (100% multi-fetal)

nmlkji Cannot determine

Clear Selection

7. Applies to research topic of maternal weight gain or the measurement body fat? 

nmlkj Yes

No- not maternal weight gain or the measurement of 

body fat

nmlkji

nmlkj No - "basic science"

nmlkj No - other (please elucidate)

nmlkj Cannot determine

Clear Selection

8. Article should be marked and saved for background but not abstracted (This question 

is optional). 

nmlkj Yes

nmlkji No

nmlkj Cannot determine

Clear Selection

9. Population 

100% healthy populations or mix of healthy 

populations and "nonhealthy" populations

nmlkj

100% populations with health conditions (ie. drug 

abuse or diabetes) Please define -

nmlkj

Clear Selection

Submit Data

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Reviewing

Reviewing at Level 2

Refid: 1611, Jain, N. J., C. E. Denk, L. K. Kruse and V. Dandolu, Maternal obesity: can pregnancy weight gain modify risk of selected adverse 

pregnancy outcomes?, Am J Perinatol, 24(5), 2007, p. 291-8

State: Ok, Level: 2

Full-Text Review

Save to finish later Submit Data

1. Article is concerned with topics relevant to maternal weight gain or the measurement of body fat? 

nmlkj Yes

nmlkj No- so exclude

Clear Selection

2. Should the article be excluded for any of the following general reasons?

gfedc Article should be excluded because (pick at least one of the following options)

gfedc n < 40 for comparisons including cohort studies 

gfedc n < 100 for case-series

gfedc Not published in english

gfedc Wrong publication type (e.g. letter, commentary or editorial)

gfedc Wrong design - please explain

gfedc Includes only a population w/ a pre-existing condition - please list condition

gfedc 100% multi-fetal

gfedc Published before 1990

gfedc Study not conducted in a developed nation? (Please provide country name)

gfedc Study reported as an abstract only

gfedc Not related to key questions

gfedc Other reason- please explain briefly

gfedc None of the above- should be included!

3. Regardless of inclusion/exclusion status, article should be retained for background. 

nmlkj Yes

nmlkj No

Clear Selection

4. Which of the following key questions are addressed by the article

KQ1 What is the evidence that either total weight gain or rate of weight gain during pregnancy is associated with: (1) birth outcomes, (2) infant health 

outcomes, and (3) maternal health outcomes?

gfedc

KQ2 What are the confounders and effect modifiers in examining the association between maternal weight gain (overall and patterns) and birth 

outcomes?

gfedc

KQ3 What is the evidence that weight gain above or below thresholds defined in the 1990 Institute of Medicine BMI Guidelines or weight loss in 

pregnancy contribute to ante-partum or post-partum complications, or longer-term maternal and fetal complications?

gfedc

KQ4 What are the harms or benefits of offering the same weight gain recommendations to all pregnant women, irrespective of age and body weight 

considerations (e.g., pregravid weight, actual body weight at a particular time point, or optimal body weight)?

gfedc

gfedc KQ5 What are the anthropometric tools for determining adiposity and their appropriateness for the pregnancy state?

gfedc None of the above so exclude!

5. If study addresses KQ 1-4 it must include pre-pregnancy weight or BMI measures. 

nmlkj Pre-pregnancy weight or BMI is not in article so exclude

nmlkj Include!

Clear Selection

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Form Last Modified: Not available

6.

If article addresses KQ 3 it must includes the IOM guidelines.

nmlkj No IOM guidelines so exclude

nmlkj Include!

Clear Selection

Save to finish later Submit Data

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Reviewing

Reviewing at Level 3

Reviewer Comments ( Add a Comment )

Refid: 127, Joseph, K. S., D. C. Young, L. Dodds, C. M. O'Connell, V. M. Allen, S. Chandra and A. C. Allen, Changes in maternal characteristics and 

obstetric practice and recent increases in primary cesarean delivery, Obstet Gynecol, 102(4), 2003, p. 791-800

State: Ok, Level: Abstraction form, KQ5

Abstraction

Save to finish later Submit Data

1. First author et. al, year 

Enlarge Shrink 

2. Country and setting 

If more than a couple of countries are included just call it multinational.

Settings include primary care, hospitals, university clinics, doctors offices, nursing home, multicenter etc. 

Enlarge Shrink 

3. Source of funding to conduct study: 

gfedc Pharmaceutical company or other commercial source- please list name.

gfedc Government or non-profit organization- please list name.

gfedc Not reported

4. Research objective (Please be brief and concise): 

Enlarge Shrink 

5. Which of the following key questions are addressed by the article

gfedc KQ1 What is the evidence that either total weight gain or rate of weight gain during pregnancy is associated with: (1) birth outcomes, (2) infant health o

gfedc KQ2 What are the confounders and effect modifiers in examining the association between maternal weight gain (overall and patterns) and birth outcom

KQ3 What is the evidence that weight gain above or below thresholds defined in the 1990 Institute of Medicine BMI Guidelines or weight loss in pregna

maternal and fetal complications?

gfedc

KQ4 What are the harms or benefits of offering the same weight gain recommendations to all pregnant women, irrespective of age and body weight co

or optimal body weight)?

gfedc

gfedc KQ5 What are the anthropometric tools for determining adiposity and their appropriateness for the pregnancy state?

gfedc None of the above so exclude!

6. Article reports on an observational study, check the applicable box - 

nmlkj Case series

nmlkj Cohort

nmlkj Case-control

SRS Form Page 1 of 10

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nmlkj Cross-sectional

nmlkj Other observational 

nmlkj No, not an observational study

Clear Selection

7. Observational study isnmlkj Prospective

nmlkj Retrospective

nmlkj Combination, please explain

nmlkj Other, please explain!

Clear Selection

8. Article reports on a RCT or meta-analysis, check appropiate box. 

nmlkj RCT

nmlkj Meta-analysis

nmlkj Other controlled study design, please explain

nmlkj No, it is not a controlled trial

Clear Selection

9. Overall study n = 

Enlarge Shrink 

10. Duration of study? 

Enlarge Shrink 

11. How was pregravid weight collected? 

gfedc Self-reported

gfedc Measured by study investigators

gfedc Routine pre-natal care

gfedc Other- please explain!

gfedc Not reported

12. How was pregravid height collected? 

gfedc Self-reported

gfedc Measured by study investigators

gfedc Routine pre-natal care

gfedc Other- please explain!

gfedc Not reported

13. Was BMI imputed? 

nmlkj Yes

nmlkj No

Clear Selection

14. How was BMI categorized? 

SRS Form Page 2 of 10

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gfedc Continuous

gfedc IOM guidelines

gfedc WHO International Taskforce

gfedc Other- please define

gfedc Not reported

15. Are any other anthrometric measures collected? 

nmlkj Yes

nmlkj No

Clear Selection

16. How were weight gain measurements categorized? 

gfedc Continuous

gfedc Quartiles

gfedc According to IOM

gfedc Other - please define

17. How were weight gain measurements collected? 

gfedc Self-reported

gfedc Collected by study investigators

gfedc Routine pre-natal care or maternity records

gfedc Other - define or explain

18. How was total weight gain ascertained? 

gfedc Self-reported

gfedc Based on last clinically measured weight prior to delivery

gfedc Other- please explain!

gfedc Not reported

19. Inclusion criteria 

Enlarge Shrink 

20. Exclusion criteria 

Enlarge Shrink 

Baseline Characteristics

Group 1 Group 2 Group 3 G

21. Groups - if only one group please put in 

first column 

22. # in group (n):

23. Mean age (years):

24. Weight at baseline (lbs or kgs)

25. BMI at baseline

SRS Form Page 3 of 10

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26. Parity (mean):

27. Race (% white):

28. Race (% black):

29. Race (% hispanic):

30. Race (% Asian and/or Pacific region 

origins):

31. Race (% other):

32. Smoking (%):

33. Gestational diabetes mellitus (%):

34. Hypertension (%):

35. Additional characteristics:

36. Additional characteristics:

37. Additional characteristics:

Outcomes

38. How was post-partum weight collected? 

gfedc Self-reported

gfedc Measured by study investigators

gfedc Routine care

gfedc Other- please explain!

gfedc Not reported

39. What type of statistical analysis was used? Check all that apply. 

gfedc Bivariate

gfedc Multivariate

gfedc Risk ratios

gfedc Odds ratios

gfedc ANOVA

gfedc Other- please explain

40. If relevant, define comparison or reference group. 

Enlarge Shrink 

Outcomes- primarily bivariate

Group 1 Group 2 Group 3 G

41. Groups - if only one group please put in 

first column. With intervention include pvalues for example, (P < 0.05). 

42. # in group (n):

43. Birthweight (lbs or kgs):

44. Maternal weight gain:

45. Gestational diabetes (%):

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46. Caeserian delivery (%):

47. Use of episiotomy:

48. Instrumental delivery (%):

49. Additional maternal outcomes of interest- please be brief! 

Enlarge Shrink 

50. Additional infant outcomes of interest- please be brief! 

Enlarge Shrink 

51. Maternal confounders accounted for in analysis: 

gfedc Age

gfedc Race

gfedc Parity

gfedc Pre-gravid BMI

gfedc GDM

gfedc Pregnancy induced hypertension

gfedc Pre-eclampsia

gfedc Eclampsia

gfedc C-section

gfedc Post-partum weight retntion

gfedc Lactation/ Breast feeding (Which one?)

gfedc Obesity (How defined or categorized?)

gfedc Type 1 Diabetes or pre-existing Type 2 Diabetes

gfedc CVD

gfedc Cancer

gfedc Others- please list

gfedc Smoking

gfedc Pre-existing hypertension

52. Infant and child confounders accounted for in analysis: 

gfedc Pre-term birth

gfedc Gestational age

gfedc Birth weight

gfedc SGA

gfedc LGA

gfedc Birth length

gfedc Child weight/height

gfedc Childhood obesity

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gfedc Childhood diabetes (Type 1)

gfedc Child with CVD

gfedc Child's blood pressure

gfedc Others- please list

53. More outcomes- mostly multivariate!

Enlarge Shrink 

Category or confounder Group 1 Group 2 Group 3 G

54. Groups - if 

only one 

group please 

put in second 

column

following

confounder. If 

result is an 

odds

ratio (95% CI) 

should be 

included.

gfedc

55. # in group 

(n): gfedc

56.

Confounder:

57.

Confounder:

58.

Confounder:

59.

Confounder:

60.

Confounder:

61.

Confounder:

62.

Confounder:

63.

Confounder:

64.

Confounder:

65.

Confounder:

66.

Confounder:

Additional outcomes

Characteristic Group 1 Group 2 Group 3 G

67.

Outcomes - if 

only

one outcome

please put in 

second

column

following

characteristic

column. If 

result is an 

odds

ratio (95% CI) 

gfedc

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should be 

included.

68. # in group 

(n): gfedc

69.

Characteristic:

70.

Characteristic:

71.

Characteristic:

72.

Characteristic:

73.

Characteristic:

74.

Characteristic:

75.

Characteristic:

76.

Characteristic:

77.

Characteristic:

78.

Characteristic:

79.

Characteristic:

80. Is study generalizable? 

nmlkj Yes - why?

nmlkj No- why not?

nmlkj Can't tell...

Clear Selection

Quality Review

81. Randomization adequate?

nmlkj Yes

nmlkj No

nmlkj Not randomized

nmlkj Method not reported

Clear Selection

82. Allocation concealment adequate?

nmlkj Yes

nmlkj No

nmlkj Not randomized

nmlkj Method not reported

Clear Selection

83. Groups similar at baseline?

nmlkj Yes

nmlkj No

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Clear Selection

84. Outcome assessors masked?

nmlkj Yes

nmlkj No

nmlkj Yes, but method not described

nmlkj Not reported

Clear Selection

85. Care provider masked?

nmlkj Yes

nmlkj No

nmlkj Yes, but method not described

nmlkj Not reported

Clear Selection

86. Patient masked?

nmlkj Yes

nmlkj No

nmlkj Yes, but method not described

nmlkj Not reported

Clear Selection

87. What was lost to follow-up (%)?

Enlarge Shrink 

88. How many dropped out (%)?

Enlarge Shrink 

89. Was the statistical analysis based on intention-to-treat (ITT)?

nmlkj Yes

nmlkj No

nmlkj Cannot tell

Clear Selection

90. Were there any post-randomization exclusions?

nmlkj Yes (how many?)

nmlkj No

nmlkj Cannot tell

Clear Selection

91. Quality rating for efficacy/effectiveness

gfedc Good

gfedc Fair

gfedc Poor

Why?

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92. Were both groups selected from the same source population?

nmlkj Yes

nmlkj No

nmlkj Yes, but method not described

nmlkj Not reported

Clear Selection

93. Did both groups have the same risk of having the outcome of interest at baseline?

nmlkj Yes

nmlkj No

nmlkj Not reported

Clear Selection

94. Were subjects in both groups recruited over the same time period?

nmlkj Yes

nmlkj No

nmlkj Yes, but method not described

nmlkj Not reported

Clear Selection

95. Was there any obvious selection bias?

nmlkj Yes

nmlkj No

nmlkj Not reported

Clear Selection

96. Were ascertainment methods adequate and equally applied to both groups?

nmlkj Yes

nmlkj No

nmlkj Not reported

Clear Selection

97. Was an attempt made to blind the outcome assessors?

nmlkj Yes

nmlkj No

nmlkj Yes, but method not described

nmlkj Not reported

Clear Selection

98. Was the time of follow-up equal in both groups?

nmlkj Yes

nmlkj No

nmlkj Not reported

Clear Selection

99. What was lost to follow-up (%)?

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Form Last Modified: Aug 20 2007 10:20AM

Enlarge Shrink 

100. How many dropped out (%)?

Enlarge Shrink 

101. Did the statistical analysis consider potential confounders or adjust for different lengths of follow-up?

nmlkj Yes

nmlkj No

nmlkj Yes, but method not described

nmlkj Not reported

Clear Selection

102. Was the length of follow-up adequate to assess the outcome of interest?

nmlkj Yes

nmlkj No

nmlkj Not reported

Clear Selection

103. Quality rating for observational studies

gfedc Good

gfedc Fair

gfedc Poor

Why?

104. Is the principle focus of this article maternal weight gain and associated outcomes 

gfedc Yes

gfedc No then limit abstraction to MWG and associated outcomes and the confounders and effect modifiers

105. Time frame? 

Enlarge Shrink 

Save to finish later Submit Data

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Evidence Table Template 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Country and setting: 

Enrollment period:

Funding: 

Study Objective: 

Time frame: 

Duration of the study: 

Design: 

Total Study N: 

Group Description: 

Group N: 

Inclusion criteria: 

Exclusion criteria: 



Pregravid weight: 

Pregravid BMI: 

Age (mean, yrs): 

Parity: 

Race,%: 

White 

Black

Hispanic 

Asian/Pacific Islander 

Other

Smoking,%: 

Diabetes mellitus,%: 

Hypertension,%: 

Additional characteristics: 
Evidence Table x 

Maternal Weight 

Gain

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized:

Collected from: 

Ascertained by: 



Birth weight: 

Gestational 

diabetes, %: 

Cesarean 

delivery,%: 

Instrumental

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

Other infant 

outcomes: 

Outcomes Description: 

Groups: 

Results: 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Background:

Sample

selection: 

Definition of 

maternal

weight gain: 

Definition of 

outcomes: 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Followup: 

Analysis 

comparability:

Analysis of 

outcomes: 

Interpretation:

Sum of 

Good/Fair/Poo

r:

Final Quality 

Score: 
Quality Rating Form 

(Items in yellow highlight not likely to be relevant for observational studies) 

1. Background/Context 

1.1. Provision of Background Information: 

Is the study presented in the context of prior research and/or clinical practice? 

Yes 

No

Partially/Somewhat

NA 

1.2. Problem/question clearly stated: 

Is the hypothesis/aim/objective of the study clearly described?1-3

Yes 

No

Partially/Somewhat

NA 

2. Sample Definition and Selection 

2.1. Retrospective/prospective: 

Is the study design prospective, retrospective, or mixed? Higher score for prospective 

Retrospective 

Prospective

Mixed

2.2. Inclusion/exclusion criteria: 

a. Are the inclusion/exclusion criteria explicitly stated? [May want to ask 

individually about unique criteria that are critically important.] 

Yes 

No

Partially/Somewhat

b. Were inclusion/exclusion criteria applied uniformly to all groups? 

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

Quality Rating Form: maternal weight gain 1
c. If prospective or mixed, were the pathways by which participants entered the 

study (recruitment strategy) clearly described? 

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

d. Are the characteristics of the participants included in the study clearly described? [In 

cohort studies and trials, inclusion and/or exclusion criteria should be given. In casecontrol studies, a case-definition and the source for controls should be given.]4

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

2.3. c. Was there a power analysis or some other basis noted for determining the 

adequacy of study group sizes?5

Yes 

No

NA (birth certificate or birth registry) 

2.4. Selected to be representative (External validity measure) 

a. Are the individuals selected to participate in the study likely to be representative 

of the target population? [selected from the relevant population, representative of 

whom results would be generalized]6,7

Very likely 

Somewhat likely 

Not likely 

Cannot determine 

NA 

 3. Interventions/exposure 

3.1. Clear specification 

a. Is weight gain or rate of weight gain clearly defined? 

Low (unclear, many details missing)

Medium (pretty clear, most details provided)

Very clear (all essential details provided)

Quality Rating Form: maternal weight gain 2
b. Does the description of the intervention/exposure adequately describe (list 

separately): setting, duration, frequency, intensity. 

Low (unclear, many details missing)

Medium (pretty clear, most details provided)

Very clear (all essential details provided)

c. Is the test reference standard (diagnostic test) clearly specified? 

Low (unclear, many details missing)

Medium (pretty clear, most details provided)

Very clear (all essential details provided)

d. Is there a clearly specified intervention protocol? 

Low (unclear, many details missing)

Medium (pretty clear, most details provided)

Very clear (all essential details provided)

3.2. Concurrent/concomitant treatment 

a. Is usual clinical care clearly described? 

Low (unclear, many details missing)

Medium (pretty clear, most details provided)

Very clear (all essential details provided)

3.4 Was pregravid weight checked for biological plausibility? 

Yes 

No

Not applicable (from first prenatal visit, or measured) 

3.5 Details on data cleaning (on outliers)? 

No information (unclear, many details missing)

Medium (pretty clear, most details provided)

Very clear (all essential details provided)

4. Outcomes 

4.1 Clear specification 

a. Are the primary outcomes clearly described?9

 [this can be asked for all outcomes 

together or each primary outcome can be listed separately] 

Quality Rating Form: maternal weight gain 3
Low (unclear, many details missing)

Medium (pretty clear, most details provided)

Very clear (all essential details provided)

c. Are study questions relevant to the key questions of the SER? This should be part 

of an applicability rating, not study quality. Should it be deleted? 

Yes 

Partially

No

5. Creation of treatment groups 

5.3. How allocation occurred 

a. Is assignment made to study groups randomly?5Yes/No

Yes 

No

b. Is an explicit case/comparison definition provided? 

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

c. Are the criteria for assignment to study groups clearly described? 

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

d. Is the selection of the non-exposed cohort appropriate?14 Drawn from the same 

community as the exposed cohort/Drawn from a different source or no 

description of the derivation of the non- exposed cohort 

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

Quality Rating Form: maternal weight gain 4
5.4. Any attempt to balance 

a. Any attempt to balance the allocation between the groups? /

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

5.7. Contamination 

a. Has the possibility of participants having received an unintended intervention 

that may influence results been reported and ruled out?14

Yes 

No

d. Was there variation from the protocol in relation to: duration, intensity, 

frequency, and/or setting sufficiently large to compromise the findings? 

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

e. Is the level of adherence adequate? 

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

f. Is the evaluation of adherence adequate?

Yes 

No

Partially/Somewhat

Cannot determine 

NA 

Quality Rating Form: maternal weight gain 5
6. Blinding 

6.1. Blind or double blind administration 

a. Is there blinding of study subjects? (Blinding may not be possible with some 

interventions.)

Yes, all arms 

Yes, some arms 

No

NA

b. Are those administering the intervention blinded to the study subject’s exposure 

status? Blinding may not be possible with some interventions. 

Yes 

No

NA

6.2. Blind outcomes assessment 

a. Are the outcome assessors blinded to the intervention or exposure status of 

participants?6,7

Yes 

No

NA

7. Soundness of information 

7.1. Source of information re interventions/exposure 

a. How was maternal weight gain or rate of weight gain obtained? 

All self report (poor) 

Combination of self report and measured by observer 

(fair)

All measured by observer, using pregravid weight 

or weight in first trimester and weight at last 

measurement before or at delivery (good)

7.2. Source of information re outcomes 

 Are the sources establishing the validity and reliability of outcome measures 

described or referenced?15,16 [may want to list important measures separately] 

Good

Quality Rating Form: maternal weight gain 6
Fair

Poor

8. Follow-up 

8.1 Equality of length of follow-up for participants 

 In trials and cohort studies, do the analyses adjust for different lengths of followup of patients, or in case-control studies, is the time period between the 

intervention and outcome the same for cases and controls?4

 [Where follow-up 

was the same for all study patients the answer is yes. If different lengths of 

follow-up were adjusted by, for example, survival analysis, the answer is yes. 

Studies where differences in follow-up are ignored should be answered no.] 

Yes 

No

Cannot determine

NA (cross-sectional) 

8.2. Length of followup adequate 

b. Is the length of followup sufficient to support the conclusions of the study? 

Yes 

No

NA (cross-sectional)

8.3. Completeness of followup 

 Are the reasons why study subjects were lost to follow-up adequately reported? 

Good

Fair

Poor

NA (cross-sectional or retrospective) 

9. Analysis comparability 

9.1 Assessment of baseline comparability by design 

b. Are the cohorts comparable through the design of the study? If not, does the 

analysis control for differences? 

Yes 

No

Cannot determine 

NA 

Quality Rating Form: maternal weight gain 7
c. For categorical variables, is the choice of control/non-exposure groups 

reasonable? Yes/No

Yes 

No

Partial/somewhat

NA 

9.2. Identification of prognostic factors 

a. Does the study adequately identify confounding and modifying variables? 

Gestational age at the time of weight measurement 

Gestational age at delivery 

Pregravid BMI 

Smoking 

Preexisting health condition (eating disorders, ??) 

Pregnancy complications (PIH, GDM) 

Parity

Age of mother 

Race 

SES or education (diet, physical, activity, access to medical care, proxy for other things) 

Weight retention confounders (diet, energy expenditure/exercise/return to work, 

breastfeeding, maternal illness, pregnancy) 

 [list measures] 

All

Some

None

b. Are the principal confounders in each group of subjects to be compared clearly 

described?4

 [A list of principal confounders is provided.] 

Yes 

No

Somewhat

Quality Rating Form: maternal weight gain 8
7.4. Source of information re confounders 

 Are the sources establishing the validity and reliability of confounders described 

or referenced?15,16 [may want to list important measures separately] 

Good (objective) 

Fair (self-report) 

Poor (not described)

9.3. Adjustment for confounding 

 Is there adequate adjustment in the analysis for confounding variables? Yes, No, 

Unable to determine

Yes 

No

Partially/somewhat

Unable to determine 

NA

10. Analysis outcome 

10.1. Intention-to-treat analysis 

a. Is intention-to-treat (ITT) analysis reported?17

Yes 

No

b. Are all enrolled subjects (patients and comparison groups) accounted for in 

follow-up?18

Yes 

No

Cannot determine 

NA 

c. Are all enrolled subjects accounted for in the follow-up through assessment of 

the impact of dropout rates, sensitivity analysis, or other intention-to-treat 

adjustment methods? 

Yes 

No

Cannot determine 

NA 

Quality Rating Form: maternal weight gain 9
d. Are subject withdrawals, lost to follow-up, and missing data adequately 

accounted for in the analysis? Inadequate/Adequate/Excellent/Unable to 

determine

Good

Fair

Poor/No

NA

Actual loss-to-followup or Missing data: 

Missing data:

10.2. Appropriate statistical methods 

a. Is the statistical approach for analyzing the data reported in sufficient detail so 

that reported results may be replicated?19

Yes 

No

Partially/somewhat

Unable to determine 

NA

b. Are the statistical methods used to assess the main outcome appropriate to the 

data?20,21 Yes/No/Unable to determine 

Yes 

No

Partially/Somewhat

i. Multivariate analysis 

Yes 

No

ii. For cohort studies only, if the outcome has a greater than 10 percent prevalence, is the 

risk ratio and relative risk calculated directly (not using logistic regression)? 

Yes 

No

For some outcomes 

NA 

Quality Rating Form: maternal weight gain 10
11. Interpretation 

11.1. Appropriately based on results 

a. Are results interpreted appropriately based on study design and statistical 

analysis (trends noted, precision of confidence intervals noted, statistical results 

are clearly differentiated)? 

Yes

No

Partially/somewhat

b. Are conclusions supported by results with possible bias and limitations taken into 

consideration?22

0 (poor, not 

defined 1 2 3 4

5

(excellent,

clearly

defined)

11.3. Application/implications 

Are the results generally applicable or limited to one particular healthcare delivery 

setting?5

General 

Limited 

11.4. Clinical importance and statistical significance 

a. Are the statistical findings presented in a manner that is clinically useful? 

Yes 

No

Somewhat

Are the statistical findings clinically useful? 

Yes 

No

Somewhat

11.5. Interpretation in context 

 Are study conclusions presented in the context of prior research? 

Yes 

No

Somewhat

Quality Rating Form: maternal weight gain 11
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Quality Rating Form: maternal weight gain 14

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D9.

23. Beach J, Rowe BH, Blitz S, Crumley E, Hooton N, Russell K, et al. Diagnosis and 

Management of Work-Related Asthma. Evidence Report/Technology Assessment No. 

129. (Prepared by the University of Alberta Evidence-based Practice Center, under 

Contract No. 290-02-0023.) AHRQ Publication No. 06-E003-2. Rockville, MD: Agency 

for Healthcare Research and Quality 2005. 

24. Shekelle P, Takata G, Chan L, Mangione-Smith R, Corley PM, Morphew T, et al. 

Diagnosis, Natural History, and Late Effects of Otitis Media with Effusion. Evidence 

Report/Technology Assessment No. 55 (Prepared by Southern California Evidence-based 

Practice Center under Contract No 290-97-0001, Task Order No. 4). AHRQ Publication 

No. 03-E023. Rockville, MD: Agency for Healthcare Research and Quality 2003. 
Appendix C. Evidence Tables 
C-1 

Glossary 

adj adjusted 

AGA appropriate for gestational age 

AOR adjusted odds ratio? 

bf body fat 

BF breast feeding 

bp blood pressure 

BMI body mass index 

CI Confidence interval 

CPD cardiopulmonary disease 

CPS Collaborative Perinatal Study 

ECW extra cellular water 

g gram 

ga gestational age 

GDM gestational diabetes 

gest gestational 

GWG gestational weigh gain 

HDL high density lipoprotein 

HDP hypertensive disorders of pregnancy 

hg hemoglobin 

ICD-9-CM International Classification of Diseases, 

Ninth Revision, Clinical Modification 

IGT impaired glucose tolerance 

IGUR intrauterine growth retardartion 

IOM Institute of Medicine 

IUGR intrauterine growth restriction 

IVF in vitro fertilization 

kg kilogram 

kg/wk kilogram per week 

lb pound 

LBW low birth weight 

LGA large for gestational age 

MCH maternal and child health 

MWG maternal weight gain 

N number 

NA not applicable 

NICU neonatal intensive care unit 

NIH National Institutes of Health 

NIMU neonatal intensive medical unit 

NR not reported 

NVSD normal spontaneous vaginal delivery 

OGTT oral glucose tolerance test 

p P-value 

PE pulmonary embolism 

pg pregnancy? 

PIH pregnancy induced hypertension 

PNC prenatal care 

PPWR postpartum weight reduction 

Prepg prepregnancy 

PTB preterm birth 

RR relative risk 

SD standard deviation 

SE standard error 

SGA small for gestational age 

TBW total body water 

TSF triceps skinfold 

UCSF University of California at San Francisco 

US United States 

VBAC vaginal birth after cesarean 

VLBW very low birth weight 

WHO World Health Organization 

WHR waist to hip ratio 

WIC Women’s, Infant, and Children program 
C-2 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Atwal et al., 2006 

Country and setting: 

United Kingdom, hospital 

Enrollment period:

4-month period (1 March 

2000 to 30 June 2000 

inclusive) 

Funding: 

NR 

Study Objective: 

To observe prevalence of 

striae gravidarum in 

primiparae and identify 

independent associated 

risk factors 

Time frame: 

4-month period (1 March 

2000 to 30 June 2000 

inclusive) 

Duration of the study: 

Duration of pregnancy 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

309 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• Primiparae who 

delivered after 28 

weeks of gestational 

age and had no 

previous pregnancies 

lasting more than 12 

weeks 

Exclusion criteria: 

• Multiple births 

• Non-white women 

Pregravid weight: 

• Booking weight 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-3 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: Odds ratio 1.08 

(95% CI 1.02-

1.14) P = 

0.0121 

Categorized: 

• Not clear 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Women with 

largest weight 

gain had 

greatest 

incidence of 

striae 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Striae gravidum (%) 

Groups: 

G1: MWG < 15 kg 

G2: MWG > 15 kg 

Results: 

G1: 47 

G2: 60 

Maternal confounders and effect 

modifiers accounted for in analysis: 

NR 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poo

r: 

1 Good, 4 Fair, 

4 Poor 

Final Quality 

Score: 

Poor 
C-4 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Madlon-Kay DJ, 1993 

Country and setting: 

USA, hospital 

Enrollment Period:

NR 

Funding: 

Grant from American 

Academy of Family 

Physicians and Ramsey 

Foundation 

Study Objective: 

To study factors 

associated with formation 

of striae gravidarum and 

measures used by women 

to prevent them 

Time frame: 

NR 

Duration of the study: 

From gestational weeks 

34 to 36 until birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

48 

Group Description: 

G1: All 

G2: Abdominal Striae 

Present 

G3: Abdominal Striae 

Absent 

Group N: 

G1: 48 

G2: 22 

G3: 26 

Inclusion criteria: 

• Nulliparous women at 

34-36 weeks’ 

gestational age who 

planned to give birth 

at either of 2 study 

hospitals 

Exclusion criteria: 

• NR 

Pregravid weight: 

• NR 

G2: 61.7kg 

G3: 58.5kg 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 26.7 

G2: 25 P < 0.05 

G3: 28 P < 0.05 

Parity: 

NR 

Race,%: 

White 

G1: 98% 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-5 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 17.6kg P < 0.05

G2: 14kg P < 0.05

Categorized: 

• Continuous 

Collected from: 

• Not stated 

Ascertained by: 

• Hospital charts 

Birth weight: 

G1: NR 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Abdominal striae (kg) 

Groups: 

G1: Abdominal Striae Present 

G2: Abdominal Striae Absent 

Results: 

Pregnancy weight gain in abdominal striae 

groups (kg) 

G1: 14.9 

G2: 13.0 

P<0.05 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

1 Good, 3 Fair, 5 

Poor 

Final Quality 

Score: 

Poor 
C-6 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Marrero et al., 1992 

Country and setting: 

UK, teaching hospital 

Enrollment Period:

NR 

Funding: 

NR 

Study Objective: 

To study prevalence and 

severity of reflux 

symptoms in pregnancy 

Time frame: 

NR 

Duration of the study: 

91 were in first trimester, 

274 in second and 228 in 

third 

Design: 

• Cross-sectional 

• Retrospective 

Total Study N: 

607 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 607 

G2: NR 

Inclusion criteria: 

• Consecutive patients 

in antenatal clinic 

Exclusion criteria: 

• incomplete survey 

responses 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.5 

G2: NR 

Parity: 

% primigravid

G1: 37.2 

G2: NR 

Race,%: 

White 

G1: 65% 

G2: NR 

Black 

G1: 14% 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 16% 

G2: NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-7 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Says record but 

not clearly stated 

Ascertained by: 

• Weight gain in 

this paper was 

up until time of 

questionnaire 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

BMI before 

pregnancy and 

weight gain in 

pregnancy were not 

found to be risk 

factors for pregnancy 

heartburn 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Heartburn 

Groups: 

NA, continuous weight gain measure 

Results: 

Weight gain in pregnancy not risk factor for 

heartburn in pregnancy 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor:

1 Good, 4 Fair, 4 

Poor 

Final Quality 

Score: 

Poor 
C-8 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rodriguez et al., 2001 

Country and setting: 

Sweden, prenatal health 

care centers 

Enrollment Period:

NR 

Funding: 

Swedish Council of 

Planning and 

Coordination of Research 

and Knut and Alice 

Wallenberg Foundation 

Study Objective: 

To document prevalence 

and frequency of 27 

pregnancy symptoms and 

to sysematically 

investigate, cross 

sectionally and 

prospectively, effect of 

psychosocial factors on 

prevalence and frequency 

of these symptoms, while 

controlling for biomedical 

Time frame: 

NR 

Duration of the study: 

initiation of prenatal care 

to delivery 

Quality: 

Fair 

Design: 

• Cohort 

• Prospective 

Total Study N: 

476 nulliparous 

Scandanavian women 

Group Description: 

Group N: 

Inclusion criteria: 

• Nulliparous 

• Scandinavian origin 

• Solicited by midwives 

from 5 prenatal health 

care centers (91% of 

women agreed to 

participate and 

provided information 

on at least one 

measure) 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Routine pre-natal care 

recorded at first prenatal 

care visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Underweight BMI < 20; 

normal weight BMI 20-

24.99; overweight BMI > 

25 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-9 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

weight at delivery 

minus prepreg 

weight 

Birth weight: 

G1: 3.457 (0.633) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Pregnancy 

symptoms: 

urogenital, 

gastrointestinal, 

musculoskeletal, 

miscellaneous 

pregnancy 

symptoms 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Pearson correlation coefficient (r) for 

prevalence of 27 pregnancy symptoms for 

continuous weight gain measure 

Pearson correlation coefficient (r) for 

frequency of 27 pregnancy symptoms for 

continuous weight gain measure 

Groups: 

G1: Week 10 

G2: Week 12 

G3: Week 20 

G4: Week 28 

G5: Week 32 

G6: Week 36 

Results 

Prevalence 

G1: 0.05 

G2: 0.03 

G3: 0.13 (P < 0.05) 

G4: 0.16 (P < 0.01) 

G5: 0.18 (P < 0.01) 

G6: 0.19 (P < 0.001) 

Frequency 

G1: 0.09 

G2: 0.04 

G3: 0.11 (P < 0.05) 

G4: 0.16 (P < 0.01) 

G5: 0.19 (P < 0.01) 

G6: 0.24 (P < 0.001) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NR 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

1 Good, 7 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 

 
C-10 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Tulman et al., 1998 

Country and setting: 

USA, obstetric and nursemidwifery practices 

Enrollment Period:

NR 

Funding: 

NR 

Study Objective: 

To examine relationship of 

prepregnancy weight and 

pregnancy weight gain to 

functional status, physical 

symptoms, and physical 

energy 

Time frame: 

NR 

Duration of the study: 

Recruited from practices 

and had home visits 

during pregnancy-thus 

during pregnancy through 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

222 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 222 

G2: NR 

Inclusion criteria: 

• Englishspeaking, 

married, pregnant 

women at low risk 

who were 18 years of 

age and older. 

• Participants could 

have no underlying 

medical problems 

(e.g., diabetes, 

chronic renal or 

cardiac disease) or 

preexisting factors in 

their obstetric 

histories that would 

classify them as high 

risk at time of 

recruitment during 

first trimester of 

pregnancy (e.g., 

previous premature 

birth, history of 

incompetent cervix) 

Exclusion criteria: 

• Mmultiple gestations, 

if they delivered 

before 36 weeks, 

missing information 

on weight at first 

trimester interview or 

third trimester 

interview 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 22.82 (SD 3.49) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelinesno obese 

category - just > 26 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-11 

Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 222 

G2: NR 

Total weight gain: 

G1: 13.93 kg (SD 

4.63) 

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

• Percentage 

weight gain 

during pregnancy 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference in 

pounds between 

prepg weight and 

weight at time of 

data collection 

• Percentage 

weight gain 

during pregnancy 

was calculatged 

as weight gain in 

pounds divided 

by prepregnancy 

weight 

Birth weight: 

NR 

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• There was a 

statistically significant 

difference in 

functional status 

between women 

whose total weight 

gain for pregnancy 

was more than 

recommended 

amount based on 

prepregnancy BMI 

(n = 62) and those 

who gained within 

recommended range 

(n = 160), t(220) = 

2.47, P = .014. 

• Women who gained 

an excessive amount 

of weight had a lower 

third trimester level of 

functional status 

(M = 2.30) than those 

who did not 

(M = 2.43). 

• There were no 

differences in number 

of physical symptoms 

or level of physical 

energy for women 

who gained an 

excessive amount of 

weight and those who 

did not 

Other infant outcomes: 

• None 

Outcomes Description: 

Inventory of Functional Status –

Anteparturn Period, 1-3 point 

scale (mean, SD) 

Groups: 

G1: Excess weight gain 

G2: Weight gain within 

recommended range 

Results: 

G1: 2.3 

G2: 2.43 

P < 0.014 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 4 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-12 

Evidence Table 2. Gestational weight gain and hyperemesis 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Dodds et al., 2006 

Country and setting: 

Cananda, perinatal 

database 

Enrollment Period:

1988-2002 

Funding: 

NR 

Study Objective: 

To evaluate maternal and 

neonatal outcomes 

among women with 

hyperemesis during 

pregnancy 

Time frame: 

1988-2002 

Duration of the study: 

Prenatal to neonatal 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

156,091 

Group Description: 

G1: Antepartum 

admission for 

hyperemesis 

G2: No antepartum 

admission for 

hyperemesis 

Group N: 

G1: 1,270 

G2: 154,821 

Inclusion criteria: 

• Singleton 

• 20 weeks or more 

gestation 

• ≥ 500g at birth 

• Hyperemetic 

pregnancies defined 

as those with 1 or 

more antepartum 

admissions for 

hyperemesis first of 

which occurred 

before 24 completed 

weeks gestation 

Exclusion criteria: 

NA 

Pregravid weight: 

• From records in database 

not mentioned whether it 

was self reported or not 

G1: < 60kg: 45.4% 

60-69: 25.3% 

70-79: 13.9% 

≥ 80: 15.3% 

G2: < 60kg: 42.8% 

60-69: 27.6% 

70-79: 15.1% 

≥ 80: 14.5% 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: < 20 years: 12.1% 

20-29: 64.8% 

30-34: 17.8% 

35-49: 5.4% 

G2: < 20 years: 8.0% 

20-29: 56.7% 

30-34: 25.5% 

35-49: 9.8% 

Parity: 

G1: % nulliparous: 48.7 

G2: 44.3 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 21.4 

G2: 30.2 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-13 

Evidence Table 2. Gestational weight gain and hyperemesis (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• < 7kg and ≥ 7kf 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not specifically 

stated by authors 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Antepartum admission for hyperemesis (Kg)

Groups: 

G1: No antepartum admission for 

hyperemesis 

G2: Antepartum admission for hyperemesis 

Results 

Adjusted RR for pregnancy weight gain < 7kg 

G1: 1.0 (ref) 

G2: 2.1 (1.8-2.5) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Maternal prepregnancy weight 

• Time period 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

1 Good, 5 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-14 

Evidence Table 2. Gestational weight gain and hyperemesis (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Dodds et al., 2006 

(continued)

 
C-15 

Evidence Table 2. Gestational weight gain and hyperemesis (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 
C-16 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and to 

determine effect of 

gestational weight gain on 

pregnancy outcome in 

morbidly obese women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 and 

34 

• Missing height 

• Missing 

prepregnancy weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference for 

women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-17 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 613

G2: 11,313

Total weight gain: 

G1: 20 (16.2)

G2: 31.4 (11.5)

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes: 

Incidence of gestational 

diabetes 

Groups 

Reported only for BMI > 

35: 

G1: weight loss or no gain 

G2: 1-15 lb gain 

G3: 16-25 lb gain 

G4: 26-35 lb gain 

Results 

G1: 15.7% 

G2: 15.0% 

G3: 14.4% 

G4: 13.4% 

G5: 12.5% 

(P =NS) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Race 

• Parity 

• Clinic service 

• Substance abuse 

• And preexisting 

medical conditions 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-18 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

Country and setting: 

Canada, medical records 

Enrollment Period:

Prenatal to birth 

Funding: 

cree board of health and 

social services of James 

Bay (Quebec) 

Study Objective: 

To determine effect of 

pregravid weight and 

pregnancy weight gain on 

pregnancy outcomes in 

Cree women 

Time frame: 

Prenatal to birth 

Duration of the study: 

7 year period: January 

1994 to December 2000 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

603 

Group Description: 

G1: Normal: 

BMI 18.5 - 24.9 

G2: Overweight: 

BMI 25-29.9 

G3: Obese: 

BMI ≥ 30 

G4: Total 

Group N: 

G1: 139 

G2: 168 

G3: 296 

G4: 603 

Inclusion criteria: 

• Used only Cree 

women 

• First birth observed 

per woman during 

study time period 

• Must have first weight 

recorded within first 

14 weeks gestation 

and final weight 

recorded within 4 

weeks of birth 

Exclusion criteria: 

• Women with 

secondary pregnancy 

in dataset (n = 792) 

• Women with first 

weight record > 14 

weeks gestation 

(n = 314) 

• Women with final 

weight record > 4 

weeks from birth 

(n = 202) 

• Women with both first 

weight record > 14 

weeks and final 

weight record > 4 

weeks (n = 70) 

• Women missing data 

on first or final weight 

(n = 3) 

Pregravid weight: 

• Routine pre-natal care 

• Medical records 

• Measured within 14 

weeks of gestation 

G1: 59.7 (5.0) 

G2: 73.0 (4.3) 

G3: 93.6 (12.3) 

G4: 80.0 (16.9) 

Pregravid BMI: 

NR 

Imputed: 

• Yes 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 20.8 (5.2) 

G2: 23.8 (5.4) 

G3: 25.5 (5.5) 

G4: 24.0 (5.7) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Hypertension,%: 

G1: 1.4 

G2: 1.8 

G3: 4.8 

G4: 3.2 

Additional characteristics: 

% low weight gain:

G1: 20.1 

G2: 10.1 

G3: 28.0 

G4: 21.2 

% acceptable weight gain:

G1: 28.8 

G2: 32.1 

G3: 33.4 

G4: 32.0 

% excessive weight gain: 

G1: 51.1 

G2: 57.7 

G3: 38.5 

G4: 46.6 
C-19 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 139 

G2: 168 

G3: 296 

Total weight gain: 

Categorized: 

• 1999 Canadian 

guidelines 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

within 4 weeks of 

birth 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Cesarean 

delivery,%: 

G1: 10.8 

G2: 11.3 

G3: 24.1 (p < 0.001) 

Instrumental 

delivery,%: 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Definition of low, 

adequate, and 

excessive weight 

gains: 

• For normal 

weight women - 

adequate weight 

gain is 11.5 to 16 

kg 

• For overweight 

women, 

adequate weight 

gain is 7 to 11.5 

kg 

• For obese 

women, 

adequate weight 

gain is 7 to 11.5 

kg 

• Weight gain 

below specified 

range is “low” 

and weight gain 

above specified 

range is 

“excessive” 

Other infant 

outcomes: 

> 4000g, > 4500g 

Outcomes: 

Incidence of gestational 

diabetes and impaired 

glucose tolerance 

Groups: 

G1: “Low weight gain” 

G2: “Acceptable weight 

gain” 

G3: “Excessive weight gain”

All categories per Canadian 

Guidelines 

Results: 

Incidence of GDM 

G1: 38.6% 

G2: 27.3% 

G3: 19.3% 

(P =0.011) 

Incidence IGT: 

G1: 12.0% 

G2: 15.2% 

G3: 7.9% 

(P = 0.249) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

NR 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 5 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-20 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

(continued) 

• Pregnancies with 

factors that may have 

influenced maternal 

weight gain such as 1 

parent being nonCree (n = 13), 

preterm deliveries 

(n = 91), twin 

pregnancies (n = 6), 

missing gestational 

age (n = 9) 

• Women with 

unknown glycemic 

status (n = 30), type 

2 DM (n = 8), 

glycemic 

abnormalities before 

pregnancy not 

followed for diagnosis 

(n = 70) 

• Women classified as 

underweight (n = 5) 

 
C-21 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

 
C-22 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period:

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal weight 

women and their 

associations with 

gestational weight change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight women 

identified from 

pregnancy and 

delivery summary 

records (normal 

weight matched to 

obese by race, age, 

parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal weight 

(BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-23 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5

G2: 14.5 P ≤ 0.001

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes: 

Incidence of gestational 

diabetes 

Groups 

Pregravid wt 19.8-26.0 BMI:

G1: < 11.5 kg gain 

G2: 11.6-16 kg gain 

G3: > 16 kg gain 

Pregravid wt > 29 kg 

G4: lost/gained nothing 

G5: 0.5-6.5 kg gain 

G6: 7-11.5 kg gain 

G7: 12-16 kg gain 

G8: >16 kg gain 

Results 

Incidence gestational 

diabetes: 

G1: 2.3% 

G2: 3.3% 

G3: 2.9% 

(P =.759) 

G4: 13.3% 

G5: 24.3% 

G6: 11.9% 

G7: 16.7% 

G8: 17.3% 

(P = .554)

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Maternal age 

• Parity 

• Race 

• Prenatal smoking 

• Prenatal alcohol use 

• Prenatal illicit drug use 

• Pregravid health 

• Weight and adequacy 

of prenatal care 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-24 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hackmon et al, 2007 

Country and setting: 

United States, Hospital 

Enrollment period: 

2003 

Funding: 

NR 

Study Objective: 

Aim was to determine 

whether maternal age, 

prepregnancy and midtrimester body mass index 

(BMI), or excessive midpregnancy weight gain 

predict abnormal glucose 

challenge test (GCT) 

results 

Time frame: 

2003 

Duration of the study: 

Entry into prenatal care 

through 24 to 28 weeks of 

pregnancy 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

75 

Group Description: 

G1: Study population 

Group N: 

G1: 75 

Inclusion criteria: 

• Consecutive, inner 

city, singleton 

pregnancies 

Exclusion criteria: 

• Known gestational 

diabetes 

Pregravid weight: 

• Routine pre-natal care 

• NR 

Pregravid BMI: 

G1: 27.4 

• 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 31 (range: 19-43) 

Parity: 

G1: 0.9 

Race,%: 

White 

G1: 22 

Black 

G1: 31 

Hispanic 

G1: 39 

Asian/Pacific Islander 

G1: 5 

Other 

G1: 3 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: Abnl GCT: 29.3% 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-25 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

• NR 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: Abnl GCT: 29.3%

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• No difference in 

maternal weight 

gain during early 

pregnancy 

between patients 

with abnormal 

versus normal 

GCT values 

(mean+SD of 

4.13+/-3.2 and 

4.16+/-1.67, 

respectively) 

Other infant 

outcomes 

NR 

Outcomes : 

Gestational diabetes 

Groups 

NR 

Results 

There was no difference in 

maternal weight gain during 

early pregnancy between 

patients with abnormal 

versus normal GCT values 

(mean+/-SD of 4.13+/-3.2 

and 4.16+/-1.67, 

respectively). 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Gravidity 

• Parity 

• Ethnicity 

• BMI 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 5 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-26 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabiru and Raynor, 2004 

Country and setting: 

USA, hospital 

Enrollment Period:

1999 to 2002 

Funding: 

NR 

Study Objective: 

To investigate effect of 

increase in body mass 

index category on 

obstetric outcomes 

Time frame: 

1999 to 2002 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,131 

Group Description: 

G1: No change in BMI 

between first prenatal 

visit and delivery 

G2: 1 category increase in 

BMI between first 

prenatal visit and 

delivery 

G3: > 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

Group N: 

G1: 2,556 

G2: 2,252 

G3: 323 

Inclusion criteria: 

• Singleton 

pregnancies 

Exclusion criteria: 

• Multiple pregnancies 

• BMI < 20 

• Missing BMI data 

Pregravid weight: 

• Measured at first prenatal 

visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• 20-24.9, 25-29.9, 30-34.9, 

35-39.9, ≥ 40 

Age (mean, yrs): 

G1: 24.7 (6.1) 

G2: 24.4 (5.7) 

G3: 25.2 (5.9) P < 0.001 

Parity: 

G1: Gravidity (mean): 1.9 (1.9)

G2: 1.5 (1.7) 

G3: 1.2 (1.7) P < 0.001 

Race,%: 

White 

G1: 1.9 

G2: 2.6 

G3: 2.8 

Black 

G1: 84.1 

G2: 82.8 

G3: 88.2 

Hispanic 

G1: 13.9 

G2: 14.6 

G3: 9.0 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean weight gain: 

G1: 8.6 pounds (8.4) 

G2: 22.2 pounds (10.2) 

G3: 55.3 pounds (23.8) 

Additional characteristics: 

NR 
C-27 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 579 

G2: 942 

G3: 189 

G4: 819 

G5: 790 

G6: 104 

Total weight gain: 

Categorized: 

• > 35 pounds for 

normal BMI, > 25 

pounds for 

overweight BMI, 

> 15 pounds for 

obese BMI 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not stated, most 

likely difference 

between weight 

at first prenatal 

visit and weight 

at delivery 

Birth weight: 

G1: 2886.0 (756) 

G2: 3174.9 (600) 

G3: 3099.5 (673) 

P < 0.001 

G4: 3116 (713) 

G5: 3269 (698) 

G6: 3371 (733) 

P = 0.015 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 8.2 

G2: 12.6 

G3: 21.0 P < 0.001 

G4: 13.0 

G5: 14.3 

G6: 19.3 P = 0.256 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes description 

Incidence of gestational 

diabetes 

Groups: 

BMI < 25 first assessment: 

G1: no change BMI 

category 

G2: increase 1 category 

G3; increase > 1 category 

BMI≥25 first assessment 

G4: no change BMI 

category 

G5: increase 1 category 

G6: increase >1 category 

Results: 

G1: 0.5% 

G2: 1.5% 

G3: 3.7% 

(P = .005) 

G4: 1.0% 

G5: 3.3% 

G6: 1.9% 

(P = .005) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Pregravid BMI 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-28 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kieffer et al., 2006 

Country and setting: 

United States, community 

health center 

Enrollment period:

Jan 1999 to Feb 2001 

Funding: 

Study supported by 

National Institutes of 

Diabetes and Digestive 

and Kidney Diseases 

(grant R18DK 062344); 

Biostatistics and 

Measurement Cores of 

Michigan Diabetes 

Research and Training 

Center(grant NIH5P60 

DK20572); General Clinic 

Center, National Institutes 

of Health (grant M01 

RR00042); Maternal and 

Child Health Bureau 

(grant R40 MC00115-03); 

and Detroit Community 

Academic Urban 

Research Center 

Study Objective: 

Study assessed combined 

influence of maternal 

weight and other 

anthropometric and 

metabolic characteristics 

on birthweights of Latino 

infants 

Time frame: 

Jan 1999 to Feb 2001 

Duration of the study: 

From entry into prenatal 

care up til delivery. Ave ga 

at entry was 17 weeks. 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1,041 

Group Description: 

G1: Total 

Group N: 

G1: 1,041 

Inclusion criteria: 

• Latino women 

entering prenatal care 

during study period 

Exclusion criteria: 

• Multiple gestation 

• Late entry into 

prenatal care 

• Previous participation 

in study 

• Miscarriage 

• Stillbirth 

• Missing records 

Pregravid weight: 

• When unknown or 

missing-used weight 

obtained within first 10 

weeks of pregnancy 

G1: 63.4 ±12.9 

Pregravid BMI: 

G1: 25.9 ±5.0 

Imputed: 

• Yes 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 25.2 ±5.1 

Parity: 

Multiparous, no. (%)

G1: 0 429 (41.2) 

1- 574 (55.1) 

≥4 38 (3.7) 

Race,%: 

Hispanic 

G1: 100% 

Smoking,%: 

G1: 9% before 

2% during 

Diabetes mellitus,%: 

G1: 6.8 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-29 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: Total 933 

Total weight gain: 

G1: Adjusted R2: 

0.30 kg [PE 8.2, 

SE 2.2, P < 0.01] 

Categorized: 

• Continuous 

according to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by:

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational diabetes, %: 

G1: 6.8 

Cesarean delivery,%: 

NR 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal outcomes:

• Women with GDM had 

significantly lower 

average weight gain 

than those without 

GDM; weight gain not 

significantly related to 

glucose category 

• Maternal waist, hip, and 

upper-arm 

circumference and 

upper-arm fat area 

associated with 

increasingly abnormal 

glucose categories 

among women with and 

without GDM 

• Significant linear 

increase in birthweight 

with increasing glucose 

level maintained after 

further adjustment for 

maternal age, parity, 

BMI, weight gain, 

hypertensive disorders, 

and family history of 

diabetes 

Other infant outcomes: 

NR 

Outcomes Description: 

GDM 

Groups: 

NA, weight gain as 

continuous variable (study 

aim to determine 

relationship of 

anthropometric and 

metabolic variables on 

infant outcomes) 

Results 

Women with GDM had 

significantly lower average 

weight gain than those 

without GDM but weight 

gain was not significantly 

related to glucose category 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Parity 

• Pregravid BMI 

• Weight gain 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

7 Good, 2 Fair, 0 Poor 

Final Quality Score: 

Good 
C-30 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kieffer et al., 2001 

Country and setting: 

USA, city health system 

Enrollment Period:

Latinas: August 1996 - 

December 1998 

African Americans: 

January 1995 to February 

1998 

Funding: 

Grants from Health 

Resources and Services 

Administration, Maternal 

and Child Health Bureau, 

and African American 

health Initiative of Blue 

Cross Blue Shield of 

Michigan Foundation 

Study Objective: 

To estimate prevalence of 

GDM, obesity, and 

excessive weight gain 

during pregnancy among 

Latinas and African 

American women and to 

explore risk factors 

associated with GDM and 

its implications 

Time frame: 

Latinas: August 1996 to 

December 1998 

African Americans: 

January 1995 to February 

1998 

Duration of the study: 

during prenatal care 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

Latinas:661 

African American: 673 

Group Description: 

G1: Latina 

G2: African American 

Group N: 

G1: 661 

G2: 673 

Inclusion criteria: 

• African American and 

Latina women 

• Received at least 4 

prenatal care visits 

• Delivery of single 

infant within large 

Detroit health system

Exclusion criteria: 

• Documented diabetes 

prior to prenatal care 

• Information on infants 

other than first 

pregnancy within 

study period 

Pregravid weight: 

• Self-reported 

• if not selfreported, used 

weight measured weight 

within 10 weeks of 

gestation 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines: < 19.8, 

19.8-26.0, > 26.0-29.0, > 

29.0-35.0, > 35.0 

Age (mean, yrs): 

G1: NR 

• < 20: 18.2% 

• 20-29: 62.6% 

• ≥ 30: 19.1% 

G2: NR 

• < 20: 22.1% 

• 20-29: 49.1% 

• ≥ 30: 28.8% 

Parity: 

% primiparous:

G1: 39.7 

G2: 43.6 

Race,%: 

White 

NR 

Black 

G1: NR 

G2: 100 

Hispanic 

G1: 100 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 3.8 

G2: 10.7 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Married: 

G1: 60.3% 

G2: 31.5% 

Additional characteristics: 

NR 
C-31 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 661 

G2: 673 

Total weight gain: 

G1: 29.1 (14.6)

G2: 32.6 (12.1) 

P < 0.004 vs. Latinas

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

GDM 

Groups: 

NR 

Results 

Multiple logistic regression 

analyses revealed 

statistically significant risk 

factors for GDM included 

weight gain during the first 

28 wks gestation 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Family history diabetes 

• Parity 

• BMI 

• Weight gain first 28 

weeks 

• Ethnicity 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-32 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Murakami et al., 2004 

Country and setting: 

Japan, hospital 

Enrollment Period:

2001 

Funding: 

NR 

Study Objective: 

To estimate risk of 

perinatal morbidity of 

mother and infant with 

respect to maternal 

prepregnancy BMI and 

weight gain in Japanese 

women 

Time frame: 

2001 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

633 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 633 

G2: NR 

Inclusion criteria: 

• Live, singletons 

delivered between 24 

to 42 weeks gestation

Exclusion criteria: 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 20.9 (2.8) 

G2: NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 29.1 (4.5) 

G2: NR 

Parity: 

G1: 0.6 (0.7) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 8.5 

G2: NR 

Diabetes mellitus,%: 

G1: 2.1 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Preeclampsia - mild: 

5.4%; severe: 4.1% 

G2: NR 

Additional characteristics: 

NR 
C-33 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 633 

G2: NR 

Total weight gain: 

G1: 10.5 (3.4)

G2: NR 

Categorized: 

• < 8.5kg, 8.5-

12.5, > 12.5 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

last 

measurement 

was taken at 

hospitalization 

prior to delivery 

Birth weight: 

G1: 3,052.6 (483.8) 

G2: NR 

Gestational 

diabetes, %: 

G1: 2.1 

G2: NR 

Cesarean 

delivery,%: 

G1: 10.3 

G2: NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

AORs (95% CI) of 

gestational diabetes 

Groups 

G1: < 8.5 kg gain 

G2: 8.5-12.5 kg gain 

G3: >12.5 kg gain 

Results 

G1: 5.14 (0.97-27.20) 

G2: Reference 

G3: 3.91 (0.61-24.73) 

Maternal confounders and 

effect modifiers 

accounted for in analysis:

• Maternal age 

• Parity 

• Smoking 

• Weight gain 

• Pregravid BMI 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 8 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-34 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Saldana et al., 2006 

Country and setting: 

United States, hospital 

Enrollment period: 

August 1,1995 through 

May 31, 2000 

Funding: 

Supported in part by 

National Institute of 

General Medical Sciences 

(Grant R25GM55336), 

National Institute of Child 

Health and Development 

(Grant 28684), and North 

Carolina Clinical Nutrition 

Research (Grant 

DK56350) 

Study Objective: 

Objective of study to 

examine weight and its 

relationship to glucose 

intolerance during 

pregnancy 

Time frame: 

August 1,1995 through 

May 31, 2000 

Duration of the study: 

Entry into prenatal care 

through end of second 

trimester 

Quality: 

Good 

Design: 

• Cohort 

• Prospective 

Total Study N: 

952 

Group Description: 

G1: Normal Glucose 

Tolerance 

G2: Impaired Glucose 

Tolerance 

G3: GDM 

Group N: 

G1: 809 

G2: 48 

G3: 95 

Inclusion criteria: 

• Singleton pregnancy 

• More than 16 years of 

age 

• English speaking 

• Access to phone 

• Planned to continue 

care at 1 of study 

sites 

Exclusion criteria: 

• From non-white or 

non-black racial 

group 

• Having a second 

pregnancy in cohort 

• Pre-existing diabetes 

• No glucose screening 

data 

• High screen without 

an oral glucose 

tolerance test 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 25 (0.24) 

G2: 28 (1.1) 

G3: 30 (0.82) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26 (0.22) 

G2: 29 (0.91) 

G3: 28 (0.59) 

Parity: 

G1: 0.9 (0.04) 

G2: 1.1 (0.16) 

G3: 0.9 (0.10) 

Race,%: 

White 

G1: 58% 

G2: 73% 

G3: 69% 

Black 

G1: 42% 

G2: 27% 

G3: 31% 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 25% 

G2: 26% 

G3: 25% 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Weight gain ratio 

(observed/recommended[compa

red with IOM range])

G1:: 1.43 (0.04) 

G2: 1.48 (0.21) 

G3: 1.88 (0.15) 

Additional characteristics: 

NR 
C-35 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: 9.1 (0.19) 

G2: 8.1 (0.90) 

G3: 9.4 (0.62) 

Categorized: 

• 2 weight gain 

variables were 

created. Weight 

gain was 

calculated by 

subtracting 

prepregnancy 

weight from 

weight at end of 

second trimester 

(G2 weeks). 

Weight gain ratio 

calculated as 

ratio of observed 

weight gain to 

recommended 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

Outcomes Description: 

Impaired Glucose Tolerance

GDM 

Groups: 

Weight gain ratio 

(observed/recommended) 

Results 

OR for weight gain ratio on 

Impaired Glucose Tolerance 

(95% CI) 

0.9 (0.7, 1.1) 

OR for weight gain ratio on 

GDM (95% CI) 

1.2 (0.9, 1.4) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

Race 

Maternal age 

Gestational age of weight 

measurment 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal weight 

gain: 

Good 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

7 Good, 2 Fair, 0 Poor 

Final Quality Score: 

Good 
C-36 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Seghieri et al., 2005 

Country and setting: 

Italy, outpatient clinic 

Enrollment Period:

January, 1997 to 

December 2003 

Funding: 

NR 

Study Objective: 

To study effect of parity 

on impairment of insulin 

sensitivity during 

pregnancy and on risk of 

GDM 

Time frame: 

January, 1997 to 

December 2003 

Duration of the study: 

Caucasian pregnant 

women who received a 3 

hour OGTT at 24 to 28 

weeks gestation; also 75 

women whose glucose 

levels were tested in 2 

consecutive pregnancies 

Design: 

• Cross-sectional 

• Retrospective 

Total Study N: 

1880 

Group Description: 

G1: Parity = 0 

G2: Parity = 1 

G3: Parity = 2 

G4: Parity = 3 

G5: Parity > 3 

Group N: 

G1: 944 

G2: 604 

G3: 232 

G4: 77 

G5: 23 

Inclusion criteria: 

• Women who tested 

glucose intolerant by 

glucose challenge or 

who had an elevated 

1 hour glucose or had 

other risk factors for 

GDM (hx glucose 

intolerance, 

macrosomic infants, 

diabetes of first 

degree relative 

Exclusion criteria: 

• No criteria are 

mentioned by authors

Pregravid weight: 

• Not explained in Methods 

section 

Pregravid BMI: 

G1: 22.5 (3.4) 

G2: 23.4 (4.1) 

G3: 23.7 (4.1) 

G4: 24.1 (5.3) 

G5: 24.4 (6.1) (P Duncan’s 

test after anova = 0.0001, 

0 vs.3, > 3) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.2 (4.3) 

G2: 31.4 (4.5) 

G3: 31.9 (4.5) 

G4: 33.8 (4.3) 

G5: 35.2 (4.2) (P Duncan’s 

test after anova = 0.0001, 

0 vs. 1,2,3, > 3) 

Parity: 

NR 

Race,%: 

White 

G1: 100 

G2: 100 

G3: 100 

G4: 100 

G5: 100 

Group 6 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Weight increase (kg)

G1: 7.4 (3.6) 

G2: 7.2 (3.7) 

G3: 6.8 (4.0) 

G4: 6.9 (3.5) 

G5: 8.7 (8.6) (P Duncan’s test 

after anova = 0.0119, 0, 

1,2,3 vs. > 3) 

Additional characteristics: 

G1: 2-hr AUC glucose (area 

under the curve of glucose 

0-120 min): 0.82 (0.17) 

G2: 0.85 (0.18) 

G3: 0.86 (0.18) 

G4: 0.86 (0.19) 

G5: 0.97 (0.17) (P Duncan’s test 

after anova = 0.0001, 0, 

1,2,3 vs. > 3) 

Additional characteristics: 

G1: ISI OGTT (mg/dl per min): 6 

(3.3) 

G2: 5.8 (2.8) 

G3: 5.6 (2.2) 

G4: 5.6 (2.2) 

G5: 4 (2.5) (P Duncan’s test 

after anova = 0.0002, 0, 

1,2,3 vs. > 3) 
C-37 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 1764 

G2: 124 

Total weight gain: 

G1: 7.3 (3.9)

G2: 7.2 (5.3)

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated by 

researchers - 

appears that 

weight gain was 

computed at time 

of testing which 

was at 24-28 

weeks rather 

than total weight 

gain 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Weight gain as predictor of 

GDM OR (95% CI) 

Groups 

NA, weight gain continuous 

variable 

Results 

1.024 (0.974-1.077) 

(P = NS) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Parity 

• Age 

• Pregestational BMI 

• Weight gain 

• Family history diabetes 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Poor 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 3 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-38 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

Country and setting: 

Maternity records, 

Department of Obstetrics 

and Gynecology at 

Landspitali University 

Hospital, Iceland 

Enrollment Period:

Funding: 

NR 

Study Objective: 

To investigate relation 

between gestational 

weight gain in women of 

normal prepregnant 

weight and complications 

during pregnancy and 

delivery in a population 

with high gestational 

weight gain and birth 

weight 

Time frame: 

NR 

Duration of the study: 

1998 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

614 

Group Description: 

G1: No complication 

G2: Complications in 

pregnancy or delivery

G3: Complications in 

pregnancy 

G4: Complications in 

delivery 

Group N: 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Inclusion criteria: 

• Women of normal 

prepregnancy weight 

randomly selected 

within 1 year (1998) 

• No history of 

diabetes, 

hypertension, CVD, 

or thyroid problems 

• Singleton births 

• 38 to 43 weeks 

gestation 

• 20 to 40 years of age

• Routine fetal biometry 

at 18 to 20 week 

ultrasound 

• Received early and 

regular antenatal care

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 63.1 (6.2) 

G2: 62.0 (5.6) P = 0.059 

G3: 61.7 (4.8) P = 0.174 

G4: 62.2 (6.1) P = 0.274 

Pregravid BMI: 

G1: 22.2 

G2: 22.4 )1.6) P = 0.270 

G3: 22.4 (1.5) P = 0.338 

G4: 22.3 P = 0.584 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29 

G2: 29 P = 0.857 

G3: 29 P = 0.404 

G4: 29 P = 0.398 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Proportional weight gain, %:

G1: 26.0 

G2: 28.0 P = 0.018 

G3: 30.0 P = 0.005 

G4: 27.0 P = 0.546 

Additional characteristics: 

NR 
C-39 

Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Total weight gain: 

G1: 16.6 (4.9)

G2: 17.4 (5.1) P = 

0.080

G3: 18.4 (5.1) P = 

0.013

G4: 16.9 (5.1) P = 

0.887

Categorized: 

• According to IOM < 

11.5, 11.-16.0, ≥

16.1, also quintiles 

< 12.5, 12.5-15.5, 

15.6-17.8, 17.9-

20.8, > 20.8 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery 

Birth weight: 

G1: 3789 (469) 

G2: 3749 (565) P = 0.389

G3: 3643 (526) P = 0.032

G4: 3806 (578) P = 0.529

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Incidence of gestational 

diabetes 

Groups: 

G1: <11.5 kg gain 

G2: 11.5-16.0 kg gain 

G3: 16.1-20.0 kg gain 

G4: >20 kg gain 

Results: 

G1: 2.9% 

G2: 0 

G3: 0 

G4: 0 

(P =.015) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Height 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-40 

Evidence Table 4. Gestational weight gain and hypertensive disorders 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-41 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Incidence of pregnancy 

induced hypertension 

Groups 

Reported only for BMI > 

35: 

G1: weight loss or no gain 

G2: 1-15 lb gain 

G3: 16-25 lb gain 

G4: 26-35 lb gain 

G5: > 35 lb gain 

(P = NS) 

Results 

G1: 11.8% 

G2: 13.7% 

G3: 13.7% 

G4: 12.4% 

G5: 21.3% 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Race 

• Parity 

• Clinic service 

• Substance abuse 

• Preexisting medical 

conditions 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-42 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

Country and setting: 

Canada, medical 

records 

Enrollment Period: 

Prenatal to birth 

Funding: 

cree board of health and 

social services of James 

Bay (Quebec) 

Study Objective: 

To determine effect of 

pregravid weight and 

pregnancy weight gain 

on pregnancy outcomes 

in Cree women 

Time frame: 

Prenatal to birth 

Duration of the study: 

7 year period: January 

1994 to December 2000 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

603 

Group Description: 

G1: Normal: 

BMI 18.5 - 24.9 

G2: Overweight: 

BMI 25-29.9 

G3: Obese: 

BMI ≥ 30 

G4: Total 

Group N: 

G1: 139 

G2: 168 

G3: 296 

G4: 603 

Inclusion criteria: 

• Used only Cree 

women 

• First birth observed 

per woman during 

study time period 

• Must have first 

weight recorded 

within first 14 

weeks gestation 

and final weight 

recorded within 4 

weeks of birth 

Exclusion criteria: 

• Women with 

secondary 

pregnancy in 

dataset (n = 792) 

• Women with first 

weight record > 14 

weeks gestation 

(n = 314) 

• Women with final 

weight record > 4 

weeks from birth 

(n = 202) 

• Women with both 

first weight record > 

14 weeks and final 

weight record > 4 

weeks (n = 70) 

• Women missing 

data on first or final 

weight (n = 3) 

Pregravid weight: 

• Routine pre-natal care 

• Medical records 

• Measured within 14 

weeks of gestation 

G1: 59.7 (5.0) 

G2: 73.0 (4.3) 

G3: 93.6 (12.3) 

G4: 80.0 (16.9) 

Pregravid BMI: 

NR 

Imputed: 

• Yes 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 20.8 (5.2) 

G2: 23.8 (5.4) 

G3: 25.5 (5.5) 

G4: 24.0 (5.7) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Hypertension,%: 

G1: 1.4 

G2: 1.8 

G3: 4.8 

G4: 3.2 

Additional characteristics: 

% low weight gain:

G1: 20.1 

G2: 10.1 

G3: 28.0 

G4: 21.2 

% acceptable weight gain:

G1: 28.8 

G2: 32.1 

G3: 33.4 

G4: 32.0 

% excessive weight gain: 

G1: 51.1 

G2: 57.7 

G3: 38.5 

G4: 46.6 
C-43 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 139 

G2: 168 

G3: 296 

Total weight gain: 

Categorized: 

• 1999 Canadian 

guidelines 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: within 

4 weeks of 

birth 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Cesarean 

delivery,%: 

G1: 10.8 

G2: 11.3 

G3: 24.1 (p < 

0.001) 

Instrumental 

delivery,%: 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Definition of 

low, adequate, 

and excessive 

weight gains: 

• For normal 

weight women 

- adequate 

weight gain is 

11.5 to 16 kg 

• For overweight 

women, 

adequate 

weight gain is 7 

to 11.5 kg 

• For obese 

women, 

adequate 

weight gain is 7 

to 11.5 kg 

• Weight gain 

below specified 

range is “low” 

and weight 

gain above 

specified range 

is “excessive” 

Other infant 

outcomes: 

> 4000g, > 4500g 

Outcomes Description: 

hypertensive disorders, 

PIH, preeclampsia 

Groups 

G1: “Low weight gain” 

G2: “Acceptable weight 

gain” 

G3: “Excessive weight 

gain” 

All categories per 

Canadian Guidelines 

Results 

HTN Disorders 

G1: 7.3% 

G2: 12.5% 

G3: 19.3% 

(P = 0.051) 

PIH: 

G1: 3.7% 

G2: 6.3% 

G3: 4.4% 

(P = 0.698) 

Preeclampsia 

G1: 3.7% 

G2: 6.3% 

G3: 14.9% 

(P = 0.013) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NR 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 5 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-44 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

(continued) 

• Pregnancies with 

factors that may 

have influenced 

maternal weight gain 

such as 1 parent 

being non-Cree (n = 

13), preterm 

deliveries 

(n = 91), twin 

pregnancies (n = 6), 

missing gestational 

age (n = 9) 

• Women with 

unknown glycemic 

status (n = 30), type 

2 DM (n = 8), 

glycemic 

abnormalities before 

pregnancy not 

followed for 

diagnosis (n = 70) 

• Women classified as 

underweight (n = 5) 

 
C-45 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

 
C-46 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cedergren, 2006 

Country and setting: 

Sweden, Medical Birth 

Registry 

Enrollment Period: 

January 1, 1994 - 

December 31, 2002 

Funding: 

Ostergotland County 

Council 

Study Objective: 

To estimate effects of 

high and low gestational 

weight gain in different 

maternal BMI classes 

on obstetric and 

neonatal outcomes 

Time frame: 

January 1, 1994 to 

December 31, 2002 

Duration of the study: 

First visit to maternity 

health care center to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

245,526 

Group Description: 

BMI 

G1: < 20 

G2: 20 to 24.9 

G3: 25 to 29.9 

G4: 30 to 34.9 

G5: ≥ 35 

Group N: 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Inclusion criteria: 

• Singleton, term 

pregnancies 

• Information on 

maternal height, 

maternal weight in 

early pregnancy, 

and gestational 

weight gain 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• If unknown, 

standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20.0-24.9, 25.0-

29.9, 30-34.9, ≥ 35 

Age (mean, yrs): 

G1: 15 to 19 years: 3.8% 

20 to 24: 23.0% 

25 to 29: 38.7% 

30 to 34: 25.7% 

35 to 39: 7.7% 

≥ 40: 1.1% 

G2: 15 to 19 years: 1.9% 

20 to 24: 15.9% 

25 to 29: 37.7% 

30 to 34: 31.1% 

35 to 39: 11.3% 

≥ 40: 1.9% 

G3: 15 to 19 years: 1.5% 

20 to 24: 15.7% 

25 to 29: 36.1% 

30 to 34: 31.2% 

35 to 39: 12.9% 

≥ 40: 2.5% 

G4: 15 to 19 years: 1.5% 

20 to 24: 17.4% 

25 to 29: 35.6% 

30 to 34: 30.0% 

35 to 39: 13.0% 

≥ 40: 2.4% 

G5: 15 to 19 years: 1.1% 

20 to 24: 17.3% 

25 to 29: 38.0% 

30 to 34: 29.6% 

35 to 39: 11.7% 

≥ 40: 2.3% 

Race,%: 

White 

G1: 96.6 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 1.4 

G2: NR 

Other 

G1: 2.0 

G2: NR 

Smoking,%: 

G1: % nonsmoking: 81.6 

G2: 85.2 

G3: 83.1 

G4: 79.9 

G5: 78.4 

Group 6 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-47 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Total weight gain: 

G1: < 8kg: 6.9% 

8-15.9kg: 65.2% 

≥ 16kg: 28.0% 

G2: < 8kg: 8.4% 

8-15.9kg: 67.1% 

≥ 16kg: 30.4% 

G3: < 8kg: 15.7% 

8-15.9kg: 54.4% 

≥ 16kg: 29.9% 

G4: < 8kg: 30.2% 

8-15.9kg: 48.7% 

≥ 16kg: 21.1% 

G5: < 8kg: 44.6% 

8-15.9kg: 40.9% 

≥ 16kg 

Categorized: 

• < 8kg, 8-16, > 16 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

maternal weights 

measured when 

woman attended 

delivery unit and 

maternal weight 

recorded at first 

visit to maternity 

health care 

center 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Preeclampsia 

Groups 

G1:BMI < 20 

G2:BMI 20-24.9 

G3:BMI 25-29.9 

G4:BMI 30-34.9 

G5:BMI>35 

Results 

Preeclampsia by BMI for 

weight gain < 8 kg 

(reference gain 8-16 kg) 

OR (95% CI): 

G1: 0.90 (0.55-1.48) 

G2: 0.73 (0.61-0.89) 

G3: 0.64 (0.54-0.76) 

G4: 0.52 (0.42-0.62) 

G5: 0.63 (0.51-0.79) 

Preeclampsia by BMI for 

weight gain >16 kg 

(reference weight gain 8-

16kg) OR (95% CI): 

G1: 2.23 (1.83-2.71) 

G2: 2.31 (2.15-2.49) 

G3: 1.88 (1.72-2.06) 

G4: 1.65 (1.43-1.92) 

G5: 1.50 (1.17-1.92) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• Smoking in early 

pregnancy 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Year of birth 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-48 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

DeVader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period: 

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate 

relationship between 

gestational weight gain 

and adverse pregnancy 

outcomes among 

women with normal 

prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 

35 lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal 

prepregnancy BMI 

(19.8 –26.0 kg/m2) 

who were 18 to 35 

years of age at time 

of delivery and who 

delivered full-term 

(37 weeks or more) 

singleton infant 

during period 

January 1, 1999, to 

December 31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older 

than 35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained 

from mother during 

postpartum hospital stay 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-49 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR 

Birth weight: 

NR 

Gestational diabetes, %: 

NR 

Cesarean delivery,%: 

NR 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Figures 1 to 3 plot 

risk for each adverse 

pregnancy outcome 

by 10-lb increments in 

gestational weight 

gain. Women who 

gained 25 to 34 lbs 

during their 

pregnancy had lower 

risks for most 

outcomes when 

balancing risk for 

SGA status and other 

adverse pregnancy 

outcomes 

• Women who gained 

15 to 24 lbs had 

lowest risks for most 

outcomes, but 

increased their risk of 

having an SGA infant 

from 9.6% to 14.3% 

• Women who gained 

more than 34 lbs had 

higher risks for all 

outcomes, although 

their risk of having an 

SGA infant decreased 

from 9.6% to 6.6% 

Other infant outcomes: 

• NR 

Outcomes Description: 

Preeclampsia 

Groups 

G1: Weight gain < 25 lbs 

G2: Weight gain 25-35 lbs 

G3: Gained > 35 lbs 

Results 

AOR (95% CI) 

G1: 0.56 (0.49-0.64) 

G2: 1 

G3: 1.88 (1.74-2.04) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Maternal age 

• Race/ethnicity 

• Education 

• Medicaid status 

• Tobacco and alcohol 

use 

• Maternal height 

• Adequacy of prenatal 

care 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Child's sex 

• Child’s birth year 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-50 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period: 

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal 

weight women and their 

associations with 

gestational weight 

change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight 

women identified 

from pregnancy 

and delivery 

summary records 

(normal weight 

matched to obese 

by race, age, parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal 

weight (BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-51 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5 

G2: 14.5 P ≤ 0.001 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Preeclampsia, gestational 

hypertension 

Groups 

Pregravid wt 19.8-26.0 BMI: 

G1: < 11.5 kg gain 

G2: 11.6-16 kg gain 

G3: > 16 kg gain 

Pregravid wt > 29 kg 

G4: lost/gained nothing 

G5: 0.5-6.5 kg gain 

G6: 7-11.5 kg gain 

G7: 12-16 kg gain 

Results 

Preeclampsia: 

G1: 2.8% 

G2: 2.9% 

G3: 6.6% 

(P =. 048) 

G4:10.7% 

G5: 7.7% 

G6: 8.3% 

G7: 7.9% 

G8: 16.5% 

(P = .076) 

Gestational HTN: 

G1: 2.3% 

G2: 3.8% 

G3: 3.3% 

(P = .607) 

G4: 9.3% 

G5: 8.3% 

G6: 11.3% 

G7:10.3% 

G8: 9.0% 

(P = .832) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Maternal age 

• Parity 

• Race 

• Prenatal smoking 

• Prenatal alcohol use 

• Prenatal illicit drug use 

• Pregravid health 

• Weight and adequacy of 

prenatal care 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 

Poor 

Final Quality Score: 

Fair 
C-52 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period: 

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain 

in obese glucose 

tolerant women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI 

≥ 30 

• Normal 2h 75g oral 

glucose tolerance 

test (OGTT) during 

third trimester 

(according to WHO 

criteria) 

• Only first 

pregnancy during 

study period 

included 

Exclusion criteria: 

• Well defined 

chronic disease 

• Twin pregnancies 

• Women with GDM 

(n = 323) 

• Known diet 

treatment (n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of 

pregravid BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-53 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight gain: 

Categorized: 

• < 5.0. 5.0-9.9, 

10.0-14.9, ≥

15.0 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated by 

authors 

Birth weight: 

G1: 3500 (3200-

3840) 

G2: 3645 (3200-

4000) 

G3: 3750 (3390-

4125) 

G4: 3762 (3400-

4120) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Gestational hypertension 

Groups 

G1: < 5kg gain 

G2: 5.0-9.9 kg gain 

G3: 10.0-14.9 kg gain 

G4: ≥ 15.0 kg gain 

Results 

OR (95% CI) 

G1: 1 

G2: 2.1 (0.8-5.7) 

G3: 3.6 (1.3-9.8) 

G4: 4.8 (1.7-13.1) 

(P = 0.001 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Results of 2 hour 

OGTT 

• Age 

• Pregravid BMI 

• Parity 

• Smoking 

• Ethnicity and site of 

prenatal care 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 4 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-54 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabiru and Raynor, 

2004 

Country and setting: 

USA, hospital 

Enrollment Period: 

1999 to 2002 

Funding: 

NR 

Study Objective: 

To investigate effect of 

increase in body mass 

index category on 

obstetric outcomes 

Time frame: 

1999 to 2002 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,131 

Group Description: 

G1: No change in BMI 

between first 

prenatal visit and 

delivery 

G2: 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

G3: > 1 category 

increase in BMI 

between first 

prenatal visit and 

delivery 

Group N: 

G1: 2,556 

G2: 2,252 

G3: 323 

Inclusion criteria: 

• Singleton 

pregnancies 

Exclusion criteria: 

• Multiple 

pregnancies 

• BMI < 20 

• Missing BMI data 

Pregravid weight: 

• Measured at first 

prenatal visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• 20-24.9, 25-29.9, 30-

34.9, 35-39.9, ≥ 40 

Age (mean, yrs): 

G1: 24.7 (6.1) 

G2: 24.4 (5.7) 

G3: 25.2 (5.9) P < 0.001 

Parity: 

G1: Gravidity (mean): 1.9 

(1.9) 

G2: 1.5 (1.7) 

G3: 1.2 (1.7) P < 0.001 

Race,%: 

White 

G1: 1.9 

G2: 2.6 

G3: 2.8 

Black 

G1: 84.1 

G2: 82.8 

G3: 88.2 

Hispanic 

G1: 13.9 

G2: 14.6 

G3: 9.0 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean weight gain: 

G1: 8.6 pounds (8.4) 

G2: 22.2 pounds (10.2) 

G3: 55.3 pounds (23.8) 

Additional characteristics: 

NR 
C-55 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 579 

G2: 942 

G3: 189 

G4: 819 

G5: 790 

G6: 104 

Total weight gain: 

Categorized: 

• > 35 pounds 

for normal BMI, 

> 25 pounds 

for overweight 

BMI, > 15 

pounds for 

obese BMI 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: not 

stated, most 

likely difference 

between 

weight at first 

prenatal visit 

and weight at 

delivery 

Birth weight: 

G1: 2886.0 (756) 

G2: 3174.9 (600) 

G3: 3099.5 (673) 

P < 0.001 

G4: 3116 (713) 

G5: 3269 (698) 

G6: 3371 (733) 

P = 0.015 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 8.2 

G2: 12.6 

G3: 21.0 P < 0.001 

G4: 13.0 

G5: 14.3 

G6: 19.3 P = 0.256 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Incidence preeclampsia 

Groups 

BMI < 25 first assessment: 

G1: no change BMI 

category 

G2: increase 1 category 

G3: increase > 1 category 

BMI>/=25 first assessment 

G4: no change BMI 

category 

G5: increase 1 category 

G6: increase >1 category 

Results 

G1: 1.9% 

G2: 3.2% 

G3: 1.6% 

(P = .203) 

G4: 2.8% 

G5: 3.7% 

(P = .002) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Pre-gravid weight 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-56 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period: 

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight 

change on pregnancy 

outcomes in obese 

women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) 

(n = 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 

37 or more weeks 

of gestation) 

liveborn, singleton 

infants during 

1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-57 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 

56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 

43% 

G3: GWG (lb)Less 

than 2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, 

and greater than 

35 lb gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR 

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Preeclampsia 

Groups 

Analysis done by each 

class of obesity and weight 

changes in gestation: 

• Weight loss ≥ 10 lbs 

• Weight loss 2-9 lbs 

• No weight change 

• Gain 2-9 lbs 

• Gain 10-14 lbs 

• Gain 15-25 lbs 

• Gain 26-35 lbs 

• Gain > 35 lbs. 

Results 

Data all presented in graph 

form: 

Using a gain of 15-25 

pounds as reference for 

each obesity class, OR of 

preeclampsia lower with 

less weight gain and higher 

with more weight gain. 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Education 

• Poverty (defined as 

participation in one or 

more subsidized 

programs) 

• Tobacco use 

• Parity 

• Chronic hypertension 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-58 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued) 

 
C-59 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis 

Other maternal outcomes: 

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA 

by GWG category for 

each obesity class. All 3 

figures show similar 

patterns of increasing risk 

of preeclampsia, cesarean 

delivery, and LGA birth 

and decreasing risk of 

SGA birth with increasing 

GWG. Collectively, 

minimal risk for all 4 

outcomes corresponds to 

GWG categories where 

risk of LGA and SGA 

births intersect. This 

equates to GWG of 10 of 

25 lb for class I obese 

women, a gain of 0 tp 9 lb 

for class II obese women, 

and weight loss of 0 to 9 

lb for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA 

by GWG category and 

obesity class. Compared 

with women who gained 

15 to 25 lb during their 

pregnancies, those who 

gained less weight had 

significantly lower odds of 

preeclampsia, cesarean 

delivery, and LGA births, 

but higher odds for SGA 

births. Women who 

gained more than 25 lbs 

had higher odds for same 

3 pregnancy outcomes 

and lower odds for SGA 

births. 

Other infant outcomes: 

NR 
C-60 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Murakami et al., 2004 

Country and setting: 

Japan, hospital 

Enrollment Period: 

2001 

Funding: 

NR 

Study Objective: 

To estimate risk of 

perinatal morbidity of 

mother and infant with 

respect to maternal 

prepregnancy BMI and 

weight gain in Japanese 

women 

Time frame: 

2001 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

633 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 633 

G2: NR 

Inclusion criteria: 

• Live, singletons 

delivered between 

24 to 42 weeks 

gestation 

Exclusion criteria: 

NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 20.9 (2.8) 

G2: NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 29.1 (4.5) 

G2: NR 

Parity: 

G1: 0.6 (0.7) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 8.5 

G2: NR 

Diabetes mellitus,%: 

G1: 2.1 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Preeclampsia - mild: 

5.4%; severe: 4.1% 

G2: NR 

Additional characteristics: 

NR 
C-61 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 633 

G2: NR 

Total weight gain: 

G1: 10.5 (3.4) 

G2: NR 

Categorized: 

• < 8.5kg, 8.5-

12.5, > 12.5 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: last 

measurement 

was taken at 

hospitalization 

prior to delivery 

Birth weight: 

G1: 3,052.6 (483.8) 

G2: NR 

Gestational diabetes, %: 

G1: 2.1 

G2: NR 

Cesarean delivery,%: 

G1: 10.3 

G2: NR 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Preeclampsia 

Groups 

G1: < 8.5 kg gain 

G2: 8.5-12.5 kg gain 

G3: >12.5 kg gain 

Results 

Estimated OR (95% CI) 

G1: 0.74 (0.37-1.48) 

G2: 1 

G3: 0.57 (0.24-1.32) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Maternal age 

• Parity 

• Smoking 

• Weight gain 

• Gestational weeks 

• Pregravid BMI 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 8 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-62 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ogunyemi et al., 1999 

Country and setting: 

USA, hospital 

Enrollment Period: 

1990 to 1995 

Funding: 

NR 

Study Objective: 

To test IOM guidelines 

in a predominantly rural 

black population 

Time frame: 

1990 to 1995 

Duration of the study: 

582 women who 

delivered and then their 

medical record was 

abstracted 

Design: 

• Other observational: 

582 women 

consecutive women 

who delivered 

• Retrospective 

Total Study N: 

582 

Group Description: 

G1: Underweight 

G2: Normal 

G3: Overweight 

G4: Obese 

Group N: 

G1: 78 

G2: 223 

G3: 78 

G4: 203 

Inclusion criteria: 

• Single child 

• > 37 weeks 

gestation 

• Black 

• Registration for 

prenatal care within 

first trimester of 

pregnancy 

Exclusion criteria: 

• Difference between 

recalled pregravid 

weight and 

measured first 

trimester weight was 

≥ 10% 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 20.3 

G2: 22.1 

G3: 23.7 

G4: 25.4 (P < 0.01) 

Parity: 

G1: # nulliparous: 53 

G2: 54 

G3: 42 

G4: 26 (P < 0.01) 

Race,%: 

White 

NR 

Black 

G1: 100 

G2: 100 

G3: 100 

G4: 100 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: n = 0 

G2: n = 4 

G3: n = 3 

G4: n = 8 (P = 0.02) 

Hypertension,%: 

G1: n = 1 

G2: n = 2 

G3: n = 4 

G4: n = 14 (P < 0.01) 

Additional characteristics: 

NR 
C-63 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 196 

G2: 181 

G3: 205 

Total weight gain: 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: weight 

at last prenatal 

visit 

Birth weight: 

G1: 3,029 

G2: 3,210 

G3: 3,283 (P < 0.01) 

Gestational 

diabetes, %: 

G1: n = 0 

G2: n = 4 

G3: n = 3 

G4: n = 8 (P = 0.02) 

Cesarean 

delivery,%: 

G1: n = 20 

G2: n = 10 

G3: n = 17 (P = 

0.02) 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

• Asthma 

• Preeclampsia 

• Vomiting 

• C-section 

Other infant 

outcomes: 

• Low birth weight 

• Fetal distress 

• NICU 

Outcomes Description: 

Incidence preeclampsia 

Groups 

G1: “low weight gain” 

G2: “normal weight gain” 

G3: “high weight gain” 

Results 

G1: 10% 

G2: 7% 

G3: 19% 

(P = <.01) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• Pregravid BMI 

• Tobacco use 

• Hypertension 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Good 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-64 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

Country and setting: 

Maternity records, 

Department of 

Obstetrics and 

Gynecology at 

Landspitali University 

Hospital, Iceland 

Enrollment Period: 

Funding: 

NR 

Study Objective: 

To investigate relation 

between gestational 

weight gain in women of 

normal prepregnant 

weight and 

complications during 

pregnancy and delivery 

in a population with high 

gestational weight gain 

and birth weight 

Time frame: 

NR 

Duration of the study: 

1998 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

614 

Group Description: 

G1: No complication 

G2: Complications in 

pregnancy or 

delivery 

G3: Complications in 

pregnancy 

G4: Complications in 

delivery 

Group N: 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Inclusion criteria: 

• Women of normal 

prepregnancy 

weight randomly 

selected within 1 

year (1998) 

• No history of 

diabetes, 

hypertension, CVD, 

or thyroid problems 

• Singleton births 

• 38 to 43 weeks 

gestation 

• 20 to 40 years of 

age 

• Routine fetal 

biometry at 18 to 20 

week ultrasound 

• Received early and 

regular antenatal 

care 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 63.1 (6.2) 

G2: 62.0 (5.6) P = 0.059 

G3: 61.7 (4.8) P = 0.174 

G4: 62.2 (6.1) P = 0.274 

Pregravid BMI: 

G1: 22.2 

G2: 22.4 )1.6) P = 0.270 

G3: 22.4 (1.5) P = 0.338 

G4: 22.3 P = 0.584 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29 

G2: 29 P = 0.857 

G3: 29 P = 0.404 

G4: 29 P = 0.398 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Proportional weight gain, %:

G1: 26.0 

G2: 28.0 P = 0.018 

G3: 30.0 P = 0.005 

G4: 27.0 P = 0.546 

Additional characteristics: 

NR 
C-65 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Total weight gain: 

G1: 16.6 (4.9) 

G2: 17.4 (5.1) P = 

0.080 

G3: 18.4 (5.1) P = 

0.013 

G4: 16.9 (5.1) P = 

0.887 

Categorized: 

• According to IOM 

< 11.5, 11.-16.0, 

≥ 16.1, also 

quintiles < 12.5, 

12.5-15.5, 15.6-

17.8, 17.9-20.8, > 

20.8 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3789 (469) 

G2: 3749 (565) P = 

0.389 

G3: 3643 (526) P = 

0.032 

G4: 3806 (578) P = 

0.529 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Gestational hypertension, 

preeclampsia 

Groups 

G1: <11.5 kg gain 

G2; 11.5-16.0 kg gain 

G3: 16.1-20.0 kg gain 

G4: >20 kg gain 

Results 

% gestational htn 

G1: 1.5% 

G2: 4.6% 

G3: 5.1% 

G4: 9.2% 

(P = 0.026) 

% preeclampsia 

G1: 1.4% 

G2: 2.3% 

G3: 5.4% 

G4: 4.4% 

(P = 0.262) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• Height 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-66 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wataba et al., 2006 

Country and setting: 

Japan, academic 

medical center 

Enrollment Period: 

1981 to 1999 

Funding: 

NR 

Study Objective: 

To analyze association 

of pregnancy 

complications with 

prepregnant body mass 

index and weight gain 

during pregnancy in 

Japanese women 

Time frame: 

1981 to 1999 

Duration of the study: 

Entry into PNC up til 

delivery 

Design: 

• Perinatal data base 

and look at medical 

records 

retrospectively 

• Retrospective 

Total Study N: 

21,718 

Group Description: 

G1: Nulliparous 

G2: Parous women 

Group N: 

G1: 10,413 

G2: 11,305 

Inclusion criteria: 

• Singleton 

pregnancy 

delivering term 

baby at Osaka Med 

Center and 

Research Institute 

for Maternal and 

Child Health in 

19811999 

Exclusion criteria: 

• None reported 

Pregravid weight: 

• In data base don’t know 

if self reported 

Pregravid BMI: 

G1: 20.5 (2.6) 

G2: 21.1 (3.0) 

Imputed: 

• No 

Categorized: 

• Categorical in 2 kg/m2 

point intervals from 

prepregnancy weight; 

categorical into low, 

medium, high BMI 

groups (< 18, 18-23.9, > 

24) 

Age (mean, yrs): 

G1: 27.8 (4.1) 

G2: 30.45 (3.9) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-67 

Evidence Table 4. Gestational weight gain and hypertensive disorders (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 10413 

G2: 11305 

Total weight gain: 

G1: kg/wk: 0.25 

(SD 0.09) 

G2: kg/wk: 0.24 

(0.09) P < 0.01 

Categorized: 

• Categorical in 

kg/wk using 

prepregnancy 

weight and 

weight at 

delivery divided 

by gestational 

age of infant at 

birth 

Collected from: 

• Rate of weight 

gain 

determined by: 

total weight 

gain divided by 

weeks ga 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: and 

subtracting 

prepregnancy 

weight 

Birth weight: 

G1: SGA: 5.4% 

LGA 5.2% 

G2: SGA 6.5% LGA 

5.2% 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Preeclampsia 

Groups 

Separate analyses done 

for low, medium and high 

pregravid weight groups by 

following intervals of 

kg/week gain: 

• <0.15 

• 0.15-.20 

• 0.20-.25 

• 0.25-.30 

• 0.30-.35 

• 0.35-40 

• >0.40 

Results 

No clear trends for 

preeclampsia or severe 

preeclampsia by pregravid 

weight status and kg/week 

weight gains. AOR 

generally crossed 1.0 or 

had wide confidence 

intervals 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Baseline BMI 

• Parity 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-68 

Evidence Table 5. Gestational weight gain and gallstones 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ko, 2006 

Country and setting: 

USA, hospital 

Enrollment Period:

1987-2001 

Funding: 

NR 

Study Objective: 

Aim was to define 

incidence and risk factors 

for postpartum 

hospitalization as a result 

of gallstone-related 

disease 

Time frame: 

1987 to 2001 

Duration of the study: 

Entry into prenatal care 

through the postpartum 

period 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

26,680 

Group Description: 

G1: Cases 

G2: Controls 

Group N: 

G1: 6,670 

G2: 20,010 

Inclusion criteria: 

• Diagnosis of biliary 

tract-related diseases 

either at delivery 

hospitalization or on 

hospitalizations within 

1 year postpartum 

• Women with acute 

pancreatitis with 

associated diagnosis 

of cholelithiasis, 

choledocholithiasis, 

or cholangitis. Cases 

were defined as any 

woman with a biliary 

tract diagnosis at 

delivery 

hospitalization, or 

with a primary 

discharge diagnosis 

related to the biliary 

tract for a postpartum 

hospitalization 

• Four controls who 

were not hospitalized 

for biliary tract 

disease within 1 yr 

postpartum were 

randomly selected for 

each case and 

matched for year of 

delivery 

Exclusion criteria: 

• See above 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 25 32.8%, 25-29.9 

26.8%, > 30 40.4% 

G2: BMI < 25 62.8%, 25-29.9 

22.1%, > 30 15.1% 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce < 25, 25-29.9, > 

30 

Age (mean, yrs): 

G1: 26.0 ± 5.9 

G2: 27.2 ± 6.0 P < 0.001 

Parity: 

G1: Median 1 (0–13) 

G2: Median 1 (0–14) 

Race,%: 

White 

G1: 71.3 

G2: 83.5 

Black 

G1: 3.6 

G2: 3.9 

Hispanic 

G1: 17.5 

G2: 11.2 

Asian/Pacific Islander 

G1: 2.6 

G2: 6.4 

Other 

G1: 17.8 

G2: 12.8 

Smoking,%: 

G1: 17.4 

G2: 15.0 

Diabetes mellitus,%: 

G1: 5.0 

G2: 3.0 

Hypertension,%: 

Prepregnancy:

G1: 1.6% 

G2: 0.8% 

Additional characteristics: 

NR 
C-69 

Evidence Table 5. Gestational weight gain and gallstones (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 6670 

G2: 20010 

Total weight gain: 

G1: 12.6 ± 7.1

G2: 14.4 ± 6.0 P < 

0.001

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• birth certificate 

data 

Birth weight: 

G1: 3,442 ± 767 

G2: 3,443 ± 718 

Gestational 

diabetes, %: 

G1: 5.0 

G2: 3.0 

Cesarean 

delivery,%: 

G1: 25.1 

G2: 21.3 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

• “Risk of 

hospitalization 

was inversely 

associated with 

weight gain 

during 

pregnancy, even 

after adjustment 

for prepregnancy 

body mass 

index.” 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• Hospitalization for gallstones at delivery 

or within the first year postpartum 

Groups: 

G1: Cases 

G2: Controls 

Results: 

OR for pregnancy weight gain, per kg 

G1: 0.98 (0.97- 0.99) P < 0.001 

G2: NR 

Outcomes Set 2: 

NR 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Pre-gravid BMI 

• GDM 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Background: 

Fair 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Poor 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 4 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-70 

Evidence Table 5. Gestational weight gain and gallstones (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lindseth and Bird-Baker, 

2004 

Country and setting: 

USA, hospitals and clinics 

Enrollment Period:

NR 

Funding: 

NIH, NICHD 

Study Objective: 

To examine relationships 

of demographics, 

anthropometrics, prenatal 

physical activity, serum 

cholesterol, and nutrient 

intakes to symptomatic 

cholelithiasis occurrence 

Time frame: 

NR 

Duration of the study: 

14 weeks gestation to 1 

month post-partum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

128 

Group Description: 

G1: total cohort 

G2: NR 

Group N: 

G1: 128 

G2: NR 

Inclusion criteria: 

• Within first 12 weeks 

of pregnancy 

• Consented to 

participation 

• 18 to 40 years of age

• Could understand, 

read, and speak 

English 

Exclusion criteria: 

NR 

Pregravid weight: 

• Measured by study 

investigators 

• Routine pre-natal care 

Pregravid BMI: 

G1: 26.5 (6.08) 

G2: NR 

Imputed: 

• No 

Categorized: 

• 1990 National Academy of 

Sciences Standards 

Age (mean, yrs): 

G1: 26.0 (4.78) 

G2: NR 

Parity: 

Gravida:

G1: 2.7 (1.65) 

G2: NR 

Race,%: 

White 

G1: 76% 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 24% (Native American) 

G2: NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-71 

Evidence Table 5. Gestational weight gain and gallstones (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not specifically 

stated 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

cholelithiasis in 16 

women (12.5%) 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Cholelithiasis during pregnancy or upto 12 

weeks postpartum 

Groups: 

NA, weight gain continuous variable 

G1: 128 

G2: NR 

Results: 

Prenatal weight gain 

Partial correlation = 0.33; B = 0.13; not 

statistically significant 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Prenatal physical activity 

• Dietary fat 

• Dietary iron supplement 

• History of gallbladder disease 

• Serum cholesterol 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-72 

Evidence Table 6. Gestational weight gain and premature rupture of membranes 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Gosselink et al., 1992 

Country and setting: 

USA, university clinics 

Enrollment Period:

September 1985-August 

1987 (University of Iowa 

Hospitals) 

September 1987-April 

1990 (University of 

Chicago) 

Funding: 

US Public Health 

Services, National 

Institute of Child Health 

and Human 

Development 

Study Objective: 

To test hypothesis that 

maternal prepregnancy 

body weight, weight 

gain during gestation, 

and prepregnancy and 

pregnancy diet and 

supplement status 

relate to PROM and 

preterm delivery 

Time frame: 

September 1985 to 

August 1987 (University 

of Iowa Hospitals) 

September 1987 to April 

1990 (University of 

Chicago) 

Duration of the study: 

Interviewed within 72 

hours of delivery to 

obtain retrospective 

data 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

Total n = 1,176 

• n = 184, preterm 

delivery (≤ 36 

weeks) and PROM 

• n = 220, preterm 

delivery without 

PROM 

• n = 184, fullterm 

delivery with PROM 

• n = 588, Controls 

Group Description: 

G1: All cases 

G2: All controls 

Group N: 

G1: 588 

G2: 588 

Inclusion criteria: 

• 15-45 years 

• Singleton delivery 

• Consented to 

interview while still 

in hospital 

Exclusion criteria: 

• Mothers with 

chronic conditions 

likely to adversely 

affect the course of 

pregnancy such as 

cystic fibrosis, 

emphysema, 

chronic heart 

failure, or poorly 

controlled diabetes 

mellitus 

• Women receiving 

chemotherapy or 

radiation treatments 

• Mothers with limited 

mental capacity 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: ≤ 20: 26.5% 

20-29: 65.0% 

≥ 30: 8.5% 

G2: ≤ 20: 19.4% 

20-29: 68.6% 

≥ 30: 12.0% 

Imputed: 

• No 

Categorized: 

• Underweight: < 20 

• Normal weight: 20-29 

(referent) 

• Obese: > 30 

Age (mean, yrs): 

NR 

Parity: 

G1: % nulliparous: 44.4 

G2: % nulliparous: 44.4 

Race,%: 

White 

G1: 36.6 

G2: 36.6 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-73 

Evidence Table 6. Gestational weight gain and premature rupture of membranes (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 588 

G2: 588 

Total weight gain: 

G1: < 21 lbs: 36.7% 

21-30 lbs: 

34.0% 

31-40 lbs: 

14.1% 

> 40 lbs: 15.1% 

G2: < 21 lbs: 19.6% 

21-30 lbs: 

28.9% 

31-40 lbs: 

24.1% 

> 40 lbs: 27.4%

Categorized: 

• < 21lbs 

• 21-30 

• 31-40 

• > 40lbs 

Collected from: 

• Routine prenatal care or 

maternity 

recordsnot 

stated 

Ascertained by: 

• Not specifically 

stated 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes descriptions: 

AOR for premature rupture of 

membrane (95% CI) 

Groups: 

G1: GWG: 21-30 lbs 

G2 GWG: 31-40 lbs 

G3 GWG: > 40 lbs 

G4 GWG: < 21 lbs or lost 

weight

Results: 

Preterm, PROM moms and 

matched controls 

G1: 1.00 

G2: 0.24 (0.09-0.61) 

G3: 0.19 (0.07-0.57) 

G4 2.70 (1.14-6.36) 

Full term, PROM moms and 

matched controls 

G1 1.00 

G2: 0.56 (0.33-0.94) 

G3 0.83 (0.48-1.46) 

G4 0.83 (0.44-1.57) 

Preterm without PROM 

moms and matched controls 

G1: 1.00 

G2: 0.42 (0.21-0.84) 

G3: 0.37 (0.17-0.80)

G4 1.34 (0.78-2.32) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Fe supplementation 

• Urinary tract infection 

• Chorioamnionitis 

• Chlamydia 

• History of previous 

PROM 

• Adequacy of preganancy 

diet 

• USDA suggested dairy 

intake 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information 

on exposure, outcomes, 

and confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 4 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-74 

Evidence Table 6. Gestational weight gain and premature rupture of membranes (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nohr et al., 2007 

Country and setting: 

Denmark, primary care 

Enrollment period:

1996 to 2002 

Funding: 

Ellen Aagaard Nohr is 

supported by a grant 

(No.2002B020) from 

Health Insurance 

Foundation. Danish 

National Research 

Foundation established 

Danish Epidemiology 

Science Centre, which 

initiated and created 

Danish National Birth 

Cohort. Cohort is also 

result of major grant 

from this Foundation. 

Additional support for 

Danish National Birth 

Cohort obtained from 

Pharmacy Foundation, 

Egmont Foundation, 

March of Dimes Birth 

Defects Foundation and 

Augustinus Foundation 

Study Objective: 

Aim of present study to 

assess impact of 

obesity and gestational 

weight gain on risk of 

subtypes of preterm 

birth 

Time frame: 

1996 to 2002 

Duration of the study: 

Entry into prenatal care 

- delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

0 

Group Description: 

G1: Total 

Group N: 

G1: 62,167 

Inclusion criteria: 

• Women with 

singleton 

pregnancies who 

provided an 

interview at 

approximately 16 

weeks gestation 

Exclusion criteria: 

• Missing data on 

weight gain in 

pregnancy 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: < 25: 7,757 (12.5%) 

25 to 29: 26,152 (42.1%) 

30 to 34: 21,181 (34.1%) 

35+: 7,077 (11.4%) 

Parity: 

G1: 47% primiparous 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 84.1% nonsmoker 

Diabetes mellitus,%: 

G1: 1.2% 

Hypertension,%: 

G1: 1.6% 

Additional characteristics: 

NR 
C-75 

Evidence Table 6. Gestational weight gain and premature rupture of membranes (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 62 167 

G2: 2751 

G3: 41 991 

G4: 12 270 

G5: 5155 

Total weight gain: 

G1: Weekly weight 

gain (g) 8722;275g: 

(15.3%) 276–675g: 

(68.3%) 676g+ 

(16.4%) 

Categorized: 

• Weekly weight 

gain categorised 

into 3 groups 

(low, medium, 

high) using 

cutpoints at 275 

and 675 g, which 

were similar to 

those used in 

other studies 

Collected from: 

• Does not specifywomen selfreported weight 

gain status 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 1.2% 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Before 34 weeks 

of gestation, risk 

of induced 

preterm delivery 

potentiated 

among obese 

women with high 

weight gain, and 

after 34 weeks, 

risk was 

potentiated at 

extremes, 

namely among 

underweight 

women with a 

low weight gain 

and obese 

women with a 

high weight gain 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Adjusted hazard of 

spontaneous preterm birth 

with preterm premature 

rupture of membrane 

(PPROM) 

Groups: 

weekly weight gain 

G1: <275 g 

G2: 276-675 g 

G2: >675 g 

Results: 

Spontaneous preterm 

birth with PPROM 

G4: 1.5 [1.2, 1.7] 

G4: 1.0 Reference 

G4: 1.2 [1.0, 1.5] 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Height 

• Alcohol use 

• Socio-occupational 

status 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 4 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-76 

Evidence Table 7. Gestational weight gain and preterm labor 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lang et al., 1996 

Country and setting: 

USA, hospital 

Enrollment period: 

August 1977-March 

1980 

Funding: 

NR 

Study Objective: 

To estimate effects of 

23 factors on 

prevalence of premature 

labor and fetal growth 

retardation across 

birthweight spectrum 

Time frame: 

August 1977 to March 

1980 

Duration of the study: 

Pregnancy through 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

11,505 

Group Description: 

G1: Prevalence of 

preterm labor 

G2: Prevalence of SGA 

Group N: 

Inclusion criteria: 

• Singleton 

• Livebirths 

• Had data on 

birthweight, 

gestational age, 

and sex 

• Infants with 

gestational age 

from 22 to 45 

weeks 

• Birthweights no 

more than 50% 

higher than 90th 

percentile for sex 

and gestational age 

Exclusion criteria: 

• Women with 

menstrual 

abnormalities for 

whom gestational 

dating was 

problematic 

• Stillbirths 

• Incomplete data 

• Preterm delivery 

• Women with 

preexisting 

diabetes mellitus, 

hypertension, 

epilepsy, asthma 

Pregravid weight: 

• Not stated by authors 

G1: NR 

• < 100 pounds: 11.2 

• 100-125: 5.9 

• 126-160: 5.1 

• 161-180: 7.3 

• > 180: 4.4 

G2: NR 

• < 100 pounds: 24.9 

• 100-125: 12.6 

• 126-160: 7.7 

• 161-180: 6.5 

• > 180: 5.9 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 

• < 15: 14.8 

• 16-19: 11.2 

• 20-24: 8.2 

• 25-34: 4.6 

• ≥ 35: 5.5 

G2: 

• < 15: 25.0 

• 16-19: 17.6 

• 20-24: 14.3 

• 25-34: 9.4 

• ≥ 35: 7.2 

Parity: 

G1: 6.4 

G2: 12.3 

Race,%: 

White 

G1: 5.3 

G2: 9.1 

Black 

G1: 9.6 

G2: 17.7 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 5.0 

G2: 14.0 

Smoking,%: 

% smoked throughout 

pregnancy:

G1: 8.3 

G2: 17.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-77 

Evidence Table 7. Gestational weight gain and premature labor (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Weekly rate of 

weight gain 

Collected from: 

• Not stated by 

authors 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• AOR for preterm labor 

(95% CI) 

Groups 

G1: Weekly weight gain ≤

0.40 

G2: Weekly weight gain > 

0.40-0.65 

G3: Weekly weight gain > 

0.65-0.90 

G4: Weekly weight gain > 

0.90 

G5: Weekly weight gain 

missing 

Results 

G1: 3.1 (2.3-4.2) 

G2: 1.6 (1.3-2.0) 

G3: 1.0 (ref) 

G4: 1.3 (1.0-1.6) 

G5: 2.4 (1.1-5.0) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Maternal height 

• Prepregnancy weight 

• Maternal education 

• Health insurance 

• Planned pregnancy 

• Previous induced 

abortion 

• Previous spontaneous 

abortion 

• Previous still birth 

• Maternal morbidity 

• Caffeine intake 

• Marijuana

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 3 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-78 

Evidence Table 8. Maternal weight gain and post-term pregnancy 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cedergren, 2006 

Country and setting: 

Sweden, Medical Birth 

Registry 

Enrollment Period:

January 1, 1994 - 

December 31, 2002 

Funding: 

Ostergotland County 

Council 

Study Objective: 

To estimate effects of 

high and low gestational 

weight gain in different 

maternal BMI classes 

on obstetric and 

neonatal outcomes 

Time frame: 

January 1, 1994 to 

December 31, 2002 

Duration of the study: 

First visit to maternity 

health care center to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

245,526 

Group Description: 

BMI 

G1: < 20 

G2: 20 to 24.9 

G3: 25 to 29.9 

G4: 30 to 34.9 

G5: ≥ 35 

Group N: 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Inclusion criteria: 

• Singleton, term 

pregnancies 

• Information on 

maternal height, 

maternal weight in 

early pregnancy, 

and gestational 

weight gain 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• If unknown, 

standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20.0-24.9, 25.0-

29.9, 30-34.9, ≥ 35 

Age (mean, yrs): 

G1: 15 to 19 years: 3.8% 

20 to 24: 23.0% 

25 to 29: 38.7% 

30 to 34: 25.7% 

35 to 39: 7.7% 

≥ 40: 1.1% 

G2: 15 to 19 years: 1.9% 

20 to 24: 15.9% 

25 to 29: 37.7% 

30 to 34: 31.1% 

35 to 39: 11.3% 

≥ 40: 1.9% 

G3: 15 to 19 years: 1.5% 

20 to 24: 15.7% 

25 to 29: 36.1% 

30 to 34: 31.2% 

35 to 39: 12.9% 

≥ 40: 2.5% 

G4: 15 to 19 years: 1.5% 

20 to 24: 17.4% 

25 to 29: 35.6% 

30 to 34: 30.0% 

35 to 39: 13.0% 

≥ 40: 2.4% 

G5: 15 to 19 years: 1.1% 

20 to 24: 17.3% 

25 to 29: 38.0% 

30 to 34: 29.6% 

35 to 39: 11.7% 

≥ 40: 2.3% 

Race,%: 

White 

G1: 96.6 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 1.4 

G2: NR 

Other 

G1: 2.0 

G2: NR 

Smoking,%: 

G1: % nonsmoking: 81.6 

G2: 85.2 

G3: 83.1 

G4: 79.9 

G5: 78.4 

Group 6 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-79 

Evidence Table 8. Maternal weight gain and post-term pregnancy (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate 

Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Total weight gain: 

G1: < 8kg: 6.9% 

8-15.9kg: 65.2% 

≥ 16kg: 28.0% 

G2: < 8kg: 8.4% 

8-15.9kg: 67.1% 

≥ 16kg: 30.4% 

G3: < 8kg: 15.7% 

8-15.9kg: 54.4% 

≥ 16kg: 29.9% 

G4: < 8kg: 30.2% 

8-15.9kg: 48.7% 

≥ 16kg: 21.1% 

G5: < 8kg: 44.6% 

8-15.9kg: 40.9% 

≥ 16kg

Categorized: 

• < 8kg, 8-16, > 

16 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between 

maternal 

weights 

measured when 

woman attended 

delivery unit and 

maternal weight 

recorded at first 

visit to maternity 

health care 

center 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery, %: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Post-term pregnancy (>41 weeks) 

Groups 

G1:BMI < 20 

G2:BMI 20-24.9 

G3:BMI 25-29.9 

G4:BMI 30-34.9 

G5:BMI>35 

Results 

Post-term pregnancy by BMI for 

weight gain < 8 kg (reference gain 

8-16 kg) 

OR (95% CI): 

G1: 0.66 (0.27-1.63) 

G2: 0.86 (0.64-1.16) 

G3: 1.08 (0.87-1.42) 

G4: 1.23 (0.84-1.79) 

G5: 1.25 (0.66-2.37) 

Post-term pregnancy by BMI for 

weight gain >16 kg (reference 

weight gain 8-16kg) OR (95% CI): 

G1: 0.88 (0.56-1.39) 

G2: 0.87 (0.74-1.03) 

G3: 0.82 (0.66-1.03) 

G4: 0.78 (0.50-1.21) 

G5: 1.11 (0.51-2.41) 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

• Age 

• Parity 

• Smoking in early pregnancy 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• Year of birth 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information 

on exposure, outcomes, 

and confounders: 

Good 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 

 
C-80 

Evidence Table 9. Gestational weight gain and induction of labor 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

DeVader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period: 

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate 

relationship between 

gestational weight gain 

and adverse pregnancy 

outcomes among 

women with normal 

prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 

35 lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal 

prepregnancy BMI 

(19.8 –26.0 kg/m2) 

who were 18 to 35 

years of age at time 

of delivery and who 

delivered full-term 

(37 weeks or more) 

singleton infant 

during period 

January 1, 1999, to 

December 31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older 

than 35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained 

from mother during 

postpartum hospital stay 

Pregravid BMI: 

NR 

• Imputed: 

• No 

• Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-81 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Figures 1 to 3 plot 

risk for each 

adverse pregnancy 

outcome by 10-lb 

increments in 

gestational weight 

gain. Women who 

gained 25 to 34 lbs 

during their 

pregnancy had 

lower risks for most 

outcomes when 

balancing risk for 

SGA status and 

other adverse 

pregnancy 

outcomes 

• Women who 

gained 15 to 24 lbs 

had lowest risks for 

most outcomes, but 

increased their risk 

of having an SGA 

infant from 9.6% to 

14.3% 

• Women who 

gained more than 

34 lbs had higher 

risks for all 

outcomes, although 

their risk of having 

an SGA infant 

decreased from 

9.6% to 6.6% 

Other infant 

outcomes: 

• NR 

Outcomes Description: 

AOR for failed induction of labor 

Groups 

G1: < 30 lbs 

G2: 30-35lbs 

G3: > 35 lbs 

Results 

G1: 0.68 

(95% CI, 0.59–0.78) 

G2: 1.0 

G3: 1.51 

(95% CI, 1.39–1.64) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, maternal race or ethnicity, 

maternal education, Medicaid status, 

tobacco use, alcohol use, maternal height, 

prior pregnancy, adequacy of prenatal care 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Child's gender, birth year 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 7 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-82 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period: 

July 1, 1985 - 

December 31, 1985 (6 

months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal 

weight or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to 

December 31, 1985 (6 

months) 

Duration of the study: 

Prepregnancy to 

delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at 

delivery 

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or 

over ideal weight for 

height) or abnormal 

pregnancy weight 

gain (≥ 20kg or ≤

5kg) 

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under normal 

weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital 

within study period 

selected those with 

abnormal maternal 

prepregnancy weight 

or abnormal weight 

gain during 

pregnancy, as well 

as next mother in 

sequential order with 

normal 

prepregnancy weight 

and weight gain 

during pregnancy to 

serve as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if 

self reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

• Imputed: 

• No 

• Categorized: 

• Continuous ≥ 20% over 

or under normal weight 

for height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 

(1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-83 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from Multivariate 

Analysis Quality Grading 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared to 

controls 

G2: 13.4 (4.5) 

G3: 3.0 (3.5) 

P < 0.0005 compared 

to controls 

G4: 23.2 (22.8) 

P < 0.0005 compared 

to controls 

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥ 20kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared to 

controls 

G2: 3293 (362) 

P < 0.05 compared to 

controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 compared to 

controls 

G5: 3538 (535) 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: Elective 7% 

Emergency 14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Induction of labor (%) 

Groups 

G1: weight gain ≤ 5kg 

G2: weight gain ≥ 20kg 

G3: reference (normal 

prepregnancy weight and 

normal weight gain [undefined]) 

Results 

G1: 23 % 

G2: 43 % 

G3: 24 % 

P < 0.05 for G2 vs. G3

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

NA 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NA 

Background: 

Fair 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

0 Good, 4 Fair, 5 

Poor 

Final Quality 

Score: 

Poor 
C-84 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Graves et al., 2006 

Country and setting: 

USA, midwifery 

practices 

Enrollment Period: 

January 1, 1998- 

December 31, 2000 

Funding: 

NR 

Study Objective: 

To identify association 

between prepregnancy 

BMI, weight gain in 

pregnancy, and 

newborn birth weight on 

route of delivery and 

induction of labor in 

patients receiving 

nurse-midwifery care 

Time frame: 

January 1, 1998- 

December 31, 2000 

Duration of the study: 

PRN care up til delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,500 

Group Description: 

G1: Total cohort 

Group N: 

G1: 1,500 

Inclusion criteria: 

• Non-diabetic 

• Entered labor after 

34 weeks gestation 

Exclusion criteria: 

• Planned cesarean 

delivery (n = 8) 

• Unknown parity (in 

analyses in which 

parity was an 

important 

consideration, 

n = 40) 

• Hypertension 

• Diabetes 

Pregravid weight: 

• Actual prepregnant 

weight or early first 

trimester weight 

documented in medical 

records 

Pregravid BMI: 

G1: < 19.8: 9.4% 

19.8-26.0: 52.1% 

26.1-29.0: 20.6% 

> 29: 17.4% 

• Imputed: 

• No 

• Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: ≤ 19 years: 32.2% 

20-34: 62.4% 

≥ 35: 4.9% 

Parity: 

G1: % nulliparous: 42.3 

Race,%: 

White 

G1: 26.9 

Black 

G1: 18.7 

Hispanic 

G1: 52.1 

Asian/Pacific Islander 

NR 

Other 

G1: 2.2 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-85 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Maternal Weight Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 1500 

G2: NR 

Total weight gain: 

G1: < 15 pounds: 

12.7% 

15-25: 25.2% 

26-35: 29.3% 

36-45: 16.3% 

> 45: 10.1% 

Categorized: 

• ≤ 15 pounds 16-

24, 25-35, 36-45, 

> 45 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: < 2500g: 3.5% 

2500-3999: 84.6% 

4000-4449: 9.1% 

≥ 4500: 1.4% 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 8.8 

G2: NR 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

OR induction of labor 

Groups 

G1: ≤ 45 pounds 

G2: > 45 pounds 

Results 

G2: 1.5 (95% CI, 1.0-2.4) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Maternal BMI 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 6 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-86 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period: 

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain 

in obese glucose 

tolerant women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI 

≥ 30 

• Normal 2h 75g oral 

glucose tolerance 

test (OGTT) during 

third trimester 

(according to WHO 

criteria) 

• Only first 

pregnancy during 

study period 

included 

Exclusion criteria: 

• Well defined 

chronic disease 

• Twin pregnancies 

• Women with GDM 

(n = 323) 

• Known diet 

treatment (n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of 

pregravid BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-87 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Maternal 

Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight 

gain: 

Categorized: 

• < 5.0. 5.0-

9.9, 10.0-

14.9, ≥ 15.0 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated 

by authors 

Birth weight: 

G1: 3500 (3200-3840) 

G2: 3645 (3200-4000) 

G3: 3750 (3390-4125) 

G4: 3762 (3400-4120) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

OR for induction of labor 

Groups 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9 kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0 kg 

Results 

G1: 1.0 

G2: 2.7 (95% CI, 1.3-5.7) 

G3: 2.8 (95% CI, 1.3-5.9) 

G4: 3.7 (95% CI, 1.7-8.0) 

P for trend=0.002 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Pre-gravid BMI 

• 2 hour OGTT result 

• Smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 4 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-88 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabiru and Raynor, 

2004 

Country and setting: 

USA, hospital 

Enrollment Period: 

1999 to 2002 

Funding: 

NR 

Study Objective: 

To investigate effect of 

increase in body mass 

index category on 

obstetric outcomes 

Time frame: 

1999 to 2002 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,131 

Group Description: 

G1: No change in BMI 

between first 

prenatal visit and 

delivery 

G2: 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

G3: > 1 category 

increase in BMI 

between first 

prenatal visit and 

delivery 

Group N: 

G1: 2,556 

G2: 2,252 

G3: 323 

Inclusion criteria: 

• Singleton 

pregnancies 

Exclusion criteria: 

• Multiple 

pregnancies 

• BMI < 20 

• Missing BMI data 

Pregravid weight: 

• Measured at first 

prenatal visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• 20-24.9, 25-29.9, 30-

34.9, 35-39.9, ≥ 40 

Age (mean, yrs): 

G1: 24.7 (6.1) 

G2: 24.4 (5.7) 

G3: 25.2 (5.9) P < 0.001 

Parity: 

G1: Gravidity (mean): 1.9 

(1.9) 

G2: 1.5 (1.7) 

G3: 1.2 (1.7) P < 0.001 

Race,%: 

White 

G1: 1.9 

G2: 2.6 

G3: 2.8 

Black 

G1: 84.1 

G2: 82.8 

G3: 88.2 

Hispanic 

G1: 13.9 

G2: 14.6 

G3: 9.0 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean weight gain: 

G1: 8.6 pounds (8.4) 

G2: 22.2 pounds (10.2) 

G3: 55.3 pounds (23.8) 

Additional characteristics: 

NR 
C-89 

Evidence Table 9. Gestational weight gain and induction of labor (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 579 

G2: 942 

G3: 189 

G4: 819 

G5: 790 

G6: 104 

Total weight gain: 

Categorized: 

• > 35 pounds 

for normal BMI, 

> 25 pounds 

for overweight 

BMI, > 15 

pounds for 

obese BMI 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: not 

stated, most 

likely difference 

between 

weight at first 

prenatal visit 

and weight at 

delivery 

Birth weight: 

G1: 2886.0 (756) 

G2: 3174.9 (600) 

G3: 3099.5 (673) 

P < 0.001 

G4: 3116 (713) 

G5: 3269 (698) 

G6: 3371 (733) 

P = 0.015 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 8.2 

G2: 12.6 

G3: 21.0 P < 0.001 

G4: 13.0 

G5: 14.3 

G6: 19.3 P = 0.256 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percent failed induction of labor

Groups 

G1: normal BMI, no change in BMI 

between first prenatal visit and 

delivery 

G2: normal BMI, 1 category 

increase in BMI between first 

prenatal visit and delivery 

G3: normal BMI, > 1 category 

increase in BMI between first 

prenatal visit and 

G4: overweight BMI, no change in 

BMI between first prenatal visit 

and delivery 

G5: overweight BMI, 1 category 

increase in BMI between first 

prenatal visit and delivery 

G6: overweight BMI, > 1 category 

increase in BMI between first 

prenatal visit and delivery 

Results 

G1: 4.7 

G2: 9.2 

G3: 15.9 

P < 0.001 for difference in normal 

BMI groups 

G4: 7.9 

G5: 10.3 

G6: 14.6 

P < 0.001 for difference in normal 

BMI groups 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

NA 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-90 

Evidence Table 10. Maternal weight gain and length of labor 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period: 

July 1, 1985 - 

December 31, 1985 (6 

months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal 

weight or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to 

December 31, 1985 (6 

months) 

Duration of the study: 

Prepregnancy to 

delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at 

delivery 

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or 

over ideal weight for 

height) or abnormal 

pregnancy weight 

gain (≥ 20kg or ≤

5kg) 

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under normal 

weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital 

within study period 

selected those with 

abnormal maternal 

prepregnancy weight 

or abnormal weight 

gain during 

pregnancy, as well 

as next mother in 

sequential order with 

normal 

prepregnancy weight 

and weight gain 

during pregnancy to 

serve as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if 

self reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over 

or under normal weight 

for height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 

(1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-91 

Evidence Table 10. Maternal weight gain and length of labor (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared 

to controls 

G2: 13.4 (4.5) 

G3: 3.0 (3.5) 

P < 0.0005 

compared to 

controls 

G4: 23.2 (22.8) 

P < 0.0005 

compared to 

controls 

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥

20kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared 

to controls 

G2: 3293 (362) 

P < 0.05 compared 

to controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 

compared to 

controls 

G5: 3538 (535) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: Elective 7% 

Emergency 

14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 

18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Labor patterns by stage in 

minutes (SD) 

Groups 

G1: weight gain ≤ 5 kg 

G2: weight gain ≥ 20 kg 

G3: reference (normal 

prepregnancy weight and 

normal weight gain 

[undefined]) 

Results 

I stage 

G1: 333 (208) 

G2: 374 (208) 

G3: 346 (188) 

II stage 

G1: 15 (18) P< 0.05 compared 

to reference category 

G2: 27 (25) 

G3: 21 (18) 

III stage 

G1: 13 (13) 

G2: 13 (11) 

G3: 12 (12) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-92 

Evidence Table 10. Maternal weight gain and length of labor (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

Country and setting: 

USA, prenatal clinics 

Enrollment Period: 

January 1, 1987- 

December 31, 1989 

Funding: 

NR 

Study Objective: 

To determine influences 

of increased maternal 

prepregnancy weight 

and increased 

gestational weight gain 

on pregnancy outcome 

Time frame: 

January 1, 1987 to 

December 31, 1989 

Duration of the study: 

Initiation of prenatal 

care to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,191 

Group Description: 

G1: BMI < 19.8 

G2: 19.8-26.0 

G3: 27-29 

G4: > 29 

G5: All 

Group N: 

G1: 755 

G2: 1,621 

G3: 329 

G4: 486 

G5: 3191 

Inclusion criteria: 

• Delivery at or 

beyond 38 weeks 

of gestation 

• Singletons 

• Received prenatal 

care and delivered 

in Shands Hospital 

Exclusion criteria: 

• Fetal abnormalities 

• Oligohydramnios 

• Polyhydramnios 

• Medical or surgical 

complications (GI 

disorders, sickle 

cell 

hemoglobinopathy, 

hepatitis, 

hematologic 

disorders, 

malignant disease, 

renal disease, 

neurologic disease, 

pulmonary disease, 

psychiatric 

disorders, 

tuberculosis) 

• Incomplete risk 

variable data or 

outcome variable 

information 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• National Academy of 

Sciences 

Age (mean, yrs): 

G1: NR 

• < 20 years: 36.6% 

• 20-26 years: 44.8% 

• > 26 years: 18.7% 

G2: NR 

• < 20 years: 30.8% 

• 20-26 years: 46.5% 

• > 26 years: 22.6% 

G3: 

• < 20 years: 25.8% 

• 20-26 years: 48.9% 

• > 26 years: 25.2% 

G4: 

• < 20 years: 16.5% 

• 20-26 years: 53.9% 

• > 26 years: 29.6% 

G5: 

• < 20 years: 29.5% 

• 20-26 years: 47.5 % 

• > 26 years: 23.0% 

Parity: 

G1: % first: 49.3 

G2: 43.1 

G3: 37.4 

G4: 31.1 

G5: 42.1 

Race,%: 

White 

G1: 64.5 

G2: 60.0 

G3: 49.8 

G4: 51.9 

G5: 58.7 

Black 

G1: 33.6 

G2: 37.9 

G3: 48.9 

G4: 47.5 

G5: 39.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 1.9 

G2: 2.1 

G3: 1.2 

G4: 0.6 

G5: 1.7 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Hypertension,%: 

G1: 3.4 

G2: 4.6 

G3: 5.8 

G4: 10.7 

G5: 5.4 

Additional characteristics: 

G1: % married: 42.6 

G2: 46.1 

G3: 40.4 

G4: 49.4 

G5: 45.2 

Additional characteristics: 

NR 
C-93 

Evidence Table 10. Maternal weight gain and length of labor (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 755 

G2: 1621 

G3: 329 

G4: 486 

G5: 3191 

Total weight gain: 

G1: 

• < 16kg: 7.8% 

• 16-25kg: 18.5% 

• 26-35kg: 35.1% 

• > 35kg: 38.5% 

G2: 

• < 16kg: 11.7% 

• 16-25kg: 18.0% 

• 26-35kg: 28.8% 

• > 35kg: 41.5% 

G3: 

• < 16kg: 19.8% 

• 16-25kg: 19.1% 

• 26-35kg: 28.3% 

• > 35kg: 32.8% 

G4: 

• < 16kg: 32.3% 

• 16-25kg: 22.0%; 

Categorized: 

• Quartiles 

• National 

Academy of 

Sciences (below, 

within, or above 

recommended 

range) 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between self 

report and weight 

at last prenatal 

visit (mean 6.1 

days prior to 

delivery) 

Birth weight: 

G1: 

• < 2500g: 4.8% 

• 2500-4000g: 

89.1% 

• > 4000g: 6.1% 

G2: 

• < 2500g: 2.0% 

• 2500-4000g: 

85.2% 

• > 4000g: 12.8% 

G3: 

• < 2500g: 1.5% 

• 2500-4000g: 

83.0% 

• > 4000g: 15.5% 

G4: 

• < 2500g: 0.2% 

• 2500-4000g: 

82.5% 

• > 4000g: 17.3% 

Gestational 

diabetes, %: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Cesarean 

delivery,%: 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 11.9 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Frequency of 

macrosomia = 

12.2% 

• Frequency of 

cesarean = 

11.9% 

• Frequency of 

LBW = 2.9% 

Outcomes Description: 

Odds of labor 

abnormalities 

Groups 

G1: total weight gain < 16 

pounds 

G2: total weight gain 16-

25 pounds 

G3: total weight gain 26-

35 pounds 

G4: total weight gain > 35 

pounds 

Results 

Elevated odds of labor 

abnormalities only in the 

group gaining > 35 

pounds compared with 

women gaining < 16 

pounds; not significant 

when adjusted for 

confounders 

Trend analysis showed 

risk of labor abnormalities 

with increased weight 

gain, a difference in 10 lb. 

corresponds to OR: 2 (P< 

0.0001) after adjusting for 

BMI, patient care (private 

vs. nonprivate), parity, 

infant sex, hypertension, 

and macrosomia 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Prepregnancy weight 

quartile 

• Height (tertile) 

• BMI category 

• Race/ethnicity 

• Marital status 

• Private physician 

• Parity 

• Maternal age 

• Hypertension 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Infant sex 

• Birth weight 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 9 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-94 

Evidence Table 10. Maternal weight gain and length of labor (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

(continued)

 
C-95 

Evidence Table 10. Maternal weight gain and length of labor (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

• Frequency of 

postdate 

pregnancy = 

9.8% 

• Frequency of 

labor 

abnormalities 

(40% were 

unscheduled 

cesareans) = 

7.8% 

• Frequency of 

oxytocin 

induction = 

13.7% 

• Frequency of 

oxytocin 

augmentation 

= 16.1% 

• Frequency of 

meconium 

staining = 

21.5% 

Other infant 

outcomes: 

NA 
C-96 

Evidence Table 10. Maternal weight gain and length of labor (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Purfield and Morin, 

1994 

Country and setting: 

Tertiary care medical 

center, Pennsylvania 

Enrollment Period: 

Funding: 

NR 

Study Objective: 

To determine whether a 

group of normal weight 

women with a low risk 

pregnancy who 

increased prepregnancy 

weight by more than 

25% experienced a 

longer second stage of 

labor or higher 

proportion of operative 

deliveries than a group 

of normal weight women 

Time frame: 

Duration of the study: 

August 1991 to June 

1992 

Design: 

• Other observational 

: convenience 

sample 

• Retrospective 

Total Study N: 

104 

Group Description: 

G1: prepregnant weight 

increased by 25% or 

less 

G2: prepregnant weight 

increased by more than 

25% 

Group N: 

G1: 52 

G2: 52 

Inclusion criteria: 

• Low risk 

primiparous 

pregnancy 

• Normal 

prepregnant weight 

for height 

• 18 to 40 years of 

age 

• No medical or 

obstetric risk 

factors 

• 37 to 42 weeks 

gestation 

• Epidural anesthesia 

• Delivery of 

singleton infant 

weighing between 

5lb 8oz and 8lb 

13oz 

Exclusion criteria: 

• Management of 

delivery influenced 

by any fetal or 

maternal risk factor 

such as fetal 

distress, 

malpresentation, 

cepalopelvic 

disproportion, or 

maternal infection 

Pregravid weight: 

• Self-reported 

G1: 135.69 (15.43) 

G2: 129.81 (14.83) 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Normal weight was 

defined as a weight 

within 90-120% of 

standard weight for 

height based on 

Metropolitan Life 

Insurance Company 

Table of 1983 

• NR 

Age (mean, yrs): 

G1: 25.75 (4.83) 

G2: 25.83 (4.81) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-97 

Evidence Table 10. Maternal weight gain and length of labor (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 52 

G2: 52 

Total weight gain: 

G1: % of weight 

gain (greater than 

prepregnant 

weight): 20.60 

(3.52) 

G2: % of weight 

gain (greater than 

prepregnant 

weight): 33.21 

(5.45) t = -14.02 P 

= 0.001 

Categorized: 

• > 25% of 

prepregnant 

weight and ≤

25% of 

prepregnant 

weight 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between self 

report and 

weight at 

admission to 

hospital for 

birth 

Birth weight: 

G1: 3266 (351.54) 

G2: 3384 (327.47) t 

= -2.33 P = 0.02 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Length of second stage labor 

Groups 

G1: prepregnant weight 

increased by 25% or less 

G2: prepregnant weight 

increased by more than 25%

Results 

Normal weight primigravidas with 

a low risk pregnancy who gained 

an excessive amount of weight 

had a longer mean length of 

second stage labor than women 

who gained less weight 

Length of second stage in 

minutes by weight groups (SD) 

G1: 72.42 (46.69) 

G2: 93.28 (52.87) 

t=-2.05 P=0.02 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-98 

Evidence Table 11. Gestational weight gain and mode of delivery 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-99 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Percentage of cesarean 

deliveries 

Groups 

G1: 0 or weight loss 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Results 

G1: 25.8% 

G2: 26.8% 

G3: 28.8% 

G4: 35.0% 

G5: 33.8% 

P = NS 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-100 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

Country and setting: 

Canada, medical 

records 

Enrollment Period: 

Prenatal to birth 

Funding: 

cree board of health and 

social services of James 

Bay (Quebec) 

Study Objective: 

To determine effect of 

pregravid weight and 

pregnancy weight gain 

on pregnancy outcomes 

in Cree women 

Time frame: 

Prenatal to birth 

Duration of the study: 

7 year period: January 

1994 to December 2000 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

603 

Group Description: 

G1: Normal: 

BMI 18.5 - 24.9 

G2: Overweight: 

BMI 25-29.9 

G3: Obese: 

BMI ≥ 30 

G4: Total 

Group N: 

G1: 139 

G2: 168 

G3: 296 

G4: 603 

Inclusion criteria: 

• Used only Cree 

women 

• First birth observed 

per woman during 

study time period 

• Must have first 

weight recorded 

within first 14 

weeks gestation 

and final weight 

recorded within 4 

weeks of birth 

Exclusion criteria: 

• Women with 

secondary 

pregnancy in 

dataset (n = 792) 

• Women with first 

weight record > 14 

weeks gestation 

(n = 314) 

• Women with final 

weight record > 4 

weeks from birth 

(n = 202) 

• Women with both 

first weight record > 

14 weeks and final 

weight record > 4 

weeks (n = 70) 

• Women missing 

data on first or final 

weight (n = 3) 

Pregravid weight: 

• Routine pre-natal care 

• Medical records 

• Measured within 14 

weeks of gestation 

G1: 59.7 (5.0) 

G2: 73.0 (4.3) 

G3: 93.6 (12.3) 

G4: 80.0 (16.9) 

Pregravid BMI: 

NR 

Imputed: 

• Yes 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 20.8 (5.2) 

G2: 23.8 (5.4) 

G3: 25.5 (5.5) 

G4: 24.0 (5.7) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Hypertension,%: 

G1: 1.4 

G2: 1.8 

G3: 4.8 

G4: 3.2 

Additional characteristics: 

% low weight gain:

G1: 20.1 

G2: 10.1 

G3: 28.0 

G4: 21.2 

% acceptable weight gain:

G1: 28.8 

G2: 32.1 

G3: 33.4 

G4: 32.0 

% excessive weight gain: 

G1: 51.1 

G2: 57.7 

G3: 38.5 

G4: 46.6 
C-101 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 139 

G2: 168 

G3: 296 

Total weight gain: 

Categorized: 

• 1999 Canadian 

guidelines 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: within 

4 weeks of 

birth 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Cesarean 

delivery,%: 

G1: 10.8 

G2: 11.3 

G3: 24.1 (p < 

0.001) 

Instrumental 

delivery,%: 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Definition of 

low, adequate, 

and excessive 

weight gains: 

• For normal 

weight women 

- adequate 

weight gain is 

11.5 to 16 kg 

• For overweight 

women, 

adequate 

weight gain is 7 

to 11.5 kg 

• For obese 

women, 

adequate 

weight gain is 7 

to 11.5 kg 

• Weight gain 

below specified 

range is “low” 

and weight 

gain above 

specified range 

is “excessive” 

Other infant 

outcomes: 

> 4000g, > 4500g 

Outcomes Description: 

Percentage of cesarean 

sections 

Groups 

Primigravid women 

(maternal weight gain 

outcomes by BMI presented 

only for obese women) 

G1: Obese - low weight gain 

(< 7 kg) 

G2: Obese - acceptable 

weight gain (7-11.5 kg) 

G3: Obese - excessive 

weight gain (> 11.5 kg) 

G4: Total 

Results 

G1: 25.3 

G2: 23.5 

G3: 23.7 χ2 P=0.952 

G4: 24 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 5 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-102 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

(continued)

• Pregnancies with 

factors that may have 

influenced maternal 

weight gain such as 1 

parent being nonCree (n = 13), 

preterm deliveries 

(n = 91), twin 

pregnancies (n = 6), 

missing gestational 

age (n = 9) 

• Women with unknown 

glycemic status (n = 

30), type 2 DM (n = 

8), glycemic 

abnormalities before 

pregnancy not 

followed for diagnosis 

(n = 70) 

• Women classified as 

underweight (n = 5) 

 
C-103 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

 
C-104 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cedergren, 2006 

Country and setting: 

Sweden, Medical Birth 

Registry 

Enrollment Period: 

January 1, 1994 - 

December 31, 2002 

Funding: 

Ostergotland County 

Council 

Study Objective: 

To estimate effects of 

high and low gestational 

weight gain in different 

maternal BMI classes 

on obstetric and 

neonatal outcomes 

Time frame: 

January 1, 1994 to 

December 31, 2002 

Duration of the study: 

First visit to maternity 

health care center to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

245,526 

Group Description: 

BMI 

G1: < 20 

G2: 20 to 24.9 

G3: 25 to 29.9 

G4: 30 to 34.9 

G5: ≥ 35 

Group N: 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Inclusion criteria: 

• Singleton, term 

pregnancies 

• Information on 

maternal height, 

maternal weight in 

early pregnancy, 

and gestational 

weight gain 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• If unknown, 

standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20.0-24.9, 25.0-

29.9, 30-34.9, ≥ 35 

Age (mean, yrs): 

G1: 15 to 19 years: 3.8% 

20 to 24: 23.0% 

25 to 29: 38.7% 

30 to 34: 25.7% 

35 to 39: 7.7% 

≥ 40: 1.1% 

G2: 15 to 19 years: 1.9% 

20 to 24: 15.9% 

25 to 29: 37.7% 

30 to 34: 31.1% 

35 to 39: 11.3% 

≥ 40: 1.9% 

G3: 15 to 19 years: 1.5% 

20 to 24: 15.7% 

25 to 29: 36.1% 

30 to 34: 31.2% 

35 to 39: 12.9% 

≥ 40: 2.5% 

G4: 15 to 19 years: 1.5% 

20 to 24: 17.4% 

25 to 29: 35.6% 

30 to 34: 30.0% 

35 to 39: 13.0% 

≥ 40: 2.4% 

G5: 15 to 19 years: 1.1% 

20 to 24: 17.3% 

25 to 29: 38.0% 

30 to 34: 29.6% 

35 to 39: 11.7% 

≥ 40: 2.3% 

Race,%: 

White 

G1: 96.6 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 1.4 

G2: NR 

Other 

G1: 2.0 

G2: NR 

Smoking,%: 

G1: % nonsmoking: 81.6 

G2: 85.2 

G3: 83.1 

G4: 79.9 

G5: 78.4 

Group 6 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-105 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate 

Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Total weight gain: 

G1: < 8kg: 6.9% 

8-15.9kg: 65.2% 

≥ 16kg: 28.0% 

G2: < 8kg: 8.4% 

8-15.9kg: 67.1% 

≥ 16kg: 30.4% 

G3: < 8kg: 15.7% 

8-15.9kg: 54.4% 

≥ 16kg: 29.9% 

G4: < 8kg: 30.2% 

8-15.9kg: 48.7% 

≥ 16kg: 21.1% 

G5: < 8kg: 44.6% 

8-15.9kg: 40.9% 

≥ 16kg 

Categorized: 

• < 8kg, 8-16, > 

16 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between 

maternal 

weights 

measured when 

woman attended 

delivery unit and 

maternal weight 

recorded at first 

visit to maternity 

health care 

center 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery, %: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

AOR for weight gain for weight gain 

groups by cesarean of instrumental 

deliveries (95% CI) 

Groups 

Weight gain< 8 kg, 8-16 kg, and > 

16 kg for each BMI class below 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

AOR for weight gain< 8 kg for 

Cesarean section compared with 

weight gain 8-16 kg 

G1: 1.07 (0.89-1.29) 

G2: 0.98 (0.92-1.05) 

G3: 0.88 (0.82-0.95) 

G4: 0.81 (0.73-0.90) 

G5: 0.75 (0.66-0.87) 

AOR for weight gain< 8 kg for 

instrumental delivery compared with 

weight gain 8-16 kg 

G1: 0.89 (0.71-1.11) 

G2: 0.88 (0.80-0.96) 

G3: 0.85 (0.76-0.95) 

G4: 0.75 (0.63-0.88) 

G5: 0.83 (0.65-1.03) 

AOR for weight gain> 16 kg for 

instrumental delivery compared with 

weight gain 8-16 kg 

G1: 1.28 (1.15-1.43) 

G2: 1.19 (1.14-1.25) 

G3: 1.14 (1.06-1.23) 

G4: 1.09 (0.93-1.27) 

G5: 1.04 (0.77-1.40) 

AOR for weight gain> 16 kg for 

Cesarean section compared with 

weight gain 8-16 kg 

G1: 1.29 (1.17-1.43) 

G2: 1.24 (1.19-1.29) 

G3: 1.23 (1.17-1.30) 

G4: 1.22 (1.10-1.35) 

G5: 1.27 (1.05-1.52) 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

Maternal age, parity, smoking in 

early pregnancy, and year of birth 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

Year of birth 

Background: 

Fair 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-106 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Chen et al., 2004 

Country and setting: 

USA, private practice 

Enrollment Period: 

Feb 1993-June 2001 

Funding: 

NR 

Study Objective: 

To develop an easily 

usable integrated 

formula for predicting 

probability of 

cephalopelvic 

disproportion/failure to 

progress (CPD) and 

cesarean delivery (CS) 

as function of 

demographic factors in 

middle-class private 

practice 

Time frame: 

Feb 1993-June 2001 

Duration of the study: 

Entry into prenatal care 

until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,355 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 3,355 

G2: NR 

Inclusion criteria: 

• All primaparous, 

singleton births 

between February 

1993 and June 13, 

2001 

Exclusion criteria: 

• insufficent data for 

analysis with 

respect to all 5 

demographic 

factors 

Pregravid weight: 

• Self-reported 

• Weight taken at first 

prenatal visit if 

presented before 20 

weeks; if after 20 

weeks, self-reported 

Pregravid BMI: 

G1: BMI 

< 20 16.3% 

20-25 48% 

25-30 21% 

30-40 12.8% 

> 40 2% 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuouscategorical 

by 5 point increments (< 

25, 20-25, etc.) 

Age (mean, yrs): 

G1: < 20: 8.9 

20-24: 25.8% 

25-29: 36.7% 

30-34: 20.2% 

> 35 8.4% 

G2: NR 

Parity: 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-107 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 852 

G2: 1,383 

G3: 1,120 

Total weight gain: 

Categorized: 

• Categorical, < 

25, 25-35, > 35 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

subtracted 

from weight at 

first prenatal 

visit 

Birth weight: 

NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 20.9 

G2: 19.3 

G3: 25.4 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

Progression of 

adjusted OR of 

Cephalopelvic 

Disproportion 

(CPD): Every 5 lbs 

more weight gain 

during pregnancy = 

1.057 (1.005-1.110) 

progression in OR. 

Progression of 

adjusted OR of 

Cesearean 

Delivery: Every 5 lb 

more weight gain 

during pregnancy = 

1.094 (1.074 - 

1.115) progression 

in OR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Progression of AOR of 

cesarean delivery weight 

gain (for every 5 lbs) 

Groups 

Gestational weight gain in 

lbs 

Results 

1.094 (1.074 - 1.115) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Maternal height 

• Body mass index 

(BMI) 

• Maternal height 

• Maternal age 

• Pregnancy weight gain 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age at 

delivery 

• Fetal birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 8 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-108 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

DeVader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period: 

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate 

relationship between 

gestational weight gain 

and adverse pregnancy 

outcomes among 

women with normal 

prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 

35 lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal 

prepregnancy BMI 

(19.8 –26.0 kg/m2) 

who were 18 to 35 

years of age at time 

of delivery and who 

delivered full-term 

(37 weeks or more) 

singleton infant 

during period 

January 1, 1999, to 

December 31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older 

than 35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained 

from mother during 

postpartum hospital stay 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-109 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Figures 1 to 3 

plot risk for each 

adverse 

pregnancy 

outcome by 10-lb 

increments in 

gestational 

weight gain. 

Women who 

gained 25 to 34 

lbs during their 

pregnancy had 

lower risks for 

most outcomes 

when balancing 

risk for SGA 

status and other 

adverse 

pregnancy 

outcomes 

• Women who 

gained 15 to 24 

lbs had lowest 

risks for most 

outcomes, but 

increased their 

risk of having an 

SGA infant from 

9.6% to 14.3% 

• Women who 

gained more than 

34 lbs had higher 

risks for all 

outcomes, 

although their 

risk of having an 

SGA infant 

decreased from 

9.6% to 6.6% 

Outcomes Description: 

Adjusted odds ratio of 

mode of delivery by weight 

groups 

Groups 

G1: < 30 lbs 

G2: 30-35lbs 

G3: > 35 lbs 

Results 

AOR for cesarean (95% 

CI): 

G1: 0.82 (0.78–0.87) 

G2: 1.0 

G3: 1.35 (1.29–1.40) 

AOR for instrumental (95% 

CI): 

G1: 0.97 (0.90–1.04) 

G2: 1.0 

G3: 1.03 (0.97–1.08) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Maternal age 

• Maternal race or 

ethnicity 

• Maternal education 

• Medicaid status 

• Tobacco use 

• Alcohol use 

• Maternal height, 

• Prior pregnancy 

• Adequacy of prenatal 

care 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Child's gender 

• Birth year 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-110 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period: 

July 1, 1985 - 

December 31, 1985 (6 

months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal 

weight or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to 

December 31, 1985 (6 

months) 

Duration of the study: 

Prepregnancy to 

delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at 

delivery 

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or 

over ideal weight for 

height) or abnormal 

pregnancy weight 

gain (≥ 20kg or ≤

5kg) 

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under normal 

weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital 

within study period 

selected those with 

abnormal maternal 

prepregnancy weight 

or abnormal weight 

gain during 

pregnancy, as well 

as next mother in 

sequential order with 

normal 

prepregnancy weight 

and weight gain 

during pregnancy to 

serve as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if 

self reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over 

or under normal weight 

for height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 

(1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-111 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared 

to controls 

G2: 13.4 (4.5) 

G3: 3.0 (3.5) 

P < 0.0005 

compared to 

controls 

G4: 23.2 (22.8) 

P < 0.0005 

compared to 

controls 

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥

20kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared 

to controls 

G2: 3293 (362) 

P < 0.05 compared 

to controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 

compared to 

controls 

G5: 3538 (535) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: Elective 7% 

Emergency 

14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 

18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percentage of vaginal, 

forceps, vacuum, breech or 

cesarean deliveries by 

weight gain categories 

Groups 

G1: weight gain ≤ 5 kg 

G2: weight gain ≥ 20 kg 

G3: reference (normal 

prepregnancy weight and 

normal weight gain 

[undefined]) 

Normal vaginal delivery 

(%) 

G1: 90 P < 0.05 compared 

to controls 

G2: 64 

G3: 71 

Forceps or vacuum 

delivery (%) 

G1: 3 

G2: 13 

G3: 5 

Breech (%) 

G1: 1 

G2: 0 

G3: 2 

Cesarean section - elective 

% 

G1: 3 

G2: 5 

G3: 13 

Cesarean section - 

emergency % 

G1: 3 

G2: 18 

G3: 9 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NA 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-112 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Graves et al., 2006 

Country and setting: 

USA, midwifery 

practices 

Enrollment Period: 

January 1, 1998- 

December 31, 2000 

Funding: 

NR 

Study Objective: 

To identify association 

between prepregnancy 

BMI, weight gain in 

pregnancy, and 

newborn birth weight on 

route of delivery and 

induction of labor in 

patients receiving 

nurse-midwifery care 

Time frame: 

January 1, 1998- 

December 31, 2000 

Duration of the study: 

PRN care up til delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,500 

Group Description: 

G1: Total cohort 

Group N: 

G1: 1,500 

Inclusion criteria: 

• Non-diabetic 

• Entered labor after 

34 weeks gestation 

Exclusion criteria: 

• Planned cesarean 

delivery (n = 8) 

• Unknown parity (in 

analyses in which 

parity was an 

important 

consideration, 

n = 40) 

• Hypertension 

• Diabetes 

Pregravid weight: 

• Actual prepregnant 

weight or early first 

trimester weight 

documented in medical 

records 

Pregravid BMI: 

G1: < 19.8: 9.4% 

19.8-26.0: 52.1% 

26.1-29.0: 20.6% 

> 29: 17.4% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: ≤ 19 years: 32.2% 

20-34: 62.4% 

≥ 35: 4.9% 

Parity: 

G1: % nulliparous: 42.3 

Race,%: 

White 

G1: 26.9 

Black 

G1: 18.7 

Hispanic 

G1: 52.1 

Asian/Pacific Islander 

NR 

Other 

G1: 2.2 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-113 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 1500 

G2: NR 

Total weight gain: 

G1: < 15 pounds: 12.7% 

15-25: 25.2% 

26-35: 29.3% 

36-45: 16.3% 

> 45: 10.1% 

Categorized: 

• ≤ 15 pounds 16-24, 

25-35, 36-45, > 45 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery 

Birth weight: 

G1: < 2500g: 3.5% 

2500-3999: 84.6% 

4000-4449: 9.1% 

≥ 4500: 1.4% 

Gestational 

diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 8.8 

G2: NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Association of weight gain 

on mode of delivery 

Groups 

G1: ≤ 45 pounds 

G2: > 45 pounds 

Results 

Greater weight gain in 

pregnancy was not 

associated 

significantly with route of 

delivery 

Confounders and effect 

modifiers 

NR 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Prepregnancy BMI 

category 

• Total prenatal weight 

gain category 

• Induction of labor 

• Race/ethnicity 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age > 41 

weeks 

• Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-114 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jain et al, 

2007 

Country and setting: 

United States, hospitals 

Enrollment period: 

2002-2005 

Funding: 

Not reported 

Study Objective: 

To analyze risks of 

cesarean section, 

macrosomia, and 

breastfeeding at 10 weeks 

postpartum using logistic 

regression to estimate 

independent effects of 

prepregnancy BMI and 

gestational weight gain 

Time frame: 

2002-2005 

Duration of the study: 

Entry into prenatal care to 

10 weeks postpartum 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

7661 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• Term (> 37 weeks) 

and singleton for 

macrosomia and 

breastfeeding 

Exclusion criteria: 

• Cesarean analysis 

limited to to women 

with cephalic 

presentation-records 

with missing data 

excluded 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 
C-115 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

• NR 

Categorized: 

• ≤ 15 lbs 

• 15-25 lbs 

• 25-35 lbs 

• 35+ lbs 

Collected from: 

• Not outlined 

Ascertained by: 

• Birth certificate 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Cesarean delivery, primiparous 

and multiparous 

Groups: 

G1: WG ≤ 15 lbs 

G2: WG 15-24 lbs 

G3: WG 25-35 lbs 

G4: WG ≥ 35 lbs 

Results: 

AOR for primiparous cesarean 

delivery (from model including 

interaction term for 

overweight/obese + > 25 lbs 

weight gain) 

G1: 0.95 (0.59-1.52) 

G2: 1.0 (ref) 

G3: 1.10 (0.76-1.60) 

G4: 1.62 (1.10-2.39) 

AOR for multiparous cesarean 

delivery (from model including 

interaction term for 

overweight/obese + > 25 lbs 

weight gain) 

G1: 1.11 (0.60-2.04) 

G2: 1.0 (ref) 

G3: 1.08 (0.63-1.85) 

G4: 1.95 (1.02-3.72) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Maternal age 

• Pregravid BMI 

• Parity 

• Education 

• Race/ethnicity 

• US/foreign origin 

• Interaction terms for 

pregravid BMI and weight 

gain 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• NA 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 7 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-116 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period: 

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain 

in obese glucose 

tolerant women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI 

≥ 30 

• Normal 2h 75g oral 

glucose tolerance 

test (OGTT) during 

third trimester 

(according to WHO 

criteria) 

• Only first 

pregnancy during 

study period 

included 

Exclusion criteria: 

• Well defined 

chronic disease 

• Twin pregnancies 

• Women with GDM 

(n = 323) 

• Known diet 

treatment (n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of 

pregravid BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-117 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight gain: 

Categorized: 

• < 5.0. 5.0-9.9, 

10.0-14.9, ≥

15.0 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated by 

authors 

Birth weight: 

G1: 3500 (3200-

3840) 

G2: 3645 (3200-

4000) 

G3: 3750 (3390-

4125) 

G4: 3762 (3400-

4120) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

OR for cesarean delivery 

(95% CI) 

Groups 

G1: GWG 5.0-9.9 kg 

G2: GWG 10.0-14.9 kg 

G3: GWG ≥ 15 kg 

Results 

G1: 1.0 

G2: 2.4 (1.1-5.3) 

G3: 3.0 (1.4-6.4) 

G4: 3.6 (1.6-7.8) 

P for trend = 0.002 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Pre-gravid BMI 

• 2h OGTT result 

• Parity 

• Smoking 

• Ethnic background 

• Clinical center 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 4 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-118 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

Country and setting: 

USA, prenatal clinics 

Enrollment Period: 

January 1, 1987- 

December 31, 1989 

Funding: 

NR 

Study Objective: 

To determine influences 

of increased maternal 

prepregnancy weight 

and increased 

gestational weight gain 

on pregnancy outcome 

Time frame: 

January 1, 1987 to 

December 31, 1989 

Duration of the study: 

Initiation of prenatal 

care to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,191 

Group Description: 

G1: BMI < 19.8 

G2: 19.8-26.0 

G3: 27-29 

G4: > 29 

G5: All 

Group N: 

G1: 755 

G2: 1,621 

G3: 329 

G4: 486 

G5: 3191 

Inclusion criteria: 

• Delivery at or 

beyond 38 weeks 

of gestation 

• Singletons 

• Received prenatal 

care and delivered 

in Shands Hospital 

Exclusion criteria: 

• Fetal abnormalities 

• Oligohydramnios 

• Polyhydramnios 

• Medical or surgical 

complications (GI 

disorders, sickle 

cell 

hemoglobinopathy, 

hepatitis, 

hematologic 

disorders, 

malignant disease, 

renal disease, 

neurologic disease, 

pulmonary disease, 

psychiatric 

disorders, 

tuberculosis) 

• Incomplete risk 

variable data or 

outcome variable 

information 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• National Academy of 

Sciences 

Age (mean, yrs): 

G1: NR 

• < 20 years: 36.6% 

• 20-26 years: 44.8% 

• > 26 years: 18.7% 

G2: NR 

• < 20 years: 30.8% 

• 20-26 years: 46.5% 

• > 26 years: 22.6% 

G3: 

• < 20 years: 25.8% 

• 20-26 years: 48.9% 

• > 26 years: 25.2% 

G4: 

• < 20 years: 16.5% 

• 20-26 years: 53.9% 

• > 26 years: 29.6% 

G5: 

• < 20 years: 29.5% 

• 20-26 years: 47.5 % 

• > 26 years: 23.0% 

Parity: 

G1: % first: 49.3 

G2: 43.1 

G3: 37.4 

G4: 31.1 

G5: 42.1 

Race,%: 

White 

G1: 64.5 

G2: 60.0 

G3: 49.8 

G4: 51.9 

G5: 58.7 

Black 

G1: 33.6 

G2: 37.9 

G3: 48.9 

G4: 47.5 

G5: 39.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 1.9 

G2: 2.1 

G3: 1.2 

G4: 0.6 

G5: 1.7 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Hypertension,%: 

G1: 3.4 

G2: 4.6 

G3: 5.8 

G4: 10.7 

G5: 5.4 

Additional characteristics: 

G1: % married: 42.6 

G2: 46.1 

G3: 40.4 

G4: 49.4 

G5: 45.2 

Additional characteristics: 

NR 
C-119 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 755 

G2: 1621 

G3: 329 

G4: 486 

G5: 3191 

Total weight gain: 

G1: 

• < 16kg: 7.8% 

• 16-25kg: 18.5% 

• 26-35kg: 35.1% 

• > 35kg: 38.5% 

G2: 

• < 16kg: 11.7% 

• 16-25kg: 18.0% 

• 26-35kg: 28.8% 

• > 35kg: 41.5% 

G3: 

• < 16kg: 19.8% 

• 16-25kg: 19.1% 

• 26-35kg: 28.3% 

• > 35kg: 32.8% 

G4: 

• < 16kg: 32.3% 

• 16-25kg: 22.0%; 

Categorized: 

• Quartiles 

• National Academy 

of Sciences 

(below, within, or 

above 

recommended 

range) 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between self 

report and weight 

at last prenatal 

visit (mean 6.1 

days prior to 

delivery) 

Birth weight: 

G1: 

• < 2500g: 4.8% 

• 2500-4000g: 

89.1% 

• > 4000g: 6.1% 

G2: 

• < 2500g: 2.0% 

• 2500-4000g: 

85.2% 

• > 4000g: 

12.8% 

G3: 

• < 2500g: 1.5% 

• 2500-4000g: 

83.0% 

• > 4000g: 15.5% 

G4: 

• < 2500g: 0.2% 

• 2500-4000g: 

82.5% 

• > 4000g: 17.3% 

Gestational 

diabetes, %: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Cesarean 

delivery,%: 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 11.9 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Frequency of 

macrosomia = 

12.2% 

• Frequency of 

cesarean = 

11.9% 

• Frequency of 

LBW = 2.9% 

Outcomes Description: 

Adjusted odds ratio for 

unscheduled cesarean 

(95% CI) 

Groups 

G1: total weight gain < 16 

pounds 

G2: total weight gain 16-25 

pounds 

G3: total weight gain 26-35 

pounds 

G4: total weight gain > 35 

pounds 

Results 

G1: 1.0 

G2: 0.95 (0.6-1.5) 

G3: 1.3 (0.86-1.95) 

G4: 1.95 (1.32 - 2.87) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Prepregnancy weight 

quartile 

• Height (tertile) 

• BMI category 

• Private physician 

(yes/no) 

• Maternal age 

• Parity 

• Diabetes 

• Hypertension 

• Maternal education 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Birth weight 

• Gestational age 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 9 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-120 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

(continued)

 
C-121 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis 

• Frequency of postdate 

pregnancy = 9.8% 

• Frequency of labor 

abnormalities (40% 

were unscheduled 

cesareans) = 7.8% 

• Frequency of oxytocin 

induction = 13.7% 

• Frequency of oxytocin 

augmentation = 16.1% 

• Frequency of 

meconium staining = 

21.5% 

Other infant outcomes: 

NA 
C-122 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Joseph et al., 2003 

Country and setting: 

All deliveries that 

occurred among 

residents of Nova 

Scotia, Canada - from 

Nova Scotia Atlee 

Perinatal Database 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

To estimate contribution 

of changes in maternal 

characteristics (namely, 

age, parity, 

prepregnancy wieght, 

weight gain in 

pregnancy, smoking 

status) and obstetric 

practice (namely labor 

induction, epidural 

anesthesia, delivery by 

an obstetrician, 

midpelvic forceps 

delivery) to recent 

increases in primary 

cesarean delivery rates 

Time frame: 

NR 

Duration of the study: 

January 1, 1988 to 

December 31, 2000 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

100,259 

Group Description: 

G1: Births 1988-1991 

G2: Births 1998-2000 

G3: % Primary 

Cesarean Rate 

1988-1991 

G4: % Primary 

Cesarean Rate 

1998-2000 

Group N: 

G1: 44,317 

G2: 24,901 

G3: 44,317 

G4: 24,901 

Inclusion criteria: 

• All deliveries that 

occurred to 

residents of Nova 

Scotia 

Exclusion criteria: 

• Women with 

previous cesarean 

delivery 

Pregravid weight: 

• Data taken from 

standardized forms and 

hospital medical records 

- no mention of selfreport 

G1: < 55: 30.1% 

55-59: 21.2% 

60-69: 27.3% 

≥ 70: 21.4% 

G2: < 55: 20.4% 

55-59: 15.9% 

60-69: 27.7% 

≥ 70: 36.0% 

G3: < 55: 12.3% 

55-59: 12.6% 

60-69: 11.8% 

≥ 70: 16.9% 

G4: < 55: 13.2% 

55-59: 13.6% 

60-69: 14.7% 

≥ 70: 18.7% 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

% Age: < 20yrs:

G1: 9.4% 

20-29 yrs: 62.6% 

30-34yrs: 21.4% 

35-39 yrs: 5.9% 

≥ 40yrs: 0.7% 

G2: 8.0% 

20-29 yrs: 54.6% 

30-34yrs: 25.8% 

35-39 yrs: 10.1% 

≥ 40yrs: 1.5% 

G3: 12.5% 

20-29 yrs: 13.2% 

30-34yrs: 12.3% 

35-39 yrs: 14.8% 

≥ 40yrs: 17.6% 

G4: 11.4% 

20-29 yrs: 15.1% 

30-34yrs: 16.6% 

35-39 yrs: 19.6% 

≥ 40yrs: 22.7% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 32.6 

G2: 23.4 

G3: 27.1 

G4: 28.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 1.4 

G2: 1.2 

G3: 38.7 

G4: 50.3 

Additional characteristics: 

NR 
C-123 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

• NR 

Categorized: 

• < 5, 5-9, 10-

14(ref), 15-19, 

≥ 20 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not explained 

by authors - 

data taken 

from maternity 

records 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

NR 

Other infant 

outcomes 

NR 

Outcomes Description: 

AOR for cesarean delivery 

(95% CI) 

Groups 

G1: < 5 kg 

G2: 5-9 kg 

G3: 10-14 kg 

G4: 15-19 kg 

G5: ≥ 20 kg 

Results 

G1: 1.10 (1.00, 1.20) 

G2: 1.04 (0.99, 1.10) 

G3: 1.00 

G4: 1.09 (1.05,1.14) 

G5: 1.41 (1.35,1.47) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• Prepregnancy weight 

• Smoking 

• Pregnancy (singleton 

or multiple) 

• Hypertension 

• Diabetes 

• Previous fetal death 

• Induction 

• Epidural 

• Physician type 

• Time 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 3 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-124 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Joseph et al., 2003 

(continued)

Parity: 

%Parity: Nulliparous:

G1: 49.1% 

1: 31.7% 

2:13.4% 

3-4: 5.2% 

≥ 5: 0.6% 

G2: 50.3% 

1: 32.5% 

2:11.9% 

3-4: 4.6% 

≥ 5: 0.7% 

G3: 20.7% 

1: 5.9% 

2: 5.3% 

3-4: 6.3% 

≥ 5: 5.5% 

G4: 24.6% 

1: 6.8% 

2: 6.7% 

3-4: 6.5% 

≥ 5: 11.6% 
C-125 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 
C-126 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabiru and Raynor, 

2004 

Country and setting: 

USA, hospital 

Enrollment Period: 

1999 to 2002 

Funding: 

NR 

Study Objective: 

To investigate effect of 

increase in body mass 

index category on 

obstetric outcomes 

Time frame: 

1999 to 2002 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,131 

Group Description: 

G1: No change in BMI 

between first 

prenatal visit and 

delivery 

G2: 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

G3: > 1 category 

increase in BMI 

between first 

prenatal visit and 

delivery 

Group N: 

G1: 2,556 

G2: 2,252 

G3: 323 

Inclusion criteria: 

• Singleton 

pregnancies 

Exclusion criteria: 

• Multiple 

pregnancies 

• BMI < 20 

• Missing BMI data 

Pregravid weight: 

• Measured at first 

prenatal visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• 20-24.9, 25-29.9, 30-

34.9, 35-39.9, ≥ 40 

Age (mean, yrs): 

G1: 24.7 (6.1) 

G2: 24.4 (5.7) 

G3: 25.2 (5.9) P < 0.001 

Parity: 

G1: Gravidity (mean): 1.9 

(1.9) 

G2: 1.5 (1.7) 

G3: 1.2 (1.7) P < 0.001 

Race,%: 

White 

G1: 1.9 

G2: 2.6 

G3: 2.8 

Black 

G1: 84.1 

G2: 82.8 

G3: 88.2 

Hispanic 

G1: 13.9 

G2: 14.6 

G3: 9.0 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean weight gain: 

G1: 8.6 pounds (8.4) 

G2: 22.2 pounds (10.2) 

G3: 55.3 pounds (23.8) 

Additional characteristics: 

NR 
C-127 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 579 

G2: 942 

G3: 189 

G4: 819 

G5: 790 

G6: 104 

Total weight gain: 

Categorized: 

• > 35 pounds 

for normal BMI, 

> 25 pounds 

for overweight 

BMI, > 15 

pounds for 

obese BMI 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: not 

stated, most 

likely difference 

between 

weight at first 

prenatal visit 

and weight at 

delivery 

Birth weight: 

G1: 2886.0 (756) 

G2: 3174.9 (600) 

G3: 3099.5 (673) 

P < 0.001 

G4: 3116 (713) 

G5: 3269 (698) 

G6: 3371 (733) 

P = 0.015 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 8.2 

G2: 12.6 

G3: 21.0 P < 0.001 

G4: 13.0 

G5: 14.3 

G6: 19.3 P = 0.256 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

 Primary cesarean 

Groups 

Primary cesarean 

G1: normal BMI, no change in 

BMI between first prenatal 

visit and delivery 

G2: normal BMI, 1 category 

increase in BMI between 

first prenatal visit and 

delivery 

G3: normal BMI, > 1 category 

increase in BMI between 

first prenatal visit and 

G4: overweight BMI, no 

change in BMI between 

first prenatal visit and 

delivery 

G5: overweight BMI, 1 

category increase in BMI 

between first prenatal visit 

and delivery 

G6: overweight BMI, > 1 

category increase in BMI 

between first prenatal visit 

and delivery 

Results 

Operative vaginal delivery 

G1: 11.4 

G2: 12.4 

G3: 12.2 P = 0.837 

G4: 8.4 

G5: 11.4 

G6: 17.3 P < 0.001 

Cesarean delivery rate for 

failure to progress 

G1: 2.5 

G2: 6.5 

G3: 10.2 P = 0.203 

G4: 3.5 

G5: 6.9 

G6: 10.2 P = 0.002 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Pre-gravid BMI 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-128 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period: 

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight 

change on pregnancy 

outcomes in obese 

women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) 

(n = 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 

37 or more weeks 

of gestation) 

liveborn, singleton 

infants during 

1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-129 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 

56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 

43% 

G3: GWG (lb)Less 

than 2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, 

and greater than 

35 lb gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR 

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Odds of preeclampsia, 

cesarean delivery, LGA 

births, SGA births 

Groups 

All obese women 

G1: Loss 10 lbs or more 

G2: Loss 2 to 9 lbs 

G3: No change 

G4: Gain 2-9 lbs 

G5: Gain 10-14 lbs 

G6: Gain 15-25 lbs 

G7: Gain 25-35 lbs 

Results 

Compared with women 

who gained 15–25 lb 

during their pregnancies, 

those who gained less 

weight had significantly 

lower odds of 

preeclampsia, cesarean 

delivery, and LGA births, 

but higher odds for SGA 

births. 

Magnitude differed by 

obesity classification, even 

after adjusting for known or 

suspected confounders 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in 

Medicaid, WIC, food 

stamp programs) 

• Tobacco use 

• Chronic hypertension 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-130 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued)

 
C-131 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis 

Other maternal outcomes: 

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA 

by GWG category for 

each obesity class. All 3 

figures show similar 

patterns of increasing risk 

of preeclampsia, cesarean 

delivery, and LGA birth 

and decreasing risk of 

SGA birth with increasing 

GWG. Collectively, 

minimal risk for all 4 

outcomes corresponds to 

GWG categories where 

risk of LGA and SGA 

births intersect. This 

equates to GWG of 10 of 

25 lb for class I obese 

women, a gain of 0 tp 9 lb 

for class II obese women, 

and weight loss of 0 to 9 

lb for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA 

by GWG category and 

obesity class. Compared 

with women who gained 

15 to 25 lb during their 

pregnancies, those who 

gained less weight had 

significantly lower odds of 

preeclampsia, cesarean 

delivery, and LGA births, 

but higher odds for SGA 

births. Women who 

gained more than 25 lbs 

had higher odds for same 

3 pregnancy outcomes 

and lower odds for SGA 

births. 

Other infant outcomes: 

NR 
C-132 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Murakami et al., 2004 

Country and setting: 

Japan, hospital 

Enrollment Period: 

2001 

Funding: 

NR 

Study Objective: 

To estimate risk of 

perinatal morbidity of 

mother and infant with 

respect to maternal 

prepregnancy BMI and 

weight gain in Japanese 

women 

Time frame: 

2001 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

633 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 633 

G2: NR 

Inclusion criteria: 

• Live, singletons 

delivered between 

24 to 42 weeks 

gestation 

Exclusion criteria: 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 20.9 (2.8) 

G2: NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 29.1 (4.5) 

G2: NR 

Parity: 

G1: 0.6 (0.7) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 8.5 

G2: NR 

Diabetes mellitus,%: 

G1: 2.1 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Preeclampsia - mild: 

5.4%; severe: 4.1% 

G2: NR 

Additional characteristics: 

NR 
C-133 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 633 

G2: NR 

Total weight gain: 

G1: 10.5 (3.4) 

G2: NR 

Categorized: 

• < 8.5kg, 8.5-

12.5, > 12.5 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: last 

measurement 

was taken at 

hospitalization 

prior to delivery 

Birth weight: 

G1: 3,052.6 (483.8) 

G2: NR 

Gestational 

diabetes, %: 

G1: 2.1 

G2: NR 

Cesarean 

delivery,%: 

G1: 10.3 

G2: NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

AOR for cesarean delivery 

(95% CI) 

Groups 

G1: < 8.5 kg 

G2: 8.5-12.5 kg 

G3: > 12.5 kg 

Results 

G1: 1.08 (0.56-2.07) 

G2: 1.00 

G3: 1.23 (0.61-2.48) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 8 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-134 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Purfield and Morin, 

1994 

Country and setting: 

Tertiary care medical 

center, Pennsylvania 

Enrollment Period: 

Funding: 

NR 

Study Objective: 

To determine whether a 

group of normal weight 

women with a low risk 

pregnancy who 

increased prepregnancy 

weight by more than 

25% experienced a 

longer second stage of 

labor or higher 

proportion of operative 

deliveries than a group 

of normal weight women 

Time frame: 

Duration of the study: 

August 1991 to June 

1992 

Design: 

• Other observational 

: convenience 

sample 

• Retrospective 

Total Study N: 

104 

Group Description: 

G1: prepregnant weight 

increased by 25% or 

less 

G2: prepregnant weight 

increased by more than 

25% 

Group N: 

G1: 52 

G2: 52 

Inclusion criteria: 

• Low risk 

primiparous 

pregnancy 

• Normal 

prepregnant weight 

for height 

• 18 to 40 years of 

age 

• No medical or 

obstetric risk 

factors 

• 37 to 42 weeks 

gestation 

• Epidural anesthesia 

• Delivery of 

singleton infant 

weighing between 

5lb 8oz and 8lb 

13oz 

Exclusion criteria: 

• Management of 

delivery influenced 

by any fetal or 

maternal risk factor 

such as fetal 

distress, 

malpresentation, 

cepalopelvic 

disproportion, or 

maternal infection 

Pregravid weight: 

• Self-reported 

G1: 135.69 (15.43) 

G2: 129.81 (14.83) 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Normal weight was 

defined as a weight 

within 90-120% of 

standard weight for 

height based on 

Metropolitan Life 

Insurance Company 

Table of 1983 

• NR 

Age (mean, yrs): 

G1: 25.75 (4.83) 

G2: 25.83 (4.81) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-135 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 52 

G2: 52 

Total weight gain: 

G1: % of weight 

gain (greater than 

prepregnant 

weight): 20.60 

(3.52) 

G2: % of weight 

gain (greater than 

prepregnant 

weight): 33.21 

(5.45) t = -14.02 P 

= 0.001 

Categorized: 

• > 25% of 

prepregnant 

weight and ≤

25% of 

prepregnant 

weight 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between self 

report and 

weight at 

admission to 

hospital for 

birth 

Birth weight: 

G1: 3266 (351.54) 

G2: 3384 (327.47) t 

= -2.33 P = 0.02 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Rates of different modes of 

delivery by weight gain 

Groups 

G1: prepregnant weight 

increased by 25% or less 

G2: prepregnant weight 

increased by more than 

25% 

Results 

Higher rate of vacuum 

extraction and cesarean 

delivery and lower rate of 

spontaneous vaginal 

delivery. with excessive 

weight gain 

No difference in forceps 

delivery and vaginal 

delivery by weight gain 

status 

Vaginal delivery 

G1: n=27 

G2: n=9 

Vacuum extraction 

G1: n=14 

G2: n=25 

Low forceps 

G1: n=8 

G2: n=8 

Cesarean section 

G1: n=3 

G2: n=10 

χ2=15.87, P=0.001 for all 4 

modes of delivery by 

weight groups 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-136 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rosenberg et al., 2005 

Country and setting: 

USA, vital statistics data 

Enrollment Period: 

Bbirth certificates with 

self reported pregravid 

weight and weight gain 

Funding: 

NR 

Study Objective: 

To examine 

associations between 

obesity, diabetes, and 3 

adverse pregnancy 

outcomes (primary 

cesarean section, 

preterm birth, and LBW) 

by race/ethnic groups 

Time frame: 

Birth certificates with 

self reproted pregravid 

weight and weight gain 

Duration of the study: 

Birth certificates from 

1999, 2000, and 2001 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

329988 

Group Description: 

G1: Non-hispanic 

blacks 

G2: Non-hispanic 

whites 

G3: Non-hispanic 

asians 

G4: Hispanics 

G5: Total 

Group N: 

G1: 86,908 

G2: 96,581 

G3: 38,570 

G4: 107,612 

G5: 329,988 

Inclusion criteria: 

• Live singleton births 

• Information on 

maternal 

prepregnancy 

weight and 

maternal weight 

gain during 

pregnancy 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: < 100 pounds: 1.7% 

100-149: 49.1% 

150-199: 37.5% 

200-299: 11.2% 

≥ 300: 0.5% 

G2: < 100 pounds: 1.8% 

100-149: 69.5% 

150-199: 24.0% 

200-299: 4.7% 

≥ 300: 0.1% 

G3: < 100 pounds: 8.1% 

100-149: 79.5% 

150-199: 11.6% 

200-299: 0.8% 

≥ 300 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 27.5 

G2: 30.6 

G3: 29.7 

G4: 26.4 P < 0.001 

G5: 28.3 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 3.7 

G2: 2.6 

G3: 6.6 

G4: 3.5 

G5: 3.7 P < 0.001 

Hypertension,%: 

G1: 1.7 

G2: 0.6 

G3: 0.5 

G4: 0.7 

G5: 0.9 P < 0.001 

Additional characteristics: 

G1: PIH 1.9 

G2: 1.2 

G3: 0.7 

G4: 1.4 

G5: 1.4 P < 0.001 

Additional characteristics: 

G1: Preeclampsia 2.9 

G2: 1.3 

G3: 1.2 

G4: 2.6 

G5: 2.1 P < 0.001 

Additional characteristics: 

NR 
C-137 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 86,908 

G2: 96,581 

G3: 38,570 

G4: 107,612 

G5: 329,988 

Total weight gain: 

G1: < 41pounds: 

79.7% 

≥ 41 pounds: 

20.3% 

G2: < 41pounds: 

83.2% 

≥ 41 pounds: 

16.8% P < 0.001 

G3: < 41pounds: 

89.2% 

≥ 41 pounds: 

10.8% 

G4: < 41pounds: 

79.1% 

≥ 41 pounds: 

20.9% 

G5: < 41pounds: 

81.6% 

≥ 41 pounds: 

18.4% 

Categorized: 

• < 41, ≥ 41 

pounds 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 3.7 

G2: 2.6 

G3: 6.6 

G4: 3.5 

G5: 3.7 P < 0.001 

Cesarean 

delivery,%: 

G1: 16.2 

G2: 14.7 P < 0.001 

G3: 14.4 

G4: 13.8 

G5: 14.7 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Preterm birth 

10.5, 5.1, 5.9, 

7.8, 7.5 

P < 0.001 

(groups 

defined above) 

• LBW 9.7, 4.1, 

5.7, 6.1, 6.4 

P < 0.001 

(groups 

defined above) 

Outcomes Description: 

AOR for primary cesarean 

(95% CI) 

Groups 

G1: < 41 pounds 

G2: ≥ 41 pounds 

Results 

1.38 (1.34-1.41) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• GDM 

• Pregnancy induced 

hypertension 

• Pre-eclampsia 

• Prepregnancy weight 

• Chronic diabetes 

• Chronic hypertension 

• Marital status 

• Maternal education 

• Mother’s birthplace 

• Prenatal care payer 

• Social risk 

• Trimester prenatal 

care began 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 7 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-138 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria 

Baseline Characteristics Baseline Characteristics 

(continued) 

Author, year: 

Sherrard, 2007 

Country and setting: 

Canada, hospital 

Enrollment Period:

1978 to 2001 

Funding: 

NR 

Study Objective: 

To quantify the effects 

of pre-gravid BMI and 

gestational weight gain 

on caeserian delivery 

Time frame: 

1978 to 2001 

Duration of the study: 

22 years 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

63,930 

Group Description: 

G1: Primary caeserean 

w/o labor 

G2: Primary caeserean 

w/ labour 

G3: Repeat w/o labour 

G4: Repeat w/ labour 

Group N: 

G1: 58039 

G2: 57468 

G3: 5351 

G4: 2206 

Inclusion criteria: 

• Singleton term 

births 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• Yes 

Categorized: 

• < 18.5, 18.5-24.9. 25-

29.9, >30 

Age (mean, yrs): 

Categories by group 

<20: 1.9%, 1.9%, 0.2%, 

0.2% 

20 to 34: 82.2%, 

82.4%,70%, 72% 

35 or more: 15.9%, 15.7%, 

29.8%, 27.8% 

Parity: 

Nulliparous- Yes 

G1: 51.5% 

G2: 51.3% 

G3: NA 

G4: NA 

Race,%: 

NR 

Smoking,% (none): 

G1: 81% 

G2: 81% 

G3: 82.1% 

G4: 82.6% 

Diabetes mellitus,%: 

NA

Hypertension,%: 

NR

Additional characteristics: 

NR 
C-139 

Evidence Table 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Weight gain rate 

Low (<0.18) 

G1: 18.9% 

G2: 18.9% 

G3: 19.5% 

G4: 19.6% 

Normal (0.18-0.5) 

G1: 75.4% 

G2: 75.4% 

G3: 74.3% 

G4: 74.8% 

High (>0.5) 

G1: 5.7% 

G2: 5.7% 

G3: 6.2% 

G4: 5.6% 

Birth weight: 

Gestational 

diabetes, %: 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Cesarean delivery, primary and 

repeat, labored and 

unlabored 

Groups: 

Rate of weight gain (kg/wk) 

G1: Low (≤0.17) 

G2: Normal (0.18-0.50) 

G3: High (>0.50 

Results: 

AOR for unlabored cesarean, 

primary 

G1: 0.79 (0.59-1.05) 

G2: 1.00 (ref) 

G3: 1.03 (0.64-1.64) 

AOR for labored cesarean, 

primary 

G1: 0.77 (0.68-0.86) 

G2: 1.00 (ref) 

G3: 1.40 (1.23-1.60) 

AOR for unlabored cesarean, 

repeat 

G1: 0.91 (0.76-1.09) 

G2: 1.00 (ref) 

G3: 1.38 (1.04-1.83) 

AOR for labored cesarean, 

repeat 

G1: 0.79 (0.54-1.15) 

G2: 1.00 (ref) 

G3: 1.22 (0.72-2.09) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• BMI 

• Gestational diabetes 

• Pregnancy-induced 

hypertension 

• Macrosomia 

• Socioeconomic factors 

• Parity 

• Maternal age 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-140 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Shepard et al., 1998 

Country and setting: 

Obstetrical practices in 

New Haven, CT 

Enrollment Period: 

1988 to 1992 

Funding: 

Grants NIH 

Study Objective: 

To examine absolute 

and proportional 

gestational weight gain 

and prepregnancy BMI 

as predictors of primary 

cesarean delivery 

Time frame: 

1988 to 1992 

Duration of the study: 

First prenatal visit to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

2,301 

Group Description: 

G1: Cesarean delivery 

G2: Vaginal delivery 

Group N: 

G1: 312 

G2: 1,989 

Inclusion criteria: 

• Privately insured 

women who 

received prenatal 

care from 13 

largest obstetrical 

practices and 

health maintenance 

organizations in 

greater New 

Haven, CT region 

(part of a larger 

study of selected 

environmental risk 

factors on 

pregnancy) 

• Singleton deliveries 

at Yale-New Haven 

Hospital 

Exclusion criteria: 

• Repeat cesareans 

births 

• Missing information 

on key variables 

Pregravid weight: 

• Self-reported 

G1: 140.9 (28.6) 

G2: 136.3 (25.2) P = 0.007 

Pregravid BMI: 

G1: 24.3 (4.6) 

G2: 22.9 (3.9) P < 0.0001 

Imputed: 

• No 

Categorized: 

• NHANES II: ≤ 19.4; 

19.5-22.4; 22.5-28.5; > 

28.5 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

G1: 88.4 

G2: 91.2 

Black 

G1: 5.8 

G2: 4.9 

Hispanic 

G1: 3.5 

G2: 2.3 

Asian/Pacific Islander 

G1: 1.3 

G2: 1.1 

Other 

G1: 1.0 

G2: 0.4 

Smoking,%: 

% never smokers:

G1: 82.3 

G2: 85.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

%married:

G1: 95.8 

G2: 92.1 

Additional characteristics: 

NR 
C-141 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 312 

G2: 1989 

Total weight gain: 

G1: 35.4 (11.9) 

G2: 33.3 (11.9) P = 

0.005 

Categorized: 

• Proportional 

weight gain 

based on 

prepregnancy 

weight and 

weight change 

during 

pregnancy 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Propotional 

weight gain, lb, 

mean: 

cesarean 

delivery - 26.5 

(10.0); vaginal 

delivery - 25.2 

(9.3) P = 0.048 

Other infant 

outcomes: 

• Low birth 

weight rate = 

3.3% for entire 

study 

population 

Outcomes Description: 

Adjusted relative risk (95% CI) of 

cesarean delivery based on types of 

weight gain 

Groups 

G1: Proportional Weight Gain (total 

weight gain/ prepregnancy weight) 

G2: Absolute Weight Gain 

Results 

Underweight (< 19.4), ≤ median 

G1: 1.00 

G2: 1.00 

Underweight (< 19.4), > median 

G1: 2.08 (0.86-5.04) 

G2: 1.20 (0.56-2.59) 

Low-Average (19.5-22.4), ≤ median 

G1: 1.62 (0.90-3.67) 

G2: 1.00 (0.54-1.84) 

Low-Average (19.5-22.4), > median 

G1: 2.35 (1.06-5.21) 

G2: 1.62 (0.94-3.02) 

High-Average(22.5-28.4), ≤ median 

G1: 2.78 (1.26-6.12) 

G2: 1.80 (1.01-3.21) 

High-Average (22.5-28.4), > median 

G1: 3.06 (1.40-6.73) 

G2: 2.02 (1.14-3.57) 

Obese (> 28.5), ≤ median 

G1: 3.25 (1.40-7.54) 

G2: 2.13 (1.12-4.08) 

Obese (> 28.5), > median 

G1: 2.69 (1.18-6.16) 

G2: 1.65 (0.90-3.03) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Ethnicity 

• Parity 

• GDM 

• Pre-eclampsia 

• Placental problems 

• Fetal distress 

• Macrosomia 

• Induction 

• Height 

• Marital status 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 4 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-142 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wataba et al., 2006 

Country and setting: 

Japan, academic 

medical center 

Enrollment Period: 

1981 to 1999 

Funding: 

NR 

Study Objective: 

To analyze association 

of pregnancy 

complications with 

prepregnant body mass 

index and weight gain 

during pregnancy in 

Japanese women 

Time frame: 

1981 to 1999 

Duration of the study: 

Entry into PNC up til 

delivery 

Design: 

• Perinatal data base 

and look at medical 

records 

retrospectively 

• Retrospective 

Total Study N: 

21,718 

Group Description: 

G1: Nulliparous 

G2: Parous women 

Group N: 

G1: 10413 

G2: 11305 

Inclusion criteria: 

• Singleton 

pregnancy 

delivering term 

baby at Osaka Med 

Center and 

Research Institute 

for Maternal and 

Child Health in 

19811999 

Exclusion criteria: 

• None reported 

Pregravid weight: 

• Not stated 

Pregravid BMI: 

G1: 20.5 (2.6) 

G2: 21.1 (3.0) 

Imputed: 

• No 

Categorized: 

• Categorical in 2 kg/m2 

point intervals from 

prepregnancy weight; 

categorical into low, 

medium, high BMI 

groups (< 18, 18-23.9, > 

24) 

Age (mean, yrs): 

G1: 27.8 (4.1) 

G2: 30.45 (3.9) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-143 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 10413 

G2: 11305 

Total weight gain: 

G1: kg/wk: 0.25 

(SD 0.09) 

G2: kg/wk: 0.24 

(0.09) P < 0.01 

Categorized: 

• Categorical in 

kg/wk using 

prepregnancy 

weight and 

weight at 

delivery divided 

by gestational 

age of infant at 

birth 

Collected from: 

• Rate of weight 

gain 

determined by: 

total weight 

gain divided by 

weeks ga 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: and 

subtracting 

prepregnancy 

weight 

Birth weight: 

G1: SGA: 5.4% 

LGA 5.2% 

G2: SGA 6.5% LGA 

5.2% 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Adjusted odds ratio for 

cesarean deliveries by 

weight gain categories 

Groups 

Rate of weight gain, 

categorized differently 

across different BMI 

groups 

Results 

For nulliparous, low BMI 

women: 

Higher risk of cesarean 

delivery for women with 

weight gain ≥ 0.4 kg/week 

(AOR: 2.30 [95% CI 1.06-

4.98] compared with 

women gaining 0.25-0.3 

kg/week) 

For nulliparous, medium 

BMI women: 

Higher risk of cesarean 

delivery for women with 

weight gain ≥ 0.4 kg/week 

(AOR: 1.61 [[95% CI 1.21-

2.14] compared with 

women gaining 0.25-0.3 

kg/week) and for women 

with weight gain 0.35-0.4 

kg/week (AOR: 1.68 [95% 

CI 1.22-2.30] compared 

with women gaining 0.25-

0.3 kg/week) 

For nulliparous, high BMI 

women: 

No increased risk 

For parous, medium BMI 

women: 

Higher risk of cesarean 

delivery for women with 

weight gain 0.25-0.3 

kg/week (AOR: 1.49 [95% 

CI 1.09-2.04] compared 

with women gaining 0.20-

0.25 kg/week) 

No data presented on 

cesarean delivery for other 

BMI groups for parous 

women 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-144 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wataba et al., 2006 

(Continued) 

 
C-145 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

 Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Baseline BMI 

• Parity 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 
C-146 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Witter et al., 1995 

Country and setting: 

Obstetric database, 

Johns Hopkins Hospital, 

MD 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

To determine whether 

greater weight gain 

during pregnancy is 

associated with an 

increased risk of 

cesarean delivery and, if 

so, whether this effect is 

explained by positive 

influence of weight gain 

on birth weight and if 

there is a threshold of 

pregnancy weight gain 

above which risk of 

cesarean delivery is 

increased differentially 

Time frame: 

NR 

Duration of the study: 

1987 to 1989 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

4,346 

Group Description: 

G1: Cesarean deliveries 

G2: Vaginal deliveries 

Group N: 

G1: 1,086 

G2: 3,260 

Group 3Inclusion 

criteria: 

• Women who 

delivered infants ≥

28 weeks gestation 

Exclusion criteria: 

• Incomplete data 

Pregravid weight: 

• Self-reported 

• NR 

Pregravid BMI: 

G1: 24.7 (5.9) 

G2: 23.1 (4.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 26.9 (6.7) 

G2: 24.3 (6.1) 

Parity: 

NR 

Race,%: 

White 

G1: 40.3 

G2: 29.0 

Black 

G1: 59.7 

G2: 71.0 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 27.3 

G2: 29.6 

Diabetes mellitus,%: 

G1: 6.1 

G2: 2.6 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-147 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 1,086 

G2: 3,260 

Total weight gain: 

G1: 14.56 (6.53) * 

P < 0.05 

compared to 

vaginal 

deliveries 

G2: 13.49 (6.44) 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: used 

weight 

recorded at last 

visit prior to 

delivery 

Birth weight: 

G1: 3,128 (841) 

G2: 3,181 (618) 

Gestational 

diabetes, %: 

G1: 6.1 

G2: 2.6 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Incidence of 

cesarean in 

study 

population was 

25% 

Other infant 

outcomes 

• NA 

Outcomes Description: 

AOR for cesarean (95% 

CI) 

Groups 

NA, continuous pregnancy 

weight gain (kg) 

Results 

1.04 (1.02-1.05) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Pre-gravid BMI 

• Height 

• At least 1 previous 

viable pregnancy 

• Diagnosis of 

preeclampsia during 

the current pregnancy 

• Previous cesarean 

delivery 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-148 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Young et al., 2002 

Country and setting: 

USA, private practice 

Enrollment Period: 

Feb 1993 to June 2001 

Funding: 

NR 

Study Objective: 

To examine body mass 

index and pregnancy 

weight gain as risk 

factors for primary 

cesarean delivery in 

nulliparous women in 

middle-class private 

practice 

Time frame: 

Feb 1993 to June 2001 

Duration of the study: 

From entry into prenatal 

care up til delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,375 (hard to tell from 

tables however as #’s 

don’t add up to this) 

Group Description: 

G1: BMI < 20 

G2: BMI 20-25 

G3: BMI 25-30 

G4: BMI > 30 

G5: All 

Group N: 

G1: 551 

G2: 1616 

G3: 709 

G4: 500 

G5: 3361 

Inclusion criteria: 

• Primiparous 

deliveries between 

Feb 1993 and June 

13,2001 in large 

private practice 

obstetric clinic 

Exclusion criteria: 

• Missing BMI data 

on mother 

Pregravid weight: 

• Self-reported Routine 

pre-natal care 

Pregravid BMI: 

G1: 16.3% 

G2: 47.8% 

G3: 21% 

G4: 14.8% 

Imputed: 

• No 

Categorized: 

• Categorical based on 

American Bariatric 

Society definition of 

obesity and categories 

used by Cnattingius et 

al 

Age (mean, yrs): 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: < 20: 8.91%, 

20-29: 62.57%, 

30-34: 20.1%, 

> 35: 8.43% 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 90.6% 

Black 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 7.56% 

Hispanic 

NR 

Asian/Pacific Islander 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 1.88% 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-149 

Evidence Table 11. Gestational weight gain and mode of delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 551 

G2: 1616 

G3: 709 

G4: 500 

Total weight gain: 

G1: * (computed 

these 

percentages 

from n values) 

< 30#: 40.7% 

30-35#:27.2% 

> 35#: 32.1% 

G2: < 30#: 35.5% 

30-35#:27.6% 

> 35#: 36.9% 

G3: < 30#: 44.6% 

30-35#: 21.6% 

> 35#: 33.8% 

G4: < 30#: 63.6% 

30-35#: 12.8% 

> 35#: 23.6% 

Categorized: 

• Less than 30#, 

30-35#, > 35# 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: last 

weight minus 

first wt 

Birth weight: 

NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 12.7 

G2: 18.44 

G3: 24.96 

G4: 37.6 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

• CPD rate 

doubles in 

women with 

BMI of < 25 

kg/m2 with 

excessive 

weight gain 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Rate of cesarean deliveries 

by weight gain categories 

Groups 

G1: < 30 lbs 

G2: 30-35lbs 

G3: > 35 lbs 

Results 

Increase in overall 

cesarean delivery rate with 

increased weight gain was 

significant at all BMI levels 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• BMI 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Poor 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

0 Good, 3 Fair, 6 Poor 

Final Quality Score: 

Poor 
C-150 

Evidence Table 12. Gestational weight gain and vaginal birth after cesarean 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Juhasz et al., 2005 

Country and setting: 

USA, hospital 

Enrollment Period:

Prepregnancy weight as 

defined by patient and 

weight at last prenatal 

visit 

Funding: 

NR 

Study Objective: 

To estimate whether 

excessive weight gain 

or obesity are risk 

factors affecting 

success for vaginal birth 

after cesarean (VBAC) 

Time frame: 

Prepregnancy weight as 

defined by patient and 

weight at last prenatal 

visit 

Duration of the study: 

January 1, 1996 to 

December 31, 2000 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,213 

Group Description: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI 26.1-29.0 

G4: BMI > 29.0 

Group N: 

G1: 160 

G2: 715 

G3: 137 

G4: 201 

Inclusion criteria: 

• Women attempting 

VBAC per chart 

entry 

Exclusion criteria: 

• Multiple gestation 

• More than one 

previous cesarean 

delivery 

• Previous uterine 

scar other than low 

transverse 

• Malpresentation in 

current pregnancy 

• Presence of an 

intrauterine fetal 

demise 

• Delivery at less 

than 36 weeks of 

gestation 

• Incomplete 

information for a 

patient 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 32.4 

G2: 31.8 

G3: 31.1 

G4: 29.9 P < 0.001 

Parity: 

G1: gravidity (mean) 3.4 

G2: 3.6 

G3: 4.0 

G4: 4.7 

Race,%: 

White 

G1: 75.6 

G2: 63.9 

G3: 48.2 

G4: 31.3 

Black 

G1: 6.9 

G2: 9.1 

G3: 22.6 

G4: 32.8 

Hispanic 

G1: 10.0 

G2: 20.6 

G3: 24.8 

G4: 34.8 

Asian/Pacific Islander 

G1: 7.5 

G2: 5.2 

G3: 2.9 

G4: 1.0 

Other 

G1: 0 

G2: 1.3 

G3: 1.5 

G4: 0 P for race < 0.001 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: diabetes: 4.0 

G2: 6.0 

G3: 16.0 

G4: 20.0 P < 0.001 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-151 

Evidence Table 12. Gestational weight gain and vaginal birth after cesarean (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 160 

G2: 715 

G3: 137 

G4: 201 

Total weight gain: 

Categorized: 

• ≤ 40 pounds, 

> 40 pounds 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between selfreported 

prepregnancy 

weight and 

weight at last 

prenatal visit 

Birth weight: 

G1: 3,345.0 

G2: 3,367.8 

G3: 3,486.6 

G4: 3,448.9 

P = 0.004 

Gestational 

diabetes, %: 

G1: Diabetes: 4.0 

G2: 6.0 

G3: 16.0 

G4: 20.0 P < 0.001 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Vaginal birth after cesarean 

Groups: 

G1: ≤ 40 pounds 

G2: > 40 pounds 

Results: 

• Adjusted odds of VBAC success 

with respect to excessive weight 

gain, adjusted for previous 

NSVD, previous VBAC, 

diabetes, induction, birth weight 

> 4000g, recurrent indication, 

one-layer closure, and 

complications with respect to 

pregnancy weight gain, VBAC 

success rate was 79.1% in those 

who gained < 40 pounds and 

66.8% for those who gained 

more than 40 pounds during the 

pregnancy, P < 0.001 

• A higher VBAC success rate was 

still noted in group gaining less 

than 40 pounds when controlling 

for previous normal spontaneous 

vaginal delivery (NSVD), 

previous VBAC, indication for 

previous cesarean, birth weight, 

and diabetes, OR 1.58 (1.04-

2.40) 

• Those who were successful at 

VBAC gained significantly less 

weight than those who failed 

VBAC (29 +/-10.1 pounds and 

31.4 +/-12.7 pounds, 

respectively, P = 0.005) 

• There were fewer patients who 

gained more than 40 pounds in 

successful VBAC group (13.6%) 

than in failed VBAC group 

(22.7%, P < 0.001). Although 

there were more uterine ruptures 

in group that gained more than 

40 pounds (2.1% vs. 1.5%), this 

difference was not statistically 

significant, P = 0.515- weight 

gain specifically was found to 

decrease VBAC success, OR 

0.65 (0.42-0.98) 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

1 Good, 5 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-152 

Evidence Table 12. Gestational weight gain and vaginal birth after cesarean (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Juhasz et al., 2005 

(continued) 

 
C-153 

Evidence Table 12. Gestational weight gain and vaginal birth after cesarean (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

 Maternal confounders and effect 

modifiers accounted for in 

analysis: 

• Previous NVSD 

• Previous VBAC 

• Diabetes 

• Induction 

• Birth weight > 4000g 

• Recurrent indication 

• One layer closure 

• Complications 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 
C-154 

Evidence Table 13. Gestational weight gain and vaginal lacerations 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabiru and Raynor, 

2004 

Country and setting: 

USA, hospital 

Enrollment Period:

1999 to 2002 

Funding: 

NR 

Study Objective: 

To investigate effect of 

increase in body mass 

index category on 

obstetric outcomes 

Time frame: 

1999 to 2002 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,131 

Group Description: 

G1: No change in BMI 

between first 

prenatal visit and 

delivery 

G2: 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

G3: > 1 category 

increase in BMI 

between first 

prenatal visit and 

delivery 

Group N: 

G1: 2,556 

G2: 2,252 

G3: 323 

Inclusion criteria: 

• Singleton 

pregnancies 

Exclusion criteria: 

• Multiple 

pregnancies 

• BMI < 20 

• Missing BMI data 

Pregravid weight: 

• Measured at first 

prenatal visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• 20-24.9, 25-29.9, 30-

34.9, 35-39.9, ≥ 40 

Age (mean, yrs): 

G1: 24.7 (6.1) 

G2: 24.4 (5.7) 

G3: 25.2 (5.9) P < 0.001 

Parity: 

G1: Gravidity (mean): 1.9 

(1.9) 

G2: 1.5 (1.7) 

G3: 1.2 (1.7) P < 0.001 

Race,%: 

White 

G1: 1.9 

G2: 2.6 

G3: 2.8 

Black 

G1: 84.1 

G2: 82.8 

G3: 88.2 

Hispanic 

G1: 13.9 

G2: 14.6 

G3: 9.0 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean weight gain: 

G1: 8.6 pounds (8.4) 

G2: 22.2 pounds (10.2) 

G3: 55.3 pounds (23.8) 

Additional characteristics: 

NR 
C-155 

Evidence Table 13. Gestational weight gain and vaginal lacerations (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 579 

G2: 942 

G3: 189 

G4: 819 

G5: 790 

G6: 104 

Total weight gain: 

Categorized: 

• > 35 pounds for 

normal BMI, > 25 

pounds for 

overweight BMI, 

> 15 pounds for 

obese BMI 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not stated, most 

likely difference 

between weight 

at first prenatal 

visit and weight 

at delivery 

Birth weight: 

G1: 2886.0 (756) 

G2: 3174.9 (600) 

G3: 3099.5 (673) 

P < 0.001 

G4: 3116 (713) 

G5: 3269 (698) 

G6: 3371 (733) 

P = 0.015 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 8.2 

G2: 12.6 

G3: 21.0 P < 0.001 

G4: 13.0 

G5: 14.3 

G6: 19.3 P = 0.256 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

 Third/fourth degree lacerations 

Groups 

Primary cesarean 

G1: normal BMI, no change in BMI 

between first prenatal visit and 

delivery 

G2: normal BMI, 1 category increase in 

BMI between first prenatal visit and 

delivery 

G3: normal BMI, > 1 category increase 

in BMI between first prenatal visit 

and 

G4: overweight BMI, no change in BMI 

between first prenatal visit and 

delivery 

G5: overweight BMI, 1 category 

increase in BMI between first 

prenatal visit and delivery 

G6: overweight BMI, > 1 category 

increase in BMI between first 

prenatal visit and delivery 

Results 

Third/fourth degree lacerations (%) 

G1: 24.0 

G2: 29.3 

G3: 31.7 P < 0.001 

G4: 26.3 

G5: 27.5 

G6: 30.8 P = 0.780 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Pre-gravid BMI 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-156 

Evidence Table 13. Gestational weight gain and vaginal lacerations (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline 

Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period:

July 1, 1985 - 

December 31, 1985 (6 

months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal 

weight or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to 

December 31, 1985 (6 

months) 

Duration of the study: 

Prepregnancy to 

delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at 

delivery 

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or 

over ideal weight 

for height) or 

abnormal 

pregnancy weight 

gain (≥ 20kg or ≤

5kg) 

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under 

normal weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital 

within study period 

selected those with 

abnormal maternal 

prepregnancy 

weight or abnormal 

weight gain during 

pregnancy, as well 

as next mother in 

sequential order 

with normal 

prepregnancy 

weight and weight 

gain during 

pregnancy to serve 

as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if self 

reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over or 

under normal weight for 

height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 (1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional 

characteristics: 

NR 
C-157 

Evidence Table 13. Gestational weight gain and vaginal lacerations (continued) 

Maternal 

Weight Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight 

gain: 

G1: 11.8 (6.2) 

P < 0.05 

compared to 

controls

G2: 13.4 (4.5)

G3: 3.0 (3.5) 

P < 0.0005 

compared to 

controls

G4: 23.2 (22.8) 

P < 0.0005 

compared to 

controls

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥

20kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on 

last clinically 

measured 

weight prior 

to delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared to 

controls 

G2: 3293 (362) 

P < 0.05 compared to 

controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 compared to 

controls 

G5: 3538 (535) 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: Elective 7% 

Emergency 14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Vaginal repair II/ III % 

Groups 

G1: weight gain ≤ 5 kg 

G2: weight gain ≥ 20 kg 

G3: reference (normal prepregnancy 

weight and normal weight gain 

[undefined]) 

Results 

G1: 4/0 

G2: 5/0 

G3: 2/0 

Maternal confounders and effect 

modifiers accounted for in analysis: 

NA 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NA 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-158 

Evidence Table 14. Maternal weight gain and shoulder dystocia 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period: 

July 1, 1985 - 

December 31, 1985 (6 

months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal 

weight or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to 

December 31, 1985 (6 

months) 

Duration of the study: 

Prepregnancy to 

delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at 

delivery 

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or 

over ideal weight for 

height) or abnormal 

pregnancy weight 

gain (≥ 20kg or ≤

5kg) 

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under normal 

weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital 

within study period 

selected those with 

abnormal maternal 

prepregnancy weight 

or abnormal weight 

gain during 

pregnancy, as well 

as next mother in 

sequential order with 

normal 

prepregnancy weight 

and weight gain 

during pregnancy to 

serve as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if 

self reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over 

or under normal weight 

for height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 

(1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-159 

Evidence Table 14. Maternal weight gain and shoulder dystocia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared 

to controls 

G2: 13.4 (4.5) 

G3: 3.0 (3.5) 

P < 0.0005 

compared to 

controls 

G4: 23.2 (22.8) 

P < 0.0005 

compared to 

controls 

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥

20kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared 

to controls 

G2: 3293 (362) 

P < 0.05 compared 

to controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 

compared to 

controls 

G5: 3538 (535) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: Elective 7% 

Emergency 

14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 

18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percentage of shoulder 

dystocia cases by weight 

gain categories 

Groups 

G1: weight gain ≤ 5 kg 

G2: weight gain ≥ 20 kg 

G3: reference (normal 

prepregnancy weight 

and normal weight gain 

[undefined]) 

Results 

G1: 3 

G2: 2 

G3: 0.6 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NA 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-160 

Evidence Table 14. Maternal weight gain and shoulder dystocia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Geary et al., 1995 

Country and setting: 

Ireland, hospital 

Enrollment Period: 

March 1991 - December 

1992 

Funding: 

NR 

Study Objective: 

To determine if routine 

clinical indicators are 

useful predictors for 

shoulder dystocia 

Time frame: 

March 1991 - December 

1992 

Duration of the study: 

Pregnancy through 

delivery 

Design: 

• Case-control 

• Prospective 

Total Study N: 

363 

Group Description: 

G1: Cases 

G2: Controls 

Group N: 

G1: 66 

G2: 297 

Inclusion criteria: 

• All cases of 

shoulder dystocia 

during study period 

• Controlofs 

consisted 

consecutive women 

recruited mid-way 

through study 

period: must have 

had delivery in 

same hospital, 

singleton births and 

cephalic, vaginal 

delivery at term 

Exclusion criteria: 

• NA 

Pregravid weight: 

• not stated 

G1: < 90 kg: 98.5% 

G2: 98.0 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: ≥ 30: 48.5% 

G2: 42.1 

Parity: 

G1: %Multiparous: 89.4 

G2: 56.6 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-161 

Evidence Table 14. Maternal weight gain and shoulder dystocia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 66 

G2: 297 

Total weight gain: 

G1: < 12kg: 59.1% 

G2: 74.1 

Categorized: 

• < 12kg and ≥

12kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated 

Birth weight: 

G1: ≥ 4000g: 

87.9% 

G2: 16.8 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Shoulder dystocia by 

weight gain categories 

Groups 

Weight gain < 12 kg and ≥

12 kg for cases with 

shoulder dystocia and 

controls 

G1: Cases with shoulder 

dystocia 

G2: Controls 

Results 

maternal weight gain < 12 

kg 

G1: 59.1% 

G2: 74.1% 

OR 2.0 (1.6-2.2) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Parity 

• Previous birth ≥ 4000g 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

3 Good, 4 Fair, 2 Poor 

Final Quality Score: 

Poor 
C-162 

Evidence Table 14. Maternal weight gain and shoulder dystocia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabiru and Raynor, 

2004 

Country and setting: 

USA, hospital 

Enrollment Period: 

1999 to 2002 

Funding: 

NR 

Study Objective: 

To investigate effect of 

increase in body mass 

index category on 

obstetric outcomes 

Time frame: 

1999 to 2002 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,131 

Group Description: 

G1: No change in BMI 

between first 

prenatal visit and 

delivery 

G2: 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

G3: > 1 category 

increase in BMI 

between first 

prenatal visit and 

delivery 

Group N: 

G1: 2,556 

G2: 2,252 

G3: 323 

Inclusion criteria: 

• Singleton 

pregnancies 

Exclusion criteria: 

• Multiple 

pregnancies 

• BMI < 20 

• Missing BMI data 

Pregravid weight: 

• Measured at first 

prenatal visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• 20-24.9, 25-29.9, 30-

34.9, 35-39.9, ≥ 40 

Age (mean, yrs): 

G1: 24.7 (6.1) 

G2: 24.4 (5.7) 

G3: 25.2 (5.9) P < 0.001 

Parity: 

G1: Gravidity (mean): 1.9 

(1.9) 

G2: 1.5 (1.7) 

G3: 1.2 (1.7) P < 0.001 

Race,%: 

White 

G1: 1.9 

G2: 2.6 

G3: 2.8 

Black 

G1: 84.1 

G2: 82.8 

G3: 88.2 

Hispanic 

G1: 13.9 

G2: 14.6 

G3: 9.0 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean weight gain: 

G1: 8.6 pounds (8.4) 

G2: 22.2 pounds (10.2) 

G3: 55.3 pounds (23.8) 

Additional characteristics: 

NR 
C-163 

Evidence Table 14. Maternal weight gain and shoulder dystocia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 579 

G2: 942 

G3: 189 

G4: 819 

G5: 790 

G6: 104 

Total weight gain: 

Categorized: 

• > 35 pounds 

for normal BMI, 

> 25 pounds 

for overweight 

BMI, > 15 

pounds for 

obese BMI 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: not 

stated, most 

likely difference 

between 

weight at first 

prenatal visit 

and weight at 

delivery 

Birth weight: 

G1: 2886.0 (756) 

G2: 3174.9 (600) 

G3: 3099.5 (673) 

P < 0.001 

G4: 3116 (713) 

G5: 3269 (698) 

G6: 3371 (733) 

P = 0.015 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 8.2 

G2: 12.6 

G3: 21.0 P < 0.001 

G4: 13.0 

G5: 14.3 

G6: 19.3 P = 0.256 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Rates of shoulder dystocia by 

weight gain categories (%) 

Groups 

G1: normal BMI, no change in 

BMI between first prenatal 

visit and delivery 

G2: normal BMI, 1 category 

increase in BMI between 

first prenatal visit and 

delivery 

G3: normal BMI, > 1 category 

increase in BMI between 

first prenatal visit and 

delivery 

G4: overweight BMI, no 

change in BMI between 

first prenatal visit and 

delivery 

G5: overweight BMI, 1 

category increase in BMI 

between first prenatal visit 

and delivery 

G6: overweight BMI, > 1 

category increase in BMI 

between first prenatal visit 

and delivery 

Preeclampsia 

Results 

G1: 0.5 

G2: 1.4 

G3: 1.1 

P = 0.278 for associations 

within normal BMI categories 

G4: 1.0 

G5: 1.8 

G6: 1.9 

P = 0.357 for associations 

within overweight BMI 

categories 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-164 

Evidence Table 15. Gestational weight gain and cephalopelvic disproportion 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Devader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period:

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate 

relationship between 

gestational weight gain 

and adverse pregnancy 

outcomes among 

women with normal 

prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 

35 lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal 

prepregnancy BMI 

(19.8 –26.0 kg/m2) 

who were 18 to 35 

years of age at time 

of delivery and who 

delivered full-term 

(37 weeks or more) 

singleton infant 

during period 

January 1, 1999, to 

December 31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older 

than 35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained 

from mother during 

postpartum hospital stay 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-165 

Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

NR

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Figures 1 to 3 plot 

risk for each 

adverse 

pregnancy 

outcome by 10-lb 

increments in 

gestational weight 

gain. Women who 

gained 25 to 34 

lbs during their 

pregnancy had 

lower risks for 

most outcomes 

when balancing 

risk for SGA 

status and other 

adverse 

pregnancy 

outcomes 

• Women who 

gained 15 to 24 

lbs had lowest 

risks for most 

outcomes, but 

increased their 

risk of having an 

SGA infant from 

9.6% to 14.3% 

• Women who 

gained more than 

34 lbs had higher 

risks for all 

outcomes, 

although their risk 

of having an SGA 

infant decreased 

from 9.6% to 6.6% 

Outcomes Description: 

Adjusted Odds Ratios for 

Women With Normal 

Prepregnancy BMI (19.8 –26.0 

kg/m2

) by GWG Category for 

cephalopelvic disproportion 

(95% CI) 

Groups: 

G1: Gained less than 25 lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 35 lbs 

Results: 

CPD 

G1: 0.64 (0.55–0.75) 

G2: 1.0 

G3: 1.58 (1.44–1.75) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Race 

• Education 

• Income 

• Alcohol use 

• Height 

• Prior pregnancy 

• Inadequate prenatal care 

use 

• Smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Child's gender 

• Birth year 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-166 

Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Devader et al., 2007 

(combined)

 
C-167 

Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Other infant 

outcomes: 

NR 

• 
C-168 

Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Young et al., 2002 

Country and setting: 

USA, private practice 

Enrollment Period:

Feb 1993 to June 2001 

Funding: 

NR 

Study Objective: 

To examine body mass 

index and pregnancy 

weight gain as risk 

factors for primary 

cesarean delivery in 

nulliparous women in 

middle-class private 

practice 

Time frame: 

Feb 1993 to June 2001 

Duration of the study: 

From entry into prenatal 

care up til delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,375 (computed) 

Group Description: 

G1: BMI < 20 

G2: BMI 20-25 

G3: BMI 25-30 

G4: BMI > 30 

G5: All 

Group N: 

G1: 551 

G2: 1616 

G3: 709 

G4: 500 

G5: 3361 

Inclusion criteria: 

• Primiparous 

deliveries between 

Feb 1993 and June 

13,2001 in large 

private practice 

obstetric clinic 

Exclusion criteria: 

• Missing BMI data 

on mother 

Pregravid weight: 

• Self-reportedRoutine 

pre-natal care 

Pregravid BMI: 

G1: 16.3% 

G2: 47.8% 

G3: 21% 

G4: 14.8% 

Imputed: 

• No 

Categorized: 

• Categorical based on 

American Bariatric 

Society definition of 

obesity and categories 

used by Cnattingius et 

al 

Age (mean, yrs): 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: < 20: 8.91%, 

20-29: 62.57%, 

30-34: 20.1%, 

> 35: 8.43% 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 90.6% 

Black 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 7.56% 

Hispanic 

NR 

Asian/Pacific Islander 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 1.88% 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-169 

Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 551 

G2: 1616 

G3: 709 

G4: 500 

Total weight gain: 

G1: (computed these 

percentages from 

n values) < 30 

lbs: 40.7% 30-35 

lbs:27.2% > 

35lbs: 32.1% 

G2: < 30 lbs: 35.5% 

30-35 lbs:27.6% > 

35 lbs: 36.9% 

G3: < 30 lbs: 44.6% 

30-35 lbs: 21.6% 

> 35 lbs: 33.8% 

G4: < 30 lbs: 63.6% 

30-35 lbs: 12.8% 

> 35 lbs: 23.6%

Categorized: 

• Less than 30 lbs, 

30-35 lbs, > 35 

lbs 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

last weight minus 

first wt 

Birth weight: 

NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 12.7 

G2: 18.44 

G3: 24.96 

G4: 37.6 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

• CPD rate doubles 

in women with 

BMI of < 25 

kg/m2 with 

excessive weight 

gain 

Other infant 

outcomes: 

NR 

Outcomes Description: 

OR for cephalopelvic disproportion (95% CI) 

Groups: 

G1: < 30 pounds 

G2: 30-35 pounds 

G3: > 35 pounds 

BMI < 20: 

G1: 1.0 

G2: - 

G3: 3.8 (3-4.6) P < 0.01 

BMI 20-25: 

G1: 1.0 

G2: -

G3: 1.85 (1.63-2.06) P < 0.0001 

BMI 25-30: 

G1: 1.0 

G2: - 

G3: NS 

BMI > 30: 

G1: 1.0 

G2: - 

G3: NS 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Obesity: BMI at first prenatal visit 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Poor 

Sample selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

0 Good, 3 Fair, 6 Poor

Final Quality Score: 

Poor 
C-170 

Evidence Table 16. Gestational weight gain and complications of labor and delivery 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Marshall, 1991 

Country and setting: 

USA, hospital 

Enrollment Period:

not stated 

Funding: 

NR 

Study Objective: 

To examine relationships 

between a healthful 

lifestyle, demonstrated by 

selected health practices, 

and complications in term 

labor 

Time frame: 

Not stated 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

493 

Group Description: 

G1: total cohort 

G2: NR 

Group N: 

G1: 493 

G2: NR 

Inclusion criteria: 

• Women who had 

reached but not 

exceeded term (37-

41 weeks) 

Exclusion criteria: 

• Women who 

delivered at an 

outside hospital 

Pregravid weight: 

• Medical records 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Weight for height < 110% 

of ideal and > 111% of 

ideal 

Age (mean, yrs): 

G1: < 18 years: 4% 

18-25: 68% 

26-34: 25% 

> 34: 3% 

G2: NR 

Parity: 

Race,%: 

White 

G1: 77 

G2: NR 

Black 

G1: 18 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 5 

G2: NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% married:

G1: 44 

G2: NR 
C-171 

Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• 20-40 lbs and < 

20/ > 40 lbs 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

from medical 

records 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Specific 

complications that 

were examined: 

dystocia, retained 

placenta, postpartum 

hemorrhage, PIH 

Other infant 

outcomes: 

Specific 

complications that 

were examined: fetal 

distress and neonatal 

distress 

Outcomes Description: 

Risk of complications (dystocia, 

retained placenta, pp hemorrhage 

PIH, fetal distress and neonatal 

distress 

Groups: 

G1: <20 lbs 

G2: 20-40 lbs 

G3: > 40 lbs 

Results: 

In multivariate analysis a gestational 

weight gain of > 40 pounds 

increased the risk of complications 

(dystocia, retained placenta, pp 

hemorrhage PIH, fetal distress and 

neonatal distress) by 40%; 

Three variables, smoking, weight for 

height, and gestational weight gain 

explain 15% of the outcome; of 

note: smoking was associated with 

a protective effect (with a beta 

coefficient of .593 (p=.021) 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

• Pre-gravid BMI 

• Exercise 

• Alcohol 

• Drugs 

• Sleep 

• Breakfast 

• Snacks 

• Smoking 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 4 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-172 

Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

Country and setting: 

Maternity records, 

Department of Obstetrics 

and Gynecology at 

Landspitali University 

Hospital, Iceland 

Enrollment Period:

Funding: 

NR 

Study Objective: 

To investigate relation 

between gestational 

weight gain in women of 

normal prepregnant 

weight and complications 

during pregnancy and 

delivery in a population 

with high gestational 

weight gain and birth 

weight 

Time frame: 

NR 

Duration of the study: 

1998 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

614 

Group Description: 

G1: No complication 

G2: Complications in 

pregnancy or delivery

G3: Complications in 

pregnancy 

G4: Complications in 

delivery 

Group N: 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Inclusion criteria: 

• Women of normal 

prepregnancy weight 

randomly selected 

within 1 year (1998) 

• No history of 

diabetes, 

hypertension, CVD, 

or thyroid problems 

• Singleton births 

• 38 to 43 weeks 

gestation 

• 20 to 40 years of age

• Routine fetal biometry 

at 18 to 20 week 

ultrasound 

• Received early and 

regular antenatal care

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 63.1 (6.2) 

G2: 62.0 (5.6) P = 0.059 

G3: 61.7 (4.8) P = 0.174 

G4: 62.2 (6.1) P = 0.274 

Pregravid BMI: 

G1: 22.2 

G2: 22.4 )1.6) P = 0.270 

G3: 22.4 (1.5) P = 0.338 

G4: 22.3 P = 0.584 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29 

G2: 29 P = 0.857 

G3: 29 P = 0.404 

G4: 29 P = 0.398 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Proportional weight gain, %:

G1: 26.0 

G2: 28.0 P = 0.018 

G3: 30.0 P = 0.005 

G4: 27.0 P = 0.546 

Additional characteristics: 

NR 
C-173 

Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Total weight gain: 

G1: 16.6 (4.9)

G2: 17.4 (5.1) P = 

0.080

G3: 18.4 (5.1) P = 

0.013

G4: 16.9 (5.1) P = 

0.887

Categorized: 

• According to IOM < 

11.5, 11.-16.0, 

16.1-20, ≥20, also 

quintiles < 12.5, 

12.5-15.5, 15.6-

17.8, 17.9-20.8, 

> 20.8 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery 

Birth weight: 

G1: 3789 (469) 

G2: 3749 (565) P = 0.389

G3: 3643 (526) P = 0.032

G4: 3806 (578) P = 0.529

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

• Rates of complications in 

pregnancy and delivery and 

neonatal outcome by maternal 

weight gian categories based on 

IOM recommendations for 

women of normal weight before 

pregnancy and additionally at 

20.0kg (G1 to G4) 

• Relative risk for complications in 

pregnancy and delivery by 

quartiles of weight gain in 

pregnancy adjusted for age, 

height, parity, gestational length, 

and birth weight (G5-G9) 

Groups: 

G1: < 11.5 

G2: 11.-16.0 

G3: 16.1-20 

G4: ≥ 20 kg 

G5: < 12.5 kg 

G6: 12.5-15.5kg 

G7: > 15.5-17.8 

G8: > 17.8-20.8 

G9: > 20.8 

Results for quartiles: 

Complications in pregnancy or 

delivery 

G1: 29 

G2: 20.7 (P < 0.05 compared to > 

20kg) 

G3: 28 

G4: 32.1 P = 0.105 

Complications in pregnancy 

G1: 5.8 

G2: 6.8 (P < 0.05 compared to > 

20kg) 

G3: 10.2 

G4: 13.1 P = 0.24 

Complications in delivery 

G1: 23.2 

G2: 14 

G3: 17.7 

G4: 19 P = 0.866 

Results for quintiles: 

Complications in pregnancy or 

delivery n = 162 

G5: 1.16 (0.63-2.13) 

G6: 1.00 

G7: 1.02 (0.54-1.90) 

G8: 1.61 (0.88-2.93) 

G9: 1.88 (1.04-3.4) 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information 

on exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-174 

Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

(continued) 

 
C-175 

Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Complications in pregnancy 

n = 56 

G5: 1.17 (0.40-3.41) 

G6: 1.00 

G7: 2.0 (0.73-5.42) 

G8: 2.69 (1.01-7.18) 

G9: 3.58 (1.36-9.4) 

Complications in delivery 

n = 106 

G5: 1.13 (0.58-2.21) 

G6: 1.00 

G7: 0.71 (0.34-1.47) 

G8: 1.10 (0.55-2.10) 

G9: 1.14 (0.57-2.2) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Age 

• Parity 

• Height 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Gestational age 

• Birth weight 
C-176 

Evidence Table 17. Gestational weight gain and preterm birth 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Carmichael et al., 1997 

Country and setting: 

USA, hospital 

Enrollment Period:

1980 to 1990 

Funding: 

Grant HD27347-05 from 

National Institute of 

Child Health and 

Human Development 

Study Objective: 

To investigate 

usefulness of monitoring 

weight gain during 

pregnancy and 

mechanisms by which 

weight gain pattern 

relate to preterm 

delivery 

Time frame: 

1980 to 1990 

Duration of the study: 

Initiation of prenatal 

care to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

7,259 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 7,259 

G2: NR 

Inclusion criteria: 

• All deliveries during 

time study period at 

study hospital 

• Spontaneous 

preterm deliveries 

Exclusion criteria: 

• Multiple births 

(n = 642) 

• Randomly selected 

1 delivery for those 

women who 

experienced more 

than 1 pregnancy 

during study period 

(n = 2412) 

• Obese women 

(BMI > 29) 

• Women with 

diabetes or 

hypertension during 

pregnancy 

• Deliveries with 

congenital 

malformations 

• Women who 

reported “other” 

race/ethnicity 

• Non-spontaneous 

or medically 

indicated preterm 

deliveries 

• Women lacking 

data on pattern of 

weight gain 

• Women with 

missing data on at 

least 1 covariate 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 28.0 

G2: NR 

Parity: 

G1: Nulliparous: 55% 

G2: NR 

Race,%: 

White 

G1: 52 

G2: NR 

Black 

G1: 10 

G2: NR 

Hispanic 

G1: 12 

G2: NR 

Asian/Pacific Islander 

G1: 26 

G2: NR 

Other 

NR 

Smoking,%: 

G1: 16 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-177 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight Gain Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 7,259 

G2: NR 

Total weight gain: 

G1: Mean estimated 

total weight gain 16.8 kg

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery: difference 

between self 

reported 

prepregnancy 

weight and last 

measured weight 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes:

• Spontaneous 

preterm birth 

• Gestational age 

Outcomes Description: 

AOR (95% CI) of spontaneous 

preterm birth/ kg increase in 

total weight gain

Groups 

Total gestational weight gain 

(continuous) 

Results 

Linear regression analysis of 

gestational age (days) as 

dependent variable and 

gestational weight gain (kg) as 

independent variable: 

Regression coefficient= 0.51; tstatistic=13.1; P < 0.001 

AOR (95% CI) of spontaneous 

preterm birth/ kg increase in 

total weight gain: 0.84 (0.82-

0.87)

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

BMI, maternal age, infant sex 

cigarettes per day maternal 

height, parity, race, pattern of 

gain derived from quadratic 

curves 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

Infant sex 

Background: 

Poor 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-178 

 Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Dietz et al., 2006 

Country and setting: 

USA, PRAMS data 

Enrollment Period:

1996-2001 

Funding: 

NR 

Study Objective: 

Objective of study to 

estimate combined 

effects of prepregnancy 

BMI and pregnancy 

weight gain on preterm 

delivery of singleton 

births 

Time frame: 

1996-2001 

Duration of the study: 

Cross-sectional 

Design: 

• Cross-sectional 

• Retrospective 

Total Study N: 

113,019 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 113,019 

G2: NR 

Inclusion criteria: 

• New mothers 

delivering live birth 

in states 

participating in 

PRAMS with 

annual reponse 

rate of 70% or 

higher during 1996-

2001 

• Stratified, 

systematic sample 

Exclusion criteria: 

• Missing or 

Implausible 

estimates of birth 

weight, prepregnancy BMI, 

weight gain during 

pg, gestational age; 

multiple births 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Underweight < 19.8 

16% (20,352) Normal 19.8–

26 54% (59,088) Overweight 

26.1–28.9 12% (12,928) 

Obese 29–34.9 12% 

(13,910) Very obese > 35 

6% (6744) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

redefined obese as 

29.0-34.9 and added 

additional category for 

very obese: BMI > 35 

Age (mean, yrs): 

G1: < 20: 13% (13,258) 

20–34: 75% (81,157) 

35+: 12% (18,586) 

G2: NR 

Parity: 

G1: 0: 43% (51,918) 

1–2: 49% (50,648) 

> 3: 8% (10,050) 

G2: NR 

Race,%: 

White 

G1: 67 

G2: NR 

Black 

G1: 18 

G2: NR 

Hispanic 

G1: 11 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4 

G2: NR 

Smoking,%: 

G1: 17 

G2: NR 

Diabetes mellitus,%: 

G1: 5 (pre-existing or 

gestational) 

G2: NR 

Hypertension,%: 

G1: 11 (pre-existing or 

during pg) 

G2: NR 

Additional characteristics: 

NR 
C-179 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 20,352 

G2: 59,088 

G3: 12,928 

G4: 13,910 

G5: 6,744 

Total weight gain: 

G1: Weight gain 

during second and 

third trimesters of 

pregnancy: < 0.12 

21% (763) 0.12–0.22 

4.4% (1299) 0.23–

0.68 75.6% (14,905) 

0.69–0.79 9.1% 

(1632) > 0.79 8.8% 

(1753)

G2: Weight gain 

during second and 

third trimesters of 

pregnancy: < 0

Categorized: 

• Based on weight 

gain second and 

third trimesters of 

pregnancy 

(kg/wk) 

Collected from: 

• Weight gain data 

from birth 

certificate - 

presumably 

measured at 

prenatal visits, 

self reporthowever rates 

were determined 

by formula 

Ascertained by: 

• Birth certificate 

data and PRAMS 

survey 

Birth weight: 

G1: Moderately 

Preterm (32-36 

weeks) 4188 

Very Preterm (20-

31 weeks) 1,753 

G2: Moderately 

Preterm (32-36 

weeks): 9,495 

Very Preterm (20-

31 weeks): 4291 

G3: Moderately 

Preterm (32-36 

weeks): 2047 

Very Preterm (20-

31 weeks): 1,143 

G4: Moderately 

Gestational 

diabetes, %: 

G1: 5 (pre-existing or 

gestational) 

G2: NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Risk of preterm birth 

Groups 

Categories of mean rate of 

gestational weight gain 

(kg/wk) during second and 

third trimesters stratified by 

pregravid BMI and type of 

preterm birth (very preterm, 

20-31 weeks; moderate 

preterm, 32-36 weeks): 

G1: < 0.12 

G2: 0.12-0.22 

G3: 0.23-0.68 

G4: 0.69-0.79 

G5: > 0.79

Results 

In general, in comparison to 

women with normal BMI in G3: 

underweight women in G1- G5 

and normal weight women in 

G1, G2, and G5 were at 

increased risk of very preterm 

births (AOR: 1.5-9.8). 

Underweight women in G1-G3 

and G5 and normal women in 

G1, G2, and G5 were at 

increased risk moderate 

preterm births (AOR: 1.4-3.1). 

Overweight and obese women 

in G1 and G5 were at 

increased risk of very preterm 

birth (AOR: 2.3-2.5) but had 

no elevated risk of moderate 

preterm birth. Very obese 

women with G1, G4, G5 had 

increased risks of very 

preterm births (AOR: 2.1-2.8) 

and with G4 had increased 

risks of moderate preterm birth 

(AOR: 1.3) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Race, Medicaid recipient, 

parity, marital status 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

3 Good, 4 Fair, 2 Poor 

Final Quality Score: 

Fair 

 
C-180 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period:

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain 

in obese glucose 

tolerant women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI 

≥ 30 

• Normal 2h 75g oral 

glucose tolerance 

test (OGTT) during 

third trimester 

(according to WHO 

criteria) 

• Only first 

pregnancy during 

study period 

included 

Exclusion criteria: 

• Well defined 

chronic disease 

• Twin pregnancies 

• Women with GDM 

(n = 323) 

• Known diet 

treatment (n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of 

pregravid BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-181 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight Gain Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight gain: 

Categorized: 

• < 5.0. 5.0-9.9, 

10.0-14.9, 

≥ 15.0 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated by 

authors 

Birth weight: 

G1: 3500 (3200-3840) 

G2: 3645 (3200-4000) 

G3: 3750 (3390-4125) 

G4: 3762 (3400-4120) 

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %:

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Percentage of preterm delivery

Groups: 

Total gestational weight gain 

categories (kg): 

G1: < 5.0 

G2: 5.0-9.9 

G3: 10.0-14.9 

G4: > 15.0 

Results 

Percent (%) preterm delivery 

by weight gain categories: 

G1: 6.5 

G2: 6.0 

G3: 4.6 

G4: 2.5 

P for trend = 0.11 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 4 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-182 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kramer et al., 1995 

Country and setting: 

Canada, university 

hospitals 

Enrollment Period:

July 1990- July 1992 

Funding: 

National Health 

Research and 

Development Program, 

Health Canada 

Study Objective: 

To assess etiologic role 

of maternal short 

stature, low 

prepregnancy BMI, and 

low rate of gestational 

weight gain in idiopathic 

preterm labor 

Time frame: 

July 1990 to July 1992 

Duration of the study: 

Initiation of prenatal 

care to delivery 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

555 

Group Description: 

G1: Cases 

G2: Controls 

Group N: 

G1: 244 

G2: 311 

Inclusion criteria: 

• Women with 

spontaneous onset of 

labor before 37 

weeks - 1 subsample 

composed of women 

with spontaneous 

onset of labor before 

34 weeks and 

another subsample 

with spontaneous 

onset of labor before 

37 weeks in index 

pregnancy plus a 

history of prior 

preterm delivery or 

second trimester 

miscarriage 

• Cases were matched 

with 1 control by 

history of smoking 

(and race in early 

preterm labor 

subsample) 

• To qualify as a case, 

1 of following a priori 

criteria had to be met: 

(1) cervical dilation at 

least 2cm and 

effacement at least 

75% on admission, 

(2) documented 

increase in cervical 

dilation or effacement 

during observation in 

hospital, or (3) at 

least 6 uterine 

contractions per hour 

for at least 2 hours 

documented during 

observation in 

hospital 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 21.8 (4.2) 

G2: 22.7 (4.0) 

Imputed: 

• No 

Categorized: 

• IOM guidelines < 19.8 

vs. ≥ 19.8 

Age (mean, yrs): 

G1: < 20: 7.8%; 20-34: 

79.1%; ≥ 35: 13.1% 

G2: < 20: 2.6%; 20-34: 

75.8%; ≥ 35: 21.6% 

Parity: 

%primiparous:

G1: 44.3% 

G2: 41.2% 

Race,%: 

White 

G1: 72.5 

G2: 79.7 

Black 

G1: 13.9 

G2: 10.9 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 13.5 

G2: 9.3 

Smoking,%: 

G1: 24.6 during pregnancy 

G2: 25.7 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: % married: 73.4 

G2: 80.7 

Additional characteristics: 

NR 
C-183 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 244 

G2: 311 

Total weight gain: 

G1: 0.35 (0.15) 

kg/wk

G2: 0.37 (0.13) 

kg/wk

Categorized: 

• Rate of weight 

gain < 

0.27kg/wk 

Collected from: 

• Self-reported 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: used 

rate of weight 

gain since 

cases had 

preterm labor 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

AOR (95% CI) for cases 

with preterm delivery 

versus controls 

Groups 

Gestational weight gain 

categories (kg/wk): 

G1: < 0.27 

G2: ≥ 0.27 

Results 

G1: 1.56 (0.94-2.58) 

G2: 1.00 (reference)

labor subsample 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• Marital status 

• English-speaking 

• Education 

• Matched on smoking 

history 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

5 Good, 4 Fair, 0 Poor 

Final Quality Score: 

Good 
C-184 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kramer et al., 1995 

(continued) 

Exclusion criteria: 

• Multifetal gestation 

• Known uterine 

malformation 

• History of exposure 

to diethylstilbestrol 

in utero 

• Cervical 

incompetence 

documented before 

pregnancy 

• Rupture of 

membranes on 

admission 

• Placenta previa 

• Abruptio placentae 

• Chronic illnesses 

known to 

predispose to 

preterm labor 

• Severely growth 

retarded fetuses 

 
C-185 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis 

 
C-186 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nohr et al., 2007 

Country and setting: 

Denmark, primary care 

Enrollment period:

1996 to 2002 

Funding: 

Ellen Aagaard Nohr is 

supported by a grant 

(No.2002B020) from 

Health Insurance 

Foundation. Danish 

National Research 

Foundation established 

Danish Epidemiology 

Science Centre, which 

initiated and created 

Danish National Birth 

Cohort. Cohort is also 

result of major grant 

from this Foundation. 

Additional support for 

Danish National Birth 

Cohort obtained from 

Pharmacy Foundation, 

Egmont Foundation, 

March of Dimes Birth 

Defects Foundation and 

Augustinus Foundation 

Study Objective: 

Aim of present study to 

assess impact of 

obesity and gestational 

weight gain on risk of 

subtypes of preterm 

birth 

Time frame: 

1996 to 2002 

Duration of the study: 

Entry into prenatal care 

- delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

0 

Group Description: 

G1: Total 

Group N: 

G1: 62,167 

Inclusion criteria: 

• Women with 

singleton 

pregnancies who 

provided an 

interview at 

approximately 16 

weeks gestation 

Exclusion criteria: 

• Missing data on 

weight gain in 

pregnancy 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: < 25: 7,757 (12.5%) 

25 to 29: 26,152 (42.1%) 

30 to 34: 21,181 (34.1%) 

35+: 7,077 (11.4%) 

Parity: 

G1: 47% primiparous 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 84.1% nonsmoker 

Diabetes mellitus,%: 

G1: 1.2% 

Hypertension,%: 

G1: 1.6% 

Additional characteristics: 

NR 
C-187 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 62 167 

G2: 2751 

G3: 41 991 

G4: 12 270 

G5: 5155 

Total weight gain: 

G1: Weekly weight 

gain (g) >275g: 

(15.3%) 276–675g: 

(68.3%) 676g+ 

(16.4%) 

Categorized: 

• Weekly weight 

gain 

categorised 

into 3 groups 

(low, medium, 

high) using 

cutpoints at 

275 and 675 g, 

which were 

similar to those 

used in other 

studies 

Collected from: 

• Does not 

specify-women 

self-reported 

weight gain 

status 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 1.2% 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Before 34 

weeks of 

gestation, risk 

of induced 

preterm 

delivery 

potentiated 

among obese 

women with 

high weight 

gain, and after 

34 weeks, risk 

was 

potentiated at 

extremes, 

namely among 

underweight 

women with a 

low weight gain 

and obese 

women with a 

high weight 

gain 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Rate of gestational weight 

gain for women with early 

or late preterm birth by 

PPROM 

Groups 

Rate of gestational weight 

gain (g/wk) for women with 

early preterm birth (22-33 

weeks) with PPROM : 

G1: < 275 

G2: 276-675 

G3: ≥ 676 

Rate of gestational weight 

gain (g/wk) for women with 

early preterm birth (22-33 

weeks) without PPROM : 

G4: < 275 

G5: 276-675 

G6: ≥ 676 

Rate of gestational weight 

gain (g/wk) for women with 

late preterm birth (34-36 

weeks) with PPROM: 

G7: < 275 

G8: 276-675 

G9: ≥ 676 

Rate of gestational weight 

gain (g/wk) for women with 

late preterm birth (34-36 

weeks) without PPROM: 

G10: < 275 

G11: 276-675 

G12: ≥ 676 

Results 

HR (95% CI): 

G1: 2.1 (1.5-3.0) 

G2: 1.0 (ref) 

G3: 1.2 (0.8-1.8) 

HR (95% CI): 

G4: 1.9 (1.3-2.6) 

G5: 1.0 (ref) 

G6: 1.9 (1.3-2.6) 

HR (95% CI): 

G7: 1.3 (1.0-1.6) 

G8: 1.0 (ref) 

G9: 1.2 (1.0-1.5) 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 4 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-188 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nohr et al., 2007 

(continued) 

 
C-189 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

 HR (95% CI): 

G10: 1.0(0.9-1.2) 

G11: 1.0(ref) 

G12: 1.0 (0.9-1.2) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

Pregravid BMI, age, height, 

parity, socio-occupational 

status, smoking alcohol 

consumption 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 
C-190 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rosenberg et al., 2005 

Country and setting: 

USA, vital statistics data 

Enrollment Period:

Birth certificates with 

self reported pregravid 

weight and weight gain 

Funding: 

NR 

Study Objective: 

To examine 

associations between 

obesity, diabetes, and 3 

adverse pregnancy 

outcomes (primary 

cesarean section, 

preterm birth, and LBW) 

by race/ethnic groups 

Time frame: 

Birth certificates with 

self reproted pregravid 

weight and weight gain 

Duration of the study: 

Birth certificates from 

1999, 2000, and 2001 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

329988 

Group Description: 

G1: Non-hispanic 

blacks 

G2: Non-hispanic 

whites 

G3: Non-hispanic 

asians 

G4: Hispanics 

G5: Total 

Group N: 

G1: 86,908 

G2: 96,581 

G3: 38,570 

G4: 107,612 

G5: 329,988 

Inclusion criteria: 

• Live singleton births 

• Information on 

maternal 

prepregnancy 

weight and 

maternal weight 

gain during 

pregnancy 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: < 100 pounds: 1.7% 

100-149: 49.1% 

150-199: 37.5% 

200-299: 11.2% 

≥ 300: 0.5% 

G2: < 100 pounds: 1.8% 

100-149: 69.5% 

150-199: 24.0% 

200-299: 4.7% 

≥ 300: 0.1% 

G3: < 100 pounds: 8.1% 

100-149: 79.5% 

150-199: 11.6% 

200-299: 0.8% 

≥ 300 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 27.5 

G2: 30.6 

G3: 29.7 

G4: 26.4 P < 0.001 

G5: 28.3 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 3.7 

G2: 2.6 

G3: 6.6 

G4: 3.5 

G5: 3.7 P < 0.001 

Hypertension,%: 

G1: 1.7 

G2: 0.6 

G3: 0.5 

G4: 0.7 

G5: 0.9 P < 0.001 

Additional characteristics: 

G1: PIH 1.9 

G2: 1.2 

G3: 0.7 

G4: 1.4 

G5: 1.4 P < 0.001 

Additional characteristics: 

G1: Preeclampsia 2.9 

G2: 1.3 

G3: 1.2 

G4: 2.6 

G5: 2.1 P < 0.001 

Additional characteristics: 

NR 
C-191 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 86,908 

G2: 96,581 

G3: 38,570 

G4: 107,612 

G5: 329,988 

Total weight gain: 

G1: < 41pounds: 79.7% 

≥ 41 pounds: 20.3% 

G2: < 41pounds: 83.2% 

≥ 41 pounds: 16.8% 

P < 0.001 

G3: < 41pounds: 89.2% 

≥ 41 pounds: 10.8% 

G4: < 41pounds: 79.1% 

≥ 41 pounds: 20.9% 

G5: < 41pounds: 81.6% 

≥ 41 pounds: 18.4% 

Categorized: 

• < 41, ≥ 41 pounds 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 3.7 

G2: 2.6 

G3: 6.6 

G4: 3.5 

G5: 3.7 P < 0.001 

Cesarean 

delivery,%: 

G1: 16.2 

G2: 14.7 P < 0.001 

G3: 14.4 

G4: 13.8 

G5: 14.7 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Preterm birth 

10.5, 5.1, 5.9, 

7.8, 7.5 

P < 0.001 

(groups 

defined above) 

• LBW 9.7, 4.1, 

5.7, 6.1, 6.4 

P < 0.001 

(groups 

defined above) 

Outcomes Description: 

AOR (95% CI) for Preterm 

Birth 

Groups 

Categories of total 

gestational weight gain 

(lbs): 

G1: <41 

G2: ≥ 41 

Results 

AOR (95% CI) for Preterm 

Birth: 

G1: 1.00 (reference) 

G2: 0.54 (0.52-0.57) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

Pregravid weight, chronic 

diabetes, GDM, chronic 

hypertension, PIH 

preeclampsia, maternal 

age marital status maternal 

education maternal 

birthplace, prenatal care 

payer, social risk, parity, 

trimester that prenatal care 

began 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 7 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-192 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Schieve et al., 1999 

Country and setting: 

USA, Pregnancy 

Nutrition Surveillance 

System of women 

participating in federally 

funded prenatal public 

health programs 

Enrollment Period:

1990 to 1993 

Funding: 

NR 

Study Objective: 

To examine 

associations between 

weight gain per week of 

pregnancy and net 

weight gain per week of 

pregnancy and preterm 

delivery 

Time frame: 

1990 to 1993 

Duration of the study: 

First prenatal visit to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

266,172 

Group Description: 

G1: Total sample 

G2: NR 

Group N: 

G1: 266,172 

G2: NR 

Inclusion criteria: 

• White, black, or 

hispanic women 

• Women attending 

WIC clinics both 

prenatally and 

postnatally 

• Liveborn, 

singletons delivered 

between 26 to 42 

weeks gestation 

Exclusion criteria: 

• Missing data for 

prepregnancy BMI, 

pregnancy weight 

gain, or infant birth 

weight 

• Incompatible birth 

weight for 

gestational age 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 12.0-19.7: 17.0% 

19.8-26.0: 50.9% 

26.1-29.0: 12.7% 

29.1-61.0 : 19.5% 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 10-14y: 0.7% 

15-19y: 24.8% 

20-29y: 58.3% 

30-34y: 11.5% 

35-39y: 3.9% 

40-55y: 0.7% 

G2: NR 

Parity: 

Primiparous:

G1: 40.9% 

G2: NR 

Race,%: 

White 

G1: 63.4 

G2: NR 

Black 

G1: 20.5 

G2: NR 

Hispanic 

G1: 16.1 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-193 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 266,172 

G2: 45,142 

G3: 135,390 

G4: 33,697 

G5: 51943 

Total weight gain: 

G1: 14.19 (6.70) kg

G2: 15.15 (5.75)

G3: 14.97 (6.27)

G4: 13.78 (6.94)

G5: 11.56 (7.62)

Categorized: 

• Weight 

gain/week was 

calculated as 

weight gain 

(kg) divided by 

completed 

weeks 

gestation 

• Weight 

gain/week and 

net weight 

gain/week 

were 

categorized on 

basis of 

percentile 

distributions in 

total sample 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Mean weight 

gain rate 

(kg/wk) for total 

sample: 0.36 

(0.17) 

• Mean net 

weight gain ( = 

weight gainbirth weight) 

(kg) for total 

sample: 10.86 

(6.60) 

• Mean net 

weight gain 

rate (kg/wk) for 

total sample: 

0.28 (0.17) 

Other infant 

outcomes: 

• 6.8% delivered 

at 32-36 weeks 

gestation 

• 0.7% delivered 

at 20-31 weeks 

gestation 

Outcomes Description: 

RD of preterm birth 

Groups 

Rate of weight gain 

(kg/week) in percentiles 

stratified by Low, Average, 

High, and Obese pregravid 

BMI: 

G1: 5th,0.10 

G2: 10th, 0.16 

G3: 25th,0.26 

G4: 50th,0.35 

G5: 75th, 0.46 

G6: 90th, 0.57 

G7: 95th, 0.65 

Results 

Reference category of rate 

of weight gain: 0.35-<0.46 

kg/wk 

RD of preterm birth varied 

by prepregnant BMI and 

gestational weight gain. 

Overall, women gaining 

0.26-0.46 kg/wk had the 

lowest RD of preterm birth. 

The highest RD occurred for 

women gaining the least and 

most amount of weight, 

irrespective of prepregnant 

BMI; however, the highest 

RD of preterm births were 

among women of low BMI 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

None 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Fair 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-194 

 Evidence Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Siega-Riz et al., 1996 

Country and setting: 

USA, public health 

clinics 

Enrollment Period:

1983 to 1987 

Funding: 

State of California 

Maternal and Child 

Health Branch, March of 

Dimes, and University of 

North Carolina 

Department of Nutrition 

Study Objective: 

To examine differences 

in pattern of weight gain 

according to trimesters 

of pregnancy and 

analyze effects on 

preterm delivery 

Time frame: 

1983 to 1987 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Prospective 

Total Study N: 

7589 

Group Description: 

G1: Preterm 

G2: Term 

Group N: 

G1: 517 

G2: 7072 

Inclusion criteria: 

• Pregnant women 

attending public 

health clinics who 

were eligible to 

participate in 

Prematurity 

Prevention Project 

Exclusion criteria: 

• Mismatched 

prenatal and birth 

outcome files 

• Unreasonable 

gestational age 

• Stillbirths 

• Missing data 

• Multiple gestations 

• Medical inductions 

• Inability to 

determine timing of 

PPROM or PTL 

Pregravid weight: 

• Self-reported 

G1: 57.6 (0.53) 

G2: 59.0 (0.15) 

Pregravid BMI: 

G1: 23.7 (0.22) 

G2: 24.5 (0.06) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 24.9 (0.25) 

G2: 24.9 (0.06) 

Parity: 

%primiparous:

G1: 36.9 

G2: 34.4 

Race,%: 

White 

G1: 8.7 

G2: 8.9 

Black 

G1: 10.3 

G2: 4,9 

Hispanic 

G1: 76.1 

G2: 82.8 

Asian/Pacific Islander 

G1: 4.0 

G2: 3.3 

Other 

NR 

Smoking,%: 

G1: 5.4 

G2: 3.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 4.8 

G2: 2.5 

Additional characteristics: 

NR 
C-195 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

AOR (95% CI) for rate of 

preterm birth, preterm labor, 

PPROM 

Groups 

Categories of 3rd trimester 

weekly weight gain rates 

(kg/week): 

G1: Inadequate (Underweight, 

< 0.34; Normal weight, < 0.35; 

Overweight/ Obese, < 0.30) 

G2: Adequate 

(Underweight, > 0.34; Normal, 

> 0.35; Overweight/Obese, 

> 0.30) 

Results 

Preterm birth: 

G1: 1.91 (1.40-2.61) 

G2: 1.00 (reference) 

Preterm labor: 

G1:1.75 (1.15-2.64) 

G2: 1.00 (reference) 

PPROM: 

G1: 2.70 (1.35-5.42) 

G2: 1.00 (reference) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Iron status, parity combined 

with maternal age, ethnicity, 

hypertension (chronic or 

pregnancy induced), smoking 

status, week prenatal care 

began

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Good 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

8 Good, 1 Fair, 0 Poor 

Final Quality Score: 

Good 
C-196 

 Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Spinillo et al., 1998 

Country and setting: 

Italy, University Hospital 

Enrollment Period:

1988 to 1995 

Funding: 

NR 

Study Objective: 

To investigate whether 

maternal anthropometric 

factors interact with 1 

another or with other 

risk factors, thus 

modifying risk of 

spontaneous preterm 

delivery 

Time frame: 

1988 to 1995 

Duration of the study: 

NR 

Design: 

• Case-control 

• Prospective 

Total Study N: 

690 

Group Description: 

G1: Cases 

G2: Controls 

Group N: 

Inclusion criteria: 

• Cases were 

patients with 

spontaneous 

preterm delivery 

between 24 and 35 

weeks gestation 

Exclusion criteria: 

• PROM indicated 

premature delivery 

associated with 

abruptio placentae, 

placenta previa, 

preeclampsia, 

impaired fetal 

growth, diabetes, or 

other severe 

maternal diseases 

prior to pregnancy 

• Severe fetal 

malformations 

• Missing data 

Pregravid weight: 

• Self-reported 

G1: 55.7 (10.3) 

G2: 57.7 (9.7) 

Pregravid BMI: 

G1: 21.3 (3.7) 

G2: 21.8 (3.4) 

Imputed: 

• No 

Categorized: 

• ≤ 19,5 or > 19.5 

Age (mean, yrs): 

G1: 28.7+/- 5.2 

G2: 29.6+/-4.6 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-197 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Dichotomized 

into second/third 

trimester weight 

gain ≤ 0.37 

kg/wk and > 0.37 

kg/wk. Also, net 

weight gain 

≤ 0.135 kg/wk or 

> 0.135 kg/wk 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Crude ORs for 

spontaneous 

preterm delivery: 

BMI < 19.5 = 

1.68(1.20-2.38) 

• Second/third 

trimester weight 

gain ≤ 0.37 

kg/wk: 2.40 (1.69 

- 3.42): Net 

weight gain ≤

0.135 kg/wk 2.31 

(1.45-3/68) 

Other infant 

outcomes: 

NR 

Outcomes Description: 

AOR for spontaneous preterm 

delivery 

Groups 

G1: Prepregnancy BMI ≤ 19.5 

and 2nd/3rd trimester weight 

gain ≤ 0.37 kg/wk 

G2: Prepregnancy BMI>19.5 

and 2nd/3rd trimester weight 

gain ≤ 0.37 kg/wk 

G3: Prepregnancy BMI ≤ 48 

kg and 2nd/3rd trimester 

weight gain ≤ 0.37 kg/wk 

G4: Prepregnancy BMI > 48 

kg and 2nd/3rd trimester 

weight gain ≤ 0.37 kg/wk 

Results 

AOR (95% CI) for cases with 

spontaneous preterm delivery 

versus controls: 

G1: 5.63 (2.35-13.8) 

G2: 2.45 (1.60-3.75) 

P = 0.06 for interaction 

between G1 and G2

G3: 5.29 (1.45-20.90) 

G4: 2.42 (1.65-3.55) 

P = 0.21 for interaction 

between G3 and G4

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Pregravid BMI, pregravid 

weight, height, age, parity, 

smoking, social class 

education 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

Gender 

Background: 

Poor 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Good 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 2 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-198 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, academic medical 

center 

Enrollment Period:

1976 to 2001 

Funding: 

NIH 

Study Objective: 

To study how 

relationship between 

gestational weight gain 

and spontaneous 

preterm birth interacts 

with maternal race or 

ethnicity and previous 

preterm birth status 

Time frame: 

1976 to 2001 

Duration of the study: 

From entry into prenatal 

care until delivery 

(actually used a 

perinatal data base and 

looked at info) 

Design: 

• Perinatal data base 

review 

• Retrospective 

Total Study N: 

15,101 

Group Description: 

G1: Total 

G2: White 

G3: African American 

G4: Latina 

G5: Asian 

Group N: 

G1: 15,101 

G2: 6,513 

G3: 1,533 

G4: 1,614 

G5: 3,440 

Inclusion criteria: 

• Women of low or 

normal 

prepregnancy BMI 

delivering singleton 

during study period 

with complete data 

on all variables 

considered 

Exclusion criteria: 

• Multiple gestations 

• Hypertension 

• Diabetes 

• Delivery before 24 

weeks of gestation 

• Congenital 

anomalies 

• Missing data on 

any key variables 

• Prepregnancy BMI 

of 26 or greater 

• Transport from 

another hospital 

Pregravid weight: 

• Self-reporteddata base 

Pregravid BMI: 

G1: Low 29.6%; Normal 

70.4% 

G2: Low25.9%; Normal 

74.1% 

G3: Low 23.0%; Normal 

77% 

G4: Low 19%; Normal 81% 

G5: Low 42.2%; 57.9% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Low (< 19.8) 

Normal (19.8-25.9) but 

this is not explicitly 

stated 

Age (mean, yrs): 

G1: 28.19 

G2: 29.43 

G3: 24.25 

G4: 26.17 

G5: 29.10 

Parity: 

Nulliparous

G1: 53.8% 

G2: 57.5 

G3: 48.0 

G4: 49.0 

G5: 52.9 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 10.9% 

G2: 14.5% 

G3: 21.4% 

G4: 6.7% 

G5: 4.5% 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Previous preterm birth (%)

G1: NR 

G2: 4.4 

G3: 4.1 

G4: 8.3 

G5: 5.58 

G6: 2.91 

Additional characteristics: 

NR 
C-199 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate 

Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 15,101 

G2: 6513 

G3: 1533 

G4: 1614 

G5: 3440 

Group 6 

Total weight gain: 

G1: Below IOM: 20.5; 

% Within IOM 

39.1%; 

Above 40.4% 

P < .001 

G2: Below 15.5%; 

Within 38.5%; 

above 46.1% 

P < .001 

G3: Below 16.9%; 

Within 30.9%; 

Above 41.2% 

P < .001 

G4: Below 21.1%; 

Within 37.4%; 

Above 41.5% 

P < .001 

G5: Below 25.4%; 

Within

Categorized: 

• Continuous 

• According to 

IOM3-way 

categorical 

variable, low 

(less than 0.27 

kg/wk), normal 

(between0.27 

and 0.52 kg/wk), 

and high (greater 

than 0.52kg/wk) 

Collected from: 

• Rate of weight 

gain was 

determined 

by:total weight 

gain divided by 

GA minus 2 

weeks 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery, %: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Spontaneous 

PTB for all 

women 4.0% 

white 3.6%, 

blacks 6.8%, 

latinas 4.4% 

asians 3.6% 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Rates of preterm delivery at 34 and 37 

weeks 

Groups 

Categories of rate of gestational 

weight gain (kg/wk): 

G1: < 0.27 

G2: 0.27 to 0.52 

G3: > 0.52 

Results 

AOR (95% CI) for preterm delivery < 

37 weeks: 

G1: 2.6 (2.1-3.2) 

G2: 1.0 (reference) 

G3: 1.0 (0.8-1.2) 

AOR (95% CI) for preterm delivery < 

34 weeks: 

G1: 3.0 (2.0-4.8) 

G2: 1.0 (ref) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Race, age pregravid BMI, year of 

delivery, parity, previous preterm birth, 

number of days between last weighing 

and delivery, smoking 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-200 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Velonakis et al., 1997 

Country and setting: 

France, hospital 

Enrollment Period: 

1988 

Funding: 

NR 

Study Objective: 

To identify impact of 

various biological, 

occupational, and 

socioeconomic factors 

on gestational age and 

birth weight 

Time frame: 

1988 

Duration of the study: 

First prenatal visit 

through delivery 

Design: 

• Cohort 

Total Study N: 

2,040 

Group Description: 

Group N: 

Inclusion criteria: 

• Women with 

regular cycle not 

exceeding 32 days 

• Last menstrual 

period was not 

withdrawal bleed 

from pill 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-201 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

calculated by 

subtracting 

prepregnancy 

weight, fetal 

and placental 

weight from 

final weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Risk for preterm birth 

Groups 

NA, total gestational weight gain 

(continuous) 

Results 

Regression analysis with 

gestational age (weeks) as the 

dependent variable and net 

gestational weight gain as the 

independent variable: 

Β = 0.191 (SE, 0.06) 

P = 0.001 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

Age, race, gravidity, previous 

diseases, parity, abortions, marital 

status, pathology of index 

pregnancy, , height, pregravid 

weight, job classification, alcohol, 

smoking, duration of pregnancy 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

Infant sex, APGAR score 

Background: 

Poor 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 6 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-202 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wen et al., 1990 

Country and setting: 

USA, hospital 

Enrollment Period:

January 1983 to 

December 1987 

Funding: 

NIH contract N01-HD-4-

2811 

Study Objective: 

To determine effect of 

factors related to LBW 

on IUGR and preterm 

delivery 

Time frame: 

January 1983 to 

December 1987 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

17,149 

Group Description: 

G1: Total 

G2: IUGR 

G3: Preterm delivery 

Group N: 

G1: 100% 

G2: 7.4% 

G3: 12.6% 

Inclusion criteria: 

• Women seen for 

prenatal care and 

delivered of infants 

at study location 

Exclusion criteria: 

• Diabetes 

• Pregnancies 

involving multiple 

births 

• Fetal death 

• Congenital 

malformation 

Pregravid weight: 

• Routine pre-natal 

careweight at first 

prenatal visit was used 

G1: (Prepregnancy?) 

Maternal weight (kg) < 

50: 10.6%, 50-60: 

32.6%, 61-72: 28.7%, 

73-84: 14.5%, > 85: 

13.6% 

G2: (Prepregnancy?) 

Maternal weight (kg) < 

50: 12.9%, 50-60: 8.5%, 

61-72: 6.4%, 73-84: 

5.5%, > 85: 4.8% 

G3: (Prepregnancy?) 

Maternal wei 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: < 17: 7.5%, 

17-19: 22.7%, 

20-25: 43.1%, 

26-30: 17.5%, 

31-35: 7.0%, 

> 36: 2.3% 

G2: < 17: 8.0%, 

17-19: 6.6%, 

20-25: 7.4%, 

26-30: 7.6%, 

31-35: 8.2%, 

> 36: 8.6% 

G3: < 17: 15.4%, 

17-19: 13.0%, 

20-25: 11.6%, 

26-30: 12.9%, 

31-35: 14.3%, 

> 36: 13.4% 

Parity: 

G1: Parity 0: 44.1, 1: 29.9, > 

1: 26.0 

G2: Parity 0: 8.4, 1: 6.3, > 1: 

6.6 

G3: Parity 0: 12.5, 1: 12.3, > 

1: 12.8 

Race,%: 

White 

G1: 29.7 

G2: NR 

Black 

G1: 70.3 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.4 

G2: 10.3 

G3: 13.3 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Married: 38.0% 

G2: Married: 6.6% 

G3: Married: 10.6% 

Additional characteristics: 

Education: 

G1: < 12: 41.1%, 

12: 41.6%, 

> 12: 15.8% 

G2: < 12: 7.7%, 

12: 7.3%, 

> 12: 7.6% 

G3: < 12: 12.8%, 

12: 12.1%, 

> 12: 12.2% 

Additional characteristics: 

NR 
C-203 

Evidence Table 17. Gestational weight gain and preterm birth (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: Weight 

gain/week 

(after the 20th 

week) in kg: 

< 0.24: 12.2%, 

0.24-0.57: 

54.4%, 

0.58-0.74: 

19.2%, 

≥ 0.75: 14.3% 

G2: Weight 

gain/week 

(after the 20th 

week) in kg: 

< 0.24: 9.9%, 

0.24-0.57: 

7.9%, 

0.58-0.74: 

5.2%, 

≥ 0.75: 5.7% 

G3: Weight gain/

Categorized: 

• Ave weight 

gain per week 

after 20th week 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Maternal 

weight at 

delivery not 

available, so 

total weight 

gain not 

calculated 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Risk for preterm birth 

Groups 

Rate of weight gain (kg/wk) after 

20 weeks gestation 

G1: < 0.24 

G2: 0.24-0.57 

G3: 0.58-0.74 

G4: ≥0.75 

Results 

AOR for preterm birth: 

G1: 1.52 (P < 0.05) 

G2: 1.11 (NS) 

G3: 1.00 (ref) 

G4: 1.71 (P < 0.05) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

Race, parity, infant sex, marital 

status, education, age, previous 

preterm delivery, smoking, alcohol 

consumption, drug use, height, 

pregravid weight 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

Gender 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 5 Fair, 2 Poor 

Final Quality Score: 

Fair 

 
C-204 

Evidence Table 18. Gestational weight gain and birthweight 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Abrams et al., 1995 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980-1990 

Funding: 

NICHD grant 

Study Objective: 

To determine 

relationship between 

maternal weight gain 

pattern and birth weight 

Time frame: 

1980-1990 

Duration of the study: 

initiation of prenatal 

care to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

4,420 

Group Description: 

G1: total sample 

G2: NR 

Group N: 

G1: 2994 

G2: NR 

Inclusion criteria: 

• White women 

delivering at 

hospital 

Exclusion criteria: 

• Multiple gestation 

• Fetal congenital 

abnormalities 

• Maternal diabetes 

• Hypertensive 

disorders 

• Maternal obesity 

(BMI > 29.0) 

• Missing data 

Pregravid weight: 

• Self-reported 

G1: 58.5 (7.8) kg 

G2: NR 

Pregravid BMI: 

G1: 21.5 (2.5) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 28.8 (5.4) 

G2: NR 

Parity: 

G1: 0.6 (0.9) 

G2: NR 

Race,%: 

White 

G1: 100 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: cigarettes per day: 2.0 

(5.6) 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-205 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 2994 

G2: NR 

Total weight gain: 

G1: 16.7 (0.5)

G2: NR 

Categorized: 

• Weight gain by 

trimester - 25th 

percentile was 

used to define 

low (L) vs. not 

low (N) maternal 

gain in each 

trimester (i.e. 

below 25th 

percentile and 

above 25th 

percentile) 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

using weight at 

last prenatal visit 

prior to delivery 

Birth weight: 

G1: 3485.8 (523.1) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• First trimester, 

25th percentile 

value (kg) = 

-0.05 

• Second 

trimester, 25th 

percentile value 

(kg) = 5.7 

• Third trimester, 

25th percentile 

value (kg) = 4.8 

• First-trimester 

gain (kg): 2.1 

(3.3) 

• Second-trimester 

gain (kg): 7.7 

(2.9) 

• Third-trimester 

gain (kg): 6.6 

(2.7) 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant weight gain 

Groups 

NA, weight gain as continuous variable

Results 

Infant BW among nonobese women 

3,485.8g ± 523.1 

Increase in birth weight per 1 kg 

increase in total pregnancy weight gain 

β = 22.6g 

(P < 0.001) 

Increase in birth weight per 1 kg 

increase in first trimester weight gain 

β = 18.0g ± 2.4 

(P < 0.001) 

Increase in birth weight per 1 kg 

increase in second trimester weight 

gain 

β = 32.8g ± 2.8 

(P < 0.001) 

Increase in birth weight per 1 kg 

increase in third trimester weight gain 

β = 17.0g ± 2.9 

(P < 0.001) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, parity, pregravid BMI, 

height, smoking, difference in weeks 

between the last measured weight and 

delivery 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

Infant sex, gestational age 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-206 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-207 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Increase in birthweight 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results 

G1: 3,302 

G2: 3,192 

G3: 3,337 

G4: 3,506 

G5: 3,453 

(P < 0.05) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-208 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brown et al., 2002 

Country and setting: 

USA, primary care 

clinics 

Enrollment Period:

1989 to 1993 

Funding: 

NIH 

Study Objective: 

To identify effects of 

maternal weight change 

by trimester of 

pregnancy on weight, 

length, head 

circumference, and 

ponderal index (PI; in 

kg/m3) of newborns 

Time frame: 

1989 - 1993 

Duration of the study: 

From preconception or 

entry into prenatal care 

through 6 to 8 weeks 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

389 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 389 

G2: NR 

Inclusion criteria: 

• Women aged 22-35 

years enrolled in 

Group Health 

managed care 

organization 

• Intended to become 

pg within 

enrollment period 

• Had not been 

attempting pg for 

> 3 mo 

• Had delivered last 

infant > 12 mo 

before enrollment 

• Did not intend to 

use contraceptives 

during study 

• Delivery of live, 

singleton infants 

• Pg lasting > 241 

days from 

conception 

Exclusion criteria: 

• History of 

hypertension, renal 

disease, DM, heart 

disease, infertility 

• No data on 

preconceptional 

weight and height 

within 6 months of 

conception or 2 

weeks after 

conception 

• Missing data on 

weight with 25 days 

of end of each 

trimester 

Pregravid weight: 

• Measured by study 

investigators 

• Weight was measured 

< 6 months before 

conception for 364 

women by study 

investigators 

G1: 61.2 ± 9.4 (50.7, 73.2) 

G2: NR 

Pregravid BMI: 

G1: 22.5 ± 3.2 (19.2, 26.9) 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.4 ± 3.1 (25.3, 33.7) 

G2: NR 

Parity: 

G1: 0.5 ± 0.7 (0, 1) 

G2: NR 

Race,%: 

White 

G1: 97 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-209 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 389 

G2: NR 

Total weight gain: 

G1: 15.6 ± 4.1 

(10.5–21.4)2

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigatorsRo

utine pre-natal 

care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3575g ± 448 

(3033–4167) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

Although 

nonsignificant, a 

trend was noted 

that suggested, 

among women with 

lower 

preconception 

weight, an 

increased effect of 

first-trimester 

weight gain on 

weight of their 

newborns (51 kg 

preconception 

weight, 51 g/kg 

weight gain; 62 kg 

preconceptional 

Outcomes Description: 

Increase in birthweight 

Groups 

NA, weight gain as continuous 

variable 

Results 

Increase in birth weight per 1 kg 

increase in total pregnancy 

weight gain

β = 20g 

(P < 0.0001) 

Increase in birth weight per 1 kg 

increase in first trimester weight 

gain 

β = 31g 

(P < 0.0007) 

Increase in birth weight per 1 kg 

increase in second trimester 

weight gain 

β = 26g 

(P < 0.007) 

Increase in birth weight per 1 kg 

increase in third trimester 

weight gain 

β = 7g 

(P < 0.40) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Maternal age, parity, pregravid 

BMI, height 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

Gestational age, sex (female) 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

8 Good, 1 Fair, 0 Poor 

Final Quality Score: 

Good 
C-210 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Butte et al., 2003 

Country and setting: 

USA, children’s nutrition 

center 

Enrollment Period:

NR 

Funding: 

US Department of Army 

and US Department of 

Agriculture/Agriculture 

Research Service 

Study Objective: 

To evaluate how 

changes in gestational 

weight and body 

composition affect infant 

birth weight and 

maternal fat retention 

after delivery in 

underweight, normal 

weight and overweight 

women 

Time frame: 

NR 

Duration of the study: 

Prior to preg through pp 

Design: 

• Cohort 

• Prospective 

Total Study N: 

63 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 63 

G2: NR 

Inclusion criteria: 

• Nonsmokers 

• 18-40 years 

• parity ≤ 4 

• Physically active 

(20 to 30 minutes of 

moderate exercise 

at least 3 

times/week) 

• No long term 

medicine use 

• No alcohol/drug 

abuse 

Exclusion criteria: 

• Multiparous 

• Preterm deliveries 

• Miscarriage 

• Preeclampsia 

Pregravid weight: 

• Measured by study 

investigators 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 31 (4) 

G2: NR 

Parity: 

NR 

Race,%: 

White 

G1: 77 

G2: NR 

Black 

G1: 10 

G2: NR 

Hispanic 

G1: 10 

G2: NR 

Asian/Pacific Islander 

G1: 3 

G2: NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-211 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 15.0 (3.8) kg

G2: 14.5 (4.5) kg

G3: 17.9 (5.4) kg

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Birth weight 

Outcomes Description: 

Infant birthweight 

Groups 

G1: Correlation coefficient 

G2: Variability in BW accounted for 

by gestational age, pregravid weight, 

and total pregnancy weight gain 

Results 

G1: 0.28 

G2: 37.9% 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

Race, pre-gravid BMI 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Poor 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-212 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cherry et al., 1993 

Country and setting: 

USA, hospital 

Enrollment Period:

NR 

Funding: 

NR 

Study Objective: 

NR-to examine effect of 

zinc on birth outcomes 

Time frame: 

NR 

Duration of the study: 

9 months-from time of 

enrollment in to prenatal 

care up to delivery 

Design: 

• RCT 

Total Study N: 

599 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 599 

G2: NR 

Inclusion criteria: 

• Adolescents in 

prenatal clinic at 

Charity Hospital of 

New Orleans 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Measured by study 

investigators 

G1: 53% were 90-110% 

Expected Weight (EW); 26% 

< 90% EW; 21% were > 

110% EW 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Calculated weight for 

age and height 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-213 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Grams gained 

per week per cm 

height 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Table 1 provided data 

above-LBW, wt for 

length of infant, % of 

infants in high risk 

nursery 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant BW by Quartiles of 

weight gain 

Groups 

Quartiles defined as weekly 

weight gain in g per cm height 

G1: Quartile 1 (≤ 1.87g) 

G2: Quartile 2 (1.88-2.68g) 

G3: Quartile 3 (2.69-3.58g) 

G4: Quartile 4 (≥ 3.59g) 

Results 

G1: 2,829g 

G2: 2,990g 

G3: 3,112g 

G4: 3,189g 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Poor 

Sample selection: 

Poor 

Definition of maternal weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on exposure, 

outcomes, and confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 3 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-214 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cianni et al., 2003 

Country and setting: 

Italy, clinic 

Enrollment Period:

not stated 

Funding: 

NR 

Study Objective: 

To determine predictive 

value of serum 

triglyceride levels for 

neonatal weight in 

pregnant women with 

positive diabetic 

screening but normal 

glucose tolerance 

Time frame: 

Not stated 

Duration of the study: 

24 to 30 weeks GA to 

birth 

Design: 

• Cohort 

• Prospective 

Total Study N: 

180 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 180 

G2: NR 

Inclusion criteria: 

• Positive diabetic 

screening 

performed at 24-

30th week of 

gestation 

Exclusion criteria: 

• Hypertensive 

disorders 

• Thyroid disorder 

• Lupus 

• Antiphospholipid 

syndrome 

Pregravid weight: 

• Not stated 

G1: 64 (11) 

G2: NR 

Pregravid BMI: 

G1: 23.6 (4) 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 33 (4) 

G2: NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-215 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 180 

G2: NR 

Total weight gain: 

G1: 8 (3)

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Not stated 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: not 

stated 

Birth weight: 

G1: 3,442 (440) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight 

Groups 

NA continuos measure 

Results 

F statistic = 3.16, P = 0.08

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Pre-gravid BMI 

• Maternal triglycerides 

• Plasma glucose 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-216 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period:

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal 

weight women and their 

associations with 

gestational weight 

change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight 

women identified 

from pregnancy 

and delivery 

summary records 

(normal weight 

matched to obese 

by race, age, parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal 

weight (BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-217 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5

G2: 14.5 P ≤ 0.001

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight 

Groups 

G1: Increase in birth weight per 

1 kg increase in total pregnancy 

weight gain for obese women 

G2: Increase in birth weight per 

1 kg increase in total pregnancy 

weight gain for normal weight 

women 

Results 

G1: β = 11g ± 2 

(P ≤ 0.001) 

G2: β = 15g ± 2 

(P ≤ 0.001) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

Age, parity, pregravid BMI, 

pregnancy-induced 

hypertension, adequacy of 

prenatal care, alcohol use, drug 

use, smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-218 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period:

July 1, 1985 - 

December 31, 1985 (6 

months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal 

weight or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to 

December 31, 1985 (6 

months) 

Duration of the study: 

Prepregnancy to 

delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at 

delivery 

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or 

over ideal weight 

for height) or 

abnormal 

pregnancy weight 

gain (≥ 20kg or 

≤ 5kg) 

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under 

normal weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital 

within study period 

selected those with 

abnormal maternal 

prepregnancy 

weight or abnormal 

weight gain during 

pregnancy, as well 

as next mother in 

sequential order 

with normal 

prepregnancy 

weight and weight 

gain during 

pregnancy to serve 

as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if 

self reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over 

or under normal weight 

for height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 (1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-219 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared 

to controls

G2: 13.4 (4.5)

G3: 3.0 (3.5) 

P < 0.0005 

compared to 

controls

G4: 23.2 (22.8) 

P < 0.0005 

compared to 

controls

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or 

≥ 20kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared 

to controls 

G2: 3293 (362) 

P < 0.05 compared 

to controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 

compared to 

controls 

G5: 3538 (535) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: Elective 7% 

Emergency 

14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 

18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight 

Groups 

G1: Normal prepregnancy 

weight and normal weight gain 

G2: Weight gain ≤5 kg 

G3: Weight gain ≥20 kg 

Results 

G1: 3,538g ± 535 

G2: 3,284g ± 880 

G3: 3,803g ± 538 

(P < 0.005 compared to G1) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-220 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Groff et al., 1997 

Country and setting: 

USA, multispecialty 

clinics 

Enrollment Period:

1991-1993 

Funding: 

National Cancer 

Institute grant 

Study Objective: 

To determine effects of 

smoking status and 

maternal weight gain on 

infant birthweight 

Time frame: 

1991-1993 

Duration of the study: 

Entry into prenatal care 

to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

341 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 341 

G2: NR 

Inclusion criteria: 

• Adult, white, nonHispanic pregnant 

women beginning 

prenatal care 

before 14 weeks 

gestation who selfidentified as never 

smokers, 

continuing 

smokers, and 

women who 

stopped smoking 

during pregnancy 

• First or second 

pregnancies, 

singletons with 

recorded weights at 

12,26, and 39 

weeks (+/- 2 

weeks) 

• Documented infant 

birth weight 

Exclusion criteria: 

• Gestation > 42 

weeks 

• Black women 

• Diabetics 

• Hispanics 

Pregravid weight: 

• Self-reported 

• Routine pre-natal care 

first prenatal visit for 

18%, self-report for 82% 

Pregravid BMI: 

G1: 23.9 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26.4 

G2: NR 

Parity: 

G1: Nulliparous: 52.8% 

G2: NR 

Race,%: 

White 

G1: 100% 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 32% Never smoked 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Married/living with partner:

G1: 73.9% 

G2: NR 

Additional characteristics: 

NR 
C-221 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 39.68 lb 

(15.42)

G2: 32.75 lb 

(13.23)

G3: 34.16 lb 

(11.77)

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

G1: 3732 g (501) 

G2: 3440 g (465) 

G3: 3693 g (443) 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal outcomes: 

• Significant effects were found 

for weight gain by smoking 

status @ < 0.001) and weight 

gain over time (P < 0.001) 

• First trimester slopes differed 

slightly, but not significantly, 

among 3 groups (P = 0.075) 

• Second trimester slopes 

differed significantly 

(P = 0.013), with women who 

reported stopping smoking 

gaining more weight than 

never smokers during this 

period (difference of 2.57 Ib, 

99% CI = 0.46, 8.07) 

• Third trimester slopes also 

differed significantly (P = 

0.003). Pairwise contrasts 

revealed significant differences 

in weight gain during third 

trimester between women who 

stopped smoking and 

continuing smokers (difference 

of 4.31 lb, 99% CI = 1.88, 

12.00) and between women 

who stopped and never 

smokers (difference f 1.25 Ib, 

99% CI = 0.56, 10.49) 

Other infant outcomes: 

• Statistically significant 

proportion of variance in infant 

birthweight was accounted for 

by both maternal weight gain 

and maternal smoking status. 

However, interaction of 

maternal weight gain with 

smoking status did not 

contribute significantly 

Outcomes Description: 

Increase in birthweight 

Groups 

G1: Increase in birth weight 

per 1 lb increase in total 

pregnancy weight gain 

Results 

G1: β = 10.1g ± 1.76 

(P ≤ 0.001) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Pre-gravid BMI 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gender 

Background: 

Good 

Sample selection: 

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

5 Good, 4 Fair, 0 

Poor 

Final Quality Score: 

Good 
C-222 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Guihard-Costa et al., 

2004 

Country and setting: 

France, hospital 

database 

Enrollment Period:

1980-1990 

Funding: 

NR 

Study Objective: 

To deterine relative 

influences of maternal 

factors on infant skinfold 

thickness and other 

outcomes 

Time frame: 

1980-1990 

Duration of the study: 

Pregnancy to birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

13,972 

Group Description: 

Group N: 

Inclusion criteria: 

• Liveborn singletons 

• Term infants (37 to 

41 weeks) 

• Both parents born 

in Ffrance 

• No maternal 

smoking during 

gestation 

• All data available, 

specifically 

subscapular 

skinfold thickness 

• French 

metropolitan 

mothers 

Exclusion criteria: 

• French mothers 

born in French 

Caribbean Islands 

or outside of 

France 

Pregravid weight: 

• Routine pre-natal care 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-223 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from database 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Effect of pregnancy weight gain 

on infant birth weight 

Groups 

G1: Standardized coefficient for 

effect of pregnancy weight gain 

on infant birth weight. 

Standardized coefficients are 

regression coefficients 

calculated as if all of the 

independent variables had a 

variance of 1 

Results 

G1: SC = 0.199 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Height 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-224 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hediger et al., 1994 

Country and setting: 

USA, setting NR 

Enrollment Period:

1985 

Funding: 

NICHD grant 

Study Objective: 

To study relationship 

between changes in 

maternal subcutaneous 

fat and infant birth 

weight 

Time frame: 

1985 

Duration of the study: 

Initiation of prenatal 

care to 4 to 6 weeks 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

608 

Group Description: 

G1: Teenagers 13-15 

years 

G2: Teenagers 16-18 

years 

G3: Adults 19-29 

Group N: 

G1: 197 

G2: 207 

G3: 204 

Inclusion criteria: 

• Primigravid and 

multigravid teenagers 

(< 19 years) with first 

pregnancy at < 16 y 

• Older women ages 18 

to 29 years at first 

pregnancy 

Exclusion criteria: 

• History of serious 

nonobstetric problems 

(seizure disorders, 

leukemia or drug or 

alcohol abuse) 

• Fetal demise 

• Multiple pregnancy 

• Missing data on study 

variables 

• Women who breast 

fed after delivery or 

who were still 

breastfeeding at 4 to 

6 weeks postpartum 

Pregravid weight: 

• Self-reported 

G1: 56.00 (0.84) kg 

G2: 59.95 (0.82) 

G3: 60.91 (0.82) 

Pregravid BMI: 

G1: 21.81 (0.30) 

G2: 23.02 (0.29) 

G3: 23.18 (0.29) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 14.49 (0.14) 

G2: 17.41 (0.13) 

G3: 22.63 (0.14) 

Parity: 

% primiparous:

G1: 93.9 

G2: 37.2 

G3: 36.3 

Race,%: 

White 

G1: 7.6 

G2: 9.2 

G3: 8.8 

Black 

G1: 69.5 

G2: 57.5 

G3: 61.8 

Hispanic 

G1: 22.8 

G2: 33.3 

G3: 29.4 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 20.8 

G2: 34.8 

G3: 40.2 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean change in arm muscle 

area, cm2:

G1: 2.19 (0.44) 

G2: 1.78 (0.38) 

G3: 2.00 (0.39) 

Change in arm fat area, 

cm2:

G1: -0.46 (0.48) 

G2: -1.18 (0.43) 

G3: -1.26 (0.44) 

Change in triceps skinfold, 

mm 

Change in subscapular 

skinfold, mm: 

G1:: -0.85 (0.38) 

 -1.13 (0.38) 

G2: 1.22 (0.33) 

 -0.87 (0.33) 

G3: -1.25 (0.34) 

-1.53 (0.34) 
C-225 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 197 

G2: 207 

G3: 204 

Total weight gain: 

G1: 14.85 (0.54) kg

G2: 13.82 (0.47)

G3: 14.12 (0.48)

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

, infant sex 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Anthropometric 

measurements 

taken were: midupper arm 

circumference, 

triceps, and 

subscapular 

skinfold thickness 

from left side of 

body - upper arm 

muscle and fat 

area 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight by maternal 

weight gain 

Groups 

G1: Increase in birth weight per 1 

kg increase in total pregnancy 

weight gain 

Results 

G1: β = 16.7g ± 2.5 

(P = 0.001) 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

Age, race/ethnicity, parity, 

pregravid weight, height, prior poor 

outcome, fat loss, pregravid weight: 

 low weight, fat accretion, smoking 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-226 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1990 

Country and setting: 

United States, prenatal 

clinics 

Enrollment Period:

Does not state 

Funding: 

Supported by Garry A 

Weber Graduate 

Fellowship in 

Anthropology, Southern 

Methodist University, 

and through University 

Affiliated Center, 

Department of 

Pediatrics, University of 

Texas Southwestern 

Medical Center at 

Dallas, Maternal and 

Child Health Training 

Grant MCJ-2000, 

Department of Health 

and Human Services 

Study Objective: 

Present study was 

designed to (1) 

determine prevalence of 

low maternal weight-forheight near term among 

low income black and 

Hispanic women 

attending public 

prenatal clinics, and (2) 

compare maternal 

weight-for-height near 

term with current 

guidelines 

Time frame: 

Does not state 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

325 

Group Description: 

G1: Black 

G2: Hispanic 

Group N: 

G1: 172 

G2: 153 

Inclusion criteria: 

• Black and Hispanic 

pregnant women 

aged ≥ 17 who 

subsequently 

delivered singleton 

infants free from 

congenital 

malformations 

Exclusion criteria: 

• Women whose last 

prenatal weight was 

recorded > 14 days 

before delivery, 

gestational 

diabetes, other 

medical or 

obstetrical 

conditions, missing 

records, moved to 

another city before 

delivery 

Pregravid weight: 

• Self-reported 

G1: NR 

• < 90% standard: 27.3% 

• 90-119%: 44.2% 

• ≥ 120%standard: 21.5% 

G2: NR 

• < 90% standard: 15.7% 

• 90-119%: 38.6% 

• ≥ 120%standard: 9.8% 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 22.65 ± 4.48 

G2: 23. 18 ± 4.78 

Parity: 

G1: 0.98± 1.23 

G2: 1.10± 1.50 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-227 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• % of standard 

weight for 

height by use 

of nomogram 

and chart 

developed by 

Rosso 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Weight gain 

Groups 

Infant BW for groups 

defined by maternal weight 

near term (% of standard 

weight-for-height) 

G1: > 135%, Black 

G2: > 135%, Hispanic 

G3: 120-135%, Black 

G4: 120-135%, Hispanic 

G5: 110-119%, Black 

G6: 110-119%, Hispanic 

G7: 100-109%, Black 

G8: 100-109%, Hispanic 

G9: < 100%, Black 

G10: < 100%, Hispanic 

Results 

G1: 3,325g ± 460 

G2: 3,543g ± 410 

G3: 3,200g ± 389 

G4: 3,381g ± 385 

G5: 3,157g ± 373 

G6: 3,282g ± 400 

G7: 3,025g ± 494 

G8: 3,154g ± 375 

G9: 2,813g ± 289 

G10: 3,205g ± 472 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NA 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

7 Good, 2 Fair, 0 Poor 

Final Quality Score: 

Good 
C-228 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period:

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain 

in obese glucose 

tolerant women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI 

≥ 30 

• Normal 2h 75g oral 

glucose tolerance 

test (OGTT) during 

third trimester 

(according to WHO 

criteria) 

• Only first 

pregnancy during 

study period 

included 

Exclusion criteria: 

• Well defined 

chronic disease 

• Twin pregnancies 

• Women with GDM 

(n = 323) 

• Known diet 

treatment (n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of 

pregravid BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-229 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight gain: 

Categorized: 

• < 5.0. 5.0-9.9, 

10.0-14.9, ≥

15.0 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated by 

authors 

Birth weight: 

G1: 3500 (3200-3840) 

G2: 3645 (3200-4000) 

G3: 3750 (3390-4125) 

G4: 3762 (3400-4120) 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Infant birthweight 

Groups 

G1: MWG < 5.0 kg 

G2: MWG 5.0-9.9 kg 

G3: MWG 10-14.9 kg 

G4: MWG ≥ 15.0 kg 

Results 

G1: 3,456g ± 620 

G2: 3,624g ±675 

G3: 3,757g ± 582 

G4: 3,784g ± 597 

P < 0.0001 

Increase in birth weight per 1 

kg increase in total pregnancy 

weight gain 

G1: β = 18.4g 

(P < 0.001) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Maternal age, pregravid BMI, 

smoking, gestational age, 

result of 2-hour oral glucose 

tolerance test 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 4 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-230 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

Country and setting: 

USA, prenatal clinics 

Enrollment Period:

January 1, 1987- 

December 31, 1989 

Funding: 

NR 

Study Objective: 

To determine influences 

of increased maternal 

prepregnancy weight 

and increased 

gestational weight gain 

on pregnancy outcome 

Time frame: 

January 1, 1987 to 

December 31, 1989 

Duration of the study: 

Initiation of prenatal 

care to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,191 

Group Description: 

G1: BMI < 19.8 

G2: 19.8-26.0 

G3: 27-29 

G4: > 29 

G5: All 

Group N: 

G1: 755 

G2: 1,621 

G3: 329 

G4: 486 

G5: 3191 

Inclusion criteria: 

• Delivery at or 

beyond 38 weeks 

of gestation 

• Singletons 

• Received prenatal 

care and delivered 

in Shands Hospital 

Exclusion criteria: 

• Fetal abnormalities 

• Oligohydramnios 

• Polyhydramnios 

• Medical or surgical 

complications (GI 

disorders, sickle 

cell 

hemoglobinopathy, 

hepatitis, 

hematologic 

disorders, 

malignant disease, 

renal disease, 

neurologic disease, 

pulmonary disease, 

psychiatric 

disorders, 

tuberculosis) 

• Incomplete risk 

variable data or 

outcome variable 

information 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• National Academy of 

Sciences 

Age (mean, yrs): 

G1: NR 

• < 20 years: 36.6% 

• 20-26 years: 44.8% 

• > 26 years: 18.7% 

G2: NR 

• < 20 years: 30.8% 

• 20-26 years: 46.5% 

• > 26 years: 22.6% 

G3: 

• < 20 years: 25.8% 

• 20-26 years: 48.9% 

• > 26 years: 25.2% 

G4: 

• < 20 years: 16.5% 

• 20-26 years: 53.9% 

• > 26 years: 29.6% 

G5: 

• < 20 years: 29.5% 

• 20-26 years: 47.5 % 

• > 26 years: 23.0% 

Parity: 

G1: % first: 49.3 

G2: 43.1 

G3: 37.4 

G4: 31.1 

G5: 42.1 

Race,%: 

White 

G1: 64.5 

G2: 60.0 

G3: 49.8 

G4: 51.9 

G5: 58.7 

Black 

G1: 33.6 

G2: 37.9 

G3: 48.9 

G4: 47.5 

G5: 39.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 1.9 

G2: 2.1 

G3: 1.2 

G4: 0.6 

G5: 1.7 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Hypertension,%: 

G1: 3.4 

G2: 4.6 

G3: 5.8 

G4: 10.7 

G5: 5.4 

Additional characteristics: 

G1: % married: 42.6 

G2: 46.1 

G3: 40.4 

G4: 49.4 

G5: 45.2 

Additional characteristics: 

NR 
C-231 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 755 

G2: 1621 

G3: 329 

G4: 486 

G5: 3191 

Total weight gain: 

G1: 

• < 16kg: 7.8% 

• 16-25kg: 

18.5% 

• 26-35kg: 

35.1% 

• > 35kg: 38.5% 

G2: 

• < 16kg: 11.7% 

• 16-25kg: 

18.0% 

• 26-35kg: 

28.8% 

• > 35kg: 41.5% 

G3: 

• < 16kg: 19.8% 

• 16-25kg: 

19.1% 

• 26-35kg: 

28.3% 

• > 35kg: 32.8% 

G4: 

• < 16kg: 32.3% 

• 16-25kg: 

22.0%; 

Categorized: 

• Quartiles 

• National 

Academy of 

Sciences 

(below, within, 

or above 

recommended 

range) 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Birth weight: 

G1: 

• < 2500g: 4.8% 

• 2500-4000g: 

89.1% 

• > 4000g: 6.1% 

G2: 

• < 2500g: 2.0% 

• 2500-4000g: 

85.2% 

• > 4000g: 

12.8% 

G3: 

• < 2500g: 1.5% 

• 2500-4000g: 

83.0% 

• > 4000g: 

15.5% 

G4: 

• < 2500g: 0.2% 

• 2500-4000g: 

82.5% 

• > 4000g: 

17.3% 

Gestational 

diabetes, %: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Cesarean 

delivery,%: 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 11.9 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Infant birthweight by 

maternallweight gain 

Groups 

G1: Increase in birth weight per 1 

lb increase in net pregnancy weight 

gain 

Results 

G1: β = 15.4g ± 2.2 

(P < 0.0001) 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

Race, parity, pregravid BMI, height, 

pregravid weight, marital status, 

education, tobacco/alcohol/drug 

use, pregnancy-induced 

hypertension, macrosomia 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

Gestational age, infant sex, 

macrosomia 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 9 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-232 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

(continued) 

 
C-233 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between self 

report and 

weight at last 

prenatal visit 

(mean 6.1 days 

prior to 

delivery) 

Other maternal 

outcomes: 

• Frequency of 

macrosomia = 

12.2% 

• Frequency of 

cesarean = 

11.9% 

• Frequency of 

LBW = 2.9% 

• Frequency of 

postdate 

pregnancy = 

9.8% 

• Frequency of 

labor 

abnormalities 

(40% were 

unscheduled 

cesareans) = 

7.8% 

• Frequency of 

oxytocin 

induction = 

13.7% 

• Frequency of 

oxytocin 

augmentation 

= 16.1% 

• Frequency of 

meconium 

staining = 

21.5% 

Other infant 

outcomes: 

NA 
C-234 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kieffer et al., 2006 

Country and setting: 

United States, 

community health 

center 

Enrollment Period:

Jan 1999 to Feb 2001 

Funding: 

This study was 

supported by National 

Institutes of Diabetes 

and Digestive and 

Kidney Diseases (grant 

R18DK 062344); 

Biostatistics and 

Measurement Cores of 

Michigan Diabetes 

Research and Training 

Center (grant NIH5P60 

DK20572); General 

Clinic Center, National 

Institutes of Health 

(grant M01 RR00042); 

the Maternal and Child 

Health Bureau (grant 

R40 MC00115-03); and 

Detroit Community 

Academic Urban 

Research Center 

Study Objective: 

Our study assessed 

combined influence of 

maternal weight and 

other anthropometric 

and metabolic 

characteristics on 

birthweights of Latino 

infants 

Time frame: 

Jan 1999 to Feb 2001 

Duration of the study: 

From entry into prenatal 

care up til delivery. Ave 

ga at entry was 17 

weeks 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1,041 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 1041 

G2: NR 

Inclusion criteria: 

• Latino women 

entering prenatal 

care during study 

period 

Exclusion criteria: 

• Multiple gestation 

• Late entry into 

prenatal care 

• Previous 

participation in 

study 

• Miscarriage 

• Stillbirth 

• Missing records 

Pregravid weight: 

• Self-reported when 

unknown or missing - 

used weight obtained 

within first 10 weeks of 

pregnancy 

G1: 63.4 ¡±12.9 

G2: NR 

Pregravid BMI: 

G1: 25.9 ±5.0 

G2: NR 

Imputed: 

• Yes 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 25.2 ±5.1 

G2: NR 

Parity: 

G1: Multiparous, no. (%)0 

429 (41.2) 1 ̈C3 574 (55.1) 

¡Ý4 38 (3.7) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

G1: 100% 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 9%before; 2% during 

G2: NR 

Diabetes mellitus,%: 

G1: 6.8 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-235 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: total n = 933 

G2: NR 

Total weight gain: 

G1: Adjusted R2: 

0.30 kg [PE 8.2, SE 

2.2, P < 0.01]

G2: NR 

Categorized: 

• Continuous 

According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery

Birth weight: 

NR 

Gestational diabetes, 

%: 

G1: 6.8 

G2: NR 

Cesarean delivery,%:

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

• Women with GDM 

had significantly 

lower average 

weight gain than 

those without 

GDM, but weight 

gain was not 

significantly 

related to glucose 

category 

• Maternal waist, 

hip, and upperarm 

circumference 

and upper-arm fat 

area were 

associated with 

increasingly 

abnormal glucose 

categories among 

women with and 

without GDM 

• Significant linear 

increase in 

birthweight with 

increasing 

glucose level was 

maintained after 

further adjustment 

for maternal age, 

parity, BMI, 

weight gain, 

hypertensive 

disorders, and 

family history of 

diabetes 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Infant birth weight 

Groups 

G1: Increase in birth weight per 

1 kg increase in total pregnancy 

weight gain 

Results 

G1: β = 19.7g ± 2.8 

(P < 0.01) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

Parity, pregravid BMI, height, 1-

hour glucose value 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

7 Good, 2 Fair, 0 Poor 

Final Quality Score: 

Good 
C-236 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kirchengast and 

Hartmann, 2003 

Country and setting: 

Singleton births that took 

place at University Clinic 

for Gynecology and 

Obstetrics in Vienna, 

Austria 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

Examine impact of 

biological factors such as 

young maternal age and 

maternal somatic 

characteristics on 

pregnancy outcome 

among group of 

adolescent mothers who 

gave birth between 39th 

and 41st week of 

gestation after period of 

intensive psychological 

support 

Time frame: 

NR 

Duration of the study: 

1985 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

8,011 

Group Description: 

G1: 12 to 16 years 

G2: 17 to 19 years 

G3: 20 to 29 years 

Group N: 

G1: 215 

G2: 1,336 

G3: 6,460 

Inclusion criteria: 

• Women ages 12 to 

29 

• All prenatal checkups of mother-child 

passport were 

performed 

• Delivery of single 

infant without 

congenital 

malformations 

• Receiving 

psychosocial support 

by family and/or 

specially trained 

social worker within 

young adolescent 

group (12 to 16 

years) 

Exclusion criteria: 

• Coincident medical 

diseases such as 

diabetes mellitus or 

nephropathy 

• Drug or alcohol 

abuse 

• Twin birth 

• IVF 

• Registered maternal 

diseases before and 

during pregnancy 

• Hypertension 

(BP < 150/90 mmHG)

• Protein or glucose in 

urine 

• Pregnancy related 

immunization 

Pregravid weight: 

Estimated by means of 

retrospective method and first 

weight determination, which 

was carried out at first prenatal 

visit (8th week of gestation) 

G1: 56.0 

G2: 57.2 

G3: 59.2 

Pregravid BMI: 

G1: 21.45 

G2: 21.59 

G3: 22.10 

Imputed: 

• Yes 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 14.5 

G2: 17.8 

G3: 24.1 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Age at menarche:

G1: 12.2 

G2: 12.9 

G3: 13.3 

Gynecological age:

G1: 3.4 

G2: 5.3 

G3: 10.8 
C-237 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 215 

G2: 1,336 

G3: 6,460 

Total weight gain: 

G1: 13.1 

G2: 13.1 

G3: 13.1 (P = .10) 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3237.6 

(significantly 

different from 17-

19 and 20-29) 

G2: 3298.3 

(significantly 

different from 

< 17 and 20-29) 

G3: 3368.9 

(significantly 

different from 

< 17 and 17-19) 

(F = 24.1, 

P < .0001) 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Chronological 

age 

• Age at menarche

• Gynecological 

age 

• Height 

• Distancia 

spinarum 

• Distancia 

christarum 

• Prepregnancy 

weight 

• Weight at end of 

pregnancy 

Other infant 

outcomes 

• Birth length 

• Head 

circumference 

• Acromial 

circumference 

• Diameter 

frontooccipitale 

Outcomes Description: 

Increase in birth weight per 1 

kg increase in total pregnancy 

weight gain 

Groups 

NA, weight gain as continuous 

variable 

Results 

Increase in birth weight per 1 

kg increase in total pregnancy 

weight gain (95% CI) 

G1: β = 17.32 (14.62, 20.03) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Maternal age, age at 

menarche, pregravid weight, 

height, distantia cristarum 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-238 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Luke et al., 1996 

Country and setting: 

USA, clinic 

Enrollment Period:

March 1, 1974 to June 15, 

1979 

Funding: 

NR 

Study Objective: 

Reanalysis of original data 

to examine contribution of 

maternal weight gain to 

infant birth weight and 

retained maternal weight 

in immediate postpartum 

period, and effect of 

weight gains below, at, 

and above IOM guidelines 

on both infant birt 

Time frame: 

March 1, 1974 to June 15, 

1979 

Duration of the study: 

Prenatal visit through 2 

days postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

487 

Group Description: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

Group N: 

G1: 104 

G2: 268 

G3: 115 

Inclusion criteria: 

• Referred for nutrition 

counseling 

• > 37- < 43 weeks 

gestation 

• Singleton pregnancy 

Exclusion criteria: 

• Women with history 

of or concurrent 

metabolic disease, 

such as diabetes, 

seizure disorder, 

hypertension, cardiac 

disease, asthma, or 

drug dependence 

• Women developing 

antepartum 

complications such 

as preeclampsia, 

GDM, or multiple 

gestation 

Pregravid weight: 

• Self-reported 

G1: 47.9 (5.1) 

G2: 58.7 (6.3) 

G3: 83.9 (16.9) 

Pregravid BMI: 

G1: 18.3 (1.0) 

G2: 22.6 (1.7) 

G3: 31.7 (5.3) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 23.1 (5.5) 

G2: 23.8 (5.5) 

G3: 27.4 (6.2) 

Parity: 

% primipara:

G1: 60.6 

G2: 48.1 

G3: 27.0 

Race,%: 

White 

NR 

Black 

G1: 48.1 

G2: 48.8 

G3: 63.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 17.3 

G2: 15.3 

G3: 13.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-239 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 104 

G2: 268 

G3: 115 

Total weight gain: 

G1: 12.6 (0.7)

G2: 13.2 (0.4)

G3: 11.7 (0.7) 

Significantly different 

from mean for normal 

BMI group at P < 0.05

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

total weight gain: 

difference 

between last 

measurement 

and pregravid 

weight; net 

weight gain: 

difference 

between 

pregravid weight 

and last 

measured weight 

minus infant birth 

weight 

Birth weight: 

G1: 3,067 (44) 

P < 0.05 

significantly 

different from 

mean for normal 

BMI 

G2: 3308 (27) 

G3: 3300 (43) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Net gain (kg): 9.5 

(0.6), 9.9 (0.4), 

7.8 (0.6) 

significantly 

different from 

mean for normal 

BMI group at P < 

0.05 

• Retained weight 

(kg): 6.6 (0.6), 

6.6 (0.4), 4.2 

(0.6) significantly 

different from 

mean for normal 

BMI group at 

P < 0.05 

• Percent retained 

weight (%): 11.4 

(0.9), 9.4 (0.5), 

4.4 (0.8) 

significantly 

different from 

mean for normal 

BMI group at 

P < 0.05 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight for total 

weight gain and net weight gain

Groups 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

Results 

Increase in birth weight per 1 

kg increase in total pregnancy 

weight gain for BMI categories

G1: β = 44.9g ±6.8 

(P < 0.01) 

G2: β = 22.9g ± 3.9 

(P < 0.01) 

G3: β = 11.9g ± 5.2 

(P < 0.05) 

Increase in birth weight per 1 

kg increase in net pregnancy 

weight gain for BMI categories: 

G1: β = 41.9g ± 7.5 

(P < 0.01) 

G2: β = 19.2g ± 3.9 

(P < 0.01) 

G3: β = 9.1g ± 5.3 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Age, parity, black ethnicity, 

smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

Gestational age, infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-240 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Muscati et al., 1996 

Country and setting: 

Canada, public health 

department 

Enrollment Period:

1979 to 1989 

Funding: 

NR 

Study Objective: 

To examine association of 

extent and timing of 

pregnancy weight gain 

with infant birth weight 

and postpartum weight 

retention 

Time frame: 

1979 to 1989 

Duration of the study: 

Pregnancy through 6 

weeks postpartum 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

371 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 371 

G2: NR 

Inclusion criteria: 

• White, low income, 

non-smoking women 

• Pregnant women 

Exclusion criteria: 

• Prematurity < 37 

weeks 

• Adolescents < 16 

years 

• Women > 40 years 

• Maternal health 

problems 

• Women who 

consume alcohol or 

drugs 

• Pregnancy 

complications such 

as proteinuria, 

hypertension, 

diabetes, negative 

weight gain, missing 

values 

Pregravid weight: 

Family physicians’ records 

G1: 62.8 +/- 16.0 kg 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Pregravid weight status 

categorized into 3 groups 

as a percentage of 

standard weight: 

underweight < 90%, 

normal 90-120%, and 

overweight > 120% 

Age (mean, yrs): 

G1: 24.5 +/- 5.6 

G2: NR 

Parity: 

G1: Primiparous 52% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: PPWR: 5.3 +/- 5.7 kg 

G2: NR 

Additional characteristics: 

NR 
C-241 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 16.1 +/- 6.4 kg

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %:

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

From Table 1: 

Pearson’s Correlation 

Coefficient and 

determination 

coefficient of maternal 

weight gain with PP 

weight retention and 

Infant BW. Maternal PP 

weight retention and 

Preg weight gain: [Total 

amount r = 0.808, R 

square 65.3%, P < 

0.001], [Up to week 20 r 

= 0.682, R square 

46.5%, P < 0.001], 

[Weeks 21-30 r = 

0.411, R square 16.9%, 

P < 0.001], [Week 31 - 

term r = 0.414, R 

square 17.1%, P < 

0.001] 

Other infant 

outcomes: 

Pregnancy Weight Gain 

and Infant Birth Weight 

(from Table 1): [Total 

amount r = 0.216, R 

square 4.7%, P < 

0.001], [Up to week 20 r 

= 0.114, R-square 

1.3%, 

P < 0.05], [Weeks 21-

30 r = 0.157, R square 

2.5%, P < 0.01], [Week 

31 - term r = 0.160, R 

square 2.6%, 

P < 0.01] 

Outcomes Description: 

Infant birthweight 

Groups 

G1: Increase in birth weight per 1 kg 

increase in total weight gain up to 

week 20 

G2: Increase in birth weight per 1 kg 

increase in total weight gain from 

weeks 21 to 30 

G3: Increase in birth weight per 1 kg 

increase in total weight gain from 

weeks 31 to term 

Results 

G1: β = 22g ± 6 

(P < 0.01) 

G2: β = 31g ± 7 

(P < 0.001) 

G3: β = 12g ± 6 

(P < 0.05) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Parity 

• Pregravid standard weight 

• Pregravid excess weight, 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Birth length 

• Infant gender 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes:

Fair 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-242 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Paauw et al., 2005 

Country and setting: 

USA, hospital 

Enrollment Period:

1995 to 1998 

Funding: 

NR 

Study Objective: 

To evaluate relationship of 

maternal hyperemesis 

gravidarum to neonatal 

birth weight, infant 

hospital length of stay, 

and other birth outcomes 

Time frame: 

1995 to 1998 

Duration of the study: 

Initiation of prenatal care 

to delivery (+any time in 

NICU or NIMU) 

Design: 

• Cohort 

• Prospective 

Total Study N: 

351 

Group Description: 

G1: Controls 

G2: HG patients 

Group N: 

G1: 306 

G2: 45 

Inclusion criteria: 

• Singleton pregnancy 

Exclusion criteria: 

• Multiple or molar 

gestation 

• Diabetes or GDM 

• Causes of nausea 

such as appendicitis 

or pyleonephritis 

Pregravid weight: 

• Self-reported 

G1: 65.2 (1.2) kg 

G2: 66.7 (3.3) 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 25.9 (0.3) 

G2: 25.5 (0.7) 

Parity: 

NR 

Race,%: 

White 

G1: 83.7 

G2: 67.4 (P < .05 vs controls) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 21.9 

G2: 11.1 

Diabetes mellitus,%: 

G1: 0.7 

G2: 2.2 

Hypertension,%: 

G1: 3.6 

G2: 4.4 

Additional characteristics: 

NR 
C-243 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 306 

G2: 45 

Total weight gain: 

G1: 14.9 (0.3)

G2: 10.6 (1.3)

Categorized: 

• Continuous 

Collected from: 

• Self-reported 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not explained by 

authors 

Birth weight: 

G1: 3523 (29) 

G2: 3232 (88) (P < 

0.05) 

Gestational 

diabetes, %: 

G1: 0.7 

G2: 2.2 

Cesarean 

delivery,%: 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight by maternal 

weight gain 

Groups 

G1: Increase in birth weight per 1 

kg increase in total pregnancy 

weight gain 

Results 

G1: β = 21.0g 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Race 

• Prepravid weight 

• Marital status 

• Smoking 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-244 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Pezzarossa et al., 1996 

Country and setting: 

Italy, not stated 

Enrollment Period:

Not stated 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

gestational weight gain on 

neonatal birthweight in 

women who were 

diagnosed with 

gestational diabetes after 

3second week gestation 

Time frame: 

Not stated 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

192 

Group Description: 

G1: Normal 

G2: GDM 

Group N: 

G1: 132 

G2: 60 

Inclusion criteria: 

• Caucasian women 

who had 1 or more 

risk factors for GDM: 

BMI > 28.6, 

gestational weight 

gain > 12kg, previous 

GDM, or previous 

neonatal macrosomia 

and underwent a 

diagnostic oral 

glucose tolerance test 

for GDM after 

3second week of 

gestation - women 

with positive tests 

formed GDM group 

while women with 

negative test results 

formed normal 

singleton 

Exclusion criteria: 

• Smoking 

• Hypertension 

• Underweight (BMI < 

19.6) 

• Previous metabolic 

treatment 

• Diabetic counseling 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 25.7 (0.5) 

G2: 25.4 (0.8) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.1 (0.4) 

G2: 28.07 (0.6) 

Parity: 

NR 

Race,%: 

White 

G1: 100 

G2: 100 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-245 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 132 

G2: 60 

Total weight gain: 

G1: 13.4 (0.5)

G2: 12.2 (0.6)

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

used weight at 

last prenatal visit 

Birth weight: 

G1: 3576.8 (41.3) 

G2: 3678.7 (69.3) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

macrosomia 

Outcomes Description: 

Infant birthweight by maternal weight 

gain 

Groups 

Increase in birth weight per 1 kg 

increase in total pregnancy weight gain 

for: 

G1: Controls (normal glucose 

tolerance) 

G2: GDM 

Results 

G1: β = 27.8g (P = 0.0001) 

G2: β = 39.5 

(P = 0.0001) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Pre-gravid BMI 

• Fasting plasma glucose 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information 

on exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor:

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-246 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Shapiro et al., 2000 

Country and setting: 

USA, community hospital 

Enrollment Period:

NR 

Funding: 

NR 

Study Objective: 

To ascertain whether 

increased weight gain 

during pregnancy resulted 

in higher birth weight 

infants in women 

delivering at a community 

hospital 

Time frame: 

NR 

Duration of the study: 

First prenatal visit (0-15 

wks of gestation) to 2 

weeks after birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

159 

Group Description: 

G1: total cohort 

G2: NR 

Group N: 

G1: 159 

G2: NR 

Inclusion criteria: 

• Randomly selected 

from hospital 

database 

• Ages 19 to 37 

• Term delivery 

Exclusion criteria: 

• Smokers 

• Drug abusers 

• Chronic 

hypertensivers 

• Preeclampsia 

requiring magnesium 

sulfate 

• Underlying systemic 

disease such as 

lupus or diabetes 

• Patients not screened 

for GDM 

Pregravid weight: 

• Routine pre-natal care 

G1: 144.4 (36.0) 

G2: NR 

Pregravid BMI: 

G1: 24.5 (5.7) 

G2: NR 

Imputed: 

• No 

Categorized: 

• < 25 > 25 

Age (mean, yrs): 

G1: 27.8 (4.6) 

G2: NR 

Parity: 

G1: 1.3 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-247 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 159 

G2: NR 

Total weight gain: 

G1: 30.3 lbs (11.4)

G2: NR 

Categorized: 

• < 35, > 35 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between weight 

measured at first 

visit (0-15 weeks 

gestation) and 

weight at last 

visit (35-41 

weeks) 

Birth weight: 

G1: 3513.4 gms 

(468.8) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight 

Groups 

G1: Low BMI (< 25), Low gain (< 

35lbs) 

G2: Low BMI (< 25), High gain 

(> 35lbs) 

G3: High BMI (> 25), Low gain 

(< 35lbs) 

G4: High BMI (> 25), High gain 

(> 35lbs) 

Results 

G1: 3,363g 

G2: 3,636g 

G3: 3,565g 

G4: 3,774g 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Poor 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-248 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Shepard et al., 1998 

Country and setting: 

Obstetrical practices in 

New Haven, CT 

Enrollment Period:

1988 to 1992 

Funding: 

Grants NIH 

Study Objective: 

To examine absolute and 

proportional gestational 

weight gain and 

prepregnancy BMI as 

predictors of primary 

cesarean delivery 

Time frame: 

1988 to 1992 

Duration of the study: 

First prenatal visit to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

2,301 

Group Description: 

G1: Cesarean delivery 

G2: Vaginal delivery 

Group N: 

G1: 312 

G2: 1,989 

Inclusion criteria: 

• Privately insured 

women who received 

prenatal care from 13 

largest obstetrical 

practices and health 

maintenance 

organizations in 

greater New Haven, 

CT region (part of a 

larger study of 

selected 

environmental risk 

factors on pregnancy)

• Singleton deliveries 

at Yale-New Haven 

Hospital 

Exclusion criteria: 

• Repeat cesareans 

births 

• Missing information 

on key variables 

Pregravid weight: 

• Self-reported 

G1: 140.9 (28.6) 

G2: 136.3 (25.2) P = 0.007 

Pregravid BMI: 

G1: 24.3 (4.6) 

G2: 22.9 (3.9) P < 0.0001 

Imputed: 

• No 

Categorized: 

• NHANES II: ≤ 19.4; 19.5-

22.4; 22.5-28.5; > 28.5 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

G1: 88.4 

G2: 91.2 

Black 

G1: 5.8 

G2: 4.9 

Hispanic 

G1: 3.5 

G2: 2.3 

Asian/Pacific Islander 

G1: 1.3 

G2: 1.1 

Other 

G1: 1.0 

G2: 0.4 

Smoking,%: 

% never smokers:

G1: 82.3 

G2: 85.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

%married:

G1: 95.8 

G2: 92.1 

Additional characteristics: 

NR 
C-249 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 312 

G2: 1989 

Total weight gain: 

G1: 35.4 (11.9)

G2: 33.3 (11.9) P = 

0.005

Categorized: 

• Proportional 

weight gain 

based on 

prepregnancy 

weight and 

weight change 

during pregnancy 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Propotional 

weight gain, lb, 

mean: cesarean 

delivery - 26.5 

(10.0); vaginal 

delivery - 25.2 

(9.3) P = 0.048 

Other infant 

outcomes: 

• Low birth weight 

rate = 3.3% for 

entire study 

population 

Outcomes Description: 

Infant birthweight 

Groups 

Infant BW for mothers with: 

G1: Low average BMI (19.5 to 22.4), 

proportional weight gained > median 

G2: Low average BMI (19.5 to 22.4), 

gained < median 

G3: High average BMI (22.5 to 28.5), 

gained > median 

G4: High average BMI (22.5 to 28.5), 

gained < median 

G5: Obese (> 28.5 BMI), gained > 

median 

G6: Obese (> 28.5 BMI), gained < 

median 

Results 

G1: 3,231g 

G2: 3,553g 

G3: 3,395g 

G4: 3,620g 

G5: 3,685g 

G6: 3,453g 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

NA 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 4 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-250 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Springer et al., 1992 

Country and setting: 

USA, university hospital 

Enrollment Period:

Sept 1988 

Funding: 

NIH-nursing 

Study Objective: 

Purpose of study to 

examine relationship 

between early weight gain 

and other nutrition-related 

risk factors and 2 

pregnancy outcomes: 

length of gestation 

and birth weight 

Time frame: 

Sept 1988 

Duration of the study: 

Entry into prenatal care up 

to delivery 

Design: 

• Other observational 

• Retrospective 

Total Study N: 

107 

Group Description: 

Group N: 

G1: 107 

G2: NR 

Inclusion criteria: 

• Women giving birth 

during September 

1988 at University of 

Michigan Women’s 

Hospital 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• Listed on medical record 

G1: Underweight 96.1 lbs 

Normal weight 128.4 lbs 

Overwt 188.5 lbs 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Weight standards 

published by Metropolitan 

Life Insurance Company 

Age (mean, yrs): 

G1: 28 

G2: NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 32% 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-251 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Weight gain at 

10 and 20 weeks 

ascertained to 

within 5 weeks 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

Estimated weight 

gain at 20 weeks’ 

gestation was 

positively related to 

both length of 

gestation and birth 

weight; this 

association was 

statistically significant 

(P = .02) for birth 

weight, as shown by 

a simple regression. 

Outcomes Description: 

Infant birthweight by maternal 

weight gain 

Groups 

G1: Increase in birth weight per 

1 lb increase in total pregnancy 

weight gain 

Results 

G1: β = 20.1g 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

Maternal age, pregravid weight, 

length of gestation, smoking, 

weight gain at 20 weeks 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-252 

 Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Velonakis et al., 1997 

Country and setting: 

France, hospital 

Enrollment Period:

1988 

Funding: 

NR 

Study Objective: 

To identify impact of 

various biological, 

occupational, and 

socioeconomic factors on 

gestational age and birth 

weight 

Time frame: 

1988 

Duration of the study: 

First prenatal visit through 

delivery 

Design: 

• Cohort 

Total Study N: 

2,040 

Group Description: 

Group N: 

Inclusion criteria: 

• Women with regular 

cycle not exceeding 

32 days 

• Last menstrual period 

was not withdrawal 

bleed from pill 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-253 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

calculated by 

subtracting 

prepregnancy 

weight, fetal and 

placental weight 

from final weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight 

Groups 

G1: Increase in birth weight for 

net pregnancy weight gain 

Results 

G1: β = 111.17g ± 12.94 

(P = 0.000)

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

Maternal age, parity, pathology of 

previous/current pregnancy, 

previous diseases, reproductive 

history, marital status, 

employment, height weight, 

smoking, alcohol use, nationality 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

Infant sex, APGAR score, 

gestational age 

Background: 

Poor 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 6 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-254 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Zaren et al., 1997 

Country and setting: 

Norway and Sweden, 

university hospitals 

Enrollment Period:

January 1986 to March 

1988 

Funding: 

NR 

Study Objective: 

To assess effects of 

maternal smoking on 

birthweight in term 

pregnancies among 

mothers with different 

anthropometric stature 

Time frame: 

January 1986 to March 

1988 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1,099 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 1,099 

G2: NR 

Inclusion criteria: 

• 10% random sample 

of nonsmoking 

mothers 

• 50% random sample 

of smokers from 

Successive Small for 

Gestational Age 

Births 

• Women speaking 

Swedish or 

Norwegian 

• Para 1 and 2 

• First prenatal visit 

before 17 weeks 

Exclusion criteria: 

• Preterm delivery 

• Incomplete 

information 

Pregravid weight: 

• Self-reported 

G1: ≤ 55: 30.9%; 

56-66: 45.8%; 

≥ 67: 23.3% 

G2: NR 

Pregravid BMI: 

G1: ≤ 19.8: 26.6%; 

19.9-23.4: 48.5%; 

≥ 23.5: 24.9% 

G2: NR 

Imputed: 

• No 

Categorized: 

• ≤ 19.8, 19.9-23.4, ≥ 23.5 

Age (mean, yrs): 

G1: 15-19 years: 0.5%; 

20-24: 13.7%; 

25-29: 42.4%; 

30-34: 32.2%; 

≥ 35: 11.2% 

G2: NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 70.4% 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-255 

Evidence Table 18. Gestational weight gain and birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 1099 

G2: NR 

Total weight gain: 

G1: ≤ 11kg: 30.8%; 

12-16kg: 45.6%; ≥

17: 23.6%

G2: NR 

Categorized: 

• ≤ 11, 12-16, ≥

17 kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

β is estimated change in infant BW (g) 

Groups 

G1: MWG ≤ 11 kg: 

G2: MWG ≥ 17 kg 

Results 

G1: β = -131 (P = 0.0001) 

G2: β = 164 (P = 0.0001) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, height, pregravid weight, 

smoking 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-256 

Evidence Table 19. Gestational weight gain and low birth weight 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-257 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

LBW (%) 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results 

G1: 2.0 

G2: 11.1 

G3: 8.3 

G4: 5.2 

G5: 3.8 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-258 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cherry et al., 1993 

Country and setting: 

USA, hospital 

Enrollment Period:

NR 

Funding: 

NR 

Study Objective: 

NR-to examine effect of 

zinc on birth outcomes 

Time frame: 

NR 

Duration of the study: 

9 months-from time of 

enrollment in to prenatal 

care up to delivery 

Design: 

• RCT 

Total Study N: 

599 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 599 

G2: NR 

Inclusion criteria: 

• Adolescents in 

prenatal clinic at 

Charity Hospital of 

New Orleans 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Measured by study 

investigators 

G1: 53% were 90-110% 

Expected Weight (EW); 26% < 

90% EW; 21% were > 110% 

EW 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Calculated weight for age 

and height 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-259 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Grams gained 

per week per cm 

height 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Table 1 provided data 

above-LBW, wt for 

length of infant, % of 

infants in high risk 

nursery 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percentage of low birth weight 

for each shifting of EW category.

Groups 

Light: < 90% EW 

Normal: 90 to 110% of EW 

Heavy: > 110% EW 

G1: Heavy to normal 

G2: Normal to light 

G3: Normal to heavy 

G4: Light to normal 

Results 

G1: 5% 

G2: 32% 

G3: 3.1% 

G4: 2.7% 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Poor 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 3 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-260 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cogswell et al., 1994 

Country and setting: 

USA, Pregnancy Nutrition 

Surveillance System 

Enrollment Period:

1990-1991 

Funding: 

NR 

Study Objective: 

To determine association 

between increased 

gestational weight gain 

and birth weight outcomes 

for low income women 

Time frame: 

1990-1991 

Duration of the study: 

Women in WIC but 

everything is self reported 

so it is when they were 

first enrolled in WIC until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

53,541 

Group Description: 

G1: Average weight 

G2: Overweight 

G3: Very overweight 

Group N: 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Inclusion criteria: 

• White, black and 

hispanic women who 

delivered single, 

liveborn, term infants 

Exclusion criteria: 

• Low or high values 

for; birth weight, 

prepregnancy BMI, or 

weight gain during 

pregnancy 

• Missing data on one 

or more study 

variables 

• Underweight women 

• Only 1 infant was 

used in analysis for 

women who delivered 

more than once 

during study period 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 11-17 yr: 11.9% 

18-34yr: 85.0% 

35-54 yr: 3.1% 

G2: 11-17 yr: 6.9% 

18-34yr: 88.7% 

35-54 yr: 4.4% 

G3: 11-17 yr: 4.0% 

18-34yr: 90.1% 

35-54 yr: 6.0% 

Parity: 

NR 

Race,%: 

White 

G1: 75.1 

G2: 72.4 

G3: 74.5 

Black 

G1: 13.8 

G2: 14.1 

G3: 16.1 

Hispanic 

G1: 11.1 

G2: 13.5 

G3: 9.4 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.9 

G2: 28.3 

G3: 25.7 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-261 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Total weight gain: 

G1: < 15 lb: 6.2% 

15-19: 5.8% 

20-24: 11.2% 

25-29: 14.4% 

30-34: 17.1% 

35-39: 13.9% 

≥ 40: 31.4%

G2: < 15 lb: 11.4% 

15-19: 7.8% 

20-24: 13.0% 

25-29: 12.7% 

30-34: 15.9% 

35-39: 11.2% 

≥ 40: 28.1%

G3: < 15 lb: 25.1% 

15-19: 10.1% 

20-24: 1

Categorized: 

• 4 lbs increments 

starting at 15 lbs 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: < 2500g: 2.7% 

2500-4000g: 87.5% 

> 4000-4500: 8.5% 

> 4500g: 1.4% 

G2: < 2500g: 2.5% 

2500-4000g: 83.9% 

> 4000-4500: 11.7% 

> 4500g: 2.0% 

G3: < 2500g: 2.1% 

2500-4000g: 81.1% 

> 4000-4500: 13.2% 

> 4500g: 3.6% 

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Odds ratio (95% CI) for LBW by MWG and 

prepregnancy BMI 

Groups 

G1: Normal BMI, MWG < 15lbs 

G2: Normal BMI, MWG ≥40lbs 

G3: Normal BMI, MWG 25-29lbs (Reference 

for Normal BMI) 

G4: Overweight BMI, MWG 30-34lbs 

G5: Overweight BMI, MWG 35-39 

G6: Overweight BMI, MWG ≥40lbs 

G7: Overweight BMI, MWG 15-19lbs 

(Reference for Overweight BMI) 

Results 

G1: 2.1 (1.6-2.6) 

G2: 0.5 (0.4-0.6) 

G3: 1.0 

G4: 0.5 (0.3-0.8) 

G5: 0.6 (0.3-1.1) 

G6: 0.4 (0.3-0.7) 

G7: 1.0

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• height 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Sex of infant 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

4 Good, 4 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-262 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Desjardins and Hardwick, 

1999 

Country and setting: 

Canada, Healthiest 

Babies Possible Program 

Enrollment Period:

January 1, 1987 - 

December 31, 1996 

Funding: 

Health Information and 

Research Services, 

Toronto Public Health 

Study Objective: 

To evaluate HBP program 

as mediator of impact of 

smoking, adolescence, 

prepregnancy 

underweight, and erratic 

weight gain/initial weight 

loss on LBW 

Time frame: 

January 1, 1987 - 

December 31, 1996 

Duration of the study: 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1,892 (1883 completed 

program to delivery - used 

in regression analyses) 

Group Description: 

G1: N - total sample 

G2: LBW - 6.8% of total 

sample 

Group N: 

G1: 1892 

G2: 128 

Inclusion criteria: 

• Singleton births 

• Women who 

remained in HBP 

program until delivery 

(31% did not 

complete program - 

mainly because they 

moved out of area) 

Exclusion criteria: 

• Women for whom 

number of visits for 

HBP program was 

missing 

Pregravid weight: 

• Self-reported 

G1: % underweight: 20.5 

G2: % underweight: 8.8 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Dichotomized as 

prepregnancy BMI < 20 

(underweight) and ≥ 20, 

done for women older 

than 19 years women 

younger than 19 years 

were determined to be 

underweight or not by 

program nurse/dietitian 

Age (mean, yrs): 

G1: % less than 19 years: 19.1

G2: % less than 19 years: 8.3 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.0 

G2: 9.1 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% Inadequate weight gain 

G1: 39.9 

G2: 7.3 

Additional characteristics: 

NR 
C-263 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating

Groups (N): 

G1: 793 

G2: 528 

G3: 562 

Total weight gain: 

Categorized: 

• NR 

Collected from: 

• Home visitor’s 

scale 

Ascertained by: 

• Dichotomized as 

inadequate 

(determined by 

nurse/dietitan as 

weight loss, lack 

of weight gain, or 

very inadequate 

weight gain since 

conception) or 

not 

Birth weight: 

% < 2500g: 

G1: 8.8 

G2: 5.1 

G3: 5.5 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Odds ratio (95% CI) for LBW and inadequate 

weight gain 

Groups 

G1: LBW and inadequate weight gain 

(defined by dietician) 

Results 

G1: 1.15 (0.78-1.67) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Gestational age, adolescence, pregravid 

underweight, number of Healthiest Baby 

Possible visits 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation:

Fair 

Sum of 

Good/Fair/Poo

r: 

2 Good, 7 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-264 

 Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1990 

Country and setting: 

United States, prenatal 

clinics 

Enrollment Period:

Does not state 

Funding: 

Supported by Garry A 

Weber Graduate 

Fellowship in 

Anthropology, Southern 

Methodist University, and 

through University 

Affiliated Center, 

Department of Pediatrics, 

University of Texas 

Southwestern Medical 

Center at Dallas, Maternal 

and Child Health Training 

Grant MCJ-2000, 

Department of Health and 

Human Services 

Study Objective: 

Present study was 

designed to (1) determine 

prevalence of low 

maternal weight-for-height 

near term among low 

income black and 

Hispanic women attending 

public prenatal clinics, and 

(2) compare maternal 

weight-for-height near 

term with current 

guidelines 

Time frame: 

Does not state 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

325 

Group Description: 

G1: Black 

G2: Hispanic 

Group N: 

G1: 172 

G2: 153 

Inclusion criteria: 

• Black and Hispanic 

pregnant women 

aged ≥ 17 who 

subsequently 

delivered singleton 

infants free from 

congenital 

malformations 

Exclusion criteria: 

• Women whose last 

prenatal weight was 

recorded > 14 days 

before delivery, 

gestational diabetes, 

other medical or 

obstetrical conditions, 

missing records, 

moved to another city 

before delivery 

Pregravid weight: 

• Self-reported 

G1: NR 

• < 90% standard: 27.3% 

• 90-119%: 44.2% 

• ≥ 120%standard: 21.5% 

G2: NR 

• < 90% standard: 15.7% 

• 90-119%: 38.6% 

• ≥ 120%standard: 9.8% 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 22.65 ± 4.48 

G2: 23. 18 ± 4.78 

Parity: 

G1: 0.98± 1.23 

G2: 1.10± 1.50 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-265 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• % of standard 

weight for height 

by use of 

nomogram and 

chart developed 

by Rosso 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Infant birthweight 

Groups 

G1: Percent BW < 3,000, Low weight gain 

< 120% of standard 

G2: Percent BW ≥ 3,000, Low weight gain 

< 120% of standard 

G3: Percent BW < 3,000, Acceptable 

weight gain ≥120% of standard 

G4: Percent BW ≥ 3,000, Acceptable 

weight gain ≥120% of standard 

Results 

G1: 38.2 

G2: 61.8 

G3: 22.1 

G4: 77.9 

Maternal confounders and effect 

modifiers accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

7 Good, 2 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-266 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

Country and setting: 

USA, prenatal clinics 

Enrollment Period:

January 1, 1987- 

December 31, 1989 

Funding: 

NR 

Study Objective: 

To determine influences 

of increased maternal 

prepregnancy weight and 

increased gestational 

weight gain on pregnancy 

outcome 

Time frame: 

January 1, 1987 to 

December 31, 1989 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,191 

Group Description: 

G1: BMI < 19.8 

G2: 19.8-26.0 

G3: 27-29 

G4: > 29 

G5: All 

Group N: 

G1: 755 

G2: 1,621 

G3: 329 

G4: 486 

G5: 3191 

Inclusion criteria: 

• Delivery at or beyond 

38 weeks of gestation

• Singletons 

• Received prenatal 

care and delivered in 

Shands Hospital 

Exclusion criteria: 

• Fetal abnormalities 

• Oligohydramnios 

• Polyhydramnios 

• Medical or surgical 

complications (GI 

disorders, sickle cell 

hemoglobinopathy, 

hepatitis, hematologic 

disorders, malignant 

disease, renal 

disease, neurologic 

disease, pulmonary 

disease, psychiatric 

disorders, 

tuberculosis) 

• Incomplete risk 

variable data or 

outcome variable 

information 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• National Academy of 

Sciences 

Age (mean, yrs): 

G1: NR 

• < 20 years: 36.6% 

• 20-26 years: 44.8% 

• > 26 years: 18.7% 

G2: NR 

• < 20 years: 30.8% 

• 20-26 years: 46.5% 

• > 26 years: 22.6% 

G3: 

• < 20 years: 25.8% 

• 20-26 years: 48.9% 

• > 26 years: 25.2% 

G4: 

• < 20 years: 16.5% 

• 20-26 years: 53.9% 

• > 26 years: 29.6% 

G5: 

• < 20 years: 29.5% 

• 20-26 years: 47.5 % 

• > 26 years: 23.0% 

Parity: 

G1: % first: 49.3 

G2: 43.1 

G3: 37.4 

G4: 31.1 

G5: 42.1 

Race,%: 

White 

G1: 64.5 

G2: 60.0 

G3: 49.8 

G4: 51.9 

G5: 58.7 

Black 

G1: 33.6 

G2: 37.9 

G3: 48.9 

G4: 47.5 

G5: 39.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 1.9 

G2: 2.1 

G3: 1.2 

G4: 0.6 

G5: 1.7 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Hypertension,%: 

G1: 3.4 

G2: 4.6 

G3: 5.8 

G4: 10.7 

G5: 5.4 

Additional characteristics: 

G1: % married: 42.6 

G2: 46.1 

G3: 40.4 

G4: 49.4 

G5: 45.2 

Additional characteristics: 

NR 
C-267 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 755 

G2: 1621 

G3: 329 

G4: 486 

G5: 3191 

Total weight gain: 

G1: 

• < 16kg: 7.8% 

• 16-25kg: 18.5% 

• 26-35kg: 35.1% 

• > 35kg: 38.5% 

G2: 

• < 16kg: 11.7% 

• 16-25kg: 18.0% 

• 26-35kg: 28.8% 

• > 35kg: 41.5% 

G3: 

• < 16kg: 19.8% 

• 16-25kg: 19.1% 

• 26-35kg: 28.3% 

• > 35kg: 32.8% 

G4: 

• < 16kg: 32.3% 

• 16-25kg: 22.0%; 

Categorized: 

• Quartiles 

• National 

Academy of 

Sciences (below, 

within, or above 

recommended 

range) 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between self 

report and weight 

at last prenatal 

visit (mean 6.1 

days prior to 

delivery) 

Birth weight: 

G1: 

• < 2500g: 4.8% 

• 2500-4000g: 

89.1% 

• > 4000g: 6.1% 

G2: 

• < 2500g: 2.0% 

• 2500-4000g: 

85.2% 

• > 4000g: 12.8% 

G3: 

• < 2500g: 1.5% 

• 2500-4000g: 

83.0% 

• > 4000g: 15.5% 

G4: 

• < 2500g: 0.2% 

• 2500-4000g: 

82.5% 

• > 4000g: 17.3% 

Gestational 

diabetes, %: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Cesarean 

delivery,%: 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 11.9 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Frequency of 

macrosomia = 

12.2% 

• Frequency of 

cesarean = 

11.9% 

• Frequency of 

LBW = 2.9% 

Outcomes Description: 

Odds ratio (95% CI) for LBW 

Groups 

G1: Net WG < 14.9 lbs (Reference) 

G2: Net WG 14.9-23.5 lbs 

G3: Net WG 24-33 lbs 

G4: Net WG > 33 lbs 

Results 

G1: 1.0 (Reference) 

G2: 0.51 (0.27-0.98) 

G3: 0.54 (0.28-1.04) 

G4: 0.38 (0.2-0.8) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal race, parity, pregravid BMI, 

height, pregravid weight, marital status, 

education, tobacco/alcohol/drug use, 

pregnancy-induced hypertension 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

• Gestational age 

• Infant sex 

• Macrosomia 

Background: 

Fair 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

0 Good, 9 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-268 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

(continued)

 
C-269 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

• Frequency of 

postdate 

pregnancy = 

9.8% 

• Frequency of 

labor 

abnormalities 

(40% were 

unscheduled 

cesareans) = 

7.8% 

• Frequency of 

oxytocin 

induction = 

13.7% 

• Frequency of 

oxytocin 

augmentation = 

16.1% 

• Frequency of 

meconium 

staining = 21.5%

Other infant 

outcomes: 

NA 

 
C-270 

 Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period:

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight change 

on pregnancy outcomes in 

obese women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) (n 

= 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 37 

or more weeks of 

gestation) liveborn, 

singleton infants 

during 1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-271 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 43% 

G3: GWG (lb)Less than 

2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, and 

greater than 35 lb 

gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%:

G1: 28 

G2: 34 

G3: 41 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Odds of low birth weight 

Groups 

G1: Odds of LBW for weight gain > 25 lbs 

G2: OR of LBW for weight gain < 15 lbs 

G3: Reference Weight gain 15-25 lbs 

Results 

G1: Lower for women in this group 

G2: Higher for women in this group 

Numerical value for ORs not reported in study 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in Medicaid, WIC, food 

stamp programs) 

• Smoking 

• Chronic hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 6 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-272 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued) 

 
C-273 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Other maternal outcomes: 

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA 

by GWG category for 

each obesity class. All 3 

figures show similar 

patterns of increasing 

risk of preeclampsia, 

cesarean delivery, and 

LGA birth and 

decreasing risk of SGA 

birth with increasing 

GWG. Collectively, 

minimal risk for all 4 

outcomes corresponds 

to GWG categories 

where risk of LGA and 

SGA births intersect. 

This equates to GWG of 

10 of 25 lb for class I 

obese women, a gain of 

0 tp 9 lb for class II 

obese women, and 

weight loss of 0 to 9 lb 

for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA 

by GWG category and 

obesity class. 

Compared with women 

who gained 15 to 25 lb 

during their 

pregnancies, those who 

gained less weight had 

significantly lower odds 

of preeclampsia, 

cesarean delivery, and 

LGA births, but higher 

odds for SGA births. 

Women who gained 

more than 25 lbs had 

higher odds for same 3 

pregnancy outcomes 

and lower odds for SGA 

births. 

Other infant outcomes: 

NR 
C-274 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kirchengast and 

Hartmann, 2003 

Country and setting: 

Singleton births that took 

place at University Clinic 

for Gynecology and 

Obstetrics in Vienna, 

Austria 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

Examine impact of 

biological factors such as 

young maternal age and 

maternal somatic 

characteristics on 

pregnancy outcome 

among group of 

adolescent mothers who 

gave birth between 39th 

and 41st week of 

gestation after period of 

intensive psychological 

support 

Time frame: 

NR 

Duration of the study: 

1985 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

8,011 

Group Description: 

G1: 12 to 16 years 

G2: 17 to 19 years 

G3: 20 to 29 years 

Group N: 

G1: 215 

G2: 1,336 

G3: 6,460 

Inclusion criteria: 

• Women ages 12 to 

29 

• All prenatal checkups of mother-child 

passport were 

performed 

• Delivery of single 

infant without 

congenital 

malformations 

• Receiving 

psychosocial support 

by family and/or 

specially trained 

social worker within 

young adolescent 

group (12 to 16 

years) 

Exclusion criteria: 

• Coincident medical 

diseases such as 

diabetes mellitus or 

nephropathy 

• Drug or alcohol 

abuse 

• Twin birth 

• IVF 

• Registered maternal 

diseases before and 

during pregnancy 

• Hypertension 

(BP < 150/90 mmHG)

• Protein or glucose in 

urine 

• Pregnancy related 

immunization 

Pregravid weight: 

Estimated by means of 

retrospective method and first 

weight determination, which 

was carried out at first prenatal 

visit (8th week of gestation) 

G1: 56.0 

G2: 57.2 

G3: 59.2 

Pregravid BMI: 

G1: 21.45 

G2: 21.59 

G3: 22.10 

Imputed: 

• Yes 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 14.5 

G2: 17.8 

G3: 24.1 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Age at menarche:

G1: 12.2 

G2: 12.9 

G3: 13.3 

Gynecological age:

G1: 3.4 

G2: 5.3 

G3: 10.8 
C-275 

Evidence Table 18. Gestational weight gain and low birthweight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 215 

G2: 1,336 

G3: 6,460 

Total weight gain: 

G1: 13.1 

G2: 13.1 

G3: 13.1 (P = .10) 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3237.6 

(significantly 

different from 17-

19 and 20-29) 

G2: 3298.3 

(significantly 

different from 

< 17 and 20-29) 

G3: 3368.9 

(significantly 

different from 

< 17 and 17-19) 

(F = 24.1, 

P < .0001) 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Chronological 

age 

• Age at menarche

• Gynecological 

age 

• Height 

• Distancia 

spinarum 

• Distancia 

christarum 

• Prepregnancy 

weight 

• Weight at end of 

pregnancy 

Other infant 

outcomes 

• Birth length 

• Head 

circumference 

• Acromial 

circumference 

• Diameter 

frontooccipitale 

Outcomes Description: 

OR and 95% CI, for LBW 

Groups 

NA, weight gain as continuous 

variable 

Results 

0.90 (0.85-0.95) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Maternal age, age at 

menarche, pregravid weight, 

height, distantia cristarum 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-276 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lasker et al., 2005 

Country and setting: 

USA, hospital 

Enrollment period: 

November 1997 to 

October 1999 

Funding: 

NR 

Study Objective: 

To investigate predictors 

of LBW in population of 

Eastern Pennsylvania 

Time frame: 

November 1997 to 

October 1999 

Duration of the study: 

NA, retrospective 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,528 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 5,528 

G2: NR 

Inclusion criteria: 

• Women delivering in 

1 of 2 hospitals in a 

single hospital 

network 

Exclusion criteria: 

• NA 

Pregravid weight: 

• NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

• BMI at delivery 

Age (mean, yrs): 

G1: 

• < 15: 0.5% 

• 15-19.9: 8.2% 

• 20-24.9: 17.2% 

• 25-29.9: 34.7% 

• 30-34.9: 23.6% 

• 35-39.9: 13.5% 

• 40-50: 2.3% 

G2: NR 

Parity: 

NR 

Race,%: 

White 

G1: 74.1 

G2: NR 

Black 

G1: 3.3 

G2: NR 

Hispanic 

G1: 11.0 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

G1: 11.5 

G2: NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-277 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• < 10, 11-20, 21-

30, > 30 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• 490 (8.9%) 

delivered LBW 

babies (< 2500g)

• 103 (1.9%) 

delivered VLBW 

babies (< 1500g)

Outcomes Description: 

Odds ratio (95% CI) for LBW 

Groups 

G1: MWG < 10 lbs 

G2: MWG > 30 lbs 

G3: MWG 21-30 lbs (Reference) 

Results 

G1: 2.43 (1.45-4.05) 

G2: 0.63 (0.47-0.85) 

G3: 1.00 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, maternal race, marital status, 

prenatal care, prior term births, prior 

abortions, prior preterm births, BMI at 

delivery, preeclampsia, bleeding, smoking, 

multiple births, premature birth, congenital 

anomaly, incompetent cervix, smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 4 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-278 

 Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Murakami et al., 2004 

Country and setting: 

Japan, hospital 

Enrollment Period:

2001 

Funding: 

NR 

Study Objective: 

To estimate risk of 

perinatal morbidity of 

mother and infant with 

respect to maternal 

prepregnancy BMI and 

weight gain in Japanese 

women 

Time frame: 

2001 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

633 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 633 

G2: NR 

Inclusion criteria: 

• Live, singletons 

delivered between 24 

to 42 weeks gestation

Exclusion criteria: 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 20.9 (2.8) 

G2: NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 29.1 (4.5) 

G2: NR 

Parity: 

G1: 0.6 (0.7) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 8.5 

G2: NR 

Diabetes mellitus,%: 

G1: 2.1 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Preeclampsia - mild: 

5.4%; severe: 4.1% 

G2: NR 

Additional characteristics: 

NR 
C-279 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 633 

G2: NR 

Total weight gain: 

G1: 10.5 (3.4)

G2: NR 

Categorized: 

• < 8.5kg, 8.5-

12.5, > 12.5 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: last 

measurement 

was taken at 

hospitalization 

prior to 

delivery 

Birth weight: 

G1: 3,052.6 (483.8) 

G2: NR 

Gestational 

diabetes, %: 

G1: 2.1 

G2: NR 

Cesarean 

delivery,%: 

G1: 10.3 

G2: NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Odds ratio (95% CI) for LBW 

Groups 

G1: MWG < 8.5 kg 

G2: MWG 8.5-12.5 kg 

G3: MWG > 12.5 kg 

Results 

G1: 1.26 (0.57-2.75) 

G2: Reference 

G3: 0.62 (0.24-1.62) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 8 Fair, 0 Poor

Final Quality Score: 

Fair 
C-280 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rosenberg et al., 2005 

Country and setting: 

USA, vital statistics data 

Enrollment Period:

Bbirth certificates with self 

reported pregravid weight 

and weight gain 

Funding: 

NR 

Study Objective: 

To examine associations 

between obesity, 

diabetes, and 3 adverse 

pregnancy outcomes 

(primary cesarean 

section, preterm birth, and 

LBW) by race/ethnic 

groups 

Time frame: 

Birth certificates with self 

reproted pregravid weight 

and weight gain 

Duration of the study: 

Birth certificates from 

1999, 2000, and 2001 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

329988 

Group Description: 

G1: Non-hispanic blacks 

G2: Non-hispanic whites 

G3: Non-hispanic asians 

G4: Hispanics 

G5: Total 

Group N: 

G1: 86,908 

G2: 96,581 

G3: 38,570 

G4: 107,612 

G5: 329,988 

Inclusion criteria: 

• Live singleton births 

• Information on 

maternal 

prepregnancy weight 

and maternal weight 

gain during 

pregnancy 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: < 100 pounds: 1.7% 

100-149: 49.1% 

150-199: 37.5% 

200-299: 11.2% 

≥ 300: 0.5% 

G2: < 100 pounds: 1.8% 

100-149: 69.5% 

150-199: 24.0% 

200-299: 4.7% 

≥ 300: 0.1% 

G3: < 100 pounds: 8.1% 

100-149: 79.5% 

150-199: 11.6% 

200-299: 0.8% 

≥ 300 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 27.5 

G2: 30.6 

G3: 29.7 

G4: 26.4 P < 0.001 

G5: 28.3 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 3.7 

G2: 2.6 

G3: 6.6 

G4: 3.5 

G5: 3.7 P < 0.001 

Hypertension,%: 

G1: 1.7 

G2: 0.6 

G3: 0.5 

G4: 0.7 

G5: 0.9 P < 0.001 

Additional characteristics: 

G1: PIH 1.9 

G2: 1.2 

G3: 0.7 

G4: 1.4 

G5: 1.4 P < 0.001 

Additional characteristics: 

G1: Preeclampsia 2.9 

G2: 1.3 

G3: 1.2 

G4: 2.6 

G5: 2.1 P < 0.001 

Additional characteristics: 

NR 
C-281 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 86,908 

G2: 96,581 

G3: 38,570 

G4: 107,612 

G5: 329,988 

Total weight gain: 

G1: < 41pounds: 79.7% 

≥ 41 pounds: 20.3% 

G2: < 41pounds: 83.2% 

≥ 41 pounds: 16.8% 

P < 0.001 

G3: < 41pounds: 89.2% 

≥ 41 pounds: 10.8% 

G4: < 41pounds: 79.1% 

≥ 41 pounds: 20.9% 

G5: < 41pounds: 81.6% 

≥ 41 pounds: 18.4% 

Categorized: 

• < 41, ≥ 41 pounds 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 3.7 

G2: 2.6 

G3: 6.6 

G4: 3.5 

G5: 3.7 P < 0.001 

Cesarean 

delivery,%: 

G1: 16.2 

G2: 14.7 P < 0.001 

G3: 14.4 

G4: 13.8 

G5: 14.7 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Preterm birth 

10.5, 5.1, 5.9, 

7.8, 7.5 

P < 0.001 

(groups defined 

above) 

• LBW 9.7, 4.1, 

5.7, 6.1, 6.4 

P < 0.001 

(groups defined 

above) 

Outcomes Description: 

Odds ration (95% CI) for LBW 

Groups 

G1: MWG ≥ 41 lbs 

G2: MGW < 41 lbs 

Results 

G1: 0.41 (0.39-0.43) 

G2: Reference 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Maternal age, parity, GDM, pregnancy-induced 

hypertension, preeclampsia, pregravid weight, 

chronic diabetes, chronic hypertension, marital 

status, maternal education, mother’s birthplace, 

prenatal care payer, social risk, trimester 

prenatal care began 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

0 Good, 7 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-282 

 Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Shepard et al., 1998 

Country and setting: 

Obstetrical practices in 

New Haven, CT 

Enrollment Period:

1988 to 1992 

Funding: 

Grants NIH 

Study Objective: 

To examine absolute and 

proportional gestational 

weight gain and 

prepregnancy BMI as 

predictors of primary 

cesarean delivery 

Time frame: 

1988 to 1992 

Duration of the study: 

First prenatal visit to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

2,301 

Group Description: 

G1: Cesarean delivery 

G2: Vaginal delivery 

Group N: 

G1: 312 

G2: 1,989 

Inclusion criteria: 

• Privately insured 

women who received 

prenatal care from 13 

largest obstetrical 

practices and health 

maintenance 

organizations in 

greater New Haven, 

CT region (part of a 

larger study of 

selected 

environmental risk 

factors on pregnancy)

• Singleton deliveries 

at Yale-New Haven 

Hospital 

Exclusion criteria: 

• Repeat cesareans 

births 

• Missing information 

on key variables 

Pregravid weight: 

• Self-reported 

G1: 140.9 (28.6) 

G2: 136.3 (25.2) P = 0.007 

Pregravid BMI: 

G1: 24.3 (4.6) 

G2: 22.9 (3.9) P < 0.0001 

Imputed: 

• No 

Categorized: 

• NHANES II: ≤ 19.4; 19.5-

22.4; 22.5-28.5; > 28.5 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

G1: 88.4 

G2: 91.2 

Black 

G1: 5.8 

G2: 4.9 

Hispanic 

G1: 3.5 

G2: 2.3 

Asian/Pacific Islander 

G1: 1.3 

G2: 1.1 

Other 

G1: 1.0 

G2: 0.4 

Smoking,%: 

% never smokers:

G1: 82.3 

G2: 85.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

%married:

G1: 95.8 

G2: 92.1 

Additional characteristics: 

NR 
C-283 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 312 

G2: 1989 

Total weight gain: 

G1: 35.4 (11.9)

G2: 33.3 (11.9) P = 

0.005

Categorized: 

• Proportional 

weight gain 

based on 

prepregnancy 

weight and 

weight change 

during pregnancy 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Propotional 

weight gain, lb, 

mean: cesarean 

delivery - 26.5 

(10.0); vaginal 

delivery - 25.2 

(9.3) P = 0.048 

Other infant 

outcomes: 

• Low birth weight 

rate = 3.3% for 

entire study 

population 

Outcomes Description: 

Percent low birth weight 

Groups 

G1: Proportional WG < median, underweight 

(BMI < 19.4) 

G2: Proportional WG < median, obese 

(BMI > 28.5) 

G3: Proportional WG > median, underweight 

(BMI < 19.4) 

G4: Proportional WG > median, Low-average 

BMI (19.5-22.4) 

G5: Proportional WG > median, High-average 

BMI (22.5-28.5) 

G6: Proportional WG > median, obese (BMI > 

28.5) 

Results 

G1: 3.5% 

G2: 7.4% 

G3: 2.1% 

G4: 2.8% 

G5: 2.1% 

G6: 4.6% 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-284 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Zhou and Olsen, 1997 

Country and setting: 

Denmark, two 

communities 

Enrollment Period:

April 1984 to April 1987 

Funding: 

Danish National Research 

Foundation and 

Sygekassernes Helsefond 

Study Objective: 

To study association 

between gestational 

weight gain and different 

birth weight indicators 

considering prepregnancy 

BMI 

Time frame: 

April 1984 to April 1987 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

7122 

Group Description: 

G1: Entire study 

G2: NR 

Group N: 

G1: 7122 

G2: NR 

Inclusion criteria: 

• Women who provided 

detailed information 

on lifestyle during 

pregnancy 

• Singletons 

• Non-diabetic women 

who gave birth 

between weeks 37 

and 42 for whom 

weight gain was 

reported 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: % < 19.8: 27.2; %19.8-26: 

63.7; %26+: 9.1 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

% < 25:

G1: 30.3 

G2: NR 

Parity: 

%nulliparous:

G1: 48.9 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

%non-smoking:

G1: 60.0 

G2: NR 

Diabetes mellitus,%: 

G1: 0 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-285 

Evidence Table 19. Gestational weight gain and low birth weight (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 7122 

G2: NR 

Total weight gain: 

G1: % < 11kg: 35.2; 

%12-15: 35.5; 

%16+: 29.3 

G2: NR 

Categorized: 

• ≤ 11, 12-15, 

≥ 16 kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between last 

measured weight 

prior to delivery 

and 

prepregnancy 

weight 

Birth weight: 

G1: %LBW: 1.7; 

%normal: 96.8; 

%HBW: 1.5 

G2: NR 

Gestational 

diabetes, %: 

G1: 0 

G2: NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Low birth weight 

(< 2500g) 

• High birth weight 

(> 4500g) 

• Growth retarded 

were newborns 

with a birth 

weight below 

3000g in spite of 

a placenta 

weight higher 

than 66 

percentile (491g)

Outcomes Description: 

Odds ratio (95% CI) for LBW for MWG 

categories by BMI 

Groups 

G1: MWG < 11 kg, Underweight (Reference) 

G2: MWG < 11 kg, Normal weight 

G3: MWG < 11 kg, Overweight 

G4: MWG 12-15 kg, Underweight, 

G5: MWG 12-15 kg, Normal weight 

G6: MWG 12-15 kg, Overweight 

G7: MWG ≥16 kg, Underweight 

G8: MWG ≥16 kg, Normal weight 

G9: MWG ≥16 kg, Overweight 

Results 

G1: 1.0 

G2: 0.9 (0.5-1.5) 

G3: 0.8 (0.3-2.0) 

G4: 0.5 (0.2-1.0) 

G5: 0.8 (0.4-1.5) 

G6: 0.9 (0.2-3.8) 

G7: 0.3 (0.1-1.0) 

G8: 0.4 (0.2-0.8) 

G9: 0.0 (0.0-2500) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Alcohol 

• No diabetes 

• Term delivery 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Infant sex 

Background: 

Fair 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

2 Good, 7 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 

 
C-286 

Evidence Table 20. Gestational weight gain and macrosomia 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bergmann, 2003 

Country and setting: 

Hospital deliveries in 

Berlin collected by Berlin 

Medical Board 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

To investigate trend in 

prevalence of neonatal 

macrosomia and to 

evaluate influences of 

potential determinants, 

key features of 206,308 

hospital deliveries (97% of 

all) in Berlin in years 1993 

to 1999, collected by 

Berlin Medical Board 

Time frame: 

NR 

Duration of the study: 

1993 to 1999 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

206,308 

Group Description: 

G1: 1993 

G2: 1994 

G3: 1995 

G4: 1996 

G5: 1997 

G6: 1998 (1999) 

Group N: 

G1: 25,449 

G2: 25,070 

G3: 24,784 

G4: 27,100 

G5: 27,753 

G6: 27,653 (27,513) 

Inclusion criteria: 

• Recorded hospital 

birth by Berlin 

Perinatal ReGistry 

Exclusion criteria: 

• Multiple births 

• Preterm infants 

Pregravid weight: 

• Hospital records 

Pregravid BMI: 

G1: % ≥ 20-26 

≥ 26: 62.3, 17.8 

G2: 62.1, 19.0 

G3: 62.4, 19.7 

G4: 62.2, 20.6 

G5: 63.1, 20.6 

G6: 61.4, 21.5 (61.2,21.1) 

Imputed: 

• No 

Categorized: 

• ≥ 20-26, ≥ 26 

Age (mean, yrs): 

% ≥ 30:

G1: 34.9 

G2: 37.5 

G3: 40.6 

G4: 43.4 

G5: 45.7 

G6: 47.7 (48.5) 

Parity: 

Multiparity:

G1: % 49.2 

G2: 51.1 

G3: 50.4 

G4: 49.9 

G5: 49.1 

G6: 50.3 (49.2) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 18.9 

G2: 18.8 

G3: 19.2 

G4: 17.2 

G5: 17.9 

G6: 18.0 (18.3) 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-287 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 25,449

G2: 25,070

G3: 24,784

G4: 27,100

G5: 27,753 

G6: 27,653 

Total weight gain: 

%10-16kg:

G1: 62.3

G2: 62.1

G3: 62.4

G4: 62.2

G5: 63.1

G6: 61.4

Categorized: 

10-16kg and ≥ 16kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Method not 

mentioned by 

authors 

Birth weight: 

% ≥ 4000g: 

G1: 10.0 

G2: 10.2 

G3: 10.6 

G4: 10.9 

G5: 11.0 

G6: 11.3 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• % weight gain: 

≥ 26: 21.0, 21.0, 

21.4, 22.3, 22.2, 

24.2 

1999: n = 27513 

% birthweight ≥

4000g, 11.3% 

% weight gain ≥

10-16kg, 45.3 

% weight gain ≥

16kg, 25.0% 

Other infant 

outcomes 

NR 

Outcomes Description: 

Odds ratio (95% CI) of macrosomia 

Groups 

G1: WG < 10 kg (Reference) 

G2: WG 10-16 kg 

G3: WG ≥ 16 kg

Results 

G1: 1.0 

G2: 1.85 (1.77-1.93) 

G3: 3.37 (3.22-3.53) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Pregravid BMI, height, parity, smoking, diabetes, 

postterm delivery 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor

: 

3 Good, 4 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-288 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

Country and setting: 

Canada, medical records 

Enrollment Period:

Prenatal to birth 

Funding: 

cree board of health and 

social services of James 

Bay (Quebec) 

Study Objective: 

To determine effect of 

pregravid weight and 

pregnancy weight gain on 

pregnancy outcomes in 

Cree women 

Time frame: 

Prenatal to birth 

Duration of the study: 

7 year period: January 

1994 to December 2000 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

603 

Group Description: 

G1: Normal: 

BMI 18.5 - 24.9 

G2: Overweight: 

BMI 25-29.9 

G3: Obese: 

BMI ≥ 30 

G4: Total 

Group N: 

G1: 139 

G2: 168 

G3: 296 

G4: 603 

Inclusion criteria: 

• Used only Cree 

women 

• First birth observed 

per woman during 

study time period 

• Must have first weight 

recorded within first 

14 weeks gestation 

and final weight 

recorded within 4 

weeks of birth 

Exclusion criteria: 

• Women with 

secondary pregnancy 

in dataset (n = 792) 

• Women with first 

weight record > 14 

weeks gestation 

(n = 314) 

• Women with final 

weight record > 4 

weeks from birth 

(n = 202) 

• Women with both first 

weight record > 14 

weeks and final 

weight record > 4 

weeks (n = 70) 

• Women missing data 

on first or final weight 

(n = 3) 

Pregravid weight: 

• Routine pre-natal care 

• Medical records 

• Measured within 14 

weeks of gestation 

G1: 59.7 (5.0) 

G2: 73.0 (4.3) 

G3: 93.6 (12.3) 

G4: 80.0 (16.9) 

Pregravid BMI: 

NR 

Imputed: 

• Yes 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 20.8 (5.2) 

G2: 23.8 (5.4) 

G3: 25.5 (5.5) 

G4: 24.0 (5.7) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Hypertension,%: 

G1: 1.4 

G2: 1.8 

G3: 4.8 

G4: 3.2 

Additional characteristics: 

% low weight gain:

G1: 20.1 

G2: 10.1 

G3: 28.0 

G4: 21.2 

% acceptable weight gain:

G1: 28.8 

G2: 32.1 

G3: 33.4 

G4: 32.0 

% excessive weight gain: 

G1: 51.1 

G2: 57.7 

G3: 38.5 

G4: 46.6 
C-289 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 139 

G2: 168 

G3: 296 

Total weight gain: 

Categorized: 

• 1999 Canadian 

guidelines 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

within 4 weeks of 

birth 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 4.3 

G2: 14.9 

G3: 27.4 

G4: 18.6 

Cesarean 

delivery,%: 

G1: 10.8 

G2: 11.3 

G3: 24.1 (p < 0.001) 

Instrumental 

delivery,%: 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Definition of low, 

adequate, and 

excessive weight 

gains: 

• For normal 

weight women - 

adequate weight 

gain is 11.5 to 16 

kg 

• For overweight 

women, 

adequate weight 

gain is 7 to 11.5 

kg 

• For obese 

women, 

adequate weight 

gain is 7 to 11.5 

kg 

• Weight gain 

below specified 

range is “low” 

and weight gain 

above specified 

range is 

“excessive” 

Other infant 

outcomes: 

> 4000g, > 4500g 

Outcomes Description: 

Percentage of macrosomia among obese women 

only 

Groups 

G1: Low WG, < 7 kg 

G2: Acceptable WG, 7-11.5 kg 

G3: Excessive WG, > 11.5 kg 

Results 

>4500g 

G1: 16.9% 

G2: 15.3% 

G3: 18.4% 

(P = 0.834) 

>4000g 

G1: 47.0% 

G2: 42.9% 

G3: 54.4% 

(P = 0.234) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor

: 

1 Good, 5 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-290 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brennand et al., 2005 

(continued) 

• Pregnancies with 

factors that may have 

influenced maternal 

weight gain such as 1 

parent being nonCree (n = 13), 

preterm deliveries 

(n = 91), twin 

pregnancies (n = 6), 

missing gestational 

age (n = 9) 

• Women with 

unknown glycemic 

status (n = 30), type 2 

DM (n = 8), glycemic 

abnormalities before 

pregnancy not 

followed for diagnosis 

(n = 70) 

• Women classified as 

underweight (n = 5) 

 
C-291 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating

 
C-292 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Clausen et al., 2005 

Country and setting: 

Norway, university 

hospital 

Enrollment Period:

1995-1996 (21 months) 

Funding: 

NR 

Study Objective: 

To investigate 

prospectively if maternal 

metabolic parameters 

associated with maternal 

weight were independent 

determinants of large 

baby size at term 

Time frame: 

1995-1996 (21 months) 

Duration of the study: 

Dring pregnancy until 

delivery 

Design: 

• Case-control 

• Combination: 

prospective cohort 

and retrospective 

nested case control 

Total Study N: 

2,50 and 219 

Group Description: 

G1: Cohort study 

G2: Birth weight < 4500 g 

G3: Birth weight > 4500 g 

Group N: 

G1: 2050 

G2: 1962 

G3: 88 

Inclusion criteria: 

• All pregnant women 

of norwegian decent 

receiving care at Aker 

Hospital 

Exclusion criteria: 

• Pre-gestational 

diabetes 

• Mltiple pregnancy 

• Peterm births 

• Mssing medical 

records 

• Mssing information 

on birth weight 

Pregravid weight: 

• Routine pre-natal careNR 

G1: 65.0 (11.2) 

G2: 64.7 (11.0) 

G3: 72.2 (13.9)***P, 0.001 

Pregravid BMI: 

G1: 23.0 (3.7) 

G2: 22.9 (3.7) 

G3: 24.8 (4.3) *** P, 0.001 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Lan < 20 

Nrmal weight 20-25 

Ovrweight 25-30 

Obse > 30 

Age (mean, yrs): 

G1: 29.9 (4.4) 

G2: 29.9 (4.5) 

G3: 30.6 (4.2) 

Parity: 

G1: 50.3% nullipara 

G2: 51% nullipara 

G3: 34.1% nullipara 

**P, 0.001 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 22.2% 

G2: 22.5% 

G3: 17.0% 

Diabetes mellitus,%: 

G1: 2.1% 

G2: 1.9 

G3: 5.7 

*P, 0.05, 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-293 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 2050 

G2: 1962 

G3: 88 

Total weight gain: 

G1: 15.4 (9.7)

G2: 15.3 (9.8)

G3: 18.2 (5.7)**P, 

0.001,

Categorized: 

• Continuous 

Quartiles 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational diabetes, %:

G1: 2.1% 

G2: 1.9 

G3: 5.7 

*P, 0.05 

Cesarean delivery,%: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant outcomes: 

NR 

Outcomes Description: 

Odds ratios (95% CIs) for macrosomia 

Groups 

G1: WG, Quartile 1 (Reference) 

G2: WG, Quartile 2 

G3: WG, Quartile 3 

G4: WG, Quartile 4 

Results 

G1: 1.0 

G2: 2.1 (0.8-5.1) 

G3: 3.5 (1.5-8.0) 

G4: 4.3 (1.9-9.8) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, parity, smoking, placental 

weight, gestational diabetes, first trimester 

BMI 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection:

Good 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

6 Good, 1 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-294 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cogswell et al., 1994 

Country and setting: 

USA, Pregnancy Nutrition 

Surveillance System 

Enrollment Period:

1990-1991 

Funding: 

NR 

Study Objective: 

To determine association 

between increased 

gestational weight gain 

and birth weight outcomes 

for low income women 

Time frame: 

1990-1991 

Duration of the study: 

Women in WIC but 

everything is self reported 

so it is when they were 

first enrolled in WIC until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

53,541 

Group Description: 

G1: Average weight 

G2: Overweight 

G3: Very overweight 

Group N: 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Inclusion criteria: 

• White, black and 

hispanic women who 

delivered single, 

liveborn, term infants 

Exclusion criteria: 

• Low or high values 

for; birth weight, 

prepregnancy BMI, or 

weight gain during 

pregnancy 

• Missing data on one 

or more study 

variables 

• Underweight women 

• Only 1 infant was 

used in analysis for 

women who delivered 

more than once 

during study period 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 11-17 yr: 11.9% 

18-34yr: 85.0% 

35-54 yr: 3.1% 

G2: 11-17 yr: 6.9% 

18-34yr: 88.7% 

35-54 yr: 4.4% 

G3: 11-17 yr: 4.0% 

18-34yr: 90.1% 

35-54 yr: 6.0% 

Parity: 

NR 

Race,%: 

White 

G1: 75.1 

G2: 72.4 

G3: 74.5 

Black 

G1: 13.8 

G2: 14.1 

G3: 16.1 

Hispanic 

G1: 11.1 

G2: 13.5 

G3: 9.4 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.9 

G2: 28.3 

G3: 25.7 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-295 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Total weight gain: 

G1: < 15 lb: 6.2% 

15-19: 5.8% 

20-24: 11.2% 

25-29: 14.4% 

30-34: 17.1% 

35-39: 13.9% 

≥ 40: 31.4%

G2: < 15 lb: 11.4% 

15-19: 7.8% 

20-24: 13.0% 

25-29: 12.7% 

30-34: 15.9% 

35-39: 11.2% 

≥ 40: 28.1%

G3: < 15 lb: 25.1% 

15-19: 10.1% 

20-24: 1

Categorized: 

• 4 lbs increments 

starting at 15 lbs 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: < 2500g: 2.7% 

2500-4000g: 87.5% 

> 4000-4500: 8.5% 

> 4500g: 1.4% 

G2: < 2500g: 2.5% 

2500-4000g: 83.9% 

> 4000-4500: 11.7% 

> 4500g: 2.0% 

G3: < 2500g: 2.1% 

2500-4000g: 81.1% 

> 4000-4500: 13.2% 

> 4500g: 3.6% 

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Odds ratios (95% CIs) for macrosomia by 

MWG and prepregnancy BMI 

Groups 

G1: Normal BMI, MWG 25-29 lbs 

(Reference for normal BMI) 

G2: Normal BMI, MWG 35-39 lbs 

G3: Normal BMI, MWG ≥ 40 lbs 

G4: Overweight BMI, MWG 15-19 lbs 

(Reference for overweight BMI) 

G5: Overweight BMI, MWG ≥ 40 lbs 

G6: Obese, MWG 15-19 lbs (Reference 

for obese GMI) 

G7: Obese BMI, MWG 30-34 lbs 

G8: Obese BMI, MWG 35-39 lbs 

G9: Obese BMI, MWG ≥ 40 lbs 

Results 

G1: 1.0 

G2: 1.5 (1.0-2.3) 

G3: 3.3 (2.3-4.7) 

G4: 1.0 

G5: 4.0 (1.6-10.1) 

G6: 1.0 

G7: 1.9 (1.3-2.9) 

G8: 2.1 (1.3-3.2) 

G9: 2.3 (1.6-3.3) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Height 

• Smoking 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

• Gestational age 

• Sex of infant 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

4 Good, 4 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-296 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hedderson et al., 2006 

Country and setting: 

USA, Kaiser Permanente 

Medical Care Program 

Enrollment Period:

January 1, 1996 - June 

31, 1998 

Funding: 

R01 DK 54834 from 

National Institute of 

Diabetes and Digestive 

and Kidney Diseases, 

grant from American 

Diabetes Association and 

Kaiser Community Benefit 

research support 

Study Objective: 

To examine whether 

pregnancy weight gains 

outside IOM 

recommendations and 

rates of maternal weight 

gain are associated with 

neonatal complications 

Time frame: 

January 1, 1996 to June 

31, 1998 

Duration of the study: 

First prenatal care visit to 

30 days post delivery 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

45,245 

Group Description: 

G1: Controls 

G2: Macrosomia 

G3: Hypoglycemia 

G4: Hyperbilirubinemia 

Group N: 

G1: 652 

G2: 391 

G3: 328 

G4: 432 

Inclusion criteria: 

• Singleton livebirth 

Exclusion criteria: 

• No pregestational 

diabetes or history of 

gestational diabetes 

(screened at 24-28 

weeks gestation - 

meeting National 

Diabetes Data Group 

criteria for GDM) 

Pregravid weight: 

• Self-reported in some 

cases used measured 

weight recorded in chart 

closes to woman’s last 

menstrual period but no 

more than 12 months 

before her last menstrual 

period 

Pregravid BMI: 

G1: < 19.8: 13.5% 

19.8-24.9: 56.4% 

25.0-29.0: 12.4% 

> 29.0: 17.6% 

G2: < 19.8: 5.1% 

19.8-24.9: 51.2% 

25.0-29.0: 16.6% 

> 29.0: 27.1% 

G3: < 19.8: 10.1% 

19.8-24.9: 50.0% 

25.0-29.0: 17.1% 

> 29.0: 22.9% 

G4: < 19.8: 13.9% 

19.8-24.9: 57.9% 

25.0-29.0: 13.2% 

> 29.0: 57.1% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 25 years: 22.1% 

25-29: 24.2% 

30-34: 33.6% 

≥ 35: 20.1% 

G2: < 25 years: 15.9% 

25-29: 28.0% 

30-34: 31.7% 

≥ 35: 24.3% 

G3: < 25 years: 24.1% 

25-29: 25.3% 

30-34: 26.8% 

≥ 35: 23.8% 

G4: < 25 years: 17.1% 

25-29: 29.4% 

30-34: 32.6% 

≥ 35: 20.8% 

Parity: 

% primiparous:

G1: 56.9 

G2: 31.2 

G3: 50.0 

G4: 59.3 

Race,%: 

White 

G1: 54.0 

G2: 67.8 

G3: 47.6 

G4: 42.6 

Black 

G1: 10.0 

G2: 5.1 

G3: 11.3 

G4: 4.4 

Hispanic 

G1: 17.2 

G2: 15.1 

G3: 20.4 

G4: 15.5 

Asian/Pacific Islander 

G1: 8.1 

G2: 3.6 

G3: 6.7 

G4: 20.1 

Other 

G1: 10.7 

G2: 8.4 

G3: 14.0 

G4: 17.4 

Smoking,%: 

G1: %nonsmoking during 

pregnancy: 92.0; %smoked 

but quit: 4.2; %smoked 3.9 

G2: %nonsmoking during 

pregnancy: 90.8; %smoked 

but quit: 5.3; %smoked 4.0 

G3: %nonsmoking during 

pregnancy: 92.6; %smoked 

but quit: 1.5; %smoked 5.8 

G4: %nonsmoking during 

pregnancy: 94.2; %smoked 

but quit: 4.9; %smoked 1.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Screening glucose value less 

than 140:

G1: 85.0%: > 140: 15.0% 

G2: 81.6%: > 140: 18.4% 

G3: 81.4%: > 140: 18.6% 

G4: 83.3%: > 140: 16.7% 
C-297 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

recordsrate of 

maternal weight 

gain was 

calculated as 

total pregnancy 

weight gain 

minus infant birth 

weight divided by 

weeks of 

gestation when 

last weight was 

measured; rate 

of maternal 

weight gain 

before the third 

trimester was 

calculated using 

the weight 

measured at or 

before the 

screening test for 

GDM (24-28 wks 

of gestation) 

minus 

prepregnancy 

weight divided by 

weeks of 

gestation 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between final 

recorded weight 

at last prenatal 

visit (within 2 

weeks of delivery 

date) and 

prepregnancy 

weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Odds ratio (95% CI) for macrosomia based on 

rate of weight gain 

Groups 

Rate of gain kg/wk: 

G1: -0.26 to 0.21 

G2: 0.22 to 0.31 (Reference) 

G3: 0.32 to 0.39 

G4: 0.40 to 1.03 

Results 

G1: 0.52 (0.34-0.79) 

G2: 1.00 

G3: 0.99 (0.67-1.47) 

G4: 2.23 (1.54-3.22) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Age, race/ethnicity, parity, pregravid BMI, 

screening glucose value 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection:

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 

 
C-298 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jain et al, 

2007 

Country and setting: 

United States, hospitals 

Enrollment period: 

2002-2005 

Funding: 

Not reported 

Study Objective: 

To analyze risks of 

cesarean section, 

macrosomia, and 

breastfeeding at 10 weeks 

postpartum using logistic 

regression to estimate 

independent effects of 

prepregnancy BMI and 

gestational weight gain 

Time frame: 

2002-2005 

Duration of the study: 

Entry into prenatal care to 

10 weeks postpartum 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

7661 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• Term (> 37 weeks) 

and singleton for 

macrosomia and 

breastfeeding 

Exclusion criteria: 

• Cesarean analysis 

limited to to women 

with cephalic 

presentation-records 

with missing data 

excluded 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 
C-299 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

• NR 

Categorized: 

• ≤ 15 lbs 

• 15-25 lbs 

• 25-35 lbs 

• 35+ lbs 

Collected from: 

• Not outlined 

Ascertained by: 

• Birth certificate 

Birth weight: 

NR 

Gestational diabetes, %:

NR 

Cesarean delivery,%: 

NR 

Instrumental delivery,%:

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant outcomes: 

NR 

Outcomes Description: 

Odds ratios (95% CIs) for macrosomia 

Groups 

G1: WG ≤ 15 lbs 

G2: WG 15-24 lbs 

G3: WG 25-35 lbs 

G4: WG ≥ 35 lbs 

Results 

G1: 0.49 (0.30-0.82) 

G2: 1.0 

G3: 1.17 (0.82-1.65) 

G4: 2.83 (2.04-3.92) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, pregravid BMI, parity, 

education, race/ethnicity, US/foreign 

origin 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Fair 

Sample selection:

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

0 Good, 7 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-300 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period:

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain in 

obese glucose tolerant 

women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI ≥

30 

• Normal 2h 75g oral 

glucose tolerance test 

(OGTT) during third 

trimester (according 

to WHO criteria) 

• Only first pregnancy 

during study period 

included 

Exclusion criteria: 

• Well defined chronic 

disease 

• Twin pregnancies 

• Women with GDM (n 

= 323) 

• Known diet treatment 

(n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of pregravid 

BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-301 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight gain: 

Categorized: 

• < 5.0. 5.0-9.9, 

10.0-14.9, ≥ 15.0 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated by 

authors 

Birth weight: 

G1: 3500 (3200-3840) 

G2: 3645 (3200-4000) 

G3: 3750 (3390-4125) 

G4: 3762 (3400-4120) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes:

NA 

Outcomes Description: 

Odds ratios (95% CIs) for macrosomia 

Groups 

G1: MWG < 5.0 kg (Reference) 

G2: MWG 5.0-9.9 kg 

G3: MWG 10.0-14.9 kg 

G4: MWG ≥ 15.0 kg 

Results 

G1: 1.0 

G2: 1.8 (0.8-3.8) 

G3: 2.2 (1.0-4.7) 

G4: 4.0 (1.8-9.0) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Pregravid BMI 

• 2h OGTT result 

• Parity 

• Smoking 

• Ethnicity 

• Clinical Center 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 4 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-302 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

Country and setting: 

USA, prenatal clinics 

Enrollment Period:

January 1, 1987- 

December 31, 1989 

Funding: 

NR 

Study Objective: 

To determine influences 

of increased maternal 

prepregnancy weight and 

increased gestational 

weight gain on pregnancy 

outcome 

Time frame: 

January 1, 1987 to 

December 31, 1989 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,191 

Group Description: 

G1: BMI < 19.8 

G2: 19.8-26.0 

G3: 27-29 

G4: > 29 

G5: All 

Group N: 

G1: 755 

G2: 1,621 

G3: 329 

G4: 486 

G5: 3191 

Inclusion criteria: 

• Delivery at or beyond 

38 weeks of gestation

• Singletons 

• Received prenatal 

care and delivered in 

Shands Hospital 

Exclusion criteria: 

• Fetal abnormalities 

• Oligohydramnios 

• Polyhydramnios 

• Medical or surgical 

complications (GI 

disorders, sickle cell 

hemoglobinopathy, 

hepatitis, hematologic 

disorders, malignant 

disease, renal 

disease, neurologic 

disease, pulmonary 

disease, psychiatric 

disorders, 

tuberculosis) 

• Incomplete risk 

variable data or 

outcome variable 

information 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• National Academy of 

Sciences 

Age (mean, yrs): 

G1: NR 

• < 20 years: 36.6% 

• 20-26 years: 44.8% 

• > 26 years: 18.7% 

G2: NR 

• < 20 years: 30.8% 

• 20-26 years: 46.5% 

• > 26 years: 22.6% 

G3: 

• < 20 years: 25.8% 

• 20-26 years: 48.9% 

• > 26 years: 25.2% 

G4: 

• < 20 years: 16.5% 

• 20-26 years: 53.9% 

• > 26 years: 29.6% 

G5: 

• < 20 years: 29.5% 

• 20-26 years: 47.5 % 

• > 26 years: 23.0% 

Parity: 

G1: % first: 49.3 

G2: 43.1 

G3: 37.4 

G4: 31.1 

G5: 42.1 

Race,%: 

White 

G1: 64.5 

G2: 60.0 

G3: 49.8 

G4: 51.9 

G5: 58.7 

Black 

G1: 33.6 

G2: 37.9 

G3: 48.9 

G4: 47.5 

G5: 39.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 1.9 

G2: 2.1 

G3: 1.2 

G4: 0.6 

G5: 1.7 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Hypertension,%: 

G1: 3.4 

G2: 4.6 

G3: 5.8 

G4: 10.7 

G5: 5.4 

Additional characteristics: 

G1: % married: 42.6 

G2: 46.1 

G3: 40.4 

G4: 49.4 

G5: 45.2 

Additional characteristics: 

NR 
C-303 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 755 

G2: 1621 

G3: 329 

G4: 486 

G5: 3191 

Total weight gain: 

G1: 

• < 16kg: 7.8% 

• 16-25kg: 18.5% 

• 26-35kg: 35.1% 

• > 35kg: 38.5% 

G2: 

• < 16kg: 11.7% 

• 16-25kg: 18.0% 

• 26-35kg: 28.8% 

• > 35kg: 41.5% 

G3: 

• < 16kg: 19.8% 

• 16-25kg: 19.1% 

• 26-35kg: 28.3% 

• > 35kg: 32.8% 

G4: 

• < 16kg: 32.3% 

• 16-25kg: 22.0%; 

Categorized: 

• Quartiles 

• National 

Academy of 

Sciences (below, 

within, or above 

recommended 

range) 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between self 

report and weight 

at last prenatal 

visit (mean 6.1 

days prior to 

delivery) 

Birth weight: 

G1: 

• < 2500g: 4.8% 

• 2500-4000g: 

89.1% 

• > 4000g: 6.1% 

G2: 

• < 2500g: 2.0% 

• 2500-4000g: 

85.2% 

• > 4000g: 12.8% 

G3: 

• < 2500g: 1.5% 

• 2500-4000g: 

83.0% 

• > 4000g: 15.5% 

G4: 

• < 2500g: 0.2% 

• 2500-4000g: 

82.5% 

• > 4000g: 17.3% 

Gestational 

diabetes, %: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Cesarean 

delivery,%: 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 11.9 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Frequency of 

macrosomia = 

12.2% 

• Frequency of 

cesarean = 

11.9% 

• Frequency of 

LBW = 2.9% 

Outcomes Description: 

Odds ratio ( 95% CI) for macrosomia 

Groups 

G1: Net WG < 14.9 lbs (Reference) 

G2: Net WG 14.9-23.5 lbs 

G3: Net WG 24-33 lbs 

G4: Net WG > 33 lbs 

Results 

G1: 1.0 

G2: 1.20 (0.83-1.75) 

G3: 1.77 (1.24-2.52) 

G5: 2.86 (2.02-4.02) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Height 

• Prepregnancy weight 

• Marital status 

• Education 

• Tobacco/alcohol/drug use 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Infant sex 

• Macrosomia 

Background: 

Fair 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

0 Good, 9 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-304 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

(continued) 

 
C-305 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

• Frequency of 

postdate 

pregnancy = 

9.8% 

• Frequency of 

labor 

abnormalities 

(40% were 

unscheduled 

cesareans) = 

7.8% 

• Frequency of 

oxytocin 

induction = 

13.7% 

• Frequency of 

oxytocin 

augmentation = 

16.1% 

• Frequency of 

meconium 

staining = 21.5%

Other infant 

outcomes: 

NA 

 
C-306 

 Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period:

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight change 

on pregnancy outcomes in 

obese women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) (n 

= 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 37 

or more weeks of 

gestation) liveborn, 

singleton infants 

during 1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-307 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 

56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 

43% 

G3: GWG (lb)Less 

than 2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, 

and greater than 

35 lb gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Odds of macrosomia 

Groups 

G1: Odds of macrosomia for WG > 2 5lbs 

G2: OR of macrosomia for WG < 15 lbs 

G3: Reference WG 15-25 lbs 

Results 

G1: higher for women in this group 

G2: lower for women in this group 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in Medicaid, WIC, 

food stamp programs) 

• Smoking 

• Chronic hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 6 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-308 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued)

 
C-309 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Other maternal outcomes:

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA 

by GWG category for 

each obesity class. All 

3 figures show similar 

patterns of increasing 

risk of preeclampsia, 

cesarean delivery, and 

LGA birth and 

decreasing risk of SGA 

birth with increasing 

GWG. Collectively, 

minimal risk for all 4 

outcomes corresponds 

to GWG categories 

where risk of LGA and 

SGA births intersect. 

This equates to GWG 

of 10 of 25 lb for class I 

obese women, a gain of 

0 tp 9 lb for class II 

obese women, and 

weight loss of 0 to 9 lb 

for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA 

by GWG category and 

obesity class. 

Compared with women 

who gained 15 to 25 lb 

during their 

pregnancies, those who 

gained less weight had 

significantly lower odds 

of preeclampsia, 

cesarean delivery, and 

LGA births, but higher 

odds for SGA births. 

Women who gained 

more than 25 lbs had 

higher odds for same 3 

pregnancy outcomes 

and lower odds for SGA 

births. 

Other infant outcomes: 

NR 
C-310 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kirchengast and 

Hartmann, 2003 

Country and setting: 

Singleton births that took 

place at University Clinic 

for Gynecology and 

Obstetrics in Vienna, 

Austria 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

Examine impact of 

biological factors such as 

young maternal age and 

maternal somatic 

characteristics on 

pregnancy outcome 

among group of 

adolescent mothers who 

gave birth between 39th 

and 41st week of 

gestation after period of 

intensive psychological 

support 

Time frame: 

NR 

Duration of the study: 

1985 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

8,011 

Group Description: 

G1: 12 to 16 years 

G2: 17 to 19 years 

G3: 20 to 29 years 

Group N: 

G1: 215 

G2: 1,336 

G3: 6,460 

Inclusion criteria: 

• Women ages 12 to 

29 

• All prenatal checkups of mother-child 

passport were 

performed 

• Delivery of single 

infant without 

congenital 

malformations 

• Receiving 

psychosocial support 

by family and/or 

specially trained 

social worker within 

young adolescent 

group (12 to 16 

years) 

Exclusion criteria: 

• Coincident medical 

diseases such as 

diabetes mellitus or 

nephropathy 

• Drug or alcohol 

abuse 

• Twin birth 

• IVF 

• Registered maternal 

diseases before and 

during pregnancy 

• Hypertension 

(BP < 150/90 mmHG)

• Protein or glucose in 

urine 

• Pregnancy related 

immunization 

Pregravid weight: 

Estimated by means of 

retrospective method and first 

weight determination, which 

was carried out at first prenatal 

visit (8th week of gestation) 

G1: 56.0 

G2: 57.2 

G3: 59.2 

Pregravid BMI: 

G1: 21.45 

G2: 21.59 

G3: 22.10 

Imputed: 

• Yes 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 14.5 

G2: 17.8 

G3: 24.1 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Age at menarche:

G1: 12.2 

G2: 12.9 

G3: 13.3 

Gynecological age:

G1: 3.4 

G2: 5.3 

G3: 10.8 
C-311 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 215

G2: 1,336

G3: 6,460

Total weight gain: 

G1: 13.1

G2: 13.1

G3: 13.1 (P = .10)

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3237.6 

(significantly 

different from 17-

19 and 20-29) 

G2: 3298.3 

(significantly 

different from 

< 17 and 20-29) 

G3: 3368.9 

(significantly 

different from 

< 17 and 17-19) 

(F = 24.1, 

P < .0001) 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Chronological 

age 

• Age at menarche

• Gynecological 

age 

• Height 

• Distancia 

spinarum 

• Distancia 

christarum 

• Prepregnancy 

weight 

• Weight at end of 

pregnancy 

Other infant 

outcomes 

• Birth length 

• Head 

circumference 

• Acromial 

circumference 

• Diameter 

frontooccipitale 

Outcomes Description: 

OR and 95% CI, for 

Macrosomia 

Groups 

NA, weight gain as continuous 

variable 

Results 

G1: 1.07 (1.05-1.10)

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Maternal age, age at 

menarche, pregravid weight, 

height, distantia cristarum 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-312 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Takimoto et al., 2006 

Country and setting: 

Japan, obstetric units 

Enrollment Period:

2001 to 2002 

Funding: 

Ministry of Health, Labour, 

and Welfare, Health, and 

Labour Research Grant, 

Research on Children and 

Families 

Study Objective: 

To identify adequate 

weight gain ranges during 

pregnancy in Japanese 

women 

Time frame: 

2001 to 2002 

Duration of the study: 

Pregnancy through 

delivery (all info derived 

from delivery records) 

Design: 

• Cross-sectional 

Total Study N: 

112,257 

Group Description: 

G1: Study cohort 

G2: NR 

Group N: 

G1: 46,659 

G2: NR 

Inclusion criteria: 

• Vaginal birth 

• Singleton pregnancy 

• Low risk 

• Term 

Exclusion criteria: 

• Cesarean deliveries 

(n = 30,559) 

• Delivery method 

unknown (n = 2258) 

• Multiple gestations (n 

= 8387) 

• Preterm deliveries 

< 37 weeks 

(n = 19623) 

• Post-term deliveries > 

41 weeks (n = 623) 

• Stillbirths and 

neonatal deaths 

(n = 2558) 

• Maternal deaths 

(n = 11) 

• Congenital anomalies 

of the infant 

(n = 2449) 

Pregravid weight: 

• Taken from records not 

stated whether it was selfreported or measured 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 29.9 (4.8) 

G2: NR 

Parity: 

% primiparous:

G1: 53.5 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 6.3 

G2: NR 

Diabetes mellitus,%: 

G1: 1.2 

G2: NR 

Hypertension,%: 

G1: 2.0 

G2: NR 

Additional characteristics: 

NR 
C-313 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 46,659 

G2: NR 

Total weight gain: 

G1: 9.9 (4.3)

G2: NR 

Categorized: 

• Gestational age 

specific percentile 

values of weight 

gain: under the 

25th, 25th-49th, 

50th-74th, 75th89th, ≥ 90th 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not stated 

Birth weight: 

G1: 2982 (472) 

G2: NR 

Gestational diabetes, 

%: 

G1: 1.2 

G2: NR 

Cesarean delivery,%:

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Macrosomia 

• IUGR 

Outcomes Description: 

Odds ratio (95% CI) for macrosomia 

Groups 

G1: Total MWG < 25th percentile for GA 

G2: Total MWG 25-49th percentile for GA 

G3: Total MWG 50-74th percentile for GA 

(Reference) 

G4: Total MWG 75-89th percentile for GA 

G5: Total MWG ≥90th percentile for GA 

Results 

G1: 0.31 (0.20,-0.47) 

G2: 0.49 (0.34-0.70) 

G3: 1.0 

G4: 1.62 (1.24-2.12) 

G5: 2.41 (1.83-3.17) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Parity 

• Pre-pregnancy weight 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information 

on exposure, outcomes, 

and confounders: 

Poor 

Followup: 

Fair 

Analysis comparability:

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor:

1 Good, 6 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-314 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Zhou and Olsen, 1997 

Country and setting: 

Denmark, two 

communities 

Enrollment Period:

April 1984 to April 1987 

Funding: 

Danish National Research 

Foundation and 

Sygekassernes Helsefond 

Study Objective: 

To study association 

between gestational 

weight gain and different 

birth weight indicators 

considering prepregnancy 

BMI 

Time frame: 

April 1984 to April 1987 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

7122 

Group Description: 

G1: Entire study 

G2: NR 

Group N: 

G1: 7122 

G2: NR 

Inclusion criteria: 

• Women who provided 

detailed information 

on lifestyle during 

pregnancy 

• Singletons 

• Non-diabetic women 

who gave birth 

between weeks 37 

and 42 for whom 

weight gain was 

reported 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: % < 19.8: 27.2; %19.8-26: 

63.7; %26+: 9.1 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

% < 25:

G1: 30.3 

G2: NR 

Parity: 

%nulliparous:

G1: 48.9 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

%non-smoking:

G1: 60.0 

G2: NR 

Diabetes mellitus,%: 

G1: 0 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-315 

Evidence Table 20. Gestational weight gain and macrosomia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 7122 

G2: NR 

Total weight gain: 

G1: % < 11kg: 

35.2; 

%12-15: 35.5; 

%16+: 29.3 

G2: NR 

Categorized: 

• ≤ 11, 12-15, 

≥ 16 kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between last 

measured 

weight prior to 

delivery and 

prepregnancy 

weight 

Birth weight: 

G1: %LBW: 1.7; 

%normal: 96.8; 

%HBW: 1.5 

G2: NR 

Gestational 

diabetes, %: 

G1: 0 

G2: NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Low birth 

weight (< 

2500g) 

• High birth 

weight (> 

4500g) 

• Growth 

retarded were 

newborns with 

a birth weight 

below 3000g in 

spite of a 

placenta 

weight higher 

than 66 

percentile 

(491g) 

Outcomes Description: 

Odds ratios (95% CI) for macrosomia by MWG 

categories and BMI 

Groups 

G1: MWG < 11 kg, underweight (Reference) 

G2: MWG < 11 kg, normal weight 

G3: MWG < 11 kg, overweight 

G4: MWG 12-15 kg, underweight, 

G5: MWG 12-15 kg, normal weight 

G6: MWG 12-15 kg, overweight 

G7: MWG ≥ 16 kg, underweight 

G8: MWG ≥ 16 kg, normal weight 

G9: MWG ≥ 16 kg, overweight 

Results 

G1: 1.0 

G2: 52.8 (0.3-22.9) 

G3: 9.7 (1.2-81.8) 

G4: 0.0 (0.0-7x105

) 

G5: 6.8 (0.9-51) 

G6: 27.1 (3.3-220) 

G7: 6.1 (0.7-52.5) 

G8: 15.7 (2.2-114) 

G9: 45.6 (6.0-349) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Alcohol 

• No diabetes 

• Term delivery 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Infant sex 

Background: 

Fair 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor

Final Quality Score: 

Fair 

 
C-316 

Evidence Table 21. Gestational weight gain and large-for-gestational age 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-317 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Percentage of LGA for MWG 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Results 

G1: 12.0 

G2: 11.8 

G3: 18.8 

G4: 25.8 

G5: 23.8 

(P < 0.01) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-318 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bo et al., 2003 

Country and setting: 

Italy, university clinic 

Enrollment Period:

April 1999 to February 

2001 

Funding: 

NR 

Study Objective: 

To evaluate pregnancy 

outcomes in cohort of 

caucasian pregnant 

women in relation to 

BMI and glucose 

toleranc status; role of 

central fat distribution, 

as indicated by waist to 

hip circumference ratio 

also considered 

Time frame: 

April 1999 to February 

2001 

Duration of the study: 

Screened during 

pregnancy at 24 to 28 

weeks, recall data on 

pregravid weight 

Design: 

• Cohort 

• Prospective 

Total Study N: 

700 

Group Description: 

G1: Normal wieight, 

normal OGTT 

G2: Overweight/Obese, 

normal OGTT 

G3: Normal Weight, 

IGT/GDM 

G4: Overweight/Obese, 

IGT/GDM 

Group N: 

G1: 333 

G2: 117 

G3: 133 

G4: 117 

Inclusion criteria: 

• Caucasian 

pregnant women 

attending 

Gynecological and 

Obstetrical 

Department of 

University of Torino 

screened with 50g 

oral glucose test at 

24 to 28 weeks 

gestation 

Exclusion criteria: 

• Women known to 

have preexistent 

diabetes mellitus, a 

disease affecting 

glucose 

metabolism, or 

hypertension 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 21.2 

G2: 29.9 

G3: 21.5 

G4: 29.9 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: 31.7 

G2: 31.1 

G3: 32.9 

G4: 32.6 

Parity: 

G1: Nulliparous (%): 63.7 

G2: 53.0 

G3: 62.4 

G4: 51.3 

Race,%: 

White 

G1: 100 

G2: 100 

G3: 100 

G4: 100 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 11.4 

G2: 15.4 

G3: 15.0 

G4: 18.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 1.2 

G2: 10.3 

G3: 4.5 

G4: 11.1 

Additional characteristics: 

Waist-to-hip ratio:

G1: 0.86 

G2: 0.87 

G3: 0.89 

G4: 0.90 

Additional characteristics: 

Preterm delivery (%):

G1: 6.9 

G2: 6.7 

G3: 9.2 

G4: 8.5 

Additional characteristics: 

LGA (%):

G1: 13.1 

G2: 27.6 

G3: 13.3 

G4: 27.4 
C-319 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 333 

G2: 117 

G3: 133 

G4: 117 

Total weight gain: 

G1: 13.2+/-4.1 

(P < 0.01 vs. G2)

G2: 10.5+/-6.1

G3: 11.8+/-5.7 

(P < 0.05 vs. G2, 

P < 0.05 vs. G4)

G4: 9.5+/-6.8 

(P < 0.01 vs. G1) 

(overall P < 0.0001)

Categorized: 

• Continuous 

Collected from: 

• Gains during 

pregnancy not 

collected 

Ascertained by: 

• Not explained by 

researchers, may 

be difference 

between 

prepregnancy 

weight and 

weight measured 

at 24 to 28 

weeks gestation 

Birth weight: 

G1: 3271+/-446 

(P < 0.05 vs. G2) 

G2: 3413+/-589 

(P < 0.01 vs. G3) 

G3: 3186+/-578 

(P < 0.01 vs. G4) 

G4: 3389+/-447 

(P < 0.05 vs. G1) 

(overall P = 0.001) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 30.5 

G2: 38.1 

G3: 39.2 

G4: 44.3 (P < 0.01 

vs. G1) (overall P = 

0.044) 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Height 

• Parental 

diabetes 

• Waist 

• Systolic bp 

• Diastolic bp 

• Hypertension 

• Triglycerides 

• HDL 

Other infant 

outcomes: 

• Weeks of 

delivery 

• SGA 

• Neonatal 

pathologies 

Outcomes Description: 

Odds ratio (95% CI) for LGA 

Groups 

G1: for each 1 kg increase in MWG 

Results 

G1: 1.08 (1.03-1.12) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Age, pregravid BMI, smoking, gestational 

hyperglycaemia 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 7 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-320 

 Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Caulfield et al., 1998 

Country and setting: 

USA, hospital obstetric 

database 

Enrollment Period:

1987 to 1989 

Funding: 

NR 

Study Objective: 

To examine relation 

between gestational 

weight gain and risk of 

delivering a small for 

gestational age and large 

for gestational age infant 

by race 

Time frame: 

1987-1989 

Duration of the study: 

Entry into pn care until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,870 

Group Description: 

G1: BMI < 19.8 Black 

G2: BMI < 19.8 White 

G3: BMI 19.8 to 26.0 Black 

G4: BMI 19.8 to 26.0 White 

G5: BMI > 26.0 Black 

G6: BMI > 26.0 White 

Group N: 

G1: 523 

G2: 267 

G3: 1,479 

G4: 796 

G5: 615 

G6: 190 

Inclusion criteria: 

• Singleton pregnancies 

• White or black ethnicity 

• At least 28 weeks’ 

gestation 

• One delivery per 

woman (randomly 

chosen) 

• Information on 

anthropometric data 

Exclusion criteria: 

• Missing data 

• Improbable data 

• Non-black or non-white 

ethnicity 

Pregravid weight: 

• Self-reported 

G1: 13.3 (5.7) 

G2: 14.6 (5.1) 

G3: 13.6 (6.7) 

G4: 15.3 (5.4) 

G5: 12.4 (7.7) 

G6: 14.5 (7.3) 

Pregravid BMI: 

G1: 18.4 (1.0) 

G2: 18.5 (1.0) 

G3: 22.7 (1.8) 

G4: 22.1 (1.8) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 21.7 (4.8) 

G2: 27.1 (6.6) 

G3: 22.7 (5.3) 

G4: 29.8 (5.8) 

G5: 24.9 (6.0) 

G6: 28.2 (5.5) 

Parity: 

G1: % primiparous: 52.4 

G2: 55.4 

G3: 50.1 

G4: 48.0 

G5: 36.9 

G6: 46.9 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 32.8 

G2: 20.6 

G3: 35.4 

G4: 20.0 

G5: 28.8 

G6: 25.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 4.3 

G2: 3.0 

G3: 6.0 

G4: 5.7 

G5: 11.9 

G6: 17.0 

Additional characteristics: 

NR 
C-321 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: 13.3 (5.7)

G2: 14.6 (5.1)

G3: 13.6 (6.7)

G4: 15.3 (5.4)

G5: 12.4 (7.7)

G6: 14.5 (7.3)

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

selfreport 

prepregnancy 

weight and last 

recorded weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

ORs and 95% CIs for LGA per 50g/wk increase in 

rate of weight gain by BMI 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

G1: 1.25 (1.11-1.41) 

G2: 1.14 (1.08,-1.20) 

G3: 1.13 (1.07-1.20) 

Maternal age, race, parity, pregravid BMI, height, 

hypertension, provider type, smoking, infant sex 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Height 

• Hypertension 

• Provider type 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Female infant 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

6 Good, 3 Fair, 0 

Poor 

Final Quality 

Score: 

Good 

 
C-322 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cedergren, 2006 

Country and setting: 

Sweden, Medical Birth 

Registry 

Enrollment Period:

January 1, 1994 - 

December 31, 2002 

Funding: 

Ostergotland County 

Council 

Study Objective: 

To estimate effects of high 

and low gestational weight 

gain in different maternal 

BMI classes on obstetric 

and neonatal outcomes 

Time frame: 

January 1, 1994 to 

December 31, 2002 

Duration of the study: 

First visit to maternity 

health care center to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

245,526 

Group Description: 

BMI 

G1: < 20 

G2: 20 to 24.9 

G3: 25 to 29.9 

G4: 30 to 34.9 

G5: ≥ 35 

Group N: 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Inclusion criteria: 

• Singleton, term 

pregnancies 

• Information on 

maternal height, 

maternal weight in 

early pregnancy, and 

gestational weight 

gain 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• If unknown, standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20.0-24.9, 25.0-

29.9, 30-34.9, ≥ 35 

Age (mean, yrs): 

G1: 15 to 19 years: 3.8% 

20 to 24: 23.0% 

25 to 29: 38.7% 

30 to 34: 25.7% 

35 to 39: 7.7% 

≥ 40: 1.1% 

G2: 15 to 19 years: 1.9% 

20 to 24: 15.9% 

25 to 29: 37.7% 

30 to 34: 31.1% 

35 to 39: 11.3% 

≥ 40: 1.9% 

G3: 15 to 19 years: 1.5% 

20 to 24: 15.7% 

25 to 29: 36.1% 

30 to 34: 31.2% 

35 to 39: 12.9% 

≥ 40: 2.5% 

G4: 15 to 19 years: 1.5% 

20 to 24: 17.4% 

25 to 29: 35.6% 

30 to 34: 30.0% 

35 to 39: 13.0% 

≥ 40: 2.4% 

G5: 15 to 19 years: 1.1% 

20 to 24: 17.3% 

25 to 29: 38.0% 

30 to 34: 29.6% 

35 to 39: 11.7% 

≥ 40: 2.3% 

Race,%: 

White 

G1: 96.6 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 1.4 

G2: NR 

Other 

G1: 2.0 

G2: NR 

Smoking,%: 

G1: % nonsmoking: 81.6 

G2: 85.2 

G3: 83.1 

G4: 79.9 

G5: 78.4 

Group 6 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-323 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Total weight gain: 

G1: < 8kg: 6.9% 

8-15.9kg: 65.2% 

≥ 16kg: 28.0% 

G2: < 8kg: 8.4% 

8-15.9kg: 67.1% 

≥ 16kg: 30.4% 

G3: < 8kg: 15.7% 

8-15.9kg: 54.4% 

≥ 16kg: 29.9% 

G4: < 8kg: 30.2% 

8-15.9kg: 48.7% 

≥ 16kg: 21.1% 

G5: < 8kg: 44.6% 

8-15.9kg: 40.9% 

≥ 16kg

Categorized: 

• < 8kg, 8-16, > 16 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

maternal weights 

measured when 

woman attended 

delivery unit and 

maternal weight 

recorded at first 

visit to maternity 

health care 

center 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Odds ratio (95% CIs) for LGA (> 2 SD above the 

mean) 

Groups 

Weight gain < 8 kg 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

Weight gain > 16 kg 

G6: BMI < 20 

G7: BMI 20-24.9 

G8: BMI 25-29.9 

G9: BMI 30-34.9 

G10: BMI ≥ 35 

Weight gain 8-16 kg (Reference) 

Results 

G1: 0.43 (0.24-0.75) 

G2: 0.53 (0.47-0.61) 

G3: 0.48 (0.43-0.53) 

G4: 0.66 (0.59-0.75) 

G5: 0.54 (0.46-0.63) 

G6: 3.26 (2.76-3.86) 

G7: 2.73 (2.60-2.88) 

G8: 2.14 (2.01-2.28) 

G9: 2.24 (2.00-2.51) 

G10: 1.54 (1.24-1.90) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Year of birth 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

4 Good, 5 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-324 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period:

July 1, 1985 - December 

31, 1985 (6 months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal weight 

or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to December 

31, 1985 (6 months) 

Duration of the study: 

Prepregnancy to delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at delivery

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or over 

ideal weight for 

height) or abnormal 

pregnancy weight 

gain (≥ 20kg or ≤ 5kg)

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under normal 

weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital within 

study period selected 

those with abnormal 

maternal 

prepregnancy weight 

or abnormal weight 

gain during 

pregnancy, as well as 

next mother in 

sequential order with 

normal prepregnancy 

weight and weight 

gain during 

pregnancy to serve 

as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if self 

reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over or 

under normal weight for 

height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 (1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-325 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared to 

controls

G2: 13.4 (4.5)

G3: 3.0 (3.5) 

P < 0.0005 compared 

to controls

G4: 23.2 (22.8) 

P < 0.0005 compared 

to controls

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥ 20kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared to 

controls 

G2: 3293 (362) 

P < 0.05 compared to 

controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 compared 

to controls 

G5: 3538 (535) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: Elective 7% 

Emergency 14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percentage of Infant BW by maternal weight 

gain groups 

Groups 

Infant weight percentile for mothers with normal 

pregravid weight and normal weight gain 

G1: < 2.5% 

G2: 2.5-10% 

G3: 10-50% 

G4: 50-90% 

G5: 90-97.5% 

G6: > 97.5% 

Infant weight percentile for mothers with weight 

gain ≤5 kg 

G7: < 2.5% 

G8: 2.5-10% 

G9: 10-50% 

G10: 50-90% 

G11: 90-97.5% 

G12: > 97.5% 

Infant weight percentile for mothers with weight 

gain ≥20 kg 

G13: < 2.5% 

G14: 2.5-10% 

G15: 10-50% 

G16: 50-90% 

G17: 90-97.5% 

G18: > 97.5% 

Results 

G1: 1% 

G2: 6% 

G3: 35% 

G4: 43% 

G5: 13% 

G6: 2% 

 

G7: 3% 

G8: 14% 

G9: 32% 

G10: 34% 

G11: 14% 

G12: 3% 

G13: 0% 

G14: 2% 

G15: 42% 

G16: 29% 

G17: 20% 

G18: 7% 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of outcomes:

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-326 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 (continued) 

 
C-327 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NAR 
C-328 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period:

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain in 

obese glucose tolerant 

women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI ≥

30 

• Normal 2h 75g oral 

glucose tolerance test 

(OGTT) during third 

trimester (according 

to WHO criteria) 

• Only first pregnancy 

during study period 

included 

Exclusion criteria: 

• Well defined chronic 

disease 

• Twin pregnancies 

• Women with GDM (n 

= 323) 

• Known diet treatment 

(n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of pregravid 

BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-329 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight gain: 

Categorized: 

• < 5.0. 5.0-9.9, 

10.0-14.9, ≥ 15.0 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated by 

authors 

Birth weight: 

G1: 3500 (3200-3840)

G2: 3645 (3200-4000)

G3: 3750 (3390-4125)

G4: 3762 (3400-4120)

Gestational diabetes, 

%: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Odds ratios (95% CIs) for LGA 

Groups 

G1: MWG < 5.0 kg (Reference) 

G2: MWG 5.0-9.9 kg 

G3: MWG 10.0-14.9 kg 

G4: MWG ≥ 15.0 kg 

Results 

G1: 1.0 

G2: 2.4 (1.1-5.3) 

G3: 2.1 (1.1-4.8) 

G4: 4.7 (2-11) 

Maternal confounders and effect modifiers accounted 

for in analysis: 

• Age 

• Pregravid BMI 

• 2h OGTT result 

• Parity 

• Smoking 

• Ethnicity 

• Clinical Center 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

2 Good, 4 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-330 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period:

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight 

change on pregnancy 

outcomes in obese 

women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) 

(n = 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 

37 or more weeks 

of gestation) 

liveborn, singleton 

infants during 

1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: < 26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: < 26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: < 26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-331 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight 

gain: 

G1: GWG (lb) 

Less than 2: 

3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 

56% 

G2: GWG (lb) 

Less than 2: 

8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 

43% 

G3: GWG (lb)Less 

than 2: 15% 

Categorized: 

• 10-lb or less 

loss 

2 to 9 lbs 

loss, no 

weight 

change, 

2 to 9 lbs 

gain, 

10 to 14 lbs 

gain, 15–25 lb 

gain, 

26–35 lb gain, 

and greater 

than 35 lb 

gain 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Odds of LGA by maternal weight gain groups 

Groups 

G1: Odds of LGA for weight gain > 25lbs 

G2: OR of LGA for weight gain < 15lbs 

G3: Reference weight gain 15-25 lbs 

Results 

G1: Odds of LGA are higher for women in this 

group 

G2: Odds of LGA are lower for women in this 

group 

Numerical value for ORs not reported in study 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in Medicaid, WIC, 

food stamp programs) 

• Smoking 

• Chronic hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poo

r: 

2 Good, 6 Fair, 

1 Poor 

Final Quality 

Score: 

Fair 
C-332 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued) 

 
C-333 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal 

Weight Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Other maternal outcomes: 

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA 

by GWG category for 

each obesity class. All 3 

figures show similar 

patterns of increasing 

risk of preeclampsia, 

cesarean delivery, and 

LGA birth and 

decreasing risk of SGA 

birth with increasing 

GWG. Collectively, 

minimal risk for all 4 

outcomes corresponds 

to GWG categories 

where risk of LGA and 

SGA births intersect. 

This equates to GWG of 

10 of 25 lb for class I 

obese women, a gain of 

0 tp 9 lb for class II 

obese women, and 

weight loss of 0 to 9 lb 

for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA 

by GWG category and 

obesity class. Compared 

with women who gained 

15 to 25 lb during their 

pregnancies, those who 

gained less weight had 

significantly lower odds 

of preeclampsia, 

cesarean delivery, and 

LGA births, but higher 

odds for SGA births. 

Women who gained 

more than 25 lbs had 

higher odds for same 3 

pregnancy outcomes 

and lower odds for SGA 

births. 

Other infant outcomes: 

NR 
C-334 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria 

Baseline 

Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kitajima et al., 2001 

Country and setting: 

Japan, university 

hospital 

Enrollment period: 

1992 to 1999 

Funding: 

NR 

Study Objective: 

To determine whether 

elevated midpregnancy 

maternal serum lipid 

levels predict newborn 

weight at term and risk 

of LGA infants in 

women with positive 

diabetic screen but 

normal glucose 

tolerance test 

Time frame: 

1992 to 1999 

Duration of the study: 

Entry of pn care to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

146 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 146 

G2: NR 

Inclusion criteria: 

• Japanese pregnant 

women who had 

positive diabetic screen 

test results (at least 135 

mg/dL of plasma 

glucose level at 1 hour 

after 50-g oral glucose 

challenge) and a normal 

75-g oral GTT at 24 to 

32 weeks’ gestation at 

Nagasaki University 

Hospital between 

November 1992 and 

October 1999 

Exclusion criteria: 

• Women with 

pregestational or 

gestational diabetes 

mellitus to eliminate 

therapeutic biases in 

association between 

maternal metabolic 

variables and fetal 

growth 

• Women with 

hypertensive disorder, 

thyroid disorder, lupus, 

and antiphospholipid 

syndrome, because 

those conditions are 

associated with fetal 

growth restriction due to 

placental insufficiency 

rather than metabolic 

factors 

• Subjects who delivered 

before 37 weeks’ 

gestation and cases of 

fetal congenital 

malformation or 

multifetal gestation 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 21.2 +/-2.7 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 32+/1 4 

G2: NR 

Parity: 

G1: Nulliparous 44% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-335 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight 

gain: 

G1: 9.6+/- 3.3 kg

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3012g+/- 359 

G2: NR 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal outcomes: 

NR 

Other infant outcomes: 

NR 

Outcomes Description: 

Odds ratio (95% CI) for LGA 

Groups 

G1: for each 1 kg increase in MWG 

Results 

G1: 1.08 (0.81-1.44) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Pre-gravid BMI 

• Maternal plasma glucose levels 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Infant sex 

Background: 

Good 

Sample 

selection: 

Good 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

6 Good, 1 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-336 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kramer et al., 1990 

Country and setting: 

Canada, university 

hospital 

Enrollment Period:

1980 to 1986 

Funding: 

National Health Research 

and Development 

Program, Health and 

Welfare Canada 

Study Objective: 

(1) Which maternal and 

fetal variables appear to 

have independent causal 

impacts on intrauterine 

growth? (2) For a given 

fetal growth status, which 

maternal and fetal 

variables affect 

proportionality? 

Time frame: 

1980 to 1986 

Duration of the study: 

Entry in to prenatal care 

up to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

8,719 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 8715 

G2: NR 

Inclusion criteria: 

• Live-born, singleton 

infants without 

evidence of 

congenital 

intrauterine infection, 

chromosomal 

anomalies, or other 

major malformations 

and for whom 

gestational age 

calculated from last 

normal menstrual 

period agreed within 

±7 days with an early 

second-trimester 

(usually 16 to 18 

weeks) 

• Ultrasonographic 

estimate based on 

fetal biparietal 

diameter 

Exclusion criteria: 

• See above 

Pregravid weight: 

• Self-reportedNR 

G1: 57.8 kg (10.8) 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• They used prepregnancy 

wt and ht separately 

• NR 

Age (mean, yrs): 

G1: 28.6 (4.7) 

G2: NR 

Parity: 

G1: 0.72 (0.86) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

Cigarettes/d:

G1: 3.2 (7.5) 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

Pg related HTN:

G1: 7.7% 

G2: NR 

Additional characteristics: 

Education, y completed:

G1: 13.0 (3.3) 

G2: NR 

Marital status: 

G1: 90.6% 

G2: NR 

Parity % primaparas:

G1: 48.0 

G2: NR 
C-337 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 8715 

G2: NR 

Total weight gain: 

G1: 14.2kg (5.5)

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery, 

using net weight 

gain (total weight 

minus wt of 

infant) 

Birth weight: 

G1: 3385g (547) 

G2: NR 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Bivariate asssociations 

between selected 

maternal and fetal 

variables and fetal 

growth and 

proportionality: 

Correlation coefficient 

for net gestational 

weight gain (kg)and 

fetal growth ratio = 

0.12 (P < 0.001); for 

prepregnancy weight 

(kg) 0.21 (P < 0.001) 

Other infant outcomes: 

• Correlation coefficients 

for Net prepregnancy 

weight gain (kg) and 

length = -0.04 (P < 

0.01) 

• Head circumference = 

-0.01 (NS); BMI 0.04 

(P < 0.001); Ponderal 

index = 0.04 (P < 

0.001) 

• Weight/height 

circumference = 0.01 

(NS) 

Outcomes Description: 

Odds ratio (95% CI) for LGA 

Groups 

G1: for each 5 kg decrease in net 

gestational WG 

Results 

G1: 0.73 (0.68-0.79) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Pregravid weight, smoking, parity, maternal 

diabetes, height, previous LBW infant, 

severe pregnancy-induced hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Sex of the infant 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-338 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Muscati et al., 1996 

Country and setting: 

Canada, public health 

department 

Enrollment Period:

1979 to 1989 

Funding: 

NR 

Study Objective: 

To examine association of 

extent and timing of 

pregnancy weight gain 

with infant birth weight 

and postpartum weight 

retention 

Time frame: 

1979 to 1989 

Duration of the study: 

Pregnancy through 6 

weeks postpartum 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

371 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 371 

G2: NR 

Inclusion criteria: 

• White, low income, 

non-smoking women 

• Pregnant women 

Exclusion criteria: 

• Prematurity < 37 

weeks 

• Adolescents < 16 

years 

• Women > 40 years 

• Maternal health 

problems 

• Women who 

consume alcohol or 

drugs 

• Pregnancy 

complications such 

as proteinuria, 

hypertension, 

diabetes, negative 

weight gain, missing 

values 

Pregravid weight: 

Family physicians’ records 

G1: 62.8 +/- 16.0 kg 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Pregravid weight status 

categorized into 3 groups 

as a percentage of 

standard weight: 

underweight < 90%, 

normal 90-120%, and 

overweight > 120% 

Age (mean, yrs): 

G1: 24.5 +/- 5.6 

G2: NR 

Parity: 

G1: Primiparous 52% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: PPWR: 5.3 +/- 5.7 kg 

G2: NR 

Additional characteristics: 

NR 
C-339 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 16.1 +/- 6.4 kg

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %:

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

From Table 1: 

Pearson’s Correlation 

Coefficient and 

determination 

coefficient of maternal 

weight gain with PP 

weight retention and 

Infant BW. Maternal PP 

weight retention and 

Preg weight gain: [Total 

amount r = 0.808, R 

square 65.3%, P < 

0.001], [Up to week 20 r 

= 0.682, R square 

46.5%, P < 0.001], 

[Weeks 21-30 r = 

0.411, R square 16.9%, 

P < 0.001], [Week 31 - 

term r = 0.414, R 

square 17.1%, P < 

0.001] 

Other infant 

outcomes: 

Pregnancy Weight Gain 

and Infant Birth Weight 

(from Table 1): [Total 

amount r = 0.216, R 

square 4.7%, P < 

0.001], [Up to week 20 r 

= 0.114, R-square 

1.3%, 

P < 0.05], [Weeks 21-

30 r = 0.157, R square 

2.5%, 

P < 0.01], [Week 31 - 

term r = 0.160, R 

square 2.6%, 

P < 0.01] 

Outcomes Description: 

Odds ratio for LGA per weight gain increase 

Groups 

G1: OR for LGA per 1 kg increase in WG up to week 20 

G2: OR for LGA per 1 kg increase in WG from weeks 

21 to 30 

G3: OR for LGA per 1 kg increase in WG from weeks 

31 to term 

Results 

G1: 1.17 (P < 0.001) 

G2: 1.16 (P < 0.01) 

G3: 1.02 (P = NS) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Parity, pregravid standard weight, pregravid excess 

weight 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Birth length, infant sex 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor:

2 Good, 5 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-340 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Parker and Abrams, 1992 

Country and setting: 

USA, hospital 

Enrollment Period:

Sept 1980 to Dec 1988 

Funding: 

UC Committee on 

Research & MCH and 

Resources Development, 

Health Resources and 

Services Administration 

Study Objective: 

To test whether gains 

outside IOM reference 

ranges were associated 

with increased risks of 

suboptimal pregnancy 

outcome (SGA, LGA, 

cesarean delivery) and to 

determine whether locally 

developed ranges were 

more applicable to study 

population 

Time frame: 

Sept 1980 to Dec 1988 

Duration of the study: 

From entry into prenatal 

care until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

6,690 

Group Description: 

G1: Overall 

G2: NR 

Group N: 

G1: 6,690 

G2: NR 

Inclusion criteria: 

• Consecutive live 

singleton births at 

Moffitt Hospital 

between September 

1980 and December 

1988 with gestational 

ages of 37 to 42 

weeks 

Exclusion criteria: 

• Maternal transfers or 

transports and 

deliveries 

complicated by fetal 

malformations, 

maternal diabetes, or 

maternal 

hypertension 

Pregravid weight: 

• Self-reported 

G1: 56.8 kg(SD 11.0) 

G2: NR 

Pregravid BMI: 

G1: Underweight: 27.7%, 

Normal weight 61.8%, 

Overweight: 5.6%, 

Obese 4.9% 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 27.7 (5.5) 

G2: NR 

Parity: 

Primiparous:

G1: 58.8% 

G2: NR 

Race,%: 

White 

G1: 44.0 

G2: NR 

Black 

G1: 8.3 

G2: NR 

Hispanic 

G1: 9.4 

G2: NR 

Asian/Pacific Islander 

G1: 21.4 

G2: NR 

Other 

G1: 12.0 

G2: NR 

Smoking,%: 

G1: 12.0 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-341 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 6690 

G2: NR 

Total weight gain: 

G1: 15.2kg (5.2)

G2: NR 

Categorized: 

• According to IOM 

Weight gain 

ranges based on 

percentiles from 

previous study of 

UC population 

with good 

pregnancy 

outcomes: 25th -

75th, 10-90th 

percentiles. For 

25-75th, weight 

gain range = 12-

17kg for 

underweight 

women (BMI < 

19.8); 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3408g (462) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratios (95% CIs) of LGA by weight gain 

Groups 

G1: Compared to UCSF Cohort 25-75th percentile 

of WG 

G2: Compared to UCSF 10-90th percentile of WG 

Results 

G1: 1.89 (1.51-2.37) 

G2: 1.87 (1.39-2.52) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Height 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

3 Good, 5 Fair, 1 

Poor 

Final Quality Score:

Fair 
C-342 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Pezzarossa et al., 1996 

Country and setting: 

Italy, not stated 

Enrollment Period:

Not stated 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

gestational weight gain on 

neonatal birthweight in 

women who were 

diagnosed with 

gestational diabetes after 

3second week gestation 

Time frame: 

Not stated 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

192 

Group Description: 

G1: Normal 

G2: GDM 

Group N: 

G1: 132 

G2: 60 

Inclusion criteria: 

• Caucasian women 

who had 1 or more 

risk factors for GDM: 

BMI > 28.6, 

gestational weight 

gain > 12kg, previous 

GDM, or previous 

neonatal macrosomia 

and underwent a 

diagnostic oral 

glucose tolerance test 

for GDM after 

3second week of 

gestation - women 

with positive tests 

formed GDM group 

while women with 

negative test results 

formed normal 

singleton 

Exclusion criteria: 

• Smoking 

• Hypertension 

• Underweight (BMI < 

19.6) 

• Previous metabolic 

treatment 

• Diabetic counseling 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 25.7 (0.5) 

G2: 25.4 (0.8) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.1 (0.4) 

G2: 28.07 (0.6) 

Parity: 

NR 

Race,%: 

White 

G1: 100 

G2: 100 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-343 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 132 

G2: 60 

Total weight gain: 

G1: 13.4 (0.5)

G2: 12.2 (0.6)

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

used weight at 

last prenatal visit 

Birth weight: 

G1: 3576.8 (41.3) 

G2: 3678.7 (69.3) 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant outcomes: 

macrosomia 

Outcomes Description: 

Relative risks for LGA 

Groups 

G1: MWG < 9 kg 

G2: MWG 9-14 kg 

Results 

G1: similar between non-diabetic and GDM 

groups 

G2: GDM group has 2 times higher risk that 

non-diabetics 

Numerical results not reported 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Pre-gravid BMI 

• Fasting plasma glucose 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 5 Fair, 1 

Poor 

Final Quality Score:

Fair 
C-344 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Sunehag et al., 1991 

Country and setting: 

Sweden, prenatal clinics 

Enrollment Period:

October 1994 to 

December 1987 

Funding: 

Grants from Gillberg 

Foundation, Swedish 

Diabetes Association, and 

Family Ernfors Foundation 

Study Objective: 

To assess perinatal 

morbidity in clinic with 

policy of liberal insulin 

treatment in pregnancies 

complicated by diabetes 

and to find predictive 

factors for adverse 

perinatal outcome 

Time frame: 

October 1994 to 

December 1987 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

133 women confirmed to 

have GDM 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 133 

G2: NR 

Inclusion criteria: 

• Women at risk for 

GDM 

Exclusion criteria: 

• Twin pregnancies 

• Incomplete case 

records 

Pregravid weight: 

• Not stated - records? 

Pregravid BMI: 

G1: 25.6 (4.7) 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuous > 23.9 

Age (mean, yrs): 

G1: 32 (range 19-43) 

G2: NR 

Parity: 

% primiparous:

G1: 30.8% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 30.8 

G2: NR 

Additional characteristics: 

NR 
C-345 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 133 

G2: NR 

Total weight gain: 

G1: 12.5 (6.3) kg

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Not stated - 

records? 

Ascertained by: 

• Not stated 

Birth weight: 

G1: 3.7 (0.6) 

G2: NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 27 

G2: NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Association between LGA and MWG 

Groups 

G1: LGA vs MWG > 18 kg 

Results 

G1: χ2

 = 8.2 (P < 0.005) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

1 Good, 5 Fair, 3 

Poor 

Final Quality Score:

Poor 
C-346 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wataba et al., 2006 

Country and setting: 

Japan, academic medical 

center 

Enrollment Period:

1981 to 1999 

Funding: 

NR 

Study Objective: 

To analyze association of 

pregnancy complications 

with prepregnant body 

mass index and weight 

gain during pregnancy in 

Japanese women 

Time frame: 

1981 to 1999 

Duration of the study: 

Entry into PNC up til 

delivery 

Design: 

• Perinatal data base 

and look at medical 

records 

retrospectively 

• Retrospective 

Total Study N: 

21,718 

Group Description: 

G1: Nulliparous 

G2: Parous women 

Group N: 

G1: 10413 

G2: 11305 

Inclusion criteria: 

• Singleton pregnancy 

delivering term baby 

at Osaka Med Center 

and Research 

Institute for Maternal 

and Child Health in 

19811999 

Exclusion criteria: 

• None reported 

Pregravid weight: 

• In data base, but don’t 

know if self reported 

Pregravid BMI: 

G1: 20.5 (2.6) 

G2: 21.1 (3.0) 

Imputed: 

• No 

Categorized: 

• Categorical in 2 kg/m2 

point intervals from 

prepregnancy weight; 

categorical into low, 

medium, high BMI groups 

(< 18, 18-23.9, > 24) 

Age (mean, yrs): 

G1: 27.8 (4.1) 

G2: 30.45 (3.9) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-347 

Evidence Table 21. Maternal weight and large for gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 10413 

G2: 11305 

Total weight gain: 

G1: kg/wk: 0.25 

(SD 0.09)

G2: kg/wk: 0.24 

(0.09) P < 0.01

Categorized: 

• Categorical in 

kg/wk using 

prepregnancy 

weight and 

weight at 

delivery divided 

by gestational 

age of infant at 

birth 

Collected from: 

• Rate of weight 

gain 

determined by: 

total weight 

gain divided by 

weeks ga 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: and 

subtracting 

prepregnancy 

weight 

Birth weight: 

G1: SGA: 5.4% 

LGA 5.2% 

G2: SGA 6.5% LGA 

5.2% 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratio for LGA (95% CIs) 

Groups 

Nulliparous 

G1: Low BMI (< 18), WG > 0.40 kg/wk 

G2: Medium BMI (18-23.9), WG 0.20-0.25 

kg/wk 

G3: WG 0.25-0.30 kg/wk (Reference) 

G4: Medium BMI, WG 0.30-0.35 kg/wk 

G5: Medium BMI, WG 0.35-0.40 kg/wk 

G6: Medium BMI, WG > 0.40 kg/wk 

Parous 

G7: Low BMI (< 18), WG > 0.40 kg/wk 

G8: WG 0.20-0.25 kg/wk (Reference for 

low/med BMI) 

G9: Medium BMI (18-23.9), WG 0.25-0.30 

kg/wk 

G10: Medium BMI, WG 0.30-0.35 kg/wk 

G11: Medium BMI, WG 0.35-0.40 kg/wk 

G12: Medium BMI, WG > 0.40 kg/wk 

G13: High BMI (≥24), WG 0.15-0.20 kg/wk 

G14: WG ≥ 0.30 kg/wk (Reference for high 

BMI) 

Results 

G1: 2.25 (1.03-4.94) 

G2: 1.41 (1.31-1.76) 

G3: 1.0 

G4: 1.76 (1.38-2.23) 

G5: 2.34 (1.77-3.10) 

G6: 2.58 (1.71-3.89) 

G7: 2.16 (0.63-/7.44) 

G8: 1.0 

G9: 1.48 (1.15-2.33) 

G10: 1.64 (1.18-2.27) 

G11: 2.23 (1.51-3.31) 

G12: 3.94 (2.56-6.03) 

G13: 2.27 (1.31-3.95) 

G14: 1.0 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Preeclampsia, C-section, 1-minute Apgar 

score < 4 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-348 

Evidence Table 22. Gestational weight gain and small-for-gestational age 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-349 

Evidence Table 22. Gestational weight gain and small-for-gestational age(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

SGA (%) 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results 

G1: 4 

G2: 3.9 

G3: 5.6 

G4: 3.1 

G5: 3.8 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-350 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Caulfield et al., 1998 

Country and setting: 

USA, hospital obstetric 

database 

Enrollment Period:

1987 to 1989 

Funding: 

NR 

Study Objective: 

To examine relation 

between gestational 

weight gain and risk of 

delivering a small for 

gestational age and large 

for gestational age infant 

by race 

Time frame: 

1987-1989 

Duration of the study: 

Entry into pn care until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,870 

Group Description: 

G1: BMI < 19.8 Black 

G2: BMI < 19.8 White 

G3: BMI 19.8 to 26.0 Black 

G4: BMI 19.8 to 26.0 White 

G5: BMI > 26.0 Black 

G6: BMI > 26.0 White 

Group N: 

G1: 523 

G2: 267 

G3: 1,479 

G4: 796 

G5: 615 

G6: 190 

Inclusion criteria: 

• Singleton pregnancies 

• White or black ethnicity 

• At least 28 weeks’ 

gestation 

• One delivery per 

woman (randomly 

chosen) 

• Information on 

anthropometric data 

Exclusion criteria: 

• Missing data 

• Improbable data 

• Non-black or non-white 

ethnicity 

Pregravid weight: 

• Self-reported 

G1: 13.3 (5.7) 

G2: 14.6 (5.1) 

G3: 13.6 (6.7) 

G4: 15.3 (5.4) 

G5: 12.4 (7.7) 

G6: 14.5 (7.3) 

Pregravid BMI: 

G1: 18.4 (1.0) 

G2: 18.5 (1.0) 

G3: 22.7 (1.8) 

G4: 22.1 (1.8) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 21.7 (4.8) 

G2: 27.1 (6.6) 

G3: 22.7 (5.3) 

G4: 29.8 (5.8) 

G5: 24.9 (6.0) 

G6: 28.2 (5.5) 

Parity: 

G1: % primiparous: 52.4 

G2: 55.4 

G3: 50.1 

G4: 48.0 

G5: 36.9 

G6: 46.9 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 32.8 

G2: 20.6 

G3: 35.4 

G4: 20.0 

G5: 28.8 

G6: 25.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 4.3 

G2: 3.0 

G3: 6.0 

G4: 5.7 

G5: 11.9 

G6: 17.0 

Additional characteristics: 

NR 
C-351 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: 13.3 (5.7)

G2: 14.6 (5.1)

G3: 13.6 (6.7)

G4: 15.3 (5.4)

G5: 12.4 (7.7)

G6: 14.5 (7.3)

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

selfreport 

prepregnancy 

weight and last 

recorded weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratio (95% CI) for SGA per 50g/wk 

increase in rate of weight gain by BMI 

Groups 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

Results 

G1: 0.87 (0.78-0.97) 

G2: 0.90 (0.84-0.96) 

G3: 0.93 (0.86-1.01) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pregravid BMI 

• Height 

• Hypertension 

• Provider type 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

6 Good, 3 Fair, 0 Poor

Final Quality Score: 

Good 
C-352 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cedergren, 2006 

Country and setting: 

Sweden, Medical Birth 

Registry 

Enrollment Period:

January 1, 1994 - 

December 31, 2002 

Funding: 

Ostergotland County 

Council 

Study Objective: 

To estimate effects of high 

and low gestational weight 

gain in different maternal 

BMI classes on obstetric 

and neonatal outcomes 

Time frame: 

January 1, 1994 to 

December 31, 2002 

Duration of the study: 

First visit to maternity 

health care center to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

245,526 

Group Description: 

BMI 

G1: < 20 

G2: 20 to 24.9 

G3: 25 to 29.9 

G4: 30 to 34.9 

G5: ≥ 35 

Group N: 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Inclusion criteria: 

• Singleton, term 

pregnancies 

• Information on 

maternal height, 

maternal weight in 

early pregnancy, and 

gestational weight 

gain 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• If unknown, standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20.0-24.9, 25.0-

29.9, 30-34.9, ≥ 35 

Age (mean, yrs): 

G1: 15 to 19 years: 3.8% 

20 to 24: 23.0% 

25 to 29: 38.7% 

30 to 34: 25.7% 

35 to 39: 7.7% 

≥ 40: 1.1% 

G2: 15 to 19 years: 1.9% 

20 to 24: 15.9% 

25 to 29: 37.7% 

30 to 34: 31.1% 

35 to 39: 11.3% 

≥ 40: 1.9% 

G3: 15 to 19 years: 1.5% 

20 to 24: 15.7% 

25 to 29: 36.1% 

30 to 34: 31.2% 

35 to 39: 12.9% 

≥ 40: 2.5% 

G4: 15 to 19 years: 1.5% 

20 to 24: 17.4% 

25 to 29: 35.6% 

30 to 34: 30.0% 

35 to 39: 13.0% 

≥ 40: 2.4% 

G5: 15 to 19 years: 1.1% 

20 to 24: 17.3% 

25 to 29: 38.0% 

30 to 34: 29.6% 

35 to 39: 11.7% 

≥ 40: 2.3% 

Race,%: 

White 

G1: 96.6 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 1.4 

G2: NR 

Other 

G1: 2.0 

G2: NR 

Smoking,%: 

G1: % nonsmoking: 81.6 

G2: 85.2 

G3: 83.1 

G4: 79.9 

G5: 78.4 

Group 6 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-353 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Total weight gain: 

G1: < 8kg: 6.9% 

8-15.9kg: 65.2% 

≥ 16kg: 28.0% 

G2: < 8kg: 8.4% 

8-15.9kg: 67.1% 

≥ 16kg: 30.4% 

G3: < 8kg: 15.7% 

8-15.9kg: 54.4% 

≥ 16kg: 29.9% 

G4: < 8kg: 30.2% 

8-15.9kg: 48.7% 

≥ 16kg: 21.1% 

G5: < 8kg: 44.6% 

8-15.9kg: 40.9% 

≥ 16kg

Categorized: 

• < 8kg, 8-16, > 16 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

maternal weights 

measured when 

woman attended 

delivery unit and 

maternal weight 

recorded at first 

visit to maternity 

health care 

center 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Odds ratios (95% CIs) for SGA (< 2 SD 

below the mean) 

Groups 

Weight gain < 8 kg 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

Weight gain > 16 kg 

G6: BMI < 20 

G7: BMI 20-24.9 

G8: BMI 25-29.9 

G9: BMI 30-34.9 

G10: BMI ≥ 35 

Weight gain 8-16 kg (Reference) 

Results 

G1: 2.35 (1.92-2.88) 

G2: 1.99 (1.77-2.23) 

G3: 1.75 (1.48-2.07) 

G4: 1.68 (1.26-2.25) 

G5: 1.71 (1.03-2.85) 

G6: 0.50 (0.41-0.61) 

G7: 0.50 (0.45-0.56) 

G8: 0.57 (0.47-0.68) 

G9: 0.61 (0.40-0.93) 

G10: 0.50 (0.20-1.24) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Parity 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Year of birth 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-354 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cheng et al., 2004 

Country and setting: 

Missouri - birth certificate 

data 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To estimate whether 

maternal weight changes 

between pregnancy 

influence risk for small for 

gestational age births 

Time frame: 

NR 

Duration of the study: 

1989 to 1997 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

• Cases: 6,973 (8,062 

used but percentages 

based on those with 

information) 

• Controls: 7,141 

(8,062 used but 

percentages based 

on those with 

information) 

Group Description: 

G1: Cases 

G2: Controls 

Group N: 

G1: 8,062 

G2: 8,062 

Inclusion criteria: 

• Second born infants: 

cases had second 

born SGA infants 

(less than the 10th 

percentile of birth 

weight) 

• Controls were 

randomly selected by 

year of birth from 

remaining cohort of 

mothers with 2 live 

births during study 

period 

Exclusion criteria: 

• Missing data 

Pregravid weight: 

• Self-reported 

• NR 

Pregravid BMI: 

G1: < 19.8: 26% 

19.8 to 26.0: 47% 

>26: 22% 

G2: < 19.8: 14% 

19.8 to 26.0: 51% 

>26: 30% 

Imputed: 

• No 

Categorized: 

IOM Guidelines 

Age (mean, yrs): 

G1: < 20: 15% 

20 to 34: 80% 

≥ 35: 5% 

G2: < 20: 10 % 

20 to 34: 83% 

≥ 35: 6% 

Parity: 

NR 

Race,%: 

White 

G1: 86 

G2: 85 

Black 

G1: 13 

G2: 13 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 40 

G2: 17 

Diabetes mellitus,%: 

G1: 2 

G2: 2 

Hypertension,%: 

NR 

Additional characteristics: 

% married:

G1: 67% 

G2: 77% 
C-355 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 8,062

G2: 8,062

Total weight gain: 

G1: < 0.2kg/wk: 17% 

≥ 0.2kg/wk: 78%

G2: < 0.2kg/wk: 11% 

≥ 0.2kg/wk: 86% 

P < 0.001 cases 

vs. controls

Categorized: 

Rate - kG/wk

Collected from: 

• Routine pre-natal 

care or maternity 

records 

• Birth certificate 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 2 

G2: 2 

Group 3Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• NA 

Other infant 

outcomes 

• NA 

Outcomes Description: 

Odds ratio (95% CI) for SGA by weight gain 

categories 

Groups 

SGA 

G1: WG < 0.2 kg/wk 

G2: WG ≥ 0.2 kg/wk (Reference) 

SGA for low weight gain (< 0.2 kg/wk) by BMI 

G1: Underweight 

G2: Normal weight 

G3: Overweight 

G4: Obese 

Results 

SGA 

G1: 1.9 (1.8-2.2) 

G2: 1.022% 

SGA by BMI 

G1: (1.2-2.4) 

G2: (1.9-2.7) 

G3: (1.6-2.9) 

G4: (1.4-2.1) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Maternal age, education, Medicaid status, 

pregravid BMI, smoking, previous SGA, 

adequacy of prenatal care, maternal cardiac 

disease, preeclampsia, year of birth of second 

infant 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Good 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 2 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-356 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cherry et al., 1993 

Country and setting: 

USA, hospital 

Enrollment Period:

NR 

Funding: 

NR 

Study Objective: 

NR-to examine effect of 

zinc on birth outcomes 

Time frame: 

NR 

Duration of the study: 

9 months-from time of 

enrollment in to prenatal 

care up to delivery 

Design: 

• RCT 

Total Study N: 

599 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 599 

G2: NR 

Inclusion criteria: 

• Adolescents in 

prenatal clinic at 

Charity Hospital of 

New Orleans 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Measured by study 

investigators 

G1: 53% were 90-110% 

Expected Weight (EW); 26% < 

90% EW; 21% were > 110% 

EW 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Calculated weight for age 

and height 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-357 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Grams gained 

per week per cm 

height 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Table 1 provided data 

above-LBW, wt for 

length of infant, % of 

infants in high risk 

nursery 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percentage SGA for each shifting of EW 

category. 

Groups 

Light:: < 90% EW 

Normal: 90 to 110% of EW 

Heavy: > 110% EW 

G1: Normal to Heavy 

G2: Light to Normal 

G3: Heavy to Heavy 

G4: Normal to Normal 

G5: Light to Light 

G6: Heavy to Normal 

G7: Normal to Light 

Results 

G1: 22% 

G2: 39% 

G3: 38% 

G4: 41% 

G5: 62% 

G6: 60% 

G7: 65% 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Poor 

Sample selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

1 Good, 3 Fair, 5 

Poor 

Final Quality 

Score: 

Poor 
C-358 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cnattingius et al., 1998 

Country and setting: 

Sweden, Medical birth 

register 

Enrollment Period:

1992-1993 

Funding: 

NR 

Study Objective: 

To examine effect of 

prepregnancy BMI on risk 

of late fetal death, early 

neonatal death, preterm 

delivery, and delivery of 

an infant who was SGA 

Time frame: 

1992-1993 

Duration of the study: 

Immediately after birth 

(from birth register) 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

167,750 

Group Description: 

G1: Total sample 

G2: NR 

Group N: 

G1: 167750 

G2: NR 

Inclusion criteria: 

• Singleton births 

• Registered on 

Swedish Birth 

Registry 

• Women with 

information on 

prepregnancy BMI 

info 

• Women born in 

Sweden, Denmark, 

Norway, Finland, or 

Iceland 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 20: 13.5% 

20-24.9: 60.4% 

25-29.9: 19.9% 

≥ 30: 6.2% 

G2: NR 

Imputed: 

• No 

Categorized: 

• < 20.0 

20-24.9 

25-29.9 

≥ 30.0 

Age (mean, yrs): 

G1: ≤ 19: 2.3% 

20-24: 20.3% 

25-29: 39.9% 

30-34: 25.9% 

≥ 35: 11.7% 

G2: NR 

Parity: 

G1: Nulliparous: 40.6% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: Nonsmoking: 77.4% 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-359 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 91,484 

G2: NR 

Total weight gain: 

G1: < 0.25 kg/wk: 

9.3%; 0.25-0.34 

kg/wk: 32.9%; 0.35-

0.44: 29.4%; ≥ 0.45: 

20.6%

G2: NR 

Categorized: 

• Rate: kg/wk 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

prepregnancy 

weight and 

weight at delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

• % late fetal 

death: 0.28% 

• % early noenatal 

death: 0.18% 

Outcomes Description: 

Odds ratios (95% CIs) for SGA 

Groups 

G1: WG < 0.25 kg/wk 

G2:WG 0.25-0.34 kg/wk 

G3: WG 0.35-0.44 kg/wk 

G4: ≥ 0.45 kg/wk (Reference) 

Results 

G1: 3.0 (2.5-3.5) 

G2: 1.9 (1.6-2.2) 

G3: 1.3 (1.1-1.5) 

G4: 1.0 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Height 

• Education 

• Mother living with father 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-360 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Dawes and Grudzinskas, 

1991 

Country and setting: 

UK, hospital 

Enrollment Period:

12 months 

Funding: 

Grant from Royal College 

of General Practitioners 

Study Objective: 

To examine patterns of 

maternal weight gain in 

relation to 

sociodemographic factors 

and pregnancy outcome 

Time frame: 

12 months 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

988 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 988 

G2: NR 

Inclusion criteria: 

• Alternate women who 

delivered at Radcliffe 

Hospital within 12 

month period 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Routine pre-natal 

careweight measured at 

first visit 

G1: 62.7 (11.15) 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 26.6 (5.1) 

G2: NR 

Parity: 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-361 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 988 

G2: NR 

Total weight gain: 

G1: 10.71 (4.3) 

average weekly 

weight gain: 0.38 

(0.16)

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3.32 (0.54) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Average weekly weight gain < 0.20 

kg as a predictor of SGA 

Groups 

G1: Sensitivity 

G2: Specificity 

Results 

G1: 12.9% 

G2: 91.3% 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

Maternal age, parity, pre-gravid 

BMI, weight, smoking 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 6 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-362 

 Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period:

July 1, 1985 - December 

31, 1985 (6 months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal weight 

or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to December 

31, 1985 (6 months) 

Duration of the study: 

Prepregnancy to delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at delivery

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or over 

ideal weight for 

height) or abnormal 

pregnancy weight 

gain (≥ 20kg or ≤ 5kg)

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under normal 

weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital within 

study period selected 

those with abnormal 

maternal 

prepregnancy weight 

or abnormal weight 

gain during 

pregnancy, as well as 

next mother in 

sequential order with 

normal prepregnancy 

weight and weight 

gain during 

pregnancy to serve 

as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if self 

reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over or 

under normal weight for 

height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 (1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-363 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared to 

controls

G2: 13.4 (4.5)

G3: 3.0 (3.5) 

P < 0.0005 compared 

to controls

G4: 23.2 (22.8) 

P < 0.0005 compared 

to controls

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥ 20kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared to 

controls 

G2: 3293 (362) 

P < 0.05 compared to 

controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 compared 

to controls 

G5: 3538 (535) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: Elective 7% 

Emergency 14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Infant birthweight by maternal weight gain group 

Groups 

Infant weight percentile for mothers with normal 

prepregnancy weight and normal weight gain 

G1: < 2.5% 

G2: 2.5-10% 

G3: 10-50% 

G4: 50-90% 

G5: 90-97.5% 

G6: > 97.5% 

Infant weight percentile for mothers with weight 

gain ≤5 kg 

G7: < 2.5% 

G8: 2.5-10% 

G9: 10-50% 

G10: 50-90% 

G11: 90-97.5% 

G12: > 97.5% 

Infant weight percentile for mothers with weight 

gain ≥20 kg 

G13: < 2.5% 

G14: 2.5-10% 

G15: 10-50% 

G16: 50-90% 

G17: 90-97.5% 

G18: > 97.5% 

Results 

G1: 1% 

G2: 6% 

G3: 35% 

G4: 43% 

G5: 13% 

G6: 2% 

 

G7: 3% 

G8: 14% 

G9: 32% 

G10: 34% 

G11: 14% 

G12: 3% 

G13: 0% 

G14: 2% 

G15: 42% 

G16: 29% 

G17: 20% 

G18: 7% 

Background: 

Fair 

Sample selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor

Final Quality Score: 

Poor 
C-364 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 (continued) 

 
C-365 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

 Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 
C-366 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jensen et al., 2005 

Country and setting: 

Denmark, university 

hospitals 

Enrollment Period:

Gestation through birth 

Funding: 

Many different funds 

Study Objective: 

To investigate effect of 

gestational weight gain in 

obese glucose tolerant 

women 

Time frame: 

Gestation through birth 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

481 

Group Description: 

G1: GWG < 5.0 kg 

G2: GWG 5.0-9.9kg 

G3: GWG 10.0-14.9 kg 

G4: GWG ≥ 15.0kg 

Group N: 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Inclusion criteria: 

• Prepregnancy BMI ≥

30 

• Normal 2h 75g oral 

glucose tolerance test 

(OGTT) during third 

trimester (according 

to WHO criteria) 

• Only first pregnancy 

during study period 

included 

Exclusion criteria: 

• Well defined chronic 

disease 

• Twin pregnancies 

• Women with GDM (n 

= 323) 

• Known diet treatment 

(n = 10) 

• Incomplete data on 

weight gain during 

pregnancy (n-153) 

Pregravid weight: 

• Records 

• Patient report of pregravid 

BMI 

Pregravid BMI: 

G1: 34.3 (32.2-39.9) 

G2: 33.9 (31.5-36.5) 

G3: 32.9 (31.2-35.6) 

G4: 32.7 (31.3-34.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.8 (26.4-33.1) 

G2: 29.1 (26.3-33.1) 

G3: 30.0 (26.6-33.2) 

G4: 27.9 (24.8-31.8) 

Parity: 

NR 

Race,%: 

White 

G1: 84.4 

G2: 85.8 

G3: 82.7 

G4: 89.9 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.7 

G2: 25.8 

G3: 30.2 

G4: 26.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-367 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 93 

G2: 134 

G3: 132 

G4: 122 

Total weight gain: 

Categorized: 

• < 5.0. 5.0-9.9, 

10.0-14.9, ≥ 15.0 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated by 

authors 

Birth weight: 

G1: 3500 (3200-3840)

G2: 3645 (3200-4000)

G3: 3750 (3390-4125)

G4: 3762 (3400-4120)

Gestational diabetes, 

%: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Rates of SGA by weight gain groups 

Groups 

G1: MWG < 5.0 kg (Reference) 

G2: MWG 5.0-9.9 kg 

G3: MWG 10.0-14.9 kg 

G4: MWG ≥ 15.0 kg 

Results 

No significant difference in rates of SGA by maternal 

weight gain group. Numerical results not reported in 

article 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Pregravid BMI 

• 2h OGTT result 

• Parity 

• Smoking 

• Ethnicity 

• Clinical Center 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection:

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 4 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-368 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabiru and Raynor, 2004 

Country and setting: 

USA, hospital 

Enrollment Period:

1999 to 2002 

Funding: 

NR 

Study Objective: 

To investigate effect of 

increase in body mass 

index category on 

obstetric outcomes 

Time frame: 

1999 to 2002 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5,131 

Group Description: 

G1: No change in BMI 

between first prenatal 

visit and delivery 

G2: 1 category increase in 

BMI between first 

prenatal visit and 

delivery 

G3: > 1 category increase 

in BMI between first 

prenatal visit and 

delivery 

Group N: 

G1: 2,556 

G2: 2,252 

G3: 323 

Inclusion criteria: 

• Singleton 

pregnancies 

Exclusion criteria: 

• Multiple pregnancies 

• BMI < 20 

• Missing BMI data 

Pregravid weight: 

• Measured at first prenatal 

visit 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• 20-24.9, 25-29.9, 30-34.9, 

35-39.9, ≥ 40 

Age (mean, yrs): 

G1: 24.7 (6.1) 

G2: 24.4 (5.7) 

G3: 25.2 (5.9) P < 0.001 

Parity: 

G1: Gravidity (mean): 1.9 (1.9)

G2: 1.5 (1.7) 

G3: 1.2 (1.7) P < 0.001 

Race,%: 

White 

G1: 1.9 

G2: 2.6 

G3: 2.8 

Black 

G1: 84.1 

G2: 82.8 

G3: 88.2 

Hispanic 

G1: 13.9 

G2: 14.6 

G3: 9.0 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean weight gain: 

G1: 8.6 pounds (8.4) 

G2: 22.2 pounds (10.2) 

G3: 55.3 pounds (23.8) 

Additional characteristics: 

NR 
C-369 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 579 

G2: 942 

G3: 189 

G4: 819 

G5: 790 

G6: 104 

Total weight gain: 

Categorized: 

• > 35 pounds for 

normal BMI, > 25 

pounds for 

overweight BMI, 

> 15 pounds for 

obese BMI 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not stated, most 

likely difference 

between weight 

at first prenatal 

visit and weight 

at delivery 

Birth weight: 

G1: 2886.0 (756) 

G2: 3174.9 (600) 

G3: 3099.5 (673) 

P < 0.001 

G4: 3116 (713) 

G5: 3269 (698) 

G6: 3371 (733) 

P = 0.015 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 8.2 

G2: 12.6 

G3: 21.0 P < 0.001 

G4: 13.0 

G5: 14.3 

G6: 19.3 P = 0.256 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percentage SGA by BMI category 

Groups 

G1: No change in BMI category 

G2: 1 category increase in BMI 

G3: > 1 category increase in BMI 

% SGA among overweight 

G4: No change in BMI category 

G5: 1 category increase in BMI 

G6: > 1 category increase in BMI 

Results 

G1: 19.5% 

G2: 13.5% 

G3: 9.5% 

G4: 14.2% 

G5: 9.9% 

G6: 11.5% 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

1 Good, 4 Fair, 4 

Poor 

Final Quality Score:

Poor 
C-370 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period:

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight change 

on pregnancy outcomes in 

obese women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) (n 

= 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 37 

or more weeks of 

gestation) liveborn, 

singleton infants 

during 1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-371 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 43% 

G3: GWG (lb)Less than 

2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, and 

greater than 35 lb 

gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, %:

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental delivery,%:

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Odds of SGA for weight gain groups 

Groups 

G1: Odds of SGA for weight gain > 25lbs 

G2: OR of SGA for weight gain < 15lbs 

G3: Reference Weight gain 15-25 lbs 

Results 

G1: lower for women in this group 

G2: higher for women in this group 

Numerical value for ORs not reported in study 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in Medicaid, WIC, food 

stamp programs) 

• Smoking 

• Chronic hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 6 Fair, 1 

Poor 

Final Quality Score:

Fair 
C-372 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued) 

 
C-373 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Other maternal outcomes:

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA 

by GWG category for 

each obesity class. All 

3 figures show similar 

patterns of increasing 

risk of preeclampsia, 

cesarean delivery, and 

LGA birth and 

decreasing risk of SGA 

birth with increasing 

GWG. Collectively, 

minimal risk for all 4 

outcomes corresponds 

to GWG categories 

where risk of LGA and 

SGA births intersect. 

This equates to GWG 

of 10 of 25 lb for class I 

obese women, a gain of 

0 tp 9 lb for class II 

obese women, and 

weight loss of 0 to 9 lb 

for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA 

by GWG category and 

obesity class. 

Compared with women 

who gained 15 to 25 lb 

during their 

pregnancies, those who 

gained less weight had 

significantly lower odds 

of preeclampsia, 

cesarean delivery, and 

LGA births, but higher 

odds for SGA births. 

Women who gained 

more than 25 lbs had 

higher odds for same 3 

pregnancy outcomes 

and lower odds for SGA 

births. 

Other infant outcomes: 

NR 
C-374 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kramer et al., 1990 

Country and setting: 

Canada, university 

hospital 

Enrollment Period:

1980 to 1986 

Funding: 

National Health Research 

and Development 

Program, Health and 

Welfare Canada 

Study Objective: 

(1) Which maternal and 

fetal variables appear to 

have independent causal 

impacts on intrauterine 

growth? (2) For a given 

fetal growth status, which 

maternal and fetal 

variables affect 

proportionality? 

Time frame: 

1980 to 1986 

Duration of the study: 

Entry in to prenatal care 

up to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

8,719 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 8715 

G2: NR 

Inclusion criteria: 

• Live-born, singleton 

infants without 

evidence of 

congenital 

intrauterine infection, 

chromosomal 

anomalies, or other 

major malformations 

and for whom 

gestational age 

calculated from last 

normal menstrual 

period agreed within 

±7 days with an early 

second-trimester 

(usually 16 to 18 

weeks) 

• Ultrasonographic 

estimate based on 

fetal biparietal 

diameter 

Exclusion criteria: 

• See above 

Pregravid weight: 

• Self-reportedNR 

G1: 57.8 kg (10.8) 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• They used prepregnancy 

wt and ht separately 

• NR 

Age (mean, yrs): 

G1: 28.6 (4.7) 

G2: NR 

Parity: 

G1: 0.72 (0.86) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

Cigarettes/d:

G1: 3.2 (7.5) 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

Pg related HTN:

G1: 7.7% 

G2: NR 

Additional characteristics: 

Education, y completed:

G1: 13.0 (3.3) 

G2: NR 

Marital status: 

G1: 90.6% 

G2: NR 

Parity % primaparas:

G1: 48.0 

G2: NR 
C-375 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 8715 

G2: NR 

Total weight gain: 

G1: 14.2kg (5.5)

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery, using 

net weight 

gain (total 

weight minus 

wt of infant) 

Birth weight: 

G1: 3385g (547) 

G2: NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Bivariate 

asssociations 

between selected 

maternal and fetal 

variables and fetal 

growth and 

proportionality: 

Correlation 

coefficient for net 

gestational weight 

gain (kg)and fetal 

growth ratio = 0.12 

(P < 0.001); for 

prepregnancy 

weight (kg) 0.21 (P 

< 0.001) 

Other infant 

outcomes: 

• Correlation 

coefficients for Net 

prepregnancy 

weight gain (kg) 

and length = -0.04 

(P < 0.01) 

• Head 

circumference = -

0.01 (NS); BMI 

0.04 (P < 0.001); 

Ponderal index = 

0.04 (P < 0.001) 

• Weight/height 

circumference = 

0.01 (NS) 

Outcomes Description: 

Odds ratio (95% CI) for SGA for weight gain 

groups 

Groups 

G1: OR and 95% CI, for SGA for each 5 kg 

decrease in net gestational WG 

Results 

G1: 1.32 (1.20-1.44) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Pregravid weight, infant sex, smoking, parity, 

maternal diabetes, height, previous LBW infant, 

severe pregnancy-induced hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Sex of the infant 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 Poor

Final Quality Score: 

Fair 
C-376 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lang et al., 1996 

Country and setting: 

USA, hospital 

Enrollment period: 

August 1977-March 1980 

Funding: 

NR 

Study Objective: 

To estimate effects of 23 

factors on prevalence of 

premature labor and fetal 

growth retardation across 

birthweight spectrum 

Time frame: 

August 1977 to March 

1980 

Duration of the study: 

Pregnancy through 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

11,505 

Group Description: 

G1: Prevalence of 

preterm labor 

G2: Prevalence of SGA 

Group N: 

Inclusion criteria: 

• Singleton 

• Livebirths 

• Had data on 

birthweight, 

gestational age, and 

sex 

• Infants with 

gestational age from 

22 to 45 weeks 

• Birthweights no more 

than 50% higher than 

90th percentile for 

sex and gestational 

age 

Exclusion criteria: 

• Women with 

menstrual 

abnormalities for 

whom gestational 

dating was 

problematic 

• Stillbirths 

• Incomplete data 

• Preterm delivery 

• Women with 

preexisting diabetes 

mellitus, 

hypertension, 

epilepsy, asthma 

Pregravid weight: 

• Not stated by authors 

G1: NR 

• < 100 pounds: 11.2 

• 100-125: 5.9 

• 126-160: 5.1 

• 161-180: 7.3 

• > 180: 4.4 

G2: NR 

• < 100 pounds: 24.9 

• 100-125: 12.6 

• 126-160: 7.7 

• 161-180: 6.5 

• > 180: 5.9 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 

• < 15: 14.8 

• 16-19: 11.2 

• 20-24: 8.2 

• 25-34: 4.6 

• ≥ 35: 5.5 

G2: 

• < 15: 25.0 

• 16-19: 17.6 

• 20-24: 14.3 

• 25-34: 9.4 

• ≥ 35: 7.2 

Parity: 

G1: 6.4 

G2: 12.3 

Race,%: 

White 

G1: 5.3 

G2: 9.1 

Black 

G1: 9.6 

G2: 17.7 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 5.0 

G2: 14.0 

Smoking,%: 

% smoked throughout 

pregnancy:

G1: 8.3 

G2: 17.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-377 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Weekly rate of 

weight gain 

Collected from: 

• Not stated by 

authors 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Odds ratios (95% CIs) for SGA be weight gain 

groups 

Groups 

G1: WG ≤ 0.40 lbs/wk 

G2: WG 0.40-0.65 lbs/wk 

G3: WG 0.65-0.90 lbs/wk (Reference) 

G4: WG > 0.90 lbs/wk 

Results 

G1: 2.8 (2.2-3.6) 

G2: 1.6 (1.4-1.9) 

G3: 1.0 (Reference) 

G4: 0.6 (0.5-0.7) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Maternal height 

• Prepregnancy weight 

• Maternal education 

• Health insurance 

• Planned pregnancy 

• Previous induced abortion 

• Previous spontaneous abortion 

• Previous still birth 

• Maternal morbidity 

• Caffeine intake 

• Marijuana 

• prenatal care 

• smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Infant sex 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 3 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-378 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Muscati et al., 1996 

Country and setting: 

Canada, public health 

department 

Enrollment Period:

1979 to 1989 

Funding: 

NR 

Study Objective: 

To examine association of 

extent and timing of 

pregnancy weight gain 

with infant birth weight 

and postpartum weight 

retention 

Time frame: 

1979 to 1989 

Duration of the study: 

Pregnancy through 6 

weeks postpartum 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

371 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 371 

G2: NR 

Inclusion criteria: 

• White, low income, 

non-smoking women 

• Pregnant women 

Exclusion criteria: 

• Prematurity < 37 

weeks 

• Adolescents < 16 

years 

• Women > 40 years 

• Maternal health 

problems 

• Women who 

consume alcohol or 

drugs 

• Pregnancy 

complications such 

as proteinuria, 

hypertension, 

diabetes, negative 

weight gain, missing 

values 

Pregravid weight: 

Family physicians’ records 

G1: 62.8 +/- 16.0 kg 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Pregravid weight status 

categorized into 3 groups 

as a percentage of 

standard weight: 

underweight < 90%, 

normal 90-120%, and 

overweight > 120% 

Age (mean, yrs): 

G1: 24.5 +/- 5.6 

G2: NR 

Parity: 

G1: Primiparous 52% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: PPWR: 5.3 +/- 5.7 kg 

G2: NR 

Additional characteristics: 

NR 
C-379 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 16.1 +/- 6.4 kg

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

From Table 1: 

Pearson’s Correlation 

Coefficient and 

determination coefficient 

of maternal weight gain 

with PP weight retention 

and Infant BW. Maternal 

PP weight retention and 

Preg weight gain: [Total 

amount r = 0.808, R 

square 65.3%, P < 

0.001], [Up to week 20 r 

= 0.682, R square 

46.5%, P < 0.001], 

[Weeks 21-30 r = 0.411, 

R square 16.9%, P < 

0.001], [Week 31 - term 

r = 0.414, R square 

17.1%, P < 0.001] 

Other infant 

outcomes: 

Pregnancy Weight Gain 

and Infant Birth Weight 

(from Table 1): [Total 

amount r = 0.216, R 

square 4.7%, P < 

0.001], [Up to week 20 r 

= 0.114, R-square 1.3%, 

P < 0.05], [Weeks 21-30 

r = 0.157, R square 

2.5%, 

P < 0.01], [Week 31 - 

term r = 0.160, R square 

2.6%, 

P < 0.01] 

Outcomes Description: 

Odds ratios for SGA by weight gain groups 

Groups 

G1: per 1 kg increase in WG up to week 20 

G2: per 1 kg increase in WG from weeks 21 to 

30 

G3: per 1 kg increase in WG from weeks 31 to 

term 

Results 

G1: 0.93 (P = NS) 

G2: 0.85 (P < 0.01) 

G3: 0.89 (P < 0.01) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Parity 

• Pregravid standard weight 

• Pregravid excess weight, 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Birth length 

• Infant sex 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-380 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Parker and Abrams, 1992 

Country and setting: 

USA, hospital 

Enrollment Period:

Sept 1980 to Dec 1988 

Funding: 

UC Committee on 

Research & MCH and 

Resources Development, 

Health Resources and 

Services Administration 

Study Objective: 

To test whether gains 

outside IOM reference 

ranges were associated 

with increased risks of 

suboptimal pregnancy 

outcome (SGA, LGA, 

cesarean delivery) and to 

determine whether locally 

developed ranges were 

more applicable to study 

population 

Time frame: 

Sept 1980 to Dec 1988 

Duration of the study: 

From entry into prenatal 

care until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

6,690 

Group Description: 

G1: Overall 

G2: NR 

Group N: 

G1: 6,690 

G2: NR 

Inclusion criteria: 

• Consecutive live 

singleton births at 

Moffitt Hospital 

between September 

1980 and December 

1988 with gestational 

ages of 37 to 42 

weeks 

Exclusion criteria: 

• Maternal transfers or 

transports and 

deliveries 

complicated by fetal 

malformations, 

maternal diabetes, or 

maternal 

hypertension 

Pregravid weight: 

• Self-reported 

G1: 56.8 kg(SD 11.0) 

G2: NR 

Pregravid BMI: 

G1: Underweight: 27.7%, 

Normal weight 61.8%, 

Overweight: 5.6%, 

Obese 4.9% 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 27.7 (5.5) 

G2: NR 

Parity: 

Primiparous:

G1: 58.8% 

G2: NR 

Race,%: 

White 

G1: 44.0 

G2: NR 

Black 

G1: 8.3 

G2: NR 

Hispanic 

G1: 9.4 

G2: NR 

Asian/Pacific Islander 

G1: 21.4 

G2: NR 

Other 

G1: 12.0 

G2: NR 

Smoking,%: 

G1: 12.0 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-381 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 6690 

G2: NR 

Total weight gain: 

G1: 15.2kg (5.2)

G2: NR 

Categorized: 

• According to IOM 

Weight gain 

ranges based on 

percentiles from 

previous study of 

UC population 

with good 

pregnancy 

outcomes: 25th -

75th, 10-90th 

percentiles. For 

25-75th, weight 

gain range = 12-

17kg for 

underweight 

women (BMI 

< 19.8); 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3408g (462) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratios (95% CIs) of SGA for low WG 

Groups 

G1: Compared to UCSF Cohort 25-75th

percentile of WG 

G2: Compared to UCSF 10-90th percentile of 

WG 

Results 

G1: 2.06 (1.62-2.63) 

G2: 1.82 (1.35-2.47)) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pregravid BMI 

• Height 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

3 Good, 5 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-382 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Steward and Moser, 2004 

Country and setting: 

USA, vital statistics data 

Enrollment Period:

1993 

Funding: 

Ohio State University 

Graduate School and 

College of Nursing 

Study Objective: 

To determine prevalence 

of IUGR in full term infants 

and to identify 

sociodemographic and 

maternal characteristics 

associated with IUGR 

Time frame: 

1993 

Duration of the study: 

Prenatal to birth 

Design: 

• Cross-sectional 

• Retrospective 

Total Study N: 

2,933 (from 14,463 births 

in county in 1993) 

Group Description: 

G1: Normal birth weight 

G2: IUGR 

Group N: 

G1: 1569 

G2: 1364 

Inclusion criteria: 

• Birth weight > 2500g 

• Reported gestational 

age ≥ 38 weeks 

• Singleton birth 

Exclusion criteria: 

• Chromosomal 

abnormality 

• Congenital anomaly 

Pregravid weight: 

• Birth statistics 

G1: 144.4 (33.3) 

G2: 134.4 (31.0) 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 27.0 (5.8) 

G2: 25.4 (5.9) 

Parity: 

NR 

Race,%: 

White 

G1: 77.9 

G2: 61.0 P < 0.001 

Black 

G1: 18.4 

G2: 33.7 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 3.6 

G2: 5.3 

Other 

NR 

Smoking,%: 

G1: 19.6 

G2: 34.5 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 1.7 

G2: 1.5 

Additional characteristics: 

Adequate PNC

G1: 53% 

G2: 45.9% (P < 0,001) 

Prev LBW 

G1: 0.7 

G2: 1.0 

Prenatal risk

G1: 24.4 

G2: 26.9 
C-383 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 32.3 pounds

G2: 29.2 P < 0.001

Categorized: 

• Continuous 

Collected from: 

• Self-reported 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Self-reported 

• Birth certificate 

data 

Birth weight: 

G1: 3484.9 (414.9) 

G2: 2781.4 (131.9) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

IUGR in full term 

newborn infants with 

birth weights > 

2500g 

Outcomes Description: 

Odds ratio (95% CI) for SGA 

Groups 

SGA defined as FGR < 0.85

Results 

G1: 0.98 (0.97-0.98) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Maternal education 

• Marital status 

• Prepregnancy weight 

• Adequacy of prenatal care 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 6 Fair, 2 

Poor 

Final Quality Score:

Fair 
C-384 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Takimoto et al., 2006 

Country and setting: 

Japan, obstetric units 

Enrollment Period:

2001 to 2002 

Funding: 

Ministry of Health, Labour, 

and Welfare, Health, and 

Labour Research Grant, 

Research on Children and 

Families 

Study Objective: 

To identify adequate 

weight gain ranges during 

pregnancy in Japanese 

women 

Time frame: 

2001 to 2002 

Duration of the study: 

Pregnancy through 

delivery (all info derived 

from delivery records) 

Design: 

• Cross-sectional 

Total Study N: 

112,257 

Group Description: 

G1: Study cohort 

G2: NR 

Group N: 

G1: 46,659 

G2: NR 

Inclusion criteria: 

• Vaginal birth 

• Singleton pregnancy 

• Low risk 

• Term 

Exclusion criteria: 

• Cesarean deliveries 

(n = 30,559) 

• Delivery method 

unknown (n = 2258) 

• Multiple gestations (n 

= 8387) 

• Preterm deliveries 

< 37 weeks 

(n = 19623) 

• Post-term deliveries > 

41 weeks (n = 623) 

• Stillbirths and 

neonatal deaths 

(n = 2558) 

• Maternal deaths 

(n = 11) 

• Congenital anomalies 

of the infant 

(n = 2449) 

Pregravid weight: 

• Taken from records not 

stated whether it was selfreported or measured 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 29.9 (4.8) 

G2: NR 

Parity: 

% primiparous:

G1: 53.5 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 6.3 

G2: NR 

Diabetes mellitus,%: 

G1: 1.2 

G2: NR 

Hypertension,%: 

G1: 2.0 

G2: NR 

Additional characteristics: 

NR 
C-385 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 46,659 

G2: NR 

Total weight gain: 

G1: 9.9 (4.3)

G2: NR 

Categorized: 

• Gestational age 

specific 

percentile values 

of weight gain: 

under the 25th, 

25th-49th, 50th74th, 75th-89th, 

≥ 90th 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

not stated 

Birth weight: 

G1: 2982 (472) 

G2: NR 

Gestational 

diabetes, %: 

G1: 1.2 

G2: NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Macrosomia 

• IUGR 

Outcomes Description: 

Odds ratios (95% CI) for SGA by weight gain 

groups 

Groups 

G1: Total MWG < 25th percentile for GA 

G2: Total MWG 25-49th percentile for GA 

G3: Total MWG 50-74th percentile for GA 

(Reference) 

G4: Total MWG 75-89th percentile for GA 

G5: Total MWG ≥90th percentile for GA 

Results 

G1: 2.87 (2.56-3.21) 

G2: 1.49 (1.35-1.66) 

G3: 1.0 

G4: 0.55 (0.55-0.72) 

G5: 0.45 (0.45-0.63) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-pregnancy weight 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 6 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-386 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wataba et al., 2006 

Country and setting: 

Japan, academic medical 

center 

Enrollment Period:

1981 to 1999 

Funding: 

NR 

Study Objective: 

To analyze association of 

pregnancy complications 

with prepregnant body 

mass index and weight 

gain during pregnancy in 

Japanese women 

Time frame: 

1981 to 1999 

Duration of the study: 

Entry into PNC up til 

delivery 

Design: 

• Perinatal data base 

and look at medical 

records 

retrospectively 

• Retrospective 

Total Study N: 

21,718 

Group Description: 

G1: Nulliparous 

G2: Parous women 

Group N: 

G1: 10413 

G2: 11305 

Inclusion criteria: 

• Singleton pregnancy 

delivering term baby 

at Osaka Med Center 

and Research 

Institute for Maternal 

and Child Health in 

19811999 

Exclusion criteria: 

• None reported 

Pregravid weight: 

• In data base but don’t 

know if self reported 

Pregravid BMI: 

G1: 20.5 (2.6) 

G2: 21.1 (3.0) 

Imputed: 

• No 

Categorized: 

• Categorical in 2 kg/m2 

point intervals from 

prepregnancy weight; 

categorical into low, 

medium, high BMI groups 

(< 18, 18-23.9, > 24) 

Age (mean, yrs): 

G1: 27.8 (4.1) 

G2: 30.45 (3.9) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-387 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 10413 

G2: 11305 

Total weight gain: 

G1: kg/wk: 0.25 (SD 

0.09)

G2: kg/wk: 0.24 

(0.09) P < 0.01

Categorized: 

• Categorical in 

kg/wk using 

prepregnancy 

weight and 

weight at delivery 

divided by 

gestational age 

of infant at birth 

Collected from: 

• Rate of weight 

gain determined 

by: total weight 

gain divided by 

weeks ga 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

and subtracting 

prepregnancy 

weight 

Birth weight: 

G1: SGA: 5.4% LGA 

5.2% 

G2: SGA 6.5% LGA 

5.2% 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratios (95% CIs) for SGA by weight gain 

categories 

Groups 

Parous, Low BMI (< 18) 

G1: WG < 0.15 kg/wk 

G2: WG 0.15-0.20 kg/wk 

G3: WG 0.20-0.25 kg/wk 

G4: WG 0.25-0.30 kg/wk (Reference 

Parous, Medium BMI (18-23.9) 

G5: WG < 0.15 kg/wk 

G6: WG 0.15-0.20 kg/wk 

G7: WG 0.20-0.25 kg/wk (Reference) 

Parous, High BMI (> 24) 

G8: WG < 0.15 kg/wk 

G9: WG 0.15-0.20 kg/wk (Reference) 

Nulliparous, Low BMI (< 18) 

G10: WG < 0.15 kg/wk 

G11: WG 0.15-0.20 kg/wk 

G12: WG 0.20-0.25 kg/wk 

G13: WG 0.25-0.30 kg/wk (Reference 

Nulliparous, Medium BMI (18-23.9) 

G14: WG < 0.15 kg/wk 

G15: WG 0.15-0.20 kg/wk 

G16: WG 0.20-0.25 kg/wk 

G17: WG 0.25-0.30 (Reference) 

Nulliparous, High BMI (> 24) 

G18: WG < 0.05 kg/wk 

G19: WG 0.15-0.20 kg/wk 

(Reference) 

Results 

G1: 5.42 (2.86-10.27) 

G2: 2.78 (1.53-5.06) 

G3: 1.39 (0.82-2.42) 

G4: 1.0 

G5: 2.21 (1.67-2.93) 

G6: 1.68 (1.23-2.07) 

G7: 1.0 

G8: 2.82 (1.17-6.78) 

G9: 1.0 

G10: 6.20 (2.72-14.09) 

G11: 2.58 (1.14-5.87) 

G12: 2.46 (1.19-5.08) 

G13: 1.0 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 4 Fair, 4 

Poor 

Final Quality 

Score: 

Poor 
C-388 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wataba et al., 2006 

(continued) 

 
C-389 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

 G14: 2.64 (1.88-3.71) 

G15: 1.60 (1.15-2.23) 

G16: 1.39 (1.03-1.87) 

G17: 1.0 

G18: 7.06 (2.11-23.61) 

G19: 1.0 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Preeclampsia, C-section 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

1-minute Apgar score < 4 
C-390 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wen et al., 1990 

Country and setting: 

USA, hospital 

Enrollment Period:

January 1983 to 

December 1987 

Funding: 

NIH contract N01-HD-4-

2811 

Study Objective: 

To determine effect of 

factors related to LBW on 

IUGR and preterm 

delivery 

Time frame: 

January 1983 to 

December 1987 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

17,149 

Group Description: 

G1: Total 

G2: IUGR 

G3: Preterm delivery 

Group N: 

G1: 100% 

G2: 7.4% 

G3: 12.6% 

Inclusion criteria: 

• Women seen for 

prenatal care and 

delivered of infants at 

study location 

Exclusion criteria: 

• Diabetes 

• Pregnancies involving 

multiple births 

• Fetal death 

• Congenital 

malformation 

Pregravid weight: 

• Routine pre-natal 

careweight at first prenatal 

visit was used 

G1: Prepregnancy weight (kg) 

< 50: 10.6%, 50-60: 

32.6%, 61-72: 28.7%, 73-

84: 14.5%, > 85: 13.6% 

G2: (Prepregnancy?) Maternal 

weight (kg) < 50: 12.9%, 

50-60: 8.5%, 61-72: 6.4%, 

73-84: 5.5%, > 85: 4.8% 

G3: (Prepregnancy?) Maternal 

wei 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: < 17: 7.5%, 

17-19: 22.7%, 

20-25: 43.1%, 

26-30: 17.5%, 

31-35: 7.0%, 

> 36: 2.3% 

G2: < 17: 8.0%, 

17-19: 6.6%, 

20-25: 7.4%, 

26-30: 7.6%, 

31-35: 8.2%, 

> 36: 8.6% 

G3: < 17: 15.4%, 

17-19: 13.0%, 

20-25: 11.6%, 

26-30: 12.9%, 

31-35: 14.3%, 

> 36: 13.4% 

Parity: 

G1: Parity 0: 44.1, 1: 29.9, > 1: 

26.0 

G2: Parity 0: 8.4, 1: 6.3, > 1: 

6.6 

G3: Parity 0: 12.5, 1: 12.3, > 1: 

12.8 

Race,%: 

White 

G1: 29.7 

G2: NR 

Black 

G1: 70.3 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.4 

G2: 10.3 

G3: 13.3 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Married: 38.0% 

G2: Married: 6.6% 

G3: Married: 10.6% 

Additional characteristics: 

Education: 

G1: < 12: 41.1%, 

12: 41.6%, 

> 12: 15.8% 

G2: < 12: 7.7%, 

12: 7.3%, 

> 12: 7.6% 

G3: < 12: 12.8%, 

12: 12.1%, 

> 12: 12.2% 

Additional characteristics: 

NR 
C-391 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: Weight 

gain/week (after 

the 20th week) in 

kg: 

< 0.24: 12.2%, 

0.24-0.57: 54.4%, 

0.58-0.74: 19.2%, 

≥ 0.75: 14.3% 

G2: Weight 

gain/week (after 

the 20th week) in 

kg: 

< 0.24: 9.9%, 

0.24-0.57: 7.9%, 

0.58-0.74: 5.2%, 

≥ 0.75: 5.7% 

G3: Weight gain/

Categorized: 

• Ave weight gain 

per week after 

20th week 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Maternal weight 

at delivery not 

available, so total 

weight gain not 

calculated 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratios for SGA by weight gain groups 

Groups 

G1: MWG < 0.24 kg/wk 

G2: MWG 0.24-0.57 kg/wk 

G3: MWG 0.58-0.74 kg/wk (Reference) 

G4: MWG ≥ 0.75 kg/wk 

Results 

G1: 2.24 (P < 0.05) 

G2: 1.55 (P < 0.05) 

G3: 1.0 

G4: 1.25 (NS) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Marital status 

• Eucation 

• Previous preterm delivery 

• Alcohol use 

• Drug use 

• Maternal height 

• Maternal weight 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Infant sex 

Background: 

Fair 

Sample selection: 

Poor 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-392 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Zhou and Olsen, 1997 

Country and setting: 

Denmark, two 

communities 

Enrollment Period:

April 1984 to April 1987 

Funding: 

Danish National Research 

Foundation and 

Sygekassernes Helsefond 

Study Objective: 

To study association 

between gestational 

weight gain and different 

birth weight indicators 

considering prepregnancy 

BMI 

Time frame: 

April 1984 to April 1987 

Duration of the study: 

Initiation of prenatal care 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

7122 

Group Description: 

G1: Entire study 

G2: NR 

Group N: 

G1: 7122 

G2: NR 

Inclusion criteria: 

• Women who provided 

detailed information 

on lifestyle during 

pregnancy 

• Singletons 

• Non-diabetic women 

who gave birth 

between weeks 37 

and 42 for whom 

weight gain was 

reported 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: % < 19.8: 27.2; %19.8-26: 

63.7; %26+: 9.1 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

% < 25:

G1: 30.3 

G2: NR 

Parity: 

%nulliparous:

G1: 48.9 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

%non-smoking:

G1: 60.0 

G2: NR 

Diabetes mellitus,%: 

G1: 0 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-393 

Evidence Table 22. Gestational weight gain and small-for-gestational age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 7122 

G2: NR 

Total weight gain: 

G1: % < 11kg: 35.2; 

%12-15: 35.5; 

%16+: 29.3 

G2: NR 

Categorized: 

• ≤ 11, 12-15, 

≥ 16 kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between last 

measured weight 

prior to delivery 

and 

prepregnancy 

weight 

Birth weight: 

G1: %LBW: 1.7; 

%normal: 96.8; 

%HBW: 1.5 

G2: NR 

Gestational 

diabetes, %: 

G1: 0 

G2: NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Low birth weight 

(< 2500g) 

• High birth weight 

(> 4500g) 

• Growth retarded 

were newborns 

with a birth 

weight below 

3000g in spite of 

a placenta 

weight higher 

than 66 

percentile (491g)

Outcomes Description: 

Percentage growth retardation (birth weight < 

3,000g and placental weight > 490g) by weight gain 

category and BMI 

Groups 

Weight gain < 11 kg 

G1: Underweight (Reference) 

G2: Normal 

G3: Overweight 

Weight gain 12-15 kg 

G4: Underweight 

G5: Normal 

G6: Overweight 

Weight gain > 16 kg 

G7: Underweight 

G8: Normal 

G9: Overweight 

Results 

G1: 1.0 

G2: 0.6 (0.4-0.8) 

G3: 0.6 (0.4-1.1) 

G4: 0.3 (0.2-0.5) 

G5: 0.4 (0.3-0.6) 

G6: 0.4 (0.1-1.0) 

G7: 0.3 (0.2-0.5) 

G8: 0.2 (0.1-0.3) 

G9: 0.2 (0.1-0.6) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Alcohol 

• Diabetes 

• Term delivery 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Infant sex 

Background: 

Fair 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor

Final Quality Score: 

Fair 
C-394 

Evidence Table 23. Gestational weight gain and Apgar Scores 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cedergren, 2006 

Country and setting: 

Sweden, Medical Birth 

Registry 

Enrollment Period: 

January 1, 1994 - 

December 31, 2002 

Funding: 

Ostergotland County 

Council 

Study Objective: 

To estimate effects of 

high and low gestational 

weight gain in different 

maternal BMI classes 

on obstetric and 

neonatal outcomes 

Time frame: 

January 1, 1994 to 

December 31, 2002 

Duration of the study: 

First visit to maternity 

health care center to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

245,526 

Group Description: 

BMI 

G1: < 20 

G2: 20 to 24.9 

G3: 25 to 29.9 

G4: 30 to 34.9 

G5: ≥ 35 

Group N: 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Inclusion criteria: 

• Singleton, term 

pregnancies 

• Information on 

maternal height, 

maternal weight in 

early pregnancy, 

and gestational 

weight gain 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• If unknown, 

standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20.0-24.9, 25.0-

29.9, 30-34.9, ≥ 35 

Age (mean, yrs): 

G1: 15 to 19 years: 3.8% 

20 to 24: 23.0% 

25 to 29: 38.7% 

30 to 34: 25.7% 

35 to 39: 7.7% 

≥ 40: 1.1% 

G2: 15 to 19 years: 1.9% 

20 to 24: 15.9% 

25 to 29: 37.7% 

30 to 34: 31.1% 

35 to 39: 11.3% 

≥ 40: 1.9% 

G3: 15 to 19 years: 1.5% 

20 to 24: 15.7% 

25 to 29: 36.1% 

30 to 34: 31.2% 

35 to 39: 12.9% 

≥ 40: 2.5% 

G4: 15 to 19 years: 1.5% 

20 to 24: 17.4% 

25 to 29: 35.6% 

30 to 34: 30.0% 

35 to 39: 13.0% 

≥ 40: 2.4% 

G5: 15 to 19 years: 1.1% 

20 to 24: 17.3% 

25 to 29: 38.0% 

30 to 34: 29.6% 

35 to 39: 11.7% 

≥ 40: 2.3% 

Race,%: 

White 

G1: 96.6 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 1.4 

G2: NR 

Other 

G1: 2.0 

G2: NR 

Smoking,%: 

G1: % nonsmoking: 81.6 

G2: 85.2 

G3: 83.1 

G4: 79.9 

G5: 78.4 

Group 6 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-395 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Total weight gain: 

G1: < 8kg: 6.9% 

8-15.9kg: 65.2% 

≥ 16kg: 28.0% 

G2: < 8kg: 8.4% 

8-15.9kg: 67.1% 

≥ 16kg: 30.4% 

G3: < 8kg: 15.7% 

8-15.9kg: 54.4% 

≥ 16kg: 29.9% 

G4: < 8kg: 30.2% 

8-15.9kg: 48.7% 

≥ 16kg: 21.1% 

G5: < 8kg: 44.6% 

8-15.9kg: 40.9% 

≥ 16kg 

Categorized: 

• < 8kg, 8-16, > 

16 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between 

maternal 

weights 

measured when 

woman attended 

delivery unit and 

maternal weight 

recorded at first 

visit to maternity 

health care 

center 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery, %: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Association of weight gain 

and Apgar scores 

Groups 

5 minute Apgar Score < 7 

Weight gain< 8 kg, 8-16 kg, 

and > 16 kg for each BMI 

class below 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

Results 

No association between 

low weight gain and Apgar 

score, despite BMI of 

mother 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• BMI 

• Age 

• Parity 

• Smoking in early 

pregnancy 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Year of birth 

Background: 

Fair 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-396 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

Country and setting: 

USA, prenatal clinics 

Enrollment Period: 

January 1, 1987- 

December 31, 1989 

Funding: 

NR 

Study Objective: 

To determine influences 

of increased maternal 

prepregnancy weight 

and increased 

gestational weight gain 

on pregnancy outcome 

Time frame: 

January 1, 1987 to 

December 31, 1989 

Duration of the study: 

Initiation of prenatal 

care to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,191 

Group Description: 

G1: BMI < 19.8 

G2: 19.8-26.0 

G3: 27-29 

G4: > 29 

G5: All 

Group N: 

G1: 755 

G2: 1,621 

G3: 329 

G4: 486 

G5: 3191 

Inclusion criteria: 

• Delivery at or 

beyond 38 weeks 

of gestation 

• Singletons 

• Received prenatal 

care and delivered 

in Shands Hospital 

Exclusion criteria: 

• Fetal abnormalities 

• Oligohydramnios 

• Polyhydramnios 

• Medical or surgical 

complications (GI 

disorders, sickle 

cell 

hemoglobinopathy, 

hepatitis, 

hematologic 

disorders, 

malignant disease, 

renal disease, 

neurologic disease, 

pulmonary disease, 

psychiatric 

disorders, 

tuberculosis) 

• Incomplete risk 

variable data or 

outcome variable 

information 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• National Academy of 

Sciences 

Age (mean, yrs): 

G1: NR 

• < 20 years: 36.6% 

• 20-26 years: 44.8% 

• > 26 years: 18.7% 

G2: NR 

• < 20 years: 30.8% 

• 20-26 years: 46.5% 

• > 26 years: 22.6% 

G3: 

• < 20 years: 25.8% 

• 20-26 years: 48.9% 

• > 26 years: 25.2% 

G4: 

• < 20 years: 16.5% 

• 20-26 years: 53.9% 

• > 26 years: 29.6% 

G5: 

• < 20 years: 29.5% 

• 20-26 years: 47.5 % 

• > 26 years: 23.0% 

Parity: 

G1: % first: 49.3 

G2: 43.1 

G3: 37.4 

G4: 31.1 

G5: 42.1 

Race,%: 

White 

G1: 64.5 

G2: 60.0 

G3: 49.8 

G4: 51.9 

G5: 58.7 

Black 

G1: 33.6 

G2: 37.9 

G3: 48.9 

G4: 47.5 

G5: 39.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 1.9 

G2: 2.1 

G3: 1.2 

G4: 0.6 

G5: 1.7 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Hypertension,%: 

G1: 3.4 

G2: 4.6 

G3: 5.8 

G4: 10.7 

G5: 5.4 

Additional characteristics: 

G1: % married: 42.6 

G2: 46.1 

G3: 40.4 

G4: 49.4 

G5: 45.2 

Additional characteristics: 

NR 
C-397 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 755 

G2: 1621 

G3: 329 

G4: 486 

G5: 3191 

Total weight gain: 

G1: 

• < 16kg: 7.8% 

• 16-25kg: 18.5% 

• 26-35kg: 35.1% 

• > 35kg: 38.5% 

G2: 

• < 16kg: 11.7% 

• 16-25kg: 18.0% 

• 26-35kg: 28.8% 

• > 35kg: 41.5% 

G3: 

• < 16kg: 19.8% 

• 16-25kg: 19.1% 

• 26-35kg: 28.3% 

• > 35kg: 32.8% 

G4: 

• < 16kg: 32.3% 

• 16-25kg: 22.0%; 

Categorized: 

• Quartiles 

• National Academy 

of Sciences 

(below, within, or 

above 

recommended 

range) 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between self 

report and weight 

at last prenatal 

visit (mean 6.1 

days prior to 

delivery) 

Birth weight: 

G1: 

• < 2500g: 4.8% 

• 2500-4000g: 

89.1% 

• > 4000g: 6.1% 

G2: 

• < 2500g: 2.0% 

• 2500-4000g: 

85.2% 

• > 4000g: 12.8% 

G3: 

• < 2500g: 1.5% 

• 2500-4000g: 

83.0% 

• > 4000g: 15.5% 

G4: 

• < 2500g: 0.2% 

• 2500-4000g: 

82.5% 

• > 4000g: 17.3% 

Gestational 

diabetes, %: 

G1: 1.9 

G2: 2.3 

G3: 6.1 

G4: 5.3 

G5: 3.1 

Cesarean 

delivery,%: 

G1: NR 

G2: NR 

G3: NR 

G4: NR 

G5: 11.9 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Frequency of 

macrosomia = 

12.2% 

• Frequency of 

cesarean = 

11.9% 

• Frequency of 

LBW = 2.9% 

Outcomes Description: 

Rate of 1-minute and 5-

minute Apgar Scores ≤ 7 

by weight gain categories 

Groups 

1-minute and 5-minute 

Apgar score ≤ 7 

G1: total weight gain < 16lb 

G2: total weight gain 16 - 

25lb 

G3: total weight gain 26-

35lb 

G4: total weight gain >35lb 

Results 

Increased OR for 

gestational weight gain, 

persists after adjusting (no 

further details provided) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Race 

• Parity 

• BMI category 

• GDM 

• Hypertension 

• Height (tertile) 

• Prepregnancy weight 

quartile 

• Other variables 

entered by stepwise 

regression model 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 9 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-398 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Johnson et al., 1992 

(continued)

 
C-399 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

• Frequency of postdate 

pregnancy = 9.8% 

• Frequency of labor 

abnormalities (40% 

were unscheduled 

cesareans) = 7.8% 

• Frequency of oxytocin 

induction = 13.7% 

• Frequency of oxytocin 

augmentation = 16.1% 

• Frequency of meconium 

staining = 21.5% 

Other infant outcomes: 

NA 
C-400 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nixon et al., 1998 

Country and setting: 

USA, county nursemidwifery services 

Enrollment Period: 

January 1991 to 

December 1994 

Funding: 

American College of 

Nurse Midwives 

Study Objective: 

To compare outcomes 

of term infants of 

average birth weight 

with outcomes of large 

infants using computer 

database 

Time frame: 

January 1991 to 

December 1994 

Duration of the study: 

First prenatal visit 

through birth collected 

retrospectively 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

2,228 

Group Description: 

G1: 2500 - 3999g 

G2: ≥ 4000g 

Group N: 

G1: 1906 

G2: 322 

Inclusion criteria: 

• Gestational age 

≥ 37 weeks 

• Birth weight 

≥ 2500g 

• Live infant at onset 

of labor 

• Birth occurred in 

hospital 

Exclusion criteria: 

• Women with 

gestational 

diabetes that 

required insulin 

therapy 

Pregravid weight: 

• Self-reported 

G1: 138 (31) 

G2: 158 (36) (P < 0.0001) 

Pregravid BMI: 

G1: 24 (5) 

G2: 26 (5.8) (P < 0.0001) 

Imputed: 

• No 

Categorized: 

• Continuous IOM 

guidelines 

Age (mean, yrs): 

G1: 25 (6) 

G2: 27.5 (6) (P < 0.0001) 

Parity: 

% parous:

G1: 56.3 

G2: 69.9 (P < 0.00001) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% shoulder dystocia:

G1: 0.6 

G2: 5.9 (P < 0.001) 

% NICU: 

G1: 4.3 

G2: 6.6 (P = ns) 
C-401 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 1906 

G2: 322 

Total weight gain: 

G1: 30.7+/-15 

G2: 37.2+/-15 

(P < 0.0001) 

Categorized: 

• Continuous 

According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Apgar scores 

Outcomes Description: 

Apgar scores less than 7 

Groups 

1-minute Apgar score < 7 

Continuous weight gain 

measure 

Results 

Gestational weight gain not 

a predictor of Apgar scores 

< 7 (details NR) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• BMI 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-402 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Wataba et al., 2006 

Country and setting: 

Japan, academic 

medical center 

Enrollment Period: 

1981 to 1999 

Funding: 

NR 

Study Objective: 

To analyze association 

of pregnancy 

complications with 

prepregnant body mass 

index and weight gain 

during pregnancy in 

Japanese women 

Time frame: 

1981 to 1999 

Duration of the study: 

Entry into PNC up til 

delivery 

Design: 

• Perinatal data base 

and look at medical 

records 

retrospectively 

• Retrospective 

Total Study N: 

21,718 

Group Description: 

G1: Nulliparous 

G2: Parous women 

Group N: 

G1: 10413 

G2: 11305 

Inclusion criteria: 

• Singleton 

pregnancy 

delivering term 

baby at Osaka Med 

Center and 

Research Institute 

for Maternal and 

Child Health in 

19811999 

Exclusion criteria: 

• None reported 

Pregravid weight: 

• In data base, on’t know 

if self reported 

Pregravid BMI: 

G1: 20.5 (2.6) 

G2: 21.1 (3.0) 

Imputed: 

• No 

Categorized: 

• Categorical in 2 kg/m2 

point intervals from 

prepregnancy weight; 

categorical into low, 

medium, high BMI 

groups (< 18, 18-23.9, > 

24) 

Age (mean, yrs): 

G1: 27.8 (4.1) 

G2: 30.45 (3.9) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-403 

Evidence Table 23. Gestational weight gain and Apgar Scores (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 10413 

G2: 11305 

Total weight gain: 

G1: kg/wk: 0.25 

(SD 0.09) 

G2: kg/wk: 0.24 

(0.09) P < 0.01 

Categorized: 

• Categorical in 

kg/wk using 

prepregnancy 

weight and 

weight at 

delivery divided 

by gestational 

age of infant at 

birth 

Collected from: 

• Rate of weight 

gain 

determined by: 

total weight 

gain divided by 

weeks ga 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: and 

subtracting 

prepregnancy 

weight 

Birth weight: 

G1: SGA: 5.4% 

LGA 5.2% 

G2: SGA 6.5% LGA 

5.2% 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Rate of 1 minute Apgar 

scores <4 by weight gain 

categories 

Groups 

1 minute Apgar score < 4 

Rate of weight gain, 

categorized differently 

across different BMI 

groups 

Results 

AOR for nulliparous 

women with low BMI with 

weekly weight gain of < 

15kg/wk versus women 

with weight gain of 0.25-

0.3kg/wk: 

12.24 (2.04 - 73.43) 

AOR for parous women 

with medium BMI, with 

weekly weight gain of 

0.35-0.4kg/wk versus 

women with weight gain 

0.2-0.25kg/wk: 

2.21 (1.08-4.53) 

No other relationships were 

significant 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Parity 

• Baseline BMI 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 4 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-404 

Evidence Table 24. Gestational weight gain and perinatal mortality 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bracero and Byrne, 

1997 

Country and setting: 

Hospital charts - 

Maimonides Medical 

Center, Brooklyn, NY 

Enrollment Period: 

Funding: 

NR 

Study Objective: 

To determine optimal 

weight gain in singleton 

pregnancy and evaluate 

current 

recommendations 

Time frame: 

Duration of the study: 

Jan 1, 1987 to Jan 1, 

1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20,971 

Group Description: 

G1: Total population 

G2: NR 

Group N: 

G1: 20,971 

G2: NR 

Inclusion criteria: 

• Delivery at 

Maimonides 

Medical Center 

• Singleton 

pregnancy 

• No documentation 

of congenital 

anomaly, 

pregnancy was not 

terminated by 

abortion 

• Documentation on 

chart of 

prepregnancy 

maternal weight, 

amount of maternal 

weight gain during 

pregnancy, and 

gender of infant 

Exclusion criteria: 

• Infants with any 

type of congenital 

anomaly 

(international 

classification of 

diseases (ICD-9-

CM) codes 740.0-

759.9 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: median BMI = 23.19 

(range 14.46-40.07) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: % < 15 years: < 0.1; 

15-19 yrs: 4.8; 

20-24: 25.1; 

25-29: 31.1; 

30-34: 24.3; 

35-39: 11.8; 

40-44: 2.8; 

45-49: 0.1; 

> 50: < 0.1 

G2: NR 

Parity: 

% primigravida:

G1: 25.1 

G2: NR 

Race,%: 

White 

G1: 92.1 

G2: NR 

Black 

G1: 4.2 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 0.9 

G2: NR 

Other 

G1: 2.1 

G2: NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% married:

G1: 12.4 

G2: NR 

Additional characteristics: 

Type of service:

G1: Ward, 22.5% 

Private: 77.5% 

G2: NR 

Additional characteristics: 

NR 
C-405 

Evidence Table 24. Gestational weight gain and perinatal mortality (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: % weight gain: lost 

weight, 0.4; 

1 to 5lbs, 0.9; 

6 to 10, 2.3; 

11 to 15, 5.4; 

16 to 20, 12.0; 

21 to 25, 17.2; 

26 to 30, 21.1; 

31 to 35, 14.8; 

36 to 40, 11.5; 

41 to 45, 6.1; 

≥ 46, 8.3 

G2: NR 

Categorized: 

• According to IOM 

ordinal categories 

in 5 pound 

intervals 

Collected from: 

• Routine prenatal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

using last 

measurement 

obtained as an 

outpatient 

Birth weight: 

G1: r = .210 

correlation with 

maternal weight 

gain 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery, %: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Optimal weight gain 

defined as 36 to 40 

pounds for 

underweight 

women, 31 to 40 

pounds for women 

of ideal 

prepregnancy 

weight, 26 to 30 

pounds for 

overweight women 

Other infant 

outcomes: 

Adverse outcomes: 

• Still birth 

• Neonatal death 

• Preterm 

delivery/low 

birth weight 

• Perinatal 

morbidity 

Outcomes Description: 

Perinatal mortality % 

Groups: 

G1: Suboptimal weight gain 

G2: Optimal weight gain 

Results: 

G1: 0.6 

G2: 0.2 

P < 0.0001 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NA 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NA 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on exposure, 

outcomes, and confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 8 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-406 

Evidence Table 24. Gestational weight gain and perinatal mortality (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Naeye, 1990 

Country and setting: 

USA, hospitals affiliated 

with medical schools 

Enrollment Period: 

1959 to 1966 

Funding: 

NR 

Study Objective: 

To evaluate relationship 

of maternal pregravid 

BMI to pregnancy 

outcome 

Time frame: 

1959 to 1966 

Duration of the study: 

First prenatal visit to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

56,857 

Group Description: 

G1: BMI < 20 

G2: BMI 20-24 

G3: BMI 25-30 

G4: BMI > 30 

Group N: 

G1: 12,669 

G2: 28,810 

G3: 10,160 

G4: 5,218 

Inclusion criteria: 

• Data from 

Collaborative 

Perinatal Study 

Exclusion criteria: 

• Deliveries taking 

place outside of 

CPS hospitals 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20-24, 25-30, > 30 

Age (mean, yrs): 

G1: 10-18: 19.3% 

35-50: 2.4% 

G2: 10-18: 17.8% 

35-50: 5.9% 

G3: 10-18: 9.8% 

35-50: 12.9% 

G4: 10-18: 7.8% 

35-50: 16.3% 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

G1: 34.7 

G2: 45.8 

G3: 55.3 

G4: 54.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 49.1 

G2: 44.9 

G3: 40.0 

G4: 39.8 

Diabetes mellitus,%: 

G1: (GDM and preexisting 

DM) 0.6 

G2: 1.0 

G3: 1.1 

G4: 5.0 

Hypertension,%: 

G1: 7.2 

G2: 7.4 

G3: 8.9 

G4: 8.8 

Additional characteristics: 

NR 
C-407 

Evidence Table 24. Gestational weight gain and perinatal mortality (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis 

Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Low weight 

gain defined as 

< 0.8 kg/month 

after first 

trimester 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational diabetes, 

%: 

G1: (GDM and 

preexisting DM) 0.6 

G2: 1.0 

G3: 1.1 

G4: 5.0 

Cesarean delivery,%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

% preterm births: BMI 

< 20: 20.8%, BMI 20-

24: 19.6% (P < 0.01 

compared to BMI < 

20), BMI 25-30: 22.5 

(P < 0.005 compared 

to BMI < 20), BMI > 

30: 30.7% (P < 0.001 

compared to BMI < 20) 

Outcomes Description: 

Attributable risk estimates for 

perinatal death for low 

pregnancy weight gain 

Groups: 

Low weight gain defined as < 

0.8 kg/week after the first 

trimester for pregravid BMI 

groups below: 

G1: BMI < 20 

G2: BMI 20-24 

G3: BMI 25-30 

G4: BMI > 30 

Results: 

G1: 0.03 (95% CI, 0.02-0.05) 

G2: 0.02 (95% CI, 0.01-0.03) 

G3: 0.01 (95% CI, 0.00-0.02) 

G4: 0.00 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 35-40 

• Diabetes mellitus 

• Hypertensive disorders 

• Black 

• Preterm birth 

• Major congenital 

malformations 

• Twins 

• Neonatal respiratory 

distress syndrome 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 2 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-408 

Evidence Table 24. Gestational weight gain and perinatal mortality (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nohr et al., 2005 

Country and setting: 

Denmark, National Birth 

Cohort 

Enrollment Period: 

May, 1998 to April, 2001 

Funding: 

NR 

Study Objective: 

To examine association 

between high 

prepregnancy BMI and 

fetal death, allowing for 

the effects of gestational 

age, weight gain, and 

maternal dieases in 

pregnancy 

Time frame: 

May, 1998 to April, 2001 

Duration of the study: 

Approximately 16 weeks 

gestational age through 

end of pregnancy 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

55432 

Group Description: 

G1: < 18.5 

G2: 18.5-24.9 

G3: 25-29.9 

G4: ≥ 30 

Group N: 

G1: 2458 

G2: 36986 

G3: 10650 

G4: 4411 

Inclusion criteria: 

• Women who had 

participated in first 

telephone interview 

Exclusion criteria: 

• Missing information 

on BMI (n = 886) 

• Missing information 

on gestational age 

(n = 30) 

• Termination of 

pregnancy after first 

telephone interview 

or at an estimated 

gestational age less 

than 28 days (n = 

11) 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: < 25 years: 19.0% 

25-29: 42.2% 

30-34: 29.5% 

≥ 35: 9.3% 

G2: < 25 years: 11.9% 

25-29: 41.2% 

30-34: 34.9% 

≥ 35: 12.0% 

G3: < 25 years: 13.9% 

25-29: 41.8% 

30-34: 33.3% 

≥ 35: 10.9% 

G4: < 25 years: 16.8% 

25-29: 40.9% 

30-34: 32.3% 

≥ 35: 10.0% 

Parity: 

G1: %primiparous: 46.8 

G2: 46.7 

G3: 43.6 

G4: 42.7 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: % non-smoking: 72.5 

G2: 84.1 

G3: 83.3 

G4: 82.1 

Diabetes mellitus,%: 

G1: 0.3 

G2: 0.6 

G3: 1.6 

G4: 5.0 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-409 

Evidence Table 24. Gestational weight gain and perinatal mortality (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 2,458 

G2: 36,986 

G3: 10,650 

G4: 4,411 

Total weight 

gain: 

G1: 459 g/wk 

G2: 487 g/wk 

G3: 462 g/wk 

G4: 347 g/wk 

Categorized: 

• Weight gain 

was defined 

as average 

weekly 

increase 

between self 

reported 

weights in 

first and 

second 

pregnancy 

interviews for 

women who 

provided a 

first interview 

between 9-

24 weeks, 

those who 

provided a 

second 

interview 

between 26 

and 38 

completed 

weeks of 

gestation, 

and those 

who had at 

least 6 

weeks 

between 2 

interviews 

Collected from: 

• Self-reported 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 0.3 

G2: 0.6 

G3: 1.6 

G4: 5.0 

Cesarean 

delivery,%: 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Adjusted odds ratio for perinatal 

mortality 

Groups: 

Weight per week for BMI groups: 

G1: Underweight <18.5 

G2: 18.5 ≤ normal weight < 25 

G3: 25 ≤ overweight < 30 

G4: Obese ≥ 30 

Results: 

Weight gain in pregnancy was not 

significantly associated with the 

risk of stillbirth for any BMI groups 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Age 

• Height 

• Parity 

• Socio-occupational status 

• Physical exercise 

• Smoking 

• Alcohol and coffee 

consumption 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 7 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-410 

Evidence Table 25. Gestational weight gain and neonatal distress 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cedergren, 2006 

Country and setting: 

Sweden, Medical Birth 

Registry 

Enrollment Period:

January 1, 1994 - 

December 31, 2002 

Funding: 

Ostergotland County 

Council 

Study Objective: 

To estimate effects of high 

and low gestational weight 

gain in different maternal 

BMI classes on obstetric 

and neonatal outcomes 

Time frame: 

January 1, 1994 to 

December 31, 2002 

Duration of the study: 

First visit to maternity 

health care center to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

245,526 

Group Description: 

BMI 

G1: < 20 

G2: 20 to 24.9 

G3: 25 to 29.9 

G4: 30 to 34.9 

G5: ≥ 35 

Group N: 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Inclusion criteria: 

• Singleton, term 

pregnancies 

• Information on 

maternal height, 

maternal weight in 

early pregnancy, and 

gestational weight 

gain 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

• If unknown, standardized 

measurement is made 

during first visit to 

maternity health care 

center 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20, 20.0-24.9, 25.0-

29.9, 30-34.9, ≥ 35 

Age (mean, yrs): 

G1: 15 to 19 years: 3.8% 

20 to 24: 23.0% 

25 to 29: 38.7% 

30 to 34: 25.7% 

35 to 39: 7.7% 

≥ 40: 1.1% 

G2: 15 to 19 years: 1.9% 

20 to 24: 15.9% 

25 to 29: 37.7% 

30 to 34: 31.1% 

35 to 39: 11.3% 

≥ 40: 1.9% 

G3: 15 to 19 years: 1.5% 

20 to 24: 15.7% 

25 to 29: 36.1% 

30 to 34: 31.2% 

35 to 39: 12.9% 

≥ 40: 2.5% 

G4: 15 to 19 years: 1.5% 

20 to 24: 17.4% 

25 to 29: 35.6% 

30 to 34: 30.0% 

35 to 39: 13.0% 

≥ 40: 2.4% 

G5: 15 to 19 years: 1.1% 

20 to 24: 17.3% 

25 to 29: 38.0% 

30 to 34: 29.6% 

35 to 39: 11.7% 

≥ 40: 2.3% 

Race,%: 

White 

G1: 96.6 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 1.4 

G2: NR 

Other 

G1: 2.0 

G2: NR 

Smoking,%: 

G1: % nonsmoking: 81.6 

G2: 85.2 

G3: 83.1 

G4: 79.9 

G5: 78.4 

Group 6 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-411 

Evidence Table 25. Gestational weight gain and neonatal distress (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28,186 

G2: 143,365 

G3: 60,626 

G4: 17,248 

G5: 6,296 

Total weight gain: 

G1: < 8kg: 6.9% 

8-15.9kg: 65.2% 

≥ 16kg: 28.0% 

G2: < 8kg: 8.4% 

8-15.9kg: 67.1% 

≥ 16kg: 30.4% 

G3: < 8kg: 15.7% 

8-15.9kg: 54.4% 

≥ 16kg: 29.9% 

G4: < 8kg: 30.2% 

8-15.9kg: 48.7% 

≥ 16kg: 21.1% 

G5: < 8kg: 44.6% 

8-15.9kg: 40.9% 

≥ 16kg

Categorized: 

• < 8kg, 8-16, > 16 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

maternal weights 

measured when 

woman attended 

delivery unit and 

maternal weight 

recorded at first 

visit to maternity 

health care 

center 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• AOR for fetal distress (95% CI) 

Groups 

GWG<8 g, 8-15.9 kg, ≥ 16kg for BMI groups (8.-

15.9 ref) 

G1: BMI < 20 

G2: BMI 20-24.9 

G3: BMI 25-29.9 

G4: BMI 30-34.9 

G5: BMI ≥ 35 

Results 

GWG<8kg 

G1: 1.05 (0.54-2.03) 

G2: 1.06 (0.81-1.40) 

G3: 0.96 (0.70-1.32) 

G4: 1.21 (0.79-1.85) 

G5: 0.59 (0.28-1.25) 

GWG≥ 16kg 

G1: 0.86 (0.57-1.29) 

G2: 1.08 (0.92-1.26) 

G3: 1.31 (1.05-1.53) 

G4: 1.02 (0.65-1.62) 

G5: 2.15 (1.10-4.20) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Year of birth 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

4 Good, 5 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-412 

Evidence Table 26. Gestational weight gain and neonatal hypoglycemia 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hedderson et al., 2006 

Country and setting: 

USA, Kaiser Permanente 

Medical Care Program 

Enrollment Period:

January 1, 1996 - June 

31, 1998 

Funding: 

R01 DK 54834 from 

National Institute of 

Diabetes and Digestive 

and Kidney Diseases, 

grant from American 

Diabetes Association and 

Kaiser Community Benefit 

research support 

Study Objective: 

To examine whether 

pregnancy weight gains 

outside IOM 

recommendations and 

rates of maternal weight 

gain are associated with 

neonatal complications 

Time frame: 

January 1, 1996 to June 

31, 1998 

Duration of the study: 

First prenatal care visit to 

30 days post delivery 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

45,245 

Group Description: 

G1: Controls 

G2: Macrosomia 

G3: Hypoglycemia 

G4: Hyperbilirubinemia 

Group N: 

G1: 652 

G2: 391 

G3: 328 

G4: 432 

Inclusion criteria: 

• Singleton livebirth 

Exclusion criteria: 

• No pregestational 

diabetes or history of 

gestational diabetes 

(screened at 24-28 

weeks gestation - 

meeting National 

Diabetes Data Group 

criteria for GDM) 

Pregravid weight: 

• Self-reported in some 

cases used measured 

weight recorded in chart 

closes to woman’s last 

menstrual period but no 

more than 12 months 

before her last menstrual 

period 

Pregravid BMI: 

G1: < 19.8: 13.5% 

19.8-24.9: 56.4% 

25.0-29.0: 12.4% 

> 29.0: 17.6% 

G2: < 19.8: 5.1% 

19.8-24.9: 51.2% 

25.0-29.0: 16.6% 

> 29.0: 27.1% 

G3: < 19.8: 10.1% 

19.8-24.9: 50.0% 

25.0-29.0: 17.1% 

> 29.0: 22.9% 

G4: < 19.8: 13.9% 

19.8-24.9: 57.9% 

25.0-29.0: 13.2% 

> 29.0: 57.1% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 25 years: 22.1% 

25-29: 24.2% 

30-34: 33.6% 

≥ 35: 20.1% 

G2: < 25 years: 15.9% 

25-29: 28.0% 

30-34: 31.7% 

≥ 35: 24.3% 

G3: < 25 years: 24.1% 

25-29: 25.3% 

30-34: 26.8% 

≥ 35: 23.8% 

G4: < 25 years: 17.1% 

25-29: 29.4% 

30-34: 32.6% 

≥ 35: 20.8% 

Parity: 

% primiparous:

G1: 56.9 

G2: 31.2 

G3: 50.0 

G4: 59.3 

Race,%: 

White 

G1: 54.0 

G2: 67.8 

G3: 47.6 

G4: 42.6 

Black 

G1: 10.0 

G2: 5.1 

G3: 11.3 

G4: 4.4 

Hispanic 

G1: 17.2 

G2: 15.1 

G3: 20.4 

G4: 15.5 

Asian/Pacific Islander 

G1: 8.1 

G2: 3.6 

G3: 6.7 

G4: 20.1 

Other 

G1: 10.7 

G2: 8.4 

G3: 14.0 

G4: 17.4 

Smoking,%: 

G1: %nonsmoking during 

pregnancy: 92.0; %smoked 

but quit: 4.2; %smoked 3.9 

G2: %nonsmoking during 

pregnancy: 90.8; %smoked 

but quit: 5.3; %smoked 4.0 

G3: %nonsmoking during 

pregnancy: 92.6; %smoked 

but quit: 1.5; %smoked 5.8 

G4: %nonsmoking during 

pregnancy: 94.2; %smoked 

but quit: 4.9; %smoked 1.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Screening glucose value less 

than 140:

G1: 85.0%: > 140: 15.0% 

G2: 81.6%: > 140: 18.4% 

G3: 81.4%: > 140: 18.6% 

G4: 83.3%: > 140: 16.7% 
C-413 

Evidence Table 26. Gestational weight gain and neonatal hypoglycemia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

recordsrate of 

maternal weight 

gain was 

calculated as 

total pregnancy 

weight gain 

minus infant birth 

weight divided by 

weeks of 

gestation when 

last weight was 

measured; rate 

of maternal 

weight gain 

before the third 

trimester was 

calculated using 

the weight 

measured at or 

before the 

screening test for 

GDM (24-28 wks 

of gestation) 

minus 

prepregnancy 

weight divided by 

weeks of 

gestation 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between final 

recorded weight 

at last prenatal 

visit (within 2 

weeks of delivery 

date) and 

prepregnancy 

weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• AOR for neonatal hypoglycemia (95% CI) 

Groups: 

G1: Rate of maternal weight gain (kg/wk): -0.26-

0.21 

G2: Rate of maternal weight gain (kg/wk): 0.22-

0.31

G3: Rate of maternal weight gain (kg/wk): 0.32-

0.39

G4: Rate of maternal weight gain (kg/wk): 0.40-

1.03

Results: 

G1: 0.87 (0.57-1.32) 

G2: 1.00 

G3: 0.74 (0.49-1.14) 

G4: 1.91 (1.33-2.82) 

Below IOM recommendations 

0.91 (0.59-1.41) 

Within IOM recommendations 

1.00 

Above IOM recommendations 

1.39 (1.02-1.90) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Screening glucose value from 1 hour after 

50g oral glucose challenge test 

• Difference between age at delivery and 

gestational age at last weight measured 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-414 

Evidence Table 26. Gestational weight gain and neonatal hypoglycemia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980 to 2001 

Funding: 

NR 

Study Objective: 

To examine relationship 

between gestational 

weight gain and adverse 

neonatal outcomes 

among infants born at 

term (37 weeks or more) 

Time frame: 

1980 to 2001 

Duration of the study: 

Entry into PN care up till 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20465 

Group Description: 

G1: Gain below IOM 

recommendations 

G2: Gain within IOM 

recommendations 

G3: Gain above IOM 

recommendations 

Group N: 

G1: 4,114 

G2: 7,490 

G3: 8,861 

Inclusion criteria: 

• Singleton 

Exclusion criteria: 

• Pregnancies 

complicated by 

multiple gestations, 

congenital anomalies, 

chronic hypertension, 

gestational or 

pregestational 

diabetes 

• Birth before 37 weeks

• Maternal transport 

• Missing data on any 

of variables 

considered in 

multivariable analysis

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 25.8% 

19.8-26.0: 19.4% 

26.1-29.0: 9.2% 

> 29.0: 20.6% 

G2: < 19.8: 49.1% 

19.8-26.0: 34.8% 

26.1-29.0: 23.3% 

> 29.0: 25.5% 

G3: < 19.8: 25.0% 

19.8-26.0: 45.8% 

26.1-29.0: 67.5% 

> 29.0: 53.9% 

P < 0.001 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20 years: 23.4% 

20-29 years: 19.3% 

30-39 years: 19.9% 

> 40 years: 25.3% 

G2: < 20 years: 31.3% 

20-29 years: 36.6% 

30-39 years: 37.6% 

> 40 years: 36.3% 

G3: < 20 years: 45.4% 

20-29 years: 44.0% 

30-39 years: 42.5% 

> 40 years: 38.4% 

P < 0.001 

Parity: 

% Nulliparous:

G1: 17.3 

G2: 36.2 

G3: 46.6 

P < 0.001 

Race,%: 

White 

G1: 16.2 

G2: 35.8 

G3: 48.0 

Black 

G1: 25.5 

G2: 29.4 

G3: 45.1 

Hispanic 

G1: 19.2 

G2: 34.8 

G3: 46.0 

Asian/Pacific Islander 

G1: 24.3 

G2: 43.3 

G3: 32.4 

Other 

G1: 21.7 

G2: 37.9 

G3: 40.4 

P for all race categories < 

0.001 

Smoking,%: 

G1: 23.5 

G2: 30.8 

G3: 45.8 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-415 

Evidence Table 26. Gestational weight gain and neonatal hypoglycemia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4114 

G2: 7490 

G3: 8861 

Total weight gain: 

Categorized: 

• According to 

IOMpercentiles 

and dichotomous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: %SGA: 36.1; 

%AGA: 20.2; 

%LGA: 8.5 

G2: %SGA: 39.4; 

%AGA: 37.5; 

%LGA: 26.5 

G3: %SGA: 24.5; 

%AGA: 42.4; 

%LGA: 65.1 

P < 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 14.7 

G2: 32.1 

G3: 53.2 

Instrumental 

delivery,%: 

Operative vaginal 

delivery:

G1: 18.0% 

G2: 37.5% 

G3: 44.5% 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Birth trauma 

• 5 min Apgar score 

less than 7 

• Assisted ventilation

• SGA 

• LGA 

• NICU admission 

• SCN admission 

• Neonatal infection 

• Seizure 

• Hypoglycemia 

• Polycythemia 

• MAS 

• RDS 

• Tachypnea 

• Hospital stay > 5 

days 

• Hospital stay > 10 

days 

Outcomes Description: 

AOR for neonatal hypoglycemia (95% CI) 

Groups: 

G1: GWG > 7 kg 

G2: GWG 11.5-16 kg 

G3: GWG >18 kg 

Results 

Hypoglycemia 

G1: 1.86 (0.91-3.81) 

G2: 1.0 

G3: 1.67 (1.13-2.46) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Date of delivery 

• Mode of delivery 

• Length of first stage of labor 

• Length of second stage of labor 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

• Gestational age 

Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

3 Good, 6 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-416 

Evidence Table 27. Gestational weight gain and hyperbilirubinemia 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hedderson et al., 2006 

Country and setting: 

USA, Kaiser Permanente 

Medical Care Program 

Enrollment Period:

January 1, 1996 - June 

31, 1998 

Funding: 

R01 DK 54834 from 

National Institute of 

Diabetes and Digestive 

and Kidney Diseases, 

grant from American 

Diabetes Association and 

Kaiser Community Benefit 

research support 

Study Objective: 

To examine whether 

pregnancy weight gains 

outside IOM 

recommendations and 

rates of maternal weight 

gain are associated with 

neonatal complications 

Time frame: 

January 1, 1996 to June 

31, 1998 

Duration of the study: 

First prenatal care visit to 

30 days post delivery 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

45,245 

Group Description: 

G1: Controls 

G2: Macrosomia 

G3: Hypoglycemia 

G4: Hyperbilirubinemia 

Group N: 

G1: 652 

G2: 391 

G3: 328 

G4: 432 

Inclusion criteria: 

• Singleton livebirth 

Exclusion criteria: 

• No pregestational 

diabetes or history of 

gestational diabetes 

(screened at 24-28 

weeks gestation - 

meeting National 

Diabetes Data Group 

criteria for GDM) 

Pregravid weight: 

• Self-reported in some 

cases used measured 

weight recorded in chart 

closes to woman’s last 

menstrual period but no 

more than 12 months 

before her last menstrual 

period 

Pregravid BMI: 

G1: < 19.8: 13.5% 

19.8-24.9: 56.4% 

25.0-29.0: 12.4% 

> 29.0: 17.6% 

G2: < 19.8: 5.1% 

19.8-24.9: 51.2% 

25.0-29.0: 16.6% 

> 29.0: 27.1% 

G3: < 19.8: 10.1% 

19.8-24.9: 50.0% 

25.0-29.0: 17.1% 

> 29.0: 22.9% 

G4: < 19.8: 13.9% 

19.8-24.9: 57.9% 

25.0-29.0: 13.2% 

> 29.0: 57.1% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 25 years: 22.1% 

25-29: 24.2% 

30-34: 33.6% 

≥ 35: 20.1% 

G2: < 25 years: 15.9% 

25-29: 28.0% 

30-34: 31.7% 

≥ 35: 24.3% 

G3: < 25 years: 24.1% 

25-29: 25.3% 

30-34: 26.8% 

≥ 35: 23.8% 

G4: < 25 years: 17.1% 

25-29: 29.4% 

30-34: 32.6% 

≥ 35: 20.8% 

Parity: 

% primiparous:

G1: 56.9 

G2: 31.2 

G3: 50.0 

G4: 59.3 

Race,%: 

White 

G1: 54.0 

G2: 67.8 

G3: 47.6 

G4: 42.6 

Black 

G1: 10.0 

G2: 5.1 

G3: 11.3 

G4: 4.4 

Hispanic 

G1: 17.2 

G2: 15.1 

G3: 20.4 

G4: 15.5 

Asian/Pacific Islander 

G1: 8.1 

G2: 3.6 

G3: 6.7 

G4: 20.1 

Other 

G1: 10.7 

G2: 8.4 

G3: 14.0 

G4: 17.4 

Smoking,%: 

G1: %nonsmoking during 

pregnancy: 92.0; %smoked 

but quit: 4.2; %smoked 3.9 

G2: %nonsmoking during 

pregnancy: 90.8; %smoked 

but quit: 5.3; %smoked 4.0 

G3: %nonsmoking during 

pregnancy: 92.6; %smoked 

but quit: 1.5; %smoked 5.8 

G4: %nonsmoking during 

pregnancy: 94.2; %smoked 

but quit: 4.9; %smoked 1.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Screening glucose value less 

than 140:

G1: 85.0%: > 140: 15.0% 

G2: 81.6%: > 140: 18.4% 

G3: 81.4%: > 140: 18.6% 

G4: 83.3%: > 140: 16.7% 
C-417 

Evidence Table 27. Gestational weight gain and hyperbilirubinemia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

recordsrate of 

maternal weight 

gain was 

calculated as 

total pregnancy 

weight gain 

minus infant birth 

weight divided by 

weeks of 

gestation when 

last weight was 

measured; rate 

of maternal 

weight gain 

before the third 

trimester was 

calculated using 

the weight 

measured at or 

before the 

screening test for 

GDM (24-28 wks 

of gestation) 

minus 

prepregnancy 

weight divided by 

weeks of 

gestation 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between final 

recorded weight 

at last prenatal 

visit (within 2 

weeks of delivery 

date) and 

prepregnancy 

weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• AOR for hyperbilirubinemia (95% CI) 

Groups: 

G1: Rate of maternal weight gain (kg/wk): -0.26-

0.21 

G2: Rate of maternal weight gain (kg/wk): 0.22-

0.31

G3: Rate of maternal weight gain (kg/wk): 0.32-

0.39

G4: Rate of maternal weight gain (kg/wk): 0.40-

1.03

Results: 

G1: 0.74 (0.49-1.11) 

G2: 1.00 

G3: 0.91 (0.62-1.34) 

G4: 1.58 (1.10-2.28) 

Below IOM recommendations 

0.98 (0.65-1.47) 

Within IOM recommendations 

1.00 

Above IOM recommendations 

1.43 (1.06-1.93) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Screening glucose value from 1 hour after 

50g oral glucose challenge test 

• Difference between age at delivery and 

gestational age at last weight measured 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 

 
C-418 

Evidence Table 28. Gestational weight gain and neonatal hospitalization 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Murakami et al., 2004 

Country and setting: 

Japan, hospital 

Enrollment Period:

2001 

Funding: 

NR 

Study Objective: 

To estimate risk of 

perinatal morbidity of 

mother and infant with 

respect to maternal 

prepregnancy BMI and 

weight gain in Japanese 

women 

Time frame: 

2001 

Duration of the study: 

Prenatal through birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

633 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 633 

G2: NR 

Inclusion criteria: 

• Live, singletons 

delivered between 24 

to 42 weeks gestation

Exclusion criteria: 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 20.9 (2.8) 

G2: NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 29.1 (4.5) 

G2: NR 

Parity: 

G1: 0.6 (0.7) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 8.5 

G2: NR 

Diabetes mellitus,%: 

G1: 2.1 

G2: NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Preeclampsia 

Mild: 5.4% 

Severe: 4.1% 

G2: NR 

Additional characteristics: 

NR 
C-419 

Evidence Table 28. Gestational weight gain and neonatal hospitalization (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 633 

G2: NR 

Total weight gain: 

G1: 10.5 (3.4)

G2: NR 

Categorized: 

• < 8.5kg, 8.5-

12.5, > 12.5 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

last 

measurement 

was taken at 

hospitalization 

prior to delivery 

Birth weight: 

G1: 3,052.6 (483.8) 

G2: NR 

Gestational 

diabetes, %: 

G1: 2.1 

G2: NR 

Cesarean 

delivery,%: 

G1: 10.3 

G2: NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Adjusted ORs of hospitalization of infant (95% CI) 

Groups: 

Gesational weight gain 

G1: < 8.5 kg 

G2: 8.5-12.5 kg 

G3: > 12.5 kg 

Hospitalization of infant 

G1: 1.60 (0.88-2.88) 

G2: 1.00 

G3: 0.93 (0.46-1.88) 

Outcomes Set 2: 

NR 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 8 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-420 

Evidence Table 29. Gestational weight gain and other infant morbidity 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Spector et al., 2007 

Country and setting: 

United States, hospital 

Enrollment period:

January 1, 1996 and 

August 20, 2002 

Funding: 

National Cancer Institute 

grant R01CA79940. 

University of Minnesota 

supported by Children’s 

Cancer Research Fund 

(Minneapolis, MN) and 

grants U10CA13539 and 

U10CA98543 

Study Objective: 

Report association 

between birth 

characteristics and 

maternal reproductive 

history with infant 

luekemia 

Time frame: 

January 1, 1996 and 

August 20, 2002 

Duration of the study: 

Entry to prenatal care until 

child's first birthday 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

495 

Group Description: 

G1: Cases 

G2: Controls 

G3: P value 

Group N: 

G1: 240 

G2: 255 

Inclusion criteria: 

• Infants diagnosed 

with leukemia at < 1 

year of age. 

Exclusion criteria: 

• No telephone 

• Down syndrome 

• Biological mother not 

available for interview 

in English 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 25.2 (5.07) 

G2: 25.1 (5.52) 

G3: 0.83 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 29 (5.54) 

G2: 30 (5.58) 

G3: 0.06 

Parity: 

NR 

Race,%: 

White 

G1: 79.5 

G2: 85.5 

G3: 0.003 

Black 

G1: 2.1 

G2: 5.5 

Hispanic 

G1: 10.5 

G2: 3.5 

Asian/Pacific Islander 

G1: 8.0 

G2: 5.5 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-421 

Evidence Table 29. Gestational weight gain and other infant morbidity (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 240 

G2: 255 

Total weight gain: 

G1: 15.3 (7.52)

G2: 14.6 (7.62)

G3: 0.31 

Categorized: 

• Quartiles 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Finally, no 

observation 

observed 

between infant 

leukemia and 

maternal 

prepregnancy 

• BMI or weight 

gain during 

pregnancy 

Other infant 

outcomes: 

NR 

Outcomes Description: 

AORs for acute lymphoblastic 

leukemia (95% CI) 

Groups: 

G1: GWG≤ 9.07 kg 

G2: GWG 9.53-13.61 kg 

G3: GWG: 13.61-18.14 kg 

G4: GWG: > 18.14 kg 

Results: 

G1: 1.0 

G2: 1.16 (0.68-1.99) 

G3: 1.25 (0.71-2.21) 

G4: 1.50 (0.84-2.68) 

P for trend=0.23 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Maternal education 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 7 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-422 

Evidence Table 29. Gestational weight gain and other infant morbidity (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980 to 2001 

Funding: 

NR 

Study Objective: 

To examine relationship 

between gestational 

weight gain and adverse 

neonatal outcomes 

among infants born at 

term (37 weeks or more) 

Time frame: 

1980 to 2001 

Duration of the study: 

Entry into PN care up till 

delivery 

Quality: 

Fair 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20465 

Group Description: 

G1: Gain below IOM 

recommendations 

G2: Gain within IOM 

recommendations 

G3: Gain above IOM 

recommendations 

Group N: 

G1: 4,114 

G2: 7,490 

G3: 8,861 

Inclusion criteria: 

• Singleton 

Exclusion criteria: 

• Pregnancies 

complicated by 

multiple gestations, 

congenital anomalies, 

chronic hypertension, 

gestational or 

pregestational 

diabetes 

• Birth before 37 weeks

• Maternal transport 

• Missing data on any 

of variables 

considered in 

multivariable analysis

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 25.8% 

19.8-26.0: 19.4% 

26.1-29.0: 9.2% 

> 29.0: 20.6% 

G2: < 19.8: 49.1% 

19.8-26.0: 34.8% 

26.1-29.0: 23.3% 

> 29.0: 25.5% 

G3: < 19.8: 25.0% 

19.8-26.0: 45.8% 

26.1-29.0: 67.5% 

> 29.0: 53.9% 

P < 0.001 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20 years: 23.4% 

20-29 years: 19.3% 

30-39 years: 19.9% 

> 40 years: 25.3% 

G2: < 20 years: 31.3% 

20-29 years: 36.6% 

30-39 years: 37.6% 

> 40 years: 36.3% 

G3: < 20 years: 45.4% 

20-29 years: 44.0% 

30-39 years: 42.5% 

> 40 years: 38.4% 

P < 0.001 

Parity: 

% Nulliparous:

G1: 17.3 

G2: 36.2 

G3: 46.6 

P < 0.001 

Race,%: 

White 

G1: 16.2 

G2: 35.8 

G3: 48.0 

Black 

G1: 25.5 

G2: 29.4 

G3: 45.1 

Hispanic 

G1: 19.2 

G2: 34.8 

G3: 46.0 

Asian/Pacific Islander 

G1: 24.3 

G2: 43.3 

G3: 32.4 

Other 

G1: 21.7 

G2: 37.9 

G3: 40.4 

P for all race categories < 

0.001 

Smoking,%: 

G1: 23.5 

G2: 30.8 

G3: 45.8 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-423 

Evidence Table 29. Gestational weight gain and other infant morbidity (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4114 

G2: 7490 

G3: 8861 

Total weight gain: 

Categorized: 

• According to 

IOMpercentiles 

and dichotomous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: %SGA: 36.1; 

%AGA: 20.2; 

%LGA: 8.5 

G2: %SGA: 39.4; 

%AGA: 37.5; 

%LGA: 26.5 

G3: %SGA: 24.5; 

%AGA: 42.4; 

%LGA: 65.1 

P < 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 14.7 

G2: 32.1 

G3: 53.2 

Instrumental 

delivery,%: 

Operative vaginal 

delivery:

G1: 18.0% 

G2: 37.5% 

G3: 44.5% 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Birth trauma 

• 5 min Apgar score 

less than 7 

• , Aassisted 

ventilation 

• SGA 

• LGA 

• NICU admission 

• SCN admission 

• Neonatal infection 

• Seizure 

• Hypoglycemia 

• Polycythemia 

• MAS 

• RDS 

• Tachypnea 

• Hospital stay > 5 

days 

• Hospital stay > 10 

days 

Outcomes Description: 

AOR for morbidity (95% CI) 

Groups: 

G1: GWG > 7 kg 

G2: GWG 11.5-16 kg 

G3: GWG >18 kg 

Results 

Seizure 

G1: 10.66 (2.17-52.36) 

G3: 6.19 (1.32-28.96) 

Polycythemia 

G1: 1.32 (0.66-2.62) 

G3: 1.59 (1.13-2.22) 

MAS (meconium aspiration syndrome)/ RDS 

(respiratory distress syndrome) or tachypnea 

G1: 1.93 (0.82-4.53) 

G3: 1.86 (1.13-3.05) 

RDS (respiratory distress syndrome) or tachypnea 

G1: 0.56 (0.29-1.06) 

G3: 1.04 (0.79-1.38) 

Hospital stay more than 5 days/ Hospital stay more 

than 10 days 

G1: 1.44 (1.02-2.04) 

G3: 1.07 (0.90-1.28) 

Hospital stay more than 10 days 

G1: 1.13 (0.51-2.53) 

G3: 1.22 (0.81-1.84) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Date of delivery 

• Mode of delivery 

• Length of first stage of labor 

• Length of second stage of labor 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Gestational age 

Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

3 Good, 6 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-424 

Evidence Table 30. Gestational weight gain and infant BMI 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kramer et al., 1990 

Country and setting: 

Canada, university 

hospital 

Enrollment Period:

1980 to 1986 

Funding: 

National Health Research 

and Development 

Program, Health and 

Welfare Canada 

Study Objective: 

(1) Which maternal and 

fetal variables appear to 

have independent causal 

impacts on intrauterine 

growth? (2) For a given 

fetal growth status, which 

maternal and fetal 

variables affect 

proportionality? 

Time frame: 

1980 to 1986 

Duration of the study: 

Entry in to prenatal care 

up to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

8,719 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 8715 

G2: NR 

Inclusion criteria: 

• Live-born, singleton 

infants without 

evidence of 

congenital 

intrauterine infection, 

chromosomal 

anomalies, or other 

major malformations 

and for whom 

gestational age 

calculated from last 

normal menstrual 

period agreed within 

±7 days with an early 

second-trimester 

(usually 16 to 18 

weeks) 

• Ultrasonographic 

estimate based on 

fetal biparietal 

diameter 

Exclusion criteria: 

• See above 

Pregravid weight: 

• Self-reportedNR 

G1: 57.8 kg (10.8) 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• They used prepregnancy 

wt and ht separately 

• NR 

Age (mean, yrs): 

G1: 28.6 (4.7) 

G2: NR 

Parity: 

G1: 0.72 (0.86) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

Cigarettes/d:

G1: 3.2 (7.5) 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

Pg related HTN:

G1: 7.7% 

G2: NR 

Additional characteristics: 

Education, y completed:

G1: 13.0 (3.3) 

G2: NR 

Marital status: 

G1: 90.6% 

G2: NR 

Parity % primaparas:

G1: 48.0 

G2: NR 
C-425 

Evidence Table 30. Gestational weight gain and infant BMI (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 8715 

G2: NR 

Total weight gain: 

G1: 14.2kg (5.5)

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery, using 

net weight gain 

(total weight 

minus wt of 

infant) 

Birth weight: 

G1: 3385g (547) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Bivariate 

asssociations 

between selected 

maternal and 

fetal variables 

and fetal growth 

and 

proportionality: 

Correlation 

coefficient for net 

gestational 

weight gain 

(kg)and fetal 

growth ratio = 

0.12 (P < 0.001); 

for prepregnancy 

weight (kg) 0.21 

(P < 0.001) 

Other infant 

outcomes: 

• Correlation 

coefficients for 

Net 

prepregnancy 

weight gain (kg) 

and length = -

0.04 (P < 0.01) 

• Head 

circumference = 

-0.01 (NS); BMI 

0.04 (P < 0.001); 

Ponderal index = 

0.04 (P < 0.001) 

• Weight/height 

circumference = 

0.01 (NS) 

Outcomes Description: 

• Infant BMI (kg/m2

) 

Groups: 

NA, net gestational weight (total 

weight gain minus weight of 

infant) as continuous variable 

Results: 

Correlation of net gestational 

weight gain with infant BMI 

R=0.037, P<0.01 

Net gestational weight gain did 

not meet criterion threshold for 

stepwise regression 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• NA 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• NA 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 5 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-426 

Evidence Table 30. Gestational weight gain and infant BMI (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Vohr et. al, 

1995 

Country and setting: 

USA, hospital 

Enrollment period: 

Funding: 

National Institute of Child 

Health and Human 

Development Grant 2P50-

HD11343 

Study Objective: 

To determine effects of 

maternal factors, including 

prepregnancy maternal 

adiposity, weight gain 

during pregnancy, degree 

of abnormality of oral 

glucose tolerance test, 

glycemia during 

pregnancy, and treatment 

with insulin vs. diet 

therapy, on neonatal body 

weight, adiposity, and 

blood pressure on IGDM 

and control infants 

Time frame: 

NR 

Duration of the study: 

21 months 

Design: 

• Case-control 

• Prospective 

Total Study N: 

262 

Group Description: 

G1: Controls - LGA 

G2: Controls - AGA 

G3: GDM mothers- LGA 

G4: GDM mothers - AGA 

Group 5Group 6 

Group N: 

G1: 74 

G2: 69 

G3: 57 

G4: 62 

Group 5Group 6 

Inclusion criteria: 

• GDM criteria based 

on screen at 24-28 

weeks of gestation. 

Women were 

diagnosed with GDM 

if an initial 1-hour 50 -

g glucose screen 

value > 130 mg/dl 

followed by two 

abnormal values in a 

100-g oral glucose 

tolerance test. An 

equal number of 

infants were selected 

based on mother's 

GDM status and 

LGA/AGA status at 

birth. All mothers of 

LGA babies were 

recruited for 

participation, and 

both GDM and 

control mothers of 

AGA infants were 

approached at 

random 

Exclusion criteria: 

• Infants with 

anomalies or 

requiring intensive 

care 

Pregravid weight: 

Self-reported 

G1: 67 kg (14) 

G2: 61 kg (12) 

G3: 71 kg (17) 

G4: 71 kg (18) 

Pregravid BMI: 

G1: 25 (5) 

G2: 23 (4) 

G3: 27 (6) 

G4: 28 (7) 

Imputed: 

No 

Categorized: 

Continuous 

Age (mean, yrs): 

G1: 29 (5) 

G2: 27 (6) 

G3: 30 (6) 

G4: 31 (5) 

Parity: 

NR 

Race,%: 

Black 

G1: 5.7% of total study 

population 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 
C-427 

Evidence Table 30. Gestational weight gain and infant BMI (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 74 

G2: 69 

G3: 57 

G4: 62 

Total weight gain: 

G1: 18 kg (7) 

P < 0.05 

G2: 15 kg (6) 

G3: 15 kg (7) 

P < 0.05 

G4: 11 kg (7) 

P < 0.05 

Categorized: 

• Continuous 

Collected from: 

• Does not state 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• Infant BMI (kg/m2

) 

Groups: 

Weight gain as a continuous 

variable for 

G1: GDM mothers 

G2: Control mothers 

Results: 

Estimates of 1-kg increase in 

gestational weight on infant BMI 

G1: 0.06, P=0.001 

G2: 0.05, P=0.003 

Correlation between weight gain 

and infant BMI overall: .022, 

P=0.01 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• NR 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-428 

Evidence Table 31. Gestational weight gain and other infant growth characteristics 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Brown et al., 2002 

Country and setting: 

USA, primary care clinics 

Enrollment Period:

1989 to 1993 

Funding: 

NIH 

Study Objective: 

To identify effects of 

maternal weight change 

by trimester of pregnancy 

on weight, length, head 

circumference, and 

ponderal index (PI; in 

kg/m3) of newborns 

Time frame: 

1989 - 1993 

Duration of the study: 

From preconception or 

entry into prenatal care 

through 6 to 8 weeks 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

389 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 389 

G2: NR 

Inclusion criteria: 

• Women aged 22-35 

years enrolled in 

Group Health 

managed care 

organization 

• Intended to become 

pg within enrollment 

period 

• Had not been 

attempting pg for > 3 

mo 

• Had delivered last 

infant > 12 mo before 

enrollment 

• Did not intend to use 

contraceptives during 

study 

• Delivery of live, 

singleton infants 

• Pg lasting > 241 days 

from conception 

Exclusion criteria: 

• History of 

hypertension, renal 

disease, DM, heart 

disease, infertility 

• No data on 

preconceptional 

weight and height 

within 6 months of 

conception or 2 

weeks after 

conception 

• Missing data on 

weight with 25 days 

of end of each 

trimester 

Pregravid weight: 

• Measured by study 

investigators 

• Weight was measured < 6 

months before conception 

for 364 women by study 

investigators 

G1: 61.2 ± 9.4 (50.7, 73.2) 

G2: NR 

Pregravid BMI: 

G1: 22.5 ± 3.2 (19.2, 26.9) 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.4 ± 3.1 (25.3, 33.7) 

G2: NR 

Parity: 

G1: 0.5 ± 0.7 (0, 1) 

G2: NR 

Race,%: 

White 

G1: 97 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-429 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 389 

G2: NR 

Total weight gain: 

G1: 15.6 ± 4.1 

(10.5–21.4)2

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigatorsRout

ine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3575g ± 448 

(3033–4167) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

Although 

nonsignificant, a 

trend was noted that 

suggested, among 

women with lower 

preconception weight, 

an increased effect of 

first-trimester weight 

gain on weight of 

their newborns (51 kg 

preconception weight, 

51 g/kg weight gain; 

62 kg preconce 

Outcomes Description: 

• Ponderal index, beta coefficients 

Groups: 

G1: Increase in Ponderal Index per 1 kg 

increase in first trimester weight gain 

G2: Increase in Ponderal Index per 1 kg 

increase in second trimester weight gain 

G3: Increase in Ponderal Index per 1 kg 

increase in third trimester weight gain 

Results: 

G1: β = 0.21 

(P < 0.0003) 

G2: β = 0.05 PI 

(P < 0.4) 

G3: β = 0.12 

(P < 0.03) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Mother’s height 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Sex (female) 

Background: 

Good 

Sample selection: 

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

8 Good, 1 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-430 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ekblad and Grenman, 

1992 

Country and setting: 

Finland, hospital 

Enrollment Period:

July 1, 1985 - December 

31, 1985 (6 months) 

Funding: 

NR 

Study Objective: 

To evaluate effects of 

abnormal maternal weight 

or weight gain on 

pregnancy outcome 

Time frame: 

July 1, 1985 to December 

31, 1985 (6 months) 

Duration of the study: 

Prepregnancy to delivery 

Design: 

• Cohort 

• Combination: 

retrospective data 

from records, 

prospective weight 

and height at delivery

Total Study N: 

Total n = 357 

• 191 women with 

abnormal 

prepregnant weight 

(≥ 20% under or over 

ideal weight for 

height) or abnormal 

pregnancy weight 

gain (≥ 20kg or ≤ 5kg)

• 166 controls 

Group Description: 

G1: ≥ 20% over normal 

weight for height 

G2: ≥ 20% under normal 

weight for height 

G3: weight gain ≤ 5kg 

G4: weight gain ≥ 20kg 

G5: control Group 6 

Group N: 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Inclusion criteria: 

• Birth at hospital within

study period selected 

those with abnormal 

maternal 

prepregnancy weight 

or abnormal weight 

gain during 

pregnancy, as well as 

next mother in 

sequential order with 

normal prepregnancy 

weight and weight 

gain during 

pregnancy to serve 

as a control 

Exclusion criteria: 

• Not stated 

Pregravid weight: 

• Records - not stated if self 

reported 

G1: 83.9 (10.1) 

G2: 46.7 (3.4) 

G3: 73.1 (16.5) 

G4: 65.0 (12.2) 

G5: 58.3 (6.5) 

Pregravid BMI: 

G1: 39.5 (3.4) 

G2: 17.2 (0.9) 

G3: 26.1 (6.1) 

G4: 23.6 (4.1) 

G5: 21.6 (2.0) 

Imputed: 

• No 

Categorized: 

• Continuous ≥ 20% over or 

under normal weight for 

height 

Age (mean, yrs): 

G1: 28 (5.1) 

G2: 25.5 (5.1) 

G3: 29.5 (5.1) 

G4: 28.7 (4.7) 

G5: 28.7 (4.4) 

Parity: 

G1: prior deliveries: 1.0 (1.0) 

G2: 0.8 (0.8) 

G3: 1.2 (1.1) 

G4: 0.8 (1.0) 

G5: 0.9 (1.0) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-431 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 28 

G3: 30 

G4: 56 

G5: 166 

Total weight gain: 

G1: 11.8 (6.2) 

P < 0.05 compared to 

controls

G2: 13.4 (4.5)

G3: 3.0 (3.5) 

P < 0.0005 compared 

to controls

G4: 23.2 (22.8) 

P < 0.0005 compared 

to controls

G5: 13.2 (3.4) 

Categorized: 

• ≤ 5kg or ≥ 20kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3712 g (614) 

P < 0.05 compared to 

controls 

G2: 3293 (362) 

P < 0.05 compared to 

controls 

G3: 3284 (880) 

G4: 3803 (538) 

P < 0.005 compared 

to controls 

G5: 3538 (535) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: Elective 7% 

Emergency 14% 

Total 21% 

G2: Elective 4% 

Emergency 4% 

Total 8% 

G3: Elective 3% 

Emergency 3% 

Total 6% 

G4: Elective 5% 

Emergency 18% 

Total 23% 

G5: Elective 13% 

Emergency 9% 

Total 22% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Mean symphysis-fundus height: 

Group: 

G1: weight gain ≤ 5kg 

G2: weight gain ≥ 20kg 

G3: control: 5-20 kg 

Results 

G1: 30.8 cm ± 4.0 

G2: 32.8 cm ± 3.4 

G3: 35.0 cm ± 3.9 

Maternal confounders and effect 

modifiers accounted for in analysis: 

NR 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Poor 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

0 Good, 4 Fair, 5 Poor 

Final Quality Score: 

Poor 
C-432 

 Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Guihard-Costa et al., 2004 

Country and setting: 

France, hospital database 

Enrollment Period:

1980-1990 

Funding: 

NR 

Study Objective: 

To deterine relative 

influences of maternal 

factors on infant skinfold 

thickness and other 

outcomes 

Time frame: 

1980-1990 

Duration of the study: 

Pregnancy to birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

13,972 

Group Description: 

Group N: 

Inclusion criteria: 

• Liveborn singletons 

• Term infants (37 to 

41 weeks) 

• Both parents born in 

Ffrance 

• No maternal smoking 

during gestation 

• All data available, 

specifically 

subscapular skinfold 

thickness 

• French metropolitan 

mothers 

Exclusion criteria: 

• French mothers born 

in French Caribbean 

Islands or outside of 

France 

Pregravid weight: 

• Routine pre-natal care 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-433 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated - from 

database 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Crown-heel length, head circumference, 

subscapular skinfold thickness 

Groups: 

NA, weight gain continuous variable, results 

reported in standardized coefficients (SC). 

SCs are regression coefficients calculated as 

if all of the independent variables had a 

variance of 1 

Results: 

G1: SC for effect of MWG on crown-heel 

length 

G2: SC for effect of MWG on head 

circumference 

G3: SC for effect of MWG on subscapular 

skinfold thickness 

G1: SC 0.142 

G2: SC 0.120 

G3: SC 0.146 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• Height 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 5 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-434 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kirchengast and 

Hartmann, 2003 

Country and setting: 

Singleton births that took 

place at University Clinic 

for Gynecology and 

Obstetrics in Vienna, 

Austria 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

Examine impact of 

biological factors such as 

young maternal age and 

maternal somatic 

characteristics on 

pregnancy outcome 

among group of 

adolescent mothers who 

gave birth between 39th 

and 41st week of 

gestation after period of 

intensive psychological 

support 

Time frame: 

NR 

Duration of the study: 

1985 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

8,011 

Group Description: 

G1: 12 to 16 years 

G2: 17 to 19 years 

G3: 20 to 29 years 

Group N: 

G1: 215 

G2: 1,336 

G3: 6,460 

Inclusion criteria: 

• Women ages 12 to 

29 

• All prenatal checkups of mother-child 

passport were 

performed 

• Delivery of single 

infant without 

congenital 

malformations 

• Receiving 

psychosocial support 

by family and/or 

specially trained 

social worker within 

young adolescent 

group (12 to 16 

years) 

Exclusion criteria: 

• Coincident medical 

diseases such as 

diabetes mellitus or 

nephropathy 

• Drug or alcohol 

abuse 

• Twin birth 

• IVF 

• Registered maternal 

diseases before and 

during pregnancy 

• Hypertension 

(BP < 150/90 mmHG)

• Protein or glucose in 

urine 

• Pregnancy related 

immunization 

Pregravid weight: 

Estimated by means of 

retrospective method and first 

weight determination, which 

was carried out at first prenatal 

visit (8th week of gestation) 

G1: 56.0 

G2: 57.2 

G3: 59.2 

Pregravid BMI: 

G1: 21.45 

G2: 21.59 

G3: 22.10 

Imputed: 

• Yes 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 14.5 

G2: 17.8 

G3: 24.1 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Age at menarche:

G1: 12.2 

G2: 12.9 

G3: 13.3 

Gynecological age:

G1: 3.4 

G2: 5.3 

G3: 10.8 
C-435 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 215

G2: 1,336

G3: 6,460

Total weight gain: 

G1: 13.1

G2: 13.1

G3: 13.1 (P = .10)

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3237.6 

(significantly 

different from 17-

19 and 20-29) 

G2: 3298.3 

(significantly 

different from 

< 17 and 20-29) 

G3: 3368.9 

(significantly 

different from 

< 17 and 17-19) 

(F = 24.1, 

P < .0001) 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Chronological 

age 

• Age at menarche

• Gynecological 

age 

• Height 

• Distancia 

spinarum 

• Distancia 

christarum 

• Prepregnancy 

weight 

• Weight at end of 

pregnancy 

Other infant 

outcomes 

• Birth length 

• Head 

circumference 

• Acromial 

circumference 

• Diameter 

frontooccipitale 

Outcomes Description: 

Change in infant size 

characteristics per 1 kg 

increase in MWG 

Groups 

NA, weight gain as continuous 

variable 

Results 

G1: Birth length (cm) 

G2: Head circumference (cm) 

G3: Acromial circumference 

(cm) 

G4: Diameter frontoccipitalis 

(cm) 

G1: β = 0.55 (0.43-0.68) 

G2: β = 0.33 (0.23-0.42) 

G3: β = 0.47 (0.39-0.55) 

G4: β = 0.12 (0.07-0.18) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Maternal age, age at 

menarche, pregravid weight, 

height, distantia cristarum 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-436 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kramer et al., 1990 

Country and setting: 

Canada, university 

hospital 

Enrollment Period:

1980 to 1986 

Funding: 

National Health Research 

and Development 

Program, Health and 

Welfare Canada 

Study Objective: 

(1) Which maternal and 

fetal variables appear to 

have independent causal 

impacts on intrauterine 

growth? (2) For a given 

fetal growth status, which 

maternal and fetal 

variables affect 

proportionality? 

Time frame: 

1980 to 1986 

Duration of the study: 

Entry in to prenatal care 

up to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

8,719 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 8715 

G2: NR 

Inclusion criteria: 

• Live-born, singleton 

infants without 

evidence of 

congenital 

intrauterine infection, 

chromosomal 

anomalies, or other 

major malformations 

and for whom 

gestational age 

calculated from last 

normal menstrual 

period agreed within 

±7 days with an early 

second-trimester 

(usually 16 to 18 

weeks) 

• Ultrasonographic 

estimate based on 

fetal biparietal 

diameter 

Exclusion criteria: 

• See above 

Pregravid weight: 

• Self-reportedNR 

G1: 57.8 kg (10.8) 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• They used prepregnancy 

wt and ht separately 

• NR 

Age (mean, yrs): 

G1: 28.6 (4.7) 

G2: NR 

Parity: 

G1: 0.72 (0.86) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

Cigarettes/d:

G1: 3.2 (7.5) 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

Pg related HTN:

G1: 7.7% 

G2: NR 

Additional characteristics: 

Education, y completed:

G1: 13.0 (3.3) 

G2: NR 

Marital status: 

G1: 90.6% 

G2: NR 

Parity % primaparas:

G1: 48.0 

G2: NR 
C-437 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 8715 

G2: NR 

Total weight gain: 

G1: 14.2kg (5.5)

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery, 

using net weight 

gain (total weight 

minus wt of 

infant) 

Birth weight: 

G1: 3385g (547) 

G2: NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Bivariate 

asssociations 

between selected 

maternal and fetal 

variables and fetal 

growth and 

proportionality: 

Correlation 

coefficient for net 

gestational weight 

gain (kg)and fetal 

growth ratio = 0.12 

(P < 0.001); for 

prepregnancy 

weight (kg) 0.21 (P 

< 0.001) 

Other infant 

outcomes: 

• Correlation 

coefficients for Net 

prepregnancy 

weight gain (kg) 

and length = -0.04 

(P < 0.01) 

• Head 

circumference = -

0.01 (NS); BMI 

0.04 (P < 0.001); 

Ponderal index = 

0.04 (P < 0.001) 

• Weight/height 

circumference = 

0.01 (NS) 

Outcomes Description: 

Length, head circumference, 

BMI, Ponderal Index, 

weight/head circumference 

Groups: 

NA, weight gain continuous 

variable 

Results: 

Correlation coefficients between 

MWG and: 

G1: Length 

G2: Head circumference 

G3: BMI 

G4: Ponderal Index 

G5: Weight/Head circumference 

G1: -0.04 

(P < 0.01) 

G2: -0.01 

G3: 0.04 

(P < 0.01) 

G4: 0.04 

(P < 0.01) 

G5: 0.01 

Net gestational weight gain was 

associated with correlation 

coefficients of -0.04 for length, -

0.01 for head circumference, 

0.04 for BMI, 0.04 for Ponderal 

Index, and 0.01 for weight/head 

circumference. Results were 

significant 

(P < 0.01) for length, BMI, and 

Ponderal Index 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Parity 

• GDM 

• Pregnancy induced 

hypertension 

• Obesity (How defined or 

categorized?) 

• previous lbw, 

• Smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Birth weight 

• Sex of the infant 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 5 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-438 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Shepard et al., 1996 

Country and setting: 

Norway and Sweden, 

multicenter study 

Enrollment Period:

January 1, 1986 to March 

31, 1988 

Funding: 

NICHHD 

Study Objective: 

To examine impact of 

BMI, proportional weight 

gain, and other variables 

on fetal growth 

Time frame: 

January 1, 1986 to March 

31, 1988 

Duration of the study: 

Early pregnancy (before 

17 wks gestation) through 

37 wks gestation 

Design: 

• Cohort 

• Combination: 

Retrospective records 

for pregravid weight, 

prospective for fetal 

growth 

Total Study N: 

369 

Group Description: 

G1: Low BMI, ≤ 19.9 

G2: Average BMI, 20-23.3

G3: High BMI, > 23.3 

Group N: 

Inclusion criteria: 

• Random 10% sample 

of NICHD SGA study 

cohort (n = 571) of 

women with data on 

prepregnant weight 

and weight gain and 

ultrasound 

measurements 

Exclusion criteria: 

NR 

Pregravid weight: 

• records 

G1: 53.1 (0.6) 

G2: 59.8 (0.5) 

G3: 72.3 (0.7) P = 0.0001 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Quetelet’s Index: ≤ 19.9; 

20-23.3; > 23.3 

Age (mean, yrs): 

G1: 29.1 (0.3) 

G2: 29.9 (0.4) 

G3: 30.0 (0.4) P = 0.14 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: # daily cigarette, 17 

weeks: 3.7 (0.5) 

G2: 2.5 (0.4) 

G3: 3.3 (0.1) P = 0.17 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-439 

Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: Overall 

proportional weight 

gain (%): 23.1

G2: 20.3

G3: 16.7 P = 0.0001

Categorized: 

• Measured at 3 

study time 

periods - 

expressed as a 

proportion of 

prepregnant 

weight gained 

during that time 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Overall 

proportional 

weight gain 

Birth weight: 

G1: 3517.1 (50.9) 

G2: 3677.9 (37.5) 

G3: 3837.1 (52.0) 

P = 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Estimates of fetal growth rate in 3 time 

periods, model for weeks 17 to 25 adjusted 

for maternal BMI; model for weeks 25 to 33 

adjusted for maternal BMI, maternal age, 

previous SGA, and male infant; model for 

33-37 weeks adjusted for maternal BMI 

and female infant 

Groups: 

NA, continuous weight gain measure 

Results: 

Increase in mean abdominal fetal growth rate 

(mm/day) per 5% increase in proportional 

weight gain in this period: 

• Weeks 17-25, β = 0.35 (P = 0.49) 

• Weeks 25-33, β = 0.88 (P = 0.02) 

• Weeks 33-37, β = 1.53 (P = 0.02) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Pre-gravid BMI 

• Previous SGA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-440 

Evidence Table 32. Gestational weight gain and childhood weight status 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Li, 2007 

Country and setting: 

USA, national survey 

Enrollment Period:

1959 to 1966 

Funding: 

NR 

Study Objective: 

To evaluate 

developmental trajectories 

of overweight in children 

and assess early life 

influences 

Time frame: 

1986 to 2000 

Duration of the study: 

20 years 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1739 

Group Description: 

G1: Early overweight 

G2: Late overweight 

G3: Never overweight 

Group N: 

G1: 10.9% 

G2: 5.2% 

G3: 83.9% 

Inclusion criteria: 

• Data from National 

Longitudinal Survey 

of Youth 

Exclusion criteria: 

• Mother reported high 

blood pressure or 

diabetes, gestational 

week less than 28 

weeks or birthweight 

less than < 0.5 or 

equal or more than 6 

kg. 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• Yes 

Categorized: 

• < 25, 25-29, > 29 

Age (mean, yrs): 

Age at birth 

<25: 40.9%% 

25 to 29: 50.5%

30 or more: 8.6%

Parity: 

Birth order 

1: 41.1% 

2: 36.9% 

3 or more: 22.0% 

Race,%: 

White 

77.8 

Black 

15.3

Hispanic 

6.9 

Smoking,%: 

NR

Diabetes mellitus,%: 

NA

Hypertension,%: 

NR

Additional characteristics: 

NR 
C-441 

Evidence Table 32. Gestational weight gain and childhood weight status (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

• NR 

Birth weight: 

<2500 : 3.5% 

2500-3999: 81.6% 

4000 or more: 12.9% 

Gestational 

diabetes, %: 

0%

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Overweight status for children for upto 12 

years 

Groups: 

Maternal weight gain categories (kg): 

G1: < 15 lbs 

G2: 15-24 lbs 

G3: 25-34 lbs 

G4: 35-44 lbs 

G5: > 45 lbs 

Results: 

AOR (95% CI) for early onset overweight 

(early onset of overweight 

that persisted throughout childhood) 

compared with normal (low 

probability of overweight throughout 

childhood and was 

characterized as the never overweight 

class) 

G5: 1.7 (1.0-2.9) 

G3: 1.0 (reference) 

Other AOR for weight gain categories for 

early onset overweight not significant 

compared with weight gain 25-34 lbs 

No association between maternal weight 

gain and risk of late onset overweight 

(moderately high probability of overweight 

at age 2 years, low probability of 

overweight at age 4 and 6 years, but 

growing probability of overweight after age 

8 years) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Breastfeeding 

Education 

Time between last pregnancy weight and 

delivery 

Household income 

Marital status 

Paternal BMI 

Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Birth length 

Sex 

Child diet 

Child television viewing 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

4 Good, 4 Fair, 1 Poor

Final Quality Score: 

Fair 
C-442 

Evidence Table 32. Gestational weight gain and childhood weight status (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Oken et al., 2007 

Country and setting: 

Reported elsewhere 

Enrollment period:

NR 

Funding: 

Supported by grants from 

US National Institutes of 

Health (HD 34568, HL 

64925, HL68041, HD 

44807), the Robert Wood 

Johnson Foundation, 

Harvard Medical School, 

and Harvard Pilgrim 

Health Care Foundation 

Study Objective: 

Purpose of study to 

examine associations of 

gestational weight gain 

with child adiposity 

Time frame: 

NR 

Duration of the study: 

Entry to prenatal care thru 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1,044 

Group Description: 

G1: Total 

Group N: 

G1: 1,044 

Inclusion criteria: 

Women delivering live 

singleton infant and 

enrolled for continuation 

of study beyond 6 months 

after delivery 

Exclusion criteria: 

• Missing information 

on prepregnancy 

weight, parental BMI, 

or infant birthweight, 

or who did not have a 

weight recorded 

within 4 weeks 

preceding delivery 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 24.6 (SD 5.0) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 15-24: 6% 

25-34: 62% 

35-44: 32% 

Parity: 

G1: Nulliparous: 48% 

Parous: 52% 

Race,%: 

White 

G1: 74% 

Black 

G1: 11% 

Hispanic 

G1: 6% 

Other 

G1: 10% 

Smoking,%: 

G1: Never: 67% 

Quit before pregnancy 20% 

Smoked in early pregnancy 10%

Diabetes mellitus,%: 

G1: 4% 
C-443 

Evidence Table 32. Gestational weight gain and childhood weight status (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: 15.6 kg (5.4) 

Categorized: 

• Continuous 

According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by:

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 4% 

Cesarean 

delivery,%: 

G1: 23% 

G2: 12% 

G3: 35% 

G4: 53% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• Association of MWG with 

child adiposity-related 

outcomes at age 3 years, 

before and after adjustment 

for potential confounding 

and pathway variables. 

Effect increments are for a 5 

kg increment in total weight 

gain. 

Groups: 

MWG for 5 kg increments 

Results: 

AOR (95%CI) BMI≥95th 

percentile vs BMI<50th 

percentile associated with a 5 kg 

increase in gestational weight 

gain: 

1.52 (1.19-1.94) 

Child BMI z-score at age 3 years 

for AOR listed above (95% CI): 

0.11 (0.05, 0.17)Maternal 

confounders and effect 

modifiers accounted for in 

analysis: 

• Breastfeeding 

• Education 

• Time between last 

pregnancy weight and 

delivery 

• Household income 

• Marital status 

• Paternal BMI 

• Smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Birth length 

• Sex 

• Child diet 

• Child television viewing 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-444 

Evidence Table 32. Gestational weight gain and childhood weight status (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ong et al., 2000 

Country and setting: 

UK, Avon longitudinal 

study of pregnancy and 

childhood 

Enrollment Period:

Births from April 1991-

December 1992 followed 

to age 5 years 

Funding: 

Medical Research 

Council, Wellcome Trust, 

Department of Health, 

Department of the 

Environment 

Study Objective: 

To identify predictors of 

postnatal catch up growth 

from birth to 2 years and 

its relation to size and 

obesity at 5 years 

Time frame: 

Births from April 1991-

December 1992 followed 

to age 5 years 

Duration of the study: 

Birth to 5 years, maternal 

data collected 

retrospectively 

Design: 

• Cohort 

• Combination: 

Maternal data 

retrospective, infant 

prospective 

Total Study N: 

848 

Group Description: 

Group N: 

Inclusion criteria: 

• 10% sample of births 

in longitudinal study 

cohort with 

information on weight 

measurements 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Obstetric records, not 

stated whether it was self 

reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-445 

Evidence Table 32. Gestational weight gain and childhood weight status (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

obstetric records 

- not stated 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Catch-up and catch-down 

growth 

Groups: 

Maternal weight gain, continuous 

measure 

Result: 

Children were grouped into three 

growth categories (catch-up, no 

change, and catch-down) based 

on a gain in weight (SD score > 

0.67 for catch-up; SD score < 

0.67 for catch-down. 

Maternal weight gain was not a 

significant predictor of catch-up 

growth between 0 and 2 years 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 7 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-446 

Evidence Table 32. Gestational weight gain and childhood weight status (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Sowan and Stember, 

2000 

Country and setting: 

USA, sample from Infant 

Growth Study Database 

Enrollment Period:

NR 

Funding: 

AAUW, NRSA, NIH, NINR 

Study Objective: 

To facilitate an 

understanding of influence 

of parental characteristics 

on development of infant 

obesity 

Time frame: 

NR 

Duration of the study: 

Birth through 15 months 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

630 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• Normal infant at birth 

(i.e. no organic 

etiology) 

• Mother able to 

communicate in 

English 

Exclusion criteria: 

• Infants weighing less 

than 2500g at birth 

• Preterm infants (< 37 

weeks) 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-447 

Evidence Table 32. Gestational weight gain and childhood weight status (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous, 5 

pound 

increments 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Infant obesity (BMI> gender 

and age specific 84th

percentile based on Infant 

Growth Study population 

Groups: 

Maternal weight gain in 5 pound 

increments 

Results: 

Model AOR (95%CI) for infant 

obesity (BMI> gender and age 

specific 84th percentile based on 

Infant Growth Study population 

norms) at 1, 4, 7, and 10 months: 

NS 

AOR (95%CI) for obesity at 14 

months: .8 (0.7-1.0) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Age 

• Race 

• Pre-gravid BMI 

• Marital status 

• Psychosocial factors 

• Sociocultural factors 

• Smoking 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• Infant gender 

• Birth BMI 

• BMI at previous month 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 4 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-448 

Evidence Table 33. Gestational weight gain and childhood hospitalization 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Yuan et al., 2001 

Country and setting: 

Denmark, birth cohort 

from midwife centers 

Enrollment Period:

April 1984 to April 1987 

Funding: 

Grant from Medical 

Research Council 

Study Objective: 

To examine whether 

maternal prenatal lifestyle 

factors were associated 

with risk of hospitalization 

with infectious disease 

during early childhood and 

whether a possible 

association was modified 

by fetal growth reduction 

Time frame: 

April 1984 to April 1987 

Duration of the study: 

Prenatal period through 

early childhood (6 to 12 

yrs) 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

10,440 

Group Description: 

G1: Cohort 

G2: NR 

Group N: 

G1: 10,400 

G2: NR 

Inclusion criteria: 

• Children born to 

mothers attending 

midwife centers at 

approximately 36th 

week gestation in 2 

study areas in 

Denmark 

Exclusion criteria: 

• Stillbirths 

• Multiple births 

• Children with 

congenital 

malformations 

Pregravid weight: 

• Self-reported, may be 

from hospital records - not 

specifically stated 

Pregravid BMI: 

G1: < 18: 5.8%; 

18-20: 42.8%; 

21-23: 33.5%; 

≥ 24: 17.9% 

G2: NR 

Imputed: 

• No 

Categorized: 

• < 18, 18-20, 21-23, > 24 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 44.3 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-449 

Evidence Table 33. Gestational weight gain and childhood hospitalization (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 7550 

G2: NR 

Total weight gain: 

G1: < 10kg: 19.1%; 

10-12: 24.6%; 

13-15: 26.0%; 

≥ 16: 30.3% 

G2: NR 

Categorized: 

• < 10, 10-12, 13-

15, ≥ 16 kg 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• Adjusted incidence rate ratio (IRR) of 

hospitalization with infectious disease 

(95% CI) 

Groups: 

G1: < 13kg 

G2: ≥ 13kg 

Results: 

G1: 1.05 (0.76-1.47) 

G2: 1.42 (1.09-1.86) 

All gestational weight gain 

1.29 (1.05-1.59) 

Stratification of analyses by either 

prepregnancy BMI or gestational weight gain 

did not show any difference in associations 

between maternal smoking, alcohol, tea, and 

fruit intake and hospitalization with infectious 

disease (of child from 6 months to 12 years) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Paternal age 

• Social group 

• Maternal cohabitation status 

• Number of siblings at birth for infant 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

4 Good, 3 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-450 

Evidence Table 34. Gestational weight gain and postpartum weight retention 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Callaway et al., 2007 

Country and setting: 

Australia, hospital 

Enrollment period: 

Received antenatal care 

between 1981 and 

1984, then followed 21 

years later 

Funding: 

Authors thank National 

Health and Medical 

Research Council and 

Queensland Health for 

funding this project. L. 

K. C. was supported by 

a National Health and 

Medical Research 

Council Postgraduate 

Medical Scholarship at 

commencement of this 

work. D. A. L. is 

fundedby a United 

Kingdom Department of 

Health Career Scientist 

Award 

Study Objective: 

To assess changes in 

body mass index (BMI; 

weight (kg)/height 

(m)2) over time in 

women with and without 

HDP 

Time frame: 

Received antenatal care 

between 1981 and 

1984, then followed 21 

years later 

Duration of the study: 

From prepregnancy to 

21 years after index 

pregnancy 

Design: 

• Cohort 

• Prospective 

Total Study N: 

3,572 

Group Description: 

G1: Included 

G2: Excluded 

G3: P value 

Group N: 

G1: 3,572 

G2: 3,651 

Inclusion criteria: 

• Women delivered 

live singleton baby, 

who neither died 

nor was adopted 

prior to leaving 

hospital, and 

completed both 

initial phases of 

data collection 

Exclusion criteria: 

NR 

Pregravid weight: 

• Correlated with first 

prenatal visit weight 

r = 0.95 

Pregravid BMI: 

G1: 21.9 (3.8) 

G2: 22.0 (4.1) 

G3: 0.1 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 25.0 (5.1) 

G2: 24.1 (5.2) 

G3: < 0.001 

Parity: 

G1: nulliparous 35.7% 

G2: nulliparous 30.8% 

G3: < 0.001 

Race,%: 

White 

G1: 94.9% 

G2: 89.8% 

G3: < 0.001 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 46.9% 

G2: 53.0% 

G3: < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-451 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 3,572 

G2: 3,651 

Total weight gain: 

G1: 14.8 (6.03? vs 

14.6) 

G2: 14.9 (14.7) 

G3: 0.3 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR 

Birth weight: 

G1: 3,388 (518) 

G2: 3,382 (523) 

G3: 0.7 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Univariable 

association of 

MWG with 

mean change 

in BMI over 21 

years: MWG < 

= 15: 5.06 

(4.85, 5.27), 

MWG >15: 6.4 

(6.19, 6.61) 

< 0.001. 

Women with 

HDP gained on 

average 2.01 

kg (95% CI, 

1.41 kg, 2.61 

kg) more than 

women without 

HDP 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

G1: Maternal weight gain 

<=15kg 

G2: Maternal weight gain 

>15kg 

Results 

G1: Mean change (95%CI) 

in BMI at 21 years 

postpartum: 5.06 kg/m2

(4.85-5.27) 

G2: Mean change (95%CI) 

in BMI at 21 years 

postpartum: 6.40 kg/m2

(6.19-6.61) 

P < 0.001 

G2 was associated with a 

mean change in BMI 

over 21 years of 0.19 

kg/m2 (95%CI: 0.16-

0.22) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Baseline income 

• Secondary school 

completion 

• Ethnicity 

• Maternal age at birth 

• Parity 

• Birth weight 

• Gestational age 

• Infant sex 

• Maternal smoking 

during pregnancy 

• Smoking at 21 years 

• Sedentary lifestyle at 

21 years 

• Baseline maternal BMI 

• Hypertensive 

disorders during 

pregnancy 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Infant sex 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

7 Good, 1 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-452 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Harris et al., 1999 

Country and setting: 

UK, antenatal care 

project 

Enrollment Period: 

Not stated 

Funding: 

DevR fund of University 

of Greenwich; NHS 

Executive, South 

Thames 

Study Objective: 

To assess relative 

importance of heritable 

characteristics and 

lifestyle in development 

of maternal obesity after 

pregnancy 

Time frame: 

Not stated 

Duration of the study: 

First antenatal visit to 

2.5 years post delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

74 

Group Description: 

G1: Women with longterm weight gains < 

0.4kg 

G2: Women with longterm weight gains > 

0.4kg 

G3: Total sample 

Group N: 

G1: 37 

G2: 37 

G3: 74 

Inclusion criteria: 

• Women who had 

been enrolled in 

Antenatal Care 

Project who had been 

weighed during first 

trimester of 

pregnancy and had 

not become pregnant 

since birth of child 

carried during ANC 

project 

Exclusion criteria: 

• Women with missing 

data 

Pregravid weight: 

• Measured during first 

trimester of 

pregnancy at prenatal 

visit 

G1: NR 

G2: NR 

G3: 66.23 (1.25) 

Pregravid BMI: 

G1: 25.0 (0.6) 

G2: 24.2 (0.7) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 33.4 (0.8) 

G2: 33.7 (0.8) 

G3: 33.54 (0.56) 

Parity: 

G1: NR 

G2: NR 

G3: % nulliparous: 37.8 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: % continual smokers: 

18.9 

G2: % continual smokers: 

18.9 

G3: % smokers at first 

antenatal visit: 43.2 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: % married: 54.1 

G2: 56.8 

G3: 55.4 

Additional characteristics: 

G1: Duration of followup 

(days): 1141.2 (20.0) 

G2: 1181.8 (20.6) 
C-453 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 37 

G2: 37 

G3: 74 

Total weight gain: 

G1: 13.14 (1.07) kg 

G2: 12.73 (0.82) 

G3: 12.93 (0.67) 

Categorized: 

• Continuous 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Mean long term 

weight gain in 

association with 

pregnancy was 

0.50 (0.71)kg, 

overall the mothers 

in sample not 

significantly heavier 

after pregnancy 

than were before 

(95%CI: -0.89-

1.89); however, 

these long term 

weight gains were 

very variable 

ranging from 13.6kg 

in weight loss to 

17.7 kg in weight 

gain 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

Continuous maternal 

weight gain, kg 

Results 

ANCOVA model with 

weight (kg) at 2.5 years 

postpartum as dependent 

variable and maternal 

weight gain (kg) as 

independent variable: 

B = -0.031 

β = -0.029 

SEM = 0.120 

P = 0.796 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Marital status 

• Increased 

dissatisfaction with 

body 

• Increased access to 

food increased energy 

intake 

• Decreased activity 

• Smoking status 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

5 Good, 4 Fair, 0 Poor 

Final Quality Score: 

Good 
C-454 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Harris et al., 1997 

Country and setting: 

UK, city hospital 

Enrollment Period: 

1992-1993 

Funding: 

DevR fund of University 

of Greenwich 

Study Objective: 

Investigated 

independent 

associations between 

parity and maternal 

body mass index and 

between parity and 

maternal weight gain 

Time frame: 

1992 to 1993 

Duration of the study: 

Previous pregnancy 

through current 

pregnancy and birth 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,637 (523 included and 

694 excluded) 

Group Description: 

G1: Included women 

G2: Excluded women 

Group N: 

G1: 523 

G2: 694 

Inclusion criteria: 

• Women who had 

singleton births at 

hospital between 

1992 and 1993 with 

obstetric notes 

available for their 

previous pregnancy 

• Women who were 

weighed regularly 

during pregnancy 

• Parity of 1,2,3,4 

Exclusion criteria: 

• Pre-existing 

hypertension or 

diabetes (n = 3) 

• Parity 5 (n = 2) or 

parity 6 (n = 2) 

• 1992/1993 

pregnancy began 

less than 12 

months after birth 

of their previous 

child 

(n = 243) 

• Missing data for 1 

or more variables 

(n = 444) 

Pregravid weight: 

• Abstracted from each 

mother’s obstetric notes 

Pregravid BMI: 

G1: 23.45 (0.17) 

G2: 23.59 (0.18) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29.6 (0.2) 

G2: 28.9 (0.2) 

Parity: 

G1: % parity = 1: 73.4% 

G2: 54.5% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 22.4 

G2: 27.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 0 

G2: 0 

Additional characteristics: 

NR 
C-455 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 523 

G2: 694 

Total weight gain: 

G1: Rate of weight 

gain: 0.47 (0.01) 

G2: 0.44 (0.1) 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: based 

on difference 

between first 

antenatal 

weight 

measurement 

and last 

antenatal 

measurement 

usually 

recorded within 

1 week of 

delivery 

Birth weight: 

G1: 3384.1 (21.2) 

G2: 3338.8 (20.2) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

G1: Maternal weight gain 

during previous 

pregnancy(kg), continuous 

G2: Interpregnancy weight 

change (kg), defined 

as the difference 

between weight at start 

of index pregnancy 

and weight at start of 

previous pregnancy 

Results 

ANCOVA model with G2 

as dependent variable and 

G1 as independent 

variable: 

B = 0.262 

β = 0.227, 

SEM = 0.52 

P < 0.001 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Marital status 

• Smoking status 

• Alcohol 

• Parity 

• Age 

• Socioeconomic status 

• Nulliparous BMI 

• Birth weight 

• Gestational age at 

start of previous 

pregnancy 

• Gestational age at 

start of index 

pregnancy 

• Gestational age at 

start of first pregnancy 

• Interpregnancy interval 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Poor 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-456 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Harris et al., 1997 

Country and setting: 

UK, hospital 

Enrollment Period: 

1990-1993 

Funding: 

DevR Fund of University 

of Greenwich 

Study Objective: 

To investigate impact of 

pregnancy on long term 

weight gain of 

primiparous mothers 

and to identify potential 

risk factors for maternal 

obesity 

Time frame: 

1990 to 1993 

Duration of the study: 

Initiation of prenatal 

care during first 

pregnancy to beginning 

of second pregnancy 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

243 

Group Description: 

G1: Mothers included in 

study 

G2: Mothers excluded 

from study 

Group N: 

G1: 243 

G2: 2,154 

Inclusion criteria: 

• Singleton births 

• Multiparous women 

with 2 consecutive 

births at hospital 

Exclusion criteria: 

• Incomplete 

obstetric records for 

1 or more previous 

pregnancy 

(n = 863) 

• Not weighed 

regularly during 

both first and 

second 

pregnancies 

(n = 247) 

• Missing first 

trimester 

measurements of 

body weight in both 

pregnancies 

(n = 2,077) 

• Women who 

became pregnant 

with second child 

less than 12 

months after birth 

of first child 

(n = 69) 

• Missing data on key 

variables (n = 8) 

Pregravid weight: 

• Used weight 

measurements recorded 

during first trimester of 

pregnancy (up to 13 

weeks gestation) 

Pregravid BMI: 

G1: 24.2 (0.5) 

G2: 23.5 (0.1) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 26.2 (0.4) 

G2: 24.5 (0.1) 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: Nonsmoker: 76.6% 

G2: Nonsmoker: 70.0% 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: PIH: 23.4% 

G2: 24.5% 

Additional characteristics: 

Married: 

G1: 79.8% 

G2: 66.9% 

Left hospital breast feeding:

G1: 59.1% 

G2: 53.4% 
C-457 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 243 

G2: 2154 

Total weight gain: 

G1: rate of weight 

gain (kg/week): 

0.48 (0.01) 

G2: 0.48 (0.01) 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3.3338 (0.0533) 

G2: 3.2886 (0.017) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 18.1 

G2: 14.1 

Instrumental 

delivery,%: 

Assisted NonCesarean:

G1: 13.8% 

G2: 13.3% 

Episiotomy,%: 

Other maternal 

outcomes: 

• Examining 

change in 

maternal body 

weight from 

beginning of first 

pregnancy to 

beginning of 

second 

pregnancy 

(interpregnancy 

weight change) 

and gestational 

weight gain 

during first 

pregnancy 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

G1: Maternal weight gain 

during first pregnancy 

as a continuous 

measure (kg) 

G2: Interpregnancy weight 

change (kg), 

defined as the difference 

between weight at start 

of first pregnancy and 

weight at start of the 

second pregnancy 

Results 

ANCOVA model with G2 as 

dependent variable and G1 

as independent variable: 

B = 0.176 

β = 0.169 

SEM = 0.070 

P < 0.013 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Marital status

• Lactation

• Smoking status 

• Alcohol 

• Height 

• Nulliparous BMI 

• Birth weight 

• Gestational age at 

start of previous 

pregnancy 

• Terminations between 

pregnancy 

• Interpregnancy interval 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-458 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hunt et al., 1995 

Country and setting: 

USA, 2 separate 

sources: populationbased family history 

database and 

participation in a study 

on obesity 

Enrollment Period: 

1991-1992 

Funding: 

NIH grant DK44655 

Study Objective: 

To examine impact of 

pregnancy during 

weight gain on later 

weight status in 

morbidly obese women; 

i.e. to study role of 

pregnancy in 

development of obesity 

Time frame: 

1991 to 1992 

Duration of the study: 

Beginning of first 

pregnancy up to time of 

study recruitment 

(includes multiple 

pregnancies per 

woman) 

Design: 

• Cohort 

• Prospective 

Total Study N: 

Controls = 115 

Morbidly obese = 96 

Group Description: 

G1: Morbidly obese 

G2: Random control 

Group N: 

G1: 96 

G2: 115 

Inclusion criteria: 

• Women with 1 or 

more pregnancies 

• Ages 30-59 

• Living in Utah 

Exclusion criteria: 

• Morbidly obese 

women were 

excluded if more 

than 13.6 kg over 

ideal weight 

between ages 20 

and 24 or prior to 

first pregnancy 

occurring before 

age 20 

• Controls were 

excluded if not less 

than 13.6kg over 

ideal weight at ages 

20-24 or prior to 

first pregnancy 

occurring before 

age 20 

Pregravid weight: 

• Self-reportedvalidated 

by hospital records 

G1: at ages 20-24: 64.4 

(9.0) 

G2: at ages 20-24: 55.8 

(7.0) 

Pregravid BMI: 

G1: at ages 20-24: 23.3 

(2.9) 

G2: at ages 20-24: 20.6 

(2.2) 

Imputed: 

• No 

Categorized: 

• NR 

Age (mean, yrs): 

G1: 48.1 (8.6) 

G2: 44.0 (5.2) 

Parity: 

G1: Number of pregnancies: 

4.2 (2.0) 

G2: Number of pregnancies: 

4.3 (1.8) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Weight at 6 weeks after last 

delivery (kg):

G1: 90.8 (18.8) 

G2: 65.0 (12.9) 

Additional characteristics: 

NR 
C-459 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Other - please 

define 

Collected from: 

• not collected 

Ascertained by: 

• Selfreportedvalidat

ed by hospital 

records 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

G1: Population-based 

sample 

G2: Morbidly obese women 

who were normal weight at 

age 20-24 years or prior to 

first pregnancy 

Results 

Regression of current 

weight on total number of 

pregnancies showed a 

1.3kg/pregnancy increase 

in current weight (P = 0.03) 

with no difference between 

G1 and G2 (P = 0.60) 

Maternal weight gain was 

significantly greater in G2

than G1 for the first 

pregnancy only (P < 0.05) 

G2 had a net weight 

retention after the first 

pregnancy of 4.0 kg 

greater than G1 at 6 weeks 

postpartum 

G2 averaged 1.6 kg/ 

pregnancy greater weight 

retention than G1 for 

additional pregnancies 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Weight at ages 20 to 

24 

• Current age 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Fair 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 6 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-460 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Linne et al., 2004 

Country and setting: 

Sweden, Stockholm 

Pregnancy and Weight 

Development study 

Enrollment Period: 

1 and 15 year followup 

of women recruited in 

1984-85 

Funding: 

NR 

Study Objective: 

Aim of this study was to 

evaluate how well 

prepregnancy BMI, 

gestational weight gain, 

and postpartum weight 

retention predict 

retention of weight 15 

years later among 

parous women 

Time frame: 

1 and 15 year followup 

of women recruited in 

1984 to 1985 

Duration of the study: 

15 years 

Design: 

• Cohort 

• Prospective 

Total Study N: 

563 

Group Description: 

G1: Total 

G2: Normal weight 

group (BMI < 25) 

G3: Overweight group 

(> 25) 

G4: Low weight gain 

< 12kg 

G5: Intermediate weight 

gain 12-15.6kg 

G6: High weight gain > 

15.6kg 

Group N: 

G1: 563 

G2: 514 

G3: 45 

Inclusion criteria: 

• Participants in 

Stockholm 

Pregnancy and 

Weight 

Development study 

in 1984 and 1985 

who agreed to 

participate in 15 

year follow up study 

Exclusion criteria: 

• Death or moving 

abroad 

• BMI = 47 

• 1 woman who had 

her first child at age 

49 

Pregravid weight: 

NR 

G1: 59.8 (7.9) 

G2: 58.5 (6.3) kg, 

G3: 74.4 (7.6) kg 

G4: 58.3 (7.8) 

G5: 59.4 (7.7) 

G6: 61.8 (7.7) P < 0.001 

Pregravid BMI: 

G1: 21.5 (2.4) kg/m2 

G2: 21.0 (1.7)kg/m2, 

G3: 26.3 (1.1) 

G4: 21.4 (2.7) 

G5: 21.2 (2.1) 

G6: 21.9 (2.4 )P < 0.05 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 25% 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: diet advice 61% 

G2: NR 

G3: 

Additional characteristics: 

NR 
C-461 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: NR 

G2: NR 

Total weight gain: 

G1: NR 

G2: 9.8 (1.9) 

G3: 14.0 (0.9) 

G4: 18.8 (2.3) 

P < 0.001 

G5: At 12 months, 

gained 1.1 +/- 

0.4 kg from 

prepregnancy 

weight 

G6: At 12 months, 

gained 1.2 +/- 

0.5 kg P = 0.64 

Categorized: 

• Tertiles based 

on weight gain 

during 

pregnancy and 

defined as low 

weight gain (< 

12.0 kg), 

intermediate 

weight gain 

(between12 

and 15.6 kg), 

and high 

weight gain (> 

15.6 kg) 

Collected from: 

• Collected by 

study 

investigators 

details of inital 

SPAWN study 

methods NR 

here 

Ascertained by: 

• NR 

Birth weight: 

G1: NR

G2: 3,269 (509) 

G3: 3,507 (482) 

G4: 3,628 (492) 

P < 0.001 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• At 15-year followup, overweight 

women had a 

mean waist 

circumference of 

81 +/- 9.3 cm, and 

normal weight 

women had a 

mean waist 

circumference of 

77 +/- 9.1 cm 

(P = 0.73). Hip 

circumference was 

101.1 +/- 8.4 cm in 

overweight women 

and 98 +/- 8.5 cm 

in normal weight 

women (P = 0.28). 

2. 

• At 6 months 

postpartum, normal 

weight women had 

retained 1.4 +/- 3.1 

kg from 

prepregnancy 

weight, and 

overweight women 

had retained 2.0 

+/- 6.7 kg 

(P < 0.40). 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

Maternal weight gain was 

used a continuous 

measure (kg): 

Results 

G1: Pregravid BMI ≤ 25 

G2: Pregravid BMI > 25 

G2 had significantly 

greater weights at 

prepregnancy, delivery, 1 

year postpartum, and 15 

years postpartum 

compared to G1 

(P < 0.001); however, G2 

did not have a higher risk 

of postpartum retention 

than G1 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Alcohol use 

• Smoking 

• Number of 

pregnancies since 

index child 

• Employment area 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-462 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Linne et al., 2004 

(continued) 

 
C-463 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

• At 15-year followup, weight 

increase from 

before pregnancy 

was 7.7 +/- 7.0 

kg in normal 

weight women 

and 6.2 +/- 12.1 

kg in overweight 

women (P = 

0.36). 

• A multiple 

regression was 

performed to 

predict weight at 

15-year followup. It is evident 

that weight 

before pregnancy 

and weight at 1 

year were most 

strongly 

correlated with 

body weight at 

15-year followup. Multiple 

regression (using 

an enter model) 

showed that 

these variables 

explained 58.1% 

of variation in 

body weight at 

15-year follow-up 

[F(3.499) = 

232.87, 

P < 0.001]. 

Weight at 1 year 

had largest 

(Beta) (0.782), 

which was most 

important 

predictor of body 

weight at 15-year 

follow-up (t = 

24.38, P < 0.001) 

Other infant 

outcomes: 

NR 

 
C-464 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Linne et al., 2003 

Country and setting: 

Stockholm, Pregnancy 

and Women’s Nutrition 

study 

Enrollment Period: 

15 year follow-up of 

women who delivered 

infants in 1984-85 

Funding: 

NR 

Study Objective: 

To investigate women 

who participated in 

Stockholm Pregnancy 

Weight Development 

study 15 years later, 

focusing on women 

whose weight 

trajectories changed 

after their pregnancies 

and in particular those 

women who were 

normal weight (BMI ≤

25) before 

Time frame: 

15 year follow-up of 

women who delivered 

infants in 1984 to 1985 

Duration of the study: 

Questionnaires 

administered at 2.5, 6, 

and 12 months and at 

15 years postpartum 

(inital questionnaires 

given to women who 

delivered children in 

1984 to 1985) 

Design: 

• Cross-sectional 

• Combination: 

retrospective for 

factors occurring 

prior to/during 

pregnancy and 

prospective for 

weight gain 

following pregnancy 

Total Study N: 

563 

Group Description: 

Group N: 

NR 

Inclusion criteria: 

• Women who took 

part in Stockholm 

Pregnancy and 

Weight 

Development 

Study, 1984 to 

1985 

Exclusion criteria: 

• BMI > 47 (n = 1) 

• First child at age 49 

(n = 1) 

• Women who were 

overweight at both 

time points 

(prepreg and 15y 

followup) (n = 33) 

and women who 

were overweight 

and who lost weight 

and regained a BMI 

in normal range at 

15y (n = 10) were 

excluded from 

analysis 

Pregravid weight: 

• Routine pre-natal care 

• Maternity records from 

original study 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-465 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

G1: Women with normal 

BMI (20-25) at 

prepregnancy and 15 

years postpartum 

G2: Women with normal 

BMI at prepregnancy 

who had overweight 

BMI (> 25) at 15 years 

postpartum 

Results 

G1: Mean (SD) maternal 

weight gain, 13.6 (3.7) kg 

G2: Mean (SD) maternal 

weight gain, 15.4 (4.4) kg 

t-Test: P < 0.001 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NR 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-466 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Muscati et al., 1996 

Country and setting: 

Canada, public health 

department 

Enrollment Period: 

1979 to 1989 

Funding: 

NR 

Study Objective: 

To examine association 

of extent and timing of 

pregnancy weight gain 

with infant birth weight 

and postpartum weight 

retention 

Time frame: 

1979 to 1989 

Duration of the study: 

Pregnancy through 6 

weeks postpartum 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

371 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 371 

G2: NR 

Inclusion criteria: 

• White, low income, 

non-smoking 

women 

• Pregnant women 

Exclusion criteria: 

• Prematurity < 37 

weeks 

• Adolescents < 16 

years 

• Women > 40 years 

• Maternal health 

problems 

• Women who 

consume alcohol or 

drugs 

• Pregnancy 

complications such 

as proteinuria, 

hypertension, 

diabetes, negative 

weight gain, 

missing values 

Pregravid weight: 

Family physicians’ records 

G1: 62.8 +/- 16.0 kg 

G2: NR 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Pregravid weight status 

categorized into 3 

groups as a percentage 

of standard weight: 

underweight < 90%, 

normal 90-120%, and 

overweight > 120% 

Age (mean, yrs): 

G1: 24.5 +/- 5.6 

G2: NR 

Parity: 

G1: Primiparous 52% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: PPWR: 5.3 +/- 5.7 kg 

G2: NR 

Additional characteristics: 

NR 
C-467 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 16.1 +/- 6.4 kg 

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

From Table 1: Pearson’s 

Correlation Coefficient 

and determination 

coefficient of maternal 

weight gain with PP 

weight retention and 

Infant BW. Maternal PP 

weight retention and 

Preg weight gain: [Total 

amount r = 0.808, R 

square 65.3%, P < 

0.001], [Up to week 20 r 

= 0.682, R square 

46.5%, P < 0.001], 

[Weeks 21-30 r = 0.411, 

R square 16.9%, P < 

0.001], [Week 31 - term r 

= 0.414, R square 

17.1%, P < 0.001] 

Other infant outcomes: 

Pregnancy Weight Gain 

and Infant Birth Weight 

(from Table 1): [Total 

amount r = 0.216, R 

square 4.7%, P < 0.001], 

[Up to week 20 r = 

0.114, R-square 1.3%, 

P < 0.05], [Weeks 21-30 

r = 0.157, R square 

2.5%, P < 0.01], [Week 

31 - term r = 0.160, R 

square 2.6%, P < 0.01] 

Outcomes Description: 

Postpartum weight retentin 

Groups 

Maternal weight gain categories: 

G1: Weight gain <= week 20 (kg) 

G2: Weight gain weeks 21-30 

(kg) 

Results 

Regression model of weight 

retention (kg) at 6 weeks 

postpartum as the dependent 

variable and G1-G5 as 

independent variables: 

G1: β = 0.86 (SE: 0.05) 

P < 0.001 

G2: β = 0.68 (SE: 0.07) 

P < 0.001 

G3: β = 0.49 (SE: 0.07) 

P < 0.001 

G4: β = 0.58 (0.13) 

P=NR 

G5: β = 0.77 (0.04) 

P = NR 

Among women with AGA infants, 

women with 6 week postpartum 

weights greater than the median 

value (6.2kg, underweight; 5.7kg, 

normal weight; 3.1kg, 

overweight) had significantly 

greater total weight gains and 

weight gains during the first 20 

weeks’ gestation compared to 

women with 6 week postpartum 

weights of the median value or 

lower 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Standard weight for height 

(based on 1983 Metropolitan 

Life Insurance Tables) 

• Pregravid weight above 

standard (difference 

between actual weight and 

standard weight) 

• Parity 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• Gestational age 

• Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 

Poor 

Final Quality Score: 

Fair 
C-468 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ohlin and Rossner, 

1990 

Country and setting: 

Sweden, maternity 

clinics 

Enrollment Period: 

NR 

Funding: 

NR 

Study Objective: 

To make a survey of 

weight changes after 

pregnancy; to analyze if 

and how different 

factors, such as parity, 

age, body weight, and 

lactation, correclate to 

post partum weight 

retention; and to 

analyze if any of these 

factors could be used as 

predictors fo 

Time frame: 

NR 

Duration of the study: 

Pregnancy through 1 

year postpartum 

Design: 

• Cohort 

• Combination: 

retrospectively 

during pregnancy 

and prospectively 

up to 1 year after 

delivery 

Total Study N: 

1,423 at 1 year 

postpartum 

Group Description: 

G1: Total group 

entering study 

G2: NR 

Group N: 

G1: 2295 

G2: NR 

Inclusion criteria: 

• Women coming to 

maternity clinic for 

last routine control 

(6-15 weeks after 

delivery) 

Exclusion criteria: 

• Twin births 

• Insulin use during 

pregnancy 

• Gastrointestinal 

problems with 

severe energy 

losses (heavy 

vomiting or 

diarrhea) 

• Missing 

prepregnancy 

weight. 

• Drop out frequency 

1 year postpartum 

= 38% 

Pregravid weight: 

• Self-reported 

G1: 59.6kg (8.5) 

G2: NR 

Pregravid BMI: 

G1: 21.5 (2.8) 

G2: NR 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 29.5 (4.8) 

G2: NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-469 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 2295 

G2: NR 

Total weight gain: 

G1: 14.1kg (4.3) 

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3442 (522) 

G2: NR 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal outcomes: 

Mean Change in body weight 

from prepregnancy weight to 1 

year postpartum (n = 1423) = 

1.5kg (SD 3.6)P < 0.001. 

Overweight women (BMI > 23.8, 

n = 190) tended to retain more 

weight after the index time - 

1.9kg +/- 5.3kg than lighter 

women (BMI < 23.9, n = 1233) - 

1.5kg +/- 3.2kg (NS). There was 

a highly significant correlation 

between weight change and 

pregnancy weight gain (r = 0.36, 

P < 0.001). This correlation was 

slightly lower when using the first 

and last weight recorded in the 

maternity clinic (vs. self reported 

prepregnancy weight), but still 

significant (r < 0.29, P < 0.001). 

Women gaining in the highest 

decentile (16.5kg) had a mean 

weight change of 3.3 +/- 3.9 kg 

while women in the lowest 

decentile (7.5kg) had a mean 

weight change of 0.0 +/- 3.3 kg. 

Using multiple stepwise 

regression analysis, weight gain 

during the third trimester 

explained 5% of the variation of 

weight change from 

prepregnancy to 1 year 

postpartum: Beta = 3.6, the 

second trimester gains explained 

2% of the change (beta = 2.8); 

and the first trimester explained 

1% of the change (beta = 1.4). 

Total weight gain explained 8% 

of change (multiple r = 0.29), P 

< 0.001) 

Other infant outcomes: 

NR 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

Maternal weight gain 

categories: 

G1: Continuous weight gain 

(kg) 

G2: Weight change (kg), 

defined as the 

difference between 

prepregnancy and 1 

year postpartum 

weights 

Results 

Regression model for G2

as the dependent variable 

and G1 as the independent 

variable: 

B = 0.32 

P < 0.001 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Lactation score 

• Age 

• Prepregnancy BMI 

• Parity 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-470 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Parham et al., 1990 

Country and setting: 

USA, prenatal clinics 

Enrollment Period: 

NR 

Funding: 

NR 

Study Objective: 

To explore relationship 

between pregnancy 

weight gain and 

postpartum weight and 

to identify variables 

associated with return to 

prepregnancy weight 

Time frame: 

NR 

Duration of the study: 

Entry into PNC up to 9 

months postpartum 

Design: 

• Other observational: 

pregnant women vs 

non pregnant 

selected from the 

same clinic 

• Retrospective 

Total Study N: 

260 (158 pregnant + 102 

non pregnant 

Group Description: 

G1: Prenatal patients 

G2: Control 

Group N: 

G1: 158 

G2: 102 

Inclusion criteria: 

• Prenatal patients in 

2 clinics serving lowincome patients ; 

singleton births 

• Non pregnant 

women who also 

had weight info 

during a 12 month 

period of time 

Exclusion criteria: 

• Incomplete or 

unusable data on 

weight changes 

during pregnancy 

and postpartum 

periods 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• < 20 (underweight), 20-

25 (acceptable), > 25 

(overweight) 

Age (mean, yrs): 

G1: 23 

G2: 23 

Parity: 

NR 

Race,%: 

White 

G1: ~50 

G2: ~50 

Black 

G1: ~25 

G2: ~25 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-471 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 158 

G2: NR 

Total weight gain: 

G1: 12.9 kg (SD 

5.8) 

G2: NR 

Categorized: 

• < 9.1kg, 9.1-

13.6, and > 

13.6kg 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3,299 g (SD 628) 

G2: NR 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal outcomes: 

Mean maternal weight gain 

was 9.7kg (“maternal weight 

gain” in this study is weight 

at delivery minus baby’s 

BW). Lower third of maternal 

weight gains ranged from - 

7.1 to 6.7 kg, with a mean of 

3.7 [+ or -] 2.9 kg; middle 

third had a range of 6.8 to 

11.9 kg (mean = 9.4 [+ or -] 

1.3 kg); and the upper third 

had a range of 11.9 to 32.8 

kg (mean = 16.0 [+ or -]3.7). 

Three maternal weight gain 

categories differed 

significantly in initial BMI 

(P = .03). Residual weight I 

was significantly correlated 

with maternal weight gain (r 

= .84, 

P < .001) and with 

prepregnancy BMI (r = .14,

P = .05). Residual weight II 

was also significantly 

correlated with maternal 

weight gain (r = .68, P < 

.001) but not with 

prepregnancy BMI 

Other infant outcomes: 

Among underweight and 

normal-weight women, gains 

were roughly evenly 

distributed among 3 

maternal gain tertiles, but 

50% of overweight women 

had gains in lower tertile and 

only 24% in upper tertile. 

Groups did not differ 

significantly 

Outcomes Description: 

Postpartum weight 

retention, percent change 

in BMI category between 

prepregnancy and 1-3 

months postpartum 

Groups 

Maternal weight gain for 

population in tertiles, mean 

(se): 

G1: 3.7 (2.9) 

G2: 9.4 (1.3) 

G3: 16.0 (3.7) 

Results 

G1, G2: 83% No change; 

7% Desirable change 

(i.e. underweight 

women becoming 

normal weight); 10% 

Undesirable change 

(~5% had an increase 

in BMI category and 

~5% had a decrease in 

BMI category) 

G3: 42% no change; 19% 

desirable change; 39% 

Undesirable change (all 

increases in BMI category) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NR 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Poor 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

1 Good, 5 Fair, 3 Poor 

Final Quality Score: 

Poor 
C-472 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Soltani and Fraser, 

2000 

Country and setting: 

UK, hospital 

Enrollment Period: 

NR 

Funding: 

NR 

Study Objective: 

To investigate pattern of 

changes in weight gain 

and fat distribution 

during pregnancy and 

postpartum and whether 

this differed by maternal 

BMI measured in first 

trimester 

Time frame: 

NR 

Duration of the study: 

First prenatal visit to 6 

months postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

77 

Group Description: 

G1: Total sample 

G2: Normal weight 

G3: Overweight 

G4: Obese 

Group N: 

G1: 77 

G2: 29 

G3: 23 

G4: 25 

Inclusion criteria: 

• Women attending 

first prenatal visit at 

Northern General 

Hospital 

Exclusion criteria: 

NR 

Pregravid weight: 

• Measured during first 

prenatal visit 

G1: 73.0 (16.8) 

G2: 60.8 (5.6) 

G3: 72.0 (5.9) 

G4: 93.0 (10.6) 

Pregravid BMI: 

G1: 27.4 (5.9) 

G2: 22.7 (1.3) 

G3: 27.7 (1.4) 

G4: 34.5 (3.54) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26.71 (4.77) 

G2: 26.44 (5.32) 

G3: 26.91 (4.50) 

G4: 27.68 (3.83) 

Parity: 

G1: 0.78 (0.86) 

G2: 0.55 (0.87) 

G3: 0.81 (0.75) 

G4: 1.00 (0.96) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 24% 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Fat mass (kg) at first visit:

G1: 24.5 (9.9) 

G2: 16.5 (3.6) 

G3: 24.6 (3.9) 

G4: 36.1 (5.9) 

Waist:hip ratio:

G1: 0.92 (0.08) 

G2: 0.88 (0.06) 

G3: 0.92 (0.08) 

G4: 0.96 (0.08) 

Total Skinfold Thickness 

(mm): 

G1: 117.09 (40.19) 

G2: 84.3 (25.31) 

G3: 125.02 (22.76) 

G4: 158.74 (21.52) 
C-473 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 77 

G2: 29 

G3: 25 

Total weight gain: 

G1: 13-36 weeks: 

10.8 (4.7) 

G2: 11.0 (3.2) 

G3: 11.9 (6.4) 

G4: 9.7 (4.3) 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3443.0 

(589.60) 

G2: 3331.5 (481.7) 

G3: 3423.7 (543.2) 

G4: 3670.4 (489.5) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Postpartum weight retention 

Groups 

Pregravid BMI categories: 

G1: Normal Weight 

G2: Underweight 

G3: Overweight 

G4: Obese 

Results 

G1: Patterns of changes in 

body weight (kg) and fat 

mass follow a monotonous 

trend; body weight and 

fatness increased during 

gestation, decreased 

substantially at 6 weeks 

postpartum, and then 

stayed the same or slightly 

decreased until 6 months 

postpartum 

G2: Showed similar pattern to 

G1. 

G3: Divergent pattern of weight 

gains and losses; body fat 

mass changes show a very 

scattered pattern 

G4: Divergent pattern of both 

weight and fat mass gains 

and losses; heavier and 

greater fat masses at 6 

months postpartum 

compared to 13 weeks 

gestation; significantly 

lower fat mass loss and 

greater skinfold thickness 

gain between 36 weeks 

gestation and 6 months 

postpartum compared to 

normal weight women 

(P < 0.05) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-474 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Walker et al., 2004 

Country and setting: 

USA, hospital 

Enrollment Period: 

1999 to 2001 

Funding: 

National Instituted of 

Nursing Research 

Study Objective: 

Longitudinal analysis of 

behavioral and 

psychosocial correlates 

of weight trends during 

first postpartum year 

Time frame: 

1999 to 2001 

Duration of the study: 

Initiation of prenatal 

care to 12 months 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

382 

Group Description: 

G1: Total cohort 

G2: White 

G3: African American 

G4: Hispanic 

Group N: 

G1: 382 

G2: 113 

G3: 100 

G4: 169 

Inclusion criteria: 

• Women with 

healthy, term, 

singleton 

pregnancies with 

prenatal care 

funded through 

Medicaid 

• Parity ≤ 3 

• English speaking 

• ≥ 18 years free of 

prenatal 

complications 

(hypertension or 

diabetes) 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reportedOtherplease explain! 

G1: NR 

G2: 65.44 (15.82) kg 

G3: 67.96 (13.99) 

G4: 67.26 (15.24) 

Pregravid BMI: 

G1: NR 

G2: 24.23 (5.78); 

Underwt% 18.75; 

Normal wt% 53.57; 

Overwt% 11.61; 

Obese % 16.07 

G3: 25.39 (5.40); 

Under 11.34%; 

Normal 56.7%; 

Over 9.28%; 

Obese 22.68% 

G4: 26.75 (6.19); 

Under 7.78%; 

Normal 48.5%; 

Over 13.77%; 

Obese 29.94% 

Imputed: 

• No 

Categorized: 

• Continuous IOM 

guidelines 

Age (mean, yrs): 

G1: NR 

G2: 22.79 (4.72) 

G3: 22.40 (3.75) 

G4: 21.89 (3.36) 

Parity: 

G1: NR 

G2: Parity = 1 (%): 45.13 

G3: 35.00% 

G4: 30.77% 

Race,%: 

White 

G1: 29.6 

G2: NR 

Black 

G1: 26.2 

G2: NR 

Hispanic 

G1: 44.2 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-475 

Evidence Table 34. Gestational weight gain and postpartum weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 113 

G2: 100 

G3: 169 

Total weight gain: 

G1: kg 16.44 

(6.51); below 

IOM rec 

16.07%; within 

IOM rec 

30.36%; more 

than IOM rec 

53.57% 

G2: kg 15.20 

(7.88); below 

IOM rec 

25.53%; within 

IOM rec 

17.02%; more 

than IOM rec 

57.45% 

G3: kg 14.87 

(7.76); below 

IOM rec 

22.29%; within 

IOM rec 

Categorized: 

• Continuous 

according to 

IOM 

Collected from: 

• Self-reported 

• Collected by 

study 

investigators 

gestational 

weight gain 

based on self 

report 

• Postpartum 

weight gain 

was measured 

by study 

investigators 

postdelivery, 

and at 6 wks, 

3, 6, and 12 

months 

postpartum 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 10.62 

G2: 15.00 

G3: 16.57 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Postpartum weight 

retention 

Groups 

Continuous maternal 

weight gain (kg) 

Results 

Each kg of maternal weight 

gain was associated with 

0.314 kg/m2

 of postpartum 

BMI 

(P < 0.001) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Ethnicity 

• Time 

• Interaction of ethnicity 

and time 

• Pregravid BMI 

• Weight-related 

distress 

• Energy intake

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-476 

Evidence Table 35. Gestational weight gain and premenopausal breast cancer 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hilakivi-Clarke et al., 

2005 

Country and setting: 

Finland, primary care 

Enrollment Period: 

Apr 1990-Dec 1993 

Funding: 

Supported by grants 

from National Cancer 

Institute, Susan G. 

Komen Breast Cancer 

Research Foundation, 

and Breast Cancer 

Research Foundation 

Study Objective: 

To investigate whether 

excessive maternal 

weight gain alters a 

woman’s risk of 

developing 

premenopausal breast 

cancer 

Time frame: 

Apr 1990 to Dec 1993 

Duration of the study: 

3 to 6 years after 

insertion of IUD 

Quality: 

Fair 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

490 

Group Description: 

G1: Cases 

G2: Controls 

Group N: 

G1: 98 

G2: 392 

Inclusion criteria: 

• Cases of reported 

breast cancer per 

survey, for each 

case- 4 controls 

matched for age 

and Mirena status 

chosen randomly 

from cohort 

Exclusion criteria: 

• Missing info on 

birth year, 

nulliparous women, 

development of 

breast cancer 

before pregnancy 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• Change in BMI < 3.5, 

3.5 to 7, > 7 units 

Age (mean, yrs): 

G1: 46.7 

G2: 46.7 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Family history of breast 

cancer:

G1: 9.4% 

G2: 5.7% 
C-477 

Evidence Table 35. Gestational weight gain and premenopausal breast cancer (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 98 

G2: 392 

Total weight gain: 

G1: < 10 kg 23.4% 

10-15 47.9% 

16-20 21.3% 

20+ 7.5% 

G2: < 10 kg 22.2% 

10-15 50.3% 

16-20 19.4% 

20+ 8.2% 

Categorized: 

• Categorical: 

< 10kg, 10-15, 

16-20, > 20 

Collected from: 

• Self-reported 

data collected 

on weight gain 

during any 

pregnancy - 

not first or last 

specified 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• AOR for Premenopausal breast cancer 

(95% CI) 

Groups: 

weight gain (kg)

G1: < 10kg 

G2: 10-15 kg 

G1: 16-20 kg 

G2: >20 kg 

Results: 

G1: 1.0 reference 

G2: 0.8 (0.44,1.47) 

G2: NR 

G3: 1.0 (0.47, 2.04) 

G4: 0.8 (0.27, 2.13) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Education 

• Age at menarche 

• Age at first birth 

• Family history of breast cancer 

• Pregnancy weight gain 

• Change in BMI during adult life 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-478 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and to 

determine effect of 

gestational weight gain on 

pregnancy outcome in 

morbidly obese women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 and 

34 

• Missing height 

• Missing 

prepregnancy weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference for 

women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-479 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 613

G2: 11,313

Total weight gain: 

G1: 20 (16.2)

G2: 31.4 (11.5)

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-15 

lbs, 16-25 lbs, 26-35 

lbs, >35 lbs 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated - from 

medical records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometritis

• Wound infections

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Distribution of GDM,%: 

Groups 

Maternal weight gain categories among morbidly obese 

(BMI > 35): 

G1: Weight loss/no change 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: > 35 lbs 

Results 

G1: 15.7 

G2: 15.0 

G3: 14.4 

G4: 13.4 

G5: 12.5 

P = NS 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Race, parity, clinic service, substance abuse, preexisting 

medical condition 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability:

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poo

r: 

2 Good, 3 Fair, 

4 Poor 

Final Quality 

Score: 

Poor 
C-480 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period:

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal weight 

women and their 

associations with 

gestational weight change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight women 

identified from 

pregnancy and 

delivery summary 

records (normal 

weight matched to 

obese by race, age, 

parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal weight 

(BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-481 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5

G2: 14.5 P ≤ 0.001

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percent with Gestational Diabetes by weight group 

Groups 

Obese BMI > 29 (kg): 

G1: Lost weight/no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal weight BMI 19.8-26 

G6: < 11.5 

G7: 11.5-16 

G8: > 16 

Results 

Gestational diabetes,% 

G1: 13.3 

G2: 24.3 

G3: 11.9 

G4: 16.7 

G5: 17.3 

P for linear trend (G1-G5) = 0.554 

G6: 2.3 

G7: 3.3 

G8: 2.9 

P for linear trend (G6-G8) = 0.759 

Maternal confounders and effect modifiers 

accounted for in analysis: 

None 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

None 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

3 Good, 6 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-482 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Saldana et al., 2006 

Country and setting: 

United States, hospital 

Enrollment period:

August 1,1995 through 

May 31, 2000 

Funding: 

Supported in part by 

National Institute of 

General Medical Sciences 

(Grant R25GM55336), 

National Institute of Child 

Health and Development 

(Grant 28684), and North 

Carolina Clinical Nutrition 

Research (Grant 

DK56350) 

Study Objective: 

Objective of study to 

examine weight and its 

relationship to glucose 

intolerance during 

pregnancy 

Time frame: 

August 1,1995 through 

May 31, 2000 

Duration of the study: 

Entry into prenatal care 

through end of second 

trimester 

Design: 

• Cohort 

• Prospective 

Total Study N: 

952 

Group Description: 

G1: Normal Glucose 

Tolerance 

G2: Impaired Glucose 

Tolerance 

G3: GDM 

Group N: 

G1: 809 

G2: 48 

G3: 95 

Inclusion criteria: 

• Singleton pregnancy 

• More than 16 years of 

age 

• English speaking 

• Access to phone 

• Planned to continue 

care at 1 of study 

sites 

Exclusion criteria: 

• From non-white or 

non-black racial 

group 

• Having a second 

pregnancy in cohort 

• Pre-existing diabetes 

• No glucose screening 

data 

• High screen without 

an oral glucose 

tolerance test 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 25 (0.24) 

G2: 28 (1.1) 

G3: 30 (0.82) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26 (0.22) 

G2: 29 (0.91) 

G3: 28 (0.59) 

Parity: 

G1: 0.9 (0.04) 

G2: 1.1 (0.16) 

G3: 0.9 (0.10) 

Race,%: 

White 

G1: 58% 

G2: 73% 

G3: 69% 

Black 

G1: 42% 

G2: 27% 

G3: 31% 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 25% 

G2: 26% 

G3: 25% 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Weight gain ratio 

(observed/recommended[com

pared with IOM range])

G1:: 1.43 (0.04) 

G2: 1.48 (0.21) 

G3: 1.88 (0.15) 

Additional characteristics: 

NR 
C-483 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Groups (N): 

NR

Total weight gain: 

G1: 9.1 (0.19)

G2: 8.1 (0.90)

G3: 9.4 (0.62)

Categorized: 

• 2 weight gain 

variables were 

created. Weight 

gain was 

calculated by 

subtracting 

prepregnancy 

weight from 

weight at end of 

second trimester 

(G2 weeks). 

Weight gain ratio 

calculated as 

ratio of observed 

weight gain to 

recommended 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

Outcomes Description: 

Mean and adjusted odds ratio (95% CI) for weight 

gain 

Groups 

G1: Normal glucose tolerance 

G2: Impaired glucose tolerance 

G3: Gestational diabetes mellitus 

BMI IOM 

Results 

Mean (SE) weight gain ratio (defined as obeserved 

weight gain/IOM recommended weight gain): 

G1: 1.43 (0.04) 

G2: 1.48 (0.21) 

G3: 1.88 (0.15) 

P < 0.05 

AOR for weight gain ratio 

G1: 1.0 (reference) 

G3: 1.2 (0.9-1.4) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Race, age 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection:

Good 

Definition of 

maternal weight 

gain: 

Good 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

7 Good, 2 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-484 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

Country and setting: 

Maternity records, 

Department of Obstetrics 

and Gynecology at 

Landspitali University 

Hospital, Iceland 

Enrollment Period:

Funding: 

NR 

Study Objective: 

To investigate relation 

between gestational 

weight gain in women of 

normal prepregnant 

weight and complications 

during pregnancy and 

delivery in a population 

with high gestational 

weight gain and birth 

weight 

Time frame: 

NR 

Duration of the study: 

1998 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

614 

Group Description: 

G1: No complication 

G2: Complications in 

pregnancy or delivery

G3: Complications in 

pregnancy 

G4: Complications in 

delivery 

Group N: 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Inclusion criteria: 

• Women of normal 

prepregnancy weight 

randomly selected 

within 1 year (1998) 

• No history of 

diabetes, 

hypertension, CVD, 

or thyroid problems 

• Singleton births 

• 38 to 43 weeks 

gestation 

• 20 to 40 years of age

• Routine fetal biometry 

at 18 to 20 week 

ultrasound 

• Received early and 

regular antenatal care

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 63.1 (6.2) 

G2: 62.0 (5.6) P = 0.059 

G3: 61.7 (4.8) P = 0.174 

G4: 62.2 (6.1) P = 0.274 

Pregravid BMI: 

G1: 22.2 

G2: 22.4 )1.6) P = 0.270 

G3: 22.4 (1.5) P = 0.338 

G4: 22.3 P = 0.584 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29 

G2: 29 P = 0.857 

G3: 29 P = 0.404 

G4: 29 P = 0.398 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Proportional weight gain, %:

G1: 26.0 

G2: 28.0 P = 0.018 

G3: 30.0 P = 0.005 

G4: 27.0 P = 0.546 

Additional characteristics: 

NR 
C-485 

Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Total weight gain: 

G1: 16.6 (4.9)

G2: 17.4 (5.1) P = 

0.080

G3: 18.4 (5.1) P = 

0.013

G4: 16.9 (5.1) P = 

0.887

Categorized: 

• According to IOM < 

11.5, 11.-16.0, ≥

16.1, also quintiles 

< 12.5, 12.5-15.5, 

15.6-17.8, 17.9-

20.8, > 20.8 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

deliverynot stated - 

based on records? 

Birth weight: 

G1: 3789 (469) 

G2: 3749 (565) P = 0.389

G3: 3643 (526) P = 0.032

G4: 3806 (578) P = 0.529

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Gestational diabetes,% 

Groups 

Maternal weight gain categories (kg): 

G1: < 11.5 

G2: 11.5-16.0 

G3: 16.1-20.0 

G4: > 20.0 

Results 

Gestational diabetes,% 

G1: 2.9 

G2: 0 

G3: 0 

G4: 0 

P for trend < 0.015 

Maternal confounders and effect modifiers 

accounted for in analysis: 

None 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

None 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

5 Good, 3 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-486 

Evidence Table 37. Gestational weight gain with reference to IOM recommendations and hypertension 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and to 

determine effect of 

gestational weight gain on 

pregnancy outcome in 

morbidly obese women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 and 

34 

• Missing height 

• Missing 

prepregnancy weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference for 

women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-487 

Evidence Table 37. Gestational weight gain with reference to IOM recommendations and hypertension 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Quality 

Rating 

Groups (N): 

G1: 613

G2: 11,313

Total weight gain: 

G1: 20 (16.2)

G2: 31.4 (11.5)

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-15 

lbs, 16-25 lbs, 26-35 

lbs, >35 lbs 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Not stated - from 

medical records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometritis

• Wound infections

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Pregnancy-induced hypertenstion 

Groups: 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results: 

G1: 11.8% 

G2: 13.7% 

G3: 13.7% 

G4: 12.4% 

G5: 21.3% (P = NS) 

Maternal confounders and effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information 

on exposure, 

outcomes, 

and 

confounders:

Poor 

Followup: 

Fair 

Analysis 

comparability

: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation

: 

Poor 

Sum of 

Good/Fair/Po

or: 

2 Good, 3 Fair, 

4 Poor 

Final Quality 

Score: 

Poor 
C-488 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Devader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period:

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate relationship 

between gestational 

weight gain and adverse 

pregnancy outcomes 

among women with 

normal prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 35 

lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal prepregnancy 

BMI (19.8 –26.0 

kg/m2) who were 18 

to 35 years of age at 

time of delivery and 

who delivered fullterm (37 weeks or 

more) singleton infant 

during period January 

1, 1999, to December 

31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older than 

35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained from 

mother during postpartum 

hospital stay 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-489 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

NR

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Figures 1 to 3 plot 

risk for each 

adverse pregnancy 

outcome by 10-lb 

increments in 

gestational weight 

gain. Women who 

gained 25 to 34 lbs 

during their 

pregnancy had 

lower risks for most 

outcomes when 

balancing risk for 

SGA status and 

other adverse 

pregnancy 

outcomes 

• Women who 

gained 15 to 24 lbs 

had lowest risks for 

most outcomes, but 

increased their risk 

of having an SGA 

infant from 9.6% to 

14.3% 

• Women who 

gained more than 

34 lbs had higher 

risks for all 

outcomes, although 

their risk of having 

an SGA infant 

decreased from 

9.6% to 6.6% 

Outcomes Description: 

AOR (95% CI) for preeclampsia 

Groups 

Maternal weight gain categories (lbs): 

G1: < 25 

G2: 25-35 

G3: > 35 

Results 

G1: 0.56 (0.49-0.64) 

G2: 1.00 (reference) 

G3: 1.88 (1.74-2.04) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Education 

• Income 

• Alcohol use 

• Height 

• Prior pregnancy 

• Inadequate prenatal care use 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Child's gender 

• Birth year 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

2 Good, 7 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-490 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Devader et al., 2007 

(combined) 

 
C-491 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Other infant 

outcomes: 

NR 
C-492 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period:

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal weight 

women and their 

associations with 

gestational weight change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight women 

identified from 

pregnancy and 

delivery summary 

records (normal 

weight matched to 

obese by race, age, 

parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal weight 

(BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-493 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5

G2: 14.5 P ≤ 0.001

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Preeclampsia 

Groups 

Obese BMI > 29 (kg): 

G1: Lost weight/ no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal weight BMI 19.8-26: 

G6: < 11.5 

G7: 11.5-16.0 

G8: > 16.0 

Results 

G1: 10.7 

G2: 7.7 

G3: 8.3 

G4: 7.9 

G5: 16.5 

P for linear trend (for G1-G5) = 0.076 

G6: 2.8 

G7: 2.9 

G8: 6.6 

P for linear trend (for G6-G8) = 0.048 

Maternal confounders and effect modifiers accounted 

for in analysis: 

None 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

None 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

3 Good, 6 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-494 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period:

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight change 

on pregnancy outcomes in 

obese women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) (n 

= 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 37 

or more weeks of 

gestation) liveborn, 

singleton infants 

during 1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-495 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 43% 

G3: GWG (lb)Less than 

2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, and 

greater than 35 lb 

gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, %:

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental delivery,%:

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Odds ratios (95% CI) for preeclampsia 

Groups 

Maternal weight gain categories stratified by 

prepregnancy obesity status, Obese Class I (BMI 

30–34.9), Obese Class II (BMI 35–39.9), Obese 

Class III (BMI ≥ 40): 

G1: ≤ -10lbs 

G2: -2 to -9 lbs 

G3: No change 

G4: 2-9 lbs 

G5: 10-14 lbs 

G6: 15-25 lbs 

G7: 26-35 lbs 

G8: > 35 lbs 

Results 

For Obese Class I: OR (95% CI) for preeclampsia 

were significantly lower (< 1.00, G6 was 

reference) for G2-G5 and significantly higher for 

G7-G8. 

For Obese Class II: OR (95% CI) for 

preeclampsia were significantly greater (> 1.00, 

G6 was reference) for G1 and G3- G5 and 

significantly lower for G8. 

For Obese Class III: OR (95% CI) for 

preeclampsia were significantly greater (> 1.00, 

G6 was reference) for G1-G3 and G5 and 

significantly lower for G7-G8

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in Medicaid, WIC, food 

stamp programs) 

• Tobacco use 

• Chronic hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor:

2 Good, 6 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-496 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued) 

 
C-497 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Maternal Weight Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Other maternal outcomes: 

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA by 

GWG category for each 

obesity class. All 3 figures 

show similar patterns of 

increasing risk of 

preeclampsia, cesarean 

delivery, and LGA birth and 

decreasing risk of SGA birth 

with increasing GWG. 

Collectively, minimal risk for 

all 4 outcomes corresponds 

to GWG categories where 

risk of LGA and SGA births 

intersect. This equates to 

GWG of 10 of 25 lb for class 

I obese women, a gain of 0 

tp 9 lb for class II obese 

women, and weight loss of 0 

to 9 lb for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA by 

GWG category and obesity 

class. Compared with 

women who gained 15 to 25 

lb during their pregnancies, 

those who gained less 

weight had significantly 

lower odds of preeclampsia, 

cesarean delivery, and LGA 

births, but higher odds for 

SGA births. Women who 

gained more than 25 lbs had 

higher odds for same 3 

pregnancy outcomes and 

lower odds for SGA births. 

Other infant outcomes: 

NR 
C-498 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

Country and setting: 

Maternity records, 

Department of Obstetrics 

and Gynecology at 

Landspitali University 

Hospital, Iceland 

Enrollment Period:

Funding: 

NR 

Study Objective: 

To investigate relation 

between gestational 

weight gain in women of 

normal prepregnant 

weight and complications 

during pregnancy and 

delivery in a population 

with high gestational 

weight gain and birth 

weight 

Time frame: 

NR 

Duration of the study: 

1998 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

614 

Group Description: 

G1: No complication 

G2: Complications in 

pregnancy or delivery

G3: Complications in 

pregnancy 

G4: Complications in 

delivery 

Group N: 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Inclusion criteria: 

• Women of normal 

prepregnancy weight 

randomly selected 

within 1 year (1998) 

• No history of 

diabetes, 

hypertension, CVD, 

or thyroid problems 

• Singleton births 

• 38 to 43 weeks 

gestation 

• 20 to 40 years of age

• Routine fetal biometry 

at 18 to 20 week 

ultrasound 

• Received early and 

regular antenatal care

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 63.1 (6.2) 

G2: 62.0 (5.6) P = 0.059 

G3: 61.7 (4.8) P = 0.174 

G4: 62.2 (6.1) P = 0.274 

Pregravid BMI: 

G1: 22.2 

G2: 22.4 )1.6) P = 0.270 

G3: 22.4 (1.5) P = 0.338 

G4: 22.3 P = 0.584 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29 

G2: 29 P = 0.857 

G3: 29 P = 0.404 

G4: 29 P = 0.398 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Proportional weight gain, %:

G1: 26.0 

G2: 28.0 P = 0.018 

G3: 30.0 P = 0.005 

G4: 27.0 P = 0.546 

Additional characteristics: 

NR 
C-499 

Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Total weight gain: 

G1: 16.6 (4.9)

G2: 17.4 (5.1) P = 

0.080

G3: 18.4 (5.1) P = 

0.013

G4: 16.9 (5.1) P = 

0.887

Categorized: 

• According to IOM < 

11.5, 11.-16.0, ≥

16.1, also quintiles 

< 12.5, 12.5-15.5, 

15.6-17.8, 17.9-

20.8, > 20.8 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery, not stated 

- based on records 

Birth weight: 

G1: 3789 (469) 

G2: 3749 (565) P = 0.389

G3: 3643 (526) P = 0.032

G4: 3806 (578) P = 0.529

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Maternal weight gain categories (kg): 

G1: < 11.5 

G2: 11.5-16.0 

G3: 16.1-20.0 

G4: > 20.0 

Preeclampsia,% 

G1: 1.4 

G2: 2.3 

G3: 5.4 

G4: 4.4 

P for trend = 0.262 

Maternal confounders and effect modifiers 

accounted for in analysis: 

None 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

None 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

5 Good, 3 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 

 
C-500 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

• Imputed: 

• No 

• Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

• Black 

NR 

• Hispanic 

NR 

• Asian/Pacific 

Islander 

NR 

• Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

• Preexisting 

diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-501 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

• Categorize

d: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

• Collected 

from: 

• Routine prenatal care or 

maternity 

records 

• Ascertaine

d by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometritis 

• Wound infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Cesarean delivery 

Groups 

G1: wt loss or 0 lbs 

G2: 1-15 lb 

G3: 16-25 lb 

G4: 26-35 lb 

G5: >35 lb 

Results 

G1: 25.5% 

G2: 26.8% 

G3: 28.8% 

G4: 35.0% 

G5: 33.8% 

(P = NS) 

No significant difference 

among morbidly obese 

women by weight gain 

categories. 

OR for Cesarean 

comparing morbidly to 

nonobese =2.3 (1.9, 2.8) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

Macrosomia 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-502 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

DeVader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period: 

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate 

relationship between 

gestational weight gain 

and adverse pregnancy 

outcomes among 

women with normal 

prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 

35 lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal 

prepregnancy BMI 

(19.8 –26.0 kg/m2) 

who were 18 to 35 

years of age at time 

of delivery and who 

delivered full-term 

(37 weeks or more) 

singleton infant 

during period 

January 1, 1999, to 

December 31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older 

than 35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained 

from mother during 

postpartum hospital stay 

Pregravid BMI: 

NR 

• Imputed: 

• No 

• Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

• Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

• Hispanic 

NR 

• Asian/Pacific 

Islander 

NR 

• Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-503 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

NR 

• Categorize

d: 

• According to 

IOM 

• Collected 

from: 

• Routine prenatal care or 

maternity 

records 

• Ascertaine

d by: 

NR 

Birth weight: 

NR 

Gestational diabetes, %: 

NR 

Cesarean delivery,%: 

NR 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal outcomes: 

• Figures 1 to 3 plot risk for 

each adverse pregnancy 

outcome by 10-lb 

increments in gestational 

weight gain. Women who 

gained 25 to 34 lbs 

during their pregnancy 

had lower risks for most 

outcomes when 

balancing risk for SGA 

status and other adverse 

pregnancy outcomes 

• Women who gained 15 

to 24 lbs had lowest risks 

for most outcomes, but 

increased their risk of 

having an SGA infant 

from 9.6% to 14.3% 

• Women who gained 

more than 34 lbs had 

higher risks for all 

outcomes, although their 

risk of having an SGA 

infant decreased from 

9.6% to 6.6% 

Other infant outcomes: 

• NR 

Outcomes Description: 

AOR for cesarean delivery 

(additionally controlled for 

LGA and cephalopelvic 

disproportion) 

Groups 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 35 

lbs 

• Results 

G1: 0.82 (0.78–0.87) 

G2: 1.0 

G3: 1.35 (1.29–1.40) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

Age, race, education, 

income, alcohol use, 

height, prior pregnancy, 

inadequate prenatal care 

use, smoking 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

Child's gender, birth year 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-504 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period: 

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal 

weight women and their 

associations with 

gestational weight 

change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight 

women identified 

from pregnancy 

and delivery 

summary records 

(normal weight 

matched to obese 

by race, age, parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

• Imputed: 

• No 

• Categorized: 

• IOM guidelinesobese 

(> 29) and normal 

weight (BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

• Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

• Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

• Asian/Pacific 

Islander 

NR 

• Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-505 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5 

G2: 14.5 P ≤ 0.001 

• Categorize

d: 

• According to 

IOM 

• Collected 

from: 

• Routine prenatal care or 

maternity 

records 

• Ascertaine

d by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Cesarean delivery 

Groups 

Obese 

G1: wt loss or 0 lbs 

G2: 1-14 lb 

G3: 15-25 lb 

G4: 26-35 lb 

G5: >35 lb 

• Normal weight 

G1:<25 lb 

G2: 25-35 lb 

G3: >35 lb 

Results 

Obese 

G1: 30.7% 

G2: 21.6% 

G3: 23.8% 

G4: 26.2% 

G5: 30.1% 

• Normal weight 

G1:5.7% 

G2:12.1% 

G3: 8.6% 

• No significant 

difference in rates of cesarean 

delivery by IOM weight gain 

categories for normal weight or 

obese women 

• Obese women AOR 

=3.2 (2.3,4.4) for cesarean 

delivery 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• GDM 

• Pregnancy induced 

hypertension 

• Prenatal adequacy 

• Alcohol use 

• Drug use 

• Smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, outcomes, 

and confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-506 

 Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Jain et al, 

2007 

Country and setting: 

United States, hospitals 

Enrollment period: 

2002-2005 

Funding: 

Not reported 

Study Objective: 

To analyze risks of 

cesarean section, 

macrosomia, and 

breastfeeding at 10 

weeks postpartum using 

logistic regression to 

estimate independent 

effects of prepregnancy 

BMI and gestational 

weight gain 

Time frame: 

2002-2005 

Duration of the study: 

Entry into prenatal care 

to 10 weeks postpartum 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

7661 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• Term (> 37 weeks) 

and singleton for 

macrosomia and 

breastfeeding 

Exclusion criteria: 

• Cesarean analysis 

limited to to women 

with cephalic 

presentationrecords with 

missing data 

excluded 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

• NR 

• Imputed: 

• No 

• Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 
C-507 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

• NR 

• Categorize

d: 

• ≤ 15 lbs 

• 15-25 lbs 

• 25-35 lbs 

• 35+ lbs 

• Collected 

from: 

• Not outlined 

• Ascertaine

d by: 

• Birth certificate 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Cesarean delivery 

Groups 

G1: ≤ 15 lbs 

G2: 16 - < 25 lbs 

G3: 25 - < 35 lbs 

G4: ≥ 35 lbs 

G5: interaction term overwt/obese and 

gaining 25-35 

Results 

Primipara (AOR, 95% CI) 

G5: 0.71 (0.43-1.19) 

Multipara 

G5: 0.77 (1.37-1.59) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Pre-gravid BMI, parity 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

0 Good, 7 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-508 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kaiser and Kirby, 2001 

Country and setting: 

USA, university nursemidwifery system 

Enrollment Period: 

1994 to 1998 

Funding: 

NR 

Study Objective: 

To determine whether 

low risk maternity 

patients in a nursemidwifery service with 

prepregnant BMI > 29.0 

are at increased risk for 

cesarean delivery 

Time frame: 

1994 to 1998 

Duration of the study: 

First prenatal visit to 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,881 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 1881 

G2: NR 

Inclusion criteria: 

• Healthy women 

who met criteria for 

nurse-midwifery 

care according to 

practice’s 

guidelines 

• Women who 

delivered preterm 

or attempted trials 

of labor 

• All pregnancies 

were included for 

women who 

delivered more than 

once within study 

period 

Exclusion criteria: 

• Women with 

chronic conditions 

(diabetes, 

hypertension, 

unstable asthma), 

prenatal 

complications 

(multiple 

gestations, fetal 

malformations, and 

gestational 

diabetes), repeat 

cesarean delivery 

• Women with 

missing height or 

prepregnancy 

weight 

Pregravid weight: 

• Self-reported 

• Used measured weight 

at first prenatal visit (if 

less than 12 weeks 

gestation) if women did 

not know 

Pregravid BMI: 

G1: NR 

BMI 

• ≤ 19.7: 13.2% 

• 19.8-26.0: 50.7% 

• 26.1-28.9: 12.0% 

• ≥ 29.0: 24.0% 

G2: NR 

• Imputed: 

• No 

• Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 21.1 (4.7) 

G2: NR 

Parity: 

G1: % primiparous: 36.5 

G2: NR 

Race,%: 

White 

G1: 14.9 

G2: NR 

• Black 

G1: 77.1 

G2: NR 

• Hispanic 

G1: 6.6 

G2: NR 

• Asian/Pacific 

Islander 

G1: 1.4 

G2: NR 

• Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: married: 9.4 

G2: NR 

Additional characteristics: 

NR 
C-509 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 1881 

G2: NR 

Total weight gain: 

• Categorize

d: 

• Study by 

Parker and 

Abrams-weight 

gain cut offs 

are different 

• Collected 

from: 

• Routine prenatal care or 

maternity 

records 

• Ascertaine

d by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between 

prepregnant 

weight and 

prenatal visit 

closest to 

delivery (not 

longer than 3 

weeks from 

delivery) 

Birth weight: 

NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 5.1 

G2: NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratios (95% CI) for 

cesarean delivery 

Groups 

G1: Below IOM 

G2: within IOM 

• G3: Above IOM 

Weight gain below IOM 

recommendations 

Results 

Crude OR 

G1: 0.82 (0.49, 1.36) 

G3:1.0 (0.62, 1.63) 

• AOR for weight 

gain above IOM 

recommendations: 

2.04 (95% CI 1.02, 4.05) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Race 

• Pre-gravid BMI 

• Pre-eclampsia 

• Height 

• Previous live births 

• Failure to progress 

• Breech presentation 

• Birth weight 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-510 

 Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period: 

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight 

change on pregnancy 

outcomes in obese 

women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) 

(n = 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 

37 or more weeks 

of gestation) 

liveborn, singleton 

infants during 

1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

• Imputed: 

• No 

• Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

• Black 

G1: 22 

G2: 23 

G3: 27 

• Hispanic 

NR 

• Asian/Pacific 

Islander 

NR 

• Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-511 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 

56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 

43% 

G3: GWG (lb)Less 

than 2: 15% 

• Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, 

and greater than 

35 lb gain 

• Collected 

from: 

• Routine pre-natal 

care or maternity 

records 

• Ascertained 

by: 

NR 

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Risk of cesarean delivery 

Groups 

G1: wt loss > 10 lbs 

G2: wt loss 2-9 lb 

G3: no change 

G4: 2-9 lb 

G5: 10-14 lb 

G6: 15-25 lb 

G7: 26-35 lb 

G8: >35 lb 

Results 

For all three classes of 

obese women, risks of 

cesarean delivery rise 

above an OR of 1 when 

weight gain exceeds 25 

pounds 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in 

medicaid 

• WIC 

• Food stamp programs) 

• Tobacco use 

• Chronic hypertension 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 6 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-512 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued)

 
C-513 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Other maternal outcomes: 

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA 

by GWG category for 

each obesity class. All 3 

figures show similar 

patterns of increasing risk 

of preeclampsia, cesarean 

delivery, and LGA birth 

and decreasing risk of 

SGA birth with increasing 

GWG. Collectively, 

minimal risk for all 4 

outcomes corresponds to 

GWG categories where 

risk of LGA and SGA 

births intersect. This 

equates to GWG of 10 of 

25 lb for class I obese 

women, a gain of 0 tp 9 lb 

for class II obese women, 

and weight loss of 0 to 9 

lb for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA 

by GWG category and 

obesity class. Compared 

with women who gained 

15 to 25 lb during their 

pregnancies, those who 

gained less weight had 

significantly lower odds of 

preeclampsia, cesarean 

delivery, and LGA births, 

but higher odds for SGA 

births. Women who 

gained more than 25 lbs 

had higher odds for same 

3 pregnancy outcomes 

and lower odds for SGA 

births. 

Other infant outcomes: 

NR 

 
C-514 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Parker and Abrams, 

1992 

Country and setting: 

USA, hospital 

Enrollment Period: 

Sept 1980 to Dec 1988 

Funding: 

UC Committee on 

Research & MCH and 

Resources 

Development, Health 

Resources and Services 

Administration 

Study Objective: 

To test whether gains 

outside IOM reference 

ranges were associated 

with increased risks of 

suboptimal pregnancy 

outcome (SGA, LGA, 

cesarean delivery) and 

to determine whether 

locally developed 

ranges were more 

applicable to study 

population 

Time frame: 

Sept 1980 to Dec 1988 

Duration of the study: 

From entry into prenatal 

care until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

6,690 

Group Description: 

G1: Overall 

G2: NR 

Group N: 

G1: 6,690 

G2: NR 

Inclusion criteria: 

• Consecutive live 

singleton births at 

Moffitt Hospital 

between 

September 1980 

and December 

1988 with 

gestational ages of 

37 to 42 weeks 

Exclusion criteria: 

• Maternal transfers 

or transports and 

deliveries 

complicated by fetal 

malformations, 

maternal diabetes, 

or maternal 

hypertension 

Pregravid weight: 

• Self-reported 

G1: 56.8 kg(SD 11.0) 

G2: NR 

Pregravid BMI: 

G1: Underweight: 27.7%, 

Normal weight 61.8%, 

Overweight: 5.6%, 

Obese 4.9% 

G2: NR 

• Imputed: 

• No 

• Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 27.7 (5.5) 

G2: NR 

Parity: 

Primiparous:

G1: 58.8% 

G2: NR 

Race,%: 

White 

G1: 44.0 

G2: NR 

• Black 

G1: 8.3 

G2: NR 

• Hispanic 

G1: 9.4 

G2: NR 

• Asian/Pacific 

Islander 

G1: 21.4 

G2: NR 

• Other 

G1: 12.0 

G2: NR 

Smoking,%: 

G1: 12.0 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-515 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 6690 

G2: NR 

Total weight gain: 

G1: 15.2kg (5.2) 

G2: NR 

• Categorize

d: 

• According to 

IOM Weight 

gain ranges 

based on 

percentiles 

from previous 

study of UC 

population with 

good 

pregnancy 

outcomes: 25th 

-75th, 10-90th 

percentiles. For 

25-75th, weight 

gain range = 

12-17kg for 

underweight 

women (BMI < 

19.8); 

• Collected 

from: 

• Routine prenatal care or 

maternity 

records 

• Ascertaine

d by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3408g (462) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Risks for cesarean delivery 

Groups 

G1: Below IOM 

G2: Above IOM 

Results 

AOR for all women weight 

gain >IOM (G2) =1.48 

(1.25,1.76) 

• For overweight 

women, there was no 

significant association 

between cesarean delivery 

and weight gain (AOR = 

0.71 (0.40-1.26). 

• For non-overweight 

women, the association 

between cesarean delivery 

and weight gain in nonoverweight women was 1.45 

(1.21 - 1.73) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Height 

• Maternal high and low 

weight gain 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-516 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2004 

Country and setting: 

USA, university hospital 

Enrollment Period: 

Not stated 

Funding: 

Grant HD01262, 

Women’s Reproductive 

Health Research 

Scholar 

Study Objective: 

To examine how 

association between 

excessive weight gain 

and cesarean birth is 

modified by infant birth 

weight in nondiabetic 

women 

Time frame: 

Not stated 

Duration of the study: 

During pregnancy until 

deliver 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

9,788 

Group Description: 

G1: All weight gain 

categories 

G2: Women gaining > 

IOM guidelines 

G3: Women gaining 

within IOM 

guidelines 

G4: Women gaining < 

IOM guidelines 

Group N: 

G1: 9,788 

G2: 4,675 

G3: 3,479 

G4: 1,634 

Inclusion criteria: 

• Singleton 

• Term 

Exclusion criteria: 

• Multiple gestation 

• Preterm birth (< 37 

completed weeks) 

• Birth weight less 

than 2500g 

• Multiparity 

• Noncephalic 

presentation 

• Gestational or 

pregestational 

diabetes 

• Placenta previa 

• Active herpes at 

delivery 

• Abdominal cerclage 

• Fetal anomaly 

requiring cesarean 

delivery 

• Missing data on 

maternal 

prepregnancy bmi 

• Missing data on 

gestational weight 

gain 

Pregravid weight: 

• Self-reported 

• Not stated - records 

Pregravid BMI: 

• Imputed: 

• No 

• Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26.6 

G2: 26.5 

G3: 26.8 

G4: 26.2 

Parity: 

NR 

Race,%: 

White 

G1: 45 

G2: 50 

G3: 43 

G4: 37 

• Black 

G1: 11 

G2: 11 

G3: 9 

G4: 14 

• Hispanic 

G1: 10 

G2: 10 

G3: 9 

G4: 10 

• Asian/Pacific 

Islander 

G1: 19 

G2: 15 

G3: 24 

G4: 24 

• Other 

G1: 11 

G2: 10 

G3: 12 

G4: 12 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-517 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 9788 

G2: 4675 

G3: 3479 

G4: 1634 

Total weight gain: 

• Categorize

d: 

• According to 

IOM 

• Collected 

from: 

• Routine prenatal care or 

maternity 

records 

• Ascertaine

d by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

measured as 

(1) difference 

between 

prepregnancy 

weight and last 

measurement 

prior to delivery 

and (2) 

absolute GWG 

= subtraction of 

infant birth 

weight and 

placental 

weight from 

total maternal 

weight 

Birth weight: 

G1: 3437 

G2: 3562 

G3: 3360 

G4: 3242 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Cesarean delivery 

Groups 

G1: Below IOM 

G2: Above IOM 

Results 

AOR with birth weight in 

model 

G1: 0.99 (0.82,1.19) 

G2 :1.40 (1.22,1.59) 

• BMI <19.8 

G1 =0.96 (0.67,1.37) 

G2 =1.93 (1.45,2.53) 

• BMI 19.8-26 

G1 =1.04 (0.81,1.33) 

G2 =1.26 (1.06,1.50) 

• BMI >26 

G1 =0.74 (0.38,1.44) 

G2 =1.21 (0.83,1.78) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Pre-gravid BMI 

• Year of delivery 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

• Birth weight 

• Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 6 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-518 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

Country and setting: 

Maternity records, 

Department of 

Obstetrics and 

Gynecology at 

Landspitali University 

Hospital, Iceland 

Enrollment Period: 

Funding: 

NR 

Study Objective: 

To investigate relation 

between gestational 

weight gain in women of 

normal prepregnant 

weight and 

complications during 

pregnancy and delivery 

in a population with high 

gestational weight gain 

and birth weight 

Time frame: 

NR 

Duration of the study: 

1998 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

614 

Group Description: 

G1: No complication 

G2: Complications in 

pregnancy or 

delivery 

G3: Complications in 

pregnancy 

G4: Complications in 

delivery 

Group N: 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Inclusion criteria: 

• Women of normal 

prepregnancy 

weight randomly 

selected within 1 

year (1998) 

• No history of 

diabetes, 

hypertension, CVD, 

or thyroid problems 

• Singleton births 

• 38 to 43 weeks 

gestation 

• 20 to 40 years of 

age 

• Routine fetal 

biometry at 18 to 20 

week ultrasound 

• Received early and 

regular antenatal 

care 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 63.1 (6.2) 

G2: 62.0 (5.6) P = 0.059 

G3: 61.7 (4.8) P = 0.174 

G4: 62.2 (6.1) P = 0.274 

Pregravid BMI: 

G1: 22.2 

G2: 22.4 )1.6) P = 0.270 

G3: 22.4 (1.5) P = 0.338 

G4: 22.3 P = 0.584 

• Imputed: 

• No 

• Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29 

G2: 29 P = 0.857 

G3: 29 P = 0.404 

G4: 29 P = 0.398 

Parity: 

NR 

Race,%: 

White 

NR 

• Black 

NR 

• Hispanic 

NR 

• Asian/Pacific 

Islander 

NR 

• Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Proportional weight gain, %:

G1: 26.0 

G2: 28.0 P = 0.018 

G3: 30.0 P = 0.005 

G4: 27.0 P = 0.546 

Additional characteristics: 

NR 
C-519 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Total weight gain: 

G1: 16.6 (4.9) 

G2: 17.4 (5.1) P = 0.080 

G3: 18.4 (5.1) P = 0.013 

G4: 16.9 (5.1) P = 0.887 

• Categorized: 

• According to IOM 

< 11.5, 11.-16.0, 

≥ 16.1, also quintiles 

< 12.5, 12.5-15.5, 

15.6-17.8, 17.9-20.8, 

> 20.8 

• Collected from: 

• Routine pre-natal 

care or maternity 

records 

• Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery, not stated - 

based on records? 

Birth weight: 

G1: 3789 (469) 

G2: 3749 (565) P = 0.389 

G3: 3643 (526) P = 0.032 

G4: 3806 (578) P = 0.529 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Percent cesarean 

deliveries 

Groups 

G1 <11.5 kg 

G2 11.5-16 kg 

G3 16.1-20 kg 

G4 >20 kg 

Results 

G1: 17.4% 

G2: 9.5% 

G3: 12.9 % 

G4: 13.1% 

• No significant 

differences in cesarean 

delivery rates by IOM 

weight gain categories in 

normal weight women 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Parity 

• Height 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-520 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

Study Description 

Study Design 

Patient Population 

Inclusion/ Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1995 

Country and setting: 

USA 

university prenatal 

clinics 

Enrollment Period: 

Dec 1985 to Oct 1988 

Funding: 

NIH 

MCH grant 

Study Objective: 

To examine relationship 

between prenatal weight 

gain and spontaneous 

preterm delivery using 

IOM guidelins 

Time frame: 

Dec 1985 to Oct 1988 

Duration of the study: 

Entry into prenatal care 

until delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1518 

Group Description: 

G1: Black women 

G2: White women 

Group N: 

G1: 677 

G2: 338 

Inclusion criteria: 

• Low income 

• Multiparous women 

• Must have at least 

1 risk factor: > 2 

spontaneous 

abortions 

• previous 

stillborn/neonatal 

death 

• previous birth < 37 

weeks 

• previous birth < 

2750g 

• maternal height < 

157cm 

• maternal weight < 

50kg 

• hypertension 

• history of phlebitis 

• current alcohol use 

• current smoking 

• first visit after 26 

weeks gestation 

Exclusion criteria: 

• Outlying or missing 

prepregnancy 

weight 

• Missing height 

• Prepregnancy BMI 

> 26.0 

• Multiple births 

• Missing data for 

type of preterm 

delivery 

• Indicated preterm 

delivery 

Pregravid weight: 

• Self-reported 

G1: 55.8 (8.4) 

G2: 54.1 (7.9) 

Pregravid BMI: 

G1: < 19.8: 37.7% 

19.8-26.0: 62.3% 

G2: < 19.8: 43.3% 

19.8-26.0: 57.7% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean 

yrs): 

G1: 24.8 (4.4) 

G2: 24.4 (4.4) 

Parity: 

G1: 1: 58.9%; 2: 41.1% 

G2: 1: 68.6%; 2: 31.4% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 34.6 

G2: 75.7 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-521 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: First trimester: 353 

Second trimester: 474 

Third trimester: 615 

G2: First trimester: 175 

Second trimester: 244 

Third trimester: 301 

Total weight gain: 

G1: First trimester: 

Low BMI -2.61 (2.91); 

Normal BMI- 2.54 (3.68); 

Second trimester: 

Low BMI: 0.49 (0.19) 

Normal BMI: 0.46 (0.21) 

Third trimester: 

Low BMI- 0.46 (0.27) 

Normal BMI-0.45 (0.27) 

G2: First trimester: low BMI -

2.93 (3.39); normal 

Categorized: 

• According to IOMweight 

gain by trimester 

Collected from: 

• Routine pre-natal care 

or maternity records 

Ascertained by: 

• Based on last clinically 

measured weight prior 

to delivery: using weight 

measured at last visit 

prior to delivery 

Birth weight: 

NR 

Gestational diabetes 

%: 

NR 

Cesarean delivery 

%: 

NR 

Instrumental 

delivery 

%: 

NR 

Episiotomy 

%: 

NR 

Other maternal 

outcomes: 

• Low first 

trimester weight 

gain: < 2.3kg for 

low BMI women 

and < 1.6kg for 

normal BMI 

women 

• Low second and 

low third 

trimester weight 

gain: < 

0.38kg/wk for low 

BMI women and 

< 0.37 kg/wk for 

normal BMI 

women 

Other infant 

outcomes: 

• Spontaneous 

preterm birth: 

12.4% in black 

women and 8.0% 

in white women 

Outcomes Description: 

Odds ratio(95% CI) for 

spontaneous preterm; and 

pattern of weight gain 

Groups 

G1: Low rate of weight gain 

first trimesterunderweight (BMI < 19.8) & < 

2.3 kg and normal weight (BMI 

19.8-26)& < 1.6 kg 

G2: Low rate of weight gain in 

second trimester (Underwt & < 

0.38 kg/wk or normal wt & < 

0.37 kg/wk) 

G3: Low rate of weight gain in 

third trimester (Underwt & < 

0.38 kg/wk or normal wt & < 

0.37 kg/wk) 

Results 

OR (95% CI) for Spontaneous 

Preterm 

G1 1.27 (0.7 

2.3) 

G2 1.23 (0.7 

2.18) 

G3 2.46 (1.53 

3.92) 

Pattern of weight gain 

G1 only 2.94 (0.73 

11.98) 

G2 only 1.08 (0.1 

11.23) 

G3 only 11.54 (2.93 

45.28) 

G1 & G2 4.89 (0.85 

28.14) 

G1 & G3 4.49 (0.96 

20.96) 

G2 & G3 7.37 (1.66 

32.76) 

All trimesters 4.18 (0.75 

23.35) 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-522 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

Study Description 

Study Design 

Patient Population 

Inclusion/ Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1995 

(continued) 

 
C-523 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

 Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Race 

• Pre-gravid BMI 

• Height 

• Alcohol use 

• History of previous infant 

less than 2750g 

• Number of days between 

last weight observation 

and delivery 

• Smoking 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

Infant sex 
C-524 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Study Description 

Study Design 

Patient Population 

Inclusion/ Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, Year: 

Schieve et al., 2000 

Country and setting: 

USA 

National Maternal and 

Infant Health Survey 

Enrollment Period: 

1988 

Funding: 

NR 

Study Objective: 

To examine 

associations between 

rate of pregnancy 

weight gain and preterm 

delivery among women 

of varying prepregnancy 

body mass indices 

(BMI) 

Time frame: 

1988 

Duration of the study: 

From initiation of 

prenatal care to delivery 

Design: 

• Cohort 

• Combination: 

medical charts but 

then women were 

asked to self report 

info after pregnancy 

Total Study N: 

3,511 

Group Description: 

G1: Preterm 

G2: Term 

Group N: 

Inclusion criteria: 

• Singleton births 

delivered between 

28 and 43 weeks’ 

gestation wtih data 

available for 3 or 

more prenatal 

weight 

measurements 

between 14 and 28 

weeks’ gestation 

Exclusion criteria: 

• Women with weight 

gain per week of > 

5.0 lb. or less than -

2.5lb. Women 

missing data for 

prepregnancy 

weight or height 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean 

yrs): 

G1: Age at delivery (y): 

15–19 12.5%* 

20–29 56.0% 

30–50 31.6% 

G2: Age at delivery (y) 

15–19 8.3% 

20–29 60.3% 

30–50 31.4% 

Parity: 

Parity 0 

G1: 49.9% 1 31.8% 2 or 

more 18.3% 

G2: 47.7%1 30.8%2 or more 

21.6% 

Race,%: 

White 

G1: 67.1% 

G2: 81.1% 

Black 

G1: 20.9% 

G2: 9.1% 

Hispanic 

G1: 12.1% 

G2: 9.8% 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 38.2 

G2: 32.4 

Diabetes mellitus,%: 

G1: 6.4 

G2: 4.4 

Hypertension,%: 

G1: 10.9 

G2: 6.6 

Additional characteristics: 

Marital status:

G1: Married 72.1% 

Not married 27.9% 

G2: Married 84.2% 

Not married 15.8% 

Additional characteristics: 

Maternal education

G1: Less than high school 17.8% 

High school 43.0% 

More than high school 39.3% 

G2: Less than high school 12.7% 

High school 39.9% 

More than high school 47.4% 
C-525 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to 

IOM pounds 

per week: Low 

- 0.5 or 

less/week; 

average 0.5-

1.5 lb/week; 

high > 1.5 

lb/week 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

deliveryNR 

Birth weight: 

NR 

Gestational 

diabetes 

%: 

G1: 6.4 

G2: 4.4 

Cesarean 

delivery,%: 

Instrumental 

delivery 

%: 

NR 

Episiotomy 

%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Adjusted odds ratio for 

preterm birth 

Groups 

G1: Low < 0.5 less/week; 

G2: Average 0.5-1.5 

lb/week 

G3: High > 1.5 lb/week 

Results 

Low BMI: 

G1=6.7 (1.1 

40.6) 

G2=0.8 (0.4 

1.4) 

G3=1.0 (0.4 

2.6) 

Average BMI: 

G1=3.6 (1.6 

8.0) 

G2 (Reference) 

G3=1.0 (0.6 

1.9) 

High BMI: 

G1=1.6 (0.7 

3.5) 

G2=1.1 (0.6 

2.1) 

G3=0.1 (0.03 

0.6) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Race 

• Parity 

• Marital status 

• Education 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

6 Good, 3 Fair, 0 Poor 

Final Quality Score: 

Good 
C-526 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Study Description 

Study Design 

Patient Population 

Inclusion/ Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, Year: 

Siega-Riz et al., 1994 

Country and setting: 

USA 

public health clinics 

Enrollment Period: 

1983 to 1986 

Funding: 

March of Dimes 

NIGMS-predoc grant 

Study Objective: 

To describe gestational 

weight gain patterns by 

prepregnancy weight 

and trimester of 

pregnancy 

and to examine risk of 

preterm birth associated 

with prepregnancy 

weight and gestational 

weight gain using 

various definitions of 

adequacy based on 

IOM 

Time frame: 

1983 to 1986 

Duration of the study: 

Entry into prenatal care 

up to delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

5854 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

Inclusion criteria: 

• Women attending 8 

public health clinics 

in West Los 

Angeles area 

• Only included first 

pregnancy for 

which women 

received care 

Exclusion criteria: 

• Women who left 

prenatal care 

setting after at least 

2 visits with no birth 

outcome available 

• Mismatched 

prenatal and 

outcome files 

• Erroneous 

gestational age 

• Pregnancy 

complications 

(diabetes 

• hypertension 

• Stillbirths 

• Multiple 

pregnancies 

• Implausible values 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Underweight: 12%; 

Normal weight: 60%; 

Overweight: 17.7%; 

Obese: 10.5% 

G2: NR 

Imputed: 

• Yes 

Categorized: 

• IOM guidelines 

Age (mean 

yrs): 

G1: 24.3 

G2: NR 

Parity: 

Primiparous:

G1: 35% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

G1: 80 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Married:

G1: 61% 

G2: NR 

Less than 12 years of 

education: 

G1: 71% 

G2: NR 
C-527 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: Underweight 

women: 

14.3kg; 

Normal weight: 

13.7 kg; 

Overweight: 

12kg; 

Obese: 11.7kg 

G2: NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3424 

G2: NR 

Gestational 

diabetes 

%: 

NR 

Cesarean delivery 

%: 

NR 

Instrumental 

delivery 

%: 

NR 

Episiotomy 

%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Risk of preterm birth 

Groups 

Total weight gain 

expressed as a ratio of 

observed: expected based 

on the IOM 

recommendation for a 

given gestational age 

Results- outcomes by 

groups Preterm birth (< 37 

weeks) 

• Adequacy of weight 

gain in the third 

trimester was 

predictive of preterm 

birth - the data 

suggested a threshold 

effect for all weight 

status groups with a 

marked decrease in 

risk at 90-110% of the 

IOM recommendation 

• With the rate of weight 

gain less than 60% of 

the IOM value 

• women in all four 

groups had more than 

double the risk of 

delivering preterm 

• which was statistically 

significant for all but 

the obese category 

• Excessive rate of 

weight gain was 

signficantly associated 

with a preterm birth 

only for women of 

normal prepregnancy 

weight status at a 

value greater than 

200% of the IOM value 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Pre-gravid BMI 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Good 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

4 Good, 3 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-528 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Study Description 

Study Design 

Patient Population 

Inclusion/ Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, Year: 

Stotland et al., 2006 

Country and setting: 

USA 

academic medical 

center 

Enrollment Period: 

1976 to 2001 

Funding: 

NIH 

Study Objective: 

To study how 

relationship between 

gestational weight gain 

and spontaneous 

preterm birth interacts 

with maternal race or 

ethnicity and previous 

preterm birth status 

Time frame: 

1976 to 2001 

Duration of the study: 

From entry into prenatal 

care until delivery 

(actually used a 

perinatal data base and 

looked at info) 

Quality: 

Fair 

Design: 

• Perinatal data base 

review 

• Retrospective 

Total Study N: 

15,101 

Group Description: 

G1: Total 

G2: White 

G3: African American 

G4: Latina 

G5: Asian 

Group N: 

G1: 15,101 

G2: 6,513 

G3: 1,533 

G4: 1,614 

G5: 3,440 

Inclusion criteria: 

• Women of low or 

normal 

prepregnancy BMI 

delivering singleton 

during study period 

with complete data 

on all variables 

considered 

Exclusion criteria: 

• Multiple gestations 

• Hypertension 

• Diabetes 

• Delivery before 24 

weeks of gestation 

• Congenital 

anomalies 

• Missing data on 

any key variables 

• Prepregnancy BMI 

of 26 or greater 

• Transport from 

another hospital 

Pregravid weight: 

• Self-reporteddata base 

Pregravid BMI: 

G1: Low 29.6%; Normal 

70.4% 

G2: Low25.9%; Normal 

74.1% 

G3: Low 23.0%; Normal 

77% 

G4: Low 19%; Normal 81% 

G5: Low 42.2%; 57.9% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Low (< 19.8) 

Normal (19.8-25.9) but 

this is not explicitly 

stated 

Age (mean 

yrs): 

G1: 28.19 

G2: 29.43 

G3: 24.25 

G4: 26.17 

G5: 29.10 

Parity: 

Nulliparous

G1: 53.8% 

G2: 57.5 

G3: 48.0 

G4: 49.0 

G5: 52.9 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 10.9% 

G2: 14.5% 

G3: 21.4% 

G4: 6.7% 

G5: 4.5% 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Previous preterm birth (%)

G1: NR 

G2: 4.4 

G3: 4.1 

G4: 8.3 

G5: 5.58 

G6: 2.91 

Additional characteristics: 

NR 
C-529 

Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate 

Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 15,101 

G2: 6,513 

G3: 1,533 

G4: 1,614 

G5: 3,440 

Total weight gain: 

G1: Below IOM: 20.5; 

% Within IOM 

39.1%; 

Above 40.4% 

P < .001 

G2: Below 15.5%; 

Within 38.5%; 

above 46.1% 

P < .001 

G3: Below 16.9%; 

Within 30.9%; 

Above 41.2% 

P < .001 

G4: Below 21.1%; 

Within 37.4%; 

Above 41.5% 

P < .001 

G5: Below 25.4%; 

Within 

Categorized: 

• Continuous 

• According to IOM3-

way categorical 

variable 

• low (less than 0.27 

kg/wk) 

• normal 

(between0.27 and 

0.52 kg/wk) 

• and high (greater 

than 0.52kg/wk) 

Collected from: 

• Rate of weight gain 

was determined 

by:total weight gain 

divided by GA 

minus 2 weeks 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes 

%: 

NR 

Cesarean 

delivery 

%: 

NR 

Instrumental 

delivery 

%: 

NR 

Episiotomy 

%: 

NR 

Other maternal 

outcomes: 

• Spontaneous 

PTB for 

• All women 

4.0% 

• White 3.6% 

• Blacks 6.8% 

• Latinas 4.4% 

• Asians 3.6% 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Odds ratio of spontaneous 

preterm birth 

Groups 

G1: low rate of weight gain 

<.27 kg/wk 

G2: ref 0.27-0.52 kg/wk 

G3: high rate of weight gain 

>0.52 kg/wk 

Results 

Crude OR 

G1: 2.6 (95% CI 2.1–3.2) 

G3: 1.0 (95% CI 0.8–1.2) 

AOR 

G1: 2.5 (95% CI 2.0–3.1) 

G3: 1.0 (95% CI 0.8–1.3) 

No differences in results by 

parity combined with Hx 

PTB 

Slightly higher risks for Af 

Am and high wt gain close 

to sign for Af Am 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Race-EMM 

• Parity-EMM 

• Pre-gravid BMI 

• History of previous 

PTB 

• Year of delivery 

• Number of days 

between last weighing 

and DOB 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-530 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-531 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

Increase in birthweight 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results 

G1: 3,302 

G2: 3,192 

G3: 3,337 

G4: 3,506 

G5: 3,453 

(P < 0.05) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-532 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1997 

Country and setting: 

USA, public health 

programs 

Enrollment Period: 

Jan 1993 to Dec 1994 

Funding: 

MCH grant, University 

of Alabama School of 

Public Health/NIH 

Intamural Basic 

Sciences Research 

grant 

Study Objective: 

Examine differences in 

birth weight among term 

infants of black and 

white women with 

weight gains in upper or 

lower half of 

recommended ranges 

Time frame: 

Jan 1993 to Dec 1994 

Duration of the study: 

From first visit to 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5198 

Group Description: 

G1: Black 

G2: White 

Group N: 

G1: 2219 

G2: 3699 

Inclusion criteria: 

• Women enrolled in 

Medicaid Maternity 

Waiver programs 

operated in 24 

counties by Alabama 

Department of 

Public Health during 

study period 

Exclusion criteria: 

• Delivered before 37 

weeks or after 42 

weeks 

• Maternal age ≤ 17 

years 

• Last prenatal weight 

recording more than 

3 weeks before 

delivery 

• Maternal risk factors 

(diabetic, cardiac, 

genetic, and 

obstetric 

conditions/complicati

ons) requiring 

external referral 

• Multiple fetuses 

• Stillborn/neonatal 

death 

• Missing or outlying 

anthropometric data 

• Missing data for 

ethnicity 

• Missing gestational 

age 

• Congenital 

anomalies 

• Missing birth weight 

• Invalid country code 

Pregravid weight: 

• Self-reported 

G1: 70.8 (19.6) 

G2: 65.8 (17.6) 

Pregravid BMI: 

G1: 26.6 (7.1) 

G2: 24.8 (6.3) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 23.7 (5.0) 

G2: 23.4 (4.6) 

Parity: 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Smoking,%: 

G1: 9.2 

G2: 35.1 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-533 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to 

IOMgain below 

range (for 

pregravid BMI), 

gain in lower 

range, gain in 

upper range, 

gain above 

range 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery, %: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Birth Weight (gms) by IOM Categories 

Groups 

G1: Below IOM Range 

G2: Lower end of IOM Range 

G3: Upper end of IOM range 

G4: Gain above IOM range 

Results 

BMI < 19.8 

G1: 

Black: 2840 

White: 3002 

G2: 

Black: 2995 

White: 3151 

G3: 

Black: 3017 

White: 3200 

G4: 

Black: 3163 

White: 3353 

BMI19.8-26.0 

G1: 

Black: 3052 

White: 3176 

G2: 

Black: 3105 

White: 3199 

G3: 

Black: 3180 

White: 3307 

G4: 

Black: 3228 

White: 3389 

BMI > 26.0 

G1: 

Black: 3126 

White: 3385 

G2: 

Black: 3192 

White: 3376 

G3: 

Black: 3312 

White: 3402 

G4: 

Black: 3300 

White 3504 

Background: 

Good 

Sample 

selection: 

Good 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

5 Good, 3 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-534 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1997 

(continued)

 
C-535 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Age 

• Education 

• Height 

• Street drugs 

• Alcohol use 

• Time between last 

prenatal weight 

observation and 

delivery 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

• Infant sex 
C-536 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1996 

Country and setting: 

USA, university prenatal 

clinics 

Enrollment Period: 

Dec 1985 to Oct 1988 

Funding: 

Maternal and Child 

Health grant 

Study Objective: 

To examine association 

between prenatal weight 

gain patterns and birth 

weight using IOM 

guidelines 

Time frame: 

Dec 1985 to Oct 1988 

Duration of the study: 

During prenatal care to 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

415 

Group Description: 

G1: Black 

G2: White 

Group N: 

G1: 275 

G2: 140 

Inclusion criteria: 

• Women who 

identified as black or 

white, were 

nonobese, and were 

para 1 or 2 and who 

enrolled in prenatal 

care clinic with at 

least one or more of 

following risk factors: 

> 2 spontaneous 

aboritions, previous 

stillborn/neonatal 

death, previous birth 

< 37 weeks GA, 

previous birth < 

2750g, maternal 

height < 157cm, 

maternal weight < 

50kg, hypertension, 

history of phlebitis, 

current alcohol use, 

current smoking 

Exclusion criteria: 

• Women with missing 

or outlying 

prepregnancy weight 

data 

• Prepregnancy BMI 

exceeding 26.0 

• Multiple births 

• Delivery before 37 

weeks gestation 

• Prenatal weight 

observations that did 

not fall within time 

frames specified at 

beginning and end 

of any trimester 

Pregravid weight: 

• Self-reported 

G1: 55.2 (9.0) 

G2: 53.8 (7.7) 

Pregravid BMI: 

G1: < 19.8: 42.9% 

19.8-26.0: 57.1% 

G2: < 19.8: 41.4% 

19.8-26.0: 58.6% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 25.8 (4.2) 

G2: 25.2 (4.3) 

Parity: 

G1: 1: 61.4%; 2: 38.6% 

G2: 1: 68.6%; 2: 31.4% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Smoking,%: 

G1: 35.6 

G2: 77.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 0.7 

G2: 0.0 

Additional characteristics: 

NR 
C-537 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 415 

G2: 415 

G3: 275 

G4: 275 

G5: 140 

G6: 140 

Total weight gain: 

G1: First trimester: 2.6 (3.2) 

Second trimester: 0.50 (0.17) 

Third trimester: 0.47 (0.24) 

G2: First trimester: 2.4 (3.5) 

Second trimester: 0.49 (0.22) 

Third trimester: 0.46 (0.26) 

G3: Total weight gain: 14.2 (4.4) 

First trimester: 2.4 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal care or 

maternity records 

Ascertained by: 

• Based on last clinically 

measured weight prior to 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• First trimester 

weight gain (kg) 

was compared to 

IOM guideline for 

low BMI women 

= 2.3kg and 

normal BMI 

women = 1.6kg 

• Second and third 

trimester weight 

gain (kg/wk) was 

compared to IOM 

guideline for low 

BMI women = 

0.49 kg/wk and 

normal BMI 

women = 0.44 

kg/wk 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Birth weight 

Groups 

G1: First Trimester <2.6 kg 

for underwt & <1.6 kg 

for normal wt 

G2: Second Trimester 

<0.38 kg/wk for 

underwt & <0.37 kg/wk 

for normal wt 

G3: <0.38 kg/wk for 

underwt & <0.37 kg/wk 

for normal wt 

Results 

Association of low trimester 

gain with birthweight 

G1: All women -18 g p=.65 

 Black -15 g P = .76 

 White -42 g P = .53 

G2: All women -166g 

p=<.001 

Black -164 g P = .005 

White -158 g P = .05 

G3: All women -111g 

p=.008 

Black -77 g P =.14 

White -194 g P =.004 

No association with low 

weight gain in only the first 

or second trimester. 

G3: All -164 g P = .01 

Black -80 g P = .38 

White -300 g P =.005 

Association with low weight 

gain during more than one 

trimester 

G1 & G2: 

All -236 g P = .01 

Black -265 g P = .04 

White -169 g P = .25 

G1 & G3: No significant diff 

G2 & G3: 

All -206 g P = .01 

Black -178 g P = .08 

White -268 g P = .06 

G1, G2 & G3: 

All -284 g P = .002 

Black -252g P = .03 

White -379g P = .008 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-538 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1996 

(continued) 

• Prenatal weight 

observations that 

did not fall within 

time frames 

specified at 

beginning and end 

of all 3 trimesters 

 
C-539 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Race 

• Pre-gravid BMI 

• Height 

• Alcohol use 

• Third trimester number 

of weeks between last 

weight observation and 

delivery 

• History of previous 

infant < 2750 g 

• Smoking 

• Gestational age 

• Infant sex 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

• Infant sex 
C-540 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1993 

Country and setting: 

USA, prenatal clinics 

Enrollment Period: 

December 1985 to 

October 1998 

Funding: 

NIH, Maternal and Child 

Health Department, and 

Agency for Health care 

policy and research 

grants 

Study Objective: 

To examine association 

of prenatal weight gain 

below, within, and 

above IOM guidelines 

with birth weight and 

fetal growth restriction 

among low income, high 

risk black and white 

women 

Time frame: 

December 1985 to 

October 1998 

Duration of the study: 

Entry to prenatal care 

until delivery 

Design: 

• Cohort 

• Combination, 

perinatal database 

Total Study N: 

1,168 

Group Description: 

G1: black 

G2: white 

Group N: 

G1: 803 

G2: 365 

Inclusion criteria: 

At least 1 of following risk 

factors: 

• History of more than 

2 spontaneous 

abortions 

• Previous fetal or 

neonatal death 

• Previous live birth 

before 37 weeks’ 

gestation 

• Previous infant 

weighing less than 

2750g 

• Maternal height less 

than 157cm 

• Prepregnancy 

weight less than 

50kg 

• First prenatal visit 

before 26 weeks’ 

gestation 

• Hypertension 

(systolic bp above 

140mmHg or 

diastolic bp above 

90 mmHg) 

• Current use of 

cigarettes or alcohol 

• 15% random sample 

of multiparous 

women in clinic 

population was also 

included after it was 

determined that 70% 

of these women 

exhibited one or 

more of the risk 

factors (listed above) 

Pregravid weight: 

• Self-reported 

G1: 63.9 (17.1) 

G2: 61.0 (16.0) 

Pregravid BMI: 

G1: < 19.8: 27.5% 

19.8-26.0: 43.6% 

> 26.0-29.0: 10.5% 

> 29.0: 18.4% 

G2: < 19.8: 32.3% 

19.8-26.0: 46.0% 

> 26.0-29.0: 8.0% 

> 29.0: 13.7% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 25.2 (4.4) 

G2: 24.8 (4.4) 

Parity: 

Para 1: 

G1: 1: 59.3% 

G2: 1: 68.2% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 37.1 

G2: 73.4 

Diabetes mellitus,%: 

G1: 5.8 

G2: 9.6 

Hypertension,%: 

G1: 2.7 

G2: 1.1 

Additional characteristics: 

Married: 

G1: 24.9% 

G2: 65.6% 
C-541 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 803 

G2: 365 

Total weight gain: 

Categorized: 

• According to 

IOM 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between self 

report and last 

measure 

weight (76,4% 

made within 2 

weeks prior to 

delivery) 

Birth weight: 

G1: 3227 (440) 

G2: 3358 (467) 

Gestational 

diabetes, %: 

G1: 5.8 

G2: 9.6 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Adjusted birthweight 

Groups 

BMI ≤ 29 

G1: gain < range 

G2: gain in the range 

G3: gain > range 

BMI >29 

G4: gain <6.0 kg 

G5: gain >6.0 kg 

Results 

G1 Black 3027 White 3246 

G2 Black 3177 White 3233 

G3 Black 3293 White 3523 

G4 Black 3214 White 3500 

G5 Black 3553 White 3596 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Maternal height 

• Education 

• Parity 

• Marital status 

• Smoking 

• Alcohol use 

• Hypertension 

• GDM 

• Gestational age at 

delivery 

• SES 

• Time between last 

weight and delivery 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

• Infant sex 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

5 Good, 4 Fair, 0 Poor 

Final Quality Score: 

Good 
C-542 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Luke et al., 1996 

Country and setting: 

USA, clinic 

Enrollment Period: 

March 1, 1974 to June 

15, 1979 

Funding: 

NR 

Study Objective: 

Reanalysis of original 

data to examine 

contribution of maternal 

weight gain to infant 

birth weight and 

retained maternal 

weight in immediate 

postpartum period, and 

effect of weight gains 

below, at, and above 

IOM guidelines on both 

infant birt 

Time frame: 

March 1, 1974 to June 

15, 1979 

Duration of the study: 

Prenatal visit through 2 

days postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

487 

Group Description: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

Group N: 

G1: 104 

G2: 268 

G3: 115 

Inclusion criteria: 

• Referred for 

nutrition counseling 

• > 37- < 43 weeks 

gestation 

• Singleton 

pregnancy 

Exclusion criteria: 

• Women with history 

of or concurrent 

metabolic disease, 

such as diabetes, 

seizure disorder, 

hypertension, 

cardiac disease, 

asthma, or drug 

dependence 

• Women developing 

antepartum 

complications such 

as preeclampsia, 

GDM, or multiple 

gestation 

Pregravid weight: 

• Self-reported 

G1: 47.9 (5.1) 

G2: 58.7 (6.3) 

G3: 83.9 (16.9) 

Pregravid BMI: 

G1: 18.3 (1.0) 

G2: 22.6 (1.7) 

G3: 31.7 (5.3) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 23.1 (5.5) 

G2: 23.8 (5.5) 

G3: 27.4 (6.2) 

Parity: 

% primipara:

G1: 60.6 

G2: 48.1 

G3: 27.0 

Race,%: 

White 

NR 

Black 

G1: 48.1 

G2: 48.8 

G3: 63.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 17.3 

G2: 15.3 

G3: 13.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-543 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 104 

G2: 268 

G3: 115 

Total weight gain: 

G1: 12.6 (0.7) 

G2: 13.2 (0.4) 

G3: 11.7 (0.7) 

Significantly 

different from mean 

for normal BMI 

group at P < 0.05 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: total 

weight gain: 

difference 

between last 

measurement 

and pregravid 

weight; net 

weight gain: 

difference 

between 

pregravid 

weight and last 

measured 

weight minus 

infant birth 

weight 

Birth weight: 

G1: 3,067 (44) 

P < 0.05 

significantly 

different from 

mean for normal 

BMI 

G2: 3308 (27) 

G3: 3300 (43) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Net gain (kg): 9.5 

(0.6), 9.9 (0.4), 

7.8 (0.6) 

significantly 

different from 

mean for normal 

BMI group at P < 

0.05 

• Retained weight 

(kg): 6.6 (0.6), 

6.6 (0.4), 4.2 

(0.6) significantly 

different from 

mean for normal 

BMI group at 

P < 0.05 

• Percent retained 

weight (%): 11.4 

(0.9), 9.4 (0.5), 

4.4 (0.8) 

significantly 

different from 

mean for normal 

BMI group at 

P < 0.05 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Adjusted birthweight 

Groups 

G1: Gain <IOM 

G2: gain equal to IOM 

G3: gain > IOM 

Results 

G1: BMI <19.8 2873g* 

 BMI 19.8-26.0 3157 g* 

 BMI >26 3138 g 

G2: BMI <19.8 3190 g 

 BMI 19.8-26 3298g 

 BMI >26 3338g 

G3 BMI <19.8 3489g* 

 BMI 19.8-26 3494g* 

 BMI >26 3347g 

* significantly different from 

gains within range within 

each BMI grouping 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Maternal age 

• Parity 

• Black ethnicity 

• Smoking 

• Gestational duration 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• fetal sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-544 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

May, 2007 

Country and setting: 

United States, WIC 

clinics 

Enrollment period: 

As of February 2001 

Funding: 

NR 

Study Objective: 

Study was designed to 

test predictors of infant 

birth weight based on 

categories of 

prepregnancy BMI, 

GWG, and smoking 

Time frame: 

As of February 2001 

Duration of the study: 

NR 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

233 

Group Description: 

G1: Total 

NR 

Group N: 

G1: 233 

NR 

Inclusion criteria: 

• Singleton live birth 

with gestation 

length between 36 

to 44 weeks 

Exclusion criteria: 

NR 

Pregravid weight: 

• Self-reported 

G1: 70.3kg (20.4) 

Pregravid BMI: 

G1: 26.7kg (7.0) 

• Imputed: 

• No 

• Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 24.7 (5.3) 

Parity: 

G1: 29.2% Primipara 

Race,%: 

White 

G1: 58.8 

Black 

G1: NR 

Hispanic 

G1: 31.8 

Asian/Pacific Islander 

G1: NR 

Other 

G1: 9.4 

Smoking,%: 

G1: 23.6% 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-545 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Birthweight Beta’s from 

multiple linear regression 

Groups 

G1: Below IOM 

G2: Greater IOM

Results 

G1: -162 g 

G2: -153 g

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

• Maternal BMI 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

• Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

1 Good, 6 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-546 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nielsen et al., 2006 

Country and setting: 

USA, clinic 

Enrollment Period: 

1990 to 2000 

Funding: 

NR 

Study Objective: 

To examine whether 

such weight gains 

improve birth outcomes 

in a cohort of 

disadvantaged African 

American adolescents 

Time frame: 

1990 to 2000 

Duration of the study: 

First prenatal care visit 

to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

815 

Group Description: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

Group N: 

G1: 193 

G2: 431 

G3: 191 

Inclusion criteria: 

• Adolescents ≤ 17 

years at conception 

• African American 

pregnancies 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 18.3 (1.1) 

G2: 22.4 (1.6) 

G3: 30.9 (4.6) 

Imputed: 

• Yes 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: mean age at infant birth 

(SD): 16.9 (1.2) 

G2: 16.8 (1.1) 

G3: 17.0 (1.1) 

Parity: 

% primiparous:

G1: 83.9 

G2: 85.2 

G3: 74.9 

Race,%: 

White 

NR 

Black 

G1: 100 

G2: 100 

G3: 100 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 11.4 

G2: 9.7 

G3: 10.5 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-547 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 193 

G2: 431 

G3: 191 

Total weight gain: 

G1: < IOM: 30.3%; 

lower half of 

IOM: 18.1%; 

upper half of 

IOM: 21.9%; > 

IOM: 29.7% 

G2: < IOM: 31.3%; 

lower half of 

IOM: 16.1%; 

upper half of 

IOM: 17.6%; > 

IOM: 35.0% 

G3: < IOM: 16.5%; 

lower half of 

IOM: 9.4%; 

upper half of 

IOM: 10.6%; > 

IOM: 63.5 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between final 

recorded 

weight within 4 

weeks delivery 

and selfreported 

prepregnancy 

weight 

Birth weight: 

G1: 2899 (595) 

G2: 3083 (645) 

P < 0.005 

compared to BMI < 

19.8 

G3: 3181 (673) 

P < 0.005 

compared to BMI < 

19.8 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Size for 

gestational age 

(small, 

average, large) 

• Birth weight 

category 

(suboptimal 

< 3000g, 

optimal 3000-

4000g, above 

optimal 

> 4000g) 

Outcomes Description: 

Adjusted birthweight in 

grams 

Groups 

G1: <IOM 

G2: lower half IOM range 

G3: Upper half IOM range 

G4: >IOM 

Results 

Adjusted birthweight <19.8 

grams 

G1: 2986 g 

G2: 3167 g 

G3:3198 g 

G4:3277 g 

All significantly different 

from each other except G2 

& G3 

Adjusted birthweight 19.8 to 

26 grams 

G1: 3018 g 

G2: 3166 g 

G3: 3255 g 

G4: 3318 g 

All significantly different 

from each other 

Adjusted birthweight >26 

grams 

G1: 3127 g 

G2: 3351 g 

G3: 3384 g 

G4: 3434 g 

G1 significantly different 

from the others, G2 ,G3 & 

G4 not significantly different 

from each other 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Parity 

• Pre-gravid BMI 

• Pre-eclampsia 

• Time between last 

weight measure and 

delivery 

• Height 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Infant sex 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Good 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

6 Good, 3 Fair, 0 Poor 

Final Quality Score: 

Good 
C-548 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ogunyemi et al., 1999 

Country and setting: 

USA, hospital 

Enrollment Period: 

1990 to 1995 

Funding: 

NR 

Study Objective: 

To test IOM guidelines 

in a predominantly rural 

black population 

Time frame: 

1990 to 1995 

Duration of the study: 

582 women who 

delivered and then their 

medical record was 

abstracted 

Design: 

• Other observational 

: 582 women 

consecutive women 

who delivered 

• Retrospective 

Total Study N: 

582 

Group Description: 

G1: Underweight 

G2: Normal 

G3: Overweight 

G4: Obese 

Group N: 

G1: 78 

G2: 223 

G3: 78 

G4: 203 

Inclusion criteria: 

• Single child 

• > 37 weeks 

gestation 

• Black 

• Registration for 

prenatal care within 

first trimester of 

pregnancy 

Exclusion criteria: 

• Difference between 

recalled pregravid 

weight and 

measured first 

trimester weight 

was ≥ 10% 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 20.3 

G2: 22.1 

G3: 23.7 

G4: 25.4 (P < 0.01) 

Parity: 

G1: # nulliparous: 53 

G2: 54 

G3: 42 

G4: 26 (P < 0.01) 

Race,%: 

White 

NR 

Black 

G1: 100 

G2: 100 

G3: 100 

G4: 100 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: n = 0 

G2: n = 4 

G3: n = 3 

G4: n = 8 (P = 0.02) 

Hypertension,%: 

G1: n = 1 

G2: n = 2 

G3: n = 4 

G4: n = 14 (P < 0.01) 

Additional characteristics: 

NR 
C-549 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 196 

G2: 181 

G3: 205 

Total weight gain: 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: weight 

at last prenatal 

visit 

Birth weight: 

G1: 3,029 

G2: 3,210 

G3: 3,283 (P < 

0.01) 

Gestational 

diabetes, %: 

G1: n = 0 

G2: n = 4 

G3: n = 3 

G4: n = 8 

(P = 0.02) 

Cesarean 

delivery,%: 

G1: n = 20 

G2: n = 10 

G3: n = 17 

(P = 0.02) 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

• Asthma, 

preeclampsia 

• Vomiting 

• C-section 

Other infant 

outcomes: 

• Low birth 

weight 

• Fetal distress 

• NICU 

Outcomes Description: 

Birthweight 

Groups 

G1: Low <IOM 

G2: Normal =IOM 

G3: High >IOM 

Results 

G1: 3,029 

G2: 3,210 

G3: 3,283 

P < 0.01 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

NR 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Fair 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Good 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-550 

 Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Scholl et al., 1995 

Country and setting: 

USA, Camden Study 

Enrollment Period: 

September 1985 to May 

1990 

Funding: 

NIH 

Study Objective: 

To determine whether 

risk of maternal 

overweight associated 

with an excessive rate 

of gestational weight 

gain needs to be 

balanced against risk of 

impaired fetal growth 

associated with low rate 

of gain 

Time frame: 

September 1985 to May 

1990 

Duration of the study: 

During pregnancy 

through 6 months 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

274 

Group Description: 

G1: Low rate of GWG 

G2: Moderate rate of 

GWG 

G3: Excessive rate of 

GWG 

Group N: 

G1: 59 

G2: 138 

G3: 77 

Inclusion criteria: 

• Women with 

pregravid BMI 19.8-

26.0 

• Enrolled before 

January 1988 

Exclusion criteria: 

• Missing information 

from delivery to 6 

months postpartum 

• Pregravid under or 

over weight 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

G1: 8.5 

G2: 10.9 

G3: 10.4 

Black 

G1: 61.0 

G2: 59.4 

G3: 62.3 

Hispanic 

G1: 30.5 

G2: 29,7 

G3: 27.3 

Asian/Pacific Islander 

NR 

Smoking,%: 

G1: 30.5 

G2: 26.8 

G3: 26.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-551 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 59 

G2: 138 

G3: 77 

Total weight gain: 

G1: Gestation 

duration (wk)38.5 

(0.28) P < 0.05, low 

vs. moderate plus 

excessive weight 

gain 

G2: 39.2 (0.17) 

G3: 39.4 (0.24) 

Categorized: 

• According to 

IOM rate of 

gestational 

weight gain 

measured 

between 20 to 

36 weeks: low 

GWG = < 

0.34kg/wk; 

moderate 

GWG = 0.34-

0.68 kg/wk; 

excessive 

GWG = > 0.68 

kg/wk 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3,049 (56.94) 

P < 0.05, low 

vs. moderate 

plus excessive 

weight gain 

G2: 3,208 (36.33) 

G3: 39.4 (0.24) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Birthweight (g) 

Groups 

Rate between 20-36 wks 

G1: low rate <0.34 kg/wk 

G2: moderate rate 0.34-

0.68 kg/wk 

G3: Excessive rate >0.68 

kg/wk 

Results 

G1: 3049 (56.94) 

P < 0.05, low vs. moderate 

plus excessive weight gain 

G2: 3208 (36.33) 

G3: 39.4 (0.24) 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NR 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-552 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stevens-Simon and 

McAnarney, 1992 

Country and setting: 

USA, adolescent 

maternity program 

Enrollment Period: 

1986 to 1989 

Funding: 

Grant from Bureau of 

Maternal and Child 

Health 

Study Objective: 

To clarify advantages 

and disadvantages of 

large gestational weight 

gain among pregnant 

adolescents 

Time frame: 

1986 to 1989 

Duration of the study: 

Entry into prenatal care 

through 6 weeks PP 

check up 

Design: 

• Cohort 

• Prospective 

Total Study N: 

141 (107 included in 

postpartum analyses) 

Group Description: 

G1: Slow gainers 

G2: Average gainers 

G3: Rapid gainers 

Group N: 

G1: 28 

G2: 66 

G3: 47 

Inclusion criteria: 

• Consecutively 

enrolled poor, 

black, 12-19 year 

olds 

• Prenatal care prior 

to 2third week 

gestation 

• No chronic disease 

• No regular 

medications 

• No known uterine 

anomalies 

• Live birth 

• Singletons 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 58.6 (11.1) 

G2: 160.9 (7.0) 

G3: 163.9 (5.5) 

Pregravid BMI: 

G1: 23.1 (3.5) 

G2: 23.5 (4.4) 

G3: 23.5 (4.2) 

• Imputed: 

• No 

• Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 16.9 

G2: 16.6 

G3: 16.2 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-553 

Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28 

G2: 66 

G3: 47 

Total weight gain: 

G1: 7.7 (average 

rate 0.2 kg/wk) 

G2: 12.4 (average 

rate 0.3 kg/wk) 

G3: 19.8 (average 

rate 0.5 kg/wk) 

Categorized: 

• According to 

IOMslow gain: 

< 0.23kg/wk; 

average gain: 

0.23-

0.4kg/week; 

rapid gain: > 

0.4kg/week 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) 

P < 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Birth weight 

Groups 

G1: slow <0.23 kg/wk 

G2: average 0.23-4 kg/wk 

G3: rapid >0.4 kg/wk 

Results 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) P < 0.0001 

No difference in pre-gravid 

by weight gain groups 

Maternal confounders 

and effect modifiers 

accounted for in 

analysis: 

NR 

Infant and child 

confounders and effect 

modifiers accounted for 

in analysis: 

NR 

Background: 

Good 

Sample selection: 

Poor 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 4 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-554 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-555 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

LBW (%) 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results 

G1: 2.0 

G2: 11.1 

G3: 8.3 

G4: 5.2 

G5: 3.8 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-556 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bracero and Byrne, 1997 

Country and setting: 

Hospital charts - 

Maimonides Medical 

Center, Brooklyn, NY 

Enrollment Period:

Funding: 

NR 

Study Objective: 

To determine optimal 

weight gain in singleton 

pregnancy and evaluate 

current recommendations 

Time frame: 

Duration of the study: 

Jan 1, 1987 to Jan 1, 

1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20,971 

Group Description: 

G1: Total population 

G2: NR 

Group N: 

G1: 20,971 

G2: NR 

Inclusion criteria: 

• Delivery at 

Maimonides Medical 

Center 

• Singleton pregnancy 

• No documentation of 

congenital anomaly, 

pregnancy was not 

terminated by 

abortion 

• Documentation on 

chart of prepregnancy 

maternal weight, 

amount of maternal 

weight gain during 

pregnancy, and 

gender of infant 

Exclusion criteria: 

• Infants with any type 

of congenital anomaly 

(international 

classification of 

diseases (ICD-9-CM) 

codes 740.0-759.9 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: median BMI = 23.19 

(range 14.46-40.07) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: % < 15 years: < 0.1; 

15-19 yrs: 4.8; 

20-24: 25.1; 

25-29: 31.1; 

30-34: 24.3; 

35-39: 11.8; 

40-44: 2.8; 

45-49: 0.1; 

> 50: < 0.1 

G2: NR 

Parity: 

% primigravida:

G1: 25.1 

G2: NR 

Race,%: 

White 

G1: 92.1 

G2: NR 

Black 

G1: 4.2 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 0.9 

G2: NR 

Other 

G1: 2.1 

G2: NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% married:

G1: 12.4 

G2: NR 

Additional characteristics: 

Type of service:

G1: Ward, 22.5% 

Private: 77.5% 

G2: NR 

Additional characteristics: 

NR 
C-557 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: % weight gain: 

lost weight, 0.4; 

1 to 5lbs, 0.9; 

6 to 10, 2.3; 

11 to 15, 5.4; 

16 to 20, 12.0; 

21 to 25, 17.2; 

26 to 30, 21.1; 

31 to 35, 14.8; 

36 to 40, 11.5; 

41 to 45, 6.1; 

≥ 46, 8.3

G2: NR 

Categorized: 

• According to IOM 

ordinal 

categories in 5 

pound intervals 

Collected from: 

• Routine prenatal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

using last 

measurement 

obtained as an 

outpatient 

Birth weight: 

G1: r = .210 

correlation with 

maternal weight gain 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Optimal weight gain 

defined as 36 to 40 

pounds for 

underweight women, 

31 to 40 pounds for 

women of ideal 

prepregnancy weight, 

26 to 30 pounds for 

overweight women 

Other infant 

outcomes: 

Adverse outcomes: 

• Still birth 

• Neonatal death 

• Preterm 

delivery/low birth 

weight 

• Perinatal 

morbidity 

Outcomes Description: 

Percentage of LBW by weight gain categories 

Groups 

Maternal weight gain categories: 

G1: Maternal weight gain under the IOM 

guidelines 

G2: Maternal weight gain within the IOM 

guidelines 

G3: Maternal weight gain over the IOM 

guidelines 

G4: Optimal weight gain (36-40 lbs for BMI < 

19.8; 31-40 lbs for BMI 19.8-26.0; 26-30 lbs 

for BMI > 26.0) 

G5: Suboptimal weight gain (< 36 lbs for BMI 

< 19.8; < 31 lbs for BMI 19.8-26.0; < 26 lbs for 

BMI > 26.0) 

Results 

G1: 10.1% 

G2: 3.3% 

G3: 2.5% (P < 0.001 comparing G1-G3) 

G4: 4.9% 

G5: 1.8% (P < 0.001 vs. G4) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NA 

Background: 

Fair 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

1 Good, 8 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-558 

 Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cogswell et al., 1994 

Country and setting: 

USA, Pregnancy Nutrition 

Surveillance System 

Enrollment Period:

1990-1991 

Funding: 

NR 

Study Objective: 

To determine association 

between increased 

gestational weight gain 

and birth weight outcomes 

for low income women 

Time frame: 

1990-1991 

Duration of the study: 

Women in WIC but 

everything is self reported 

so it is when they were 

first enrolled in WIC until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

53,541 

Group Description: 

G1: Average weight 

G2: Overweight 

G3: Very overweight 

Group N: 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Inclusion criteria: 

• White, black and 

hispanic women who 

delivered single, 

liveborn, term infants 

Exclusion criteria: 

• Low or high values 

for; birth weight, 

prepregnancy BMI, or 

weight gain during 

pregnancy 

• Missing data on one 

or more study 

variables 

• Underweight women 

• Only 1 infant was 

used in analysis for 

women who delivered 

more than once 

during study period 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 11-17 yr: 11.9% 

18-34yr: 85.0% 

35-54 yr: 3.1% 

G2: 11-17 yr: 6.9% 

18-34yr: 88.7% 

35-54 yr: 4.4% 

G3: 11-17 yr: 4.0% 

18-34yr: 90.1% 

35-54 yr: 6.0% 

Parity: 

NR 

Race,%: 

White 

G1: 75.1 

G2: 72.4 

G3: 74.5 

Black 

G1: 13.8 

G2: 14.1 

G3: 16.1 

Hispanic 

G1: 11.1 

G2: 13.5 

G3: 9.4 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.9 

G2: 28.3 

G3: 25.7 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-559 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Total weight gain: 

G1: < 15 lb: 6.2% 

15-19: 5.8% 

20-24: 11.2% 

25-29: 14.4% 

30-34: 17.1% 

35-39: 13.9% 

≥ 40: 31.4%

G2: < 15 lb: 11.4% 

15-19: 7.8% 

20-24: 13.0% 

25-29: 12.7% 

30-34: 15.9% 

35-39: 11.2% 

≥ 40: 28.1%

G3: < 15 lb: 25.1% 

15-19: 10.1% 

20-24: 1

Categorized: 

• 4 lbs increments 

starting at 15 lbs 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: < 2500g: 2.7% 

2500-4000g: 87.5% 

> 4000-4500: 8.5% 

> 4500g: 1.4% 

G2: < 2500g: 2.5% 

2500-4000g: 83.9% 

> 4000-4500: 11.7% 

> 4500g: 2.0% 

G3: < 2500g: 2.1% 

2500-4000g: 81.1% 

> 4000-4500: 13.2% 

> 4500g: 3.6% 

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

AOR (95% CI) for low birth weight 

Groups 

Maternal weight gain categories (lbs) 

stratified by pregravid BMI: 

Normal weight (BMI 19.8-26.0): 

G1: < 15 

G2: 15-19 

G3: 20-24 

G4: 25-29 

G5: 30-34 

G6: 35-39 

G7: ≥ 40 

Overweight (BMI > 26.0-29.0): 

G8: < 15 

G9: 15-19 

G10: 20-24 

G11: 25-29 

G12: 30-34 

G13: 35-39 

G14: > = 40 

Obese (BMI > 29.0): 

G15: < 15 

G16: 15-19 

G17: 20-24 

G18: 25-29 

Results 

G1: 2.1 (1.6-2.6) 

G2: 1.4 (1.1-1.8) 

G3: 1.0 (0.8-1.3) 

G4: 1.0 (reference) 

G5: 0.8 (0.6-1.0) 

G6: 0.6 (0.5-0.8) 

G7: 0.5 (0.4-0.6) 

G8: 1.1 (0.7-1.9) 

G9: 1.0 (reference) 

G10: 0.7 (0.4-1.2) 

G11: 0.8 (0.5-1.4) 

G12: 0.5 (0.3-0.8) 

G13: 0.6 (0.3-1.1) 

G14: 0.4 (0.3-0.7) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• height 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Sex of infant 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

4 Good, 4 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-560 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period:

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal weight 

women and their 

associations with 

gestational weight change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight women 

identified from 

pregnancy and 

delivery summary 

records (normal 

weight matched to 

obese by race, age, 

parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal weight 

(BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-561 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5

G2: 14.5 P ≤ 0.001

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Percentage of LBW by weight gain categories 

Groups 

Maternal weight gain categories (kg) 

Obese BMI > 29: 

G1: Lost weight/no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal BMI 19.8-26 

G6: < 11.5kg 

G7: 11.5-16 

G8: > 16kg 

Results 

G1:12.8% 

G2: 8.9% 

G3: 7.9% 

G4: 6.8% 

G5: 8.7% 

P (for G1-G5) = 0.405 

G6: 8.5% 

G7: 5.6% 

G8: 8.9% 

P (for G6-G8) = 0.183 

AOR (95%CI) for birthweight < 2500g among 

obese women (BMI> 29.0): 

G3: 1.0 (reference) 

G1: 4.2 (0.9-19.6) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• GDM 

• Pregnancy induced hypertension 

• Prenatal adequacy 

• Alcohol use 

• Drug use 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-562 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hellerstedt et al., 1997 

Country and setting: 

United States, medical 

center 

Enrollment Period:

1977-1993 

Funding: 

NR 

Study Objective: 

To examine association 

between infant birth 

outcomes and maternal 

pregravid obesity, 

gestational weight gain, 

and prenatal smoking 

Time frame: 

1977 to 1993 

Duration of the study: 

Entry into prenatal care 

until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,343 

Group Description: 

G1: Obese 

G2: Normal weight 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese and normalweight women 

delivering singleton 

during study period 

Exclusion criteria: 

• Missing data 

• Siblings 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 kg (13.7) 

G2: 61.1kg (5.9) 

Pregravid BMI: 

G1: 38.3 (4.6) 

G2: 22.8 (1.6) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: NR 

• 16-34 years: 91% 

• ≥ 35 years: 8.8% 

G2: NR 

• 16-34 years: 93.5% 

• ≥ 35 years: 5.8% 

Parity: 

G1: NR 

• 0: 31.8% 

• 1-3: 64.7% 

• ≥ 4: 3.5% 

G2: NR 

• 0: 33.3% 

• 1-3: 64.9% 

• ≥ 4: 1.8% 

Race,%: 

White 

G1: 68.8 

G2: 69.1 

Black 

G1: 20.4 

G2: 20.6 

Hispanic 

G1: 6.6 

G2: 6.5 

Asian/Pacific Islander 

G1: Native Am: 3.8 

G2: Native Am: 3.2 

Other 

NR 

Smoking,%: 

G1: 26.4 

G2: 26.2 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-563 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Percentage of LBW by weight gain categories 

and smoking status 

Groups 

Maternal weight gain categories stratified by 

pregravid BMI and smoking status: 

Obese (BMI > 29.0): 

G1: Smokers, < IOM 

G2: Smokers, within IOM 

G3: Smokers, > IOM 

G4: Nonsmokers, < IOM 

G5: Nonsmokers, within IOM 

G6: Nonsmokers, > IOM 

Normal weight (BMI 19.8-26.0): 

G7: Smokers, < IOM 

G8: Smokers, within IOM 

G9: Smokers, > IOM 

G10: Nonsmokers, < IOM 

G11: Nonsmokers, within IOM 

G12: Nonsmokers, > IOM 

Obese: 

G13: Lost/no gain 

G14: 0.5-6.5 kg 

G15: 7-11.5 kg 

G16: 12-16 kg 

G17: > 16 kg 

Normal weight: 

G18: < 11.5kg 

G19: 11.5-16kg 

G20: > 16kg 

Results 

G1: 17.3% 

G2: 10.0% 

G3: 12.3% 

G4: 10.5% 

G5: 7.8% 

G6: 2.6% 

G7: 17.5% 

G8: 3.5% 

G9: 3.6% 

G10: 12.4% 

G11: 6.0% 

G12: 5.3% 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-564 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hellerstedt et al., 1997 

(continued) 

 
C-565 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

G13: 16.0% 

G14: 11.1% 

G15: 8.3% 

G16: 4.0% 

G17: 6.0% 

P = 0.003 for G13-G17 

G18: 14.2% 

G19: 5.4% 

G20: 4.9% 

P = 0.001 for G18-G20 

For obese women, compared to nonsmokers 

who gained 7-11.5 kg, smokers who gained 

< 7 kg were at significantly higher risk of 

LBW: 

AOR: 7.7 (95% CI, 1.5-40.0) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, pregravid BMI, infant sex, 

race, parity, prenatal alcohol use, prenatal 

illicit drug use, adequacy of prenatal care, 

gestational hypertension, GDM 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 
C-566 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hickey et al., 1997 

Country and setting: 

USA, public health 

programs 

Enrollment Period:

Jan 1993 to Dec 1994 

Funding: 

MCH grant, University of 

Alabama School of Public 

Health/NIH Intamural 

Basic Sciences Research 

grant 

Study Objective: 

Examine differences in 

birth weight among term 

infants of black and white 

women with weight gains 

in upper or lower half of 

recommended ranges 

Time frame: 

Jan 1993 to Dec 1994 

Duration of the study: 

From first visit to delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

5198 

Group Description: 

G1: Black 

G2: White 

Group N: 

G1: 2219 

G2: 3699 

Inclusion criteria: 

• Women enrolled in 

Medicaid Maternity 

Waiver programs 

operated in 24 

counties by Alabama 

Department of Public 

Health during study 

period 

Exclusion criteria: 

• Delivered before 37 

weeks or after 42 

weeks 

• Maternal age ≤ 17 

years 

• Last prenatal weight 

recording more than 

3 weeks before 

delivery 

• Maternal risk factors 

(diabetic, cardiac, 

genetic, and obstetric 

conditions/complicati

ons) requiring 

external referral 

• Multiple fetuses 

• Stillborn/neonatal 

death 

• Missing or outlying 

anthropometric data 

• Missing data for 

ethnicity 

• Missing gestational 

age 

• Congenital anomalies

• Missing birth weight 

• Invalid country code 

Pregravid weight: 

• Self-reported 

G1: 70.8 (19.6) 

G2: 65.8 (17.6) 

Pregravid BMI: 

G1: 26.6 (7.1) 

G2: 24.8 (6.3) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 23.7 (5.0) 

G2: 23.4 (4.6) 

Parity: 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 9.2 

G2: 35.1 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-567 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to 

IOMgain below 

range (for 

pregravid BMI), 

gain in lower 

range, gain in 

upper range, 

gain above range 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Adjusted odds ratio (95% CI) for LBW by weight 

gain categories 

Groups 

Maternal weight gain categories stratified by race: 

Black Women: 

G1: Below range (< 12.5kg for BMI< 19.8; < 13.9kg 

for BMI 19.8-26.0; < 7.0kg for BMI > 26.0) 

G2: In lower range (12.5-15.2kg for BMI< 19.8; 

11.5-13.8kg for BMI 19.8-26.0; 7.0-9.2kg for BMI > 

26.0) 

G3: In upper range (15.3-18kg for BMI< 19.8; 13.9-

16.0kg for BMI 19.8-26.0; 9.3-11.5kg for BMI 

> 26.0) 

Results 

G1: 2.6 (1.2-5.6) 

G2: 1.0 (reference) 

G3: 1.2 (0.4-3.3) 

G4: 1.4 (0.6-3.6) 

G5: 1.5 (0.8-2.6) 

G6: 1.0 (reference) 

G7: 0.4 (0.2-0.9) 

G8: 0.7 (0.3-1.2) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Education 

• Height 

• Drug use 

• Alcohol use 

• Time between last prenatal weight observation 

and delivery 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Infant sex 

Background: 

Good 

Sample 

selection: 

Good 

Definition of 

maternal weight 

gain: 

Poor 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

5 Good, 3 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-568 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hulsey et al., 2005 

Country and setting: 

USA, birth certificates 

linked to PRAMS data 

Enrollment Period:

1998 to 1999 

Funding: 

NR 

Study Objective: 

To describe proportion of 

low birth weight that could 

be potentially prevented 

by programs focusing on 

maternal prepregnant BMI 

and/or weight gain during 

pregnancy 

Time frame: 

1998 to 1999 

Duration of the study: 

Cross-sectional women 

surveyed after delivery 

(PRAMS) 

Design: 

• Cross-sectional 

• Retrospective 

Total Study N: 

87,293 

Group Description: 

G1: Total 

G2: BMI < 19.8 (U-BMI) 

G3: BMI 19.8-26 (N-BMI) 

G4: BMI 26.1-29.0) 

OW-BMI 

G5: BMI > 29.0 (O-BMI) 

Group N: 

G1: 87,293 (100%) 

G2: 16.2% (Note: 

corrected 

Discrepency between 

Table 1 values and 

Results text/Table 

2&3 values) 

G3: 52.6%(Note: 

corrected 

Discrepency between 

Table 1 values and 

Results text/Table 

2&3 values) 

G4: 11.5%(Note: correcte

Inclusion criteria: 

• Ddata consist of birth 

certificates linked to 

PRAMS for South 

Carolina resident 

women delivering in 

South Carolina during 

1998 and 1999 

Exclusion criteria: 

• BW < 500 g 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

G1: 56.3 

G2: 18.6 

G3: 55.7 

G4: 10.9 

G5: 19.2 (P < 0.0001) 

Black 

G1: 43.7 

G2: 11.9 

G3: 49.3 

G4: 14.3 

G5: 24.6 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 4.1 

G2: 3.7 

G3: 36.4 

G4: 21.1 

G5: 38.8 P < 0.09 

Hypertension,%: 

G1: 4.8 

G2: 7.8 

G3: 36.4 

G4: 15.2 

G5: 40.6 (P < 0.56) 

Additional characteristics: 

NR 
C-569 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight Gain 

Outcomes from Bivariate 

Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: NR 

• Adequate: 72.3% 

• Less than adequate: 27.7 

G2: NR 

• Adequate: 14.9% 

• Less than adequate: 19.6 

G3: 

• Adequate: 52.1% 

• Less than adequate: 53.9 

G4: 

• Adequate: 13.6% 

• Less than adequate: 5.9 

G5: 

• Adequate: 19.4% 

• Less than adequate: 20.7 

Categorized: 

• According to IOMLTA = 

less than adequate; AWG

= adequate weight gain 

Birth weight: 

NR 

Gestational diabetes, %: 

G1: 4.1 

G2: 3.7 

G3: 36.4 

G4: 21.1 

G5: 38.8 P < 0.09 

Cesarean delivery,%: 

NR 

Instrumental delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal outcomes:

NR 

Other infant outcomes: 

NR 

Outcomes Description: 

Adjusted odds ratio for low birth weight 

by categories of weight gain 

Groups 

Pregravid BMI and gestational weight 

gain categories: 

G1: BMI < 19.8 and < IOM 

G2: BMI 19.8-26.0 and < IOM 

G3: BMI 19.8-26.0 and within IOM 

G4: BMI 26.1-29.0 and < IOM 

G5: BMI > 29.0 and < IOM 

G6: BMI > 29.0 and within IOM 

Results 

AOR (95% CI) for very low birth weight 

(500-1,499g): 

G1: 2.06 (1.26-2.87) 

G2: 1.82 (1.22-2.29) 

G3: 1.00 (reference) 

G4: 2.05 (0.90-4.44) 

G5: 1.25 (0.61-1.61) 

G6: 1.74 (1.23-2.42) 

AOR (95% CI) for moderately low birth 

weight (1500-2499g): 

G1: 4.83 (2.98-7.83) 

G2: 1.77 (1.23-2.60) 

G3: 1.00 (reference) 

G4: 0.28 (0.11-1.83) 

G5: 1.09 (0.67-2.13 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Ethnicity, intendedness of pregnancy, 

Medicaid status, WIC status, prenatal 

care, diabetes, hypertension 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 4 Fair, 3 

Poor 

Final Quality 

Score: 

Poor 
C-570 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hulsey et al., 2005 

(continued) 

 
C-571 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Collected from: 

• To determine LTA and 

AWG:for each BMl group, 

weight gain at 20 weeks 

was determined from 

formula (12.6 lbs for UBMI; 10.6 lbs for NBMI;6.8 

lbs for OW-BMI; and 3.8 

lbs for 0-BMI). Next, 

lowest total weight gain 

expected from the weight 

gain range for women 

delivering at term, for each 

BMl, was obtained(for UBMI, 28 lbs; N-BMI, 25 

lbs; OW-BMI, 15 lbs; 

and0-BMI, 15 lbs). The 

weight gain expected at 

20 weeks was then 

subtracted from the total 

weight gain to arrive at 

weight gain after 20 

weeks. This was then 

divided by 20 to determine 

the expected weight gain 

per week after the 20th 

week of gestation.Weight 

gain after the 20th week of 

gestation is linear toterm. 

Each delivery was then 

categorized as having 

LTA or AWG adjusted for 

gestational age and 

prepregnant BMI. 

Ascertained by: 

• Self-reported 
C-572 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nida et al., 1996 

Country and setting: 

United States, multicenter 

Enrollment Period:

April 1988 to March 1995 

Funding: 

Funding for the PRAMS 

Program is providedin part 

by the Centers for 

Disease Control and 

Prevention, Atlanta, GA 

(Grant No. 

U50/CCU602873-07), and 

Maternal and Child Health 

Bureau, Department of 

Health and Human 

Services 

Study Objective: 

To examine prepregnancy weight, 

prenatal weight gain and 

their relationship to low 

(< 2,500 grams) birth 

weight 

Time frame: 

April 1988-March 1995 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

NR. PRAMS data in OK 

collects data on 200 

mothers/month. Report 

reflects data with 71% 

response rate 

Group Description: 

G1: Low BMI/less than 

recommended weight gain

G2: Normal BMI/within 

recommended weight gain

G3: High BMI/over 

recommended wt gain 

Group N: 

Inclusion criteria: 

• New mothers of 

singleton births from 

state’s live birth 

registry 

Exclusion criteria: 

NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: Age 

 < 20: 21.2% (15.5-26.9) 

20-24: 35.5% (29.2-41.8)

25-29: 24.2% (18.7-29.7) 

30-34: 15.2% (10.9-19.5) 

35+: 3.9% (1.7-6.1) 

[numbers in () are 95% CI]

G2: Age 

 < 20: 10.9% (8.5-13.3) 

20-24: 30.0% (26.9-33.1)

25-29: 31.6% (28.7-34.5)

30-34: 19.2% (16.7-21.8)

35+: 8.3% (6.5-10.1) 

G3: Age 

 < 20: 12.5% (8.7-16.2) 

20-24: 33.9% (29.0-38.8)

25-29: 29.2% (24.7-33.7)

30-34: 17.5% (14.0-21.0)

35+: 6.9% (4.6-9.3) 

Parity: 

NR 

Race,%: 

White 

G1: 84.7 (79.9-89.7) 

G2: 85.1 (82.5-87.6) 

G3: 75.5 (71.0-80.0) 

Black 

G1: 9.8 (5.5 - 14.1) 

G2: 5.8 (4.0-7.6) 

G3: 11.4 (7.7-15.1) 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: Native Am 3.9 (1.4-6.5) 

G2: Native Am 7.5 (5.7-9.3) 

G3: Native Am 12.6 (9.3-15.9) 

Smoking,%: 

G1: Prenatal smoking: 26.2% 

(20.5-31.9) 

G2: 19.5 % (16.8-22.2) 

G3: 21.6 (17.2-26.0) 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: Education 

 < 12 years: 21.7% (15.6-

27.8); 

12+ years: 78.3% (72.2-84.4) 

G2: Education 

 < 12 years: 13.2% (10.5-

15.9), 

12+years: 86.8% (84.1-89.5) 

G3: Education: 

< 12 years: 14.8% (10.8-18.8)

12+ years: 85.2% (81.2-89.2) 

Additional characteristics: 

NR 
C-573 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: Percent LBW: 

10.2%/ 6%/ 4.7%

G2: 8.4%/ 3.9%/ 

4.5% 

G3: 6.1%/ 3.8%/ 

5.1% 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• LBW by smoking status by BMI and 

prenatal weight gain 

Groups: 

G1: Low BMI/less than recommended 

weight gain 

G2: Normal BMI/within recommended 

weight gain 

G3: High BMI/over recommended wt gain 

Results: 

Low BMI: less than rec weight gain 

G1: 16.9 (12.2-21.6) 

G2: 7.7 (6.1-9.3) 

Low BMI: within recommended 

G1: 12.7 (9.4-16.0) 

G2: 4.2 (3.4-5.0) 

Low BMI: more than recommended 

G1: 6.5 (14.3-8.7) 

G2: 3.6 (2.8-4.4) 

Normal BMI: less than recommended 

G1: 12.9 (9.6-16.2) 

G2: 6.9 (5.7-8.1) 

Normal BMI: within recommended 

G1: 6.9 (5.3-8.5) 

G2: 3.2 (2.8-3.6) 

Normal BMI; more than recommended 

G1: 8.9 (7.1-10.7) 

G2: 3.3 (2.9-3.7) 

High BMI: less than recommended 

G1: 7.7 (4.0-11.4) 

G2: 5.4 (3.8-7.0) 

High BMI: within recommended 

G1: 4.6 (2.6-6.6) 

G2: 3.4 (2.6-4.2) 

High BMI: more than recommended 

G1: 7.5 (5.2-9.9) 

G2: 4.5 (3.7-5.3) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

NR 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Poor 

Sample selection:

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

0 Good, 4 Fair, 5 

Poor 

Final Quality 

Score: 

Poor 
C-574 

 Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Ogunyemi et al., 1999 

Country and setting: 

USA, hospital 

Enrollment Period:

1990 to 1995 

Funding: 

NR 

Study Objective: 

To test IOM guidelines in 

a predominantly rural 

black population 

Time frame: 

1990 to 1995 

Duration of the study: 

582 women who delivered 

and then their medical 

record was abstracted 

Design: 

• Other observational : 

582 women 

consecutive women 

who delivered 

• Retrospective 

Total Study N: 

582 

Group Description: 

G1: Underweight 

G2: Normal 

G3: Overweight 

G4: Obese 

Group N: 

G1: 78 

G2: 223 

G3: 78 

G4: 203 

Inclusion criteria: 

• Single child 

• > 37 weeks gestation

• Black 

• Registration for 

prenatal care within 

first trimester of 

pregnancy 

Exclusion criteria: 

• Difference between 

recalled pregravid 

weight and measured 

first trimester weight 

was ≥ 10% 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 20.3 

G2: 22.1 

G3: 23.7 

G4: 25.4 (P < 0.01) 

Parity: 

G1: # nulliparous: 53 

G2: 54 

G3: 42 

G4: 26 (P < 0.01) 

Race,%: 

White 

NR 

Black 

G1: 100 

G2: 100 

G3: 100 

G4: 100 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: n = 0 

G2: n = 4 

G3: n = 3 

G4: n = 8 (P = 0.02) 

Hypertension,%: 

G1: n = 1 

G2: n = 2 

G3: n = 4 

G4: n = 14 (P < 0.01) 

Additional characteristics: 

NR 
C-575 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 196 

G2: 181 

G3: 205 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

weight at last 

prenatal visit 

Birth weight: 

G1: 3,029 

G2: 3,210 

G3: 3,283 (P < 0.01) 

Gestational 

diabetes, %: 

G1: n = 0 

G2: n = 4 

G3: n = 3 

G4: n = 8 (P = 0.02) 

Cesarean 

delivery,%: 

G1: n = 20 

G2: n = 10 

G3: n = 17 (P = 0.02)

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

asthma,preeclampsia

, vomiting, c-section 

Other infant 

outcomes: 

low birth weight, fetal 

distress, NICU 

Outcomes Description: 

Adjusted odds ratio for low birth weight by 

weight gain categories 

Groups 

Maternal weight gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI IOM 

Results 

AOR (95% CI) for very low birth weight: 

G1: 1.8 (0.6-4.7) 

G2: 1.1 (0.4-4.7) 

G3: 1.0 (Reference) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Parity 

• Pregravid BMI 

• Pre-eclampsia 

• C-section 

• Previous cesarean 

• Tobacco use 

• Previous fetal death 

• Hypertension 

• Asthma 

• Previous LBW 

• Vomiting 

• NICU 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Fair 

Sample selection:

Poor 

Definition of 

maternal weight 

gain: 

Good 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 5 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-576 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Schieve, 1998 

Country and setting: 

Pregnancy Nutrition 

Surveillance System - 

data from WIC clinics 

(99%) from Indiana, 

Kansas, Massachusetts, 

Minnesota, Nebraska, 

North Dakota, New York, 

Tennessee, and Vermont 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To examine associations 

between pregnancy 

weight gain outside and 

within ranges 

recommended by IOM 

and birth weight by both 

prepregnant BMI and race 

ethnicity 

Time frame: 

NR 

Duration of the study: 

1990 to 1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

173,066 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• White, black, and 

hispanic women who 

visited WIC clinics 

prenatally and 

subsequently 

delivered liveborn, 

singleton infants 

• Delivered between 39 

and 41 weeks 

Exclusion criteria: 

• Missing data for 

infant birth weight 

(n = 4223) 

• Prepregnant BMI 

(n = 31477) 

• Pregnancy weight 

gain (n = 7542) 

• Maternal age 

(n = 43) 

• Maternal education 

(n = 3819) 

Pregravid weight: 

• Self-reported 

• NR 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

IOM Guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-577 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 112,524

G2: 33,101

G3: 27,441

Total weight gain: 

G1: 32.5

G2: 30.5

G3: 30.2

Categorized: 

According to IOM >10 

pounds below lower 

bound of IOM 

recommended range 

for woman's 

prepregnant BMI, 1-9 

pounds below lower 

bound of IOM lower 

bound, in lower half 

of IOM recommended 

range, in upper half of 

IOM range, 1-9 

pounds above IOM 

range, >10 pounds 

above IOM upper 

bound 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• NA 

Other infant 

outcomes 

• NA 

Outcomes Description: 

Distribution of LBW,%: 

Groups 

Maternal weight gain categories stratified by pregravid 

BMI (IOM underweight, normal weight, overweight, and 

obese) and race (non-Hispanic white, non-Hispanic 

black, and Hispanic): 

G1: > = 10 lbs below IOM 

G2: 1-9 lbs below IOM 

G3: Lower half of IOM 

G4: Upper half of IOM 

G5: 1-9 lbs above IOM 

G6 > = 10lbs above IOM 

Results 

G1: 2.7 (2.1-3.5), 1.6 (1.3-1.9), 1.0, 0.7 (0.6-0.9), 0.4 

(0.3,0.6), 0.4 (0.3,0.6) 

G2: 3.2 (2.1-5.1), 2.8 (1.9-4.2), 1.0, 1.3 (0.8-2.1), 0.5 

(0.2-1.03), 0.7 (0.4-1.5) 

G3: 2.8 (1.7-4.7), 1.1 (0.6-1.8) 

G4: 1.4 (0.5-4.2); 0.4 (0.2-1.2); 1.0; 2.1 (1.1-4.0); 2.8 

(1.4-5.4); 7.3 (4.0-13.2) 

G5: no data for first category 

0.6 (0.05-5.6); 1.0; 0.7 (0.06-7.3); 1.8 (0.3-13.2); 

10.8 (2.3-51.4) 

G6: no data for first category;0.8 (0.1-4.9); 1.0; 1.8 

(0.4-8.0); 3.3 (0.8-14.1); 6.1 (1.6-24.1) 

Group: average BMI: ≥ 10 lb< IOM, 1-9 lb< IOM, lower 

IOM, upper IOM, 1-9 lb >IOM, ≥ 10 lb>IOM 

G1: 2.5 (2.0-3.0); 1.5 (1.3-1.8); 1.0; 0.8 (0.6-0.9); 0.6 

(0.5-0.7); 0.3 (0.3-0.4) 

G2: 2.5 (1.9-3.3); 1.7 (1.3-2.2); 1.0; 0.7 (0.5-1.03); 0.7 

(0.5-1.03); 0.6 (0.4-0.9) 

G3: 1.8 (1.3-2.6); 1.2 (0.9-1.6); 1.0; 0.8 (0.5-1.2); 0.6 

(0.4-0.9); 0.4 (0.3-0.7) 

G4: 0.5 (0.3-0.9); 0.7 (0.5-0.9); 1.0; 1.7 (1.3-2.2); 2.3 

(1.8-3.0); 4.2 (3.3-5.2) 

G5: 0.8 (0.2-2.8); 1.3 (0.5-3.2); 1.0; 1.5 (0.6-3.7); 3.6 

(1.7-7.7); 5.2 (2.5-10.8) 

G6: 0.2 (0.1-0.99); 0.8 (0.4-1.5); 1.0; 1.3 (0.7-2.4); 1.9 

(1.1-3.3); 4.6 (2.8-7.5) 

Group: high BMI: ≥ 10 lb< IOM, 1-9 lb< IOM, lower 

IOM, upper IOM, 1-9 lb >IOM, ≥ 10 lb>IOM 

G1: 1.1 (0.6-2.3); 1.2 (0.7-1.9); 1.0; 0.7 (0.4-1.1); 0.5 

(0.3-0.8); 0.5 (0.3-0.7) 

G2: 1.7 (0.8-3.6); 0.9 (0.4-1.7); 1.0; 0.3 (0.2-0.8); 0.5 

(0.3-0.9); 0.6 (0.3-0.97) 

G3: 1.5 (0.6-4.0); 1.1 (0.5-2.3); 1.0; 0.9 (0.4-1.9); 0.4 

(0.2-0.9); 0.4 (0.2-0.8) 

G4: 0.8 ((0.3-0.9); 0.2 (0.04-0.7); 1.0; 1.1 (0.6-2.1); 1.6 

(0.97-2.7); 3.5 (2.2-5.6) 

G5: 0.7 (0.1-6.0); 0.3 (0.03-2.3); 1.0; 1.7 (0.5-5.1); 1.6 

(0.5-4.4); 2.9 (1.1-7.3) 

Background: 

Good 

Sample selection:

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

3 Good, 4 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-578 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Schieve, 1998 

(continued) 

 
C-579 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

G6: 0.9 (0.1-7.5); 0.3 (0.04-2.9); 1.0; 0.8 (0.2-3.2); 1.4 

(0.5-4.1); 5.2 (2.1-13.3) 

Group: obese BMI: ≥ 10 lb< IOM, 1-9 lb< IOM, lower 

IOM, upper IOM, 1-9 lb >IOM, ≥ 10 lb>IOM 

G1: 1.6 (1.04-2.4); 1.3 (0.9-2.0); 1.0; 1.1 (0.7-1.7); 0.8 

(0.5-1.2); 0.8 (0.6-1.2) 

G2: 2.6 (1.5-4.5); 1.3 (0.7-2.3); 1.0; 1.3 (0.7-2.5); 1.1 

(0.6-1.9); 1.0 (0.6-1.7) 

G3: 1.0 (0.4-2.5); 0.8 (0.4-1.8); 1.0; 0.8 (0.3-1.7); 0.2 

(0.08-0.6); 0.5 (0.3-1.1) 

G4: 0.7 (0.5-0.95); 0.5 (0.4-0.7); 1.0; 1.2 (0.9-1.6); 1.3 

(1.03-1.7); 2.2 (1.8-2.8) 

G5: 0.4 (0.2-1.1); 0.6 (0.3-1.4); 1.0; 0.9 (0.4-2.1); 1.5 

(0.8-2.9); 2.8 (1.6-4.8) 

G6: 0.8 (0.3-2.3); 0.8 (0.3-1.8); 1.0; 1.3 (0.6-2.8); 1.4 

(0.7-2.7); 2.9 (1.6-5.2) 

Results for confounders and effect modifiers 

G1: Non-hispanic white adjusted mean birth weight (g) 

G2: Non-hispanic black adjusted mean birth weight (g) 

G3: Hispanic adjusted mean birth weight (g) 

Characteristic: low BMI: ≥ 10 lb< IOM 

1-9 lb< IOM 

lower IOM (reference) 

upper IOM 

1-9 lb >IOM 

≥ 10 lb>IOM 

G1: 3,073 

3,161 

3,274 (ref) 

3,346 

3,412 

3,531 

G2: 2,981 

3,060 

3,184 (ref) 

3,240 

3,340 

3,387 (all adjusted mean birth weights are 

significantly different from reference category, 

lower IOM P < 0.05) 

G3: 3,070 

3,175 

3,218 (ref) 

3,309 

3,381 

3,493 (all adjusted mean birth weights are 

significantly different from reference category, 

lower IOM P < 0.05) 
C-580 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Schieve, 1998 

(continued) 

 
C-581 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Average BMI: ≥ 10 lb< IOM 

1-9 lb< IOM 

lower IOM (reference) 

upper IOM 

1-9 lb >IOM 

≥ 10 lb>IOM 

G1: 3,221 

3,314 

3,389 (ref) 

3,455 

3,509 

3,618 

G2: 3,115 

3,184 

3,254 (ref) 

3,314 

3,373 

3,445 (all adjusted mean birth weights are 

significantly different from reference category, 

lower IOM P < 0.05) 

G3: 3,240 

3,291 

3,366 (ref) 

3,400 

3,463 

3,568 (all adjusted mean birth weights are 

significantly different from reference category, 

lower IOM P < 0.05) 

Characteristic: hiGh BMI: ≥ 10 lb< IOM 

1-9 lb< IOM 

lower IOM (reference) 

upper IOM 

1-9 lb >IOM 

≥ 10 lb>IOM 

G1: 3,305 

3,335 

3,421 (ref) 

3,476;3,539 

3,630 

G2: 3,188 

3,241 

3,304 (ref) 

3,349 

3,403 

3,490 (adjusted mean birth weights for first, 

second, fifth, and sixth categories are significantly 

different from reference category, lower IOM P < 

0.05) 

G3: 3,272 

3,331 

3,384 (ref) 

3,420 

3,471 

3,593 (adjusted mean birth weights for first, second, 

fifth, and sixth categories are significantly different from 

reference category, lower IOM P < 0.05) 
C-582 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Schieve, 1998 

(continued) 

 
C-583 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Obese BMI: ≥ 10 lb< IOM 

1-9 lb< IOM 

lower IOM (reference) 

upper IOM 

1-9 lb >IOM 

≥ 10 lb>IOM 

G1: 3,431 

3,485 

3,528 (ref) 

3,575 

3,620 

3,700 

G2: 3,280 

3,353 

3,393 (ref) 

3,412 

3,461 

3,525 (adjusted mean birth weights for first, 

second, fifth, and sixth categories are significantly 

different from reference category, lower IOM P < 

0.05) 

G3: 3,350 

3,420 

3,445 (ref) 

3,517 

3 (adjusted mean birth weights for first, fourth, fifth, and 

sixth categories are significantly different from 

reference category, lower IOM P < 0.05) 555 

3,615 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Height 

• Education 

• Trimester of the Special Supplemental Nutrition 

Program for Women, Infants, and Children 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 
C-584 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stevens-Simon and 

McAnarney, 1992 

Country and setting: 

USA, adolescent 

maternity program 

Enrollment Period:

1986 to 1989 

Funding: 

Grant from Bureau of 

Maternal and Child Health 

Study Objective: 

To clarify advantages and 

disadvantages of large 

gestational weight gain 

among pregnant 

adolescents 

Time frame: 

1986 to 1989 

Duration of the study: 

Entry into prenatal care 

through 6 weeks PP 

check up 

Design: 

• Cohort 

• Prospective 

Total Study N: 

141 (107 included in 

postpartum analyses) 

Group Description: 

G1: Slow gainers 

G2: Average gainers 

G3: Rapid gainers 

Group N: 

G1: 28 

G2: 66 

G3: 47 

Inclusion criteria: 

• Consecutively 

enrolled poor, black, 

12-19 year olds 

• Prenatal care prior to 

2third week gestation

• No chronic disease 

• No regular 

medications 

• No known uterine 

anomalies 

• Live birth 

• Singletons 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 58.6 (11.1) 

G2: 160.9 (7.0) 

G3: 163.9 (5.5) 

Pregravid BMI: 

G1: 23.1 (3.5) 

G2: 23.5 (4.4) 

G3: 23.5 (4.2) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 16.9 

G2: 16.6 

G3: 16.2 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-585 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28 

G2: 66 

G3: 47 

Total weight gain: 

G1: 7.7 (average rate 

0.2 kg/wk)

G2: 12.4 (average 

rate 0.3 kg/wk)

G3: 19.8 (average 

rate 0.5 kg/wk)

Categorized: 

• According to 

IOMslow gain: 

< 0.23kg/wk; 

average gain: 

0.23-0.4kg/week; 

rapid gain: 

> 0.4kg/week 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) 

P < 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Distribution of LBW,%: 

Groups 

Maternal weight gain categories (kg/wk): 

G1: < 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Results 

G1: 21.4 

G2: 10.6 

G3: 4.3 

P = NS 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

3 Good, 4 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-586 

 Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Strauss and Dietz, 1999 

Country and setting: 

USA, National 

Collaborative Perinatal 

Project and Child Health 

and Development Study 

Enrollment Period:

NCPP: 1959 to 1976 

CHDS: 1959 to 1973 

Funding: 

Grants from NIH and 

Massachusetts Dept of 

Public Health 

Study Objective: 

To examine relationship 

between maternal weight 

gain and risk of 

intrauterine growth 

retardation 

Time frame: 

NCPP: 1959 to 1976 

CHDS: 1959 to 1973 

Duration of the study: 

First visit (prior to 14 

weeks since LMP) to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

Total = 10,756 

NCPP = 5,403 

CHDS = 5,353 

Group Description: 

G1: NCPP 

G2: CHDS 

Group N: 

G1: 4,771 

G2: 5,333 

Inclusion criteria: 

• Women enrolled in 

NCPP or CHDS 

• Patients enrolled 

within 14 weeks of 

last menstrual period 

Exclusion criteria: 

• Women with missing 

trimester weight gain 

data 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 22.8 (4.1) 

G2: 22.7 (3.6) 

Imputed: 

• No 

Categorized: 

• Continuous 

• WHO International 

Taskforce < 20, ≥ 20 - 

< 25, ≥ 25 

Age (mean, yrs): 

G1: 25.2 (5.8) 

G2: 27.4 (5.7) sig dif from 

NCPP P < 0.001 

Parity: 

G1: % primiparous: 28 

G2: 38 sig dif from NCPP P < 

0.001 

Race,%: 

White 

NR 

Black 

G1: 30 

G2: 16 sig dif from NCPP 

P < 0.001 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 39 

G2: 28 sig dif from NCPP 

P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: % single mothers: 10.4 

G2: 2.1 sig dif from NCPP 

P < 0.001 
C-587 

Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4771 

G2: 5333 

Total weight gain: 

G1: 10.4 (4.5)

G2: 11.5 (4.6) P < 

0.001

Categorized: 

• According to IOM 

low weight gain 

in first trimester: 

< 0.1kg/wk; low 

weight gain in 

second and third 

trimesters: < 

0.3kg/wk; low 

pregnancy 

weight gain: < 

6.8 kg 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

first trimester 

weight gain: 

prepregnancy to 

13 to 16 wk since 

LMP; second 

trimester: end of 

first trimester to 

26-29 wk since 

LMP; third 

trimester: end of 

second trimester 

to delivery 

Birth weight: 

G1: 3287 (469) 

G2: 3401 (470) P < 

0.001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• First trimester 

weight gain 

(kg/wk): in 

NCPP, 0.14 

(0.23); in CHDS, 

0.19 (0.24) 

• Second trimester 

weight gain 

(kg/wk): in 

NCPP, 0.36 

(0.17); in CHDS, 

0.41 (0.16) 

• Third trimester 

weight gain 

(kg/wk): in 

NCPP, 0.27 

(0.20); in CHDS, 

0.30 (0.16) 

Other infant 

outcomes: 

% IUGR: in NCPP, 

4.5%; in CHDS, 2.2%

Outcomes Description: 

Adjusted odds ratios(95% CI) for < 2500g: 

Groups 

Maternal weight gain categories stratified by pregravid 

BMI: 

BMI < 20.0: 

G1: Low 1st trimester gain (< 0.1kg/wk) 

G2: Low 2nd trimester gain (< 0.3kg/wk) 

G3: Low 3rd trimester gain (< 0.3kg/wk) 

BMI 20.0-25.0: 

G4: Low 1st trimester gain 

G5: Low 2nd trimester gain 

G6: Low 3rd trimester gain 

BMI > 25.0: 

G7: Low 1st trimester gain 

G8: Low 2nd trimester gain 

G9: Low 3rd trimester gain 

Results 

AOR (95% CI) for < 2500g: 

G1: 0.88 (0.50-1.57) 

G2: 2.68 (1.46-4.94) 

G3: 2.07 (1.22-3.51) 

G4: 1.31 (0.88-1.95) 

G5: 1.92 (1.29-2.87) 

G6: 2.12 (1.48-3.04) 

G7: 1.02 (0.50-2.08) 

G8: 1.88 (1.03-3.43) 

G9: 1.53 (0.86-2.74) 

Reference group-normal rate of weight gain in the 

trimester 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Race, GDM, toxemia, smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 

 
C-588 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-589 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

LGA (%) 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results 

G1: 12.0 

G2: 11.8 

G3: 18.8 

G4: 25.8 

G5: 23.8 

P < 0.01 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Fair 

Analysis comparability: 

Poor 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

2 Good, 3 Fair, 4 Poor 

Final Quality Score: 

Poor 
C-590 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Caulfield et al., 1998 

Country and setting: 

USA, hospital obstetric 

database 

Enrollment Period:

1987 to 1989 

Funding: 

NR 

Study Objective: 

To examine relation 

between gestational 

weight gain and risk of 

delivering a small for 

gestational age and large 

for gestational age infant 

by race 

Time frame: 

1987-1989 

Duration of the study: 

Entry into pn care until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,870 

Group Description: 

G1: BMI < 19.8 Black 

G2: BMI < 19.8 White 

G3: BMI 19.8 to 26.0 Black 

G4: BMI 19.8 to 26.0 White 

G5: BMI > 26.0 Black 

G6: BMI > 26.0 White 

Group N: 

G1: 523 

G2: 267 

G3: 1,479 

G4: 796 

G5: 615 

G6: 190 

Inclusion criteria: 

• Singleton pregnancies 

• White or black ethnicity 

• At least 28 weeks’ 

gestation 

• One delivery per 

woman (randomly 

chosen) 

• Information on 

anthropometric data 

Exclusion criteria: 

• Missing data 

• Improbable data 

• Non-black or non-white 

ethnicity 

Pregravid weight: 

• Self-reported 

G1: 13.3 (5.7) 

G2: 14.6 (5.1) 

G3: 13.6 (6.7) 

G4: 15.3 (5.4) 

G5: 12.4 (7.7) 

G6: 14.5 (7.3) 

Pregravid BMI: 

G1: 18.4 (1.0) 

G2: 18.5 (1.0) 

G3: 22.7 (1.8) 

G4: 22.1 (1.8) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 21.7 (4.8) 

G2: 27.1 (6.6) 

G3: 22.7 (5.3) 

G4: 29.8 (5.8) 

G5: 24.9 (6.0) 

G6: 28.2 (5.5) 

Parity: 

G1: % primiparous: 52.4 

G2: 55.4 

G3: 50.1 

G4: 48.0 

G5: 36.9 

G6: 46.9 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 32.8 

G2: 20.6 

G3: 35.4 

G4: 20.0 

G5: 28.8 

G6: 25.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 4.3 

G2: 3.0 

G3: 6.0 

G4: 5.7 

G5: 11.9 

G6: 17.0 

Additional characteristics: 

NR 
C-591 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: 13.3 (5.7)

G2: 14.6 (5.1)

G3: 13.6 (6.7)

G4: 15.3 (5.4)

G5: 12.4 (7.7)

G6: 14.5 (7.3)

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

selfreport 

prepregnancy 

weight and last 

recorded weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• AOR for LGA (95% CI) 

Groups: 

G1: Underweight, BMI< 19.8 

G2: Normal weight, BMI 19.8-26.0 

G3: Overweight, BMI> 26.0 

Black women: 

G4: No weight gain < IOM 

G5: No weight gain > IOM 

White women: 

G6: No weight gain < IOM 

G7: No weight gain > IOM 

Results: 

AOR (95%CI) for LGA and rate of weight gain 

(per 50 g/wk): 

G1: 1.25 (1.11-1.41) 

G2: 1.14 (1.08-1.20) 

G3: 1.13 (1.07-1.20) 

Expected Absolute Change (as % of baseline) 

in Incidence of LGA associated with modifiable 

risk factor (G4-G7): 

G4: +1.28 (+26) 

G5: -0.77 (-16) 

G6: +2.58 (+17) 

G7: -2.87 (-19) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Height 

• Hypertension 

• Provider type 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Female infant 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of outcomes:

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

6 Good, 3 Fair, 0 Poor 

Final Quality Score: 

Good 
C-592 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Devader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period:

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate relationship 

between gestational 

weight gain and adverse 

pregnancy outcomes 

among women with 

normal prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 35 

lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal prepregnancy 

BMI (19.8 –26.0 

kg/m2) who were 18 

to 35 years of age at 

time of delivery and 

who delivered fullterm (37 weeks or 

more) singleton infant 

during period January 

1, 1999, to December 

31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older than 

35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained from 

mother during postpartum 

hospital stay 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-593 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

NR

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Figures 1 to 3 plot 

risk for each 

adverse pregnancy 

outcome by 10-lb 

increments in 

gestational weight 

gain. Women who 

gained 25 to 34 lbs 

during their 

pregnancy had 

lower risks for most 

outcomes when 

balancing risk for 

SGA status and 

other adverse 

pregnancy 

outcomes 

• Women who 

gained 15 to 24 lbs 

had lowest risks for 

most outcomes, but 

increased their risk 

of having an SGA 

infant from 9.6% to 

14.3% 

• Women who 

gained more than 

34 lbs had higher 

risks for all 

outcomes, although 

their risk of having 

an SGA infant 

decreased from 

9.6% to 6.6% 

Outcomes Description: 

AOR for Women With Normal 

Prepregnancy BMI (19.8 –26.0 

kg/m2) by GWG Category, 

Missouri Birth Certificates, 1999–

2001 (95% CI) 

Groups: 

G1: Gained less than 25 lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 35 lbs 

Results: 

AOR (95%CI) for LGA: 

G1: 0.40 (0.37-0.44) 

G2: 1.00 (reference) 

G3: 2.43 (2.30-2.56) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Age 

• Race 

• Education 

• Income 

• Alcohol use 

• Height 

• Prior pregnancy 

• Inadequate prenatal care use

• Smoking 

Infant and child confounders 

and effect modifiers accounted 

for in analysis: 

• Child's gender 

Birth year 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

2 Good, 7 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-594 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hellerstedt et al., 1997 

Country and setting: 

United States, medical 

center 

Enrollment Period:

1977-1993 

Funding: 

NR 

Study Objective: 

To examine association 

between infant birth 

outcomes and maternal 

pregravid obesity, 

gestational weight gain, 

and prenatal smoking 

Time frame: 

1977 to 1993 

Duration of the study: 

Entry into prenatal care 

until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,343 

Group Description: 

G1: Obese 

G2: Normal weight 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese and normalweight women 

delivering singleton 

during study period 

Exclusion criteria: 

• Missing data 

• Siblings 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 kg (13.7) 

G2: 61.1kg (5.9) 

Pregravid BMI: 

G1: 38.3 (4.6) 

G2: 22.8 (1.6) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: NR 

• 16-34 years: 91% 

• ≥ 35 years: 8.8% 

G2: NR 

• 16-34 years: 93.5% 

• ≥ 35 years: 5.8% 

Parity: 

G1: NR 

• 0: 31.8% 

• 1-3: 64.7% 

• ≥ 4: 3.5% 

G2: NR 

• 0: 33.3% 

• 1-3: 64.9% 

• ≥ 4: 1.8% 

Race,%: 

White 

G1: 68.8 

G2: 69.1 

Black 

G1: 20.4 

G2: 20.6 

Hispanic 

G1: 6.6 

G2: 6.5 

Asian/Pacific Islander 

G1: Native Am: 3.8 

G2: Native Am: 3.2 

Other 

NR 

Smoking,%: 

G1: 26.4 

G2: 26.2 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-595 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

LGA (%) 

Groups 

Maternal weight gain categories stratified by 

pregravid BMI and smoking status: 

Obese (BMI > 29.0): 

G1: Smokers, < IOM 

G2: Smokers, within IOM 

G3: Smokers, > IOM 

G4: Nonsmokers, < IOM 

G5: Nonsmokers, within IOM 

G6: Nonsmokers, > IOM 

Normal weight (BMI 19.8-26.0): 

G7: Smokers, < IOM 

G8: Smokers, within IOM 

G9: Smokers, > IOM 

G10: Nonsmokers, < IOM 

G11: Nonsmokers, within IOM 

G12: Nonsmokers, > IOM 

Obese: 

G13: Lost/no gain 

G14: 0.5-6.5 kg 

G15: 7-11.5 kg 

G16: 12-16 kg 

G17: > 16 kg 

Normal weight: 

G18: < 11.5kg 

G19: 11.5-16kg 

G20: > 16kg 

Results 

Frequencies of LGA, %: 

G1: 5.3 

G2: 10.0 

G3: 12.3 

G4: 12.2 

G5: 11.7 

G6:22.2 

G7: 0 

G8: 1.8 

G9: 9.1 

G10: 4.4 

G11: 8.1 

G12: 14.3 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-596 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hellerstedt et al., 1997 

(continued) 

 
C-597 

Evidence Table 39. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

G13: 9.3 

G14: 10.5 

G15: 11.3 

G16: 17.5 

G17: 21.8 

P = 0.001 for G13-G17 

G18: 2.8 

G19: 6.7 

G20: 13.1 

P < 0.001 for G18-G20 

Compared with infants of obese nonsmokers 

who gained 7-11.5kg, the only group at 

significantly higher risk of LGA was non 

smokers who gained > 11.5kg: AOR: 2.3 

(95%CI: 1.2-4.5) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

Maternal age, pregravid BMI, infant sex, 

race, parity, prenatal alcohol use, prenatal 

illicit drug use, adequacy of prenatal care, 

gestational hypertension, GDM 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 
C-598 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period:

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight change 

on pregnancy outcomes in 

obese women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) (n 

= 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 37 

or more weeks of 

gestation) liveborn, 

singleton infants 

during 1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-599 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 43% 

G3: GWG (lb)Less than 

2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, and 

greater than 35 lb 

gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, %:

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental delivery,%:

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Absolute risk and OR (95% CI) of pregnancy 

outcomes for various classes of obese 

women (class I, II, III) 

Groups: 

Maternal weight gain categories stratified by 

prepregnancy obesity status, Obese Class 

I(BMI 30–34.9), Obese Class II (BMI 35–

39.9), Obese Class III (> = BMI 40): 

G1: < = -10lbs 

G2: -2 to -9 lbs 

G3: No change 

G4: 2-9 lbs 

G5: 10-14 lbs 

G6: 15-25lbs 

G7: 26-35lbs 

G8: > 35 lbs 

Result: 

For Obese Class I: OR (95% CI) for LGA 

were significantly lower (< 1.00, G6 was 

reference) for G1- G5 and significantly higher 

for G7-G8. 

For Obese Class II: OR (95% CI) for LGA 

were significantly lower (< 1.00, G6 was 

reference) for G1- G5 and significantly higher 

for G7-G8. 

For Obese Class III:OR (95% CI) for LGA 

were significantly lower (< 1.00, G6 was 

reference) for G1- G4 and significantly higher 

for G7-G8 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in Medicaid, WIC, 

food stamp programs) 

• Tobacco use 

• Chronic hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 6 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-600 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

(continued) 

 
C-601 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Other maternal outcomes: 

• Figures 1 to 3 show 

absolute risk of 

preeclampsia, cesarean 

delivery, LGA, and SGA by 

GWG category for each 

obesity class. All 3 figures 

show similar patterns of 

increasing risk of 

preeclampsia, cesarean 

delivery, and LGA birth and 

decreasing risk of SGA birth 

with increasing GWG. 

Collectively, minimal risk for 

all 4 outcomes corresponds 

to GWG categories where 

risk of LGA and SGA births 

intersect. This equates to 

GWG of 10 of 25 lb for class 

I obese women, a gain of 0 

tp 9 lb for class II obese 

women, and weight loss of 0 

to 9 lb for class III obese 

women. Adjusted odds 

ratios and 95% CIs for 

preeclampsia, cesarean 

delivery, SGA, and LGA by 

GWG category and obesity 

class. Compared with 

women who gained 15 to 25 

lb during their pregnancies, 

those who gained less 

weight had significantly 

lower odds of preeclampsia, 

cesarean delivery, and LGA 

births, but higher odds for 

SGA births. Women who 

gained more than 25 lbs had 

higher odds for same 3 

pregnancy outcomes and 

lower odds for SGA births. 

Other infant outcomes: 

NR 
C-602 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Parker and Abrams, 1992 

Country and setting: 

USA, hospital 

Enrollment Period:

Sept 1980 to Dec 1988 

Funding: 

UC Committee on 

Research & MCH and 

Resources Development, 

Health Resources and 

Services Administration 

Study Objective: 

To test whether gains 

outside IOM reference 

ranges were associated 

with increased risks of 

suboptimal pregnancy 

outcome (SGA, LGA, 

cesarean delivery) and to 

determine whether locally 

developed ranges were 

more applicable to study 

population 

Time frame: 

Sept 1980 to Dec 1988 

Duration of the study: 

From entry into prenatal 

care until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

6,690 

Group Description: 

G1: Overall 

G2: NR 

Group N: 

G1: 6,690 

G2: NR 

Inclusion criteria: 

• Consecutive live 

singleton births at 

Moffitt Hospital 

between September 

1980 and December 

1988 with gestational 

ages of 37 to 42 

weeks 

Exclusion criteria: 

• Maternal transfers or 

transports and 

deliveries 

complicated by fetal 

malformations, 

maternal diabetes, or 

maternal 

hypertension 

Pregravid weight: 

• Self-reported 

G1: 56.8 kg(SD 11.0) 

G2: NR 

Pregravid BMI: 

G1: Underweight: 27.7%, 

Normal weight 61.8%, 

Overweight: 5.6%, 

Obese 4.9% 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 27.7 (5.5) 

G2: NR 

Parity: 

Primiparous:

G1: 58.8% 

G2: NR 

Race,%: 

White 

G1: 44.0 

G2: NR 

Black 

G1: 8.3 

G2: NR 

Hispanic 

G1: 9.4 

G2: NR 

Asian/Pacific Islander 

G1: 21.4 

G2: NR 

Other 

G1: 12.0 

G2: NR 

Smoking,%: 

G1: 12.0 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-603 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 6690 

G2: NR 

Total weight gain: 

G1: 15.2kg (5.2)

G2: NR 

Categorized: 

• According to IOM 

Weight gain 

ranges based on 

percentiles from 

previous study of 

UC population 

with good 

pregnancy 

outcomes: 25th -

75th, 10-90th 

percentiles. For 

25-75th, weight 

gain range = 12-

17kg for 

underweight 

women (BMI < 

19.8); 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3408g (462) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• AOR for LGA (95% CI) 

Groups: 

G1: < IOM range 

G2: Within IOM range 

G3: > IOM 

Results: 

AOR (95% CI) for LGA: 

G3: 1.92 (1.52-2.43) 

G2: 1.00 (reference) 

Incidence of LGA in nonobese women, %: 

G1: 3.25 

G2: 6.14 

G3: 13.11 

Incidence of LGA in obese women, %: 

G1: 5.88 

G2: 17.53 

AOR for LGA and high weight gain 

UCSF 25-75 

1.89 (1.51-2.37) 

UCSF 10-90 

1.87 (1.39-2.52) 

IOM 

1.92 (1.52-2.43) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Height 

• Maternal high and low weight gain 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

• Gestational age 

Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poo

r: 

3 Good, 5 Fair, 

1 Poor 

Final Quality 

Score: 

Fair 
C-604 

 Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stevens-Simon and 

McAnarney, 1992 

Country and setting: 

USA, adolescent 

maternity program 

Enrollment Period:

1986 to 1989 

Funding: 

Grant from Bureau of 

Maternal and Child Health 

Study Objective: 

To clarify advantages and 

disadvantages of large 

gestational weight gain 

among pregnant 

adolescents 

Time frame: 

1986 to 1989 

Duration of the study: 

Entry into prenatal care 

through 6 weeks PP 

check up 

Design: 

• Cohort 

• Prospective 

Total Study N: 

141 (107 included in 

postpartum analyses) 

Group Description: 

G1: Slow gainers 

G2: Average gainers 

G3: Rapid gainers 

Group N: 

G1: 28 

G2: 66 

G3: 47 

Inclusion criteria: 

• Consecutively 

enrolled poor, black, 

12-19 year olds 

• Prenatal care prior to 

2third week gestation

• No chronic disease 

• No regular 

medications 

• No known uterine 

anomalies 

• Live birth 

• Singletons 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 58.6 (11.1) 

G2: 160.9 (7.0) 

G3: 163.9 (5.5) 

Pregravid BMI: 

G1: 23.1 (3.5) 

G2: 23.5 (4.4) 

G3: 23.5 (4.2) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 16.9 

G2: 16.6 

G3: 16.2 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-605 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28 

G2: 66 

G3: 47 

Total weight gain: 

G1: 7.7 (average rate 

0.2 kg/wk)

G2: 12.4 (average 

rate 0.3 kg/wk)

G3: 19.8 (average 

rate 0.5 kg/wk)

Categorized: 

• According to 

IOMslow gain: 

< 0.23kg/wk; 

average gain: 

0.23-0.4kg/week; 

rapid gain: > 

0.4kg/week 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) 

P < 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Distribution of LGA,%: 

Groups 

Maternal weight gain categories (kg/wk): 

G1: < 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Results 

G1: 3.6 

G2: 4.5 

G3: 12.8 

P = NS 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor:

3 Good, 4 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-606 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980 to 2001 

Funding: 

NR 

Study Objective: 

To examine relationship 

between gestational 

weight gain and adverse 

neonatal outcomes 

among infants born at 

term (37 weeks or more) 

Time frame: 

1980 to 2001 

Duration of the study: 

Entry into PN care up till 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20465 

Group Description: 

G1: Gain below IOM 

recommendations 

G2: Gain within IOM 

recommendations 

G3: Gain above IOM 

recommendations 

Group N: 

G1: 4,114 

G2: 7,490 

G3: 8,861 

Inclusion criteria: 

• Singleton 

Exclusion criteria: 

• Pregnancies 

complicated by 

multiple gestations, 

congenital anomalies, 

chronic hypertension, 

gestational or 

pregestational 

diabetes 

• Birth before 37 weeks

• Maternal transport 

• Missing data on any 

of variables 

considered in 

multivariable analysis

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 25.8% 

19.8-26.0: 19.4% 

26.1-29.0: 9.2% 

> 29.0: 20.6% 

G2: < 19.8: 49.1% 

19.8-26.0: 34.8% 

26.1-29.0: 23.3% 

> 29.0: 25.5% 

G3: < 19.8: 25.0% 

19.8-26.0: 45.8% 

26.1-29.0: 67.5% 

> 29.0: 53.9% 

P < 0.001 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20 years: 23.4% 

20-29 years: 19.3% 

30-39 years: 19.9% 

> 40 years: 25.3% 

G2: < 20 years: 31.3% 

20-29 years: 36.6% 

30-39 years: 37.6% 

> 40 years: 36.3% 

G3: < 20 years: 45.4% 

20-29 years: 44.0% 

30-39 years: 42.5% 

> 40 years: 38.4% 

P < 0.001 

Parity: 

% Nulliparous:

G1: 17.3 

G2: 36.2 

G3: 46.6 

P < 0.001 

Race,%: 

White 

G1: 16.2 

G2: 35.8 

G3: 48.0 

Black 

G1: 25.5 

G2: 29.4 

G3: 45.1 

Hispanic 

G1: 19.2 

G2: 34.8 

G3: 46.0 

Asian/Pacific Islander 

G1: 24.3 

G2: 43.3 

G3: 32.4 

Other 

G1: 21.7 

G2: 37.9 

G3: 40.4 

P for all race categories < 

0.001 

Smoking,%: 

G1: 23.5 

G2: 30.8 

G3: 45.8 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-607 

Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4114 

G2: 7490 

G3: 8861 

Total weight gain: 

Categorized: 

• According to 

IOMpercentiles 

and dichotomous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: %SGA: 36.1; %AGA: 

20.2; %LGA: 8.5 

G2: %SGA: 39.4; %AGA: 

37.5; %LGA: 26.5 

G3: %SGA: 24.5; %AGA: 

42.4; %LGA: 65.1 

P < 0.001 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 14.7 

G2: 32.1 

G3: 53.2 

Instrumental delivery,%: 

Operative vaginal delivery:

G1: 18.0% 

G2: 37.5% 

G3: 44.5% 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

• Birth trauma 

• 5 min Apgar score less 

than 7 

• Aassisted ventilation 

• SGA 

• LGA 

• NICU admission 

• SCN admission 

• Neonatal infection 

• Seizure 

• Hypoglycemia 

• Polycythemia 

• MAS 

• RDS 

• Tachypnea 

• Hospital stay > 5 days 

• Hospital stay > 10 

days 

Outcomes Description: 

• Risk of adverse neonatal outcomes by 

gestational weight gain by IOM guidelines, 

adjusted ORs compared to women with GWG 

within IOM guidelines and risk of adverse 

neonatal outcomes by extremes of GWG 

compared to women with weight gain 11.5-

16.0kg 

Groups: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: < 7kg 

G5: > 18kg 

Results: 

Unadjusted Rates of LGA: 

G1: 3.85 P< 0.001 vs. G2 

G2: 6.62 

G3:13.76 P< 0.001 vs. G2 

G4: 5.26 

G5: 14.60 P< 0.05 vs. G2 

AOR (95% CI) for LGA: 

G1: 0.58 (0.47-0.72) 

G2: 1.00 (reference) 

G3: 1.98 (1.74-2.25) 

G4: 0.50 (0.33-0.78) 

G5: 2.28 (2.00-2.62) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Date of delivery 

• Mode of delivery 

• Length of first stage of labor 

• Length of second stage of labor 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-608 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cogswell et al., 1994 

Country and setting: 

USA, Pregnancy Nutrition 

Surveillance System 

Enrollment Period:

1990-1991 

Funding: 

NR 

Study Objective: 

To determine association 

between increased 

gestational weight gain 

and birth weight outcomes 

for low income women 

Time frame: 

1990-1991 

Duration of the study: 

Women in WIC but 

everything is self reported 

so it is when they were 

first enrolled in WIC until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

53,541 

Group Description: 

G1: Average weight 

G2: Overweight 

G3: Very overweight 

Group N: 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Inclusion criteria: 

• White, black and 

hispanic women who 

delivered single, 

liveborn, term infants 

Exclusion criteria: 

• Low or high values 

for; birth weight, 

prepregnancy BMI, or 

weight gain during 

pregnancy 

• Missing data on one 

or more study 

variables 

• Underweight women 

• Only 1 infant was 

used in analysis for 

women who delivered 

more than once 

during study period 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 11-17 yr: 11.9% 

18-34yr: 85.0% 

35-54 yr: 3.1% 

G2: 11-17 yr: 6.9% 

18-34yr: 88.7% 

35-54 yr: 4.4% 

G3: 11-17 yr: 4.0% 

18-34yr: 90.1% 

35-54 yr: 6.0% 

Parity: 

NR 

Race,%: 

White 

G1: 75.1 

G2: 72.4 

G3: 74.5 

Black 

G1: 13.8 

G2: 14.1 

G3: 16.1 

Hispanic 

G1: 11.1 

G2: 13.5 

G3: 9.4 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 29.9 

G2: 28.3 

G3: 25.7 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-609 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 33,809 

G2: 7,661 

G3: 12,071 

Total weight gain: 

G1: < 15 lb: 6.2% 

15-19: 5.8% 

20-24: 11.2% 

25-29: 14.4% 

30-34: 17.1% 

35-39: 13.9% 

≥ 40: 31.4%

G2: < 15 lb: 11.4% 

15-19: 7.8% 

20-24: 13.0% 

25-29: 12.7% 

30-34: 15.9% 

35-39: 11.2% 

≥ 40: 28.1%

G3: < 15 lb: 25.1% 

15-19: 10.1% 

20-24: 1

Categorized: 

• 4 lbs increments 

starting at 15 lbs 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: < 2500g: 2.7% 

2500-4000g: 87.5% 

> 4000-4500: 8.5% 

> 4500g: 1.4% 

G2: < 2500g: 2.5% 

2500-4000g: 83.9% 

> 4000-4500: 11.7% 

> 4500g: 2.0% 

G3: < 2500g: 2.1% 

2500-4000g: 81.1% 

> 4000-4500: 13.2% 

> 4500g: 3.6% 

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

AOR (95% CI) for high birth weight 

Groups 

Maternal weight gain categories (lbs) 

stratified by pregravid BMI: 

Normal weight (BMI 19.8-26.0): 

G1: < 15 

G2: 15-19 

G3: 20-24 

G4: 25-29 

G5: 30-34 

G6: 35-39 

G7: ≥ 40 

Overweight (BMI > 26.0-29.0): 

G8: < 15 

G9: 15-19 

G10: 20-24 

G11: 25-29 

G12: 30-34 

G13: 35-39 

G14: > = 40 

Obese (BMI > 29.0): 

G15: < 15 

G16: 15-19 

G17: 20-24 

G18: 25-29 

Results 

AOR (95% CI) for high birth weight: 

G1: 1.0 (0.5-2.0) 

G2: 0.4 (0.2-1.0) 

G3: 0.6 (0.3-1.1) 

G4: 1.0 (reference) 

G5: 1.1 (0.7-1.8) 

G6: 1.5 (1.0-2.3) 

G7: 3.3 (2.3-4.7) 

G8: 0.8 (0.2-2.6) 

G9: 1.0 (reference) 

G10: 1.1 (0.4-3.5) 

G11: 2.1 (0.8-5.7) 

G12: 2.4 (0.9-6.4) 

G13: 1.6 (0.6-4.6) 

G14: 4.0 (1.6-10.1) 

G15:0.7 (0.5-1.1) 

G16: 1.0 (reference) 

G17: 1.1 (0.7-1.7) 

G18: 1.3 (0.8-2.0) 

G19: 1.9 (1.3-2.9) 

G20: 2.1 (1.3-3.2) 

G21: 2.3 (1.6-3.3) 
C-610 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Cogswell et al., 1994 

(continued) 

 
C-611 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• height 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Sex of infant 
C-612 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period:

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal weight 

women and their 

associations with 

gestational weight change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight women 

identified from 

pregnancy and 

delivery summary 

records (normal 

weight matched to 

obese by race, age, 

parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal weight 

(BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-613 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5

G2: 14.5 P ≤ 0.001

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Birthweight ≥ 4000g 

Groups: 

Maternal weight gain categories (kg) Obese > 29: 

G1: Lost weight/no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal BMI 19.8-26 

G6: < 11.5kg 

G7: 11.5-16 

G8: > 16kg 

Results: 

Birthweight > = 4000g, %: 

G1:12.0 

G2: 12.5 

G3: 13.3 

G4: 15.4 

G5: 24.4 

P (for G1-G5) = 0.026 

G6: 5.7 

G7: 6.6 

G8: 16.9 

P (for G6-G8) < 0.001 

AOR (95%CI) for birthweight> = 4000g among obese 

women (BMI> 29.0): 

G3: 1.0 (reference) 

G8: 2.8 (1.4-5.6) 

AOR (95%CI) for birthweight> = 4000g among normal 

weight women (BMI 19.8-26.0): 

G7: 1.0 (reference) 

G8: 2.4 (1.3-4.7) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• GDM 

• Pregnancy induced hypertension 

• Prenatal adequacy 

• Alcohol use 

• Drug use 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-614 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hedderson et al., 2006 

Country and setting: 

USA, Kaiser Permanente 

Medical Care Program 

Enrollment Period:

January 1, 1996 - June 

31, 1998 

Funding: 

R01 DK 54834 from 

National Institute of 

Diabetes and Digestive 

and Kidney Diseases, 

grant from American 

Diabetes Association and 

Kaiser Community Benefit 

research support 

Study Objective: 

To examine whether 

pregnancy weight gains 

outside IOM 

recommendations and 

rates of maternal weight 

gain are associated with 

neonatal complications 

Time frame: 

January 1, 1996 to June 

31, 1998 

Duration of the study: 

First prenatal care visit to 

30 days post delivery 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

45,245 

Group Description: 

G1: Controls 

G2: Macrosomia 

G3: Hypoglycemia 

G4: Hyperbilirubinemia 

Group N: 

G1: 652 

G2: 391 

G3: 328 

G4: 432 

Inclusion criteria: 

• Singleton livebirth 

Exclusion criteria: 

• No pregestational 

diabetes or history of 

gestational diabetes 

(screened at 24-28 

weeks gestation - 

meeting National 

Diabetes Data Group 

criteria for GDM) 

Pregravid weight: 

• Self-reported in some cases 

used measured weight 

recorded in chart closes to 

woman’s last menstrual 

period but no more than 12 

months before her last 

menstrual period 

Pregravid BMI: 

G1: < 19.8: 13.5% 

19.8-24.9: 56.4% 

25.0-29.0: 12.4% 

> 29.0: 17.6% 

G2: < 19.8: 5.1% 

19.8-24.9: 51.2% 

25.0-29.0: 16.6% 

> 29.0: 27.1% 

G3: < 19.8: 10.1% 

19.8-24.9: 50.0% 

25.0-29.0: 17.1% 

> 29.0: 22.9% 

G4: < 19.8: 13.9% 

19.8-24.9: 57.9% 

25.0-29.0: 13.2% 

> 29.0: 57.1% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 25 years: 22.1% 

25-29: 24.2% 

30-34: 33.6% 

≥ 35: 20.1% 

G2: < 25 years: 15.9% 

25-29: 28.0% 

30-34: 31.7% 

≥ 35: 24.3% 

G3: < 25 years: 24.1% 

25-29: 25.3% 

30-34: 26.8% 

≥ 35: 23.8% 

G4: < 25 years: 17.1% 

25-29: 29.4% 

30-34: 32.6% 

≥ 35: 20.8% 

Parity: 

% primiparous:

G1: 56.9 

G2: 31.2 

G3: 50.0 

G4: 59.3 

Race,%: 

White 

G1: 54.0 

G2: 67.8 

G3: 47.6 

G4: 42.6 

Black 

G1: 10.0 

G2: 5.1 

G3: 11.3 

G4: 4.4 

Hispanic 

G1: 17.2 

G2: 15.1 

G3: 20.4 

G4: 15.5 

Asian/Pacific Islander 

G1: 8.1 

G2: 3.6 

G3: 6.7 

G4: 20.1 

Other 

G1: 10.7 

G2: 8.4 

G3: 14.0 

G4: 17.4 

Smoking,%: 

G1: %nonsmoking during 

pregnancy: 92.0; %smoked 

but quit: 4.2; %smoked 3.9 

G2: %nonsmoking during 

pregnancy: 90.8; %smoked 

but quit: 5.3; %smoked 4.0 

G3: %nonsmoking during 

pregnancy: 92.6; %smoked 

but quit: 1.5; %smoked 5.8 

G4: %nonsmoking during 

pregnancy: 94.2; %smoked 

but quit: 4.9; %smoked 1.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Screening glucose value less 

than 140:

G1: 85.0%: > 140: 15.0% 

G2: 81.6%: > 140: 18.4% 

G3: 81.4%: > 140: 18.6% 

G4: 83.3%: > 140: 16.7% 
C-615 

Evidence Table 48. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

recordsrate of 

maternal weight 

gain was 

calculated as 

total pregnancy 

weight gain 

minus infant birth 

weight divided by 

weeks of 

gestation when 

last weight was 

measured; rate 

of maternal 

weight gain 

before the third 

trimester was 

calculated using 

the weight 

measured at or 

before the 

screening test for 

GDM (24-28 wks 

of gestation) 

minus 

prepregnancy 

weight divided by 

weeks of 

gestation 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between final 

recorded weight 

at last prenatal 

visit (within 2 

weeks of delivery 

date) and 

prepregnancy 

weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• AOR for birthweight>4500g (95% CI) 

Groups: 

G1: < IOM recommendations 

G2: Within IOM recommendations

G3: > IOM recommendations

Results: 

% Distribution of maternal weight gain 

categories among women with macrosomia: 

G1: 4.0 

G2: 16.3 

G3: 79.7 P< 0.05 (compared to controls) 

AOR (95% CI) for macrosomia: 

G1: 0.38 (0.20-0.70) 

G2: 1.00 reference 

G3: 3.05 (2.19-4.26) 

OR (95% CI) for macrosomia: 

Underweight women (BMI < 19.8) 

G2: 1.00 (reference) 

G3: 2.70 (0.83-8.61) 

Normal weight women(BMI 19.8-26.0) 

G2: 1.00 (reference) 

G3: 3.60 (2.27-5.83) 

Overweight/obese women (BMI > 26.0) 

G2: 1.00 (reference) 

G3: 2.00 (1.14-3.47) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Screening glucose value from 1 hour after 

50g oral glucose challenge test 

• Difference between age at delivery and 

gestational age at last weight measured 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-616 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kabali, C and Werler, MM, 

2007 

Country and setting: 

Canada and United 

States, multicenter 

Enrollment period:

1996 to 2002 

Funding: 

National Instituteof Dental 

and Craniofacial 

Research, grant # 

DE11393 

Study Objective: 

To establish whether 

excessive pre-pregnancy 

weight as measured by 

BMI, excessive PWG, or 

their combined effects are 

risk factors for delivering 

large babies 

Time frame: 

1996 to 2002 

Duration of the study: 

Entry into prenatal care 

through pregnancy 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

815 

Group Description: 

G1: Total Study 

Group N: 

G1: 815 

Inclusion criteria: 

• Controls were 

selected by pediatric 

practice (or one of 

similar size and 

location) of each case 

by identifying next 

four children seen in 

practice whose ages 

were within 2 months 

of case's age. 

Exclusion criteria: 

• Diabetic women 

• Multiple gestations 

• Missing weight, 

height, or weight gain 

data 

• Women with outlying 

data 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: <24 years 208 (25.5%) 

24 to 34 years 478 (58.7%)

35 to 45 years 129 (15.8%) 

Parity: 

G1: Primaparae (56.2%) 

Race,%: 

White 

G1: (67.7) 

Black 

G1: (11.3) 

Hispanic 

G1: (16.2) 

Asian/Pacific Islander 

NR 

Other 

G1: (4.8) 

Smoking,%: 

G1: throughout pregnancy - 

yes: 8.2% 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-617 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

NR

Categorized: 

• According to IOM 

Collected from: 

• NR 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational diabetes, %: 

NR 

Cesarean delivery,%: 

NR 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal outcomes:

NR 

Other infant outcomes: 

Outcomes Description: 

OR for maternal BMI and weight gain in 

relation to risk of macrosomia (95% CI) 

Groups: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Results: 

AOR 

G1: 1.0 (0.4, 1.9) 

G2: ref 

G3: 1.5 (0.7, 2.5) 

Combined effect with BMI OR (AOR similar 

but not all could be calculated) 

Underweight/G1: 0.7 (0.2, 3.3) 

Underweight/G2: 1.0 (0.3, 3.5) 

Underweight/ G3: 1.7 (0.4, 6.4) 

Normal/G1: 0.7 (0.3, 1.8) 

Normal/G2 Ref 

Normal/ G3: 1.1 (0.5, 2.3) 

Overweight/G1: 1.2 (0.4, 3.8) 

Overweight/G2: 0.8 (0,2, 2.7) 

Overweight/G3: 2.4 (1.2, 4.8) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Parity 

• Marital status 

• Family income 

• Alcohol intake 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Child's sex 
C-618 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rode et al., 2007 

Country and setting: 

Smoke-free Newborn 

Study, University Hospital, 

Denmark 

Enrollment period: 

November 1996 to 

October 1998 

Funding: 

NR 

Study Objective: 

To investigate association 

between maternal weight 

gain and birthweight 

Time frame: 

November 1996 to 

October 1998 

Duration of the study: 

12 to 18 weeks gestation 

through delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

2248 

Group Description: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI 26.1-29.0 

G4: BMI > 29.0 

Group N: 

G1: 385 

G2: 1,531 

G3: 177 

G4: 385 

Inclusion criteria: 

• Women who 

answered 

questionnaire at both 

12 to 18 weeks and 

37 weeks gestation 

Exclusion criteria: 

• Multiple gestation 

• Women who 

delivered prior to 37 

weeks 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

IOM Guidelines 

Age (mean, yrs): 

G1: Less than 25:15.3% 

25-30: 45.7% 

30-35: 33.5% 

>35: 5.5% 

G2: Less than 25:17.5% 

25-30: 36.7% 

30-35: 34.5% 

>35: 11.3% 

G3: Less than 25:15.3% 

25-30: 45.7% 

30-35%: 33.5% 

>35: % 

G4: Less than 25: 20.0% 

25-30: 39.4% 

30-35: 29.7% 

>35: 11.0% P < 0.001 

Parity: 

% nulliparous:

G1: 52.2 

G2: 58.6 

G3: 51.4 

G4: 49.0 P = 0.02 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

%nonsmokers:

G1: 58.3 

G2: 65.5 

G3: 61.1 

G4: 67.3 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% married/cohabiting:

G1: 92.3 

G2: 91.4 

G3: 94.2 

G4: 92.7 

Additional characteristics: 

NR 
C-619 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 385

G2: 1,531

G3: 177

G4: 385 

Total weight gain: 

G1: < 1kg: 0% 

1-5:0.5% 

6-10: 16.1% 

11-15: 45.7% 

16-20: 30.1% 

>20: 7.5%

G2: < 1kg: 0.3% 

1-5: 1.6% 

6-10: 16.9% 

11-15: 41.5% 

16-20: 29.1% 

>20: 10.5%

G3: < 1kg: 1.7% 

1-5: 4.5% 

6-10: 24.9% 

11-15: 40.1% 

16-20: 24.3% 

>20: 4.5%

G4:

Categorized: 

AccordinG to IOM

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: less than 2500g: 1.8% 

2500-2999: 10.9% 

3000-3999: 72.7% 

4000-4499: 11.4% 

≥ 4500: 3.1% 

G2: less than 2500g: 1.1% 

2500-2999: 7.1% 

3000-3999: 69.6% 

4000-4499: 18.2% 

≥ 4500: 4.0% 

G3: less than 2500g: 2.3% 

2500-2999: 4.5% 

3000-3999 

Gestational diabetes, %: 

NR 

Cesarean delivery,%: 

NR 

Instrumental delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal outcomes 

NR 

Other infant outcomes 

• Birthweight 

Outcomes Description: 

• AOR for birthweight ≥ 4000g (95% CI) 

Groups: 

Maternal weight gain categories stratified by 

pregravid BMI status: 

BMI less than 19.8 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI 19.8–26.0 

G4: < IOM 

G5: Within IOM 

G6: > IOM 

BMI 26.1–29.0 

G7: < IOM 

G8: Within IOM 

G9: > IOM 

Results: 

AOR (95%CI) for birthweight > = 4000g: 

G1: 0.8 (0.4-1.6) 

G2: 1.0 (reference) 

G3: 1.7 (0.8-3.6) 

G4: 0.7 (0.5-0.999) 

G5: 1.0 (reference) 

G6: 1.9 (1.5-2.5) 

G7: 0.6 (0.1-3.1) 

G8: 1.0 (reference) 

G9: 1.8 (0.8-3.9) 

G10: 0.8 (0.4-1.7) 

G11: 1.0 (reference) 

G12: 0.9 (0.4-2.0) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Pre-eclampsia 

• Caffeine consumption 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

6 Good, 2 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-620 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Schieve, 1998 

Country and setting: 

Pregnancy Nutrition 

Surveillance System - 

data from WIC clinics 

(99%) from Indiana, 

Kansas, Massachusetts, 

Minnesota, Nebraska, 

North Dakota, New York, 

Tennessee, and Vermont 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To examine associations 

between pregnancy 

weight gain outside and 

within ranges 

recommended by IOM 

and birth weight by both 

prepregnant BMI and race 

ethnicity 

Time frame: 

NR 

Duration of the study: 

1990 to 1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

173,066 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• White, black, and 

hispanic women who 

visited WIC clinics 

prenatally and 

subsequently 

delivered liveborn, 

singleton infants 

• Delivered between 39 

and 41 weeks 

Exclusion criteria: 

• Missing data for 

infant birth weight 

(n = 4223) 

• Prepregnant BMI 

(n = 31477) 

• Pregnancy weight 

gain (n = 7542) 

• Maternal age 

(n = 43) 

• Maternal education 

(n = 3819) 

Pregravid weight: 

• Self-reported 

• NR 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

IOM Guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-621 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 112,524

G2: 33,101

G3: 27,441

Total weight gain: 

G1: 32.5

G2: 30.5

G3: 30.2

Categorized: 

According to IOM >10 

pounds below lower 

bound of IOM 

recommended range 

for woman's 

prepregnant BMI, 1-9 

pounds below lower 

bound of IOM lower 

bound, in lower half 

of IOM recommended 

range, in upper half of 

IOM range, 1-9 

pounds above IOM 

range, >10 pounds 

above IOM upper 

bound 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• NA 

Other infant 

outcomes 

• NA 

Outcomes Description: 

Macrosomia (>4500g) 

Groups 

Maternal weight gain categories stratified by pregravid 

BMI (IOM underweight, normal weight, overweight, and 

obese) and race (non-Hispanic white, non-Hispanic 

black, and Hispanic): 

G1: > = 10 lbs below IOM 

G2: 1-9 lbs below IOM 

G3: Lower half of IOM 

G4: Upper half of IOM 

G5: 1-9 lbs above IOM 

G6 > = 10lbs above IOM 

Results 

Within every BMI-race ethnicity stratum, the odds of 

delivering a > 4500g infant tended to increase as 

weight gain increased. This trend was statistically 

significant for all strata; however, the trend 

diminished with decreasing BMI. Women in G6 

were 2.2–10.8 times more likely to deliver a > 4500 

g infant compared to women in G3, irrespective of 

BMI status. 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Height 

• Education 

• Trimester of the Special Supplemental Nutrition 

Program for Women, Infants, and Children 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

3 Good, 4 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-622 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Thorsdottir et al., 2002 

Country and setting: 

Maternity records, 

Department of Obstetrics 

and Gynecology at 

Landspitali University 

Hospital, Iceland 

Enrollment Period:

Funding: 

NR 

Study Objective: 

To investigate relation 

between gestational 

weight gain in women of 

normal prepregnant 

weight and complications 

during pregnancy and 

delivery in a population 

with high gestational 

weight gain and birth 

weight 

Time frame: 

NR 

Duration of the study: 

1998 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

614 

Group Description: 

G1: No complication 

G2: Complications in 

pregnancy or delivery

G3: Complications in 

pregnancy 

G4: Complications in 

delivery 

Group N: 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Inclusion criteria: 

• Women of normal 

prepregnancy weight 

randomly selected 

within 1 year (1998) 

• No history of 

diabetes, 

hypertension, CVD, 

or thyroid problems 

• Singleton births 

• 38 to 43 weeks 

gestation 

• 20 to 40 years of age

• Routine fetal biometry 

at 18 to 20 week 

ultrasound 

• Received early and 

regular antenatal care

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 63.1 (6.2) 

G2: 62.0 (5.6) P = 0.059 

G3: 61.7 (4.8) P = 0.174 

G4: 62.2 (6.1) P = 0.274 

Pregravid BMI: 

G1: 22.2 

G2: 22.4 )1.6) P = 0.270 

G3: 22.4 (1.5) P = 0.338 

G4: 22.3 P = 0.584 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 29 

G2: 29 P = 0.857 

G3: 29 P = 0.404 

G4: 29 P = 0.398 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Proportional weight gain, %:

G1: 26.0 

G2: 28.0 P = 0.018 

G3: 30.0 P = 0.005 

G4: 27.0 P = 0.546 

Additional characteristics: 

NR 
C-623 

Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia 

(continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 452 

G2: 162 

G3: 56 

G4: 106 

Total weight gain: 

G1: 16.6 (4.9)

G2: 17.4 (5.1) P = 

0.080

G3: 18.4 (5.1) P = 

0.013

G4: 16.9 (5.1) P = 

0.887

Categorized: 

• According to IOM < 

11.5, 11.-16.0, ≥

16.1, also quintiles 

< 12.5, 12.5-15.5, 

15.6-17.8, 17.9-

20.8, > 20.8 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically measured 

weight prior to 

delivery 

Birth weight: 

G1: 3789 (469) 

G2: 3749 (565) P = 0.389

G3: 3643 (526) P = 0.032

G4: 3806 (578) P = 0.529

Gestational diabetes, %:

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

NA 

Outcomes Description: 

Birthweight > 4500g 

Groups: 

Maternal weight gain 

categories: 

G1: < 11.5 kg 

G2: 11.5-16.0 kg 

G3: 16.1-20.0 kg 

G4: > 20.0 kg 

G5: 12.5-15.5kg 

G6: > 17.8-20.8 kg 

Results: 

Birth weight > 4500g, % 

G1: 4.3 

G2: 4.1 (P< 0.05 between 

groups) 

G3: 9.1 (P< 0.05 between 

groups) 

G4: 10.2 (P< 0.05 between 

groups) 

P for trend< 0.015 

RR (95%CI) for > 4500g: 

G5: 1.00 (reference) 

G6: 3.54 (1.26-9.97) 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Height 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Fair 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-624 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bianco et al., 1998 

Country and setting: 

Mount Sinai Medical 

Center, New York City 

Enrollment period: 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

outcomes between 

morbidly obese and 

nonobese women and 

to determine effect of 

gestational weight gain 

on pregnancy outcome 

in morbidly obese 

women 

Time frame: 

NR 

Duration of the study: 

1988 to 1995 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

613 morbidly obese 

11,313 nonobese 

Group Description: 

G1: Obese 

G2: Controls 

Group N: 

G1: 613 

G2: 11,313 

Inclusion criteria: 

• Singleton 

pregnancy 

• Age 20 to 34 years 

Exclusion criteria: 

• Multiple gestations 

• Extremes of age 

• BMI between 27 

and 34 

• Missing height 

• Missing 

prepregnancy 

weight 

Pregravid weight: 

• Routine pre-natal care 

G1: 104.7 (16.2) 

G2: 58.8 (7.1) (P < 0.05) 

Pregravid BMI: 

• NR 

Imputed: 

• No 

Categorized: 

• NHANES II reference 

for women 20 to 29 

Age (mean, yrs): 

G1: 27.5 

G2: 28.7 (P = NS) 

Parity: 

% multiparous:

G1: 66.7% 

G2: 44.8% (P < 0.01) 

Race,%: 

White 

G1: 17.7% 

G2: 57.3% (P < 0.01) 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

G1: 14.2% 

G2: 4.3% (P < 0.01) 

Hypertension,%: 

G1: 5.4% 

G2: 0.3% (P < 0.01) 

Additional characteristics: 

% college education:

G1: 37.1% 

G2: 63.1% (P < 0.01) 

Preexisting diabetes: 

G1: 7.3% 

G2: 1.6% (P < 0.01) 
C-625 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 613 

G2: 11,313 

Total weight gain: 

G1: 20 (16.2) 

G2: 31.4 (11.5) 

Categorized: 

Only calculated for 

morbidly obese: 

0 or weight loss, 1-

15 lbs, 16-25 lbs, 

26-35 lbs, >35 lbs 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Not stated - 

from medical 

records 

Birth weight: 

G1: 3352 (598) 

G2: 3269 (532) 

(P < 0.05) 

Gestational 

diabetes, %: 

G1: 14.2% 

G2: 4.3% (P < 

0.01) 

Cesarean 

delivery,%: 

G1: 31.3% 

G2: 15.9% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• Preeclampsia 

• Placental 

abruption 

• Meconium 

• Failure to 

progress 

• Shoulder 

dystocia 

• Postpartum 

hemorrhage 

• Endomyometrit

is 

• Wound 

infections 

Other infant 

outcomes 

• Fetal growth 

restriction 

• Preterm 

delivery 

• Fetal demise 

• Fetal distress 

Outcomes Description: 

SGA (%) 

Groups 

G1: Weight loss or 0 lbs 

G2: 1-15 lbs 

G3: 16-25 lbs 

G4: 26-35 lbs 

G5: >35 lbs 

Results 

G1: 4 

G2: 3.9 

G3: 5.6 

G4: 3.1 

G5: 3.8 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 
C-626 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Caulfield et al., 1998 

Country and setting: 

USA, hospital obstetric 

database 

Enrollment Period:

1987 to 1989 

Funding: 

NR 

Study Objective: 

To examine relation 

between gestational 

weight gain and risk of 

delivering a small for 

gestational age and 

large for gestational 

age infant by race 

Time frame: 

1987-1989 

Duration of the 

study: 

Entry into pn care until 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

3,870 

Group Description: 

G1: BMI < 19.8 Black 

G2: BMI < 19.8 White 

G3: BMI 19.8 to 26.0 Black 

G4: BMI 19.8 to 26.0 White 

G5: BMI > 26.0 Black 

G6: BMI > 26.0 White 

Group N: 

G1: 523 

G2: 267 

G3: 1,479 

G4: 796 

G5: 615 

G6: 190 

Inclusion criteria: 

• Singleton pregnancies 

• White or black ethnicity 

• At least 28 weeks’ gestation

• One delivery per woman 

(randomly chosen) 

• Information on 

anthropometric data 

Exclusion criteria: 

• Missing data 

• Improbable data 

• Non-black or non-white 

ethnicity 

Pregravid weight: 

• Self-reported 

G1: 13.3 (5.7) 

G2: 14.6 (5.1) 

G3: 13.6 (6.7) 

G4: 15.3 (5.4) 

G5: 12.4 (7.7) 

G6: 14.5 (7.3) 

Pregravid BMI: 

G1: 18.4 (1.0) 

G2: 18.5 (1.0) 

G3: 22.7 (1.8) 

G4: 22.1 (1.8) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 21.7 (4.8) 

G2: 27.1 (6.6) 

G3: 22.7 (5.3) 

G4: 29.8 (5.8) 

G5: 24.9 (6.0) 

G6: 28.2 (5.5) 

Parity: 

G1: % primiparous: 52.4 

G2: 55.4 

G3: 50.1 

G4: 48.0 

G5: 36.9 

G6: 46.9 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 32.8 

G2: 20.6 

G3: 35.4 

G4: 20.0 

G5: 28.8 

G6: 25.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 4.3 

G2: 3.0 

G3: 6.0 

G4: 5.7 

G5: 11.9 

G6: 17.0 

Additional characteristics: 

NR 
C-627 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: 13.3 (5.7)

G2: 14.6 (5.1)

G3: 13.6 (6.7)

G4: 15.3 (5.4)

G5: 12.4 (7.7)

G6: 14.5 (7.3)

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

selfreport 

prepregnancy 

weight and last 

recorded weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• AOR for SGA (95% CI) 

Groups: 

G1: Underweight, BMI< 19.8 

G2: Normal weight, BMI 19.8-26.0 

G3: Overweight, BMI> 26.0 

Black women: 

G4: No weight gain < IOM 

G5: No weight gain > IOM 

White women: 

G6: No weight gain < IOM 

G7: No weight gain > IOM 

Results: 

AOR (95%CI) for SGA and Rate of weight gain (per 

50 g/wk): 

G1: 0.87 (0.78-0.97) 

G2: 0.90 (0.84-0.96) 

G3: 0.93 (0.86-1.01) 

Expected Absolute Change (as % of baseline) in 

Incidence of SGA associated with modifiable risk 

factors (G4-G7): 

G4: -1.17 (-16) 

G5: +0.97 (+13) 

G6: -0.44 (-11) 

G7: +0.60 (+15)Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Height 

• Hypertension 

• Provider type 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Female infant 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

6 Good, 3 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-628 

 Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-forgestational age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Devader et al., 2007 

Country and setting: 

United States, birth 

certificate data 

Enrollment period:

1999 to 2001 

Funding: 

NR 

Study Objective: 

To investigate relationship 

between gestational 

weight gain and adverse 

pregnancy outcomes 

among women with 

normal prepregnancy BMI 

Time frame: 

1999 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

94,696 

Group Description: 

G1: Gained less than 25 

lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 35 

lbs 

Group N: 

G1: 16,852 

G2: 37,292 

G3: 40,552 

Inclusion criteria: 

• All mothers with 

normal prepregnancy 

BMI (19.8 –26.0 

kg/m2) who were 18 

to 35 years of age at 

time of delivery and 

who delivered fullterm (37 weeks or 

more) singleton infant 

during period January 

1, 1999, to December 

31, 2001 

Exclusion criteria: 

• Women aged 

younger than 18 

years and older than 

35 years 

• Non-Missouri 

residents 

• Preterm deliveries 

• Multiple gestations 

Pregravid weight: 

• Routine pre-natal care 

• If missing, obtained from 

mother during postpartum 

hospital stay 

Pregravid BMI: 

NR 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: Maternal age (y) 

18 to 24*: 42.3% 

25 to 30: 36.2% 

31 to 35: 21.5% 

G2: Maternal age (y) 

18 to 24*: 36.7% 

25 to 30: 39.5% 

31 to 35: 23.8% 

G3: Maternal age (y) 

18 to 24*: 44.7% 

25 to 30: 35.9% 

31 to 35: 19.4% 

Parity: 

NR 

Race,%: 

White 

G1: 79.7 

G2: 85.6 

G3: 85.2 

Black 

G1: 15.7 

G2: 10.8 

G3: 12.1 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 4.6 

G2: 3.5 

G3: 2.7 

Smoking,%: 

G1: 20.5 

G2: 14.9 

G3: 17.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-629 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

NR

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Figures 1 to 3 plot 

risk for each 

adverse pregnancy 

outcome by 10-lb 

increments in 

gestational weight 

gain. Women who 

gained 25 to 34 lbs 

during their 

pregnancy had 

lower risks for most 

outcomes when 

balancing risk for 

SGA status and 

other adverse 

pregnancy 

outcomes 

• Women who 

gained 15 to 24 lbs 

had lowest risks for 

most outcomes, but 

increased their risk 

of having an SGA 

infant from 9.6% to 

14.3% 

• Women who 

gained more than 

34 lbs had higher 

risks for all 

outcomes, although 

their risk of having 

an SGA infant 

decreased from 

9.6% to 6.6% 

Outcomes Description: 

AOR for SGA for Women With Normal 

Prepregnancy BMI (19.8 –26.0 kg/m2) by 

GWG Category, Missouri Birth Certificates, 

1999–2001 (95%CI) 

Groups: 

G1: Gained less than 25 lbs 

G2: Gained 25 to 35 lbs 

G3: Gained more than 35 lbs 

Results: 

G1: 2.14 (2.01–2.27) 

G2: 1.0 

G3: 0.48 (0.45–0.50) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Education 

• Income 

• Alcohol use 

• Height 

• Prior pregnancy 

• Inadequate prenatal care use 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Child's gender 

Birth year 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor:

2 Good, 7 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-630 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Devader et al., 2007 

(combined) 

 
C-631 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Other infant 

outcomes: 

NR 
C-632 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Edwards et al., 1996 

Country and setting: 

USA, hospital 

Enrollment Period:

1997-1993 

Funding: 

NR 

Study Objective: 

To compare pregnancy 

course and outcomes in 

obese and normal weight 

women and their 

associations with 

gestational weight change 

Time frame: 

1997-1993 

Duration of the study: 

1997-1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,443 

Group Description: 

G1: Obese 

G2: Normal Weight 

G3: total sample 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese women and 

normal weight women 

identified from 

pregnancy and 

delivery summary 

records (normal 

weight matched to 

obese by race, age, 

parity) 

• Singleton deliveries 

• Live births 

Exclusion criteria: 

• Missing data 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 

G2: 61 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelinesobese 

(> 29) and normal weight 

(BMI 19.8-26.0) 

Age (mean, yrs): 

G1: 27.1 

G2: 25.4 

Parity: 

NR 

Race,%: 

White 

G1: NR 

G2: NR 

G3: 69.0 (Total sample) 

Black 

G1: NR 

G2: NR 

G3: 21.0 (Total sample) 

Hispanic 

G1: NR 

G2: NR 

G3: 7.0 (Total sample) 

Asian/Pacific Islander 

NR 

Other 

G1: NR 

G2: NR 

G3: 4.0 (Total sample) 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-633 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 683 

G2: 660 

Total weight gain: 

G1: 9.5

G2: 14.5 P ≤ 0.001

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3420 

G2: 3285 P ≤ 0.001 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 25.6 

G2: 9.1 P < 0.001 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• SGA 

Groups: 

Maternal weight gain categories (kg) Obese > 

29: 

G1: Lost weight/no change 

G2: 0.5-6.5 

G3: 7-11.5 

G4: 12-16 

G5: > 16 

Normal BMI 19.8-26 

G6: < 11.5kg 

G7: 11.5-16 

G8: > 16kg 

Results: 

% SGA for Obese 

G1: 10.7% 

G2: 6.6% 

G3: 6.0% 

G4: 4.0% 

G5: 5.3% 

P = 0.11 

For Normal weight 

G6: 15.9% 

G7: 7.5% 

G8: 5.7% 

P = 0.001 

AOR (95%CI) 

Obese 

G1 vs G3 2.9 (1.1, 8.4) 

Normal weight 

G6 vs G7 1.7 (0.9,3.4) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Parity 

• Pre-gravid BMI 

• GDM 

• Pregnancy induced hypertension 

• Prenatal adequacy 

• Alcohol use 

• Drug use 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

Gestational age 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Fair 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-634 

 Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-forgestational age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hellerstedt et al., 1997 

Country and setting: 

United States, medical 

center 

Enrollment Period:

1977-1993 

Funding: 

NR 

Study Objective: 

To examine association 

between infant birth 

outcomes and maternal 

pregravid obesity, 

gestational weight gain, 

and prenatal smoking 

Time frame: 

1977 to 1993 

Duration of the study: 

Entry into prenatal care 

until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,343 

Group Description: 

G1: Obese 

G2: Normal weight 

Group N: 

G1: 683 

G2: 660 

Inclusion criteria: 

• Obese and normalweight women 

delivering singleton 

during study period 

Exclusion criteria: 

• Missing data 

• Siblings 

• Fetal deaths 

Pregravid weight: 

• Self-reported 

G1: 103.5 kg (13.7) 

G2: 61.1kg (5.9) 

Pregravid BMI: 

G1: 38.3 (4.6) 

G2: 22.8 (1.6) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: NR 

• 16-34 years: 91% 

• ≥ 35 years: 8.8% 

G2: NR 

• 16-34 years: 93.5% 

• ≥ 35 years: 5.8% 

Parity: 

G1: NR 

• 0: 31.8% 

• 1-3: 64.7% 

• ≥ 4: 3.5% 

G2: NR 

• 0: 33.3% 

• 1-3: 64.9% 

• ≥ 4: 1.8% 

Race,%: 

White 

G1: 68.8 

G2: 69.1 

Black 

G1: 20.4 

G2: 20.6 

Hispanic 

G1: 6.6 

G2: 6.5 

Asian/Pacific Islander 

G1: Native Am: 3.8 

G2: Native Am: 3.2 

Other 

NR 

Smoking,%: 

G1: 26.4 

G2: 26.2 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-635 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

SGA (%) 

Groups 

Maternal weight gain categories stratified by 

pregravid BMI and smoking status: 

Obese (BMI > 29.0): 

G1: Smokers, < IOM 

G2: Smokers, within IOM 

G3: Smokers, > IOM 

G4: Nonsmokers, < IOM 

G5: Nonsmokers, within IOM 

G6: Nonsmokers, > IOM 

Normal weight (BMI 19.8-26.0): 

G7: Smokers, < IOM 

G8: Smokers, within IOM 

G9: Smokers, > IOM 

G10: Nonsmokers, < IOM 

G11: Nonsmokers, within IOM 

G12: Nonsmokers, > IOM 

Obese: 

G13: Lost/no gain 

G14: 0.5-6.5 kg 

G15: 7-11.5 kg 

G16: 12-16 kg 

G17: > 16 kg 

Normal weight: 

G18: < 11.5kg 

G19: 11.5-16kg 

G20: > 16kg 

Results 

Frequencies of SGA, %: 

G1: 13.3 

G2: 10.0 

G3: 7.7 

G4: 5.5 

G5: 4.7 

G6: 3.6 

G7: 28.6 

G8: 10.9 

G9: 3.6 

G10: 8.9 

G11: 6.5 

G12: 6.4 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-636 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hellerstedt et al., 1997 

(continued)

 
C-637 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

G13: 10.7 

G14: 6.6 

G15: 6.0 

G16: 4.0 

G17: 5.3 

P = 0.115 for G13-G17 

G18: 15.9 

G19: 7.5 

G20: 5.7 

P = 0.001 for G18-G20 

For obese women, compared to nonsmokers who 

gained 7-11.5kg, smokers who gained < 7kg were at 

significantly higher risk of SGA OR: 3.2 (95%CI: 1.1-

10.1) 

For normal weight women, compared to nonsmokers 

who gained 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Maternal age, pregravid BMI, infant sex, race, parity, 

prenatal alcohol use, prenatal illicit drug use, 

adequacy of prenatal care, gestational hypertension, 

GDM 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

• Gestational age 
C-638 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Kiel et al., 2007 

Country and setting: 

United States, birth 

registry 

Enrollment period:

1990 to 2001 

Funding: 

NR 

Study Objective: 

To examine effect of 

gestational weight change 

on pregnancy outcomes in 

obese women 

Time frame: 

1990 to 2001 

Duration of the study: 

Entry into prenatal care 

through delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

120,170 

Group Description: 

G1: Obese Class I 

(BMI 30–34.9) (n = 

70,536) 

G2: Obese Class II 

(BMI 35–39.9) (n = 

30,609) 

G3: Obese Class III 

(BMI 40 and More) (n 

= 19,025) 

Group N: 

NR 

Inclusion criteria: 

• Obese women 

residing in Missouri 

who delivered (at 37 

or more weeks of 

gestation) liveborn, 

singleton infants 

during 1990–2001 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: Total: 

Class I obese: 59% 

Class II obese: 25% 

Class III obese: 16% 

Imputed: 

• No 

Categorized: 

• NIH guidelines 

Age (mean, yrs): 

G1: <26: 46% 

26-35: 47% 

Older than 35: 8% 

G2: <26: 44% 

26-35: 48% 

Older than 35: 8% 

G3: <26: 40% 

26-35: 52% 

Older than 35: 9% 

Parity: 

Nulliparous:

G1: 34% 

G2: 33% 

G3: 32% 

Race,%: 

White 

G1: 78 

G2: 77 

G3: 73 

Black 

G1: 22 

G2: 23 

G3: 27 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

G1: 22 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-639 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: GWG (lb) 

Less than 2: 3% 

2 to 14: 15% 

15 to 25: 26% 

More than 25: 56% 

G2: GWG (lb) 

Less than 2: 8% 

2 to 14: 22% 

15 to 25: 27% 

More than 25: 43% 

G3: GWG (lb)Less than 

2: 15% 

Categorized: 

• 10-lb or less loss 

2 to 9 lbs loss, no 

weight change, 

2 to 9 lbs gain, 

10 to 14 lbs gain, 

15–25 lb gain, 

26–35 lb gain, and 

greater than 35 lb 

gain 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

NR

Birth weight: 

G1: SGA: 7 

LGA:13% 

(P < 0.05) 

G2: SGA: 7% 

LGA:16% 

(P < 0.05) 

G3: SGA: 6% 

LGA:18% 

(P < 0.05) 

Gestational diabetes, %:

NR 

Cesarean delivery,%: 

G1: 28 

G2: 34 

G3: 41 

Instrumental delivery,%:

NR 

Episiotomy,%: 

NR 

Outcomes Description: 

Absolute risk and OR (95% CI) of pregnancy 

outcomes for various classes of obese women 

(class I, II, III) 

Groups: 

Maternal weight gain categories stratified by 

prepregnancy obesity status, Obese Class 

I(BMI 30–34.9), Obese Class II (BMI 35–39.9), 

Obese Class III (> = BMI 40): 

G1: < = -10lbs 

G2: -2 to -9 lbs 

G3: No change 

G4: 2-9 lbs 

G5: 10-14 lbs 

G6: 15-25lbs 

G7: 26-35lbs 

G8: > 35 lbs 

Result: 

For Obese Class I: AOR (95% CI) for SGA 

were significantly greater (> 1.00, G6 was 

reference) for G1- G5 and significantly lower for 

G7-G8. 

For Obese Class II: AOR (95% CI) for SGA 

were significantly greater (> 1.00, G6 was 

reference) for G1- G5 and significantly lower for 

G7-G8 

For Obese Class III: AOR (95% CI) for SGA 

were significantly greater (> 1.00, G6 was 

reference) for G1 and G3 and significantly 

lower for G7-G8 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Education 

• Poverty (enrollment in Medicaid, WIC, food 

stamp programs) 

• Tobacco use 

• Chronic hypertension 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 6 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-640 

 Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-forgestational age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nielsen et al., 2006 

Country and setting: 

USA, clinic 

Enrollment Period:

1990 to 2000 

Funding: 

NR 

Study Objective: 

To examine whether such 

weight gains improve birth 

outcomes in a cohort of 

disadvantaged African 

American adolescents 

Time frame: 

1990 to 2000 

Duration of the study: 

First prenatal care visit to 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

815 

Group Description: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

Group N: 

G1: 193 

G2: 431 

G3: 191 

Inclusion criteria: 

• Adolescents ≤ 17 

years at conception 

• African American 

pregnancies 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 18.3 (1.1) 

G2: 22.4 (1.6) 

G3: 30.9 (4.6) 

Imputed: 

• Yes 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: mean age at infant birth 

(SD): 16.9 (1.2) 

G2: 16.8 (1.1) 

G3: 17.0 (1.1) 

Parity: 

% primiparous:

G1: 83.9 

G2: 85.2 

G3: 74.9 

Race,%: 

White 

NR 

Black 

G1: 100 

G2: 100 

G3: 100 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 11.4 

G2: 9.7 

G3: 10.5 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-641 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 193 

G2: 431 

G3: 191 

Total weight gain: 

G1: < IOM: 30.3%; 

lower half of IOM: 

18.1%; upper half 

of IOM: 21.9%; 

> IOM: 29.7% 

G2: < IOM: 31.3%; 

lower half of IOM: 

16.1%; upper half 

of IOM: 17.6%; 

> IOM: 35.0% 

G3: < IOM: 16.5%; 

lower half of IOM: 

9.4%; upper half 

of IOM: 10.6%; 

> IOM: 63.5

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between final 

recorded weight 

within 4 weeks 

delivery and selfreported 

prepregnancy 

weight 

Birth weight: 

G1: 2899 (595) 

G2: 3083 (645) 

P < 0.005 compared 

to BMI < 19.8 

G3: 3181 (673) 

P < 0.005 compared 

to BMI < 19.8 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Size for 

gestational age 

(small, average, 

large) 

• Birth weight 

category 

(suboptimal 

< 3000g, optimal 

3000-4000g, 

above optimal 

> 4000g) 

Outcomes Description: 

• SGA 

Groups: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

G4: < IOM recommendation 

G5: Lower half of IOM recommendation 

G6: Upper half of IOM recommendation 

G7: > IOM recommendation 

Results: 

SGA, %: 

G1: 22.3 

G2: 15.6 

G3: 11.5 

P < 0.01 for G1-G3 

AOR (95%CI) for SGA: 

G4: 2.31 (1.22-4.37) 

G5: 1.00 (reference) 

G6: 0.88 (0.41-1.89) 

G7: 0.68 (0.34-1.35) 

P < 0.01 for G4-G7 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Parity 

• Pre-gravid BMI 

• Pre-eclampsiatime between last weight measure 

and delivery 

• Height 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

Infant sex 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Good 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability:

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

6 Good, 3 Fair, 

0 Poor 

Final Quality 

Score: 

Good 
C-642 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Parker and Abrams, 1992 

Country and setting: 

USA, hospital 

Enrollment Period:

Sept 1980 to Dec 1988 

Funding: 

UC Committee on 

Research & MCH and 

Resources Development, 

Health Resources and 

Services Administration 

Study Objective: 

To test whether gains 

outside IOM reference 

ranges were associated 

with increased risks of 

suboptimal pregnancy 

outcome (SGA, LGA, 

cesarean delivery) and to 

determine whether locally 

developed ranges were 

more applicable to study 

population 

Time frame: 

Sept 1980 to Dec 1988 

Duration of the study: 

From entry into prenatal 

care until delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

6,690 

Group Description: 

G1: Overall 

G2: NR 

Group N: 

G1: 6,690 

G2: NR 

Inclusion criteria: 

• Consecutive live 

singleton births at 

Moffitt Hospital 

between September 

1980 and December 

1988 with gestational 

ages of 37 to 42 

weeks 

Exclusion criteria: 

• Maternal transfers or 

transports and 

deliveries 

complicated by fetal 

malformations, 

maternal diabetes, or 

maternal 

hypertension 

Pregravid weight: 

• Self-reported 

G1: 56.8 kg(SD 11.0) 

G2: NR 

Pregravid BMI: 

G1: Underweight: 27.7%, 

Normal weight 61.8%, 

Overweight: 5.6%, 

Obese 4.9% 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 27.7 (5.5) 

G2: NR 

Parity: 

Primiparous:

G1: 58.8% 

G2: NR 

Race,%: 

White 

G1: 44.0 

G2: NR 

Black 

G1: 8.3 

G2: NR 

Hispanic 

G1: 9.4 

G2: NR 

Asian/Pacific Islander 

G1: 21.4 

G2: NR 

Other 

G1: 12.0 

G2: NR 

Smoking,%: 

G1: 12.0 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-643 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 6690 

G2: NR 

Total weight gain: 

G1: 15.2kg (5.2)

G2: NR 

Categorized: 

• According to IOM 

Weight gain 

ranges based on 

percentiles from 

previous study of 

UC population 

with good 

pregnancy 

outcomes: 25th -

75th, 10-90th 

percentiles. For 

25-75th, weight 

gain range = 12-

17kg for 

underweight 

women (BMI 

< 19.8); 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3408g (462) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• SGA 

Groups: 

G1: < IOM range 

G2: Within IOM range 

G3: > IOM 

Results: 

AOR (95% CI) for SGA: 

G1: 1.78 (1.39-2.27) 

G2: 1.00 (reference) 

Incidence of SGA in nonobese women, %: 

G1: 3.25 

G2: 6.14 

G3: 13.11 

Incidence of SGA in obese women, %: 

G1: 11.76 

G2: 3.09 

AOR of SGA and low weight gain 

UCSF 25-75 

2.06 (1.62-2.63) 

UCSF 10-90 

1.82 (1.35-2.47) 

IOM 

1.78 (1.39-2.27) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Height 

• Maternal high and low weight gain 

• Smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

• Gestational age 

Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

3 Good, 5 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-644 

 Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-forgestational age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stevens-Simon and 

McAnarney, 1992 

Country and setting: 

USA, adolescent 

maternity program 

Enrollment Period:

1986 to 1989 

Funding: 

Grant from Bureau of 

Maternal and Child Health 

Study Objective: 

To clarify advantages and 

disadvantages of large 

gestational weight gain 

among pregnant 

adolescents 

Time frame: 

1986 to 1989 

Duration of the study: 

Entry into prenatal care 

through 6 weeks PP 

check up 

Design: 

• Cohort 

• Prospective 

Total Study N: 

141 (107 included in 

postpartum analyses) 

Group Description: 

G1: Slow gainers 

G2: Average gainers 

G3: Rapid gainers 

Group N: 

G1: 28 

G2: 66 

G3: 47 

Inclusion criteria: 

• Consecutively 

enrolled poor, black, 

12-19 year olds 

• Prenatal care prior to 

2third week gestation

• No chronic disease 

• No regular 

medications 

• No known uterine 

anomalies 

• Live birth 

• Singletons 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 58.6 (11.1) 

G2: 160.9 (7.0) 

G3: 163.9 (5.5) 

Pregravid BMI: 

G1: 23.1 (3.5) 

G2: 23.5 (4.4) 

G3: 23.5 (4.2) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 16.9 

G2: 16.6 

G3: 16.2 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-645 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28 

G2: 66 

G3: 47 

Total weight gain: 

G1: 7.7 (average rate 

0.2 kg/wk)

G2: 12.4 (average 

rate 0.3 kg/wk)

G3: 19.8 (average 

rate 0.5 kg/wk)

Categorized: 

• According to 

IOMslow gain: 

< 0.23kg/wk; 

average gain: 

0.23-0.4kg/week; 

rapid gain: > 

0.4kg/week 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) 

P < 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Distribution of SGA,%: 

Groups 

Maternal weight gain categories (kg/wk): 

G1: < 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Results 

G1: 7.1 

G2: 9.1 

G3: 2.1 

P = NS 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor:

3 Good, 4 Fair, 2 

Poor 

Final Quality 

Score: 

Fair 
C-646 

 Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-forgestational age (continued) 

Study Description 

Study Design, Patient 

Population, 

Inclusion/Exclusion 

Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980 to 2001 

Funding: 

NR 

Study Objective: 

To examine relationship 

between gestational 

weight gain and adverse 

neonatal outcomes 

among infants born at 

term (37 weeks or more) 

Time frame: 

1980 to 2001 

Duration of the study: 

Entry into PN care up till 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20465 

Group Description: 

G1: Gain below IOM 

recommendations 

G2: Gain within IOM 

recommendations 

G3: Gain above IOM 

recommendations 

Group N: 

G1: 4,114 

G2: 7,490 

G3: 8,861 

Inclusion criteria: 

• Singleton 

Exclusion criteria: 

• Pregnancies 

complicated by 

multiple gestations, 

congenital anomalies, 

chronic hypertension, 

gestational or 

pregestational 

diabetes 

• Birth before 37 weeks

• Maternal transport 

• Missing data on any 

of variables 

considered in 

multivariable analysis

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 25.8% 

19.8-26.0: 19.4% 

26.1-29.0: 9.2% 

> 29.0: 20.6% 

G2: < 19.8: 49.1% 

19.8-26.0: 34.8% 

26.1-29.0: 23.3% 

> 29.0: 25.5% 

G3: < 19.8: 25.0% 

19.8-26.0: 45.8% 

26.1-29.0: 67.5% 

> 29.0: 53.9% 

P < 0.001 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20 years: 23.4% 

20-29 years: 19.3% 

30-39 years: 19.9% 

> 40 years: 25.3% 

G2: < 20 years: 31.3% 

20-29 years: 36.6% 

30-39 years: 37.6% 

> 40 years: 36.3% 

G3: < 20 years: 45.4% 

20-29 years: 44.0% 

30-39 years: 42.5% 

> 40 years: 38.4% 

P < 0.001 

Parity: 

% Nulliparous:

G1: 17.3 

G2: 36.2 

G3: 46.6 

P < 0.001 

Race,%: 

White 

G1: 16.2 

G2: 35.8 

G3: 48.0 

Black 

G1: 25.5 

G2: 29.4 

G3: 45.1 

Hispanic 

G1: 19.2 

G2: 34.8 

G3: 46.0 

Asian/Pacific Islander 

G1: 24.3 

G2: 43.3 

G3: 32.4 

Other 

G1: 21.7 

G2: 37.9 

G3: 40.4 

P for all race categories < 

0.001 

Smoking,%: 

G1: 23.5 

G2: 30.8 

G3: 45.8 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-647 

Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational 

age (continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4114 

G2: 7490 

G3: 8861 

Total weight gain: 

Categorized: 

• According to 

IOMpercentiles 

and dichotomous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: %SGA: 36.1; %AGA: 

20.2; %LGA: 8.5 

G2: %SGA: 39.4; %AGA: 

37.5; %LGA: 26.5 

G3: %SGA: 24.5; %AGA: 

42.4; %LGA: 65.1 

P < 0.001 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 14.7 

G2: 32.1 

G3: 53.2 

Instrumental delivery,%: 

Operative vaginal delivery:

G1: 18.0% 

G2: 37.5% 

G3: 44.5% 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

• Birth trauma 

• 5 min Apgar score less 

than 7 

• , Aassisted ventilation 

• SGA 

• LGA 

• NICU admission 

• SCN admission 

• Neonatal infection 

• Seizure 

• Hypoglycemia 

• Polycythemia 

• MAS 

• RDS 

• Tachypnea 

• Hospital stay > 5 days 

• Hospital stay > 10 

days 

Outcomes Description: 

• Risk of adverse neonatal outcomes by 

gestational weight gain by IOM guidelines, 

adjusted ORs compared to women with GWG 

within IOM guidelines and risk of adverse 

neonatal outcomes by extremes of GWG 

compared to women with weight gain 11.5-

16.0kg 

Groups: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: < 7kg 

G5: > 18kg 

Results: 

Unadjusted Rates of SGA: 

G1: 11.74 P< 0.001 vs. G2 

G2: 7.05 

G3:3.70 P< 0.001 vs. G2 

G4: 13.99 P< 0.05 vs. G2 

G5: 3.87 P< 0.05 vs. G2 

AOR (95% CI) for SGA: 

G1: 1.66 (1.44-1.92) 

G2: 1.00 (reference) 

G3: 0.51 (0.44-0.59) 

G4: 2.26 (1.76-2.90) 

G5: 0.50 (0.42-0.60) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Date of delivery 

• Mode of delivery 

• Length of first stage of labor 

• Length of second stage of labor 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample 

selection: 

Good 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

4 Good, 5 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 

 
C-648 

Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Nixon et al., 1998 

Country and setting: 

USA, county nursemidwifery services 

Enrollment Period:

January 1991 to 

December 1994 

Funding: 

American College of 

Nurse Midwives 

Study Objective: 

To compare outcomes of 

term infants of average 

birth weight with 

outcomes of large infants 

using computer database 

Time frame: 

January 1991 to 

December 1994 

Duration of the study: 

First prenatal visit through 

birth collected 

retrospectively 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

2,228 

Group Description: 

G1: 2500 - 3999g 

G2: ≥ 4000g 

Group N: 

G1: 1906 

G2: 322 

Inclusion criteria: 

• Gestational age ≥ 37 

weeks 

• Birth weight ≥ 2500g 

• Live infant at onset of 

labor 

• Birth occurred in 

hospital 

Exclusion criteria: 

• Women with 

gestational diabetes 

that required insulin 

therapy 

Pregravid weight: 

• Self-reported 

G1: 138 (31) 

G2: 158 (36) (P < 0.0001) 

Pregravid BMI: 

G1: 24 (5) 

G2: 26 (5.8) (P < 0.0001) 

Imputed: 

• No 

Categorized: 

• Continuous IOM 

guidelines 

Age (mean, yrs): 

G1: 25 (6) 

G2: 27.5 (6) (P < 0.0001) 

Parity: 

% parous:

G1: 56.3 

G2: 69.9 (P < 0.00001) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% shoulder dystocia:

G1: 0.6 

G2: 5.9 (P < 0.001) 

% NICU: 

G1: 4.3 

G2: 6.6 (P = ns) 
C-649 

Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 1906 

G2: 322 

Total weight gain: 

G1: 30.7+/-15

G2: 37.2+/-15 

(P < 0.0001) 

Categorized: 

• Continuous 

According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Apgar scores 

Outcomes Description: 

Apgar scores < 7 

Groups: 

NR 

Outcomes Set 2: 

Gestational weight gain not a predictor of 

Apgar scores < 7 (details NR) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

NR 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Fair 

Sum of Good/Fair/Poor: 

3 Good, 6 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-650 

Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stevens-Simon and 

McAnarney, 1992 

Country and setting: 

USA, adolescent 

maternity program 

Enrollment Period:

1986 to 1989 

Funding: 

Grant from Bureau of 

Maternal and Child Health 

Study Objective: 

To clarify advantages and 

disadvantages of large 

gestational weight gain 

among pregnant 

adolescents 

Time frame: 

1986 to 1989 

Duration of the study: 

Entry into prenatal care 

through 6 weeks PP 

check up 

Design: 

• Cohort 

• Prospective 

Total Study N: 

141 (107 included in 

postpartum analyses) 

Group Description: 

G1: Slow gainers 

G2: Average gainers 

G3: Rapid gainers 

Group N: 

G1: 28 

G2: 66 

G3: 47 

Inclusion criteria: 

• Consecutively 

enrolled poor, black, 

12-19 year olds 

• Prenatal care prior to 

2third week gestation

• No chronic disease 

• No regular 

medications 

• No known uterine 

anomalies 

• Live birth 

• Singletons 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 58.6 (11.1) 

G2: 160.9 (7.0) 

G3: 163.9 (5.5) 

Pregravid BMI: 

G1: 23.1 (3.5) 

G2: 23.5 (4.4) 

G3: 23.5 (4.2) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 16.9 

G2: 16.6 

G3: 16.2 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-651 

Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28 

G2: 66 

G3: 47 

Total weight gain: 

G1: 7.7 (average rate 

0.2 kg/wk)

G2: 12.4 (average 

rate 0.3 kg/wk)

G3: 19.8 (average 

rate 0.5 kg/wk)

Categorized: 

• According to 

IOMslow gain: 

< 0.23kg/wk; 

average gain: 

0.23-0.4kg/week; 

rapid gain: > 

0.4kg/week 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) 

P < 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Distribution of 1- and 5-minute Apgar scores,%: 

Groups 

Maternal weight gain categories (kg/wk): 

G1: < 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Results 

Distribution of 1 minute Apgar score < = 4, %: 

G1: 25.0 

G2: 4.5 

G3: 14.9 

P = 0.02 for G1 vs. G2 or G3 

Distribtution of 5 minute Apgar score < = 4, %: 

G1: 3.5 

G2: 0 

G3:0 

P = NS 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poo

r: 

3 Good, 4 Fair, 

2 Poor 

Final Quality 

Score: 

Fair 
C-652 

Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980 to 2001 

Funding: 

NR 

Study Objective: 

To examine relationship 

between gestational 

weight gain and adverse 

neonatal outcomes 

among infants born at 

term (37 weeks or more) 

Time frame: 

1980 to 2001 

Duration of the study: 

Entry into PN care up till 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20465 

Group Description: 

G1: Gain below IOM 

recommendations 

G2: Gain within IOM 

recommendations 

G3: Gain above IOM 

recommendations 

Group N: 

G1: 4,114 

G2: 7,490 

G3: 8,861 

Inclusion criteria: 

• Singleton 

Exclusion criteria: 

• Pregnancies 

complicated by 

multiple gestations, 

congenital anomalies, 

chronic hypertension, 

gestational or 

pregestational 

diabetes 

• Birth before 37 weeks

• Maternal transport 

• Missing data on any 

of variables 

considered in 

multivariable analysis

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 25.8% 

19.8-26.0: 19.4% 

26.1-29.0: 9.2% 

> 29.0: 20.6% 

G2: < 19.8: 49.1% 

19.8-26.0: 34.8% 

26.1-29.0: 23.3% 

> 29.0: 25.5% 

G3: < 19.8: 25.0% 

19.8-26.0: 45.8% 

26.1-29.0: 67.5% 

> 29.0: 53.9% 

P < 0.001 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20 years: 23.4% 

20-29 years: 19.3% 

30-39 years: 19.9% 

> 40 years: 25.3% 

G2: < 20 years: 31.3% 

20-29 years: 36.6% 

30-39 years: 37.6% 

> 40 years: 36.3% 

G3: < 20 years: 45.4% 

20-29 years: 44.0% 

30-39 years: 42.5% 

> 40 years: 38.4% 

P < 0.001 

Parity: 

% Nulliparous:

G1: 17.3 

G2: 36.2 

G3: 46.6 

P < 0.001 

Race,%: 

White 

G1: 16.2 

G2: 35.8 

G3: 48.0 

Black 

G1: 25.5 

G2: 29.4 

G3: 45.1 

Hispanic 

G1: 19.2 

G2: 34.8 

G3: 46.0 

Asian/Pacific Islander 

G1: 24.3 

G2: 43.3 

G3: 32.4 

Other 

G1: 21.7 

G2: 37.9 

G3: 40.4 

P for all race categories < 

0.001 

Smoking,%: 

G1: 23.5 

G2: 30.8 

G3: 45.8 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-653 

Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores 

(continued) 

Maternal Weight 

Gain 

Outcomes from Bivariate 

Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4114 

G2: 7490 

G3: 8861 

Total weight gain: 

Categorized: 

• According to 

IOMpercentiles 

and dichotomous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: %SGA: 36.1; %AGA: 

20.2; %LGA: 8.5 

G2: %SGA: 39.4; %AGA: 

37.5; %LGA: 26.5 

G3: %SGA: 24.5; %AGA: 

42.4; %LGA: 65.1 

P < 0.001 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 14.7 

G2: 32.1 

G3: 53.2 

Instrumental delivery,%: 

Operative vaginal delivery:

G1: 18.0% 

G2: 37.5% 

G3: 44.5% 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

• Birth trauma 

• 5 min Apgar score less 

than 7 

• , Aassisted ventilation 

• SGA 

• LGA 

• NICU admission 

• SCN admission 

• Neonatal infection 

• Seizure 

• Hypoglycemia 

• Polycythemia 

• MAS 

• RDS 

• Tachypnea 

• Hospital stay > 5 days 

• Hospital stay > 10 

days 

Outcomes Description: 

• Risk of adverse neonatal outcomes by 

gestational weight gain by IOM guidelines, 

adjusted ORs compared to women with GWG 

within IOM guidelines and risk of adverse 

neonatal outcomes by extremes of GWG 

compared to women with weight gain 11.5-

16.0kg 

Groups: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: < 7kg 

G5: > 18kg 

Results: 

Unadjusted Rates of 5 minute Apgar score < 7: 

G1: 1.94 

G2: 1.58 

G3: 2.14 (P< 0.05, G3 vs. G2) 

G4: 2.39 

G5: 2.16 (P< 0.05, G5 vs. G2) 

AOR (95% CI) for 5 minute Apgar score < 7: 

G1: 1.18 (0.84-1.66) 

G2: 1.00 (reference) 

G3: 1.33 (1.01-1.76) 

G4: 1.29 (0.70-2.39) 

G5: 1.30 (0.95-1.77) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Date of delivery 

• Mode of delivery 

• Length of first stage of labor 

• Length of second stage of labor 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor:

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-654 

Evidence Table 47. Gestational weight gain with reference to IOM recommendations and perinatal mortality 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bracero and Byrne, 1997 

Country and setting: 

Hospital charts - 

Maimonides Medical 

Center, Brooklyn, NY 

Enrollment Period:

Funding: 

NR 

Study Objective: 

To determine optimal 

weight gain in singleton 

pregnancy and evaluate 

current recommendations 

Time frame: 

Duration of the study: 

Jan 1, 1987 to Jan 1, 

1993 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20,971 

Group Description: 

G1: Total population 

G2: NR 

Group N: 

G1: 20,971 

G2: NR 

Inclusion criteria: 

• Delivery at 

Maimonides Medical 

Center 

• Singleton pregnancy 

• No documentation of 

congenital anomaly, 

pregnancy was not 

terminated by 

abortion 

• Documentation on 

chart of prepregnancy 

maternal weight, 

amount of maternal 

weight gain during 

pregnancy, and 

gender of infant 

Exclusion criteria: 

• Infants with any type 

of congenital anomaly 

(international 

classification of 

diseases (ICD-9-CM) 

codes 740.0-759.9 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: median BMI = 23.19 

(range 14.46-40.07) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: % < 15 years: < 0.1; 

15-19 yrs: 4.8; 

20-24: 25.1; 

25-29: 31.1; 

30-34: 24.3; 

35-39: 11.8; 

40-44: 2.8; 

45-49: 0.1; 

 > 50: < 0.1 

G2: NR 

Parity: 

% primigravida:

G1: 25.1 

G2: NR 

Race,%: 

White 

G1: 92.1 

G2: NR 

Black 

G1: 4.2 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

G1: 0.9 

G2: NR 

Other 

G1: 2.1 

G2: NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% married:

G1: 12.4 

G2: NR 

Additional characteristics: 

Type of service:

G1: Ward, 22.5% 

Private: 77.5% 

G2: NR 

Additional characteristics: 

NR 
C-655 

Evidence Table 47. Gestational weight gain with reference to IOM recommendations and perinatal mortality 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: % weight gain: 

lost weight, 0.4; 

1 to 5lbs, 0.9; 

6 to 10, 2.3; 

11 to 15, 5.4; 

16 to 20, 12.0; 

21 to 25, 17.2; 

26 to 30, 21.1; 

31 to 35, 14.8; 

36 to 40, 11.5; 

41 to 45, 6.1; 

≥ 46, 8.3

G2: NR 

Categorized: 

• According to IOM 

ordinal 

categories in 5 

pound intervals 

Collected from: 

• Routine prenatal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

using last 

measurement 

obtained as an 

outpatient 

Birth weight: 

G1: r = .210 

correlation with 

maternal weight gain 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Optimal weight gain 

defined as 36 to 40 

pounds for 

underweight women, 

31 to 40 pounds for 

women of ideal 

prepregnancy weight, 

26 to 30 pounds for 

overweight women 

Other infant 

outcomes: 

Adverse outcomes: 

• Still birth 

• Neonatal death 

• Preterm 

delivery/low birth 

weight 

• Perinatal 

morbidity 

Outcomes Description: 

• Perinatal mortality and adverse perinatal outcome 

Groups: 

Maternal weight gain in relation to IOM 

recommendations:

G1: Under 17.6% 

G2: Within 56.9% 

G3: Over 25.5% 

Results: 

Adverse perinatal outcome % 

G1: 14.4 

G2: 8.4 

G3: 8.5 P < 0.001 

Birthweight < 2500 % 

G1: 10.1 

G2: 3.3 

G3: 2.5 P < 0.001 

Perinatal mortality % 

G1: 1.1 

G2: 0.4 

G3: 0.4 P < 0.001 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

G4: 0.7 P = 0.298 

G5: 0.6 

G6: 0.2 P < 0.001 

Background: 

Fair 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

1 Good, 8 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 

 
C-656 

Evidence Table 48. Gestational weight gain with reference to IOM recommendations and hypoglycemia 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hedderson et al., 2006 

Country and setting: 

USA, Kaiser Permanente 

Medical Care Program 

Enrollment Period:

January 1, 1996 - June 

31, 1998 

Funding: 

R01 DK 54834 from 

National Institute of 

Diabetes and Digestive 

and Kidney Diseases, 

grant from American 

Diabetes Association and 

Kaiser Community Benefit 

research support 

Study Objective: 

To examine whether 

pregnancy weight gains 

outside IOM 

recommendations and 

rates of maternal weight 

gain are associated with 

neonatal complications 

Time frame: 

January 1, 1996 to June 

31, 1998 

Duration of the study: 

First prenatal care visit to 

30 days post delivery 

Design: 

• Case-control 

• Retrospective 

Total Study N: 

45,245 

Group Description: 

G1: Controls 

G2: Macrosomia 

G3: Hypoglycemia 

G4: Hyperbilirubinemia 

Group N: 

G1: 652 

G2: 391 

G3: 328 

G4: 432 

Inclusion criteria: 

• Singleton livebirth 

Exclusion criteria: 

• No pregestational 

diabetes or history of 

gestational diabetes 

(screened at 24-28 

weeks gestation - 

meeting National 

Diabetes Data Group 

criteria for GDM) 

Pregravid weight: 

• Self-reported in some 

cases used measured 

weight recorded in chart 

closes to woman’s last 

menstrual period but no 

more than 12 months 

before her last menstrual 

period 

Pregravid BMI: 

G1: < 19.8: 13.5% 

19.8-24.9: 56.4% 

25.0-29.0: 12.4% 

> 29.0: 17.6% 

G2: < 19.8: 5.1% 

19.8-24.9: 51.2% 

25.0-29.0: 16.6% 

> 29.0: 27.1% 

G3: < 19.8: 10.1% 

19.8-24.9: 50.0% 

25.0-29.0: 17.1% 

> 29.0: 22.9% 

G4: < 19.8: 13.9% 

19.8-24.9: 57.9% 

25.0-29.0: 13.2% 

> 29.0: 57.1% 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 25 years: 22.1% 

25-29: 24.2% 

30-34: 33.6% 

≥ 35: 20.1% 

G2: < 25 years: 15.9% 

25-29: 28.0% 

30-34: 31.7% 

≥ 35: 24.3% 

G3: < 25 years: 24.1% 

25-29: 25.3% 

30-34: 26.8% 

≥ 35: 23.8% 

G4: < 25 years: 17.1% 

25-29: 29.4% 

30-34: 32.6% 

≥ 35: 20.8% 

Parity: 

% primiparous:

G1: 56.9 

G2: 31.2 

G3: 50.0 

G4: 59.3 

Race,%: 

White 

G1: 54.0 

G2: 67.8 

G3: 47.6 

G4: 42.6 

Black 

G1: 10.0 

G2: 5.1 

G3: 11.3 

G4: 4.4 

Hispanic 

G1: 17.2 

G2: 15.1 

G3: 20.4 

G4: 15.5 

Asian/Pacific Islander 

G1: 8.1 

G2: 3.6 

G3: 6.7 

G4: 20.1 

Other 

G1: 10.7 

G2: 8.4 

G3: 14.0 

G4: 17.4 

Smoking,%: 

G1: %nonsmoking during 

pregnancy: 92.0; %smoked 

but quit: 4.2; %smoked 3.9 

G2: %nonsmoking during 

pregnancy: 90.8; %smoked 

but quit: 5.3; %smoked 4.0 

G3: %nonsmoking during 

pregnancy: 92.6; %smoked 

but quit: 1.5; %smoked 5.8 

G4: %nonsmoking during 

pregnancy: 94.2; %smoked 

but quit: 4.9; %smoked 1.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Screening glucose value less 

than 140:

G1: 85.0%: > 140: 15.0% 

G2: 81.6%: > 140: 18.4% 

G3: 81.4%: > 140: 18.6% 

G4: 83.3%: > 140: 16.7% 
C-657 

Evidence Table 48. Gestational weight gain with reference to IOM recommendations and neonatal 

hypoglycemia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

recordsrate of 

maternal weight 

gain was 

calculated as 

total pregnancy 

weight gain 

minus infant birth 

weight divided by 

weeks of 

gestation when 

last weight was 

measured; rate 

of maternal 

weight gain 

before the third 

trimester was 

calculated using 

the weight 

measured at or 

before the 

screening test for 

GDM (24-28 wks 

of gestation) 

minus 

prepregnancy 

weight divided by 

weeks of 

gestation 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between final 

recorded weight 

at last prenatal 

visit (within 2 

weeks of delivery 

date) and 

prepregnancy 

weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• AOR for neonatal hypoglycemia (95% CI) 

Groups: 

G1: Rate of maternal weight gain (kg/wk): -0.26-

0.21 

G2: Rate of maternal weight gain (kg/wk): 0.22-

0.31

G3: Rate of maternal weight gain (kg/wk): 0.32-

0.39

G4: Rate of maternal weight gain (kg/wk): 0.40-

1.03

Results: 

G1: 0.87 (0.57-1.32) 

G2: 1.00 

G3: 0.74 (0.49-1.14) 

G4: 1.91 (1.33-2.82) 

Below IOM recommendations 

0.91 (0.59-1.41) 

Within IOM recommendations 

1.00 

Above IOM recommendations 

1.39 (1.02-1.90) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Screening glucose value from 1 hour after 

50g oral glucose challenge test 

• Difference between age at delivery and 

gestational age at last weight measured 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Good 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 4 Fair, 0 

Poor 

Final Quality 

Score: 

Good 
C-658 

Evidence Table 48. Gestational weight gain with reference to IOM recommendations and neonatal 

hypoglycemia (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980 to 2001 

Funding: 

NR 

Study Objective: 

To examine relationship 

between gestational 

weight gain and adverse 

neonatal outcomes 

among infants born at 

term (37 weeks or more) 

Time frame: 

1980 to 2001 

Duration of the study: 

Entry into PN care up till 

delivery 

Quality: 

Fair 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20465 

Group Description: 

G1: Gain below IOM 

recommendations 

G2: Gain within IOM 

recommendations 

G3: Gain above IOM 

recommendations 

Group N: 

G1: 4,114 

G2: 7,490 

G3: 8,861 

Inclusion criteria: 

• Singleton 

Exclusion criteria: 

• Pregnancies 

complicated by 

multiple gestations, 

congenital anomalies, 

chronic hypertension, 

gestational or 

pregestational 

diabetes 

• Birth before 37 weeks

• Maternal transport 

• Missing data on any 

of variables 

considered in 

multivariable analysis

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 25.8% 

19.8-26.0: 19.4% 

26.1-29.0: 9.2% 

> 29.0: 20.6% 

G2: < 19.8: 49.1% 

19.8-26.0: 34.8% 

26.1-29.0: 23.3% 

> 29.0: 25.5% 

G3: < 19.8: 25.0% 

19.8-26.0: 45.8% 

26.1-29.0: 67.5% 

> 29.0: 53.9% 

P < 0.001 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20 years: 23.4% 

20-29 years: 19.3% 

30-39 years: 19.9% 

> 40 years: 25.3% 

G2: < 20 years: 31.3% 

20-29 years: 36.6% 

30-39 years: 37.6% 

> 40 years: 36.3% 

G3: < 20 years: 45.4% 

20-29 years: 44.0% 

30-39 years: 42.5% 

> 40 years: 38.4% 

P < 0.001 

Parity: 

% Nulliparous:

G1: 17.3 

G2: 36.2 

G3: 46.6 

P < 0.001 

Race,%: 

White 

G1: 16.2 

G2: 35.8 

G3: 48.0 

Black 

G1: 25.5 

G2: 29.4 

G3: 45.1 

Hispanic 

G1: 19.2 

G2: 34.8 

G3: 46.0 

Asian/Pacific Islander 

G1: 24.3 

G2: 43.3 

G3: 32.4 

Other 

G1: 21.7 

G2: 37.9 

G3: 40.4 

P for all race categories < 

0.001 

Smoking,%: 

G1: 23.5 

G2: 30.8 

G3: 45.8 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-659 

Evidence Table 48. Gestational weight gain with reference to IOM recommendations and neonatal 

hypoglycemia (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4114 

G2: 7490 

G3: 8861 

Total weight gain: 

Categorized: 

• According to 

IOMpercentiles 

and dichotomous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: %SGA: 36.1; %AGA: 

20.2; %LGA: 8.5 

G2: %SGA: 39.4; %AGA: 

37.5; %LGA: 26.5 

G3: %SGA: 24.5; %AGA: 

42.4; %LGA: 65.1 

P < 0.001 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 14.7 

G2: 32.1 

G3: 53.2 

Instrumental delivery,%:

Operative vaginal 

delivery:

G1: 18.0% 

G2: 37.5% 

G3: 44.5% 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

• Birth trauma 

• 5 min Apgar score 

less than 7 

• Assisted ventilation 

• SGA 

• LGA 

• NICU admission 

• SCN admission 

• Neonatal infection 

• Seizure 

• Hypoglycemia 

• Polycythemia 

• MAS 

• RDS 

• Tachypnea 

• Hospital stay > 5 

days 

• Hospital stay > 10 

days 

Outcomes Description: 

AOR for neonatal hypoglycemia (95% CI) 

Groups: 

G1: Below IOM guidelines 

G2: Within IOM guidelines 

G3: Above IOM guidelines 

Results 

Hypoglycemia 

G1: 1.02 (0.64–1.62) 

G2: 1.0 

G3: 1.52 (1.06–2.16) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Date of delivery 

• Mode of delivery 

• Length of first stage of labor 

• Length of second stage of labor 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

Birth weight 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

3 Good, 6 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-660 

Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to 

neonatal intensive care 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stevens-Simon and 

McAnarney, 1992 

Country and setting: 

USA, adolescent 

maternity program 

Enrollment Period:

1986 to 1989 

Funding: 

Grant from Bureau of 

Maternal and Child Health 

Study Objective: 

To clarify advantages and 

disadvantages of large 

gestational weight gain 

among pregnant 

adolescents 

Time frame: 

1986 to 1989 

Duration of the study: 

Entry into prenatal care 

through 6 weeks PP 

check up 

Design: 

• Cohort 

• Prospective 

Total Study N: 

141 (107 included in 

postpartum analyses) 

Group Description: 

G1: Slow gainers 

G2: Average gainers 

G3: Rapid gainers 

Group N: 

G1: 28 

G2: 66 

G3: 47 

Inclusion criteria: 

• Consecutively 

enrolled poor, black, 

12-19 year olds 

• Prenatal care prior to 

2third week gestation

• No chronic disease 

• No regular 

medications 

• No known uterine 

anomalies 

• Live birth 

• Singletons 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 58.6 (11.1) 

G2: 160.9 (7.0) 

G3: 163.9 (5.5) 

Pregravid BMI: 

G1: 23.1 (3.5) 

G2: 23.5 (4.4) 

G3: 23.5 (4.2) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 16.9 

G2: 16.6 

G3: 16.2 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-661 

Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to 

neonatal intensive care (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28 

G2: 66 

G3: 47 

Total weight gain: 

G1: 7.7 (average rate 

0.2 kg/wk)

G2: 12.4 (average 

rate 0.3 kg/wk)

G3: 19.8 (average 

rate 0.5 kg/wk)

Categorized: 

• According to 

IOMslow gain: 

< 0.23kg/wk; 

average gain: 

0.23-0.4kg/week; 

rapid gain: > 

0.4kg/week 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) 

P < 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Admission to NICU (%) 

Groups: 

Maternal weight gain categories (kg/wk): 

G1: < 0.23 (slow gainers) 

G2: 0.23-0.40 (average gainers) 

G3: > 0.40 (ra[od gainers) 

Results: 

G1: 28.6 

G2: 15.2 

G3: 8.5 P = 0.1 for infants of slow gainers vs. all other 

infants 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NA 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poo

r: 

3 Good, 4 Fair, 

2 Poor 

Final Quality 

Score: 

Fair 
C-662 

Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to 

neonatal intensive care (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stotland et al., 2006 

Country and setting: 

USA, university hospital 

Enrollment Period:

1980 to 2001 

Funding: 

NR 

Study Objective: 

To examine relationship 

between gestational 

weight gain and adverse 

neonatal outcomes 

among infants born at 

term (37 weeks or more) 

Time frame: 

1980 to 2001 

Duration of the study: 

Entry into PN care up till 

delivery 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

20465 

Group Description: 

G1: Gain below IOM 

recommendations 

G2: Gain within IOM 

recommendations 

G3: Gain above IOM 

recommendations 

Group N: 

G1: 4,114 

G2: 7,490 

G3: 8,861 

Inclusion criteria: 

• Singleton 

Exclusion criteria: 

• Pregnancies 

complicated by 

multiple gestations, 

congenital anomalies, 

chronic hypertension, 

gestational or 

pregestational 

diabetes 

• Birth before 37 weeks

• Maternal transport 

• Missing data on any 

of variables 

considered in 

multivariable analysis

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 25.8% 

19.8-26.0: 19.4% 

26.1-29.0: 9.2% 

> 29.0: 20.6% 

G2: < 19.8: 49.1% 

19.8-26.0: 34.8% 

26.1-29.0: 23.3% 

> 29.0: 25.5% 

G3: < 19.8: 25.0% 

19.8-26.0: 45.8% 

26.1-29.0: 67.5% 

> 29.0: 53.9% 

P < 0.001 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20 years: 23.4% 

20-29 years: 19.3% 

30-39 years: 19.9% 

> 40 years: 25.3% 

G2: < 20 years: 31.3% 

20-29 years: 36.6% 

30-39 years: 37.6% 

> 40 years: 36.3% 

G3: < 20 years: 45.4% 

20-29 years: 44.0% 

30-39 years: 42.5% 

> 40 years: 38.4% 

P < 0.001 

Parity: 

% Nulliparous:

G1: 17.3 

G2: 36.2 

G3: 46.6 

P < 0.001 

Race,%: 

White 

G1: 16.2 

G2: 35.8 

G3: 48.0 

Black 

G1: 25.5 

G2: 29.4 

G3: 45.1 

Hispanic 

G1: 19.2 

G2: 34.8 

G3: 46.0 

Asian/Pacific Islander 

G1: 24.3 

G2: 43.3 

G3: 32.4 

Other 

G1: 21.7 

G2: 37.9 

G3: 40.4 

P for all race categories < 

0.001 

Smoking,%: 

G1: 23.5 

G2: 30.8 

G3: 45.8 P < 0.001 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-663 

Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to 

neonatal intensive care (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 4114 

G2: 7490 

G3: 8861 

Total weight gain: 

Categorized: 

• According to 

IOMpercentiles 

and dichotomous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: %SGA: 36.1; %AGA: 

20.2; %LGA: 8.5 

G2: %SGA: 39.4; %AGA: 

37.5; %LGA: 26.5 

G3: %SGA: 24.5; %AGA: 

42.4; %LGA: 65.1 

P < 0.001 

Gestational diabetes,%: 

NR 

Cesarean delivery,%: 

G1: 14.7 

G2: 32.1 

G3: 53.2 

Instrumental delivery,%:

Operative vaginal 

delivery:

G1: 18.0% 

G2: 37.5% 

G3: 44.5% 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NA 

Other infant outcomes: 

• Birth trauma 

• 5 min Apgar score 

less than 7 

• , Aassisted ventilation

• SGA 

• LGA 

• NICU admission 

• SCN admission 

• Neonatal infection 

• Seizure 

• Hypoglycemia 

• Polycythemia 

• MAS 

• RDS 

• Tachypnea 

• Hospital stay > 5 

days 

• Hospital stay > 10 

days 

Outcomes Description: 

• Risk of adverse neonatal outcomes by 

gestational weight gain by IOM 

guidelines, adjusted ORs compared to 

women with GWG within IOM guidelines 

and risk of adverse neonatal outcomes 

by extremes of GWG compared to 

women with weight gain 11.5-16.0kg 

Groups: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: < 7kg 

G5: > 18kg 

Results: 

AOR (95% CI) for NICU admission: 

G1: 0.66 (0.46-0.96) 

G2: 1.03 (0.79-1.35) 

G3: 0.50 (0.23-1.12) 

G4: 0.66 (0.46-0.96) 

G5: 1.03 (0.79-1.35) 

Maternal confounders and effect 

modifiers accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Pregnancy induced hypertension 

• Date of delivery 

• Mode of delivery 

• Length of first stage of labor 

• Length of second stage of labor 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Gestational age 

• Birth weight 

Background: 

Good 

Sample 

selection: 

Good 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Good 

Sum of 

Good/Fair/Poo

r: 

4 Good, 5 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 

 
C-664 

Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight 

status 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Oken et al., 2007 

Country and setting: 

Reported elsewhere 

Enrollment period:

NR 

Funding: 

Supported by grants from 

US National Institutes of 

Health (HD 34568, HL 

64925, HL68041, HD 

44807), the Robert Wood 

Johnson Foundation, 

Harvard Medical School, 

and Harvard Pilgrim 

Health Care Foundation 

Study Objective: 

Purpose of study to 

examine associations of 

gestational weight gain 

with child adiposity 

Time frame: 

NR 

Duration of the study: 

Entry to prenatal care thru 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

1,044 

Group Description: 

G1: Total 

Group N: 

G1: 1,044 

Inclusion criteria: 

Women delivering live 

singleton infant and 

enrolled for continuation 

of study beyond 6 months 

after delivery 

Exclusion criteria: 

• Missing information 

on prepregnancy 

weight, parental BMI, 

or infant birthweight, 

or who did not have a 

weight recorded 

within 4 weeks 

preceding delivery 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 24.6 (SD 5.0) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 15-24: 6% 

25-34: 62% 

35-44: 32% 

Parity: 

G1: Nulliparous: 48% 

Parous: 52% 

Race,%: 

White 

G1: 74% 

Black 

G1: 11% 

Hispanic 

G1: 6% 

Other 

G1: 10% 

Smoking,%: 

G1: Never: 67% 

Quit before pregnancy 20% 

Smoked in early pregnancy 10%

Diabetes mellitus,%: 

G1: 4% 
C-665 

Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight 

status (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

NR

Total weight gain: 

G1: 15.6 kg (5.4) 

Categorized: 

• Continuous 

According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by:

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

G1: 4% 

Cesarean 

delivery,%: 

G1: 23% 

G2: 12% 

G3: 35% 

G4: 53% 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• Association of MWG with 

child adiposity-related 

outcomes at age 3 years, 

before and after adjustment 

for potential confounding 

and pathway variables. 

Effect increments are for 

IOM weight gain categories 

Groups: 

G1: Inadequate gestational 

weight gain 

G2: Adequate weight gain 

G3: Excessive weight gain 

Results: 

AOR of having overweight 

(< 95th percentile) child 

G1: 1.0 

G2: 3.77 (1.38, 10.27) 

G3: 4.35 (1.69, 11.24) 

AOR of having child between 

85-94th percentile 

G1: 1.0 

G2: 2.09 (1.12, 3.92) 

G3: 2.03 (1.11, 3.72) 

AOR of having child between 

50th-84th percentile 

G1: 1.0 

G2: 1.85 (1.17, 2.92) 

G3: 1.84 (1.17, 2.88) 

Characteristic: Adjusted mean 

BMI z-score 

G1: 0.17 (95% CI, 0.01, 0.33) 

G2: (0.47 units, 95% CI, 0.37, 

0.57) 

G3: (0.52 units, 95% CI, 0.44, 

0.61) 

Maternal confounders and 

effect modifiers accounted for 

in analysis: 

• Breastfeeding 

• Education 

• Time between last 

pregnancy weight and 

delivery 

• Household income 

• Marital status 

• Paternal BMI 

• Smoking 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 5 Fair, 0 Poor 

Final Quality Score: 

Fair 
C-666 

Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight 

status (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Oken et al., 2007 

continued 

 
C-667 

Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight 

status (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

• Birth length 

• Sex 

• Child diet 

• Child television viewing 
C-668 

Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation 

performance 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria 

Baseline 

Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Baker et al, 

2007 

Country and setting: 

Denmark, birth registry 

Enrollment period: 

4 years - 1999 to 2002 

Funding: 

Data analysis supported 

by Hatch 

grantNYC399405 (to 

KMR) and a grant from 

the Einaudi Center at 

CornellUniversity (to 

JLB). JLB was 

supported by National 

Institutes of 

Healthtraining grant 

HD07331 (to KMR). 

Study Objective: 

To determine whether 

this association was 

stronger with increasing 

maternal obesity, was 

modified by gestational 

weight gain, and still 

existed when there was 

greater 

social support for 

breastfeeding 

Time frame: 

4 years - 1999 to 2002 

Duration of the study: 

Entry into prenatal care 

through 18 months 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

37,459 

Group Description: 

NR 

Group N: 

G1: 37,459 

Inclusion criteria: 

• Delivered of liveborn, 

singleton infant 

Exclusion criteria: 

• Subjects who were 

aged 18 y or 45 y (n 40) 

• Preexisting or 

gestational diabetes (n: 

554) 

• Chose to not breastfeed 

(n: 745) 

• Used alternative 

breastfeeding method 

(e.g., breast pump only 

or feeding infant banked 

human milk; n: 14), 

whose infant was born 

preterm (gestation 259 

d; n: 1,316) or at a very 

low birth weight (2000 

g; n: 29) 

• Infant had birth defect, 

severe illness, or other 

condition that might 

preclude successful 

breastfeeding (as 

determined by KFM; n: 

420) 

• Excluded women (n 

529) for whom duration 

of breastfeeding could 

not be determined; most 

of these women had 

extreme inconsistencies 

in answers to infant 

feeding questions 

Pregravid weight: 

• Self-reported 

• 

Pregravid BMI: 

• G1: 23.6 +/ 4.2 

Imputed: 

• No 

Categorized: 

• WHO International 

Taskforce 

Age (mean, yrs): 

G1: 30.5 (4.22) 

Parity: 

G1: 46.7 % primiparous 

(37,429) 

Race,%: 

NR 

Smoking,%: 

G1: 18.0 (37,430) 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 
C-669 

Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 37 459 

Total weight gain: 

G1: 15.1kg +/ 6.0

Categorized: 

• < 8 kg

• 8-15.9 kg

• ≥ 16 kg 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: 3.64 +/ 0.49 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes 

• GWG 

increased 

odds of 

termination of 

breastfeeding 

inconsistently. 

Significant for 

termination of 

full 

breastfeeding 

at 1 (P 0.0001), 

16 (P < 0.05), 

and 20 (P < 

0.05) wk. 

Significant for 

termination of 

any 

breastfeeding 

only at 16 and 

20 wk (P

0.0001 for 

both) 

Other infant 

outcomes 

NR 

Outcomes Description: 

Any breastfeeding or full 

breastfeeding 

Groups 

G1:<8 kg 

G2:8-15.9 kg 

G3:>=16 kg 

Results 

Overall higher risk of 

terminating full or any 

breastfeeding with higher 

pregravid BMI. 

Unadjusted RR full BF 

G1:1.13 (95%1.08, 1.18) 

G2: NR 

G3:1.05 (1.03, 1.08) 

Any BF 

G1:RR 1.16 (1.11, 1.22) 

G2: NR 

G3:1.05 (1.03, 1.08). 

GWG not a predictor of full 

or any when BMI was in the 

model. 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Pre-gravid BMI 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• NR 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Good 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

7 Good, 1 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-670 

Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Li et al., 2003 

Country and setting: 

USA, WIC clinics 

Enrollment Period: 

1996 to 1998 

Funding: 

Conducted by staff at 

CDC 

Study Objective: 

To test hypothesis that 

women who are obese 

before pregnancy or 

who gain excessive 

weight during 

pregnancy are less 

likely to initiate and 

maintain breast-feeding 

than are their normalweight counterparts 

Time frame: 

1996 to 1998 

Duration of the study: 

From entry into WIC for 

mom until 1 yr 

postpartum or she stops 

BF 

Design: 

• WIC mother and 

child data sets that 

were linked 

• Retrospective 

Total Study N: 

51,329 

Group Description: 

G1: Total Group 

(multiple logistic 

regression) 

G2: NR 

Group N: 

G1: 51329 

G2: NR 

Inclusion criteria: 

• Low income US 

women and 

children 

participating in 

federally funded 

public health 

programs such as 

WIC 

Exclusion criteria: 

• Multiple births 

• Records with 

missing data for 

pregravid BMI, 

gestational weight 

gain, characteristics 

of children, 

characteristics of 

mother, 

breastfeeding 

initiation 

information 

• Biologically 

implausible values 

for BW, gestational 

age, maternal BMI, 

maternal age, parity 

Pregravid weight: 

Self-reported 

Pregravid BMI: 

G1: BMI before pregnancy 

(in kg/m2) 

Underweight (< 19.8) 

7591 (14.8%) 

Normal (19.8 ̈C26.0) 

24417 (47.6%) 

Overweight (> 

26.0 ̈C29.0) 6836 

(13.3%) 

Obese (> 29.0) 12485 

(24.3%) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: Maternal age 

< 20 y 9631 (18.8%) 

20 ̈C24 y 18 256 

(35.6%) 

25 ̈C29 y 13 251 

(25.8%) 

¡Ý30 y 10 191 (19.9%) 

G2: NR 

Parity: 

G1: Multiparous 27897 

(54.3%) Primiparous 23432 

(45.7%) 

G2: NR 

Race,%: 

White 

G1: 69.9% 

G2: NR 

Black 

G1: 17.9 

G2: NR 

Hispanic 

G1: 9.7 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

G1: 2.5 

G2: NR 

Smoking,%: 

G1: 27.1 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-671 

Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

G1: 51329 

G2: NR 

Total weight gain: 

G1: Gestational 

weight gain 

Below IOM 15888 

(31.0%) 

Within IOM 13634 

(26.6%) 

Above IOM 21 807 

(42.5%) 

G2: NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Selfreportedselfreported by 

subjects at the 

postpartum 

visit 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: Low (< 2500 g) 

3432 (6.7%) 

Normal (¡Ý2500 g) 

47897 (93.3%) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Adjusted OR for failure to 

initiate breast feeding by 

BMI 

Groups 

G1:<IOM 

G2: within IOM 

G3:>IOM BMI before 

pregnancy: Underweight < 

19.8 

Results 

Under, normal and 

overweight G1 groups had a 

significant increased odds of 

failure to initiate BF 

compared to G2 within BMI 

strata. Obese women 

regardless of weight gain 

had increased odds of 

failure to initiate compared 

to normal wt G2. 

Adjusted mean duration of 

BF (p<0.01)* 

G1:12.9 wk* 

G2:13.6 wk (ref) 

G3:12.8wk* 

Maternal confounders and 

effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pre-gravid BMI 

• Maternal education 

• Marital status 

• Prenatal care 

• Poverty-income ratio 

• Gestational weight gain 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

• Gestational age, 

• Birth weight 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Poor 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

4 Good, 3 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-672 

Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rasmussen et al., 2002 

Country and setting: 

USA, hospital 

Enrollment Period: 

Jan 1988 ti Dec 1997 

Funding: 

NR 

Study Objective: 

To examine how 

gestational weight gain 

might modify 

association between 

prepregnant bmi and 

lactational performance 

Time frame: 

Jan 1988 to Dec 1997 

Duration of the study: 

Entry into prenatal care 

through child’s second 

year 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

2,494 

Group Description: 

Group N: 

Inclusion criteria: 

• 19 to 40 year old 

women delivering 

singleton infants at 

Mary Imogene 

Bassett Hospital in 

Cooperstown, NY 

who attempted to 

BF at delivery and 

for whom complete 

data were available 

Exclusion criteria: 

• Contraindications 

for BF, gestational 

DM, underweight 

(BMI < 19.8) at 

conceptioni or lost 

weight during 

pregnancy 

Pregravid weight: 

• Routine pre-natal care 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-673 

Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from 

Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: weight 

at delivery 

minus 

prepregnancy 

weight 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

OR unsuccessful initiation of 

BF (normal wt G2 ref) 

Groups 

G1:<IOM 

G2 within IOM 

G3:>IOM 

Results 

Underweight: no significant 

diff 

Normal wt: G3 1.66 

(1.05,2.63) 

Overwt: no significant diff 

Obese: G3 2.89 (1.78, 4.69) 

Hazard OR discontinuing 

exclusive BF 

(normal wt G2 ref) 

Underwt G3 1.39 (1.01, 1.92) 

Normal wt-no signif 

differences 

Overwt G3 1.27 (1.03, 1.56) 

Obese G1:1.37 (1.01, 1.84), 

G2 1.50 (1.11, 2.03), G3:1.78 

(1.48, 2.14) 

Hazard OR discontinuing any 

BF 

(normal wt G2 ref) 

Underwt-no sign difference 

Normal wt-no sign difference 

Overwt- no sign difference 

Obese G2 1.57 (1.14, 2.18), 

G3:1.99 (1.64, 2.43) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

• Age 

• Parity 

• Participation in 

WIC/PCAP 

• Type of delivery 

• Mother attended college 

• Smoking 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Poor 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor: 

2 Good, 5 Fair, 2 Poor 

Final Quality Score: 

Fair 
C-674 

Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hilson et al., 2006 

Country and setting: 

USA, hospital 

Enrollment Period: 

Jan 1988 to Dec 1997 

Funding: 

NIH and USDA-Hatch 

Study Objective: 

To determine whether 

GWG was 

independently 

associated with initiation 

and continuation of BF 

and whether GWG 

modified previously 

observed association 

between high 

prepregnant BMI and 

these outcomes 

Time frame: 

Jan 1988 to Dec 1997 

Duration of the study: 

From entry into PNC 

through 1 year of life but 

all based on medical 

record info 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

2,783 

Group Description: 

G1: Underweight BMI < 

19.8 

G2: Normal BMI 19.8-

26.0 

G3: Overweight 26.1-

29.0 

G4: Obese > 29.0 

G5: < IOM/ Within IOM 

G6: > IOM 

Group N: 

G1: 364 

G2: 1522 

G3: 354 

G4: 543 

G5: 520/ 877 

G6: 1386 

Inclusion criteria: 

• Mother-infant dyads 

in which BF was 

ever attempted and 

to those thought to 

have a low potential 

for 

contraindications to 

BF 

• Mothers also had to 

be 19–49 y old and 

free of gestational 

diabetes 

• Singleton births 

• Had information for 

all key variables 

analysed in present 

study 

Exclusion criteria: 

See above 

Pregravid weight: 

Self-reported 

G1: 51.2 +/-4.9 

G2: 61.5 +/-6.8 

G3: 73.9 +/- 6.5 

G4: 90.4 +/-13.6 

G5: 66.8(17.9)/ 63.2(13.1) 

G6: 70.2(14.7) 

Pregravid BMI: 

G1: 18.6 +/- 0.9 

G2: 22.7 +/-1.7 

G3: 27.4 +/- 0.9 

G4: 33.7 +/- 4.1 

G5: 24.9(6.4) / 23.4(4.5) 

G6: 25.8(5.2) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 27.3 +/- 5.1 

G2: 28.5 +/- 5.1 

G3: 28.0 +/-4.8 

G4: 27.9 +/-4.9 

G5: 27.8(5.0) / 28.9 (5.0) 

G6: 27.9 (5.0) 

Parity: 

G1: Nulliparous (%) 44.6 

G2: Nulliparous (%) 37.6 

G3: Nulliparous (%) 39.4 

G4: Nulliparous (%) 34.1 

G5: 29.1%/33.9% 

G6: 44.1% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

Before pg:

G1: 22.2% 

G2: 18.5 

G3: 20.3 

G4: 19.9 

G5: 24.0/18.8 

G6: 18.4 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Vaginal delivery:

G1: 93.1% 

G2: 90.2% 

G3: 85.9% 

G4: 80.5% 

G5: 91.7/89.7 

G6: 85.8 

Additional characteristics: 

NR 
C-675 

Evidence Table 50. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 364 

G2: 1,522 

G3: 354 

G4: 543 

G5: 520/877 

G6: 1,386 

Total weight gain: 

G1: 15.7 +/-4.7 

G2: 15.8 +/- 3.4 

G3: 15.0 +/- 6.1 

G4: 11.6 +/-7.2 

P < 0.01 from 

underweight 

group; P < 0.01 

from normal; 

P < 0.01 from 

overweight 

group 

G5: 7.5 (4.1)/13.1 

(2.6) P < 0.01) 

G6: 18.7 (5.0) 

P < 0.01 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 3469 g (SD 462) 

G2: 3602 P < 0.01 from 

underweight group 

G3: 3662 P < 0.01 from 

underweight 

G4: 3703 P < 0.01 from 

underweight group; P

< 0.01 from normal 

G5: 3413 g(462)/ 3571 

g(455) P < 0.01 

G6: 3713 ( 

Gestational diabetes, %: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Initiated BF,%: 

Underweight 89, 

Normal 90.1, 

Overweight 88.4, 

Obese 82.58 

(P < .05, P < 0.01 

from normal weight 

group), < IOM 87.9, 

Within IOM 91.1, > 

IOM 86.7 P < 0.01 

from women who 

gained within IOM 

Other infant outcomes: 

Macrosomic, %: 

• Underweight 11.5 

• Normal 20.08 (P < 

0.01 from 

underweight group) 

• Overweight 23.48 

(P < 0.01 from 

underweight group) 

 

Outcomes Description: 

• The predicted duration of EBF was 

1 wk shorter for underweight and 

overweight women whose GWG 

was above IOM recommendations 

and 3 wk shorter for obese women 

whose GWG was above IOM 

recommendation (Fig. 2) 

• For obese women, predicted 

duration of ABF was 17 wk shorter 

among those who gained within 

IOM recommendation and 20 wk 

shorter among those who gained 

above IOM recommendation than 

among women in reference group 

(Fig. 2) 

Groups: 

G1: Underweight BMI < 19.8 

G2: Normal BMI 19.8-26.0 

G3: Overweight 26.1-29.0 

G4: Obese > 29.0 

G5: < IOM/ Within IOM 

G6: > IOM 

Results: 

Underweight BMI 

G1: 1.21 (0.53, 2.76) 

G2: 1.59 (0.82, 3.07) 

G3: 1.88 (0.91, 3.92) 

G4: 1.31 (0.995, 1.71) 

G5: 1.04 (0.82, 1.31) 

G6: 1.39 (1.01, 1.92) 

Normal weight BMI 

G1: 1.69 (0.99, 2.88) 

G2: 1.0 

G3: 1.66 (1.05, 2.63) P < 0.05) 

G4: 1.19 (0.981, 1.44) 

G5: 1.0 

G6: 1.14 (0.969, 1.33) 

Overweight 

G1: 2.96 (0.90, 9.79) 

G2: 1.47 (0.61, 3.53) 

G3: 1.62 (0.90, 2.91) 

G4: 1.59 (0.94, 2.68) 

G5: 1.13 (0.81, 1.58) 

G6: 1.27 (1.03, 1.56) P < 0.05) 

Obese 

G1: 1.81 (0.86, 3.83) 

G2: 1.84 (0.83, 4.11) 

G3: 2.89 (1.78, 4.69) P < 0.01 

G4: 1.37 (1.01, 1.84) P < 0.05) 

G5: 1.50 (1.11, 2.03) P < 0.01 

G6: 1.78 (1.48, 2.14) P < 0.01 

Background: 

Good 

Sample selection: 

Good 

Definition of maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of information 

on exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

6 Good, 3 Fair, 0 Poor 

Final Quality Score: 

Good 
C-676 

Evidence Table 50. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hilson et al., 2006 

(continued) 

 
C-677 

Evidence Table 50. Gestational weight gain with reference to IOM recommendations and lactation 

performance (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

• Overweight 

23.48(P < 0.01 

from underweight 

group) 

• Obese 28.08 (P < 

0.01 from 

underweight 

group, P < 0.01 

from normal 

weight group, < 

IOM 10.0% 

• Within IOM 17.4 

(P<0.01), >IOM 

27.4% P<0.01 

G1: Hazard ratio (HR) of 

discontinuing Any BF: < IOM 

G2: Hazard ratio (HR) of 

discontinuing Any BF: Within IOM 

G3: Hazard ratio (HR) of 

discontinuing Any BF: > IOM 

Underweight BMI 

G1: 1.21 (0.89, 1.64) 

G2: 0.95 (0.73, 1.24) 

G3: 1.34 (0.95, 1.88) 

Normal Weight 

G1: 1.09 (0.88, 1.35) 

G2: 1.0 

G3: 1.09 (0.92, 1.30) 

Overweight 

G1: 0.84 (0.43, 1.64) 

G2: 1.16 (0.82, 1.64) 

G3: 1.24 (0.989, 1.55) 

Obese 

G1: 1.33 (0.963, 1.85) 

G2: 1.57 (1.14, 2.18) P < 0.01 

G3: 1.99 (1.64, 2.43) P < 0.01 

Maternal confounders and effect 

modifiers accounted for in 

analysis: 

• Age 

• Parity 

• Participation in WIC/PCAP 

• Type of delivery 

• Mother attended college 

• Smoking 

Infant and child confounders and 

effect modifiers accounted for in 

analysis: 

NR 
C-678 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Butte et al., 2003 

Country and setting: 

USA, children’s nutrition 

center 

Enrollment Period:

NR 

Funding: 

US Department of Army 

and US Department of 

Agriculture/Agriculture 

Research Service 

Study Objective: 

To evaluate how changes 

in gestational weight and 

body composition affect 

infant birth weight and 

maternal fat retention after 

delivery in underweight, 

normal weight and 

overweight women 

Time frame: 

NR 

Duration of the study: 

Prior to preg through pp 

Design: 

• Cohort 

• Prospective 

Total Study N: 

63 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 63 

G2: NR 

Inclusion criteria: 

• Nonsmokers 

• 18-40 years 

• parity ≤ 4 

• Physically active (20 

to 30 minutes of 

moderate exercise at 

least 3 times/week) 

• No long term 

medicine use 

• No alcohol/drug 

abuse 

Exclusion criteria: 

• Multiparous 

• Preterm deliveries 

• Miscarriage 

• Preeclampsia 

Pregravid weight: 

• Measured by study 

investigators 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 31 (4) 

G2: NR 

Parity: 

NR 

Race,%: 

White 

G1: 77 

G2: NR 

Black 

G1: 10 

G2: NR 

Hispanic 

G1: 10 

G2: NR 

Asian/Pacific Islander 

G1: 3 

G2: NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-679 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 15.0 (3.8) kg

G2: 14.5 (4.5) kg

G3: 17.9 (5.4) kg

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Birth weight 

Outcomes Description: 

Fat retention 

Groups: 

BMI groups, low, normal, high 

Results: 

• After adjustment for gestational duration, gravidity, 

and ethnicity, gestational weight gain and net 

gestational weight gain (GWG-birth weight) were 

significantly lower in normal BMI group than in high 

BMI group (P = 0.04) - GWG and net GWG in low 

BMI group was not significantly different from women 

in normal and high BMI groups 

• On average weight gain was 42% fat mass and 58% 

fat free mass 

• Weight gain was linearly correlated with gains in TBW 

(r = 0.39, P = 0.003), TBK (r = 0.49, P = 0.001), 

protein (r = 0.49, P = 0.001), Fat free mass (r = 0.50, 

P = 0.001), and FM (r = 0.76, P = 0.001) 

• Mean gestational weight gain (14.4kg) of women who 

gained within IOM recommendations was associated 

with gains of 7.1kg TBW, 5.0g TBK, 370g protein, 8.4 

kg FFM, and 4.1 kg FM and a mean birth weight of 

3.44kg 

• Changes in body weight differed among BMI groups in 

first trimester (normal BMI < high BMI group, P = 

0.004) and third trimester (low BMI < normal and high 

BMI group, P < 0.01) 

• No effect of breast feeding on body weight and 

composition 

• Birth weight correlated significantly with GWG (r = 

0.35, P = 0.006), net GWG (r = 0.26, P = 0.04), and 

rate of weight gain (r = 0.28, P = 0.03), FFM (r = 

0.39, P = 0.003) but not with FM 

• Partitioning GWG into FFM and FM showed that FFM 

gain accounted for effect on birth weight (not FM) 

• Maternal FFM gains in first (P = 0.008), second (P = 

0.005), and third trimesters (P = 0.005) were shown 

to make independed contributions to birth weight 

• Total gestational gains in maternal weight, TBW, TBK, 

FFM and FM were not shown to have an effect on 

infant FFM, FM, or percentage of FM at 2 weeks of 

age 

• Postpartum weight retention was correlated positively 

with GWG (r = 0.67, P = 0.001), total FM gain (r = 

0.61, P = 0.001) but not with FFM gain 

• Postpartum fat retention was correlated positively with 

GWG (r = 0.56, P = 0.001) and total FM gain (r = 

0.57, P = 0.001) 

• Maternal fat retention at 27 weeks after delivery 

(5.3kg) was significantly higher in women who gained 

above IOM recommendations for weight gain 

compared to those women who gained within (2.3kg) 

or below (-0.5kg) recommendations 

• 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Poor 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poo

r: 

3 Good, 5 Fair, 

1 Poor 

Final Quality 

Score: 

Fair 
C-680 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Butte et al., 2003 

(continued) 

 
C-681 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Maternal confounders and effect modifiers accounted 

for in analysis: 

• Race 

• Pre-gravid BMI 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

• Gestational age 
C-682 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lederman et al., 1997 

Country and setting: 

USA, clinics 

Enrollment Period:

Jan 1991-Aug 1993 

Funding: 

Grant from Maternal and 

Child Health Bureau and 

Department of Health and 

Human Services 

Study Objective: 

To determine fat 

deposited during 

pregnancy in women 

according to 

recommendations of IOM 

and relationship of weight 

gain to fat gain in women 

of different starting 

weights classified by BMI 

Time frame: 

Jan 1991 to Aug 1993 

Duration of the study: 

From first visit through 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

196 

Group Description: 

G1: study cohort 

G2: NR 

Group N: 

G1: 196 

G2: NR 

Inclusion criteria: 

• 18 to 35 years of age

• Non-smokers 

• Self-identified as 

Hispanic, black, or 

white 

• Expecting singleton 

birth 

• Able to schedule their 

first body composition 

laboratory visit before 

16th week of 

gestation 

• Free of medical 

illnesses requiring 

regular medication 

• Not knowingly 

infected with HIV 

• Not a regular user of 

drugs or alcohol 

according to mother’s 

report 

Exclusion criteria: 

• NA they had to have 

a 37 week 

measurement and 

medical record 

available 

Pregravid weight: 

• Self-reported 

G1: 63.4 (12.9) 

G2: NR 

Pregravid BMI: 

Imputed: 

• NR 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26.0 (4.8) 

G2: NR 

Parity: 

G1: 0.8 (1.0) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-683 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 196 

G2: NR 

Total weight gain: 

G1: 13.6 (6.1)

G2: NR 

Categorized: 

• According to IOM 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

measurement at 

week 37+ and 

prepregnancy 

Birth weight: 

G1: 3,449 (433) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Study investigators 

measured body 

weight, body density 

by 

hydrodensitometry, 

and deuterium 

dilution volume twice 

during pregnancy (at 

weeks 12-16 and at 

37+ weeks) 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Fat gain between pregnancy weeks 14-37 

Groups: 

< IOM, within IOM, > IOM, for BMI groups for three 

outcomes: 

G1: Body weight gain 

G2: Body water gain 

G3: Fat gain 

Results: 

BMI < 19.8: all women (n = 21) 

G1: 12.6 (4.4) 

G2: 6.1 (2.4) 

G3: 4.8 (3.8) 

BMI < 19.8: less than recommended; recommended; 

more than recommended 

G1: 7.9 (1.6); 12.6 (2.4); 16.1 (3.9) 

G2: 6.4 (3.7); 5.9 (1.6); 6.1 (2.2) 

G3: 0.6 (1.9); 6.0 (2.6); 6.9 (3.5) 

BMI19.8-26.0: all women (n = 118) 

G1: 12.2 (4.0) 

G2: 7.0 (2.7) 

G3: 3.9 (3.7) 

BMI19.8-26.0: less than recommended; recommended; 

more than recommended 

G1: 8.6 (1.9); 12.1 (3.4); 15.2 (3.4) 

G2: 6.2 (2.1); 6.9 (2.7); 7.6 (3.0) 

G3: 1.3 (3.0); 3.8 (3.5); 6.0 (3.1) 

BMI > 26.0-29.0: all women (n = 29) 

G1: 11.0 (4.6) 

G2: 7.8 (3.5) 

G3: 2.8 (5.4) 

Background: 

Good 

Sample 

selection: 

Good 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Poor 

Analysis 

comparability:

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poo

r: 

3 Good, 4 Fair, 

2 Poor 

Final Quality 

Score: 

Fair 
C-684 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

(continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lederman et al., 1997 

(continued) 

 
C-685 

Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention 

(continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

BMI > 26.0-29.0: less than recommended; recommended; 

more than recommended 

G1: 8.5 (3.2); 9.1 (3.1); 13.6 (5.1) 

G2: 6.9 (3.0); 5.7 (3.0); 9.7 (3.2) 

G3: 0.3 (2.5); 2.8 (4.1); 4.2 (6.9) 

BMI > 29.0: all women (n = 28) 

G1: 8.7 (5.6) 

G2: 7.3 (2.9) 

G3: 0.2 (5.0) 

BMI > 29.0: less than recommended; recommended; more 

than recommended 

G1: 3.2 (2.7); 6.9 (4.4); 12.0 (4.6) 

G2: 7.8 (3.5); 6.0 (2.9); 7.6 (2.7) 

G3: -5.2 (1.5); -0.6 (4.6); 3.1 (3.9) 

Results for BMI and IOM recommendations over time: 

G1: BMI < 19.8 and gained within IOM recommendations 

G2: BMI 19.8-26.0 and gained within IOM 

recommendations 

G3: BMI > 26.0-29.0 and gained within IOM 

recommendations 

G4: BMI > 29.0 and gained within IOM recommendations 

G1: 7 

G2: 46 

G3: 9 

G4: 6 

Total body fat at week 14 

G1: 12.2 (2.3) 

G2: 18.2 (2.8) 

Total body fat at week 37+ 

G1: 17.9 (5.4) 

G2: 21.7 (5.8) 

Characteristics: 

G1: 25.1 (4.5) 

G2: 28.0 (3.8) 

Group 

G1: 33.1 (8.3) 

G2: 32.5 (5.7) 

Maternal confounders and effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 
C-686 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Luke et al., 1996 

Country and setting: 

USA, clinic 

Enrollment Period:

March 1, 1974 to June 15, 

1979 

Funding: 

NR 

Study Objective: 

Reanalysis of original data 

to examine contribution of 

maternal weight gain to 

infant birth weight and 

retained maternal weight 

in immediate postpartum 

period, and effect of 

weight gains below, at, 

and above IOM guidelines 

on both infant birt 

Time frame: 

March 1, 1974 to June 15, 

1979 

Duration of the study: 

Prenatal visit through 2 

days postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

487 

Group Description: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

Group N: 

G1: 104 

G2: 268 

G3: 115 

Inclusion criteria: 

• Referred for nutrition 

counseling 

• > 37- < 43 weeks 

gestation 

• Singleton pregnancy 

Exclusion criteria: 

• Women with history 

of or concurrent 

metabolic disease, 

such as diabetes, 

seizure disorder, 

hypertension, cardiac 

disease, asthma, or 

drug dependence 

• Women developing 

antepartum 

complications such 

as preeclampsia, 

GDM, or multiple 

gestation 

Pregravid weight: 

• Self-reported 

G1: 47.9 (5.1) 

G2: 58.7 (6.3) 

G3: 83.9 (16.9) 

Pregravid BMI: 

G1: 18.3 (1.0) 

G2: 22.6 (1.7) 

G3: 31.7 (5.3) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 23.1 (5.5) 

G2: 23.8 (5.5) 

G3: 27.4 (6.2) 

Parity: 

% primipara:

G1: 60.6 

G2: 48.1 

G3: 27.0 

Race,%: 

White 

NR 

Black 

G1: 48.1 

G2: 48.8 

G3: 63.5 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 17.3 

G2: 15.3 

G3: 13.0 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-687 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 104 

G2: 268 

G3: 115 

Total weight gain: 

G1: 12.6 (0.7)

G2: 13.2 (0.4)

G3: 11.7 (0.7) 

Significantly different 

from mean for normal 

BMI group at P < 0.05

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

total weight gain: 

difference 

between last 

measurement 

and pregravid 

weight; net 

weight gain: 

difference 

between 

pregravid weight 

and last 

measured weight 

minus infant birth 

weight 

Birth weight: 

G1: 3,067 (44) 

P < 0.05 

significantly 

different from 

mean for normal 

BMI 

G2: 3308 (27) 

G3: 3300 (43) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Net gain (kg): 9.5 

(0.6), 9.9 (0.4), 

7.8 (0.6) 

significantly 

different from 

mean for normal 

BMI group at P < 

0.05 

• Retained weight 

(kg): 6.6 (0.6), 

6.6 (0.4), 4.2 

(0.6) significantly 

different from 

mean for normal 

BMI group at 

P < 0.05 

• Percent retained 

weight (%): 11.4 

(0.9), 9.4 (0.5), 

4.4 (0.8) 

significantly 

different from 

mean for normal 

BMI group at 

P < 0.05 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Mean retained weight 

Groups 

Maternal weight gain < IOM 

recommendations: 

G1: BMI < 19.8 

G2: BMI 19.8-26.0 

G3: BMI > 26.0 

Maternal weight gain within 

IOM recommendations: 

G4: BMI < 19.8 

G5: BMI 19.8-26.0 

G6: BMI > 26.0 

Maternal weight gain > IOM 

recommendations: 

G7: BMI < 19.8 

G8: BMI 19.8-26.0 

G9: BMI > 26.0

Results 

Mean (SEM) retained weight 

(defined as 2-day postpartum 

weight minus pregravid weight, 

kg): 

G1: 3.2 (0.5) P < 0.05 

compared to G4 

G2: 0.8 (0.4) P < 0.05 

compared to G5 

G3: -5.0 (0.7) P < 0.05 

compared to G6 

G4: 8.2 (0.7) 

G5: 7.0 (0.4) 

G6: 1.4 (0.8) 

G7: 15.5 (0.9) P < 0.05 

compared to G4 

G8: 12.9 (0.4) P < 0.05 

compared to G5 

G9: 9.5 (0.5) P < 0.05 

compared to G6 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Age, parity, race, smoking, 

gestation duration, fetal sex 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal weight 

gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis comparability: 

Good 

Analysis of outcomes: 

Fair 

Interpretation: 

Poor 

Sum of Good/Fair/Poor: 

3 Good, 5 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-688 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Scholl et al., 1995 

Country and setting: 

USA, Camden Study 

Enrollment Period:

September 1985 to May 

1990 

Funding: 

NIH 

Study Objective: 

To determine whether risk 

of maternal overweight 

associated with an 

excessive rate of 

gestational weight gain 

needs to be balanced 

against risk of impaired 

fetal growth associated 

with low rate of gain 

Time frame: 

September 1985 to May 

1990 

Duration of the study: 

During pregnancy through 

6 months postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

274 

Group Description: 

G1: Low rate of GWG 

G2: Moderate rate of 

GWG 

G3: Excessive rate of 

GWG 

Group N: 

G1: 59 

G2: 138 

G3: 77 

Inclusion criteria: 

• Women with 

pregravid BMI 19.8-

26.0 

• Enrolled before 

January 1988 

Exclusion criteria: 

• Missing information 

from delivery to 6 

months postpartum 

• Pregravid under or 

over weight 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

G1: 8.5 

G2: 10.9 

G3: 10.4 

Black 

G1: 61.0 

G2: 59.4 

G3: 62.3 

Hispanic 

G1: 30.5 

G2: 29,7 

G3: 27.3 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 30.5 

G2: 26.8 

G3: 26.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-689 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 59 

G2: 138 

G3: 77 

Total weight gain: 

G1: Gestation 

duration (wk)38.5 

(0.28) P < 0.05, low 

vs. moderate plus 

excessive weight 

gain

G2: 39.2 (0.17)

G3: 39.4 (0.24)

Categorized: 

• According to 

IOM rate of 

gestational 

weight gain 

measured 

between 20 to 

36 weeks: low 

GWG = < 

0.34kg/wk; 

moderate 

GWG = 0.34-

0.68 kg/wk; 

excessive 

GWG = > 0.68 

kg/wk 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3,049 (56.94) 

P < 0.05, low 

vs. moderate 

plus excessive 

weight gain 

G2: 3,208 (36.33) 

G3: 39.4 (0.24) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Mean change in weight 

Groups 

Maternal weight gain categories (kg/wk): 

G1: ≤ 0.34 

G2: > 0.34-0.68 

G3: > 0.68 

Results 

Mean (SEM) change in weight (kg) from pregravid to 6 weeks 

postpartum: 

G1: 3.1 (0.80) 

G2: 3.9 (0.51) 

G3: 9.4 (0.70) P < 0.001, G3 vs. G1,G2 

Maternal confounders and effect modifiers accounted for 

in analysis: 

Age, parity, race, height, lactation status, smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poo

r: 

3 Good, 6 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-690 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Stevens-Simon and 

McAnarney, 1992 

Country and setting: 

USA, adolescent 

maternity program 

Enrollment Period:

1986 to 1989 

Funding: 

Grant from Bureau of 

Maternal and Child Health 

Study Objective: 

To clarify advantages and 

disadvantages of large 

gestational weight gain 

among pregnant 

adolescents 

Time frame: 

1986 to 1989 

Duration of the study: 

Entry into prenatal care 

through 6 weeks PP 

check up 

Design: 

• Cohort 

• Prospective 

Total Study N: 

141 (107 included in 

postpartum analyses) 

Group Description: 

G1: Slow gainers 

G2: Average gainers 

G3: Rapid gainers 

Group N: 

G1: 28 

G2: 66 

G3: 47 

Inclusion criteria: 

• Consecutively 

enrolled poor, black, 

12-19 year olds 

• Prenatal care prior to 

2third week gestation

• No chronic disease 

• No regular 

medications 

• No known uterine 

anomalies 

• Live birth 

• Singletons 

Exclusion criteria: 

• NA 

Pregravid weight: 

• Self-reported 

G1: 58.6 (11.1) 

G2: 160.9 (7.0) 

G3: 163.9 (5.5) 

Pregravid BMI: 

G1: 23.1 (3.5) 

G2: 23.5 (4.4) 

G3: 23.5 (4.2) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 16.9 

G2: 16.6 

G3: 16.2 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-691 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 28 

G2: 66 

G3: 47 

Total weight gain: 

G1: 7.7 (average rate 

0.2 kg/wk)

G2: 12.4 (average 

rate 0.3 kg/wk)

G3: 19.8 (average 

rate 0.5 kg/wk)

Categorized: 

• According to 

IOMslow gain: < 

0.23kg/wk; 

average gain: 

0.23-0.4kg/week; 

rapid gain: > 

0.4kg/week 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 2745 (694) 

G2: 3097 (457) 

G3: 3351 (482) 

P < 0.0001 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Short-term weight retention; adjusted odds ratio for 

subsequent maternal obesity 

Groups 

Maternal weight gain categories (kg/wk): 

G1:< 0.23 

G2: 0.23-0.40 

G3: > 0.40 

Results 

Short term weight retention (2-11 weeks postpartum), total 

kg: 

G1: -1.7 (SD 2.9) 

G2: 2.9 (SD 2.9) 

G3: 9.6 (SD 5.6) 

P < 0.0001 

AOR (95% CI) for subsequent maternal obesity (> 120% 

ideal weight for height): 

G3: 190.94 (7.55-4,779.02) 

Maternal confounders and effect modifiers accounted 

for in analysis: 

• Age 

• Pregravid BMI 

• Level of physical activity 

• Timing of first prenatal and postpartum visits 

• Substance use 

• Body habitus 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability:

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poo

r: 

3 Good, 4 Fair, 

2 Poor 

Final Quality 

Score: 

Fair 
C-692 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Walker et al., 2004 

Country and setting: 

USA, Austin New Mothers 

Study 

Enrollment Period:

1999-2001 

Funding: 

National Institute of 

Nursing Research grant 

Study Objective: 

To assess proportion of 

women attaining 

prepregnant weight and to 

ascertain predictors of 

amount of retained weight 

at 6 weeks postpartum in 

a tri-ethnic low income 

population 

Time frame: 

1999 to 2001 

Duration of the study: 

Delivery to 6 weeks was 

prospective natureretrospectively they 

obtained info from medical 

record 

Design: 

• Cross-sectional 

• Combination: 

recruited at deliverythey filled out 

questionniares and 

then got some info 

from medical records 

Total Study N: 

419 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 419 

G2: NR 

Inclusion criteria: 

• Low income women 

• Term infants 

• Singletons 

• Low-risk pregnancies

• At least 18 years 

• Perinatal care funded 

by Medicaid 

Exclusion criteria: 

• Women who reported 

weighing less at end 

of pregnancy than 

before (n = 4) 

• Missing weight data 

(n = 137) 

Pregravid weight: 

• Self-reported 

G1: 66.9 (15.1) 

G2: NR 

Pregravid BMI: 

G1: 25.6 (6.0) 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines since few 

underweight and 

overweight women 2 

groups were made: 

underweight/normal and 

overweight/obese 

Age (mean, yrs): 

G1: 22.2 (3.8) 

G2: NR 

Parity: 

G1: 1.0 (0.0) 

G2: NR 

Race,%: 

White 

G1: 30.3 

G2: NR 

Black 

G1: 24.1 

G2: NR 

Hispanic 

G1: 45.6 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-693 

Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 419 

G2: NR 

Total weight gain: 

G1: 15.8 (7.1)

G2: NR 

Categorized: 

• According to IOM 

Collected from: 

• Self-reported 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

G1: 3377 (424) 

G2: NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 14.3 

G2: NR 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Mean weight retention; percentage of women with 

retained weight, correlation and multiple regression 

analysis 

Groups 

Maternal weight gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Mean (SD) weight (kg) retained at 6 weeks postpartum: 

G1: -0.34 (3.44) 

G2: 3.86 (3.45) 

G3: 10.55 (6.14) 

P = 0.000 

% Women who attained pregravid weight at 6 weeks 

postpartum: 

G1: 48.8 

G2: 14.3 

G3: 2.3 

Correlation of gestational weight gain, excluding infant 

weight, (continuous variable) and weight retained at 6 

weeks postpartum: r = 0.90 P = 0.000 

Multiple regression analysis predicted a mean increase 

in retained weight of 0.88 kg for each 1 kg increase in 

maternal weight gain (B = 0.88, SE = 0.02, P = 0.000) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Race 

• Parity 

• Pregravid BMI 

• Gestational weight gain 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

• Gestational age 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

3 Good, 6 Fair, 0 

Poor 

Final Quality 

Score: 

Fair 
C-694 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Amorim et al., 2007 

Country and setting: 

Sweden, hospital 

Enrollment period: 

Study comprised followup period from delivery 

(1984 to 1985) to 15 

years postpartum (1999 

to 2000). 

Funding: 

Study supported by 

Brazilian Foundation for 

training of researchers 

in Doctoral Exchange 

Programe (CAPES) (to 

A.R.A.)and by 

Arbeitsmarknadens 

Forsakrings-och 

Aktiebolag(AFA) (to 

M.N.) 

Study Objective: 

Explore effect of GWG 

according to IOM 

recommendations on 

long-term BMI, 

accounting for several 

potentially confounding 

factors, including 

postpartum weight 

changes and prepregnancy BMI 

Time frame: 

Study comprised followup period from delivery 

(1984 to 1985) to 15 

years postpartum (1999 

to 2000). 

Duration of the study: 

Entry into prenatal care 

through 15 years after 

childbirth 

Design: 

• Cohort 

• Combination: In 

maternity unit, staff 

invited women to 

take part in study at 

first control visit 

after delivery. Up to 

that point, study 

was retrospective in 

that information 

about weight 

development during 

pregnancy was 

collected from 

obstetrics records. 

Women were then 

prospectively 

monitored up to 1 

year postpartum 

and15 years later 

Total Study N: 

483 

Group Description: 

G1: Total 

Group N: 

NR 

Inclusion criteria: 

• Women who 

delivered children 

in 1984 to 1985 in 

14 maternity units 

in Stockholm, 

Sweden 

Exclusion criteria: 

NR 

Pregravid weight: 

Self-reported 

Pregravid BMI: 

G1: 21.5 (2.4) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 30.0 (4.6) 

Parity: 

G1: Primiparous 52% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-695 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: 14.2 (4.1) kg 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR 

Birth weight: 

G1: 3506 (470) g 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Time and weight gain 

interaction 

Groups 

Maternal weight gain 

categories: 

< IOM 

Within IOM 

>IOM 

Results 

A mixed ANOVA with one 

repeated measures factor 

(weight before pregnancy, 6 

months, 1, and 15 years) and 

one between-subjects factor 

(< IOM, within IOM, > IOM) 

showed a main effect of time 

[F (9.024) = 113.7, P = 0.000] 

and a significant time group 

interaction [F(6,12) = 77.23, P 

= 0.000] 

The weight of women who 

gained excessive during 

pregnancy was significantly 

greater at each time-point 

[main effect of group: F 

(10.55) = 870.0, P = 0.000] 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Pre-gravid BMI 

Infant and child 

confounders and effect 

modifiers accounted for in 

analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of maternal 

weight gain: 

Fair 

Definition of outcomes: 

Good 

Source of information on 

exposure, outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis comparability: 

Fair 

Analysis of outcomes: 

Good 

Interpretation: 

Good 

Sum of Good/Fair/Poor: 

5 Good, 3 Fair, 1 Poor 

Final Quality Score: 

Fair 
C-696 

 Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Keppel and Taffel, 1993 

Country and setting: 

USA, 1988 National 

Maternal and Infant 

Health Survey 

Enrollment Period: 

1988 

Funding: 

National Center for 

Health Statistics 

Study Objective: 

To examine implications 

of compliance with IOM 

guidelines for 

postpartum weight 

retention 

Time frame: 

1988 

Duration of the study: 

NA, cross-sectional 

Design: 

• Cross-sectional 

• Retrospective 

Total Study N: 

2,944 

Group Description: 

NR 

Group N: 

NR 

Inclusion criteria: 

• Live births 

• Singletons 

• Women interviewed 

10-18 months 

following delivery 

• Births at ≥ 37 

weeks gestation 

• White or black 

women 

• ≥ 15 years of age 

Exclusion criteria: 

• Obese women, BMI 

> 29.0 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-697 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

Categorized: 

• According to 

IOM 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Weight retention by postpartum time 

Groups 

Categories of amount of weight retained (lbs) at 10-18 

months postpartum: 

G1: Lost weight 

G2: 0-3 

G3: 4-8 

G4: 9-13 

G5: ≥ 14 

Results 

The percent distribution of women in G1-G5 stratified 

by maternal weight gain categories showed that both 

black and white women who gained < IOM or within the 

IOM guidelines retained less weight (10-18 months 

postpartum) than women who gained > IOM 

recommendations. Irrespective of maternal weight gain, 

black women retained more weight than white women 

Maternal confounders and effect modifiers 

accounted for in analysis: 

None 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

None 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Poor 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Poor 

Sum of 

Good/Fair/Poor

: 

3 Good, 3 Fair, 

3 Poor 

Final Quality 

Score: 

Poor 
C-698 

 Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Olson et al., 2003 

Country and setting: 

USA, hospital and primary 

care clinic system 

Enrollment Period: 

Mid 1990s 

Funding: 

NIH grants 

Study Objective: 

To describe importance of 

GWG, postpartum 

exercise, food intake and 

breastfeeding to weight 

change from eary 

pregnancy to 1 year post 

partum and to identify 

subgroups of women at 

greatest risk for major 

weight gain surrounding 

child bearing 

Time frame: 

Mid 1990s 

Duration of the study: 

Women were followed 

from early pregnancy to 

one year postpartum 

(specific dates are not 

mentioned) 

Design: 

• Cohort 

• Prospective 

Total Study N: 

540 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 540 

G2: NR 

Inclusion criteria: 

• ≥ 18 years 

• Singleton infants 

Exclusion criteria: 

• No 1 year weight 

available 

• Invalid 1 year weight 

• Pregnant at 1 year 

• Serious postpartum 

illness affecting body 

weight 

• Last prenatal weight 

taken more than 6 

weeks prior to 

delivery 

Pregravid weight: 

• Measured at first prenatal 

visit 

Pregravid BMI: 

G1: < 19.8: 8.9%; 19.8-26.0: 

50.6%; > 29.0: 25.2% 

G2: NR 

Imputed: 

• Yes 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: < 20y: 3.9% 

20-40y: 93.5% 

> 40y: 2.6% 

G2: NR 

Parity: 

G1: Nulliparous: 41.2% 

G2: NR 

Race,%: 

White 

G1: 96 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% married:

G1: 92.8% 

G2: NR 
C-699 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis 

Outcomes from Multivariate 

Analysis Quality Rating 

Groups (N): 

G1: 540 

G2: NR 

Total weight gain: 

G1: Less than 

recommended: 

20.4%; 

recommended: 

37.8%; more than 

recommended: 

41.9% 

G2: NR 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between first 

trimesters weight 

and last weight 

measured 

(usually within 1 

week of delivery) 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• At 1 year 

postpartum, 

women were on 

average 1.51 

(5.95) kg heavier 

than they were in 

early pregnancy 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Pregnancy weight versus 

postpartum weight 

Groups 

Maternal weight gain 

categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

G4: Interaction for > IOM and 

income ≤ 185% federal poverty 

line 

Results 

Regression coefficient (SE) for 

weight change from early 

pregnancy to 1 year postpartum 

(kg): 

G1: -1.50 (0.62) P = 0.016 

G2: reference 

G3: 0.32 (0.65) P = 0.621 

G4: 3.41 (0.91) P < 0.001 

AOR (95% CI) for major weight 

gain (≥ 10 lbs) at 1 year 

postpartum: 

G1: 0.33 (0.13-0.83) 

G2: 1.00 (reference) 

G3: 1.47 (0.73-2.94) 

G4: 3.23 (1.25-9.08) 

Compared to normal-weight 

women (BMI 19.8-26.0) in G2, 

normal weight, overweight (BMI 

26.1-29.0) and obese (BMI > 

29.0) women in G3 retained 

significantly more weight at 1 

year postpartum (all P < 0.01) 

Maternal confounders and 

effect modifiers accounted 

for in analysis: 

Exercise, food intake, 

breastfeeding, pregravid BMI, 

age, marital status, income, 

postpartum month that weight 

was measured 

Infant and child confounders 

and effect modifiers 

accounted for in analysis: 

NR 
C-700 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rooney et al., 2002 

Country and setting: 

USA, hospital 

Enrollment Period: 

10 year followup of 

study from Apr 1989 to 

March 1990 

Funding: 

Gundersen Lutheran 

Medical Center 

Study Objective: 

To estimate impact of 

excess pregnancy 

weight gain and failure 

to lose weight by 6 

months postpartum on 

excess weight 8 to 10 

years later 

Time frame: 

10 year followup of 

study from Apr 1989 to 

March 1990 

Duration of the study: 

April 1, 1989 to 1999 

(10 years) 

Entry into prenatal care 

up to 10 years 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

540 

Group Description: 

G1: Group Studied 

(Continued Care) 

G2: NR 

Group N: 

G1: 540 

G2: NR 

Inclusion criteria: 

• Convenience 

sample of women 

with uncomplicated 

pregnancies 

receiving care at 

Gundersen Clinic 

from April first 1989 

to March 30 1990 

Exclusion criteria: 

• Women who 

discontinued care 

at clinic or did not 

have a weight 

available 5-10 

years after their 

study pregnancy 

Pregravid weight: 

• weight at first pn visit 

Pregravid BMI: 

G1: 25.0 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 28.6 

G2: NR 

Parity: 

NR 

Race,%: 

White 

G1: 97% 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-701 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 540 

G2: NR 

Total weight gain: 

G1: 13.1 kg (mean) 

G2: NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: Study 

investigators 

measured 

weight at 

delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Mean retained 

maternal 

weight (kg) 

was 1.7kg 

• 66% retained 

pregnancy 

weight at 6 

months follow 

up 

• 26% gained 

less than 

recommended 

(IOM) amount 

of weight 

during 

pregnancy, 

50% gained 

recommended 

amount, and 

24% gained 

more than 

recommended 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Weight change 

Groups 

Maternal weight gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

BMI IOM 

Results 

Average weight change between prepregnancy and 6 

months postpartum (kg): 

G1: -0.61 

G2: 1.8 

G3: 4.2 

P = 0.01 

Regression coefficient (95% CI) for weight at 6 months 

postpartum: 

G1: -1.53 (-3.36–0.30) 

G2: Reference 

G3: 1.24 (-0.63–3.11) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Duration of breastfeeding, postpartum aerobic 

exercise, weight loss by 6 months 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

4 Good, 4 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-702 

 Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Scholl et al., 1995 

Country and setting: 

USA, Camden Study 

Enrollment Period: 

September 1985 to May 

1990 

Funding: 

NIH 

Study Objective: 

To determine whether 

risk of maternal 

overweight associated 

with an excessive rate 

of gestational weight 

gain needs to be 

balanced against risk of 

impaired fetal growth 

associated with low rate 

of gain 

Time frame: 

September 1985 to May 

1990 

Duration of the study: 

During pregnancy 

through 6 months 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

274 

Group Description: 

G1: Low rate of GWG 

G2: Moderate rate of 

GWG 

G3: Excessive rate of 

GWG 

Group N: 

G1: 59 

G2: 138 

G3: 77 

Inclusion criteria: 

• Women with 

pregravid BMI 19.8-

26.0 

• Enrolled before 

January 1988 

Exclusion criteria: 

• Missing information 

from delivery to 6 

months postpartum 

• Pregravid under or 

over weight 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

NR 

Parity: 

NR 

Race,%: 

White 

G1: 8.5 

G2: 10.9 

G3: 10.4 

Black 

G1: 61.0 

G2: 59.4 

G3: 62.3 

Hispanic 

G1: 30.5 

G2: 29,7 

G3: 27.3 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 30.5 

G2: 26.8 

G3: 26.9 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-703 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 59 

G2: 138 

G3: 77 

Total weight gain: 

G1: Gestation 

duration (wk)38.5 

(0.28) P < 0.05, low 

vs. moderate plus 

excessive weight 

gain 

G2: 39.2 (0.17) 

G3: 39.4 (0.24) 

Categorized: 

• According to 

IOM rate of 

gestational 

weight gain 

measured 

between 20 to 

36 weeks: low 

GWG = < 

0.34kg/wk; 

moderate 

GWG = 0.34-

0.68 kg/wk; 

excessive 

GWG = > 0.68 

kg/wk 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3,049 (56.94) 

P < 0.05, low 

vs. moderate 

plus excessive 

weight gain 

G2: 3,208 (36.33) 

G3: 39.4 (0.24) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Change in weight, risk for becoming overweight 

Groups 

Maternal weight gain categories (kg/wk): 

G1: ≤ 0.34 

G2: > 0.34-0.68 

G3: > 0.68 

Results 

Mean (SEM) change in weight (kg) from pregravid to 6 

months postpartum: 

G1: 3.2 (0.95) 

G2: 3.8 (0.61) 

G3: 7.9 (0.83) P < 0.001, G3 vs. G1, G2 

Mean (SEM) change in weight (kg) from 6 weeks to 6 

months postpartum: 

G1: 0.13 (0.64) 

G2: -0.05 (0.41) 

G3: -1.48 (0.56) P < 0.05, G3 vs. G1, G2 

AOR (95% CI) for becoming overweight (BMI > 26.0) at 

6 months postpartum: 

G1, G2: 1.0 (reference) 

G3: 2.89 (1.36-6.00) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Age, race, parity, pregravid BMI, lactation, height, 

smoking 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information 

on exposure, 

outcomes, 

and 

confounders: 

Fair 

Followup: 

Fair 

Analysis 

comparability

: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Po

or: 

2 Good, 7 Fair, 

0 Poor 

Final Quality 

Score: 

Fair 
C-704 

 Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Walker, 1996 

Country and setting: 

USA, multicounty 

community 

Enrollment Period: 

NR 

Funding: 

Biomedical Research 

Support Grant; Luci B. 

Johnson Centennial 

Professorship in 

Nursing 

Study Objective: 

To test contributions of 

life-style and stress to 

postpartum weight gain 

after controlling for 

sociodemographic and 

reproductive influences 

Time frame: 

NR 

Duration of the study: 

Pregravid 

(retrospective) through 

18 months postpartum 

Design: 

• Cohort 

• Combination: 

Prospective on 

outcomes, 

retrospective on 

pregravid weight 

Total Study N: 

88 

Group Description: 

G1: Total 

G2: NR 

Group N: 

G1: 88 

G2: NR 

Inclusion criteria: 

• Women identified 

through newspaper 

birth 

announcements 

were sent 

questionnaires in 

mail 

Exclusion criteria: 

• Hypertensive or 

bleeding 

complications 

during pregnancy 

• Illnesses between 

delivery and 6 

months 

• Pregnant or may be 

pregnant at time of 

survey 

• Missing prenatal or 

postpartum weight 

data 

• Extensive missing 

predictor data for 6-

month follow-up 

• Obese women 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26.4 

G2: NR 

Parity: 

G1: 41% primiparae 

G2: NR 

Race,%: 

White 

G1: 98% 

G2: NR 

Black 

G1: NR 

G2: NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-705 

Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention 

during the first year postpartum (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 88 

G2: NR 

Total weight gain: 

G1: 16.4 kg (SD 

7.2) 

G2: NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Self-reported 

Ascertained by: 

• Self-reported 

Birth weight: 

G1: 3544 

G2: NR 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 81% vaginal 

births 

G2: NR 

Instrumental 

delivery,%: 

Episiotomy,%: 

Other maternal 

outcomes: 

GWG was 

significantly related 

to weight gain at 6 

(r[86] = 0.60, P < 

0.001) and 18 

months (r[73] = 

0.49, P < 0.001) 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Maternal weight gain and postpartum weight 

Groups 

Maternal weight gain categories: 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Results 

Mean weight retention at 6 months postpartum, lbs: 

G1: 0.4 

G2: 3.7 

G3: 13.5 

P < 0.001 

Maternal weight gain was significantly related to 

weight at 6 months postpartum: r = 0.60, P < 0.001 

Mean weight retention at 18 months postpartum, 

lbs: 

G1, G2: 0.7 

G3: 11.0 

P < 0.01 

Maternal weight gain was significantly related to 

weight at 18 months postpartum: r = 0.49, P < 0.001 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Mode of delivery, infant sex, breastfeeding, infant 

birth weight, pregravid BMI 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

4 Good, 4 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-706 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Amorim et al., 2007 

Country and setting: 

Sweden, hospital 

Enrollment period: 

Study comprised followup period from delivery 

(1984 to 1985) to 15 

years postpartum (1999 

to 2000). 

Funding: 

Study supported by 

Brazilian Foundation for 

training of researchers 

in Doctoral Exchange 

Programe (CAPES) (to 

A.R.A.)and by 

Arbeitsmarknadens 

Forsakrings-och 

Aktiebolag(AFA) (to 

M.N.) 

Study Objective: 

Explore effect of GWG 

according to IOM 

recommendations on 

long-term BMI, 

accounting for several 

potentially confounding 

factors, including 

postpartum weight 

changes and prepregnancy BMI 

Time frame: 

Study comprised followup period from delivery 

(1984 to 1985) to 15 

years postpartum (1999 

to 2000). 

Duration of the study: 

Entry into prenatal care 

through 15 years after 

childbirth 

Design: 

• Cohort 

• Combination: In 

maternity unit, staff 

invited women to 

take part in study at 

first control visit 

after delivery. Up to 

that point, study 

was retrospective in 

that information 

about weight 

development during 

pregnancy was 

collected from 

obstetrics records. 

Women were then 

prospectively 

monitored up to 1 

year postpartum 

and15 years later 

Total Study N: 

483 

Group Description: 

G1: Total 

Group N: 

NR 

Inclusion criteria: 

• Women who 

delivered children 

in 1984 to 1985 in 

14 maternity units 

in Stockholm, 

Sweden 

Exclusion criteria: 

NR 

Pregravid weight: 

Self-reported 

Pregravid BMI: 

G1: 21.5 (2.4) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 30.0 (4.6) 

Parity: 

G1: Primiparous 52% 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-707 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

NR 

Total weight gain: 

G1: 14.2 (4.1) kg 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

NR 

Birth weight: 

G1: 3506 (470) g 

Gestational 

diabetes, %: 

NR 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Weight change across postpartum years 

Groups 

G1: < IOM 

G2: Within IOM 

G3: > IOM 

Results 

Mean (SD) change in weight at 15 years 

postpartum, kg: 

G1: 6.2 (6.8) 

G2: 6.7 (6.8) 

G3: 10.3 (8.5) 

P = 0.000 

Mean (SD) BMI at 15 years postpartum: 

G1: 23.5 (3.7) 

G2: 23.6 (3.0) 

G3: 25.9 (3.9) 

P = 0.000 

Multiple regression coefficient, B (95% CI) for 15 

year BMI status: 

G1: 0.01 (-0.56-0.59) 

G2: Reference 

G3: 0.72 (0.15-1.30) 

P = 0.033 

Multiple regression coefficient (95% CI) for 

change in BMI status between pregravid and 15 

years postpartum: 

G1: 0.02 (-0.56-0.59) 

G2: Reference 

G3: 0.68 (0.11-1.24) 

P = 0.042 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Education, lactation, weight retention at 6 

months postpartum, weight gain between 6 

months and 1 year postpartum, pregravid BMI 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample selection: 

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Poor 

Followup: 

Good 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor: 

5 Good, 3 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-708 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Gunderson et al., 2000 

Country and setting: 

USA, university hospital 

Enrollment Period: 

1980-1990 

Funding: 

Grants from California 

Dietetic Association, 

Zellmer Grant, Dowdle 

Endowment and 

Grossman Medical 

Research Funds, NIH, 

University at California, 

Berkeley 

Study Objective: 

To assess relationships 

between gestational 

weight gain, 

race/ethnicity, 

reproductive history, 

age, education, and risk 

of becoming overweight 

after pregnancy 

Time frame: 

1980 to 1990 

Duration of the study: 

2 pregnancies; weight 

gain in first up to second 

pregnancy 

Design: 

• Cohort 

• Retrospective 

Total Study N: 

1,300 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 1300 

G2: NR 

Inclusion criteria: 

• White, black, 

Hispanic, and Asian 

adult women who 

delivered two 

consecutive 

singleton births 

Exclusion criteria: 

• < 18 years 

• Adoptions 

• Pregnancy 

complications 

• Medical conditions 

which could modify 

gestational weight 

gain or retention 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: < 19.8: 28.3% 

19.8-26.0: 59.5% 

> 26-29.0: 6.6% 

> 29.0: 5.6% 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 27 (5) 

G2: NR 

Parity: 

G1: % nulliparous: 72.4 

G2: NR 

Race,%: 

White 

G1: 53.3 

G2: NR 

Black 

G1: 10.5 

G2: NR 

Hispanic 

G1: 12.4 

G2: NR 

Asian/Pacific Islander 

G1: 23.8 

G2: NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

G1: % married: 77% 

G2: NR 

Additional characteristics: 

NR 
C-709 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

Total weight gain: 

G1: 16.1kg 

G2: NR 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery: 

difference 

between self 

reported weight 

and weight at 

last prenatal 

visit (average 

of 0.9 weeks 

prior to 

delivery) 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• 6.4% (n = 72)of 

women became 

overweight by 

second 

pregnancy (all 

perviously normal 

weight except for 

1 underweight 

woman) 

• Mean weight 

increase from 

baseline 

(pregravid weight 

at index 

pregnancy) until 

start of second 

pregnancy = 

10.4 (5.2) kg 

among women 

who became 

overweight 

compared with 

1.6 (3.6) kg 

among women 

who did not 

become 

overweight (P < 

0.001) 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Adjusted odds ratio (95% CI) for becoming 

overweight between baseline (pregravid weight at 

start of index pregnancy) and start of second study 

pregnancy (median interval time = 1.5 years): 

Groups 

G1: < IOM/ within IOM 

G2: > IOM 

Results 

G1: Reference 

G2: 2.95 (1.67-5.24) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Smoking, PIH, education, parity, marital status, age 

at menarche, interval to first birth 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Fair 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Fair 

Followup: 

Good 

Analysis 

comparability: 

Good 

Analysis of 

outcomes: 

Good 

Interpretation: 

Good 

Sum of 

Good/Fair/Poor

: 

6 Good, 3 Fair, 

0 Poor 

Final Quality 

Score: 

Good 
C-710 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rooney et al., 2002 

Country and setting: 

USA, hospital 

Enrollment Period: 

10 year followup of 

study from Apr 1989 to 

March 1990 

Funding: 

Gundersen Lutheran 

Medical Center 

Study Objective: 

To estimate impact of 

excess pregnancy 

weight gain and failure 

to lose weight by 6 

months postpartum on 

excess weight 8 to 10 

years later 

Time frame: 

10 year followup of 

study from Apr 1989 to 

March 1990 

Duration of the study: 

April 1, 1989 to 1999 

(10 years) 

Entry into prenatal care 

up to 10 years 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

540 

Group Description: 

G1: Group Studied 

(Continued Care) 

G2: NR 

Group N: 

G1: 540 

G2: NR 

Inclusion criteria: 

• Convenience 

sample of women 

with uncomplicated 

pregnancies 

receiving care at 

Gundersen Clinic 

from April first 1989 

to March 30 1990 

Exclusion criteria: 

• Women who 

discontinued care 

at clinic or did not 

have a weight 

available 5-10 

years after their 

study pregnancy 

Pregravid weight: 

• weight at first pn visit 

Pregravid BMI: 

G1: 25.0 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 28.6 

G2: NR 

Parity: 

NR 

Race,%: 

White 

G1: 97% 

G2: NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-711 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 540 

G2: NR 

Total weight gain: 

G1: 13.1 kg (mean)

G2: NR 

Categorized: 

• According to IOM 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

Study 

investigators 

measured weight 

at delivery 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Mean retained 

maternal weight 

(kg) was 1.7kg 

• 66% retained 

pregnancy 

weight at 6 

months follow up

• 26% gained less 

than 

recommended 

(IOM) amount of 

weight during 

pregnancy, 50% 

gained 

recommended 

amount, and 

24% gained 

more than 

recommended 

Other infant 

outcomes: 

NR 

Outcomes Description: 

Change in weight or BMI across postpartum time 

Groups 

G1: < IOM 

G2: within IOM 

G3: > IOM 

Results 

Average weight change between prepregnancy and 

~8.5 years postpartum (kg): 

G1: 4.1 

G2: 6.5 

G3: 8.4 

P = 0.01 

Regression coefficients (95% CI) for BMI at ~8.5 years 

postpartum: 

G1: -3.86 (-5.56 - -2.16) 

G2: Reference 

G3: -0.70 (-2.13-0.74) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Duration of breastfeeding, postpartum aerobic exercise, 

weight loss by 6 months 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample selection:

Fair 

Definition of 

maternal weight 

gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information on 

exposure, 

outcomes, and 

confounders: 

Good 

Followup: 

Poor 

Analysis 

comparability: 

Fair 

Analysis of 

outcomes: 

Good 

Interpretation: 

Fair 

Sum of 

Good/Fair/Poor: 

4 Good, 4 Fair, 1 

Poor 

Final Quality 

Score: 

Fair 
C-712 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Rooney et al., 2005 

Country and setting: 

USA, medical center 

Enrollment Period: 

1988 to 2004 

Funding: 

Gundersen Luterhan 

Medical Foundation 

Study Objective: 

To estimate impact of 

perinatal weight change 

on obesity, weight gain, 

and development of 

obesity related illnesses 

15 years after 

pregnancy 

Time frame: 

1988 to 2004 

Duration of the study: 

Original study 

conducted April 12, 

1988 to October 12, 

1990 followed up until 

15 years later (2004) 

Quality: 

Fair 

Design: 

• Cohort 

• Prospective 

Total Study N: 

484 

Group Description: 

G1: Cohort (at 

beginning of study) 

G2: NR 

Group N: 

G1: 484 

G2: NR 

Inclusion criteria: 

• NA 

Exclusion criteria: 

• Multiple births 

• Missing weight 

measurements 

• Deceased 

Pregravid weight: 

• Measured at first 

prenatal visit (average 

of 10.3 weeks gestation) 

Pregravid BMI: 

G1: 24.2 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 28.6 

G2: NR 

Parity: 

% primiparous:

G1: 39% 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Retained weight at 6 months 

postpartum:

G1: 1.7kg 

G2: NR 

% married:

G1: 90 

G2: NR 
C-713 

Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight 

retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating 

Groups (N): 

G1: 484 

G2: NR 

Total weight gain: 

Categorized: 

• According to 

IOM 

Collected from: 

• Routine prenatal care or 

maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured 

weight prior to 

delivery 

Birth weight: 

G1: 13.0 kg 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

NA 

Outcomes Description: 

Change in weight or BMI 

Groups 

G1: < IOM 

G2: within IOM 

G3: > IOM 

Results 

Multivariable regression coefficient (95% CI) for BMI at 

15 years postpartum: 

G1: -0.57 (-0.57-1.21) 

G2: reference 

G3: 1.69 (0.79-2.58) 

Multivariable regression coefficient (95% CI) for change 

in weight between baseline and 15 years postpartum: 

G1: 0.43 (-1.87-2.73) 

G2: reference 

G3: 4.19 (1.88-6.51) 

Maternal confounders and effect modifiers 

accounted for in analysis: 

Marital status at delivery, change in marital status, 

current parity, insurance status at delivery, current 

insurance status, baseline BMI, weight gain at index 

pregnancy, retained weight at 6 months postpartum, 

participation in postpartum aerobic exercise, duration of 

breastfeeding

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 

Background: 

Good 

Sample 

selection: 

Poor 

Definition of 

maternal 

weight gain: 

Fair 

Definition of 

outcomes: 

Good 

Source of 

information 

on exposure, 

outcomes, 

and 

confounders: 

Good 

Followup: 

Good 

Analysis 

comparability

: 

Fair 

Analysis of 

outcomes: 

Fair 

Interpretation: 

Fair 

Sum of 

Good/Fair/Po

or: 

4 Good, 4 Fair, 

1 Poor 

Final Quality 

Score: 

Fair 
C-714 

Evidence Table 56. Anthropometrics of maternal weight retention 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bartha, 2007 

Country and setting: 

Spain, tertiary referral 

university center 

Enrollment Period:

NR 

Funding: 

Consejeria de Salud 

Study Objective: 

to study the relationships 

between ultrasound 

estimated visceral fat and 

metabolic risk factors 

during early pregnancy. 

Time frame: 

NA 

Duration of the study: 

NR 

Quality: 

Design: 

• Cohort 

• Prospective 

Total Study N: 

30 

Group Description: 

NA

Group N: 

30

Inclusion criteria: 

• 11-14 weeks of 

gestation 

Exclusion criteria: 

• NR 

Pregravid weight: 

• 64.01 kg 

Pregravid BMI: 

Imputed: 

• Yes 24.4 

Categorized: 

10 women were overweight 

BMI > 25 

Age (mean, yrs): 

29.07 years

Parity: 

NR 

Race,%: 

NR 

Smoking,%: 

NR

Diabetes mellitus,%: 

NA

Hypertension,%: 

NR

Additional characteristics: 

NR 
C-715 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

Total weight gain: 

• NR 

Birth weight: 

Gestational 

diabetes, %: 

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Decriptions 

Metabolic risk factors as a function of visceral fat 

thickness (VFT) versus subcutaneous fat thickness 

(SFT) 

Groups 

NA 

Results 

VFT significantly correlated with 

• Diastolic blood pressure (r= 0.37, p= 0.04) 

• Glycemia (r= 0.37, p =0.04) 

• Insulinemia (r= 0.59, p = 0.001) 

• Insulin sensitivity (HOMA; r = 0.59, p= 0.001), 

Triglycerides (r = 0.58, p =0.03) 

• HDL-C (r=0.39, p = 0.03) 

• Total cholesterol/HDL-C ratio (p = 0.002) 

SFT significantly correlated with 

• Diastolic blood pressure (p _ 0.03). 

VFT better significantly correlated with the metabolic 

risk factors than pre-gestational BMI 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NA 
C-716 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bo et al., 2003 

Country and setting: 

Italy, university clinic 

Enrollment Period:

April 1999 to February 

2001 

Funding: 

NR 

Study Objective: 

To evaluate pregnancy 

outcomes in cohort of 

caucasian pregnant 

women in relation to BMI 

and glucose toleranc 

status; role of central fat 

distribution, as indicated 

by waist to hip 

circumference ratio also 

considered 

Time frame: 

April 1999 to February 

2001 

Duration of the study: 

Screened during 

pregnancy at 24 to 28 

weeks, recall data on 

pregravid weight 

Design: 

• Cohort 

• Prospective 

Total Study N: 

700 

Group Description: 

G1: Normal wieight, 

normal OGTT 

G2: Overweight/Obese, 

normal OGTT 

G3: Normal Weight, 

IGT/GDM 

G4: Overweight/Obese, 

IGT/GDM 

Group N: 

G1: 333 

G2: 117 

G3: 133 

G4: 117 

Inclusion criteria: 

• Caucasian pregnant 

women attending 

Gynecological and 

Obstetrical 

Department of 

University of Torino 

screened with 50g 

oral glucose test at 

24 to 28 weeks 

gestation 

Exclusion criteria: 

• Women known to 

have preexistent 

diabetes mellitus, a 

disease affecting 

glucose metabolism, 

or hypertension 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

G1: 21.2 

G2: 29.9 

G3: 21.5 

G4: 29.9 

Imputed: 

• No 

Categorized: 

NR 

Age (mean, yrs): 

G1: 31.7 

G2: 31.1 

G3: 32.9 

G4: 32.6 

Parity: 

G1: Nulliparous (%): 63.7 

G2: 53.0 

G3: 62.4 

G4: 51.3 

Race,%: 

White 

G1: 100 

G2: 100 

G3: 100 

G4: 100 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 11.4 

G2: 15.4 

G3: 15.0 

G4: 18.8 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

G1: 1.2 

G2: 10.3 

G3: 4.5 

G4: 11.1 

Additional characteristics: 

Waist-to-hip ratio:

G1: 0.86 

G2: 0.87 

G3: 0.89 

G4: 0.90 

Additional characteristics: 

Preterm delivery (%):

G1: 6.9 

G2: 6.7 

G3: 9.2 

G4: 8.5 

Additional characteristics: 

LGA (%):

G1: 13.1 

G2: 27.6 

G3: 13.3 

G4: 27.4 
C-717 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

G1: 333 

G2: 117 

G3: 133 

G4: 117 

Total weight gain: 

G1: 13.2+/-4.1 

(P < 0.01 vs. G2)

G2: 10.5+/-6.1

G3: 11.8+/-5.7 

(P < 0.05 vs. G2, 

P < 0.05 vs. G4)

G4: 9.5+/-6.8 

(P < 0.01 vs. G1) 

(overall P < 0.0001)

Categorized: 

• Continuous 

Collected from: 

• Gains during 

pregnancy not 

collected 

Ascertained by: 

• Not explained by 

researchers, may 

be difference 

between 

prepregnancy 

weight and 

weight measured 

at 24 to 28 

weeks gestation 

Birth weight: 

G1: 3271+/-446 

(P < 0.05 vs. G2) 

G2: 3413+/-589 

(P < 0.01 vs. G3) 

G3: 3186+/-578 

(P < 0.01 vs. G4) 

G4: 3389+/-447 

(P < 0.05 vs. G1) 

(overall P = 0.001) 

Gestational 

diabetes,%: 

NR 

Cesarean 

delivery,%: 

G1: 30.5 

G2: 38.1 

G3: 39.2 

G4: 44.3 (P < 0.01 

vs. G1) (overall P = 

0.044) 

Instrumental 

delivery,%: 

NR 

Episiotomy,%: 

NR 

Other maternal 

outcomes: 

• Height 

• Parental 

diabetes 

• Waist 

• Systolic bp 

• Diastolic bp 

• Hypertension 

• Triglycerides 

• HDL 

Other infant 

outcomes: 

• Weeks of 

delivery 

• SGA 

• Neonatal 

pathologies 

Outcomes Description: 

Explanation of multivariate models: 

• OR for hypertension in pregnancy and obesity - 

adjusted for age, gestational age, weight gain, 

and gestational hypergylcemia 

• OR for cesarean sections included gestational 

hyperglycemia, gestational weight gain, age, 

obesity 

• OR for LGA included obesity (BMI ≥ 30), 

gestational weight gain, age, gestational 

hyperglycemia, and smoking 

• OR for LGA/cesarean sections and WHR 

adjusted for age, gestational age, weight gain, 

gestational hyperglycemia, obesity, smoking 

habits 

• Prepregnancy weight was not associated with 

adverse outcomes, also height and parity not 

significantly associated with any pregnancy 

outcomes 

Groups: 

G1: Normal wieight, normal OGTT 

G2: Overweight/Obese, normal OGTT 

G3: Normal Weight, IGT/GDM 

G4: Overweight/Obese, IGT/GDM 

Results: 

Per kg increase in gestational weight gain 

G1: 1.06 (1.02 - 1.10) 

G2: 1.08 (1.03 - 1.12) 

Gestational hyperglycemia 

G1: 1.78 (1.21 - 2.62) 

G2: ns 

Age 

G1: NS 

G2: NS 

Obesity 

G1: NS 

G2: 4.48 (2.30 - 8.71) 

Smoking 

G1: NR 

G2: NS 

Waist to hip ratio > .90 

G1: 1.51 (1.02 - 2.24) 

G2: 1.81 (1.12- 2.93) 

Height 

G1: ns 

G2: ns 

Parity 

G1: ns 

G2: ns 
C-718 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Bo et al., 2003 

(continued) 

 
C-719 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Prepregnancy overweight 

G1: ns 

G2: ns 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NR 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

NR 
C-720 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Butte et al., 2003 

Country and setting: 

USA, children’s nutrition 

center 

Enrollment Period:

NR 

Funding: 

US Department of Army 

and US Department of 

Agriculture/Agriculture 

Research Service 

Study Objective: 

To evaluate how changes 

in gestational weight and 

body composition affect 

infant birth weight and 

maternal fat retention after 

delivery in underweight, 

normal weight and 

overweight women 

Time frame: 

NR 

Duration of the study: 

Prior to preg through pp 

Design: 

• Cohort 

• Prospective 

Total Study N: 

63 

Group Description: 

G1: Total cohort 

G2: NR 

Group N: 

G1: 63 

G2: NR 

Inclusion criteria: 

• Nonsmokers 

• 18-40 years 

• parity ≤ 4 

• Physically active (20 

to 30 minutes of 

moderate exercise at 

least 3 times/week) 

• No long term 

medicine use 

• No alcohol/drug 

abuse 

Exclusion criteria: 

• Multiparous 

• Preterm deliveries 

• Miscarriage 

• Preeclampsia 

Pregravid weight: 

• Measured by study 

investigators 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 31 (4) 

G2: NR 

Parity: 

NR 

Race,%: 

White 

G1: 77 

G2: NR 

Black 

G1: 10 

G2: NR 

Hispanic 

G1: 10 

G2: NR 

Asian/Pacific Islander 

G1: 3 

G2: NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-721 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

Total weight gain: 

G1: 15.0 (3.8) kg

G2: 14.5 (4.5) kg

G3: 17.9 (5.4) kg

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NA 

Other infant 

outcomes: 

• Birth weight 

Outcomes Description: 

Fat retention 

Groups: 

BMI groups, low, normal, high 

Results: 

• After adjustment for gestational duration, gravidity, 

and ethnicity, gestational weight gain and net 

gestational weight gain (GWG-birth weight) were 

significantly lower in normal BMI group than in high 

BMI group (P = 0.04) - GWG and net GWG in low 

BMI group was not significantly different from women 

in normal and high BMI groups 

• On average weight gain was 42% fat mass and 58% 

fat free mass 

• Weight gain was linearly correlated with gains in TBW 

(r = 0.39, P = 0.003), TBK (r = 0.49, P = 0.001), 

protein (r = 0.49, P = 0.001), Fat free mass (r = 0.50, 

P = 0.001), and FM (r = 0.76, P = 0.001) 

• Mean gestational weight gain (14.4kg) of women who 

gained within IOM recommendations was associated 

with gains of 7.1kg TBW, 5.0g TBK, 370g protein, 8.4 

kg FFM, and 4.1 kg FM and a mean birth weight of 

3.44kg 

• Changes in body weight differed among BMI groups in 

first trimester (normal BMI < high BMI group, P = 

0.004) and third trimester (low BMI < normal and high 

BMI group, P < 0.01) 

• No effect of breast feeding on body weight and 

composition 

• Birth weight correlated significantly with GWG (r = 

0.35, P = 0.006), net GWG (r = 0.26, P = 0.04), and 

rate of weight gain (r = 0.28, P = 0.03), FFM (r = 

0.39, P = 0.003) but not with FM 

• Partitioning GWG into FFM and FM showed that FFM 

gain accounted for effect on birth weight (not FM) 

• Maternal FFM gains in first (P = 0.008), second (P = 

0.005), and third trimesters (P = 0.005) were shown 

to make independed contributions to birth weight 

• Total gestational gains in maternal weight, TBW, TBK, 

FFM and FM were not shown to have an effect on 

infant FFM, FM, or percentage of FM at 2 weeks of 

age 

• Postpartum weight retention was correlated positively 

with GWG (r = 0.67, P = 0.001), total FM gain (r = 

0.61, P = 0.001) but not with FFM gain 

• Postpartum fat retention was correlated positively with 

GWG (r = 0.56, P = 0.001) and total FM gain (r = 

0.57, P = 0.001) 

• Maternal fat retention at 27 weeks after delivery 

(5.3kg) was significantly higher in women who gained 

above IOM recommendations for weight gain 

compared to those women who gained within (2.3kg) 

or below (-0.5kg) recommendations 

• 
C-722 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Butte et al., 2003 

(continued) 

 
C-723 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Maternal confounders and effect modifiers accounted 

for in analysis: 

• Race 

• Pre-gravid BMI 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

• Gestational age 
C-724 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hediger et al., 1994 

Country and setting: 

USA, setting NR 

Enrollment Period:

1985 

Funding: 

NICHD grant 

Study Objective: 

To study relationship 

between changes in 

maternal subcutaneous 

fat and infant birth weight 

Time frame: 

1985 

Duration of the study: 

Initiation of prenatal care 

to 4 to 6 weeks 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

608 

Group Description: 

G1: Teenagers 13-15 years 

G2: Teenagers 16-18 years 

G3: Adults 19-29 

Group N: 

G1: 197 

G2: 207 

G3: 204 

Inclusion criteria: 

• Primigravid and 

multigravid teenagers 

(< 19 years) with first 

pregnancy at < 16 y 

• Older women ages 18 

to 29 years at first 

pregnancy 

Exclusion criteria: 

• History of serious 

nonobstetric problems 

(seizure disorders, 

leukemia or drug or 

alcohol abuse) 

• Fetal demise 

• Multiple pregnancy 

• Missing data on study 

variables 

• Women who breast fed 

after delivery or who 

were still breastfeeding 

at 4 to 6 weeks 

postpartum 

Pregravid weight: 

• Self-reported 

G1: 56.00 (0.84) kg 

G2: 59.95 (0.82) 

G3: 60.91 (0.82) 

Pregravid BMI: 

G1: 21.81 (0.30) 

G2: 23.02 (0.29) 

G3: 23.18 (0.29) 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 14.49 (0.14) 

G2: 17.41 (0.13) 

G3: 22.63 (0.14) 

Parity: 

% primiparous:

G1: 93.9 

G2: 37.2 

G3: 36.3 

Race,%: 

White 

G1: 7.6 

G2: 9.2 

G3: 8.8 

Black 

G1: 69.5 

G2: 57.5 

G3: 61.8 

Hispanic 

G1: 22.8 

G2: 33.3 

G3: 29.4 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 20.8 

G2: 34.8 

G3: 40.2 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Mean change in arm muscle 

area, cm2:

G1: 2.19 (0.44) 

G2: 1.78 (0.38) 

G3: 2.00 (0.39) 

Change in arm fat area, cm2:

G1: -0.46 (0.48) 

G2: -1.18 (0.43) 

G3: -1.26 (0.44) 

Change in triceps skinfold, mm

Change in subscapular 

skinfold, mm: 

G1:: -0.85 (0.38) 

 -1.13 (0.38) 

G2: 1.22 (0.33) 

 -0.87 (0.33) 

G3: -1.25 (0.34) 

-1.53 (0.34) 
C-725 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

G1: 197 

G2: 207 

G3: 204 

Total weight gain: 

G1: 14.85 (0.54) kg

G2: 13.82 (0.47)

G3: 14.12 (0.48)

Categorized: 

• Continuous 

Collected from: 

• Routine pre-natal 

care or maternity 

records 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery 

Birth weight: 

NR 

Gestational diabetes, 

%: 

NR 

Cesarean delivery, %: 

NR 

Instrumental delivery, 

%: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Anthropometric 

measurements 

taken were: midupper arm 

circumference, 

triceps, and 

subscapular 

skinfold thickness 

from left side of 

body - upper arm 

muscle and fat 

area 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• r = 0.21, P < 0.001 for infant birth weight and 

arm fat area at 28 wk gestation 

• r = 0.16, P < 0.001 for infant birth weight and 

arm muscle area at 28 wk gestation 

• Question 54: Shows multiple linear regression 

analysis of infant birth weight (g) - model 

included: gestation (wk), maternal age (y), low 

pregravid weight, maternal height, prior poor 

outcome, primiparity, infant sex, race, smoking 

• Question 67: Shows pattern of pregnancy 

weight gain, birth weight, and weight retention 

by arm fat area changes (28 weeks to the 

postpartum period) 

• * designates model was adjusted for maternal 

age, parity, ethnicity, low pregravid weight, 

height, smoking, length of gestation or iterval 

(wk) to the 4-6 wk postpartum visit 

• ** designates model was adjusted for length of 

gestation, maternal age, parity, ethnicity, low 

pregravid weight, height, smoking, total weight 

gain, prior poor outcome, infant sex 

• *** designates model was adjusted for length 

of gestation, maternal age, parity, ethnicity, 

low pregravid weight, height, smoking, total 

weight gain, prior poor outcome, infant sex - 

but not significantly different from zero 

Groups: 

G1: Teenagers 13 to 15 years 

G2: Teenagers 16 to 18 years 

G3: Adults 19-29 

Results: 

Total weight gain (kg) 

G1: 16.7 (2.5) P = 0.001 

G2: NR 

Fat loss > 6.4 cm2 

G1: 144.3 (51.9) P = 0.006 

G2: NR 

Fat loss and low weight (< 25th percentile for 

chronological age) 

G1: -339.5 (130.9) P = 0.010 

G2: NR 

Fat accretion > 5 cm2 

G1: -123.3 (49.5) P = 0.013 

G2: NR 
C-726 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hediger et al., 1994 

(continued) 

 
C-727 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Confounders and effect modifiers 

G1: < 1fifth percentile arm fat area loss 

G2: 1fifth-50th percentile arm fat area loss 

G3: 50th-8fifth percentile arm fat area loss 

G4: > 8fifth percentile arm fat area loss 

G1: 89 

G2: 214 

G3: 223 

G4: 82 

Weight gain at 28 wk, kg 

G1: 9.77 (0.60) 

G2: 9.02 (0.38) 

G3: 8.74 (0.37) 

G4: 10.63 (0.62) *P < 0.05 significantly different from 

means for other arm fat area change percentile 

groups by analysis of covariance 

Weight gain in third trimester, kg 

G1: 4.44 (0.36) 

G2: 4.74 (0.23) 

G3: 5.01 (0.23) 

G4: 6.33 (0.38) *P < 0.05 significantly different from 

means for other arm fat area change percentile 

groups by analysis of covariance 

Total gain, kg 

G1: 14.06 (0.70) 

G2: 13.73 (0.44) 

G3: 13.90 (0.44) 

G4: 16.81 (0.72) *P < 0.05 significantly different from 

means for other arm fat area change percentile 

groups by analysis of covariance 

Change in arm muscle area, cm2 

G1: 6.71 (0.52) **P < 0.05 significantly different from 

means for other arm fat area change percentile 

groups by analysis of covariance 

G2: 2.24 (0.33) 

G3: 0.92 (0.33) 

G4: -0.89 (0.54) ***P < 0.05 si 

infant birth weight, g 

G1: 3247.2 (43.5) **P < 0.05 significantly different 

from means for other arm fat area change percentile 

groups by analysis of covariance 

G2: 3146.4 (27.7) 

G3: 3163.1 (27.2) 

G4: 3026.7 (45.3) **P < 0.05 sign 

Gestation, wk 

G1: 39.2 (0.2) 

G2: 39.0 (0.1) 

G3: 38.7 (0.1) 

G4: 39.1 (0.2) 
C-728 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Hediger et al., 1994 

(continued) 

 
C-729 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Interval 28 wk to 4 to 6 wk postpartum, wk 

G1: 16.4 (0.4) 

G2: 15.8 (0.2) 

G3: 15.8 (0.2) 

G4: 16.7 (0.4) 

Retained weight, kg 

G1: 3.72 (0.38) 

G2: 4.40 (0.25) 

G3: 5.25 (0.24) *P < 0.05 significantly different from 

means for other arm fat area change percentile 

groups by analysis of covariance 

G4: 7.08 (0.40) *P < 0.05 significantly dif 

Small for gestational age, % 

G1: 7.9% 

G2: 6.1% 

G3: 9.4% 

G4: 11.0% 

Maternal confounders and effect modifiers 

accounted for in analysis: 

• Age 

• Race 

• Parity 

• Pregravid weight 

• Height 

• Length of gestation/interval to delivery 

• Total weight gain prior poor outcome 

• Fat loss 

• Fat loss & low weight 

• Fat accretion 

• Smoking 

Infant and child confounders and effect 

modifiers accounted for in analysis: 

• Infant sex 
C-730 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Javanovic-Peterson 

1993 

Country and setting: 

USA, hospitals affiliated 

with medical schools 

Enrollment Period:

1959 to 1966 

Funding: 

NR 

Study Objective: 

to investigate with MRI the 

relationship between 

maternal weight, fat 

distribution, and glucose 

levels and neonatal 

birthweight ratio, percent 

fat, and infant outcome in 

pregnancies complicated 

by gestational diabetes. 

Time frame: 

NR 

Duration of the study: 

NA 

Design: 

• Observational 

• Prospective 

Total Study N: 

20 

Group Description: 

NA

Group N: 

20

Inclusion criteria: 

• Women with GDM at 

36 to 38 weeks' 

gestation 

Exclusion criteria: 

• NR 

Pregravid weight: 

• Self-reported 

Pregravid BMI: 

Imputed: 

• No 

Categorized: 

• No 

Age (mean, yrs): 

28.8 years 

Parity: 

NR 

Race,%: 

NR 

Smoking,%: 

NR

Diabetes mellitus,%: 

100%

Hypertension,%: 

NR

Additional characteristics: 

NR 
C-731 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

Total weight gain: 

• NR 

Birth weight: 

Gestational 

diabetes, %: 

0%

Cesarean 

delivery,%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Decription: 

Maternal body composition measures, infant birthweight and 

neonatal morbidity 

Groups: 

NA 

Results: 

• Maternal body composition was related to maternal 

weight (p=0.012, r=0.54) 

• Maternal arm fat was related to maternal weight (p=0.05, 

r=0.60) 

• Maternal arm fat correlated with trunk fat 

• Maternal trunk fat not correlated with wegith (NS) 

• Maternal hemoglobin correlated with maternal weight 

(p=0.05, r=0.43) 

• Maternal hemoglobin not correlated with infant birth 

weight 

• Infant birth weight ratio predicted by MRI (p<0.001, 

r=0.88) 

• Mother’s arm > 50mm2

 risk or fetus more than 4.0 mm 

mean thinkcness of maximal abdominal fat, risk of 

macrosomia and neonatal glycemia increased 

Maternal confounders and effect modifiers accounted for 

in analysis: 

• NA 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NA 
C-732 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Larciprete et al., 2003 

Country and setting: 

Italy, obstetrics 

ambulatory clinic 

Enrollment period: 

NR 

Funding: 

NR 

Study Objective: 

To evaluate changes in 

maternal body 

composition and normal 

ranges of maternal body 

components during 

various periods of 

pregnancy 

Time frame: 

NR 

Duration of the study: 

First prenatal visit to 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

170 

Group Description: 

G1: Total sample 

G2: NR 

Group N: 

G1: 170 

G2: NR 

Inclusion criteria: 

• Women with 

singleton healthy 

pregnancy were 

consecutively 

recruited for a 

longitudinal study at 

early gestation 

Exclusion criteria: 

• Did not complete 

study program 

• Premature rupture of 

membranes at 24 to 

26 weeks gestation 

• Spontaneous 

miscarriage 

• Incomplete prenatal 

data 

• Gestational diabetes 

that required insulin 

• Gestational 

hypertension treated 

with nifedipine 

Pregravid weight: 

• Routine pre-natal care 

G1: 66.73 (1.39) kg 

G2: NR 

Pregravid BMI: 

G1: 24.15 (0.48) 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 32.06 (0.50) 

G2: NR 

Parity: 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-733 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

G1: 170 

G2: NR 

Total weight gain: 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3472.75 (42.35) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• analysis of correlations 

• TBW and ECW significantly increase during second and 

third trimester of gestation - progressive decrease in 

resistance provides indirect proof of TBW and ECW 

expansion at mid-gestation and term gestation, since 

inverse relationship between first and last 2 parameters 

is well known 

• Reactance undergoes a progressive rise during entire 

gestation, following maternal weight gain - this result 

demonstrates that even fat mass deposition and not only 

fluid retention is responsible for GWG, since reactance 

is an indirect parameter in estimating fat mass amount 

• Intracellular water slightly enhances during course of 

gestation with a peak in late third trimester - this 

observation may be explained by water filling need of 

some tissues, occurring at term gestation to guarantee 

correct development of labor, delivery, and puerperium 

Groups: 

G1: Total sample 

G2: NR 

Results: 

Extracellular water 

G1: 0.146 P = 0.116 

G2: NR 

Intracellular water 

G1: 0.151 P = 0.108 

G2: 0.398 P = 0.000 

Total body water 

G1: 0.147 P = 0.116 

G2: 1.00 P = 0.000 

G3: 0.998 P = 0.000 

Reactance 

G1: 0.105 P = 0.251 

G2: 0.315 P = 0.001 

G3: 0.302 P = 0.002 

G4: 0.313 P = 0.002 

Resistance 

G1: -0.538 P = 0.000 

G2: -0.135 P = 0.144 

G3: -0.146 P = 0.118 

G4: -0.135 P = 0.149 

Outcomes Set 2: 

NR 

Maternal confounders and effect modifiers accounted for 

in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 
C-734 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lederman et al., 1997 

Country and setting: 

USA, clinics 

Enrollment Period:

Jan 1991-Aug 1993 

Funding: 

Grant from Maternal and 

Child Health Bureau and 

Department of Health and 

Human Services 

Study Objective: 

To determine fat 

deposited during 

pregnancy in women 

according to 

recommendations of IOM 

and relationship of weight 

gain to fat gain in women 

of different starting 

weights classified by BMI 

Time frame: 

Jan 1991 to Aug 1993 

Duration of the study: 

From first visit through 

delivery 

Design: 

• Cohort 

• Prospective 

Total Study N: 

196 

Group Description: 

G1: study cohort 

G2: NR 

Group N: 

G1: 196 

G2: NR 

Inclusion criteria: 

• 18 to 35 years of age

• Non-smokers 

• Self-identified as 

Hispanic, black, or 

white 

• Expecting singleton 

birth 

• Able to schedule their 

first body composition 

laboratory visit before 

16th week of 

gestation 

• Free of medical 

illnesses requiring 

regular medication 

• Not knowingly 

infected with HIV 

• Not a regular user of 

drugs or alcohol 

according to mother’s 

report 

Exclusion criteria: 

• NA they had to have 

a 37 week 

measurement and 

medical record 

available 

Pregravid weight: 

• Self-reported 

G1: 63.4 (12.9) 

G2: NR 

Pregravid BMI: 

Imputed: 

• NR 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26.0 (4.8) 

G2: NR 

Parity: 

G1: 0.8 (1.0) 

G2: NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-735 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

G1: 196 

G2: NR 

Total weight gain: 

G1: 13.6 (6.1)

G2: NR 

Categorized: 

• According to IOM 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• Based on last 

clinically 

measured weight 

prior to delivery: 

difference 

between 

measurement at 

week 37+ and 

prepregnancy 

Birth weight: 

G1: 3,449 (433) 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

Study investigators 

measured body 

weight, body density 

by 

hydrodensitometry, 

and deuterium 

dilution volume twice 

during pregnancy (at 

weeks 12-16 and at 

37+ weeks) 

Other infant 

outcomes: 

NA 

Outcomes Description: 

• Fat gain between pregnancy weeks 14-37 

Groups: 

< IOM, within IOM, > IOM, for BMI groups for three 

outcomes: 

G1: Body weight gain 

G2: Body water gain 

G3: Fat gain 

Results: 

BMI < 19.8: all women (n = 21) 

G1: 12.6 (4.4) 

G2: 6.1 (2.4) 

G3: 4.8 (3.8) 

BMI < 19.8: less than recommended; recommended; 

more than recommended 

G1: 7.9 (1.6); 12.6 (2.4); 16.1 (3.9) 

G2: 6.4 (3.7); 5.9 (1.6); 6.1 (2.2) 

G3: 0.6 (1.9); 6.0 (2.6); 6.9 (3.5) 

BMI19.8-26.0: all women (n = 118) 

G1: 12.2 (4.0) 

G2: 7.0 (2.7) 

G3: 3.9 (3.7) 

BMI19.8-26.0: less than recommended; recommended; 

more than recommended 

G1: 8.6 (1.9); 12.1 (3.4); 15.2 (3.4) 

G2: 6.2 (2.1); 6.9 (2.7); 7.6 (3.0) 

G3: 1.3 (3.0); 3.8 (3.5); 6.0 (3.1) 

BMI > 26.0-29.0: all women (n = 29) 

G1: 11.0 (4.6) 

G2: 7.8 (3.5) 

G3: 2.8 (5.4) 
C-736 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Lederman et al., 1997 

(continued) 

 
C-737 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

BMI > 26.0-29.0: less than recommended; recommended; 

more than recommended 

G1: 8.5 (3.2); 9.1 (3.1); 13.6 (5.1) 

G2: 6.9 (3.0); 5.7 (3.0); 9.7 (3.2) 

G3: 0.3 (2.5); 2.8 (4.1); 4.2 (6.9) 

BMI > 29.0: all women (n = 28) 

G1: 8.7 (5.6) 

G2: 7.3 (2.9) 

G3: 0.2 (5.0) 

BMI > 29.0: less than recommended; recommended; more 

than recommended 

G1: 3.2 (2.7); 6.9 (4.4); 12.0 (4.6) 

G2: 7.8 (3.5); 6.0 (2.9); 7.6 (2.7) 

G3: -5.2 (1.5); -0.6 (4.6); 3.1 (3.9) 

Results for BMI and IOM recommendations over time: 

G1: BMI < 19.8 and gained within IOM recommendations 

G2: BMI 19.8-26.0 and gained within IOM 

recommendations 

G3: BMI > 26.0-29.0 and gained within IOM 

recommendations 

G4: BMI > 29.0 and gained within IOM recommendations 

G1: 7 

G2: 46 

G3: 9 

G4: 6 

Total body fat at week 14 

G1: 12.2 (2.3) 

G2: 18.2 (2.8) 

Total body fat at week 37+ 

G1: 17.9 (5.4) 

G2: 21.7 (5.8) 

Characteristics: 

G1: 25.1 (4.5) 

G2: 28.0 (3.8) 

Group 

G1: 33.1 (8.3) 

G2: 32.5 (5.7) 

Maternal confounders and effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 
C-738 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Paxton et al., 1998 

Country and setting: 

USA, prenatal clinics 

Enrollment Period:

Jan 1991 to Jan 1994 

Funding: 

Supported by grant MCJ360601 from Maternal and 

Child HealthBureau (Title 

V, SSA), HRSA, DHHS 

Study Objective: 

To accurately estimate fat 

without making extensive 

assumptions regarding 

composition of lean tissue 

in pregnant women, 

authors developed a 4-

compartment model 

(weight, water, bone 

mineral mass, and body 

density) as standard, 

tested 4 exist 

Time frame: 

Jan 1991 to Jan 1994 

Duration of the study: 

From week 14 to week 37 

of pregnancy 

Design: 

• Cohort 

• Prospective 

Total Study N: 

200 

Group Description: 

G1: All 

G2: NR 

Group N: 

G1: 200 

G2: NR 

Inclusion criteria: 

• Black, Hispanic, and 

white women 18-35 

years of age with 

singleton pregnancy, 

free of major illness 

Exclusion criteria: 

• Smoker during 

pregnancy 

• Regular drug or 

alcohol use during 

pregnancy 

• Delivered before 

second measurement 

visit 

Pregravid weight: 

• Self-reported 

G1: 63.2 ± 12.8 

G2: NR 

Pregravid BMI: 

G1: Maternal prepregnancy 

weight classification: 

Underweight (BMI < 19.8) 

10.5%Normal weight (BMI 

19.8–26.0) 61.5%Overweight 

(BMI > 26 to 29.0) 

14.5%Obese (BMI > 29) 

13.5% 

G2: NR 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26 ± 4.8 

G2: NR 

Parity: 

G1: 0.8 ± 1.0 

G2: NR 

Race,%: 

White 

G1: 21% 

G2: NR 

Black 

G1: 25% 

G2: NR 

Hispanic 

G1: 55% 

G2: NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

NR 
C-739 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

G1: 200 

G2: NR 

Total weight gain: 

G1: 13.6 kg ± 4.5

G2: NR 

Categorized: 

• (classified as < 5, 

5 to < 10, 10 to < 

15, and 3 15 kg), 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3451 ± 439g 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

• Existing 

anthropometric 

measures varied 

from each other, 

with 4-

compartment 

model providing 

lowest estimate 

of weight gain 

• Change in fat 

and fat mass 

estimate from 

weeks 14 to 37 

or at week 37 

from new 

anthropometric 

model was not 

significantly 

different from 

estimate from 

4-compartment 

model (weight, 

water, bone 

mineral mass, 

and body 

density) 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• Traditional anthropometric measures 

• Comparisons between new anthropometric 

model and 4-compartment model 

Groups: 

G1: Anthropometric equation for fat at 37 weeks 

G2: Four compartment model for fat at 37 weeks 

G3: Anthropometric equation for change in fat mass 

from 14- 37 weeks 

G4: Four-compartment model for change in fat mass 

from 14- 37 weeks 

G5: Weight and body-composition changes during 

gestation 

Results: 

GWG (wks 14 to 37) < 5 kg 

G1: 27.83 ± 13.51 

G2: 23.55 ± 13.00 

G3: – 4.17 ± 1.99 

G4: – 5.66 ± 4.01 (no significant differences based 

on repeated-measures) 

GWG (wks 14 to 37) 5 to < 10 kg 

G1: 22.00 ± 6.96 

G2: 21.46 ± 7.69 

G3: 0.24 ± 1.16 

G4: 0.96 ± 2.36 (no significant differences based on 

repeated-measures) 

GWG (wks 14 to 37) 10 to < 15 kg 

G1: 23.14 ± 6.09 

G2: 22.90 ± 6.91 

G3: 3.87 ± 1.38 

G4: 4.36 ± 2.80 (no significant differences based on 

repeated-measures) 

GWG (wks 14 to 37) ≥ 15 kg 

G1: 30.93 ± 10.08 

G2: 31.55 ± 10.33 

G3: 9.73 ± 2.17 

G4: 8.70 ± 2.73 (no significant differences based on 

repeated-measures) 

Change in weight (prepregnancy to week 14 

Prepregnancy to week 14) 

G5: 2.1 ± 4.5 (–9.5, 26.9) 

Change in weight (week 14 to 37) 

G5: 11.5 ± 4.5 (–0.9, 23.8) 

Change in total body water (week 14 to 37) 

G5: 7.0 ± 2.9 (–2.5, 16.1) 

Change in fat (week 14 to 37) 

G5: 3.3 ± 4.3 (–9.2, 14.1) 
C-740 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Paxton et al., 1998 

(continued) 

 
C-741 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Hydration of fat-free mass (%) at week 14 

G5: 73.84 ± 3.43 (64.88, 82.37) 

Hydration of fat-free mass (%) at week 37 

G5: 75.66 ± 3.58 (60.81, 87.87) 

Density of fat-free mass (g/L) at week 14 

G5: 1100 ± 12 (1074, 1128) 

Density of fat-free mass (g/L) at week 37 

G5: 1091 ± 12 (1054, 1135) 

Maternal confounders and effect modifiers accounted 

for in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 
C-742 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Sohlstrom et al., 1993 

Country and setting: 

Sweden, setting NR 

Enrollment Period:

not stated 

Funding: 

NR 

Study Objective: 

To validate and assess 

precision of MRI method; 

to estimate changes in 

amount of TBF and FF 

body weight during 

pregnancy and throughout 

first year post partum in a 

group of healthy Swedish 

women; to study how 

distribution of TBF is 

affected during pregnancy 

and throughout the first 

year post partum 

Time frame: 

Not stated 

Duration of the study: 

First visit during 

pregnancy to 1 year 

postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

10 

Group Description: 

G1: Total sample 

G2: NR 

Group N: 

G1: 10 

G2: NR 

Inclusion criteria: 

NR 

Exclusion criteria: 

NR 

Pregravid weight: 

• NR 

G1: 62.6 (9.7) kg 

G2: NR 

Pregravid BMI: 

G1: 22.4 (2.7) 

G2: NR 

Imputed: 

• No 

Categorized: 

• Continuous 

Age (mean, yrs): 

G1: 28 (5) 

G2: NR 

Parity: 

NR 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

% total body fat prepregnancy: 

G1: 25.7 (4.8) 

G2: NR 
C-743 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

G1: 10 

G2: NR 

Total weight gain: 

G1: 19.0 (7.9) kg

G2: NR 

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3700 (620) g 

G2: NR 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

net weight gain 

during pregnancy: 

9.8 (6.3)kg - 5.5 

(3.2)kg was TBF 

and 4.3 (3.7)kg was 

fat free body weight 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• During first 6 and 12 months postpartum women 

mobilized 2.6 (3.6) and 3.2 (3.2)kg body fat, 

respectively 

• Correlations - indicates that women who retained 

more fat during pregnancy also were those who 

mobilized more fat post partum 

• On average, 84% of fat retained during pregnancy 

was placed subcutaneously - amount of 

subcutaneous fat decreased during whole year post 

partum while non subcutaneous fat did not change 

or even tended to increase during this period of time 

• 44% of fat retained during pregnancy was place in 

lower trunk, 30% in upper trunk, 1% in thighs, 4% in 

upper arms, 2% in calves, and 1% in forearms 

• During first 2 months postpartum fat was mainly 

mobilized from lower trunk, most of fat retained in 

thighs was mobilized during first year post partum 

while fat which still remained after 1 year mainly 

was found in upper and lower trunk 

Groups: 

G1: Total sample 

Results: 

Fat mobilized at 6 months postpartum 

G1: r = -0.66 P < 0.05 

Fat mobilized at 12 months postpartum 

G1: r = -0.83 P < 0.01 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 
C-744 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Soltani and Fraser, 2000 

Country and setting: 

UK, hospital 

Enrollment Period:

NR 

Funding: 

NR 

Study Objective: 

To investigate pattern of 

changes in weight gain 

and fat distribution during 

pregnancy and 

postpartum and whether 

this differed by maternal 

BMI measured in first 

trimester 

Time frame: 

NR 

Duration of the study: 

First prenatal visit to 6 

months postpartum 

Design: 

• Cohort 

• Prospective 

Total Study N: 

77 

Group Description: 

G1: Total sample 

G2: Normal weight 

G3: Overweight 

G4: Obese 

Group N: 

G1: 77 

G2: 29 

G3: 23 

G4: 25 

Inclusion criteria: 

• Women attending first 

prenatal visit at 

Northern General 

Hospital 

Exclusion criteria: 

NR 

Pregravid weight: 

• Measured during first 

prenatal visit 

G1: 73.0 (16.8) 

G2: 60.8 (5.6) 

G3: 72.0 (5.9) 

G4: 93.0 (10.6) 

Pregravid BMI: 

G1: 27.4 (5.9) 

G2: 22.7 (1.3) 

G3: 27.7 (1.4) 

G4: 34.5 (3.54) 

Imputed: 

• No 

Categorized: 

• IOM guidelines 

Age (mean, yrs): 

G1: 26.71 (4.77) 

G2: 26.44 (5.32) 

G3: 26.91 (4.50) 

G4: 27.68 (3.83) 

Parity: 

G1: 0.78 (0.86) 

G2: 0.55 (0.87) 

G3: 0.81 (0.75) 

G4: 1.00 (0.96) 

Race,%: 

White 

NR 

Black 

NR 

Hispanic 

NR 

Asian/Pacific Islander 

NR 

Other 

NR 

Smoking,%: 

G1: 24% 

G2: NR 

Diabetes mellitus,%: 

NR 

Hypertension,%: 

NR 

Additional characteristics: 

Fat mass (kg) at first visit:

G1: 24.5 (9.9) 

G2: 16.5 (3.6) 

G3: 24.6 (3.9) 

G4: 36.1 (5.9) 

Waist:hip ratio:

G1: 0.92 (0.08) 

G2: 0.88 (0.06) 

G3: 0.92 (0.08) 

G4: 0.96 (0.08) 

Total Skinfold Thickness (mm): 

G1: 117.09 (40.19) 

G2: 84.3 (25.31) 

G3: 125.02 (22.76) 

G4: 158.74 (21.52) 
C-745 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Groups (N): 

G1: 77 

G2: 29 

G3: 25 

Total weight gain: 

G1: 13-36 weeks: 

10.8 (4.7)

G2: 11.0 (3.2)

G3: 11.9 (6.4)

G4: 9.7 (4.3)

Categorized: 

• Continuous 

Collected from: 

• Collected by 

study 

investigators 

Ascertained by: 

• NR 

Birth weight: 

G1: 3443.0 (589.60) 

G2: 3331.5 (481.7) 

G3: 3423.7 (543.2) 

G4: 3670.4 (489.5) 

Gestational 

diabetes, %: 

NR 

Cesarean delivery, 

%: 

NR 

Instrumental 

delivery, %: 

NR 

Episiotomy, %: 

NR 

Other maternal 

outcomes: 

NR 

Other infant 

outcomes: 

NR 

Outcomes Description: 

• Pattern of weight changes during pregnancy and 

up to 6 months postpartum follow a monotonous 

trend in normal weight women, all seem to 

increase weight during pregnancy and a 

considerable weight loss is obeserved at 6 

weeks post partum - from then until 6 months 

postpartum, they either tend to reduce slightly or 

stay at the same level 

• Normal weight women follow a comparatively 

monotonous pattern of changes in fat mass 

• Overweight women show a divergent pattern - 

women with maximum weight gain and also 

maximum weight loss are seen in this -

overweight women show a very scattered 

pattern of changes in fat mass 

• Majority of obese women seem to be 

considerably heavier at 6 months postpartum in 

comparison with 13 weeks gestation 

• Obese women mostly have higher values of fat 

mass at 6 months postpartum than early 

pregnancy 

• Underweight women showed a similar trend of 

change as normal weight women 

Groups: 

G1: Total sample 

G2: Normal weight 

G3: Overweight 

G4: Obese 

G1: 29 

G2: 23 

G3: 25 

G4: 77 

Results: 

Change in fat mass 13 weeks gestation - 36 weeks 

gestation 

G1: 4.9 (2.7) 

G2: 5.3 (4.5) 

G3: 3.7 (2.8) 

G4: 4.6 (3.4) 

Change in fat mass: 13 weeks gestation - 6 months 

postpartum (n = 47; normal wt n = 18; overwt n = 

12; obese n = 17) 

G1: 1.1 (2.7) 

G2: 3.9 (6.5) 

G3: 3.2 (4.1) 

G4: 2.6 (4.5) 

Change in fat mass: 36 weeks gestation - 6 months 

postpartum (n = 47; normal wt n = 18; overwt n = 

12; obese n = 17) 

G1: -4.1 (2.1) 

G2: -1.1 (4.3) 

G3: -0.9 (3.9) P < 0.05 

G4: -2.4 (3.8) 
C-746 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Study Description 

Study Design, Patient 

Population, Inclusion/ 

Exclusion Criteria Baseline Characteristics 

Baseline Characteristics 

(continued) 

Author, year: 

Soltani and Fraser, 2000 

(continued) 

 
C-747 

Evidence Table 56. Anthropometrics of maternal weight retention (continued) 

Maternal Weight 

Gain 

Outcomes from 

Bivariate Analysis Outcomes from Multivariate Analysis 

Change in body weight 13 weeks gestation - 36 weeks 

gestation 

G1: 11.0 (3.2) 

G2: 11.9 (6.4) 

G3: 9.7 (4.3) 

G4: 10.8 (4.7) 

Change in body weight: 13 weeks gestation - 6 

months postpartum (n = 47; normal wt n = 18; overwt 

n = 12; obese n = 17) 

G1: 0.4 (3.2) 

G2: 2.8 (8.4) 

G3: 0.6 (6.4) 

G4: 1.1 (6.0) 

Change in body weight: 13 weeks gestation - 6 

months postpartum (n = 47; normal wt n = 18; overwt 

n = 12; obese n = 17) 

G1: -10.7 (2.5) 

G2: -8.8 (5.0) 

G3: -9.7 (5.4) 

G4: -9.9 (4.4) 

Change in TSF(mm): 13-36 weeks gestation 

G1: 30.26 (18.61) 

G2: 28.82 (24.97) 

G3: 22.20 (17.86) 

Change in TSF (mm): 13 weeks gestation - 6 months 

postpartum (n = 47; normal wt n = 18; overwt n = 12; 

obese n = 17) 

G1: 8.74 (15.77) 

G2: 24.10 (38.68) 

G3: 28.04 (19.18) 

Change in TSF (mm): 36 weeks gestation - 6 months 

postpartum (n = 47; normal wt n = 18; overwt n = 12; 

obese n = 17) 

G1: -23.96 (14.85) 

G2: -9.48 (28.49) 

G3: 3.93 (22.05) P < 0.05 

Change in waist to hip ratio 6 weeks to 6 months 

postpartum 

G1: -0.02 (0.05) 

G2: 0.01 (0.03) 

G3: 0.02 (0.03) P < 0.05 

Maternal confounders and effect modifiers 

accounted for in analysis: 

NR 

Infant and child confounders and effect modifiers 

accounted for in analysis: 

NR 
Appendix D. List of Excluded Studies 
D-1 

Exclusion Codes 

Code Criteria N 

X-1 

Article is not concerned with topics relevant to maternal weight gain or the 

measurement of body fat 

80 

X-2 Wrong publication type (e.g. letter, commentary or editorial) 32 

X-4 n < 40 for comparisons including cohort studies 10 

X-5 n < 100 for case-series 2 

X-6 Not published in english 0 

X-7 Wrong publication type (e.g. letter, commentary or editorial) 2 

X-8 Wrong design - please explain 23 

X-9 Includes only a population w/ a pre-existing condition - please list condition 18 

X-10 100% multi-fetal 2 

X-12 Study not conducted in a developed nation? 21 

X-14 Not related to key questions 74 

X-17 Pre-pregnancy weight or BMI is not in article 36 
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Appendix E. Acknowledgments 

E-1 

Appendix E. Acknowledgments 

This study was supported by Contract 290-02-0016 from the Agency for Healthcare Research 

and Quality (AHRQ), Task No.1, Work Assignment 8. We acknowledge the continuing support 

of Beth Collins Sharp, Ph.D., R.N. Acting Director of the AHRQ Evidence-Based Practice 

Center (EPC) Program and the AHRQ Task Order Officer for this project. 

The investigators deeply appreciate the considerable support, commitment, and contributions 

of the EPC team staff at RTI International and the University of North Carolina (UNC). From 

UNC, we thank EPC Co-Director, Timothy S. Carey, MD, MPH; EPC Literature Search 

Specialist, B. Lynn Whitener, PhD. We express our gratitude to Loraine Monroe, EPC word 

processing specialist, and Tammeka Swinson Evans, BA, research specialist, at RTI 

International. 

Technical Expert Panel 

We extend our appreciation to the members of our Technical Expert Panel (TEP), who 

provided advice and input during our research process. The RTI-UNC EPC team solicited the 

views of TEP members from the beginning of the project. TEP members also provided insights 

into and reactions to work in progress and advice on substantive issues or possibly overlooked 

areas of research. TEP members participated in refining the analytic framework and key 

questions and discussing the preliminary assessment of the literature, including 

inclusion/exclusion criteria, and also provided input on the information and categories, including 

evidence tables. The TEP was both a substantive resource and a “sounding board” throughout the 

study. It was also the body from which expertise was formally sought at several junctions. TEP 

members are listed below (* also a peer review): 

Erica Gunderson, PhD 

Investigator 

Division of Research (DOR) 

Kaiser Permanente Northern California 

Naomi Stotland, MD 

Assistant Professor 

Department of Obstetrics and Gynecology 

University of California, San Francisco 

Calvin Hobel, MD 

Vice Chair 

Department of Obstetrics and Gynecology 

Cedars-Sinai Medical Center 

Lorraine Walker, RN, EdD, FAAN* 

Professor 

School of Nursing 

University of Texas at Austin 
E-2 

Esa M. Davis, M.D., M.P.H.* 

Assistant Professor 

Department of Family Medicine 

Case Western Reserve University School of Medicine 

Mary H. Hager, PhD, RD, FADA* 

Senior Manager, Regulatory Affairs Policy Initiatives and Advocacy 

American Dietetic Association 

Peer Reviewers 

We gratefully acknowledge the following individuals who reviewed the initial draft of this 

report and provided us with constructive feedback. External reviewers comprised clinicians, 

researchers, representatives of professional societies, and potential users of the report. We would 

also like to extend our appreciation to David Atkins, MD and other reviewers from AHRQ for 

contributing peer review comments. Our peer review panel also includes three members of the 

TEP. Peer review was a separate duty for these individuals and not part of their commitment as 

TEP members. All are active professionals in the field. The peer reviewers were asked to provide 

comments on the content, structure, and format of the evidence report and to complete a 

checklist. The peer reviewers’ comments and suggestions formed the basis of our revisions to the 

evidence report. Acknowledgments are made with the explicit statement that this does not 

constitute endorsement of the report. 

Barbara Hackley, MS, RN, CNM 

Associate Professor 

Yale School of Nursing 

Denise Sofka, RD, MPH 

Project Officer 

Maternal and Child Health Bureau 

Department of Health and Human. Services 

Mary Hediger, PhD 

Epidemiologist 

Epidemiology (EPI) Branch/DESPR 

National Institute of Child Health and Human Development 

National Institutes of Health 

Barbara Abrams, DrPH, RD 

Professor 

University of California, Berkeley 

School of Public Health 
E-3 

Emily Oken, MD, MPH 

Physician 

Department of Ambulatory Care and Prevention 

Harvard Medical School and Harvard Pilgrim Health Care 

Mary Dallavalle M.S., RD, LD 

Nutrition Education Specialist 

Special Supplemental Nutrition Program for Women, Infants, and Children 

(WIC Program) 

Kathleen Rasmussen, Sc.D. 

Professor of Nutrition 

Division of Nutritional Science 

International Professor of Nutritional Science 

College of Agriculture and Life Sciences 

Cornell University 

Patricia Fontaine MD, MS 

Associate Professor 

Department of Family Medicine

University of Minnesota Medical School