# Marked Disparities in Pre-Pregnancy Obesity and Overweight Prevalence among US Women by Race/Ethnicity, Nativity/Immigrant Status, and Sociodemographic Characteristics, 2012–2014

Authors: Gopal K. Singh; Jessica N. DiBari
Journal: Journal of Obesity
 (2019)

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## Abstract

This study examines racial/ethnic, nativity, and sociodemographic disparities in the prevalence of pre-pregnancy obesity and overweight in the United States. Logistic regression was fitted to the 2012–2014 national birth cohort data to derive unadjusted and adjusted differentials in pre-pregnancy obesity (BMI ≥30), severe obesity (BMI ≥40), and overweight/obesity (BMI ≥25) prevalence among 10.4 million US women of childbearing age. Substantial racial/ethnic differences existed, with pre-pregnancy obesity rates ranging from 2.6% for Chinese and 3.3% for Vietnamese women to 34.9% for American Indians/Alaska Natives (AIANs) and 60.2% for Samoans. Pre-pregnancy overweight/obese prevalence ranged from 13.6% for Chinese women to 61.7% for AIANs and 86.3% for Samoans. Compared to non-Hispanic whites, women in all Asian subgroups had markedly lower risks of pre-pregnancy obesity, severe obesity, and overweight/obesity, whereas Samoans, Hawaiians, AIANs, blacks, Mexicans, Puerto Ricans, and Central/South Americans had significantly higher risks. Immigrant women in each racial/ethnic group had lower rates of pre-pregnancy obesity than the US-born. Sociodemographic risk factors accounted for 33–47% of racial/ethnic disparities and 12–16% of ethnic-immigrant disparities in pre-pregnancy obesity and overweight/obesity. Further research is needed to assess the effects of diet, physical inactivity, and social environments in explaining the reported ethnic and nativity differences in pre-pregnancy obesity.


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## Body

## 1. Introduction

Obesity rates have increased dramatically in the United States during the past four decades, with the prevalence having more than doubled for all racial/ethnic, gender, immigrant, and socioeconomic groups [1–4]. Currently, 38% of US men and 40% of US women are classified as obese (body mass index (BMI) ≥30 kg/m2), and more than 70% of the US adult population are considered overweight or obese (BMI ≥25 kg/m2) [1, 2]. Rates of obesity and overweight/obesity for the US adult population are projected to reach 43% and 77%, respectively, by 2020 [4].According to the national data, obesity prevalence among US women of childbearing age (18–49) increased nearly 4-fold, from 7.4% in 1976 to 27.5% in 2014; the overweight/obese prevalence rose from 22.8% in 1976 to 53.5% in 2014 [3, 5]. Nearly 4 million women give births each year in the US, and rates of pre-pregnancy obesity among mothers are high with a prevalence >20% [6, 7]. Pre-pregnancy obesity is associated with increased risk for a number of adverse pregnancy and birth outcomes, including gestational diabetes, preeclampsia, gestational hypertension, cesarean section, dysfunctional and prolonged labor, induced labor, miscarriage, stillbirth, fetal macrosomia, preterm birth, select birth defects, and infant mortality [7–14]. Women with pre-pregnancy obesity are also at greater lifetime risks for developing chronic hypertension and type 2 diabetes than those of normal weight [11]. Children born to women with pre-pregnancy obesity are at increased risk of obesity during childhood and adult life [9, 11, 13].Data from the Pregnancy Risk Assessment and Monitoring System (PRAMS) indicate a significant rise in the prevalence of pregnancy-related obesity in 20 US states, increasing from 17.6% in 2003 to 20.5% in 2009 [7]. Studies using PRAMS and birth certificate data show highest rates of pre-pregnancy obesity among non-Hispanic black women and American Indians/Alaska Native (AIAN) women, followed by Hispanics, non-Hispanic whites, and Asian/Pacific Islanders (APIs) [7, 13, 15, 16]. Socioeconomic differences in pre-pregnancy obesity have also been reported, with women at lower education and income levels having markedly higher prevalence [13, 16].Despite the many adverse health effects of obesity in the preconception period, detailed racial/ethnic and sociodemographic risk factors associated with increased risk of pre-pregnancy obesity are not well documented in the US. While maternal pre-pregnancy obesity prevalence for broad racial/ethnic groups has previously been reported [7, 13, 15–17], disparities in pre-pregnancy obesity and overweight among specific API, Hispanic, and immigrant subgroups are not analyzed. Moreover, although characteristics such as maternal age, parity, marital status, education, and place of residence have been mentioned as possible risk factors for maternal obesity, few studies have examined racial/ethnic and immigrant disparities adjusted for these factors [7, 12, 13]. A better understanding of pre-pregnancy obesity risks and their determinants among major racial/ethnic and immigrant groups is vital to improving preconception health and health outcomes among mothers and children. Targeted and culturally relevant interventions for obesity prevention and control can reduce overall health disparities, improve intergenerational weight trends, and promote health equity for the nation [3, 4, 8].The primary aim of this study is to examine the extent of racial/ethnic and immigrant disparities in the prevalence of pre-pregnancy obesity and overweight among US women and to identify relevant sociodemographic risk factors, using the latest national birth cohort data. The study also explores a wider range of social inequalities by examining whether racial/ethnic disparities in pre-pregnancy obesity and overweight vary according to nativity/immigrant status and maternal education. Since immigration is a major characteristic of the Asian and Hispanic populations and nearly a quarter of all US births occur among foreign-born mothers [6], our analysis is also stratified by nativity status to highlight immigrant differences in obesity rates within each racial/ethnic group.


## 2. Methods

Maternal pre-pregnancy BMI data in this study are derived from the birth certificates filed in the 50 states, New York City, and the District of Columbia (DC) [6, 18]. These data have been included in the annual natality files by the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), for selected states since 2003. The number of states reporting pre-pregnancy BMI data increased from 40 in 2012 to 42 in 2013 and 48 in 2014 [6, 18]. The annual natality file includes birth certificate data for about 4 million births that occur in the United States each year [6, 18]. The US Standard Certificate of Live Birth is the basis for the national birth data [6].In addition to pre-pregnancy BMI and detailed race/ethnicity, the birth certificate data include maternal and paternal age, nativity/immigrant status, marital status, education, place of residence, parity/birth order, birth interval, birthweight, gestational age, congenital anomalies of the newborn, tobacco and alcohol use during pregnancy, prenatal care utilization, gestational weight gain, method of delivery (vaginal or cesarean), attendant at birth, pregnancy history, and a variety of medical risk factors and complications such as pre-pregnancy and gestational diabetes, chronic and pregnancy-induced hypertension, eclampsia, uterine bleeding, placenta previa, prolonged labor, and induction of labor. Detailed descriptions of the birth certificate data and national natality files are available elsewhere [1, 6, 18, 19].We used the 2012–2014 national birth cohort data [6, 18]. During 2012–2014, 11,873,098 births occurred among US mothers. Approximately 12.1% of the births did not include pre-pregnancy maternal BMI data, which included several states that did not report BMI data during the three years [18]. The sample for the analysis included 10,431,092 live births. Of these, 2,529,920 births occurred among mothers with pre-pregnancy obesity, 5,191,191 births among mothers with pre-pregnancy overweight/obesity, and 459,283 births among mothers with severe obesity. Aggregating data for three years ensured sufficient sample sizes for analyzing obesity patterns among groups stratified by race/ethnicity, immigrant status, and maternal education. Consistent with the WHO and CDC guidelines, pre-pregnancy overweight/obesity was defined as a BMI ≥25 kg/m2, obesity as a BMI ≥30 kg/m2, and severe or grade 3 obesity as a BMI ≥40 kg/m2 [1–4, 20]. Note that the overweight/obesity category includes obese women.Race/ethnicity was classified into 17 major categories: Non-Hispanic whites, Non-Hispanic blacks, AIANs, Chinese, Asian Indians, Filipinos, Japanese, Koreans, Vietnamese, Hawaiians, Samoans, and other Asian/Pacific Islanders, Mexicans, Puerto Ricans, Cubans, Central and South Americans, and other Hispanics. Immigrant status was defined on the basis of mothers’ place of birth [6, 18, 19]. US-born were those born in one of the 50 states or Washington, DC. Immigrants or foreign-born refer to those born outside these territories [6, 18, 19]. The joint variable of ethnic-immigrant status included 31 categories, with each racial/ethnic group divided into the US-born and foreign-born categories. Note that although AIANs, Hawaiians, and Samoans are considered native-born in the present analysis, a small percentage of AIANs and Hawaiians and 33% of Samoans are born outside the 50 states and Washington, DC [6, 19].In addition to race/ethnicity and immigrant status, we considered the following sociodemographic factors that have been associated with obesity risk and were available in the natality files: maternal age, parity, marital status, metropolitan/nonmetropolitan residence, geographic region of residence, and maternal education [3, 4, 12, 13, 15, 16]. These covariates were measured as shown in Tables 1 and 2.Table 1
Observed prevalence and logistic regressions showing unadjusted and covariate-adjusted differentials in pre-pregnancy obesity (BMI ≥30) among reproductive-age women in major racial/ethnic groups and by selected sociodemographic characteristics, United States, 2012–2014 (N=10,431,092)
Covariate
Number of births
Prevalence percent
Prevalence ratio
Model 11
Model 22
Covariate-adjusted
OR
95% CI
OR
95% CI
Prevalence
SE
Race/ethnicity
Non-Hispanic white
57,28,722
22.31
1.00
1.00
Reference
1.00
Reference
21.09
0.02
Non-Hispanic black
15,23,283
33.94
1.52∗
1.79
1.79
1.79
1.82
1.82
1.82
32.25
0.04
American Indian/AN
96,037
34.86
1.56∗
1.86
1.86
1.87
1.65
1.64
1.65
30.19
0.14
Chinese
1,44,479
2.58
0.12∗
0.09
0.09
0.10
0.17
0.17
0.18
4.57
0.07
Japanese
18,074
4.25
0.19∗
0.15
0.15
0.16
0.25
0.24
0.27
6.54
0.22
Filipino
83,470
10.94
0.49∗
0.43
0.43
0.43
0.68
0.67
0.68
15.50
0.14
Hawaiian
2,041
32.44
1.45∗
1.67
1.57
1.79
1.58
1.48
1.69
29.32
0.96
Asian Indian
1,63,921
9.25
0.41∗
0.36
0.35
0.36
0.76
0.76
0.76
16.99
0.12
Korean
42,101
4.80
0.22∗
0.18
0.17
0.18
0.32
0.32
0.33
8.17
0.17
Vietnamese
59,579
3.26
0.15∗
0.12
0.11
0.12
0.18
0.17
0.18
4.68
0.10
Samoan
5,336
60.23
2.70∗
5.28
5.11
5.44
6.10
5.91
6.30
60.08
0.66
Other API
1,55,158
15.64
0.70∗
0.65
0.64
0.65
0.90
0.89
0.90
19.37
0.11
Mexican
14,91,966
27.95
1.25∗
1.35
1.35
1.35
1.66
1.66
1.66
30.29
0.04
Puerto Rican
1,61,294
28.60
1.28∗
1.40
1.39
1.40
1.52
1.51
1.52
28.51
0.11
Cuban
51,202
18.98
0.85∗
0.82
0.81
0.82
1.05
1.05
1.06
21.95
0.19
Central/South American
3,17,066
19.92
0.89∗
0.87
0.87
0.87
1.26
1.26
1.26
25.04
0.09
Other Hispanics
3,87,363
27.04
1.21∗
1.29
1.29
1.29
1.48
1.48
1.48
28.09
0.07
Maternal age (years)
<20
7,35,009
16.06
1.00
1.00
Reference
1.00
Reference
12.47
0.04
20–24
23,75,337
24.74
1.54∗
1.72
1.71
1.73
1.84
1.83
1.86
20.42
0.03
25–29
29,91,749
25.54
1.59∗
1.79
1.78
1.81
2.51
2.49
2.53
25.58
0.03
30–34
27,47,472
23.89
1.49∗
1.64
1.63
1.65
2.81
2.79
2.83
27.66
0.03
35–39
12,75,698
25.31
1.58∗
1.77
1.76
1.78
3.22
3.20
3.25
30.31
0.05
40–44
2,84,881
26.63
1.66∗
1.90
1.88
1.92
3.47
3.43
3.51
31.77
0.09
≥45
20,946
23.34
1.45∗
1.59
1.54
1.64
3.15
3.04
3.26
29.84
0.33
Parity
0
41,06,378
20.18
1.00
1.00
Reference
1.00
Reference
22.72
0.02
1
33,02,759
24.38
1.21∗
1.27
1.27
1.28
1.12
1.12
1.13
24.72
0.02
2
17,36,143
27.81
1.38∗
1.52
1.51
1.53
1.15
1.14
1.15
25.10
0.03
3
7,36,876
31.06
1.54∗
1.78
1.77
1.79
1.20
1.19
1.21
25.92
0.05
≥4
5,07,957
34.17
1.69∗
2.05
2.03
2.06
1.23
1.22
1.24
26.41
0.06
Marital status
Married
62,25,913
22.29
1.00
1.00
Reference
1.00
Reference
24.03
0.02
Unmarried
42,05,179
27.16
1.22∗
1.30
1.30
1.30
1.03
1.03
1.03
24.54
0.02
Nativity/immigrant status
US-born
81,19,717
26.10
1.47∗
1.64
1.64
1.65
1.86
1.85
1.87
26.45
0.02
Foreign-born
22,80,862
17.71
1.00
1.00
Reference
1.00
Reference
16.62
0.03
Maternal education (years)
<12
16,33,121
25.53
1.60∗
1.80
1.80
1.81
2.02
2.01
2.03
27.55
0.04
12
25,69,666
28.18
1.76∗
2.07
2.06
2.07
2.09
2.08
2.10
28.23
0.03
13–15
30,44,340
28.73
1.80∗
2.12
2.11
2.13
1.99
1.98
2.00
27.25
0.03
≥16
30,79,059
15.97
1.00
1.00
Reference
1.00
Reference
16.17
0.02
Place of residence
Metropolitan county
81,60,502
23.16
1.00
1.00
Reference
1.00
Reference
23.33
0.02
Non-metropolitan county
22,70,590
28.19
1.22∗
1.30
1.30
1.31
1.26
1.25
1.26
27.43
0.03
Region of residence
New England
2,71,499
20.44
0.94∗
0.93
0.92
0.94
1.16
1.15
1.18
23.81
0.08
Mid-Atlantic
10,98,599
21.61
0.99∗
0.99
0.99
1.00
1.15
1.14
1.15
23.53
0.04
East Northcentral
16,27,751
26.33
1.21∗
1.29
1.28
1.30
1.34
1.33
1.35
26.25
0.03
West Northcentral
8,04,150
25.21
1.16∗
1.22
1.21
1.22
1.26
1.25
1.27
25.15
0.05
South Atlantic
19,61,847
24.84
1.14∗
1.19
1.18
1.20
1.19
1.18
1.20
24.19
0.03
East Southcentral
5,38,839
27.43
1.26∗
1.36
1.35
1.37
1.28
1.27
1.29
25.44
0.06
West Southcentral
15,43,133
25.24
1.16∗
1.22
1.21
1.23
1.16
1.15
1.17
23.74
0.03
Mountain
7,35,534
21.72
1.00
1.00
Reference
1.00
Reference
21.29
0.05
Pacific
18,49,740
22.78
1.05∗
1.06
1.06
1.07
1.17
1.16
1.18
23.89
0.03
OR = odds ratio; CI = confidence interval; AN = Alaska Native; API = Asian/Pacific Islander.∗Statistically significant at p<0.05. 1Unadjusted for the effects of other covariates. 2Adjusted for race/ethnicity, maternal age, parity, marital status, nativity, maternal education, and place and region of residence. Source: data derived from the 2012–2014 US National Natality data files.Table 2
Observed prevalence and logistic regressions showing unadjusted and covariate-adjusted differentials in pre-pregnancy overweight or obesity (BMI ≥25) among reproductive-age women in major racial/ethnic groups and by selected sociodemographic characteristics, United States, 2012–2014 (N=10,431,092).
Covariate
Prevalence percent
Prevalence ratio
Model 11
Model 22
Covariate-adjusted
OR
95% CI
OR
95% CI
Prevalence
SE
Race/ethnicity
Non-Hispanic white
46.37
1.00
1.00
Reference
1.00
Reference
45.15
0.02
Non-Hispanic black
60.88
1.31∗
1.80
1.80
1.80
1.86
1.86
1.86
59.92
0.04
American Indian/Alaska Native
61.69
1.33∗
1.86
1.85
1.87
1.73
1.72
1.73
58.22
0.16
Chinese
13.63
0.29∗
0.18
0.18
0.19
0.27
0.26
0.27
18.57
0.12
Japanese
15.20
0.33∗
0.21
0.20
0.21
0.27
0.27
0.28
18.91
0.31
Filipino
34.27
0.74∗
0.60
0.60
0.61
0.79
0.79
0.80
39.66
0.17
Hawaiian
61.29
1.32∗
1.83
1.70
1.97
1.76
1.63
1.90
58.72
1.08
Asian Indian
35.94
0.78∗
0.65
0.65
0.65
1.07
1.07
1.08
46.82
0.13
Korean
19.26
0.42∗
0.28
0.27
0.28
0.40
0.40
0.41
25.40
0.23
Vietnamese
14.84
0.32∗
0.20
0.20
0.20
0.25
0.25
0.25
17.57
0.17
Samoan
86.28
1.86∗
7.27
6.82
7.75
7.95
7.45
8.48
86.02
0.48
Other Asian/Pacific Islander
40.38
0.87∗
0.78
0.78
0.79
0.95
0.95
0.96
43.97
0.13
Mexican
57.95
1.25∗
1.59
1.59
1.59
1.81
1.81
1.81
59.36
0.05
Puerto Rican
55.41
1.19∗
1.44
1.43
1.44
1.56
1.56
1.56
55.82
0.12
Cuban
46.44
1.00∗
1.00
0.99
1.01
1.19
1.18
1.20
49.37
0.22
Central and South American
50.93
1.10∗
1.20
1.20
1.20
1.48
1.48
1.48
54.53
0.09
Other Hispanic
55.18
1.19∗
1.42
1.42
1.43
1.61
1.61
1.61
56.55
0.08
Maternal age (years)
<20
38.47
1.00
1.00
Reference
1.00
Reference
32.78
0.06
20–24
49.54
1.29∗
1.57
1.56
1.58
1.67
1.66
1.67
44.11
0.03
25–29
51.26
1.33∗
1.68
1.67
1.69
2.26
2.25
2.27
51.23
0.03
30–34
49.74
1.29∗
1.58
1.57
1.59
2.52
2.50
2.54
53.79
0.03
35–39
52.09
1.35∗
1.74
1.73
1.75
2.88
2.86
2.90
56.86
0.05
40–44
54.78
1.42∗
1.94
1.92
1.96
3.20
3.17
3.23
59.28
0.09
≥45
52.05
1.35∗
1.74
1.69
1.78
3.07
2.98
3.16
58.32
0.33
Parity
0
43.75
1.00
1.00
Reference
1.00
Reference
47.33
0.03
1
50.10
1.15∗
1.29
1.29
1.29
1.14
1.14
1.15
50.46
0.03
2
55.18
1.26∗
1.58
1.58
1.59
1.19
1.19
1.20
51.53
0.04
3
59.63
1.36∗
1.90
1.89
1.91
1.28
1.27
1.28
53.12
0.06
≥4
63.14
1.44∗
2.20
2.19
2.22
1.33
1.32
1.34
54.06
0.07
Marital status
Married
47.63
1.00
1.00
Reference
1.00
Reference
49.61
0.02
Unmarried
52.92
1.11∗
1.24
1.23
1.24
1.02
1.01
1.02
50.00
0.03
Nativity/immigrant status
US-born
51.00
1.12∗
1.25
1.25
1.26
1.44
1.43
1.45
51.57
0.02
Foreign-born
45.39
1.00
1.00
Reference
1.00
Reference
43.06
0.04
Maternal education (years)
<12
52.95
1.33∗
1.71
1.70
1.72
1.75
1.74
1.76
53.58
0.04
12
53.83
1.36∗
1.77
1.76
1.78
1.78
1.77
1.79
53.98
0.03
13–15
54.88
1.38∗
1.85
1.84
1.85
1.76
1.75
1.76
53.69
0.03
≥16
39.70
1.00
1.00
Reference
1.00
Reference
40.37
0.03
Place of residence
Metropolitan county
48.72
1.00
1.00
Reference
1.00
Reference
48.69
0.02
Nonmetropolitan county
53.54
1.10∗
1.21
1.21
1.22
1.23
1.23
1.23
53.56
0.03
Region of residence
New England
45.21
0.97∗
0.94
0.93
0.95
1.16
1.15
1.17
49.54
0.09
Mid-Atlantic
46.65
1.00
1.00
0.99
1.00
1.13
1.13
1.14
49.01
0.05
East Northcentral
52.05
1.11∗
1.24
1.23
1.24
1.31
1.31
1.32
52.50
0.04
West Northcentral
50.96
1.09∗
1.18
1.18
1.19
1.26
1.25
1.26
51.43
0.06
South Atlantic
50.34
1.08∗
1.16
1.15
1.16
1.16
1.15
1.17
49.57
0.04
East Southcentral
51.99
1.11∗
1.23
1.23
1.24
1.22
1.21
1.23
50.70
0.07
West Southcentral
50.78
1.09∗
1.18
1.17
1.18
1.11
1.10
1.11
48.44
0.04
Mountain
46.74
1.00
1.00
Reference
1.00
Reference
46.09
0.06
Pacific
48.86
1.05∗
1.09
1.08
1.09
1.16
1.16
1.17
49.60
0.04
OR = odds ratio; CI = confidence interval.∗Statistically significant at p<0.05. 1Unadjusted for the effects of other covariates. 2Adjusted for race/ethnicity, maternal age, parity, marital status, nativity, maternal education, and place and region of residence. Source: data derived from the 2012–2014 US National Natality data files.Multivariate logistic regression was used to model the adjusted association between each sociodemographic characteristic and the risk of pre-pregnancy obesity and overweight [21]. In estimating odds of obesity or overweight for race/ethnicity and ethnic-immigrant status, we considered white women or US-born white women as the reference group based on prior research and because they represent the majority population [1, 19].We used root-mean-square deviation (RMSD) as a summary measure of health disparities among 17 racial/ethnic and 31 ethnic-immigrant groups [4]. The RMSD is similar to the square root of the variance, except that the average-squared deviations are calculated using a “standard” estimate other than the sample mean. The RMSD is given by the formula:(1)RMSD=SQRT∑iOri−Orl2I,where Ori is the obesity or overweight/obesity prevalence for the ith group i=1,2,and,31,Orl is the corresponding statistic for the “standard” group (total US population) or group with the lowest prevalence (i.e., Chinese women), and I is the number of racial/ethnic (17) or ethnic-immigrant groups (31) being compared.While RMSD is a measure of absolute health disparity, the coefficient of variation (CV) of the RMSD provides an estimate of relative disparity and is given by(2)CVRMSD=RMSDOrl×100,Orl>0.In both the obesity and overweight/obesity models, we examined interactions of race/ethnicity with nativity and maternal education by estimating logistic models that included the joint variables of ethnicity-immigrant status and race/ethnicity-education. Fitted logistic models were used to derive adjusted obesity and overweight prevalence at mean values of the covariates [4, 21].


## 3. Results

### 3.1. Racial/Ethnic Disparities in Pre-Pregnancy Obesity and Overweight

During 2012–2014, the overall prevalence of pre-pregnancy obesity and overweight/obesity among US mothers was 24.3% and 49.8%, respectively. Of all racial/ethnic groups, Samoan women had the highest prevalence of pre-pregnancy obesity (60.2%), followed by AIANs (34.9%), blacks (33.9%), Hawaiians (32.4%), Puerto Ricans (28.6%), and Mexicans (28.0%) (Table1). Chinese women had the lowest pre-pregnancy obesity prevalence at 2.6%. Indeed, all Asian subgroups, including Chinese, Japanese, Vietnamese, Koreans, Asian Indians, and Filipinos, had markedly lower pre-pregnancy obesity prevalence than non-Hispanic whites (22.3%). Mexicans and Puerto Ricans had significantly higher prevalence of pre-pregnancy obesity than non-Hispanic white women.Pre-pregnancy overweight/obesity prevalence ranged from a low of 13.6% for Chinese women to 61.7% for AIANs and 86.3% for Samoans (Table2). Overweight/obesity prevalence exceeded 55% for Puerto Ricans, Mexicans, Hawaiians, and blacks but was lower than 20% for Vietnamese, Japanese, and Korean mothers. The overall prevalence of severe pre-pregnancy obesity among US mothers was 4.4% (Figure 1). Chinese women had the lowest prevalence of severe obesity (0.1%), with all major Asian subgroups reporting a prevalence of <1%. Samoans had the highest prevalence of severe obesity (16.0%), followed by blacks (7.7%), AIANs (6.6%), Hawaiians (6.5%), and Puerto Ricans (5.4%).Figure 1
Racial/ethnic disparities in observed and adjusted1 prevalence (%) of severe pre-pregnancy obesity (BMI ≥40) among US women, 2012–2014. 1Adjusted for maternal age, parity, marital status, nativity/immigrant status, maternal education, and place and region of residence.Racial/ethnic groups varied greatly in their sociodemographic characteristics that are associated with pre-pregnancy obesity (Table3). For example, while <12% of births occurred among AIAN, Puerto Rican, and black mothers aged ≥35 years, this percentage was 35% among Chinese and 49% among Japanese mothers. More than 19% of Hawaiian, Samoan, and AIAN mothers reported previously having 4 or more births, compared to <3% of Chinese and Asian Indian mothers. Educational attainment was highest among Asian Indian and Korean women and lowest among Mexican and Samoan women. The percentage of mothers with a college degree ranged from 75.3% for Koreans and 77.0% for Asian Indians to 7.5% for Samoans, 8.4% for Mexicans, and 9.3% for AIANs. More than 87% of Chinese and Asian Indian mothers were foreign-born, compared with 6.2% of non-Hispanic whites and 14.2% of blacks. The proportion of births outside marriage was much higher among blacks, AIANs, and Hispanics compared to white and Asian women. The percentage of unmarried mothers ranged from 3.5% for Asian Indians and 7.0% for Japanese to 63.4% for Puerto Ricans, 66.3% for AIANs, and 71.4% for blacks. More than 55% of Hawaiian, Japanese, Filipino, and Samoan mothers resided in the Western region, compared to 7.7% of Puerto Ricans and 8.7% of blacks.Table 3
Racial/ethnic variation in selected sociodemographic risk factors for pre-pregnancy overweight or obesity among women, United States, 2012–2014 (N=10,431,092).
Race/ethnicity
Maternal age <20 years
Maternal age ≥35 years
Parity ≥4
Maternal education <12 years
Maternal education ≥16 years
Unmarried mother
Foreign-born
Western or Pacific region
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
All races
7.1
15.2
11.9
15.9
30.5
40.3
21.9
24.8
Non-Hispanic white
5.1
15.4
9.8
8.4
38.8
29.34
6.15
20.18
Non-Hispanic black
10.8
11.8
15.8
17.7
15.0
71.40
14.21
8.67
American Indian/AN
12.3
9.2
20.4
22.5
9.3
66.26
1.37
43.92
Chinese
0.3
31.1
2.0
9.1
66.1
11.21
87.29
47.07
Japanese
0.4
48.5
3.6
1.1
66.9
6.95
76.15
56.11
Filipino
1.5
31.5
7.0
2.3
53.8
20.09
73.75
62.59
Asian Indian
0.5
17.8
2.9
4.8
77.0
3.50
90.09
28.14
Korean
0.4
34.9
3.3
0.8
75.3
7.24
80.97
43.67
Vietnamese
1.2
30.2
5.7
11.9
38.7
19.94
83.72
45.94
Hawaiian
6.4
13.9
19.0
12.8
18.0
46.94
5.07
55.76
Samoan
6.3
12.8
26.8
11.9
7.5
39.45
32.38
86.24
Other API
4.1
17.8
13.3
16.8
34.3
28.79
62.52
41.11
Mexican
11.2
13.8
17.7
37.8
8.4
51.49
51.13
47.89
Puerto Rican
11.7
11.4
12.8
21.7
14.6
63.42
18.26
7.72
Cuban
4.7
17.5
5.4
9.0
25.1
50.21
52.56
8.43
Central/South American
5.9
20.2
13.6
38.6
17.4
49.65
82.75
22.90
Other Hispanic
12.5
11.4
13.0
24.8
12.9
55.96
26.81
41.06
Source: data derived from the 2012–2014 US National Natality data files. AN = Alaska Native.After controlling for sociodemographic factors, Central/South Americans, Puerto Ricans, Mexicans, Hawaiians, AIANs, and non-Hispanic blacks had 26–82% higher odds of pre-pregnancy obesity and 48–86% higher odds of overweight/obesity compared to non-Hispanic white women (Tables1 and 2). Samoans had 6.1 times higher adjusted odds of pre-pregnancy obesity and 8.0 times higher adjusted odds of overweight/obesity compared to non-Hispanic whites. Blacks and Samoans, respectively, had 2.0 and 5.7 times higher adjusted odds of severe obesity than non-Hispanic whites (data not shown).Non-Hispanic white women, on the other hand, had 5.8 higher adjusted odds of pre-pregnancy obesity, 3.7 times higher adjusted odds of overweight/obesity, and 14.3 times higher adjusted odds of severe obesity compared to Chinese women. Indeed, compared to non-Hispanic whites, women in all Asian subgroups had 21–93% lower odds of pre-pregnancy obesity, severe obesity, and overweight/obesity.Tables1 and 2 show variation in prevalence and odds of pre-pregnancy obesity and overweight/obesity according to other sociodemographic characteristics. Increasing maternal age and parity, lower education, US-born status, nonmetropolitan residence, and residence in the Midwest and Southern regions were independently associated with pre-pregnancy obesity and overweight. Mothers aged 40–44 years had 3.5 times higher adjusted odds of pre-pregnancy obesity and 3.2 times higher adjusted odds of overweight/obesity than those aged <20 years. US-born mothers had 86% higher adjusted odds of pre-pregnancy obesity and 35% higher odds of overweight/obesity than immigrant mothers. Mothers in the Midwest and Southeast regions had 22–34% higher adjusted odds of pre-pregnancy obesity and overweight/obesity than those in the Mountain region. Mothers with lower education levels had two times higher adjusted odds of pre-pregnancy obesity than those with a college degree. Risk of pre-pregnancy obesity and overweight/obesity increased consistently with increasing maternal parity. Based on disparity indices, sociodemographic factors accounted for 33%, 47%, and 61% of the racial/ethnic disparities in pre-pregnancy overweight/obesity, obesity, and severe obesity, respectively.


### 3.2. Ethnic-Immigrant Disparities in Pre-Pregnancy Obesity and Overweight/Obesity

Pre-pregnancy obesity ranged from 1.9% for Chinese immigrants to 35.7% for US-born blacks and 60.2% for Samoans (Table4). US-born Chinese women had 3.7 times higher risk of obesity than Chinese immigrants, while US-born black women had 51% higher risk of obesity than immigrant black women. Overweight/obesity prevalence ranged from 10.5% for Japanese immigrants and 12.1% for Chinese immigrants to 61.7% for US-born blacks and AIANs and 86.3% for Samoans (Table 5). US-born Chinese and Japanese women had 2 and 3 times higher risks of overweight/obesity compared to their foreign-born counterparts, respectively. Prevalence of severe pre-pregnancy obesity varied from a low of <0.50% for Chinese, Japanese, Vietnamese, Korean, Asian Indian, and Filipino immigrants to a high of 8.6% for US-born blacks and 16.0% for Samoans (Figure 2).Table 4
Observed prevalence and adjusted odds and prevalence of pre-pregnancy obesity (BMI ≥30) among women in 31 ethnic-immigrant groups, United States, 2012–2014 (N=10,431,092).
Ethnic-immigrant group
Number of births
Prevalence percent
Prevalence ratio
Model 11
Model 22
Covariate-adjusted
OR
95% CI
OR
95% CI
Prevalence
SE
Non-Hispanic white, US-born
53,65,062
22.94
1.00
1.00
Reference
1.00
Reference
23.16
0.02
Non-Hispanic white, immigrant
3,51,397
12.74
0.56∗
0.49
0.49
0.50
0.51
0.51
0.52
13.56
0.06
Non-Hispanic black, US-born
12,97,869
35.68
1.56∗
1.86
1.86
1.87
1.83
1.82
1.84
35.10
0.05
Non-Hispanic black, immigrant
2,14,957
23.61
1.03∗
1.04
1.03
1.05
0.94
0.93
0.95
22.14
0.09
American Indian/Alaska Native
96,037
34.86
1.52∗
1.80
1.77
1.82
1.63
1.61
1.66
32.67
0.15
Chinese, US-born
18,330
7.09
0.31∗
0.26
0.24
0.27
0.34
0.32
0.36
9.45
0.24
Chinese, immigrant
1,25,839
1.92
0.08∗
0.07
0.06
0.07
0.07
0.07
0.08
2.25
0.05
Japanese, US-born
4,305
10.76
0.47∗
0.41
0.37
0.45
0.49
0.44
0.54
12.99
0.55
Japanese, immigrant
13,746
2.22
0.10∗
0.08
0.07
0.09
0.08
0.07
0.09
2.43
0.14
Hawaiian
2,041
32.44
1.41∗
1.61
1.47
1.77
1.53
1.39
1.68
31.26
1.00
Filipino, US-born
21,876
17.51
0.76∗
0.71
0.69
0.74
0.81
0.78
0.84
19.64
0.28
Filipino, immigrant
61,472
8.61
0.38∗
0.32
0.31
0.33
0.33
0.32
0.34
9.23
0.12
Asian Indian, US-born
16,211
11.59
0.51∗
0.44
0.42
0.46
0.58
0.55
0.60
14.93
0.31
Asian Indian, immigrant
1,47,308
8.99
0.39∗
0.33
0.33
0.34
0.43
0.42
0.43
11.57
0.09
Korean, US-born
7,800
6.83
0.30∗
0.25
0.23
0.27
0.32
0.29
0.34
8.85
0.36
Korean, immigrant
33,191
4.27
0.19∗
0.15
0.14
0.16
0.18
0.17
0.19
5.19
0.13
Vietnamese, US-born
9,682
9.22
0.40∗
0.34
0.32
0.37
0.40
0.38
0.43
10.99
0.34
Vietnamese, immigrant
49,791
2.10
0.09∗
0.07
0.07
0.08
0.07
0.06
0.07
1.99
0.06
Samoan
5,336
60.23
2.63∗
5.09
4.82
5.37
4.95
4.68
5.23
58.51
0.66
Other API, US-born
57,723
21.18
0.92∗
0.90
0.88
0.92
0.97
0.95
0.99
22.64
0.18
Other API, immigrant
96,281
12.31
0.54∗
0.47
0.46
0.48
0.45
0.44
0.46
12.11
0.10
Mexican, US-born
7,28,465
31.16
1.36∗
1.52
1.51
1.53
1.61
1.60
1.62
32.33
0.06
Mexican, immigrant
7,62,159
24.88
1.08∗
1.11
1.11
1.12
0.92
0.92
0.93
21.77
0.05
Puerto Rican, mainland US-born
1,30,522
29.13
1.27∗
1.38
1.36
1.40
1.40
1.38
1.42
29.47
0.13
Puerto Rican, Puerto Rico-born
29,148
26.33
1.15∗
1.20
1.17
1.23
1.21
1.18
1.24
26.60
0.26
Cuban, US-born
24,274
24.00
1.05∗
1.06
1.03
1.09
1.14
1.11
1.17
25.48
0.28
Cuban, immigrant
26,898
14.44
0.63∗
0.57
0.55
0.59
0.51
0.50
0.53
13.58
0.20
Central/South American, US-born
54,615
25.78
1.12∗
1.17
1.15
1.19
1.32
1.30
1.35
28.33
0.20
Central/South American, immigrant
2,61,909
18.70
0.81∗
0.77
0.77
0.78
0.67
0.66
0.68
16.94
0.07
Other Hispanic, US-born
2,82,921
29.39
1.28∗
1.40
1.39
1.41
1.49
1.47
1.50
30.68
0.09
Other Hispanic, immigrant
1,03,647
20.62
0.90∗
0.87
0.86
0.89
0.79
0.77
0.80
19.25
0.12
OR = odds ratio; CI = confidence interval; API = Asian/Pacific Islander.∗Statistically significant at p<0.05. 1Unadjusted for the effects of other covariates. 2Adjusted for race/ethnicity, maternal age, parity, marital status, nativity, maternal education, and place and region of residence. Source: data derived from the 2012–2014 US National Natality data files.Table 5
Observed prevalence and adjusted odds and prevalence of pre-pregnancy overweight or obesity (BMI ≥25) among women in 31 ethnic-immigrant groups, United States, 2012–2014 (N=10,431,092)
Ethnic-immigrant group
Prevalence percent
Prevalence ratio
Model 11
Model 22
Covariate-adjusted
OR
95% CI
OR
95% CI
Prevalence
SE
Non-Hispanic white, US-born
47.06
1.00
1.00
Reference
1.00
Reference
47.17
0.02
Non-Hispanic white, immigrant
35.87
0.76∗
0.63
0.63
0.63
0.64
0.64
0.65
36.80
0.08
Non-Hispanic black, US-born
61.70
1.31∗
1.81
1.81
1.82
1.84
1.83
1.85
61.66
0.05
Non-Hispanic black, immigrant
56.11
1.19∗
1.44
1.43
1.45
1.32
1.31
1.34
53.93
0.11
American Indian/Alaska Native
61.69
1.31∗
1.81
1.79
1.84
1.71
1.69
1.73
60.01
0.16
Chinese, US-born
24.07
0.51∗
0.36
0.35
0.37
0.43
0.42
0.45
28.39
0.34
Chinese, immigrant
12.10
0.26∗
0.16
0.15
0.16
0.17
0.16
0.17
13.42
0.10
Japanese, US-born
30.27
0.64∗
0.49
0.46
0.52
0.55
0.51
0.59
33.27
0.72
Japanese, immigrant
10.48
0.22∗
0.13
0.13
0.14
0.13
0.12
0.14
10.91
0.27
Hawaiian
61.29
1.30∗
1.78
1.63
1.95
1.72
1.57
1.88
60.15
1.07
Filipino, US-born
43.79
0.93∗
0.88
0.85
0.90
0.96
0.93
0.98
46.10
0.33
Filipino, immigrant
30.90
0.66∗
0.50
0.49
0.51
0.51
0.50
0.52
31.62
0.19
Asian Indian, US-born
33.04
0.70∗
0.56
0.54
0.57
0.67
0.65
0.70
37.88
0.38
Asian Indian, immigrant
36.24
0.77∗
0.64
0.63
0.65
0.78
0.77
0.79
41.27
0.13
Korean, US-born
23.35
0.50∗
0.34
0.33
0.36
0.41
0.39
0.43
27.15
0.52
Korean, immigrant
18.22
0.39∗
0.25
0.24
0.26
0.28
0.27
0.29
20.38
0.23
Vietnamese, US-born
28.49
0.61∗
0.45
0.43
0.47
0.51
0.49
0.54
31.89
0.48
Vietnamese, immigrant
12.18
0.26∗
0.16
0.15
0.16
0.14
0.14
0.14
11.56
0.14
Samoan
86.28
1.83∗
7.07
6.54
7.64
6.97
6.44
7.54
85.52
0.49
Other API, US-born
46.42
0.99∗
0.97
0.96
0.99
1.04
1.02
1.06
48.07
0.20
Other API, immigrant
36.72
0.78∗
0.65
0.64
0.66
0.62
0.61
0.63
36.03
0.15
Mexican, US-born
58.45
1.24∗
1.58
1.57
1.59
1.73
1.72
1.73
60.22
0.06
Mexican, immigrant
57.47
1.22∗
1.52
1.51
1.53
1.31
1.30
1.32
53.68
0.06
Puerto Rican, mainland US-born
56.01
1.19∗
1.43
1.42
1.45
1.49
1.47
1.50
56.71
0.14
Puerto Rican, Puerto Rico-born
52.84
1.12∗
1.26
1.23
1.29
1.29
1.26
1.32
53.37
0.29
Cuban, US-born
50.45
1.07∗
1.15
1.12
1.18
1.23
1.20
1.26
52.22
0.32
Cuban, immigrant
42.81
0.91∗
0.84
0.82
0.86
0.80
0.78
0.82
41.71
0.30
Central/South American, US-born
53.73
1.14∗
1.31
1.28
1.33
1.49
1.47
1.52
56.82
0.21
Central/South American, immigrant
50.34
1.07∗
1.14
1.13
1.15
1.02
1.01
1.03
47.65
0.10
Other Hispanic, US-born
56.66
1.20∗
1.47
1.46
1.48
1.61
1.60
1.62
58.61
0.09
Other Hispanic, immigrant
51.12
1.09∗
1.18
1.16
1.19
1.09
1.08
1.11
49.30
0.15
OR = odds ratio; CI = confidence interval; API = Asian/Pacific Islander.∗Statistically significant at p<0.05. 1Unadjusted for the effects of other covariates. 2Adjusted for race/ethnicity, maternal age, parity, marital status, nativity, maternal education, and place and region of residence. Source: data derived from the 2012–2014 US National Natality data files.Figure 2
Ethnic-immigrant disparities in observed and adjusted1 prevalence (%) of severe pre-pregnancy obesity (BMI ≥40) among US women, 2012–2014. 1Adjusted for maternal age, parity, marital status, maternal education, and place and region of residence.Ethnic-immigrant disparities in obesity risks were greater than disparities shown by race/ethnicity alone. Compared with US-born whites, the adjusted odds of obesity were 49% lower for white immigrants, 83% higher for US-born blacks, 6% lower for black immigrants, 61% higher for US-born Mexicans, and 8% lower for Mexican immigrants (Table4). Compared with US-born whites, all US-born and foreign-born Asian subgroups had 19–93% lower adjusted odds of obesity. Compared with US-born whites, the adjusted odds of overweight/obesity were 36% lower for white immigrants, 83% lower for Chinese immigrants, and 57% lower for US-born Chinese (Table 5). All Asian nativity groups had significantly lower adjusted risks of overweight/obesity than US-born whites. Compared with US-born whites, the adjusted odds of severe obesity were 4.2 times higher for Samoans, 2.1 times higher for US-born blacks, and 1.2 times higher for AIANs. However, compared with US-born whites, the adjusted odds of severe obesity was 68% lower for white immigrants and 52% lower for black immigrants. All Asian nativity groups had considerably lower adjusted risks of severe obesity than US-born whites (data not shown). Sociodemographic factors accounted for 12%, 16%, and 21% of ethnic-immigrant disparities in pre-pregnancy overweight/obesity, obesity, and severe obesity, respectively.


### 3.3. Ethnic-Specific Educational Gradients in Pre-Pregnancy Obesity and Overweight

Marked educational inequalities in pre-pregnancy obesity and overweight/obesity were generally found for all broad racial/ethnic groups, with mothers with less than a college education having significantly higher obesity and overweight/obesity prevalence than their counterparts with a college degree (Table6). Obesity prevalence ranged from 6.2% for API women with a college degree to over 37% for black and AIAN women with 13–15 years of education. Overweight/obesity prevalence ranged from 25.3% for API women with a college degree to over 64% for black and AIAN women with 13–15 years of education. Compared with API women with a college degree, the adjusted odds of obesity were almost 4 times higher for white women with less than a college degree and 5–7 times higher for Hispanic, AIAN, and black women with less than a college degree. The patterns in overweight/obesity risks were similar. Within each educational stratum, significant racial/ethnic disparities in obesity and overweight risks existed.Table 6
Observed and adjusted prevalence and odds of pre-pregnancy obesity and overweight/obesity among women in 15 joint racial/ethnic and education groups, United States, 2012-2014 (N=10,326,186)
Racial/ethnic-education group
Observed prevalence1
Adjusted odds ratio2
Adjusted prevalence2
%
SE
OR
95% CI
%
SE
Pre-pregnancy obesity (BMI ≥30)
Non-Hispanic white, education ≤12 years
26.15
0.03
3.92
3.87
3.98
25.74
0.04
Non-Hispanic white, education 13–15 years
27.11
0.03
3.62
3.57
3.67
24.26
0.03
Non-Hispanic white, education 16+ years
15.52
0.02
1.68
1.65
1.70
13.12
0.02
Non-Hispanic black, education ≤12 years
32.41
0.05
6.07
5.98
6.16
34.60
0.06
Non-Hispanic black, education 13–15 years
37.11
0.07
6.56
6.46
6.66
36.32
0.07
Non-Hispanic black, education 16+ years
32.04
0.10
5.03
4.95
5.11
30.60
0.10
American Indian/AN, education ≤12 years
34.43
0.20
5.92
5.79
6.06
34.07
0.20
American Indian/AN, education 13–15 years
37.60
0.27
5.84
5.68
6.00
33.75
0.26
American Indian/AN, education 16+ years
28.05
0.48
3.43
3.27
3.60
23.33
0.41
Hispanic, education ≤12 years
26.84
0.04
5.92
5.84
6.01
34.06
0.05
Hispanic, education 13–15 years
29.26
0.06
5.29
5.22
5.37
31.67
0.06
Hispanic, education 16+ years
19.49
0.08
2.85
2.80
2.90
20.24
0.08
Asian/Pacific Islander, education ≤12 years
12.30
0.09
2.37
2.33
2.42
17.52
0.11
Asian/Pacific Islander, education 13–15 years
13.00
0.09
2.26
2.22
2.31
16.85
0.12
Asian/Pacific Islander, education 16+ years
6.22
0.04
1.00
Reference
8.31
0.05
Pre-pregnancy overweight or obesity (BMI ≥25)
Non-Hispanic white, education ≤12 years
49.82
0.04
2.62
2.60
2.64
50.22
0.04
Non-Hispanic white, education 13-15 years
52.43
0.04
2.55
2.52
2.57
49.52
0.04
Non-Hispanic white, education 16+ years
38.85
0.03
1.36
1.35
1.37
34.74
0.04
Non-Hispanic black, education ≤12 years
58.00
0.06
4.09
4.05
4.13
60.84
0.06
Non-Hispanic black, education 13–15 years
64.22
0.07
4.67
4.63
4.72
63.88
0.07
Non-Hispanic black, education 16+ years
63.11
0.10
4.14
4.10
4.19
61.14
0.10
American Indian/AN, education ≤12 years
60.58
0.21
4.18
4.10
4.26
61.34
0.21
American Indian/AN, education 13–15 years
65.36
0.27
4.39
4.28
4.50
62.48
0.27
American Indian/AN, education 16+ years
55.79
0.53
2.65
2.54
2.76
50.46
0.52
Hispanic, education ≤12 years
57.04
0.04
4.47
4.43
4.50
62.85
0.04
Hispanic, education 13–15 years
58.01
0.07
3.98
3.94
4.02
60.21
0.06
Hispanic, education 16+ years
46.91
0.10
2.28
2.26
2.31
46.90
0.10
Asian/Pacific Islander, education ≤12 years
32.89
0.12
1.60
1.58
1.62
38.45
0.13
Asian/Pacific Islander, education 13–15 years
34.58
0.13
1.60
1.58
1.62
38.50
0.14
Asian/Pacific Islander, education 16+ years
25.27
0.07
1.00
Reference
28.33
0.08
OR = odds ratio; SE = standard error; CI = confidence interval; AN = Alaska Native.1Weighted prevalence. 2Adjusted prevalence was derived from fitted logistic regression models that included the joint variable of race/ethnicity and education, age, parity, marital status, nativity, and place and region of residence.


## 3.1. Racial/Ethnic Disparities in Pre-Pregnancy Obesity and Overweight

During 2012–2014, the overall prevalence of pre-pregnancy obesity and overweight/obesity among US mothers was 24.3% and 49.8%, respectively. Of all racial/ethnic groups, Samoan women had the highest prevalence of pre-pregnancy obesity (60.2%), followed by AIANs (34.9%), blacks (33.9%), Hawaiians (32.4%), Puerto Ricans (28.6%), and Mexicans (28.0%) (Table1). Chinese women had the lowest pre-pregnancy obesity prevalence at 2.6%. Indeed, all Asian subgroups, including Chinese, Japanese, Vietnamese, Koreans, Asian Indians, and Filipinos, had markedly lower pre-pregnancy obesity prevalence than non-Hispanic whites (22.3%). Mexicans and Puerto Ricans had significantly higher prevalence of pre-pregnancy obesity than non-Hispanic white women.Pre-pregnancy overweight/obesity prevalence ranged from a low of 13.6% for Chinese women to 61.7% for AIANs and 86.3% for Samoans (Table2). Overweight/obesity prevalence exceeded 55% for Puerto Ricans, Mexicans, Hawaiians, and blacks but was lower than 20% for Vietnamese, Japanese, and Korean mothers. The overall prevalence of severe pre-pregnancy obesity among US mothers was 4.4% (Figure 1). Chinese women had the lowest prevalence of severe obesity (0.1%), with all major Asian subgroups reporting a prevalence of <1%. Samoans had the highest prevalence of severe obesity (16.0%), followed by blacks (7.7%), AIANs (6.6%), Hawaiians (6.5%), and Puerto Ricans (5.4%).Figure 1
Racial/ethnic disparities in observed and adjusted1 prevalence (%) of severe pre-pregnancy obesity (BMI ≥40) among US women, 2012–2014. 1Adjusted for maternal age, parity, marital status, nativity/immigrant status, maternal education, and place and region of residence.Racial/ethnic groups varied greatly in their sociodemographic characteristics that are associated with pre-pregnancy obesity (Table3). For example, while <12% of births occurred among AIAN, Puerto Rican, and black mothers aged ≥35 years, this percentage was 35% among Chinese and 49% among Japanese mothers. More than 19% of Hawaiian, Samoan, and AIAN mothers reported previously having 4 or more births, compared to <3% of Chinese and Asian Indian mothers. Educational attainment was highest among Asian Indian and Korean women and lowest among Mexican and Samoan women. The percentage of mothers with a college degree ranged from 75.3% for Koreans and 77.0% for Asian Indians to 7.5% for Samoans, 8.4% for Mexicans, and 9.3% for AIANs. More than 87% of Chinese and Asian Indian mothers were foreign-born, compared with 6.2% of non-Hispanic whites and 14.2% of blacks. The proportion of births outside marriage was much higher among blacks, AIANs, and Hispanics compared to white and Asian women. The percentage of unmarried mothers ranged from 3.5% for Asian Indians and 7.0% for Japanese to 63.4% for Puerto Ricans, 66.3% for AIANs, and 71.4% for blacks. More than 55% of Hawaiian, Japanese, Filipino, and Samoan mothers resided in the Western region, compared to 7.7% of Puerto Ricans and 8.7% of blacks.Table 3
Racial/ethnic variation in selected sociodemographic risk factors for pre-pregnancy overweight or obesity among women, United States, 2012–2014 (N=10,431,092).
Race/ethnicity
Maternal age <20 years
Maternal age ≥35 years
Parity ≥4
Maternal education <12 years
Maternal education ≥16 years
Unmarried mother
Foreign-born
Western or Pacific region
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
All races
7.1
15.2
11.9
15.9
30.5
40.3
21.9
24.8
Non-Hispanic white
5.1
15.4
9.8
8.4
38.8
29.34
6.15
20.18
Non-Hispanic black
10.8
11.8
15.8
17.7
15.0
71.40
14.21
8.67
American Indian/AN
12.3
9.2
20.4
22.5
9.3
66.26
1.37
43.92
Chinese
0.3
31.1
2.0
9.1
66.1
11.21
87.29
47.07
Japanese
0.4
48.5
3.6
1.1
66.9
6.95
76.15
56.11
Filipino
1.5
31.5
7.0
2.3
53.8
20.09
73.75
62.59
Asian Indian
0.5
17.8
2.9
4.8
77.0
3.50
90.09
28.14
Korean
0.4
34.9
3.3
0.8
75.3
7.24
80.97
43.67
Vietnamese
1.2
30.2
5.7
11.9
38.7
19.94
83.72
45.94
Hawaiian
6.4
13.9
19.0
12.8
18.0
46.94
5.07
55.76
Samoan
6.3
12.8
26.8
11.9
7.5
39.45
32.38
86.24
Other API
4.1
17.8
13.3
16.8
34.3
28.79
62.52
41.11
Mexican
11.2
13.8
17.7
37.8
8.4
51.49
51.13
47.89
Puerto Rican
11.7
11.4
12.8
21.7
14.6
63.42
18.26
7.72
Cuban
4.7
17.5
5.4
9.0
25.1
50.21
52.56
8.43
Central/South American
5.9
20.2
13.6
38.6
17.4
49.65
82.75
22.90
Other Hispanic
12.5
11.4
13.0
24.8
12.9
55.96
26.81
41.06
Source: data derived from the 2012–2014 US National Natality data files. AN = Alaska Native.After controlling for sociodemographic factors, Central/South Americans, Puerto Ricans, Mexicans, Hawaiians, AIANs, and non-Hispanic blacks had 26–82% higher odds of pre-pregnancy obesity and 48–86% higher odds of overweight/obesity compared to non-Hispanic white women (Tables1 and 2). Samoans had 6.1 times higher adjusted odds of pre-pregnancy obesity and 8.0 times higher adjusted odds of overweight/obesity compared to non-Hispanic whites. Blacks and Samoans, respectively, had 2.0 and 5.7 times higher adjusted odds of severe obesity than non-Hispanic whites (data not shown).Non-Hispanic white women, on the other hand, had 5.8 higher adjusted odds of pre-pregnancy obesity, 3.7 times higher adjusted odds of overweight/obesity, and 14.3 times higher adjusted odds of severe obesity compared to Chinese women. Indeed, compared to non-Hispanic whites, women in all Asian subgroups had 21–93% lower odds of pre-pregnancy obesity, severe obesity, and overweight/obesity.Tables1 and 2 show variation in prevalence and odds of pre-pregnancy obesity and overweight/obesity according to other sociodemographic characteristics. Increasing maternal age and parity, lower education, US-born status, nonmetropolitan residence, and residence in the Midwest and Southern regions were independently associated with pre-pregnancy obesity and overweight. Mothers aged 40–44 years had 3.5 times higher adjusted odds of pre-pregnancy obesity and 3.2 times higher adjusted odds of overweight/obesity than those aged <20 years. US-born mothers had 86% higher adjusted odds of pre-pregnancy obesity and 35% higher odds of overweight/obesity than immigrant mothers. Mothers in the Midwest and Southeast regions had 22–34% higher adjusted odds of pre-pregnancy obesity and overweight/obesity than those in the Mountain region. Mothers with lower education levels had two times higher adjusted odds of pre-pregnancy obesity than those with a college degree. Risk of pre-pregnancy obesity and overweight/obesity increased consistently with increasing maternal parity. Based on disparity indices, sociodemographic factors accounted for 33%, 47%, and 61% of the racial/ethnic disparities in pre-pregnancy overweight/obesity, obesity, and severe obesity, respectively.


## 3.2. Ethnic-Immigrant Disparities in Pre-Pregnancy Obesity and Overweight/Obesity

Pre-pregnancy obesity ranged from 1.9% for Chinese immigrants to 35.7% for US-born blacks and 60.2% for Samoans (Table4). US-born Chinese women had 3.7 times higher risk of obesity than Chinese immigrants, while US-born black women had 51% higher risk of obesity than immigrant black women. Overweight/obesity prevalence ranged from 10.5% for Japanese immigrants and 12.1% for Chinese immigrants to 61.7% for US-born blacks and AIANs and 86.3% for Samoans (Table 5). US-born Chinese and Japanese women had 2 and 3 times higher risks of overweight/obesity compared to their foreign-born counterparts, respectively. Prevalence of severe pre-pregnancy obesity varied from a low of <0.50% for Chinese, Japanese, Vietnamese, Korean, Asian Indian, and Filipino immigrants to a high of 8.6% for US-born blacks and 16.0% for Samoans (Figure 2).Table 4
Observed prevalence and adjusted odds and prevalence of pre-pregnancy obesity (BMI ≥30) among women in 31 ethnic-immigrant groups, United States, 2012–2014 (N=10,431,092).
Ethnic-immigrant group
Number of births
Prevalence percent
Prevalence ratio
Model 11
Model 22
Covariate-adjusted
OR
95% CI
OR
95% CI
Prevalence
SE
Non-Hispanic white, US-born
53,65,062
22.94
1.00
1.00
Reference
1.00
Reference
23.16
0.02
Non-Hispanic white, immigrant
3,51,397
12.74
0.56∗
0.49
0.49
0.50
0.51
0.51
0.52
13.56
0.06
Non-Hispanic black, US-born
12,97,869
35.68
1.56∗
1.86
1.86
1.87
1.83
1.82
1.84
35.10
0.05
Non-Hispanic black, immigrant
2,14,957
23.61
1.03∗
1.04
1.03
1.05
0.94
0.93
0.95
22.14
0.09
American Indian/Alaska Native
96,037
34.86
1.52∗
1.80
1.77
1.82
1.63
1.61
1.66
32.67
0.15
Chinese, US-born
18,330
7.09
0.31∗
0.26
0.24
0.27
0.34
0.32
0.36
9.45
0.24
Chinese, immigrant
1,25,839
1.92
0.08∗
0.07
0.06
0.07
0.07
0.07
0.08
2.25
0.05
Japanese, US-born
4,305
10.76
0.47∗
0.41
0.37
0.45
0.49
0.44
0.54
12.99
0.55
Japanese, immigrant
13,746
2.22
0.10∗
0.08
0.07
0.09
0.08
0.07
0.09
2.43
0.14
Hawaiian
2,041
32.44
1.41∗
1.61
1.47
1.77
1.53
1.39
1.68
31.26
1.00
Filipino, US-born
21,876
17.51
0.76∗
0.71
0.69
0.74
0.81
0.78
0.84
19.64
0.28
Filipino, immigrant
61,472
8.61
0.38∗
0.32
0.31
0.33
0.33
0.32
0.34
9.23
0.12
Asian Indian, US-born
16,211
11.59
0.51∗
0.44
0.42
0.46
0.58
0.55
0.60
14.93
0.31
Asian Indian, immigrant
1,47,308
8.99
0.39∗
0.33
0.33
0.34
0.43
0.42
0.43
11.57
0.09
Korean, US-born
7,800
6.83
0.30∗
0.25
0.23
0.27
0.32
0.29
0.34
8.85
0.36
Korean, immigrant
33,191
4.27
0.19∗
0.15
0.14
0.16
0.18
0.17
0.19
5.19
0.13
Vietnamese, US-born
9,682
9.22
0.40∗
0.34
0.32
0.37
0.40
0.38
0.43
10.99
0.34
Vietnamese, immigrant
49,791
2.10
0.09∗
0.07
0.07
0.08
0.07
0.06
0.07
1.99
0.06
Samoan
5,336
60.23
2.63∗
5.09
4.82
5.37
4.95
4.68
5.23
58.51
0.66
Other API, US-born
57,723
21.18
0.92∗
0.90
0.88
0.92
0.97
0.95
0.99
22.64
0.18
Other API, immigrant
96,281
12.31
0.54∗
0.47
0.46
0.48
0.45
0.44
0.46
12.11
0.10
Mexican, US-born
7,28,465
31.16
1.36∗
1.52
1.51
1.53
1.61
1.60
1.62
32.33
0.06
Mexican, immigrant
7,62,159
24.88
1.08∗
1.11
1.11
1.12
0.92
0.92
0.93
21.77
0.05
Puerto Rican, mainland US-born
1,30,522
29.13
1.27∗
1.38
1.36
1.40
1.40
1.38
1.42
29.47
0.13
Puerto Rican, Puerto Rico-born
29,148
26.33
1.15∗
1.20
1.17
1.23
1.21
1.18
1.24
26.60
0.26
Cuban, US-born
24,274
24.00
1.05∗
1.06
1.03
1.09
1.14
1.11
1.17
25.48
0.28
Cuban, immigrant
26,898
14.44
0.63∗
0.57
0.55
0.59
0.51
0.50
0.53
13.58
0.20
Central/South American, US-born
54,615
25.78
1.12∗
1.17
1.15
1.19
1.32
1.30
1.35
28.33
0.20
Central/South American, immigrant
2,61,909
18.70
0.81∗
0.77
0.77
0.78
0.67
0.66
0.68
16.94
0.07
Other Hispanic, US-born
2,82,921
29.39
1.28∗
1.40
1.39
1.41
1.49
1.47
1.50
30.68
0.09
Other Hispanic, immigrant
1,03,647
20.62
0.90∗
0.87
0.86
0.89
0.79
0.77
0.80
19.25
0.12
OR = odds ratio; CI = confidence interval; API = Asian/Pacific Islander.∗Statistically significant at p<0.05. 1Unadjusted for the effects of other covariates. 2Adjusted for race/ethnicity, maternal age, parity, marital status, nativity, maternal education, and place and region of residence. Source: data derived from the 2012–2014 US National Natality data files.Table 5
Observed prevalence and adjusted odds and prevalence of pre-pregnancy overweight or obesity (BMI ≥25) among women in 31 ethnic-immigrant groups, United States, 2012–2014 (N=10,431,092)
Ethnic-immigrant group
Prevalence percent
Prevalence ratio
Model 11
Model 22
Covariate-adjusted
OR
95% CI
OR
95% CI
Prevalence
SE
Non-Hispanic white, US-born
47.06
1.00
1.00
Reference
1.00
Reference
47.17
0.02
Non-Hispanic white, immigrant
35.87
0.76∗
0.63
0.63
0.63
0.64
0.64
0.65
36.80
0.08
Non-Hispanic black, US-born
61.70
1.31∗
1.81
1.81
1.82
1.84
1.83
1.85
61.66
0.05
Non-Hispanic black, immigrant
56.11
1.19∗
1.44
1.43
1.45
1.32
1.31
1.34
53.93
0.11
American Indian/Alaska Native
61.69
1.31∗
1.81
1.79
1.84
1.71
1.69
1.73
60.01
0.16
Chinese, US-born
24.07
0.51∗
0.36
0.35
0.37
0.43
0.42
0.45
28.39
0.34
Chinese, immigrant
12.10
0.26∗
0.16
0.15
0.16
0.17
0.16
0.17
13.42
0.10
Japanese, US-born
30.27
0.64∗
0.49
0.46
0.52
0.55
0.51
0.59
33.27
0.72
Japanese, immigrant
10.48
0.22∗
0.13
0.13
0.14
0.13
0.12
0.14
10.91
0.27
Hawaiian
61.29
1.30∗
1.78
1.63
1.95
1.72
1.57
1.88
60.15
1.07
Filipino, US-born
43.79
0.93∗
0.88
0.85
0.90
0.96
0.93
0.98
46.10
0.33
Filipino, immigrant
30.90
0.66∗
0.50
0.49
0.51
0.51
0.50
0.52
31.62
0.19
Asian Indian, US-born
33.04
0.70∗
0.56
0.54
0.57
0.67
0.65
0.70
37.88
0.38
Asian Indian, immigrant
36.24
0.77∗
0.64
0.63
0.65
0.78
0.77
0.79
41.27
0.13
Korean, US-born
23.35
0.50∗
0.34
0.33
0.36
0.41
0.39
0.43
27.15
0.52
Korean, immigrant
18.22
0.39∗
0.25
0.24
0.26
0.28
0.27
0.29
20.38
0.23
Vietnamese, US-born
28.49
0.61∗
0.45
0.43
0.47
0.51
0.49
0.54
31.89
0.48
Vietnamese, immigrant
12.18
0.26∗
0.16
0.15
0.16
0.14
0.14
0.14
11.56
0.14
Samoan
86.28
1.83∗
7.07
6.54
7.64
6.97
6.44
7.54
85.52
0.49
Other API, US-born
46.42
0.99∗
0.97
0.96
0.99
1.04
1.02
1.06
48.07
0.20
Other API, immigrant
36.72
0.78∗
0.65
0.64
0.66
0.62
0.61
0.63
36.03
0.15
Mexican, US-born
58.45
1.24∗
1.58
1.57
1.59
1.73
1.72
1.73
60.22
0.06
Mexican, immigrant
57.47
1.22∗
1.52
1.51
1.53
1.31
1.30
1.32
53.68
0.06
Puerto Rican, mainland US-born
56.01
1.19∗
1.43
1.42
1.45
1.49
1.47
1.50
56.71
0.14
Puerto Rican, Puerto Rico-born
52.84
1.12∗
1.26
1.23
1.29
1.29
1.26
1.32
53.37
0.29
Cuban, US-born
50.45
1.07∗
1.15
1.12
1.18
1.23
1.20
1.26
52.22
0.32
Cuban, immigrant
42.81
0.91∗
0.84
0.82
0.86
0.80
0.78
0.82
41.71
0.30
Central/South American, US-born
53.73
1.14∗
1.31
1.28
1.33
1.49
1.47
1.52
56.82
0.21
Central/South American, immigrant
50.34
1.07∗
1.14
1.13
1.15
1.02
1.01
1.03
47.65
0.10
Other Hispanic, US-born
56.66
1.20∗
1.47
1.46
1.48
1.61
1.60
1.62
58.61
0.09
Other Hispanic, immigrant
51.12
1.09∗
1.18
1.16
1.19
1.09
1.08
1.11
49.30
0.15
OR = odds ratio; CI = confidence interval; API = Asian/Pacific Islander.∗Statistically significant at p<0.05. 1Unadjusted for the effects of other covariates. 2Adjusted for race/ethnicity, maternal age, parity, marital status, nativity, maternal education, and place and region of residence. Source: data derived from the 2012–2014 US National Natality data files.Figure 2
Ethnic-immigrant disparities in observed and adjusted1 prevalence (%) of severe pre-pregnancy obesity (BMI ≥40) among US women, 2012–2014. 1Adjusted for maternal age, parity, marital status, maternal education, and place and region of residence.Ethnic-immigrant disparities in obesity risks were greater than disparities shown by race/ethnicity alone. Compared with US-born whites, the adjusted odds of obesity were 49% lower for white immigrants, 83% higher for US-born blacks, 6% lower for black immigrants, 61% higher for US-born Mexicans, and 8% lower for Mexican immigrants (Table4). Compared with US-born whites, all US-born and foreign-born Asian subgroups had 19–93% lower adjusted odds of obesity. Compared with US-born whites, the adjusted odds of overweight/obesity were 36% lower for white immigrants, 83% lower for Chinese immigrants, and 57% lower for US-born Chinese (Table 5). All Asian nativity groups had significantly lower adjusted risks of overweight/obesity than US-born whites. Compared with US-born whites, the adjusted odds of severe obesity were 4.2 times higher for Samoans, 2.1 times higher for US-born blacks, and 1.2 times higher for AIANs. However, compared with US-born whites, the adjusted odds of severe obesity was 68% lower for white immigrants and 52% lower for black immigrants. All Asian nativity groups had considerably lower adjusted risks of severe obesity than US-born whites (data not shown). Sociodemographic factors accounted for 12%, 16%, and 21% of ethnic-immigrant disparities in pre-pregnancy overweight/obesity, obesity, and severe obesity, respectively.


## 3.3. Ethnic-Specific Educational Gradients in Pre-Pregnancy Obesity and Overweight

Marked educational inequalities in pre-pregnancy obesity and overweight/obesity were generally found for all broad racial/ethnic groups, with mothers with less than a college education having significantly higher obesity and overweight/obesity prevalence than their counterparts with a college degree (Table6). Obesity prevalence ranged from 6.2% for API women with a college degree to over 37% for black and AIAN women with 13–15 years of education. Overweight/obesity prevalence ranged from 25.3% for API women with a college degree to over 64% for black and AIAN women with 13–15 years of education. Compared with API women with a college degree, the adjusted odds of obesity were almost 4 times higher for white women with less than a college degree and 5–7 times higher for Hispanic, AIAN, and black women with less than a college degree. The patterns in overweight/obesity risks were similar. Within each educational stratum, significant racial/ethnic disparities in obesity and overweight risks existed.Table 6
Observed and adjusted prevalence and odds of pre-pregnancy obesity and overweight/obesity among women in 15 joint racial/ethnic and education groups, United States, 2012-2014 (N=10,326,186)
Racial/ethnic-education group
Observed prevalence1
Adjusted odds ratio2
Adjusted prevalence2
%
SE
OR
95% CI
%
SE
Pre-pregnancy obesity (BMI ≥30)
Non-Hispanic white, education ≤12 years
26.15
0.03
3.92
3.87
3.98
25.74
0.04
Non-Hispanic white, education 13–15 years
27.11
0.03
3.62
3.57
3.67
24.26
0.03
Non-Hispanic white, education 16+ years
15.52
0.02
1.68
1.65
1.70
13.12
0.02
Non-Hispanic black, education ≤12 years
32.41
0.05
6.07
5.98
6.16
34.60
0.06
Non-Hispanic black, education 13–15 years
37.11
0.07
6.56
6.46
6.66
36.32
0.07
Non-Hispanic black, education 16+ years
32.04
0.10
5.03
4.95
5.11
30.60
0.10
American Indian/AN, education ≤12 years
34.43
0.20
5.92
5.79
6.06
34.07
0.20
American Indian/AN, education 13–15 years
37.60
0.27
5.84
5.68
6.00
33.75
0.26
American Indian/AN, education 16+ years
28.05
0.48
3.43
3.27
3.60
23.33
0.41
Hispanic, education ≤12 years
26.84
0.04
5.92
5.84
6.01
34.06
0.05
Hispanic, education 13–15 years
29.26
0.06
5.29
5.22
5.37
31.67
0.06
Hispanic, education 16+ years
19.49
0.08
2.85
2.80
2.90
20.24
0.08
Asian/Pacific Islander, education ≤12 years
12.30
0.09
2.37
2.33
2.42
17.52
0.11
Asian/Pacific Islander, education 13–15 years
13.00
0.09
2.26
2.22
2.31
16.85
0.12
Asian/Pacific Islander, education 16+ years
6.22
0.04
1.00
Reference
8.31
0.05
Pre-pregnancy overweight or obesity (BMI ≥25)
Non-Hispanic white, education ≤12 years
49.82
0.04
2.62
2.60
2.64
50.22
0.04
Non-Hispanic white, education 13-15 years
52.43
0.04
2.55
2.52
2.57
49.52
0.04
Non-Hispanic white, education 16+ years
38.85
0.03
1.36
1.35
1.37
34.74
0.04
Non-Hispanic black, education ≤12 years
58.00
0.06
4.09
4.05
4.13
60.84
0.06
Non-Hispanic black, education 13–15 years
64.22
0.07
4.67
4.63
4.72
63.88
0.07
Non-Hispanic black, education 16+ years
63.11
0.10
4.14
4.10
4.19
61.14
0.10
American Indian/AN, education ≤12 years
60.58
0.21
4.18
4.10
4.26
61.34
0.21
American Indian/AN, education 13–15 years
65.36
0.27
4.39
4.28
4.50
62.48
0.27
American Indian/AN, education 16+ years
55.79
0.53
2.65
2.54
2.76
50.46
0.52
Hispanic, education ≤12 years
57.04
0.04
4.47
4.43
4.50
62.85
0.04
Hispanic, education 13–15 years
58.01
0.07
3.98
3.94
4.02
60.21
0.06
Hispanic, education 16+ years
46.91
0.10
2.28
2.26
2.31
46.90
0.10
Asian/Pacific Islander, education ≤12 years
32.89
0.12
1.60
1.58
1.62
38.45
0.13
Asian/Pacific Islander, education 13–15 years
34.58
0.13
1.60
1.58
1.62
38.50
0.14
Asian/Pacific Islander, education 16+ years
25.27
0.07
1.00
Reference
28.33
0.08
OR = odds ratio; SE = standard error; CI = confidence interval; AN = Alaska Native.1Weighted prevalence. 2Adjusted prevalence was derived from fitted logistic regression models that included the joint variable of race/ethnicity and education, age, parity, marital status, nativity, and place and region of residence.


## 4. Discussion

To our knowledge, this is the largest population-based study of pre-pregnancy obesity in the US. We have shown marked disparities in pre-pregnancy obesity among a large number of racial/ethnic and immigrant groups in the US, maternal obesity risks for many of which were not previously examined. For several racial/ethnic groups, pre-pregnancy obesity levels were found to be very high, such as Hawaiians, blacks, AIANs, and Samoans who have a prevalence of 32%, 34%, 35%, and 60%, respectively. Indeed, more than 86% of Samoan women were classified as overweight or obese entering into pregnancy, with the prevalence exceeding 60% for Hawaiians, AIANs, and US-born black women. The results of our national study indicate substantial racial/ethnic and nativity disparities in the risk of maternal pre-pregnancy obesity and overweight, which were only partially explained by socioeconomic and demographic differences.The increased risk of pre-pregnancy obesity observed here for several ethnic-minority and socially disadvantaged groups such as AIANs, blacks, Mexicans, Puerto Ricans, Hawaiians, and Samoans is consistent with prior studies reporting high levels of obesity and overweight among adult women in these subgroups [3, 4, 7, 13, 16, 19]. Similarly, low levels of obesity and overweight among specific Asian subgroups such as Chinese, Japanese, Vietnamese, Koreans, Asian Indians, and Filipinos are consistent with those reported in previous studies on adult obesity in the US [3, 4, 19]. Previous studies have shown Hispanics to be at an increased risk of pre-pregnancy obesity and adult obesity [1–3, 7, 13, 16]. Compatible with adult obesity patterns, our analysis showed particularly high risks of pre-pregnancy obesity among Mexicans and Puerto Ricans compared to non-Hispanic whites and Asian subgroups [3, 18].Substantial geographic variation in adult obesity prevalence has previously been reported, and our findings of higher prevalence of pre-pregnancy obesity in the Midwest and Southern regions are consistent with the previously reported regional patterns [1, 3, 22]. Increased risk of pre-pregnancy obesity associated with lower maternal education is consistent with studies showing association between low socioeconomic status and higher obesity levels in women [1, 3, 13, 16, 22]. Diet, physical activity, genetic, and social environmental factors could account for ethnic, immigrant, and socioeconomic disparities in pre-pregnancy obesity [3, 4, 7, 8, 11, 23].Although immigrants account for 13% of the total US population, immigrant women make up approximately 20% of the reproductive-age population [24]. Given the profound inequalities in obesity by nativity/immigrant status shown here and in previous studies and the fact that immigrants represent a larger percentage of the population aged 15–49 than all ages, the magnitude of health disparities is likely to be greater for women in reproductive ages than for the general population, all else being equal [3, 4, 19]. Although immigrant women in each racial/ethnic group had lower rates of pre-pregnancy obesity and overweight than the US-born, their reduced obesity risks and other health advantages are likely to diminish with increasing acculturation levels or duration of residence in the US [3, 4, 19, 25]. Although genetic factors might partly explain racial/ethnic disparities in pre-pregnancy obesity, findings from previous studies on migrant health as well as lower obesity risks among immigrants of similar ethnicities seen here might indicate the significance of social environments, acculturation, and lifestyle factors [3, 4, 19, 25]. Ethnic-minority and socially disadvantaged groups in the US differ greatly from the majority, affluent groups in their social, physical, and living environments. They have limited access to neighborhood amenities such as sidewalks, parks/playgrounds, green spaces, public transportation, and healthy, affordable foods that promote physical activity, healthy lifestyle, and healthy living [3, 4, 25, 26].Our study has some limitations. Because of lack of data, important risk factors for obesity such as diet, physical activity, and the social and built environments could not be taken into account. Moreover, prevalence estimates of pre-pregnancy obesity and overweight were for women who had a live birth during 2012–2014 and excluded women who became pregnant but experienced fetal loss, miscarriages, or abortions [6, 18]. Since pre-pregnancy obesity in women is associated with these adverse perinatal outcomes, the reported pre-pregnancy obesity prevalence is likely to be underestimated [7]. Additionally, since pre-pregnancy weight on the birth certificate is self-reported by the mothers, pre-pregnancy obesity and overweight prevalence is likely to be underestimated [7]. The advantages of our study are its large sample size, national representativeness, and the ability to estimate pre-pregnancy obesity prevalence for a large number of racial/ethnic and immigrant groups, allowing for a more nuanced understanding of ethnic and socioeconomic disparities.


### 4.1. Implications for Practice and Policy

Factors such as inequalities in the social and built environments, physical activity levels, and dietary behavior are likely determinants of the racial/ethnic and nativity disparities in maternal pre-pregnancy obesity shown here [3, 4, 7, 11, 23, 26, 27]. Regular obstetric/gynecologic encounters offer an opportunity for behavioral counseling and lifestyle interventions to improve dietary intake and physical activity from preconception through pregnancy and well into the postpartum period [7, 11, 13, 28, 29]. Clinical guidelines are necessary to make improvements to the preconception, pregnancy, and postpartum visits [30, 31]. Interventions during these frequent medical encounters may be an effective strategy to counteract the rising rates of maternal obesity in the US [11, 29, 30]. Obesity is a leading health-risk factor for the nation and is associated with excess morbidity and mortality [2, 3, 32]. Due to high prevalence, a rapidly increasing trend, and large social-group disparities, obesity is a major public health concern due to its linkage to a myriad of chronic health conditions and the considerable toll it takes on healthcare costs [2, 3, 32, 33]. Marked social inequalities in pre-pregnancy obesity among US women contribute to persistent disparities in maternal and child health and overall health.The recent release of theUS Dietary Guidelines for Americans 2015–2020 provides evidence-based recommendations for health and nutrition. Counterpart guidelines for women of reproductive age are necessary to provide specific recommendations for this subpopulation [34]. The nutritional needs for women vary during pregnancy to provide adequate nutrients to the fetus and postpartum particularly among lactating women. In addition, obese women tend to give rise to infants who are of large-for-gestational age [35]. Healthy eating patterns and regular physical activity can help women, pre-pregnancy, during pregnancy, and postpartum, to optimize fetal growth and development, thus changing the intergenerational trajectory of obesity.


## 4.1. Implications for Practice and Policy

Factors such as inequalities in the social and built environments, physical activity levels, and dietary behavior are likely determinants of the racial/ethnic and nativity disparities in maternal pre-pregnancy obesity shown here [3, 4, 7, 11, 23, 26, 27]. Regular obstetric/gynecologic encounters offer an opportunity for behavioral counseling and lifestyle interventions to improve dietary intake and physical activity from preconception through pregnancy and well into the postpartum period [7, 11, 13, 28, 29]. Clinical guidelines are necessary to make improvements to the preconception, pregnancy, and postpartum visits [30, 31]. Interventions during these frequent medical encounters may be an effective strategy to counteract the rising rates of maternal obesity in the US [11, 29, 30]. Obesity is a leading health-risk factor for the nation and is associated with excess morbidity and mortality [2, 3, 32]. Due to high prevalence, a rapidly increasing trend, and large social-group disparities, obesity is a major public health concern due to its linkage to a myriad of chronic health conditions and the considerable toll it takes on healthcare costs [2, 3, 32, 33]. Marked social inequalities in pre-pregnancy obesity among US women contribute to persistent disparities in maternal and child health and overall health.The recent release of theUS Dietary Guidelines for Americans 2015–2020 provides evidence-based recommendations for health and nutrition. Counterpart guidelines for women of reproductive age are necessary to provide specific recommendations for this subpopulation [34]. The nutritional needs for women vary during pregnancy to provide adequate nutrients to the fetus and postpartum particularly among lactating women. In addition, obese women tend to give rise to infants who are of large-for-gestational age [35]. Healthy eating patterns and regular physical activity can help women, pre-pregnancy, during pregnancy, and postpartum, to optimize fetal growth and development, thus changing the intergenerational trajectory of obesity.


## 5. Conclusions

This large population-based study of 10.4 million US women has shown considerable heterogeneity in pre-pregnancy obesity and overweight risks across various racial/ethnic and immigrant groups. Some of the ethnic-minority groups such as Samoans, Hawaiians, Puerto Ricans, Mexicans, AIANs, and non-Hispanic blacks have relatively high levels of maternal obesity, ranging from 32% to 60%. High rates of pre-pregnancy obesity correspond closely with the increased risks of various adverse maternal and perinatal outcomes among these groups such as gestational hypertension and diabetes, preeclampsia, pregnancy complications, preterm birth, and infant mortality. Immigrants have substantially lower rates of pre-pregnancy obesity and overweight than their US-born counterparts regardless of race/ethnicity. These findings highlight the significance of stratifying obesity analyses by immigrant status and suggest ethnic group-specific and culturally appropriate interventions to prevent obesity in women of reproductive age and to improve health outcomes [3, 4, 19, 23]. Further research is needed to assess the role of sociobehavioral and environmental factors responsible for ethnic, immigrant, and sociodemographic disparities in maternal pre-pregnancy obesity.



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*Source: 2419263-2019-02-10.xml*