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
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.

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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.

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

Director Director, Center for Outcomes and Evidence
Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

Beth Collins Sharp, Ph.D., R.N. Carmen Kelly, Pharm.D., R.Ph.

Director, EPC Program EPC Program Task Order Officer
Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

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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.

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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

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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

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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

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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.

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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-for-
gestational-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

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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

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association between high weight gain and high birthweight, macrosomia, and large-for-
gestational-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).

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 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 normal-
weight 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

4
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

5
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.

6
 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.

7
Evidence Report
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 large-
for-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.

11
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

12
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.

13
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 (KQ4)

Energy intake
(composition of Energy
the diet) Energy balance expenditure
(physical
KQ2 activity)

Maternal weight gain

- fetus
- placenta KQ5 Anthropometric tools to
- amniotic fluid measure adiposity during
- increased maternal fat pregnancy
stores, uterine weight, breast
tissue, and plasma volume

KQ1 KQ3

- Maternal antenatal and

intrapartum outcomes
- Birth outcomes
- Infant health outcomes
- Child health outcomes
- Maternal postpartum outcomes
(short- and long-term)

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

14
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.

15
 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.

16
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 KQ 1, KQ 2, KQ 4: Developed nations: United States, Canada, Western Europe, Japan, Australia,
geography New Zealand
KQ 3: United States
KQ 5: All countries
Time period January 1990 through October 2007
Publication English only
languages
Admissible Admissible designs
evidence (study • Controlled trials (n ≥ 40), nonrandomized controlled trials (n ≥ 40), systematic reviews, meta-
design and other analyses, prospective trials with historical controls (n ≥ 40), prospective or retrospective
criteria) 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.

17
 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 332,914
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
#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.

18
 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

19
 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.

20
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 Fair
present
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.

21
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 Fair
any poor ratings

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

22
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 RTI-
UNC 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.

23
acknowledge their review of the draft. We compiled all comments and addressed each one
individually, revising the text as appropriate.

24
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.

25
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.

26
 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 Pregravid Weight
Sample Size (How Measured) Confounders and Effect
Baseline BMI Total Weight Gain Definition of Modifiers Included in
Quality (How Measured) Groups Results Analysis
Kieffer et al., Pregravid weight: Note: study aim to Women with GDM had Parity, pregravid BMI,
200648 Self-report; if determine significantly lower weight gain
unknown relationship of average weight gain than
US Michigan calculated from wt anthropometric and those without GDM but
federally qualified at ≤ 10 wks metabolic variables weight gain was not
community health gestation on infant outcomes significantly related to
center glucose category
Total weight gain:
1,041 Latinas Computed from
last weight
All BMIs recorded within 7
days delivery
Good
Saldana et al., Pregravid weight: Weight gain ratio Race, maternal age,
3
2006 Self-report (observed/recommended) gestation age of weight
measurement
US North Carolina Total weight gain: IGT OR (95% CI)
prenatal study Calculated on 0.9 (0.7-1.1)
prenatal
2,254 measurement to GDM OR (95% CI)
end of second 1.2 (0.9-1.4)
All BMIs trimester

Good

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.

27
Table 4. Gestatiornal weight gain and abnormal glucose control (continued)

Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and Effect
Baseline BMI Total Weight Gain Definition of Modifiers Included in
Quality (How Measured) Groups Results Analysis
Edwards et al., Pregravid weight: Pregravid wt 19.8- Incidence gestational Maternal age, parity, race,
55
1996 Self-report 26.0 BMI: diabetes: prenatal smoking, prenatal
G1: < 11.5 kg gain G1: 2.3% alcohol use, prenatal illicit
US Minnesota, Total weight gain: G2: 11.6-16 kg gain G2: 3.3% drug use, pregravid
births at specific Last prenatal G3: > 16 kg gain G3: 2.9% health, weight and
medical center assessment (P = .759) adequacy of prenatal care
Pregravid wt > 29 kg
1,343 divided G4: lost/gained G4: 13.3%
between nothing G5: 24.3%
obese women G5: 0.5-6.5 kg gain G6: 11.9%
(BMI > 29) G6: 7-11.5 kg gain G7: 16.7%
matched to G7: 12-16 kg gain G8: 17.3%
nonobese (BMI G8: >16 kg gain (P = .554)
19.8-26.0)

Fair
Hackmon, et al., Pregravid weight: There was no difference Gravidity, parity, ethnicity,
57
2007 How determined in maternal weight gain BMI
not described during early pregnancy
US inner city between patients with
population Weight gain: abnormal versus normal
Weight at 24-28 GCT values (mean±SD of
75 weeks end point 4.13±3.2 and 4.16±1.67,
for calculations respectively).
All BMIs

Fair
Kieffer et al., Pregravid weight: Wt gain to 28 wk GA: Multiple logistic Age, family history
200156 Self-report or, if regression analyses diabetes, parity, BMI,
unknown, weight Latinas: revealed statistically weight gain first 28 weeks,
US Detroit health assessment in 1st G1: < 14 lbs gain significant risk factors for ethnicity
care system 10 wks gestation G2: 14-28 lbs gain GDM included increasing
(reference) weight gain during first 28
1,334 AA and Total weight gain: G3: >28 lbs gain wks of gestation
Hispanic How determined
not described AAs:
All BMIs G4: < 14 lbs gain
G5: 14-28 lbs gain
Fair G6: > 28 lbs gain
Murakami et al., Pregravid weight: G1: < 8.5 kg gain AOR (95% CI) gestational Maternal age, parity,
52
2005 Self-report on first G2: 8.5-12.5 kg gain diabetes smoking, weight gain,
visit G3: >12.5 kg gain G1: 5.14 (0.97-27.20) gestational weeks;
Japan hospital G2: Reference pregravid BMI
data Total weight gain: G3: 3.91 (0.61-24.73)
Measured on
633 admission for birth

All BMIs

Fair

28
Table 4. Gestational weight gain and abnormal glucose control (continued)

Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and Effect
Baseline BMI Total Weight Gain Modifiers Included in
Quality (How Measured) Definition of Groups Results Analysis
Thorsdottir, et al., Pregravid weight: G1: <11.5 kg gain Incidence Age, parity, height,
53
2002 Self-report G2: 11.5-16.0 kg gain gestational gestational age
G3: 16.1-20.0 kg gain diabetes
Iceland University Total weight gain: G4: >20 kg gain G1: 2.9%
Hospital Maternity records G2: 0
(no specifics G3: 0
615 offered) G4: 0
(P = .015)
BMI: 19.5-25.5

Fair
Bianco, et al., Pregravid weight: Reported only for BMI > 35: Incidence GDM: Race, parity, clinic
199854 Self-report G1: weight loss or no gain G1: 15.7% service, substance abuse,
G2: 1-15 lb gain G2: 15.0% and preexisting medical
US New York Total weight gain: G3: 16-25 lb gain G3: 14.4% conditions
Medical Center Computed from G4: 26-35 lb gain G4: 13.4%
Database measured weight G5: > 35 lb gain G5: 12.5%
within 4 weeks of
11,840 delivery (P = NS)

Nonobese (BMI
19-27) and
Morbidly obese
(BMI > 35) ages
20-34

Poor
Brennand et al.,Pregravid weight: G1: “Low weight gain” Incidence GDM: None reported
200549 Measured weight G2: “Acceptable weight G1: 38.6%
≤14 wk GA used gain” G2: 27.3%
Quebec, Canada, as proxy G3: “Excessive weight gain” G3: 19.3%
First Nation’s (P = 0.011)
People (Cree) Total weight: All categories per Canadian
Last recorded Guidelines Incidence IGT:
603 weight within 4 G1: 12.0%
wks of giving birth G2: 15.2%
All BMIs ≥18.5 G3: 7.9%
(P = 0.249)
Poor
Kabiru and Pregravid weight: BMI < 25 first assessment: Incidence Pregravid weight
51
Raynor, 2004 First prenatal visit G1: no change BMI gestational
category diabetes
US Atlanta public Total weight gain: G2: increase 1 category G1: 0.5%
hospital database Computed on G3: increase > 1 category G2: 1.5%
weight at G3: 3.7%
5,131 admission for birth BMI ≥ 25 first assessment: (P = .005)
G4: no change BMI
All BMIs ≥ 20 category G4: 1.0%
G5: increase 1 category G5: 3.3%
Poor G6: increase >1 category G6: 1.9%
(P = .005)

29
Table 4. Gestational weight gain and abnormal glucose control (continued)
Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and Effect
Baseline BMI Total Weight Gain Modifiers Included in
Quality (How Measured) Definition of Groups Results Analysis
Seghieri et al., Pregravid weight: Weight gain as Parity, age, pregestational
50
2005 How determined predictor of GDM OR BMI, weight gain, family
not described (95% CI) history diabetes
Italy Outpatient
Diabetes Unit Total weight gain: 1.024 (0.974-1.077)
How determined (P = NS)
1,880 not described

All BMIs

Poor

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

30
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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Cedergren, 200658 Pregravid weight: G1: BMI < 20 Preeclampsia by BMI for Age, parity,
Self-report; if G2: BMI 20-24.9 weight gain < 8 kg (reference smoking in early
Swedish Medical unknown G3: BMI 25-29.9 gain 8-16 kg). pregnancy, year of
Birth Registry “standardized G4: BMI 30-34.9 OR (95% CI): birth
measurement” G5: BMI > 35 G1: 0.90 (0.55-1.48)
245,526 used G2: 0.73 (0.61-0.89)
G3: 0.64 (0.54-0.76)
All BMIs Total weight gain: G4: 0.52 (0.42-0.62)
Computed on G5: 0.63 (0.51-0.79)
Fair weight at
presentation for Preeclampsia by BMI for
delivery 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)
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.

31
Table 5. Gestational weight gain and pregnancy-induced hypertension (continued)
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
DeVader, et al., Pregravid weight: G1: Weight gain < 25 lbs AOR for preeclampsia (95% Maternal age,
25
2007 Noted on prenatal G2: Weight gain 25-35 CI) race/ethnicity,
record or reported lbs education,
USA Missouri, birth at postpartum stay G3: Gained > 35 lbs G1: 0.56 (0.49-0.64) Medicaid status,
certificate data G2: 1 tobacco and
Total weight gain: G3: 1.88 (1.74-2.04) alcohol use,
94,696 As stated on birth maternal height,
certificate data. adequacy of
BMI: 19.8-26.0 Specifics not prenatal care,
provided child’s sex, child’s
Fair birth year
Edwards et Pregravid weight: Pregravid wt 19.8-26.0 Preeclampsia: Maternal age,
al.,199655 Self-reported BMI: G1: 2.8% parity, race,
G1: < 11.5 kg gain G2: 2.9% prenatal smoking,
USA Minnesota, Total weight gain: G2: 11.6-16 kg gain G3: 6.6% prenatal alcohol
births at specific Last prenatal G3: > 16 kg gain (P = .048) use, prenatal illicit
medical center assessment drug use,
Pregravid wt > 29 kg G4:10.7% pregravid health,
1,343 divided G4: lost/gained nothing G5: 7.7% weight and
between obese G5: 0.5-6.5 kg gain G6: 8.3% adequacy of
women (BMI > 29) G6: 7-11.5 kg gain G7: 7.9% prenatal care
matched to G7: 12-16 kg gain G8: 16.5%
nonobese (BMI G8: > 16 kg gain (P = .076)
19.8-26.0)
Gestational HTN:
Fair 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)
Kiel et al., 20074 Total weight gain: Analysis done by each Data all presented in graph Age, education,
As stated on birth class of obesity and form: poverty (defined
USA Missouri, birth certificate data. weight changes in Using a gain of 15-25 pounds as participation
certificate data Specifics not gestation including: as reference for each obesity in one or more
provided weight loss ≥ 10 lbs; class, OR of preeclampsia subsidized
120,251 weight loss 2-9 lbs; no lower with less weight gain programs) tobacco
weight change; gain 2-9 and higher with more weight use, parity,
BMIs ≥ 30.0 lbs; gain 10-14 lbs; gain gain chronic
15-25 lbs; gain 26-35 hypertension
Fair lbs; gain > 35 lbs

32
Table 5. Gestational weight gain and pregnancy-induced hypertension (continued)
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Murakami et al., Pregravid weight: G1: < 8.5 kg gain Estimated OR (95% CI) Maternal age,
52
2005 Self-reported at G2: 8.5-12.5 kg gain preeclampsia parity, smoking,
first visit G3: >12.5 kg gain weight gain,
Japan hospital data Total weight gain: G1: 0.74 (0.37-1.48) gestational weeks;
Measured on G2: 1 pregravid BMI
633 admission for birth G3: 0.57 (0.24-1.32)

All BMIs

Fair
Ogunyemi et al., Pregravid weight: G1: “low weight gain” Incidence preeclampsia: Age, parity,
60
1998, Self-reported G2: “normal weight gain” G1: 10% pregravid BMI,
G3: “high weight gain” G2: 7% tobacco use,
USA, rural Alabama Total weight gain: G3: 19% hypertension
Weight at last (P = < .01)
582 prenatal visit

All BMIs

Fair
Thorsdottir, et al., Pregravid weight: G1: <11.5 kg gain % gestational HTN Age, parity, height,
200253 Self-reported G2: 11.5-16.0 kg gain G1: 1.5% gestational age
G3: 16.1-20.0 kg gain G2: 4.6%
Iceland, university Total weight gain: G4: > 20 kg gain G3: 5.1%
hospital Maternity records G4: 9.2%
(no specifics (P = 0.026)
615 offered)
% preeclampsia
BMI: 19.5-25.5 G1: 1.4%
G2: 2.3%
Fair G3: 5.4%
G4: 4.4%
(P = 0.262)
Bianco, et al., Pregravid weight: Reported only for BMI > Incidence PIH Race, parity, clinic
54
1998 Self-reported 35: G1: 11.8% service, substance
G2: 13.7% abuse, and
USA, New York Total weight gain: G1: weight loss or no G3: 13.7% preexisting
Medical Center Computed on gain G4: 12.4% medical conditions
Database measured weight G2: 1-15 lb gain G5: 21.3%
within 4 weeks of G3: 16-25 lb gain
11,840 delivery G4: 26-35 lb gain (P = NS)
G5: > 35 lb gain
Nonobese
(BMI 19-27) and
morbidly obese
(BMI > 35) ages
20-34

Poor

33
Table 5. Gestational weight gain and pregnancy-induced hypertension (continued)
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Brennand et al., Pregravid weight: G1: “Low weight gain” HTN disorders None reported
49
2005 Measured weight G2: “Acceptable weight G1: 7.3%
≤ 14 wk GA used gain” G2: 12.5%
Quebec, Canada, as proxy G3: “Excessive weight G3: 19.3%
First Nation’s gain” (P = 0.051)
People (Cree) Total weight gain:
Computed on last All categories per PIH:
603 recorded weight Canadian G1: 3.7%
within 4 wks of Guidelines G2: 6.3%
BMI ≥ 18.5 giving birth G3: 4.4%
(P = 0.698)
Poor
Preeclampsia
G1: 3.7%
G2: 6.3%
G3: 14.9%
(P = 0.013)
Jensen et al., Pregravid weight: G1: < 5 kg gain OR (95% CI) gestational HTN Results of 2 hour
200559 Self-reported G2: 5.0-9.9 kg gain G1: 1 OGTT, age,
G3: 10.0-14.9 kg gain G2: 2.1 (0.8-5.7) pregravid BMI,
Danish medical Total weight gain: G4: ≥ 15.0 kg gain G3: 3.6 (1.3-9.8) gestational age,
centers Details not G4: 4.8 (1.7-13.1) parity, smoking,
provided (P = 0.001) ethnicity, and site
481 of prenatal care

BMI ≥ 30

Poor
Kabiru and Raynor, Pregravid weight: BMI < 25 first Incidence preeclampsia Pregravid weight
200451 First prenatal visit assessment: G1: 1.9%
G1: no change BMI G2: 3.2%
USA Atlanta, public Total weight gain: category G3: 1.6%
hospital database Computed on G2: increase 1 category (P = .203)
weight at G3: increase > 1
5,131 admission for birth category G4: 2.8%
G5: 3.7%
BMI ≥20 BMI ≥ 25 first G6: 3.7%
assessment: (P = .002)
Poor G4: no change BMI
category
G5: increase 1 category
G6: increase > 1
category
Wataba et al., Total weight gain: Separate analyses done No clear trends for
61
2006 Computed by for low, medium and high preeclampsia or severe
delivery weight less pregravid weight groups preeclampsia by pregravid
Japanese medical pregravid weight by following intervals of weight status and kg/week
center (no details on how kg/week gain: weight gains. AOR generally
assessed) divided < 0.15: crossed 1.0 or had wide
21,718 by gestational age 0.15-.20; 0.20-.25; 0.25- confidence intervals.
.30; 0.30-.35; 0.35-40;
All BMIs >0.40

Poor

34
 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

35
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,

36
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

37
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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

DeVader et al., Pregravid weight: G1: < 30 lbs AOR for failed induction Maternal age,
200725 Medical record: G2: 30-35 lbs of labor vs. other birth maternal race or
If missing, obtained G3: > 35 lbs outcomes ethnicity, maternal
USA, birth certificate from mother during G1: 0.68 education, Medicaid
data postpartum hospital (95% CI, 0.59-0.78) status, tobacco use,
stay G2: 1.0 alcohol use,
94,696 G3: 1.51 maternal height,
Total weight gain: (95% CI, 1.39-1.64) prior pregnancy,
Normal weight only Obstetrical records adequacy of
prenatal care,
Fair child’s sex, and
child’s birth year

Graves et al., Pregravid weight: ≤ 45 pounds vs. > 45 OR induction of labor for Maternal BMI, infant
67
2006 Actual prepregnant pounds > 45 lb: 1.5 (95% CI, birthweight, and
weight or early first 1.0-2.4) gestational age at
USA, midwifery trimester weight delivery
practices documented in
medical records
1,500
Total weight gain:
All weights/BMI Last prenatal
assessment
Fair

Ekblad and Pregravid weight: G1: weight gain ≤ 5 kg Percentage induced NA

Grenman, 199268 Data from records, G2: weight gain ≥ 20 kg G1: 23%
unclear if self- G2: 43%
Finland, hospital reported G3: reference (normal G3: 24
prepregnancy weight P < 0.05 for G2 vs. G3
357 Total weight gain: and normal weight gain
Last prenatal [undefined])
Normal weight only assessment

Poor

AOR, adjusted odds ratio; BMI, body mass index; G, group; GWG: gestational weight gain; OGTT, oral glucose tolerance test.

38
Table 6. Gestational weight gain and induction of labor (continued)

Author, Date Pregravid Weight

Country, Setting (How Measured) Confounders and
Sample Size Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

Jensen et al., Pregravid weight: G1: < 5.0 kg OR for induction of labor Age, pregravid BMI,
59
2005 Records or self- G2: GWG 5.0-9.9 kg G1: 1.0 2 hour OGTT result,
report of pregravid G3: GWG 10.0-14.9 kg G2: 2.7 smoking,
Denmark, university BMI G4: GWG ≥ 15 kg (95% CI, 1.3-5.7) gestational age
hospitals G3: 2.8
Total weight gain: (95% CI, 1.3-5.9)
481 Last prenatal G4: 3.7
assessment (95% CI, 1.7-8.0)
Obese only P for trend = 0.002

Poor

Kabiru and Raynor, Pregravid weight: G1: normal BMI, no Percent failed induction NA
200451 Weight at first change in BMI between of labor
prenatal visit first prenatal visit and G1: 4.7
USA, hospital delivery G2: 9.2
Total weight gain: G2: normal BMI, 1 G3: 15.9
5,131 Weight at admission category increase in BMI P < 0.001
for birth between first prenatal
All BMIs > 20 visit and delivery G4: 7.9
G3: normal BMI, > 1 G5: 10.3
Poor category increase in BMI G6: 14.6
between first prenatal P < 0.001
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

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

39
 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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis

Johnson et al., Pregravid weight: G1: total weight gain Elevated odds of labor Prepregnancy weight
199270 Self-report collected < 16 pounds abnormalities only in the quartile, height
at first antepartal visit G2: total weight gain group gaining > 35 pounds (tertile), BMI
USA, prenatal 16-25 pounds compared with women category,
clinics Total weight gain: G3: total weight gain gaining < 16 pounds; not race/ethnicity, marital
Last prenatal visit 26-35 pounds significant when adjusted status, private
3,191 G4: total weight gain for confounders physician, parity,
> 35 pounds infant sex, maternal
All weights/BMI Trend analysis showed risk age, hypertension,
of labor abnormalities with and birthweight
Fair 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

Purfield and Morin, Pregravid weight: G1: prepregnant Normal weight NA

199469 Self-report as noted in weight increased by primigravidas with a low risk
medical chart 25% or less pregnancy who gained an
USA, Tertiary care G2: prepregnant excessive amount of weight
medical center Total weight gain: weight increased by had a longer mean length of
Weight at admission more than 25% second stage labor than
104 to hospital for birth women who gained less
weight
Normal weight
women only Minutes of length of second
stage in minutes by weight
Fair groups (SD):
G1: 72.42 (46.69)
G2: 93.28 (52.87)
t = -2.05 P = 0.02

BMI, body mass index; G, group; SD, standard deviation.

40
Table 7. Gestational weight gain and length of labor (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Labor pattern - I stage NA
Ekblad and Pregravid weight: G1: weight gain ≤ 5 (minutes± SD)
68
Grenman, 1992 Data from records, kg G1: 333±208
unclear if self- G2: weight gain ≥ 20 G2: 374±208
Finland, hospital reported kg G3: 346±188
G3: reference
357 Total weight gain: (normal Labor pattern - II stage
Last clinically prepregnancy weight (minutes)
Normal weight only measured weight and normal weight G1: 15±18) P < 0.05
prior to delivery gain [undefined]) compared to reference
Poor category
G2: 27±25
G3: 21±18
Labor pattern - III stage
(minutes)
G1: 13±13
G2: 13±11
G3: 12±12

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

41
Table 8. Gestational weight gain and mode of delivery

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

Cedergren, 200658 Pregravid weight: Weight gain < 8 kg, 8- AOR for weight gain < 8 kg for Maternal age,
Self-report; if unknown, 16 kg, and > 16 kg for cesarean section compared parity, smoking in
Sweden, Medical standardized each BMI class below with weight gain 8-16 kg (95% early pregnancy,
Birth Registry measurement is made CI) and year of birth
during first visit to G1: BMI< 20 G1: 1.07 (0.89-1.29)
245,526 maternity health care G2: BMI 20-24.9 G2: 0.98 (0.92-1.05)
center G3: BMI 25-29.9 G3: 0.88 (0.82-0.95)
All weights/BMI G4: BMI 30-34.9 G4: 0.81 (0.73-0.90)
Total weight gain: G5: BMI ≥ 35 G5: 0.75 (0.66-0.87)
Fair Measured when
woman entered AOR for weight gain > 16 kg
delivery unit 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)

Chen et al., 200473 Pregravid weight: Gestational weight Progression of AOR of BMI, maternal
Weight taken at first gain in lbs cesarean delivery weight gain height, maternal
USA, private practice prenatal visit if (for every 5 lbs): 1.094 (1.074- age, pregnancy
presented before 20 1.115) weight gain,
3,355 weeks; if after 20 gestational age at
weeks, self report delivery, and fetal
All weights/BMI birthweight
Total weight gain:
Fair Last clinically
measured weight prior
to delivery

AOR, adjusted odds ratio; BMI, body mass index; G, group; GDM, gestational diabetes mellitus; kg, kilogram; lbs, pounds; LGA, large-for-
gestational-age; SGA, small-for-gestational-age.

42
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

DeVader et al., 200725 Pregravid weight: G1: < 30 lbs AOR for cesarean (95% CI): Maternal age,
Medical record; if G2: 30-35 lbs G1: 0.82 (0.78-0.87) maternal race or
USA, birth certificate missing, obtained G3: > 35 lbs G2: 1.0 ethnicity, maternal
data from mother during G3: 1.35 (1.29-1.40) education, Medicaid
postpartum hospital status, tobacco use,
94,696 stay AOR for instrumental (95% alcohol use,
CI): G1: 0.97 (0.90-1.04) maternal height,
Normal weight only Total weight gain: G2: 1.0 prior pregnancy,
Obstetrical records G3: 1.03 (0.97-1.08) adequacy of
Fair prenatal care,
child’s sex, and
child’s birth year

Graves et al., 200667 Pregravid weight: ≤ 45 lbs vs. > 45 lbs Greater weight gain in Prepregnancy BMI
Actual prepregnant pregnancy was not associated category, total
USA, midwifery weight or early first significantly with route of prenatal weight gain
practices trimester weight delivery category, induction
documented in of labor, newborn
1,500 medical records birthweight ≥ 4,000
g, gestational age >
All weights/BMI Total weight gain: 41 weeks, and
Last prenatal race/ethnicity
Fair assessment

Jain et al. 200777 Pregravid weight: G1: WG ≤ 15 lbs AOR for primiparous cesarean Maternal age,
Not stated G2: WG 15-24 lbs delivery (from model including pregravid BMI,
USA, birth certificate G3: WG 25-35 lbs interaction term for parity, education,
records and Total weight gain: G4: WG ≥ 35 lbs overweight/obese + > 25 lbs race/ethnicity,
Pregnancy Risk Birth certificate weight gain) US/foreign origin,
Assessment G1: 0.95 (0.59-1.52) interaction terms for
Monitoring System G2: 1.0 (ref) pregravid BMI and
G3: 1.10 (0.76-1.60) weight gain
7,661 G4: 1.62 (1.10-2.39)

All weights/BMI AOR for multiparous cesarean

delivery (from model including
Fair 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)

Johnson et al., 199270 Pregravid weight: G1: total weight gain < AOR for unscheduled Prepregnancy
Self report collected at 16 lbs cesarean (95% CI) weight quartile,
USA, prenatal clinics first antepartal visit G2: total weight gain G1: 1.0 height (tertile), BMI
16-25 lbs G2: 0.95 (0.6-1.5) category, private
3,191 Total weight gain: G3: total weight gain G3: 1.3 (0.86-1.95) physician (yes/no),
Last prenatal visit 26-35 lbs maternal age,
G4: 1.95 (1.32- 2.87)
All weights/BMI G4: total weight gain parity, birthweight,
> 35 lbs diabetes,
Fair hypertension, and
maternal education

43
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

Joseph et al., 200372 Pregravid weight: G1: < 5 kg AOR for cesarean delivery Age, parity,
Data taken from G2: 5-9 kg (95% CI) prepregnancy
Nova Scotia Atlee standardized forms G3: 10-14 kg G1: 1.10 (1.00-1.20) weight, smoking,
Perinatal Database and hospital medical G4: 15-19 kg pregnancy
records - no mention of G5: ≥ 20 kg G2: 1.04 (0.99-1.10) (singleton or
100,259 self report G3: 1.00 multiple),
G4: 1.09 (1.05-1.14) hypertension,
All weights/BMI Total weight gain: diabetes, previous
Not explained by G5: 1.41 (1.35,-1.47)
fetal death,
Fair authors - data taken induction, epidural,
from maternity records physician type, time

Kiel et al., 20074 Pregravid weight: All obese women Compared with women who Age, race, parity,
USA, birth registry Self report from data gained 15-25 lbs during their education, poverty
on birth certificate G1: Loss 10 lbs or pregnancies, those who (enrollment in
120,170 more gained less weight had Medicaid, WIC,
Total weight gain: G1: Loss 2-9 lbs significantly lower odds of food stamp
Obese women only Abstracted from G1: No change preeclampsia, cesarean programs), tobacco
medical chart G1: Gain 2-9 lbs delivery, and LGA births, but use, chronic
Fair G1: Gain 10-14 lbs higher odds for SGA births hypertension
G1: Gain 15-25 lbs
G1: Gain 25-35 lbs Magnitude differed by obesity
classification, even after
adjusting for known or
suspected confounders

Murakami et al., Pregravid weight: G1: < 8.5 kg AOR for cesarean delivery Maternal age,
200552 Self report at first visit G2: 8.5-12.5 kg (95% CI) parity, smoking,
to clinic G3: > 12.5 kg G1: 1.08 (0.56-2.07) prepregnancy BMI,
Japan, hospital G2: 1.00 and gestational age
Total weight gain: G3: 1.23 (0.61-2.48) (weeks)
633 Based on last clinically
measured weight prior
All weights/BMI to delivery

Fair

44
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

Purfield and Morin, Pregravid weight: G1: prepregnant Higher rate of vacuum NA
69
1995 Self report as noted inweight increased by extraction and cesarean
medical chart 25% or less delivery and lower rate of
USA, Tertiary care G2: prepregnant spontaneous vaginal delivery
medical center Total weight gain: weight increased by with excessive weight gain
Weight at admission to more than 25%
104 hospital for birth No difference in forceps
delivery and vaginal delivery
Normal weight by weight gain status
women only Vaginal delivery
G1: n = 27
Fair 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
Age, parity, GDM,
Rosenberg et al., Pregravid weight: < 41 vs. ≥ 41 pounds AOR for primary cesarean pregnancy-induced
200571 Self report on birth (95% CI): 1.38 (1.34-1.41) hypertension,
certificate preeclampsia,
USA, vital statistics prepregnancy
data Total weight gain:
Weight data on birth weight, chronic
file diabetes, chronic
329,988 hypertension,
marital status,
All weights/ no BMI maternal education,
mother's birthplace,
Fair prenatal care payer,
social risk, trimester
prenatal care began

45
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Preeclampsia,
Shepard et al., 199875 Pregravid weight: Proportional weight G1: Proportional Gain: gestational
Self report before 15 gain (total weight gain/ Adjusted Relative Risk (95% diabetes, placental
USA, obstetrical weeks of gestation prepregnancy weight) CI) problems, fetal
practices and absolute weight G2: Absolute Gain: distress,
Total weight gain: gain Adjusted RR (95% CI)
Self report of weight at macrosomia,
2,301 Underweight (< 19.4), induction, maternal
delivery ≤ median age and height,
All weights/BMI G1: 1.00 parity, ethnicity, and
G2: 1.00 marital status
Fair
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)

46
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

Sherrard et al., 200778 Pregravid weight: Rate of weight gain AOR for unlabored cesarean, BMI, gestational
Self report (kg/wk) primary diabetes,
Canada, hospital G1: Low (≤0.17) G1: 0.79 (0.59-1.05) pregnancy-induced
database Total weight gain: G2: Normal (0.18- G2: 1.00 (ref) hypertension,
Self report or 0.50) G3: 1.03 (0.64-1.64) macrosomia,
63,390 measured G3: High (>0.50) socioeconomic
All BMIs AOR for labored cesarean, factors, parity, and
primary maternal age
Fair 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)

Witter et al., 199576 Pregravid weight: Pregnancy weight AOR for cesarean (95% CI): Age, pregravid BMI,
Self report, unclear at gain (kg) 1.04 (1.02-1.05) height, at least one
USA,obstetric what timepoint previous viable
database at major pregnancy,
medical center Total weight gain: diagnosis of
Weight recorded at last preeclampsia
4,346 prenatal visit during the current
pregnancy,
All weights/BMI previous cesarean
delivery
Fair
NA
Bianco et al., 199854 Pregravid weight: G1: 0 or weight loss Cesarean %
Unclear G2: 1-15 lbs G1: 25.8%
USA, major medical G3: 16-25 lbs G2: 26.8%
center Total weight gain: G4: 26-35 lbs G3: 28.8%
Weight from before 36 G5: > 35 lbs G4: 35.0%
11,926 weeks gestation or not G5: 33.8% (P = NS)
within 4 weeks of
BMI OF 27 and 34 delivery
are excluded from Maternal weight gain
analysis outcomes by BMI
presented for morbidly
Poor obese women only,
N: 613

47
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
NA
Brennand et al., Pregravid weight: Primigravid women Cesarean section (%)
49
2005 Routine prenatal care (maternal weight gain G1: 25.3
medical records, outcomes by BMI G2: 23.5
Canada, medical measured within 14 presented only for G3: 23.7
records weeks of gestation obese women)
G1: Obese - low χ2 P = 0.952
603 Total weight gain: weight gain (< 7 kg) G4: 24.1
Based on last clinically G2: Obese -
All weights/BMI measured weight prior acceptable weight
to delivery: within 4 gain (7-11.5 kg)
Poor weeks of birth G3: Obese -
Primigravid women excessive weight gain
(maternal weight gain (> 11.5 kg)
outcomes by BMI G4: Total
presented only for
obese women)

Ekblad and Grenman, Pregravid weight: G1: weight gain ≤ 5 kg Normal vaginal delivery (%) NA
199268 Data from records, G2: weight gain ≥ 20 G1: 90 P < 0.05 compared to
unclear if self reported kg reference category
Finland, hospital G3: reference (normal G2: 64
Total weight gain: prepregnancy weight G3: 71
357 Routine prenatal care and normal weight
or maternity records gain [undefined]) Forceps or vacuum delivery
Normal weight only based on last clinically (%)
measured weight prior G1: 3
Poor to delivery 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

48
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

Jensen et al., 200559 Pregravid weight: G1: GWG 5.0-9.9 kg OR for cesarean delivery 2-h OGTT result,
Records or self report G2: GWG 10.0-14.9 (95% CI) maternal
Denmark, university of pregravid BMI kg G1: 1.0 age, prepregnancy
hospitals G3: GWG ≥ 15 kg G2: 2.4 (1.1-5.3) BMI, gestational
Total weight gain: G3: 3.0 (1.4-6.4) age (continuous
481 Last prenatal G4: 3.6 (1.6-7.8) variables), parity,
assessment P for trend=0.002 smoking, ethnic
Obese only background, and
clinical center
Poor (categorical
variables

Kabiru and Raynor, Pregravid weight: Primary cesarean Operative vaginal delivery Pregravid BMI,
200451 First prenatal visit G1: normal BMI, no G1: 11.4 none other
change in BMI G2: 12.4
USA, hospital Total weight gain: between first prenatal G3: 12.2 P = 0.837
Weight at admission visit and delivery G4: 8.4
5,131 for birth G2: normal BMI, 1 G5: 11.4
category increase in G6: 17.3 P < 0.001
All BM’s > 20I BMI between first
prenatal visit and Cesarean delivery rate for
Poor delivery failure to progress
G3: normal BMI, > 1 G1: 2.5
category increase in G2: 6.5
BMI between first G3: 10.2 P = 0.203
prenatal visit and G4: 3.5
delivery G5: 6.9
G4: overweight BMI, G6: 10.2 P = 0.002
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

49
Table 8. Gestational weight gain and mode of delivery (continued)

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis

Wataba et al., 200661 Pregravid weight: Rate of weight gain, For nulliparous, low BMI Parity, baseline BMI
Unreported categorized differently women:
Japan, academic across different BMI Higher risk of cesarean
medical center Total weight gain: groups delivery for women with weight
From hospital gain ≥ 0.4 kg/week (AOR: 2.30
21,718 database/ register [95% CI, 1.06-4.98] compared
with women gaining 0.25-0.3
All weights/BMI kg/week)

Poor 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

Young et al., 200274 Pregravid weight: G1: < 30 lbs Increase in overall cesarean BMI
Self reported G2: 30-35 lbs delivery rate with increased
USA, private practice G3: > 35 lbs weight gain was significant at
Total weight gain: all BMI levels
3,375 Based on last clinically
measured weight prior
All weights/BMI to delivery

Poor

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

50
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

51
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

52
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.

53
 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

54
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 Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis

Ekblad and Pregravid weight: G1: weight gain ≤ 5 kg Shoulder dystocia% NA

Grenman, 199268 Data from records, G2: weight gain ≥ 20 kg G1: 3
unclear if self reported G3: reference (normal G2: 2
Finland, hospital prepregnancy weight and G3: 0.6
Total weight gain: normal weight gain
357 Last clinically measured [undefined])
weight prior to delivery
Normal weight only

Poor

Geary et al., 199580 Pregravid weight: Weight gain < 12 kg and Maternal weight Parity
First prenatal visit ≥ 12 kg for cases gain < 12 kg Previous birth
Ireland, hospital shoulder dystocia and ≥ 4,000 g
Total weight gain: controls G1: 59.1%
363 Not described G2: 74.1%
G1: Cases with shoulder OR 2.0 (1.6-2.2)
All weights/BMI dystocia
G2: Controls
Poor

BMI, body mass index; g, gram; G, group; kg, kilogram; N, number; OR, odds ratio.

55
Table 9. Gestational weight gain and shoulder dystocia (continued)

Author, Date
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis

Kabiru and Raynor, Pregravid weight: G1: normal BMI, no Shoulder dystocia% NA
51
2004 First prenatal visit change in BMI between G1: 0.5
first prenatal visit and G2: 1.4
USA, hospital Total weight gain: delivery G3: 1.1
Weight at admission for G2: normal BMI, 1 P = 0.278 for
5,131 birth category increase in BMI associations within
between first prenatal normal BMI
All weights/BMI visit and delivery categories
G3: normal BMI, > 1
Poor category increase in BMI G4: 1.0
between first prenatal G5: 1.8
visit and delivery G6: 1.9
G4: overweight BMI, no P = 0.357 for
change in BMI between associations within
first prenatal visit and overweight BMI
delivery categories
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

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

56
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.

57
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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Kramer et al., Pregravid weight: Gestational weight gain AOR (95% CI) for cases with Parity, marital
88
1995 Self-report categories (kg/wk): preterm delivery versus controls status, language,
G1: < 0.27 age, education,
Canada, University Total weight gain: G2: ≥ 0.27 G1: 1.56 (0.94-2.58) matched on
Hospitals Self-report G2: 1.00 (reference) smoking history

396

All weight/BMI

Good
Siega-Riz et al., Pregravid weight: Categories of 3rd AOR (95% CI) for rate of preterm Iron status, parity
199684 Self-reported trimester weekly weight birth: combined with
gain rates (kg/week): G1: 1.91 (1.40-2.61) maternal age,
USA, Public Health Total weight gain: G2: 1.00 (reference) ethnicity,
Clinics (California) Measured G1: Inadequate hypertension
(Underweight, < 0.34; AOR (95% CI) for rate of preterm (chronic or
7,589 Normal weight, < 0.35; labor: pregnancy
Overweight/ Obese, G1:1.75 (1.15-2.64) induced), smoking
All weight/BMI < 0.30) G2: 1.00 (reference) status, week
prenatal care
Good G2: Adequate AOR (95% CI) for rate of began
(Underweight, > 0.34; PPROM:
Normal, > 0.35; G1: 2.70 (1.35-5.42)
Overweight/Obese, G2: 1.00 (reference)
> 0.30)
Carmichael et Pregravid weight: Total gestational weight Linear regression analysis of BMI, maternal age,
al.,199782 Self-report gain (continuous) gestational age (days) as infant sex
dependent variable and cigarettes per day
USA, University Total weight gain: gestational weight gain (kg) as maternal height,
Hospital (California) Maternity Records independent variable: Regression parity, race,
coefficient = 0.51; t-statistic = pattern of gain
7,259 13.1; P < 0.001 derived from
quadratic curves
Nonobese AOR (95% CI) of spontaneous
preterm birth/ kg increase in total
Fair weight gain: 0.84 (0.82-0.87)

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.

58
Table 10. Gestational weight gain and preterm birth (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
23
Dietz et al., 2006 Pregravid weight: Categories of mean rate of In general, in comparison to Race, Medicaid
Self-report gestational weight gain women with normal BMI in recipient, parity,
USA, Pregnancy (kg/wk) during second and G3: underweight women in marital status
Risk Assessment Total weight gain: third trimesters stratified by G1- G5 and normal weight
Monitoring System Birth Certificates pregravid BMI and type of women in G1, G2, and G5
preterm birth (very preterm, were at increased risk of
113,019 20-31 weeks; moderate very preterm births (AOR:
preterm, 32-36 weeks): 1.5-9.8). Underweight
All weight/BMI G1: < 0.12 women in G1-G3 and G5
G2: 0.12-0.22 and normal women in G1,
Fair G3: 0.23-0.68 G2, and G5 were at
G4: 0.69-0.79 increased risk moderate
G5: > 0.79 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)
Nohr et al., 200765 Pregravid weight: Rate of gestational weight HR (95% CI): Pregravid BMI,
Self-reported gain (g/wk) for women with G1: 2.1 (1.5-3.0) age, height, parity,
Danish National early preterm birth (22-33 G2: 1.0 (ref) socio-occupational
Birth Cohort Total weight gain: weeks) with PPROM : G3: 1.2 (0.8-1.8) status, smoking
Self-reported G1: < 275 alcohol
16,167 G2: 276-675 HR (95% CI): consumption
G3: ≥ 676 G4: 1.9 (1.3-2.6)
All weight/BMI G5: 1.0 (ref)
Rate of gestational weight G6: 1.9 (1.3-2.6)
Fair gain (g/wk) for women with
early preterm birth (22-33 HR (95% CI):
weeks) without PPROM : G7: 1.3 (1.0-1.6)
G4: < 275 G8: 1.0 (ref)
G5: 276-675 G9: 1.2 (1.0-1.5)
G6: ≥ 676
HR (95% CI):
Rate of gestational weight G10: 1.0(0.9-1.2)
gain (g/wk) for women with G11: 1.0(ref)
late preterm birth (34-36 G12: 1.0 (0.9-1.2)
weeks) with PPROM:
G7: < 275
G8: 276-675
G9: ≥ 676

59
Table 10. Gestational weight gain and preterm birth (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
65
Nohr et al., 2007 Rate of gestational weight
(continued) gain (g/wk) for women with
late preterm birth (34-36
weeks) without PPROM:
G10: < 275
G11: 276-675
G12: ≥ 676
Rosenberg et al., Pregravid weight: Categories of total AOR (95% CI) for Preterm Pregravid weight,
200571 Self-report gestational weight gain Birth: chronic diabetes,
(lbs): G1: 1.00 (reference) GDM, chronic
USA, New York City Total weight gain: G2: 0.54 (0.52-0.57) hypertension, PIH
birth files Self-report G1: <41 preeclampsia,
G2: ≥ 41 maternal age
329,988 marital status
maternal education
All weight/BMI maternal
birthplace, prenatal
Fair care payer, social
risk, parity,
trimester that
prenatal care
began
Schieve, et al., Pregravid weight: Rate of weight gain Reference category of rate None
86
1999 Self-reported (kg/week) in percentiles of weight gain: 0.35-<0.46
stratified by Low, Average, kg/wk
USA, Pregnancy Total weight gain: High, and Obese pregravid
Nutrition Self-reported BMI: RD of preterm birth varied
Surveillance System G1: 5th,0.10 by prepregnant BMI and
(PNSS) G2: 10th, 0.16 gestational weight gain.
G3: 25th,0.26 Overall, women gaining
266,172 G4: 50th,0.35 0.26-0.46 kg/wk had the
G5: 75th, 0.46 lowest RD of preterm birth.
All weight/BMI G6: 90th, 0.57 The highest RD occurred
G7: 95th, 0.65 for women gaining the least
Fair and most amount of weight,
irrespective of prepregnant
BMI; however, the highest
RD of preterm births were
among women of low BMI
Stotland et al., Pregravid weight: Categories of rate of AOR (95% CI) for preterm Race, age
85
2006 Medical Charts gestational weight gain delivery < 37 weeks: pregravid BMI,
(kg/wk): G1: 2.6 (2.1-3.2) year of delivery,
USA, University Total weight gain: G2: 1.0 (reference) parity, previous
Hospital (California) Medical Charts G1: < 0.27 G3: 1.0 (0.8-1.2) preterm birth,
G2: 0.27 to 0.52 number of days
15,101 G3: > 0.52 AOR (95% CI) for preterm between last
delivery < 34 weeks: weighing and
Underweight/Normal G1: 3.0 (2.0-4.8) delivery, smoking
BMI G2: 1.0 (ref)

Fair

60
Table 10. Gestational weight gain and preterm birth (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
89
Wen et al., 1990 Pregravid weight: Rate of weight gain (kg/wk) AOR for preterm birth: Race, parity, infant
Measured at first after 20 weeks gestation G1: 1.52 (P < 0.05) sex, marital status,
USA, University prenatal visit G2: 1.11 (NS) education, age,
Hospital (Alabama) G1: < 0.24 G3: 1.00 (ref) previous preterm
Total weight gain: G2: 0.24-0.57 G4: 1.71 (P < 0.05) delivery, smoking,
17,149 Medical records G3: 0.58-0.74 alcohol
G4: ≥0.75 consumption, drug
All weight/BMI use, height,
pregravid weight
Fair
Jensen et al., Pregravid weight: Total gestational weight Percent (%) preterm NA
59
2005 Self-report gain categories (kg): delivery by weight gain
categories:
Denmark, University G1: < 5.0
hospital centers Total weight gain: G2: 5.0-9.9 G1: 6.5
Hospital records G3: 10.0-14.9 G2: 6.0
481 G4: > 15.0 G3: 4.6
G4: 2.5
Obese P for trend = 0.11

Poor
Spinillo et al., Pregravid weight: G1: Prepregnancy AOR (95% CI) for cases Pregravid BMI,
199887 Self-report BMI ≤ 19.5 and 2nd/3rd with spontaneous preterm pregravid weight,
trimester weight gain ≤ 0.37 delivery versus controls: height, age, parity,
Italy, University Total weight gain: kg/wk smoking, social
Hospital Medical records G1: 5.63 (2.35-13.8) class education,
G2: Prepregnancy G2: 2.45 (1.60-3.75) infant sex
690 BMI>19.5 and 2nd/3rd P = 0.06 for interaction
trimester weight gain ≤ 0.37 between G1 and G2
All weight/BMI kg/wk
G3: 5.29 (1.45-20.90)
Poor G3: Prepregnancy BMI ≤ 48 G4: 2.42 (1.65-3.55)
kg and 2nd/3rd trimester P = 0.21 for interaction
weight gain ≤ 0.37 kg/wk between G3 and G4

G4: Prepregnancy BMI > 48

kg and 2nd/3rd trimester
weight gain ≤ 0.37 kg/wk

61
Table 10. Gestational weight gain and preterm birth (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Velonakis et Pregravid weight: Total gestational weight Regression analysis with Age, race,
83
al.,1997 Self-reported gain (continuous) gestational age (weeks) as gravidity, previous
the dependent variable and diseases, parity,
France, Hospital Total weight gain: net gestational weight gain abortions, marital
Measured as the independent status, pathology
2040 variable: of index
Β = 0.191 (SE, 0.06) pregnancy, infant
All weight/BMI P = 0.001 sex, height
pregravid weight,
Poor 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

62
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

63
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

64
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 fair-
quality 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

65
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.

66
Table 11. Total gestational weight gain (categorical) and infant birthweight

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Hickey et al., Pregravid weight: Infant BW for groups G1: 3,325 g ± 460 N/A
106
1990 Self-report defined by maternal weight G2: 3,543 g ± 410
near term (% of standard G3: 3,200 g ± 389
United States, Total weight gain: weight-for-height) G4: 3,381 g ± 385
prenatal clinics Routine prenatal G5: 3,157 g ± 373
care or maternity G1: > 135%, Black G6: 3,282 g ± 400
325 records G2: > 135%, Hispanic G7: 3,025 g ± 494
G3: 120-135%, Black G8: 3,154 g ± 375
All weight/BMI G4: 120-135%, Hispanic G9: 2,813 g ± 289
G5: 110-119%, Black G10: 3,205 g ± 472
Good G6: 110-119%, Hispanic
G7: 100-109%, Black
G8: 100-109%, Hispanic
G9: < 100%, Black
G10: < 100%, Hispanic
Abrams et al., Pregravid weight: G1: Infant BW among 3,485.8 g ± 523.1 Maternal age,
1995101 Self-report nonobese women parity, pregravid
BMI, height,
USA, university Total weight gain: smoking, infant
hospital Routine prenatal sex, difference
care or maternity in weeks
4,420 records between the
last measured
Nonobese weight and
delivery
Fair
Zaren et al., 199799 Pregravid weight: β is estimated change in G1: β = -131 (P = 0.0001) Maternal age,
Self-report infant BW (g) G2: β = 164 (P = 0.0001) height,
Norway and pregravid
Sweden, university Total weight gain: G1: GWG ≤ 11 kg: weight, smoking
hospitals Routine prenatal G2: GWG ≥ 17 kg:
care or maternity
1,099 records

All weights/BMI

Fair
Bianco et al., 199854 Pregravid weight: Infant BW for GWG: G1: 3,302 N/A
Self-report G2: 3,192
USA, medical center G1: Weight loss or 0 lbs G3: 3,337
Total weight gain: G2: 1-15 lbs G4: 3,506
613 Routine prenatal G3: 16-25 lbs G5: 3,453
care or maternity G4: 26-35 lbs (P < 0.05)
Morbidly obese (BMI records G5: >35 lbs
> 35)

Poor

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

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
95
Cherry et al., 1993 Pregravid weight: Infant BW by Quartiles of G1: 2,829 g N/A
USA, hospital Measured by study weight gain G2: 2,990 g
investigators G3: 3,112 g
RCT Quartiles defined as weekly G4: 3,189 g
Total weight gain: weight gain in g per cm
599 Routine prenatal height
care or maternity
All weights/BMI records G1: Quartile 1 (≤ 1.87g)
G2: Quartile 2 (1.88-2.68g)
Poor G3: Quartile 3 (2.69-3.58g)
G4: Quartile 4 (≥ 3.59g)
Ekblad and Pregravid weight: Infant BW by group G1: 3,538 g ± 535 N/A
Grenman, 199268 Medical records G2: 3,284 g ± 880
G1: Normal prepregnancy G3: 3,803 g ± 538
Finland, hospital Total weight gain: weight and normal weight
Routine prenatal gain (P < 0.005 compared to
357 care or maternity G2: Weight gain ≤5 kg G1)
records G3: Weight gain ≥20 kg
Prepregnancy
weight 20% over or
under ideal body
weight for height
and normal weight

Poor
Jensen et al., 200559 Pregravid weight: Infant BW for groups G1: 3,456 g ± 620 N/A
Self-report defined by GWG G2: 3,624 g ±675
Denmark, university G3: 3,757 g ± 582
hospitals Total weight gain: G1: GWG < 5.0 kg G4: 3,784 g ± 597
Routine prenatal G2: GWG 5.0-9.9 kg
481 care or maternity G3: GWG 10-14.9 kg P < 0.0001
records G4: GWG ≥ 15.0 kg
Obese

Poor
Shapiro et al., Pregravid weight: Infant BW for groups G1: 3,363 g N/A
94
2000 Routine prenatal defined by BMI and weight G2: 3,636 g
care gain G3: 3,565 g
USA, community G4: 3,774 g
hospital Total weight gain: G1: Low BMI (< 25), Low
Routine prenatal gain (< 35lbs)
159 care or maternity G2: Low BMI (< 25), High
records gain (> 35lbs)
All weight/BMI G3: High BMI (> 25), Low
gain (< 35lbs)
Poor G4: High BMI (> 25), High
gain (> 35lbs)

68
 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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
98
Brown et al., 2002 Pregravid weight: G1: Increase in birthweight G1: β = 20 g Maternal age,
Measured by study per 1 kg increase in total (P < 0.0001) parity, pregravid
USA, primary care investigators pregnancy weight gain BMI, height, infant
clinics sex, gestational
Total weight gain: age
389 Collected by study
investigators
All weight/BMI

Good
Groff et al., 1997103 Pregravid weight: G1: Increase in birthweight G1: β = 10.1g ± 1.76 Pregravid BMI,
USA, multispecialty Self-report 82% per 1 lb increase in total (P ≤ 0.001) infant sex, smoking
clinics First prenatal visit pregnancy weight gain
18%
341
Total weight gain:
All weights/BMI Routine prenatal
care or maternity
Good records

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

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
48
Kieffer et al., 2006 Pregravid weight: G1: Increase in birthweight G1: β = 19.7 g ± 2.8 Parity, pregravid
USA, community Self-report per 1 kg increase in total (P < 0.01) BMI, height, 1-hour
health center pregnancy weight gain glucose value,
Total weight gain: gestational age
1,041 Routine prenatal care
or maternity records
All weights/BMI

Good
Abrams et al., Pregravid weight: G1: Increase in birthweight G1: β = 22.6 g Maternal age,
1995101 Self-report per 1 kg increase in total (P < 0.001) parity, pregravid
pregnancy weight gain BMI, height,
USA, university Total weight gain: smoking, infant
hospital Routine prenatal care sex, gestational
or maternity records age
4,420

Nonobese

Fair
Butte et al., 200397 Pregravid weight: G1: Correlation coefficient G1: 0.28 Maternal race,
Measured by study G2: Variability in birthweight G2: 37.9% pregravid BMI,
USA, US Agriculture investigators accounted for by gestational gestational age
Research Service age, pregravid weight, and
Children’s Nutrition Total weight gain: total pregnancy weight gain
Research Center Measured by study
investigators
63

All weights/BMI

Fair
Edwards et al., Pregravid weight: G1: Increase in birthweight G1: β = 11 g ± 2 Maternal age,
199655 Self-report per 1 kg increase in total (P ≤ 0.001) parity, pregravid
USA, hospital pregnancy weight gain for G2: β = 15 g ± 2 BMI, pregnancy-
Total weight gain: obese women (P ≤ 0.001) induced
1,443 Routine prenatal care hypertension,
or maternity records G2: Increase in birthweight adequacy of
Normal and obese per 1 kg increase in total prenatal care,
BMI pregnancy weight gain for alcohol use, drug
normal weight women use, smoking,
Fair gestational age

70
Table 12. Total gestational weight gain (continuous) and infant birthweight (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Guihard-Costa et al., Pregravid weight: G1: Standardized G1: SC = 0.199 Maternal age,
92
2004 Routine prenatal care coefficient for effect of parity, pregravid
pregnancy weight gain on BMI, height
France, hospital Total weight gain: infant birthweight.
database Routine prenatal care
or maternity records Standardized coefficients
13,972 are regression coefficients
calculated as if all of the
All weights/BMI independent variables had
a variance of 1
Fair
Hediger et al., Pregravid weight: G1: Increase in birthweight G1: β = 16.7 g ± 2.5 Maternal age,
1994102 Self-report per 1 kg increase in total (P = 0.001) maternal
USA, setting not pregnancy weight gain race/ethnicity,
stated Total weight gain: parity, pregravid
Routine prenatal care weight, height,
608 or maternity records gestational age,
prior poor
All weights/BMI outcome, fat loss,
pregravid weight:
Fair low weight, fat
accretion, smoking,
infant sex
Kirchengast and Pregravid weight: G1: Increase in birthweight G1: β = 17.32 (14.62, Maternal age, age
Hartmann, 200393 Estimated from per 1 kg increase in total 20.03) at menarche,
measured weight at pregnancy weight gain pregravid weight,
Austria, university first prenatal visit height, distantia
hospital cristarum
Total weight gain:
8,011 Routine prenatal care
or maternity records
All weights/BMI

Fair
Luke et al., 1996104 Pregravid weight: Increase in birthweight per G1: β = 44.9 g ±6.8 Maternal age,
Self-report 1 kg increase in total (P < 0.01) parity, black
USA, clinic pregnancy weight gain for G2: β = 22.9 g ± 3.9 ethnicity, smoking,
Total weight gain: BMI categories: (P < 0.01) gestational age,
487 Routine prenatal care G3: β = 11.9 g ± 5.2 infant sex
or maternity records G1: Underweight (P < 0.05)
All weights/BMI G2: Normal weight
G3: Overweight
Fair

71
Table 12. Total gestational weight gain (continuous) and infant birthweight (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Muscati et al., Pregravid weight: G1: Increase in birthweight G1: β = 22 g ± 6 Parity, pregravid
105
1996 Medical records per 1 kg increase in total (P < 0.01) standard weight,
weight gain up to week 20 pregravid excess
Canada, public Total weight gain: weight, birth
health department Collected by study length, infant sex
investigators
371

All weight/BMI

Fair
Pezzarossa et al., Pregravid weight: Increase in birthweight per G1: β = 27.8 g Pregravid BMI,
1996100 Self-report 1 kg increase in total (P = 0.0001) fasting plasma
pregnancy weight gain for: G2: β = 39.5 glucose
Italy, not stated Total weight gain: (P = 0.0001)
Routine prenatal care G1: Controls (normal
192 or maternity records glucose tolerance)
G2: GDM
All weights/BMI

Fair
Di Cianni et al., Pregravid weight: F statistic = 3.16, Pregravid BMI,
200491 Not reported P = 0.08 maternal
triglycerides,
Italy, diabetes clinic Total weight gain: plasma glucose
Collected by study
180 investigators

All weights/BMI

Poor
Jensen et al., 200559 Pregravid weight: G1: Increase in birthweight G1: β = 18.4 g Maternal age,
Self-report per 1 kg increase in total (P < 0.001) pregravid BMI,
Denmark, university pregnancy weight gain smoking,
hospitals Total weight gain: gestational age,
Routine prenatal care result of 2-hour
481 or maternity records oral glucose
tolerance test
Obese

Poor
Paauw et al., 200590 Pregravid weight: G1: Increase in birthweight G1: β = 21.0 g Maternal race,
Self-report per 1 kg increase in total pregravid weight,
USA, hospital pregnancy weight gain marital status,
Total weight gain: smoking,
351 Self-report gestational age

All weights/BMI

Poor

72
Table 12. Total gestational weight gain (continuous) and infant birthweight (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Springer et al., Pregravid weight: G1: Increase in birthweight G1: β = 20.1g Maternal age,
96
1992 Self-report per 1 lb increase in total pregravid weight,
pregnancy weight gain length of gestation,
USA, university Total weight gain: smoking, weight
hospital Routine prenatal care gain at 20 weeks
or maternity records
107

All weights/BMI

Poor

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, glucose-
tolerant 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

73
Table 13. Continuous gestational weight gain by trimester and infant birthweight
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Brown et al., 200298 Pregravid weight:G1: Increase in G1: β = 31 g Maternal age, parity,
Measured by studybirthweight per 1 kg (P < 0.0007) pregravid BMI,
USA, primary care investigators increase in first height, infant sex,
clinics trimester weight gain G2: β = 26 g gestational age
Total weight gain: G2: Increase in (P < 0.007)
389 Collected by study birthweight per 1 kg
investigators increase in second G3: β = 7 g
All weight/BMI trimester weight gain (P < 0.40)
G3: Increase in
Good birthweight per 1 kg
increase in third
trimester weight gain
Abrams et al., 1995101 Pregravid weight: G1: Increase in G1: β = 18.0 g ± 2.4 Maternal age, parity,
Self-report birthweight per 1 kg (P < 0.001) pregravid BMI,
USA, university increase in first height, smoking,
hospital Total weight gain: trimester weight gain G2: β = 32.8 g ± 2.8 infant sex,
Routine prenatal care G2: Increase in (P < 0.001) gestational age
4,420 or maternity records birthweight per 1 kg
increase in second G3: β = 17.0 g ± 2.9
Nonobese trimester weight gain (P < 0.001)
G3: Increase in
Fair birthweight per 1 kg
increase in third
trimester weight gain
Muscati et al., 1996105 Pregravid weight: G1: Increase in G1: β = 31 g ± 7 Parity, pregravid
Medical records birthweight per 1 kg (P < 0.001) standard weight,
Canada, public health increase in total pregravid excess
department Total weight gain: weight gain from G2: β = 12 g ± 6 weight, birth length,
Collected by study weeks 21 to 30 (P < 0.05) infant sex
371 investigators G2: Increase in
birthweight per 1 kg
All weight/BMI increase in total
weight gain from
Fair weeks 31 to term
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

74
Table 14. Net and proportional gestational weight gain and infant birthweight
Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis
Johnson et al., Pregravid weight: G1: Increase in G1: β = 15.4 g ± 2.2 Maternal race, parity,
70
1992 Self-report birthweight per 1 lb (P < 0.0001) pregravid BMI, height,
increase in net pregravid weight,
USA, prenatal Total weight gain: pregnancy weight gain marital status,
clinics Routine prenatal education,
care or maternity tobacco/alcohol/drug
3,191 records use, pregnancy-induced
hypertension,
All weights/BMI gestational age,
macrosomia, infant sex
Fair
Luke et al., 1996104 Pregravid weight: Increase in birthweight G1: β = 41.9 g ± 7.5 Maternal age, parity,
Self-report per 1 kg increase in (P < 0.01) black ethnicity, smoking,
USA, clinic net pregnancy weight G2: β = 19.2 g ± 3.9 gestational age, infant
Total weight gain: gain for BMI (P < 0.01) sex
487 Routine prenatal categories: G3: β = 9.1 g ± 5.3
care or maternity
All weights/BMI records G1: Underweight
G2: Normal weight
Fair G3: Overweight
Shepard 199875 Pregravid weight: Infant birthweight for G1: 3,231 g N/A
Self-report mothers with: G2: 3,553 g
USA, obstetrical G3: 3,395 g
practices in New Total weight gain: G1: Low average BMI G4: 3,620 g
Haven, CT Routine prenatal (19.5 to 22.4), G5: 3,685 g
care or maternity proportional weight G6: 3,453 g
2,301 records gained > median
G2: Low average BMI
All weights/BMI (19.5 to 22.4), gained
< median
Fair 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
Velonakis et al., Pregravid weight: G1: Increase in G1: β = 111.17 g ± 12.94 Maternal age, parity,
83
1997 Self-report birthweight for net (P = 0.000) pathology of
pregnancy weight gain previous/current
France, hospital Total weight gain: pregnancy, previous
Routine prenatal diseases, reproductive
2,040 care or maternity history, marital status,
records employment, infant sex,
All weights/BMI height, weight, smoking,
alcohol use, APGAR
Poor 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.

75
 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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
106
Hickey et al., 1990 Pregravid weight: G1: Percent BW < 3,000, Low G1: 38.2 N/A
Self-report weight gain < 120% of standard G2: 61.8
United States, prenatal G2: Percent BW ≥ 3,000, Low G3: 22.1
clinics Total weight gain: weight gain < 120% of standard G4: 77.9
Routine prenatal G3: Percent BW < 3,000,
325 care or maternity Acceptable weight gain ≥ 120%
records of standard
All weights/BMI G4: Percent BW ≥ 3,000,
Acceptable weight gain ≥ 120%
Good of standard
Cogswell et al., 19942 Pregravid weight: ORs and 95% CI, for LBW by G1: 2.1 (1.6-2.6) Maternal age,
Self-report GWG and prepregnancy BMI G2: 0.5 (0.4-0.6) maternal race,
USA, Pregnancy G3: 1.0 height, smoking,
Nutrition Surveillance Total weight gain: G1: Normal BMI, GWG < 15 lbs G4: 0.5 (0.3-0.8) infant sex,
System Self-report G2: Normal BMI, GWG ≥ 40 lbs G5: 0.6 (0.3-1.1) gestational age
G3: Normal BMI, GWG 25-29 lbs G6: 0.4 (0.3-0.7)
53,541 (Reference for normal BMI) G7: 1.0
G4: Overweight BMI, GWG 30-34
Normal/Overweight/ lbs
Obese G5: Overweight BMI, GWG 35-39
G6: Overweight BMI, GWG ≥40
Fair lbs
G7: Overweight BMI, GWG 15-19
lbs (Reference for overweight
BMI)

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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Desjardins and Pregravid weight: G1: OR and 95% CI, for G1: 1.15 (0.78-1.67) Gestational age,
Hardwick, 1999107 Self-report LBW and inadequate adolescence,
weight gain (defined by pregravid
Canada, Healthiest Total weight gain: dietician) underweight,
Babies Possible Home visitor's scale number of
Program Healthiest Baby
Possible visits
1,892

All weights/BMI

Fair
Kiel et al., 20074 Pregravid weight: G1: Odds of LBW for G1: Odds of LBW Maternal age,
Medical records weight gain > 25 lbs are lower for women maternal race,
USA, birth certificate G2: OR of LBW for weight in this group maternal
registry Total weight gain: gain < 15 lbs G2: Odds of LBW education, poverty,
Routine prenatal G3: Reference Weight gain are higher for smoking, parity,
120,251 care or maternity 15-25 lbs women in this group chronic
records Numerical value for hypertension
Obese ORs not reported in
study
Fair
Kirchengast and Pregravid weight: G1: OR and 95% CI, for G1: 0.90 (0.85-0.95) Maternal age,
Hartmann 200393 Estimated from LBW pregravid weight,
measured weight at height, distantia
Austria, university first prenatal visit cristarum
hospital
Total weight gain:
8,011 Routine prenatal
care or maternity
All weights/BMI records

Fair
Murakami et al., Pregravid weight: OR and 95% CI, for LBW G1: 1.26 (0.57-2.75) Maternal age,
200452 Self-report G2: Reference parity, pregravid
G1: GWG < 8.5 kg G3: 0.62 (0.24-1.62) BMI, smoking,
Japan, hospital Total weight gain: G2: GWG 8.5-12.5 kg gestational age
Routine prenatal G3: GWG > 12.5 kg
633 care or maternity
records
All weights/BMI

Fair

77
Table 15. Total gestational weight gain and low birthweight (LBW) (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Rosenberg et al., Pregravid weight: OR and 95% CI, for LBW G1: 0.41 (0.39- Maternal age,
71
2005 Self-report 0.43) parity, GDM,
G1: GWG ≥ 41 lbs G2: Reference pregnancy-induced
USA, vital statistics Total weight gain: G2: GWG < 41 lbs hypertension,
data Routine prenatal preeclampsia,
care or maternity pregravid weight,
329,988 records chronic diabetes,
chronic
All weights/BMI hypertension,
marital status,
Fair maternal education,
mother’s birthplace,
prenatal care payer,
social risk, trimester
prenatal care began
Zhou and Olsen, Pregravid weight: OR and 95% CI, for LBW for G1: 1.0 Maternal age,
1997108 Self-report GWG categories by BMI G2: 0.9 (0.5-1.5) parity, alcohol, no
G3: 0.8 (0.3-2.0) diabetes, term
Denmark, two Total weight gain: G1: GWG < 11 kg, G4: 0.5 (0.2-1.0) delivery, smoking,
communities Routine prenatal Underweight (Reference) G5: 0.8 (0.4-1.5) infant sex,
care or maternity G2: GWG < 11 kg, Normal G6: 0.9 (0.2-3.8) gestational age
7,122 records weight G7: 0.3 (0.1-1.0)
G3: GWG < 11 kg, Overweight G8: 0.4 (0.2-0.8)
All weights/BMI G4: GWG 12-15 kg, G9: 0.0 (0.0-2,500)
Underweight
Fair 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
Bianco et al., 199854 Pregravid weight: % LBW for GWG: G1: 2 N/A
Self-report G2: 11.1
USA, medical center G1: Weight loss or 0 lbs G3: 8.3
Total weight gain: G2: 1-15 lbs G4: 5.2
613 Routine prenatal G3: 16-25 lbs G5: 3.8
care or maternity G4: 26-35 lbs
Morbidly obese records G5: > 35 lbs
(BMI > 35)

Poor

78
Table 15. Total gestational weight gain and low birthweight (LBW) (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
109
Lasker et al., 2005 Pregravid weight: OR and 95% CI, for LBW G1: 2.43 (1.45-4.05) Maternal age,
Not stated G2: 0.63 (0.47-0.85) maternal race,
USA, hospital G1: GWG < 10 lbs G3: 1.00 marital status,
Total weight gain: G2: GWG > 30 lbs prenatal care, prior
5,528 Routine prenatal G3: GWG 21-30 lbs term births, prior
care or maternity (Reference) abortions, prior
All weights/BMI records preterm births, BMI
at delivery,
Poor 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 good-
quality 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 poor-
quality studies showed results in the same general direction.54,109

79
Table 16. Other gestational weight gain measures and LBW
Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis
Johnson et al., Pregravid weight: OR and 95% CI, for LBW G1: 1.0 (Reference) Maternal race, parity,
70
1992 Self-report G2: 0.51 (0.27-0.98) pregravid BMI, height,
G1: Net WG < 14.9 lbs G3: 0.54 (0.28-1.04) pregravid weight,
USA, prenatal Total weight gain: (Reference) G4: 0.38 (0.2-0.8) marital status,
clinics Routine prenatal G2: Net WG 14.9-23.5 lbs education,
care or maternity G3: Net WG 24-33 lbs tobacco/alcohol/drug
3,191 records G4: Net WG > 33 lbs use, pregnancy-
induced hypertension,
All weights/BMI gestational age,
macrosomia, infant sex
Fair
Shepard 199875 Pregravid weight: %LBW G1: 3.5% N/A
Self-report G2: 7.4%
USA, obstetrical G1: Proportional WG < median, G3: 2.1%
practices in New Total weight gain: underweight (BMI < 19.4) G4: 2.8%
Haven, CT Routine prenatal G2: Proportional WG < median, G5: 2.1%
care or maternity obese (BMI > 28.5) G6: 4.6%
2,301 records G3: Proportional WG > median,
underweight (BMI < 19.4)
All weights/BMI G4: Proportional WG > median,
Low-average BMI (19.5-22.4)
Fair G5: Proportional WG > median,
High-average BMI (22.5-28.5)
G6: Proportional WG > median,
obese (BMI > 28.5)
Cherry et al., Pregravid weight: %LBW for each shifting of EW G1: 5% N/A
95
1993 Measured by study category. G2: 32%
investigators G3: 3.1%
USA, hospital Light: < 90% EW G4: 2.7%
Total weight gain: Normal: 90 to 110% of EW
599 Routine prenatal Heavy: > 110% EW
care or maternity
All weights/BMI records G1: Heavy to normal
G2: Normal to light
Poor G3: Normal to heavy
G4: Light to normal
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

80
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

81
Table 17. Gestational weight gain and macrosomia > 4,500 g

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Hedderson et al., Pregravid weight: ORs and 95% CI, for G1: 0.52 (0.34-0.79) Maternal age,
110
2006 Self-report macrosomia based on rate G2: 1.00 maternal
of weight gain G3: 0.99 (0.67-1.47) race/ethnicity,
USA, Kaiser Total weight gain: G4: 2.23 (1.54-3.22) parity, pregravid
Permanente Medical Routine prenatal Rate of gain kg/wk: BMI, screening
Care Program care or maternity G1: -0.26 to 0.21 glucose value,
records G2: 0.22 to 0.31 gestational age
45,245 (Reference)
G3: 0.32 to 0.39
All weights/BMI G4: 0.40 to 1.03

Good
Clausen et al., 2005113 Pregravid weight: ORs and 95% CIs for G1: 1.0 Maternal age,
Routine prenatal macrosomia G2: 2.1 (0.8-5.1) parity, smoking,
Norway, university care G3: 3.5 (1.5-8.0) placental weight,
hospital G1: WG, Quartile 1 G4: 4.3 (1.9-9.8) gestational
Total weight gain: (Reference) diabetes, first
2050 Routine prenatal G2: WG, Quartile 2 trimester BMI
care of maternity G3: WG, Quartile 3
All weights/BMI records G4: WG, Quartile 4

Fair
Cogswell et al., 19942 Pregravid weight: ORs and 95% CIs for G1: 1.0 Maternal age,
Self-report macrosomia by GWG and G2: 1.5 (1.0-2.3) maternal race,
USA, Pregnancy prepregnancy BMI G3: 3.3 (2.3-4.7) height, smoking,
Nutrition Surveillance Total weight gain: G4: 1.0 infant sex,
System Self-report G1: Normal BMI, GWG 25- G5: 4.0 (1.6-10.1) gestational age
29 lbs (Reference for G6: 1.0
53,541 normal BMI) G7: 1.9 (1.3-2.9)
G2: Normal BMI, GWG 35- G8: 2.1 (1.3-3.2)
Normal/Overweight/ 39 lbs G9: 2.3 (1.6-3.3)
Obese G3: Normal BMI, GWG ≥ 40
lbs
Fair 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

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.

82
Table 17. Gestational weight gain and macrosomia > 4,500 g (continued)
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Zhou and Olsen, Pregravid weight: OR and 95% CI, for G1: 1.0 Maternal age,
108
1997 Self-report macrosomia by GWG G2: 52.8 (0.3-22.9) parity, alcohol, no
categories and BMI G3: 9.7 (1.2-81.8) diabetes, term
Denmark, two Total weight gain: G4: 0.0 (0.0-7x105) delivery, smoking,
communities Routine prenatal G1: GWG < 11 kg, G5: 6.8 (0.9-51) infant sex,
care or maternity underweight (Reference) G6: 27.1 (3.3-220) gestational age
7,122 records G2: GWG < 11 kg, normal G7: 6.1 (0.7-52.5)
weight G8: 15.7 (2.2-114)
All weights/BMI G3: GWG < 11 kg, G9: 45.6 (6.0-349)
overweight
Fair 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
Brennand et al., 200549 Pregravid weight: % Macrosomia among G1: 16.9% N/A
Medical records obese women only G2: 15.3%
Canada, medical G3: 18.4%
records Total weight gain: G1: Low WG, < 7 kg (P = 0.834)
Routine prenatal G2: Acceptable WG, 7-11.5
603 care or maternity kg
records G3: Excessive WG, > 11.5
Normal/Overweight/ kg
Obese

Poor

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

83
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 Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis
Bergmann et al., Pregravid weight: ORs and 95% CIs of G1: 1.0 Pregravid BMI, height,
2003112 Not stated macrosomia G2: 1.85 (1.77-1.93) parity, smoking,
G3: 3.37 (3.22-3.53) diabetes, postterm
Germany, Berlin Total weight gain: G1: WG < 10 kg delivery
Perinatal Registry Not stated (Reference)
G2: WG 10-16 kg
206,308 G3: WG ≥ 16 kg

All weights/BMI

Fair
Jain et al., 200777 Pregravid weight: ORs and 95% CIs for G1: 0.49 (0.30-0.82) Maternal age, pregravid
Not stated macrosomia G2: 1.0 BMI, parity, education,
USA, birth G3: 1.17 (0.82-1.65) race/ethnicity,
certificate records Total weight gain: G1: WG ≤ 15 lbs G4: 2.83 (2.04-3.92) US/foreign origin
and Pregnancy Birth certificate G2: WG 15-24 lbs
Risk Assessment G3: WG 25-35 lbs
Monitoring G4: WG ≥ 35 lbs
System

7,661

All weights/BMI

Fair
Johnson et al., Pregravid weight: OR and 95% CI, for G1: 1.0 Maternal race, parity,
199270 Self-report macrosomia G2: 1.20 (0.83-1.75) pregravid BMI, height,
G3: 1.77 (1.24-2.52) pregravid weight,
USA, prenatal Total weight gain: G1: Net WG < 14.9 lbs G5: 2.86 (2.02-4.02) marital status,
clinics Routine prenatal care (Reference) education,
3,191 or maternity records G2: Net WG 14.9-23.5 lbs tobacco/alcohol/drug
G3: Net WG 24-33 lbs use, pregnancy-induced
All weights/BMI G4: Net WG > 33 lbs hypertension,
gestational age,
Fair 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.

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

Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis
4
Kiel et al., 2007 Pregravid weight: G1: Odds of macrosomia G1: Odds of Maternal age, maternal
Medical records for WG > 25 lbs Macrosomia are race, maternal
USA, birth G2: OR of macrosomia higher for women in education, poverty,
certificate registry Total weight gain: for WG < 15 lbs this group smoking, parity, chronic
120,251 Routine prenatal care G3: Reference WG 15-25 G2: Odds of hypertension
or maternity records lbs Macrosomia are
Obese lower for women in
this group
Fair
Numerical value for
ORs not reported in
study
Kirchengast and Pregravid weight: G1: OR and 95% CI, for G1: 1.07 (1.05-1.10) Maternal age, pregravid
93
Hartmann 2003 Estimated from Macrosomia weight, height, distantia
measured weight at cristarum
Austria, university first prenatal visit
hospital
Total weight gain:
8,011 Routine prenatal care
or maternity records
All weights/BMI

Fair
Takimoto et al., Pregravid weight: ORs and 95% CI, for G1: 0.31 (0.20,-0.47) Maternal age, parity,
2006111 Medical records macrosomia G2: 0.49 (0.34-0.70) pregravid weight,
G3: 1.0 gestational age, infant
Japan, obstetric Total weight gain: G1: Total GWG < 25th G4: 1.62 (1.24-2.12) sex
units Routine prenatal care percentile for GA G5: 2.41 (1.83-3.17)
112,257 or maternity records G2: Total GWG 25-49th
percentile for GA
All weights/BMI G3: Total GWG 50-74th
percentile for GA
Fair (Reference)
G4: Total GWG 75-89th
percentile for GA
G5: Total GWG ≥90th
percentile for GA
Brennand et al., Pregravid weight: % Macrosomia among G1: 47.0% N/A
49
2005 Medical records obese women only G2: 42.9%
G3: 54.4%
Canada, medical Total weight gain: G1: Low WG, < 7 kg (P = 0.234)
records Routine prenatal care G2: Acceptable WG, 7-
603 or maternity records 11.5 kg
G3: Excessive WG,
Normal/Over- > 11.5 kg
weight/Obese

Poor

85
Table 18. Gestational weight gain and macrosomia > 4,000g (continued)

Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis
Jensen et al., Pregravid weight: ORs and 95% CIs for G1: 1.0 Maternal age, pregravid
59
2005 Self-report Macrosomia G2: 1.8 (0.8-3.8) BMI, gestational age, 2-
G3: 2.2 (1.0-4.7) hour OGTT, parity,
Denmark, Total weight gain: G1: GWG < 5.0 kg G4: 4.0 (1.8-9.0) smoking, ethnicity,
university Routine prenatal care (Reference) clinical center
hospitals or maternity records G2: GWG 5.0-9.9 kg
G3: GWG 10.0-14.9 kg
481 G4: GWG ≥ 15.0 kg

Obese

Poor

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 poor-
quality 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

86
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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
115
Bo et al., 2003 Pregravid weight: G1: OR and 95% CI, G1: 1.08 (1.03-1.12) Maternal age,
Self-report for LGA for each 1 kg pregravid BMI,
Italy, university clinic increase in GWG smoking,
700 Total weight gain: gestational
Not collected hyperglycaemia
All weights/BMI

Fair
Kitajima et al., 2001121 Pregravid weight: G1: OR and 95% CI, G1: 1.08 (0.81-1.44) Pregravid BMI,
Self-report for LGA for each 1 kg maternal plasma
Japan, university increase in GWG glucose levels,
hospital Total weight gain: gestational age,
146 Routine prenatal infant sex
care or maternity
All weights/BMI records

Fair

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.

87
Table 19. Gestational weight gain and LGA (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
122
Kramer et al., 1990 Pregravid weight: G1: OR and 95% CI, G1: 0.73 (0.68-0.79) Pregravid weight,
Self-report for LGA for each 5 kg infant sex, smoking,
Canada, university decrease in net parity, maternal
hospital Total weight gain: gestational WG diabetes, height,
8,719 Routine prenatal previous LBW
care or maternity infant, severe
All weights/BMI records pregnancy-induced
hypertension
Fair
Muscati et al., 1996105 Pregravid weight: G1: OR for LGA per 1 G1: 1.17 (P < 0.001) Parity, pregravid
Medical records kg increase in WG up G2: 1.16 (P < 0.01) standard weight,
Canada, public health to week 20 G3: 1.02 (P = NS) pregravid excess
department Total weight gain: G2: OR for LGA per 1 weight, birth length,
Collected by study kg increase in WG infant sex
371 investigators from weeks 21 to 30
G3: OR for LGA per 1
All weight/BMI kg increase in WG
from weeks 31 to term
Fair
Parker and Abrams, Pregravid weight: ORs and 95% CIs of G1: 1.89 (1.51-2.37) Maternal age,
118
1992 Self-report LGA for high WG G2: 1.87 (1.39-2.52) maternal race,
parity, gestational
USA, hospital Total weight gain: G1: Compared to age, smoking,
6,690 Routine prenatal UCSF Cohort 25-75th pregravid BMI,
care or maternity percentile of WG height
All weights/BMI records
G2: Compared to
Fair UCSF 10-90th
percentile of WG
Pezzarossa et al., Pregravid weight: Relative risks for LGA G1: Relative risks for Pregravid BMI,
1996100 Self-report LGA similar between fasting plasma
G1: GWG < 9 kg non-diabetic and GDM glucose
Italy, not stated Total weight gain: G2: GWG 9-14 kg groups
Routine prenatal G2: GDM group has 2
192 care or maternity times higher risk that
records non-diabetics
All weights/BMI
Numerical results not
Fair reported.
Bianco et al., 199854 Pregravid weight: % LGA for GWG: G1: 12.0 N/A
Self-report G2: 11.8
USA, medical center G1: Weight loss or 0 G3: 18.8
Total weight gain: lbs G4: 25.8
613 Routine prenatal G2: 1-15 lbs G5: 23.8
care or maternity G3: 16-25 lbs (P < 0.01)
Morbidly obese records G4: 26-35 lbs
(BMI > 35) G5: > 35 lbs

Poor

88
Table 19. Gestational weight gain and LGA (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Ekblad and Grenman, Pregravid weight: Infant BW by group G1: 1% N/A
68
1992 Medical records G2: 6%
Infant weight G3: 35%
Finland, hospital Total weight gain: percentile for mothers G4: 43%
Routine prenatal with normal pregravid G5: 13%
357 care or maternity weight and normal G6: 2%
records weight gain
Prepregnancy weight G1: < 2.5% G7: 3%
20% over or under ideal G2: 2.5-10% G8: 14%
body weight for height G3: 10-50% G9: 32%
and normal weight G4: 50-90% G10: 34%
G5: 90-97.5% G11: 14%
Poor G6: > 97.5% G12: 3%

Infant weight G13: 0%

percentile for mothers G14: 2%
with weight gain ≤5 kg G15: 42%
G7: < 2.5% G16: 29%
G8: 2.5-10% G17: 20%
G9: 10-50% G18: 7%
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%
Jensen et al., 200559 Pregravid weight: ORs and 95% CIs for G1: 1.0 Maternal age,
Self-report LGA G2: 2.4 (1.1-5.3) pregravid BMI,
Denmark, university G3: 2.1 (1.1-4.8) gestational age, 2
hospitals Total weight gain: G1: GWG < 5.0 kg G4: 4.7 (2-11) hour OGTT, parity,
Routine prenatal (Reference) smoking, ethnicity,
481 care or maternity G2: GWG 5.0-9.9 kg clinical center
records G3: GWG 10.0-14.9
Obese kg
G4: GWG ≥ 15.0 kg
Poor
Sunehag et al., 1991120 Pregravid weight: G1: Association G1: χ2 = 8.2 N/A
Not stated between LGA and (P < 0.005)
Italy, prenatal clinics GWG > 18 kg
133 Total weight gain:
Not stated
All weights/BMI

Poor

89
 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).

90
Table 20. Gestational weight gain and LGA by BMI status

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
116
Caulfield et al., 1998 Pregravid weight: ORs and 95% CIs for G1: 1.25 (1.11-1.41) Maternal age, race,
Self-report LGA per 50g/wk G2: 1.14 (1.08,-1.20) parity, pregravid
USA, hospital obstetric increase in rate of G3: 1.13 (1.07-1.20) BMI, height,
database Total weight gain: weight gain by BMI hypertension,
3,870 Routine prenatal provider type,
care or maternity G1: Underweight smoking, infant sex
All weights/BMI records G2: Normal weight
G3: Overweight
Good
Cedergren, 200658 Pregravid weight: ORs and 95% CIs for G1: 0.43 (0.24-0.75) Maternal age,
Self-report LGA (> 2 SD above the G2: 0.53 (0.47-0.61) parity, smoking,
Sweden, Medical Birth mean) G3: 0.48 (0.43-0.53) year of birth
Registry Total weight gain: G4: 0.66 (0.59-0.75)
245,526 Routine prenatal Weight gain < 8 kg G5: 0.54 (0.46-0.63)
care or maternity G1: BMI < 20
All weights/BMI records G2: BMI 20-24.9 G6: 3.26 (2.76-3.86)
G3: BMI 25-29.9 G7: 2.73 (2.60-2.88)
Fair G4: BMI 30-34.9 G8: 2.14 (2.01-2.28)
G5: BMI ≥ 35 G9: 2.24 (2.00-2.51)
G10: 1.54 (1.24-1.90)
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)
Kiel et al., 20074 Pregravid weight: G1: Odds of LGA for G1: Odds of LGA are Maternal age,
Medical records weight gain > 25lbs higher for women in this maternal race,
USA, birth certificate G2: OR of LGA for group maternal education,
registry Total weight gain: weight gain < 15lbs G2: Odds of LGA are poverty, smoking,
120,251 Routine prenatal G3: Reference weight lower for women in this parity, chronic
care or maternity gain 15-25 lbs group hypertension
Obese records
Numerical value for ORs
Fair not reported in study

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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Wataba et al., 200661 Pregravid weight: ORs and 95% CIs for G1: 2.25 (1.03-4.94) Preeclampsia, C-
Not stated LGA G2: 1.41 (1.31-1.76) section, 1-minute
Japan, academic G3: 1.0 Apgar score < 4
medical center Total weight gain: Nulliparous G4: 1.76 (1.38-2.23)
21,718 Routine prenatal G1: Low BMI (< 18), G5: 2.34 (1.77-3.10)
care or maternity WG > 0.40 kg/wk G6: 2.58 (1.71-3.89)
All weights/BMI records G2: Medium BMI (18- G7: 2.16 (0.63-/7.44)
23.9), WG 0.20-0.25 G8: 1.0
Poor kg/wk G9: 1.48 (1.15-2.33)
G3: WG 0.25-0.30 G10: 1.64 (1.18-2.27)
kg/wk (Reference) G11: 2.23 (1.51-3.31)
G4: Medium BMI, WG G12: 3.94 (2.56-6.03)
0.30-0.35 kg/wk G13: 2.27 (1.31-3.95)
G5: Medium BMI, WG G14: 1.0
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)

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.

92
 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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Parker and Abrams, Pregravid weight: ORs and 95% CIs G1: 2.06 (1.62-2.63) Maternal age,
1992118 Self-report of SGA for low G2: 1.82 (1.35-2.47)) maternal race,
WG parity, gestational
USA, hospital Total weight gain: age, smoking,
6,690 Routine prenatal care G1: Compared to pregravid BMI,
or maternity records UCSF Cohort 25- height
All weights/BMI 75th percentile of
WG
Fair G2: Compared to
UCSF 10-90th
percentile of WG
Cheng et al., 2004124 Pregravid weight: OR and 95% CI, G1: 1.9 (1.8-2.2) Maternal age,
Self-report for SGA G2: 1.0 education,
USA, birth certificate Medicaid status,
registry Total weight gain: G1: WG < 0.2 pregravid BMI,
Not stated kg/wk smoking, previous
14,114 G2: WG ≥ 0.2 SGA, adequacy of
kg/wk (Reference) prenatal care,
All weights/BMI maternal cardiac
disease,
Fair 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.

93
Table 21. Gestational weight gain and SGA (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Cnattingius et al., Pregravid weight: ORs and 95% CIs G1: 3.0 (2.5-3.5) Maternal age,
123
1998 Self-report for SGA G2: 1.9 (1.6-2.2) parity, pregravid
G3: 1.3 (1.1-1.5) BMI, height,
Sweden, Medical Total weight gain: G1: WG < 0.25 G4: 1.0 education, mother
birth register Routine prenatal care kg/wk living with father,
167,750 or maternity records G2:WG 0.25-0.34 smoking
kg/wk
All weights/BMI G3: WG 0.35-0.44
kg/wk
Fair G4: ≥ 0.45 kg/wk
(Reference)
Dawes and Pregravid weight: Average weekly G1: 12.9% Maternal age,
Grudzinskas, 1991119 Measured at first weight gain < 0.20 G2: 91.3% parity, pregravid
prenatal visit kg as a predictor BMI, weight,
UK, hospital of SGA smoking,
1,092 Total weight gain: gestational age
Routine prenatal care G1: Sensitivity
All weights/BMI or maternity records G2: Specificity

Fair
Kiel et al., 20074 Pregravid weight: G1: Odds of SGA G1: Odds of SGA are Maternal age,
Medical records for weight gain > lower for women in this maternal race,
USA, birth certificate 25lbs group maternal
registry Total weight gain: G2: OR of SGA for G2: Odds of SGA are education, poverty,
120,251 Routine prenatal care weight gain < 15 higher for women in this smoking, parity,
or maternity records lbs group chronic
Obese G3: Reference hypertension
Weight gain 15-25 Numerical value for ORs
Fair lbs not reported in study
Kramer et al., Pregravid weight: G1: OR and 95% G1: 1.32 (1.20-1.44) Pregravid weight,
122
1990 Self-report CI, for SGA for infant sex,
each 5 kg smoking, parity,
Canada, university Total weight gain: decrease in net maternal diabetes,
hospital Routine prenatal care gestational WG height, previous
8,719 or maternity records LBW infant, severe
pregnancy-
All weights/BMI induced
hypertension
Fair

94
Table 21. Gestational weight gain and SGA (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Muscati et al., Pregravid weight: G1: OR for SGA G1: 0.93 (P = NS) Parity, pregravid
105
1996 Medical records per 1 kg increase G2: 0.85 (P < 0.01) standard weight,
in WG up to week G3: 0.89 (P < 0.01) pregravid excess
Canada, public Total weight gain: 20 weight, birth
health department Collected by study G2: OR for SGA length, infant sex
investigators per 1 kg increase
371 in WG from weeks
21 to 30
All weight/BMI G3: OR for SGA
per 1 kg increase
Fair in WG from weeks
31 to term
Steward and Moser, Pregravid weight: G1: OR and 95% G1: 0.98 (0.97-0.98) Maternal age,
114
2004 Not stated CI, for SGA race, education,
defined as FGR marital status,
USA, vital statistics Total weight gain: < 0.85 pregravid weight,
data Self-report adequacy of
2,933 prenatal care,
smoking, infant
All weights/BMI sex

Fair
Takimoto et al., Pregravid weight: ORs and 95% CI, G1: 2.87 (2.56-3.21) Maternal age,
2006111 Medical records for SGA G2: 1.49 (1.35-1.66) parity, pregravid
G3: 1.0 weight, gestational
Japan, obstetric units Total weight gain: G1: Total GWG G4: 0.55 (0.55-0.72) age, infant sex
112,257 Routine prenatal care < 25th percentile G5: 0.45 (0.45-0.63)
or maternity records for GA
All weights/BMI G2: Total GWG
25-49th percentile
Fair 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

95
Table 21. Gestational weight gain and SGA (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
89
Wen et al., 1990 Pregravid weight: ORs for SGA G1: 2.24 (P < 0.05) Maternal age,
Measured at first G2: 1.55 (P < 0.05) race, parity,
USA, hospital prenatal visit G1: GWG < 0.24 G3: 1.0 marital status,
Cohort kg/wk G4: 1.25 (NS) education,
Total weight gain: G2: GWG 0.24- previous preterm
17,149 Routine prenatal care 0.57 kg/wk delivery, alcohol
or maternity records G3: GWG 0.58- use, drug use,
Fair 0.74 kg/wk maternal height,
(Reference) maternal weight,
G4: GWG ≥ 0.75 smoking, infant
kg/wk sex
Bianco et al., 199854 Pregravid weight: % SGA for GWG: G1: 4 N/A
Self-report G2: 3.9
USA, medical center G1: Weight loss or G3: 5.6
Total weight gain: 0 lbs G4: 3.1
613 Routine prenatal care G2: 1-15 lbs G5: 3.8
or maternity records G3: 16-25 lbs
Morbidly obese (BMI G4: 26-35 lbs
> 35) G5: > 35 lbs

Poor
Cherry et al., 199395 Pregravid weight: %SGA for each G1: 22% N/A
Measured by study shifting of EW G2: 39%
USA, hospital investigators category. G3: 38%
599 G4: 41%
Total weight gain: Light: < 90% EW G5: 62%
All weights/BMI Routine prenatal care Normal: 90 to G6: 60%
or maternity records 110% of EW G7: 65%
Poor 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

96
Table 21. Gestational weight gain and SGA (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Ekblad and Pregravid weight: Infant BW by G1: 1% N/A
68
Grenman, 1992 Medical records group G2: 6%
G3: 35%
Finland, hospital Total weight gain: Infant weight G4: 43%
Routine prenatal care percentile for G5: 13%
357 or maternity records mothers with G6: 2%
normal
Prepregnancy weight prepregnancy G7: 3%
20% over or under weight and normal G8: 14%
ideal body weight for weight gain G9: 32%
height and normal G1: < 2.5% G10: 34%
weight G2: 2.5-10% G11: 14%
G3: 10-50% G12: 3%
Poor G4: 50-90%
G5: 90-97.5% G13: 0%
G6: > 97.5% G14: 2%
G15: 42%
Infant weight G16: 29%
percentile for G17: 20%
mothers with G18: 7%
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%
Jensen et al., 200559 Pregravid weight: Rates of SGA No significant difference Maternal age,
Self-report in rates of SGA by pregravid BMI,
Denmark, university G1: GWG < 5.0 kg maternal weight gain gestational age, 2
hospitals Total weight gain: (Reference) group. Numerical results hour OGTT, parity,
Routine prenatal care G2: GWG 5.0-9.9 not reported in article. smoking, ethnicity,
481 or maternity records kg clinical center
G3: GWG 10.0-
Obese 14.9 kg
G4: GWG ≥ 15.0
Poor kg

97
Table 21. Gestational weight gain and SGA (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
66
Lang et al., 1996 Pregravid weight: ORs and 95% CIs G1: 2.8 (2.2-3.6) Maternal age,
Not stated for SGA G2: 1.6 (1.4-1.9) race, parity,
USA, hospital G3: 1.0 (Reference) height, pregravid
11,505 Total weight gain: G1: WG ≤ 0.40 G4: 0.6 (0.5-0.7) weight, maternal
Not stated lbs/wk education, health
All weights/BMI G2: WG 0.40-0.65 insurance, planned
lbs/wk pregnancy,
Poor G3: WG 0.65-0.90 previous induced
lbs/wk (Reference) abortion, previous
G4: WG > 0.90 spontaneous
lbs/wk 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 Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Caulfield et al., Pregravid weight:ORs and 95% CIs for SGA G1: 0.87 (0.78-0.97) Maternal age,
1998116 Self-report per 50g/wk increase in rate G2: 0.90 (0.84-0.96) race, parity,
of weight gain by BMI G3: 0.93 (0.86-1.01) pregravid BMI,
USA, hospital obstetric Total weight gain: height,
database Routine prenatal care G1: Underweight hypertension,
3,870 or maternity records G2: Normal weight provider type,
G3: Overweight smoking, infant
All weights/BMI sex

Good

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.

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

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
58
Cedergren, 2006 Pregravid weight: ORs and 95% CIs for SGA G1: 2.35 (1.92-2.88) Maternal age,
Self-report (< 2 SD below the mean) G2: 1.99 (1.77-2.23) parity, smoking,
Sweden, Medical Birth G3: 1.75 (1.48-2.07) year of birth
Registry Total weight gain: Weight gain < 8 kg G4: 1.68 (1.26-2.25)
245,526 Routine prenatal care G1: BMI < 20 G5: 1.71 (1.03-2.85)
or maternity records G2: BMI 20-24.9
All weights/BMI G3: BMI 25-29.9 G6: 0.50 (0.41-0.61)
G4: BMI 30-34.9 G7: 0.50 (0.45-0.56)
Fair G5: BMI ≥ 35 G8: 0.57 (0.47-0.68)
G9: 0.61 (0.40-0.93)
Weight gain > 16 kg G10: 0.50 (0.20-1.24)
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)
Cheng et al., 2004124 Pregravid weight: 95% CIs of SGA for low G1: (1.2-2.4) Maternal age,
Self-report weight gain (< 0.2 kg/wk) G2: (1.9-2.7) education,
USA, birth certificate by BMI G3: (1.6-2.9) Medicaid status,
registry Total weight gain: G4: (1.4-2.1) pregravid BMI,
Not stated G1: Underweight smoking,
14,114 G2: Normal weight previous SGA,
G3: Overweight adequacy of
All weights/BMI G4: Obese prenatal care,
maternal cardiac
Fair disease,
preeclampsia,
year of birth of
second infant
Zhou and Olsen, Pregravid weight: % Growth retardation G1: 1.0 Maternal age,
108
1997 Self-report (birthweight < 3,000g and G2: 0.6 (0.4-0.8) parity, alcohol,
placental weight > 490g) G3: 0.6 (0.4-1.1) diabetes, term
Denmark, two Total weight gain: by weight gain category delivery,
communities Routine prenatal care and BMI G4: 0.3 (0.2-0.5) smoking,
Cohort or maternity records G5: 0.4 (0.3-0.6) gestational age,
Weight gain < 11 kg G6: 0.4 (0.1-1.0) infant sex
7,122 G1: Underweight
(Reference) G7: 0.3 (0.2-0.5)
Fair G2: Normal G8: 0.2 (0.1-0.3)
G3: Overweight G9: 0.2 (0.1-0.6)

Weight gain 12-15 kg

G4: Underweight
G5: Normal
G6: Overweight

Weight gain > 16 kg

G7: Underweight
G8: Normal
G9: Overweight

99
Table 22. Gestational weight gain and SGA by BMI status (continued)

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Kabiru and Raynor, Pregravid weight: % SGA G1: 19.5% N/A
200451 Measured at first G1: No change in BMI G2: 13.5%
prenatal visit category G3: 9.5%
USA, hospital G2: 1 category increase in G4: 14.2%
5,131 Total weight gain: BMI G5: 9.9%
Routine prenatal care G3: > 1 category increase G6: 11.5%
All weights/BMI or maternity records in BMI

Poor % SGA among overweight

G4: No change in BMI
category
G5: 1 category increase in
BMI
G6: > 1 category increase
in BMI
Wataba et al., 200661 Pregravid weight: ORs and 95% CIs for SGA G1: 5.42 (2.86-10.27) Preeclampsia,
Not stated G2: 2.78 (1.53-5.06) C-section, 1-
Japan, academic Parous, Low BMI (< 18) G3: 1.39 (0.82-2.42) minute Apgar
medical center Total weight gain: G1: WG < 0.15 kg/wk G4: 1.0 score < 4
21,718 Routine prenatal care G2: WG 0.15-0.20 kg/wk
or maternity records G3: WG 0.20-0.25 kg/wk G5: 2.21 (1.67-2.93)
All weights/BMI G4: WG 0.25-0.30 kg/wk G6: 1.68 (1.23-2.07)
(Reference G7: 1.0
Poor
Parous, Medium BMI (18- G8: 2.82 (1.17-6.78)
23.9) G9: 1.0
G5: WG < 0.15 kg/wk
G6: WG 0.15-0.20 kg/wk G10: 6.20 (2.72-14.09)
G7: WG 0.20-0.25 kg/wk G11: 2.58 (1.14-5.87)
(Reference) G12: 2.46 (1.19-5.08)
G13: 1.0
Parous, High BMI (> 24)
G8: WG < 0.15 kg/wk G14: 2.64 (1.88-3.71)
G9: WG 0.15-0.20 kg/wk G15: 1.60 (1.15-2.23)
(Reference) G16: 1.39 (1.03-1.87)
G17: 1.0
Nulliparous, Low BMI (< 18)
G10: WG < 0.15 kg/wk G18: 7.06 (2.11-23.61)
G11: WG 0.15-0.20 kg/wk G19: 1.0
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)

100
Table 22. Gestational weight gain and SGA by BMI status (continued)

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
61
Wataba et al., 2006 Nulliparous, High BMI
(continued) (> 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

101
 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

102
 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.

103
Table 23. Gestational weight gain and Apgar scores

Author, Date
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Definition of Effect Modifiers
Quality (How Measured) Groups Results Included in Analysis

Cedergren, 200658 Pregravid weight: Weight gain < 8 kg, No association BMI, maternal age,
Self report, if unknown, 8-16 kg, and >16 kg between low weight parity, smoking in
Sweden, Medical standardized for each BMI class gain and Apgar score early pregnancy, year
Birth Registry measurement is made below (< 7), despite BMI of of birth
during first visit to mother
245,526 maternity health care G1: BMI < 20
center G2: BMI 20-24.9
All weights/BMI G3: BMI 25-29.9
Total weight gain: G4: BMI 30-34.9
Fair Measured when G5: BMI ≥35
woman entered
delivery unit

Johnson et al., Pregravid weight: G1: total weight gain Increased OR for Prepregnancy weight
70
1992 Self report collected at < 16 lb gestational weight gain quartile, height
first antepartal visit G2: total weight gain on 1-minute and 5- (tertile), BMI category,
USA, prenatal clinics 16-25 lb minute Apgar score race, parity,
Total weight gain: G3: total weight gain ≤ 7, persists after hypertension, other
3,191 Last prenatal visit 26-35 lb adjusting (no further variables entered by
G4: total weight gain details provided) stepwise regression
All weights/BMI > 35 lb model

Fair

AOR, adjusted odds ratio; BMI, body mass index; kg/wk, kilogram per week.

104
Table 23. Gestational weight gain and Apgar scores (continued)

Author, Date
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis
Continuous weight
Nixon et al., 1998125 Pregravid weight: gain measure Gestational weight gain was Age, parity, BMI
Routine data forms, not a predictor of Apgar
USA, county nurse- self report collected scores < 7
midwifery services at first prenatal visit
2,228 Total weight gain:
All weights (IOM) Routine data forms,
prenatal care or
Fair maternity records
prior to delivery
Rate of weight gain, AOR for 1 min Apgar scores
Wataba et al., Pregravid weight: categorized < 4 for nulliparous women Parity, baseline
200661 Hospital database/ differently across with low BMI, weekly weight BMI
register different BMI groups gain < 15 kg/wk, compared
Japan, academic with women gaining 0.25-0.3
medical center Total weight gain:
Hospital database/ kg/wk: 12.24 (2.04-73.43)
21,718 record AOR for 1 min Apgar scores
< 4 for parous women with
All weights/BMI medium BMI, weekly weight
gain 0.35-0.4 kg/wk
Poor compared with women
gaining 0.2-0.25 kg/wk: 2.21
(1.08-4.53)
No other relationships were
significant

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.

105
Table 24. Gestational weight gain and perinatal mortality

Author, Date
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis

Bracero and Byrne, Pregravid weight: G1: Suboptimal Perinatal mortality% NA

127
1997 Self-report at first weight gain G1: 0.6
prenatal visit G2: Optimal weight G2: 0.2
USA, hospital gain P < 0.0001
Total weight gain:
20,971 Last prenatal
assessment
All weights/BMI

Fair
126
Nohr et al., 2005 Pregravid weight: Weight per week for Weight gain in AOR adjusted for
Self-report of pre- BMI groups pregnancy was not age, height, parity,
Denmark, National pregnancy weight at (underweight < 18.5; significantly associated socio-occupational
Birth Cohort first telephone interview 18.5 ≤ normal weight with the risk of stillbirth status, physical
54,505 between 9 and 24 < 25; 25 ≤ for any BMI groups. exercise, smoking,
weeks weeks overweight < 30; and alcohol and coffee
All weights/BMI obese ≥ 30) consumption
Total weight gain:
Fair 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

Naeye, 1990128 Pregravid weight: Low weight gain Attributable risk Age 35-40,
Self-report at first defined as < 0.8 estimates for perinatal diabetes mellitus,
USA, hospitals antenatal care visit kg/week after the death for low pregnancy hypertensive
affiliated with medical first trimester for weight gain disorders, black,
schools Total weight gain: pregravid BMI G1: 0.03 preterm birth, major
Data from medical groups below: (95% CI, 0.02-0.05) congenital
56,857 records after first G1: BMI < 20 G2: 0.02 malformations,
trimester G2: BMI 20-24 (95% CI, 0.01-0.03) twins, neonatal
All weights/BMI G3: BMI 25-30 G3: 0.01 respiratory distress
G4: BMI > 30 (95% CI, 0.00-0.02) syndrome
Poor G4: 0.00
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

106
 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, race-
ethnicity, 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.

107
 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 hospital-
based, 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
108
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, live-
born 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

109
Table 25. Gestational Weight Gain and Other Infant Growth Measures

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Brown et al., 200298 Pregravid weight: G1: Increase in G1: β = 0.21 Maternal age,
Measured by study ponderal index per 1 (P < 0.0003) parity, pregravid
USA, primary care investigators kg increase in first BMI, height, infant
clinics trimester weight gain G2: β = 0.05 PI sex, gestational
Total weight gain: G2: Increase in (P < 0.4) age
389 Collected by study ponderal index per 1
investigators kg increase in second G3: β = 0.12
All weight/BMI trimester weight gain (P < 0.03)
G3: Increase in
Good Ponderal Index per 1
kg increase in third
trimester weight gain
Guihard-Costa et al., Pregravid weight: G1: SC for effect of G1: SC 0.142 Maternal age,
92
2004 Routine prenatal GWG on crown-heel G2: SC 0.120 parity, pregravid
care length G3: SC 0.146 BMI, height
France, hospital G2: SC for effect of
database Total weight gain: GWG on head
Routine prenatal circumference
13,972 care or maternity G3: SC for effect of
records GWG on subscapular
All weights/BMI skinfold thickness

Fair SCs are regression

coefficients calculated
as if all of the
independent variables
had a variance of 1
Kirchengast and Pregravid weight: Change in infant size G1: β = 0.55 (0.43-0.68) Maternal age, age
Hartmann 200393 Estimated from characteristics per 1 G2: β = 0.33 (0.23-0.42) at menarche,
measured weight kg increase in GWG G3: β = 0.47 (0.39-0.55) pregravid weight,
Austria, university at first prenatal G4: β = 0.12 (0.07-0.18) height, distantia
hospital visit G1: Birth length (cm) cristarum
G2: Head
8,011 Total weight gain: circumference (cm)
Routine prenatal G3: Acromial
All weights/BMI care or maternity circumference (cm)
records G4: Diameter
Fair frontoccipitalis (cm)
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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
122
Kramer et al., 1990 Pregravid weight: Correlation coefficients
G1: -0.04 Pregravid weight,
Self-report between GWG and: (P < 0.01) infant sex, smoking,
Canada, university G2: -0.01 parity, maternal
hospital Total weight gain: G1: Length G3: 0.04 diabetes, height,
8,719 Routine prenatal G2: Head circumference (P < 0.01) previous LBW
care or maternity G3: BMI G4: 0.04 infant, severe
All weights/BMI records G4: Ponderal Index (P < 0.01) pregnancy-induced
G5: Weight/Head G5: 0.01 hypertension
Fair 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
Shepard et al., 1996117 Pregravid weight: Increase in mean G1: β = 0.35 (P = 0.49) Maternal age,
Medical records abdominal fetal growth G2: β = 0.88 (P = 0.02) pregravid BMI,
Norway and Sweden, rate (mm/day) per 5% G3: β = 1.53 (P = 0.02) previous SGA,
multicenter study Total weight gain: increase in proportional infant sex
369 Measured at 3 weight gain in this
study time periods period:
All weights/BMI G1: Weeks 17-25
G2: Weeks 25-33
Fair G3: Weeks 33-37
Ekblad and Grenman, Pregravid weight: Mean symphysis-fundus G1: 30.8 cm ± 4.0 N/A
199268 Medical records height: G2: 32.8 cm ± 3.4
G3: 35.0 cm ± 3.9
Finland, hospital Total weight gain: G1: Weight gain ≤ 5 kg
Routine prenatal G2: Weight gain 5-20 kg
357 care or maternity G3: Weight gain ≥ 20 kg
records
Prepregnancy weight
20% over or under
ideal body weight for
height and normal
weight

Poor

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

111
 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 crown-
heel 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

112
 Overview of results. Due to the different definitions of the outcomes, the results from three
100-102
fair 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 catch-
down 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 Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
134
Li et al., 2007 Pregravid weight: Maternal AOR (95% CI) for early onset overweight Infant sex, race,
Self-report weight gain (early onset of overweight birth order,
USA, National categories that persisted throughout childhood) gestational age,
Longitudinal Total weight gain: (kg): compared with normal (low birthweight,
Survey of youth Self-report G1: < 15 lbs probability of overweight throughout breastfeeding,
1979 Child and G2: 15-24 lbs childhood and was pregravid BMI,
Young Adult file G3: 25-34 lbs characterized as the never overweight maternal age,
G4: 35-44 lbs class) maternal
1,739 G5: > 45 lbs G5: 1.7 (1.0-2.9) education, family
G3: 1.0 (reference) income
All weight/BMI
Other AOR for weight gain categories for
Fair 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)
Oken et al., Pregravid weight: Maternal AOR (95%CI) BMI≥95th percentile vs Smoking, race,
24
2007 Self-report weight gain, 5 BMI<50th percentile associated with a 5 kg household
kg increments increase in gestational weight gain: income, marital
USA, HMO Total weight gain: 1.52 (1.19-1.94) status, glucose
Measured tolerance,
1,044 Child BMI z-score at age 3 years for AOR gestation length,
listed above (95% CI): breastfeeding
All weight/BMI 0.11 (0.05, 0.17) duration, child’s
sex
Fair
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.

113
Table 26. Gestational weight gain and childhood weight status (continued)
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Ong et al., 2000133 Pregravid weight: Maternal weight Children were grouped into three NA
Self-report gain, growth categories (catch-up, no
UK, Avon continuous change, and catch-down) based on a
longitudinal study Total weight gain: measure gain in weight (SD score > 0.67 for
of pregnancy and Obstetric records catch-up; SD score < 0.67 for catch-
childhood down.

848 Maternal weight gain was not a

significant predictor of catch-up
All weight/BMI growth between 0 and 2 years

Fair
Sowan et al., Pregravid weight: Maternal weight AOR (95%CI) for infant obesity (BMI> Maternal age,
132
2000 Self-report gain, 5 lb. gender and age specific 84th nonpregnant weight,
increments percentile based on Infant Growth smoking, marital
USA, NIH-funded Total weight gain: Study population norms) at 1, 4, 7, status, father living in
Infant Growth Self-report and 10 months: NS home, family stress,
Study grandmother living in
AOR (95%CI) for obesity at 14 home,
630 months: .8 (0.7-1.0) socioeconomic
status, gender, race,
All weight/BMI infant BMI at birth,
infant BMI from
Poor 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.

114
 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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Callaway et al., Pregravid weight: G1: Gestational weight G1: Mean change (95% Baseline income,
146
2007 Self report gain ≤ 15 kg CI) in BMI at 21 years secondary school
2
postpartum: 5.06 kg/m completion,
Australia, Total weight gain: G2: Gestational weight (4.85-5.27) ethnicity, maternal
University Hospital Obstetric records/ gain >15 kg age at birth, parity,
maternal G2: Mean change (95% birthweight,
3,572 questionnaires CI) in BMI at 21 years gestational age,
postpartum: 6.40 kg/m2 infant sex, maternal
All weight/BMI (6.19-6.61) smoking during
P < 0.001 pregnancy, smoking
Good at 21 years,
G2 was associated with a sedentary lifestyle at
mean change in BMI over 21 years, baseline
2
21 years of 0.19 kg/m maternal BMI,
(95%CI: 0.16-0.22) 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.

115
Table 27. Gestational weight gain and postpartum weight retention (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Harris et al., Pregravid weight: Continuous maternal ANCOVA model with Marital status,
144
1999 Measured at first weight gain, kg weight (kg) at 2.5 years increased
trimester prenatal postpartum as dependent dissatisfaction with
UK, Antenatal Care visit variable and maternal body, increased
Project weight gain (kg) as access to food,
Total weight gain: independent variable: increased energy
74 Self report B = -0.031 intake, decreased
β = -0.029 activity, smoking
All weight/BMI SEM = 0.120 status, maternal
P = 0.796 age, duration of
Good followup, pregravid
BMI, parity,
gestational age at
booking, parental
obesity, social
support
Harris et al., Pregravid weight: Gestational weight gain ANCOVA model for Marital status,
137
1997 Measured within 13 during previous interpregnancy weight smoking status,
weeks’ gestation pregnancy (kg), change (kg), defined as alcohol, parity, age,
UK, Hospital continuous the difference between socioeconomic
Total weight gain: weight at start of index status, nulliparous
523 Measured pregnancy and weight at BMI, birthweight,
start of previous gestational age at
All weight/BMI pregnancy: start of previous
B = 0.262 pregnancy,
Fair β = 0.227 gestational age at
SEM = 0.52 start of index
P < 0.001 pregnancy,
gestational age at
start of first
pregnancy,
interpregnancy
interval, gestational
age at delivery
Harris et al., Pregravid weight: Gestational weight gain ANCOVA model for Marital status,
138
1997 Measured within 13 during first pregnancy as interpregnancy weight lactation, smoking
weeks’ gestation a continuous measure change (kg), defined as status, alcohol,
UK, Hospital (kg) the difference between height, nulliparous
Total weight gain: weight at start of first BMI, birthweight,
243 Measured pregnancy and weight at gestational age at
start of the second start of previous
All weight/BMI pregnancy: pregnancy,
B = 0.176 terminations
Fair β = 0.169 between pregnancy,
SEM = 0.070 interpregnancy
P < 0.013 interval

116
Table 27. Gestational weight gain and postpartum weight retention (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
139
Hunt et al., 1995 Pregravid weight: G1: Population-based Regression of current Weight at ages 20 to
Self-report sample weight on total number of 24, current age
USA, population- (validated by pregnancies showed a
based family history hospital records if G2: Morbidly obese 1.3 kg/pregnancy increase
database (Utah) and available) women who were in current weight
participants of an normal weight at age (P = 0.03) with no
obesity study Total weight gain: 20-24 years or prior to difference between G1
Self-report first pregnancy and G2 (P = 0.60)
221 (validated by
hospital records if Gestational weight gain
All weight/BMI available) was significantly greater in
Morbidly obese G2 than G1 for the first
pregnancy only (P < 0.05)
Fair
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
Linne et al., 2004142 Pregravid weight: Gestational weight gain G2 had significantly Alcohol use,
Self-report as a continuous variable greater weights at smoking, number of
Sweden, Stockholm (kg): prepregnancy, delivery, 1 pregnancies since
Pregnancy and Total weight gain: year postpartum, and 15 index child,
Weight Medical Records G1: Pregravid BMI ≤ 25 years postpartum employment area
Development Study compared to G1
G2: Pregravid BMI > 25 (P < 0.001); however, G2
563 did not have a higher risk
of postpartum retention
All weight/BMI than G1

Fair
Linne et al., 2003136 Pregravid weight: G1: Women with normal G1: Mean (SD) maternal None
Self-report BMI (20-25) at weight gain, 13.6 (3.7) kg
Sweden, Stockholm prepregnancy and 15
Pregnancy and Total weight gain: years postpartum G2: Mean (SD) maternal
Women's Nutrition Medical records weight gain, 15.4 (4.4) kg
Study G2: Women with normal
BMI at prepregnancy t-Test: P<0.001
563 who had overweight BMI
(> 25) at 15 years
Normal postpartum
weight/overweight

Fair

117
Table 27. Gestational weight gain and postpartum weight retention (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Muscati et al., Pregravid weight: G1: Weight gain ≤ week Regression model of Standard weight for
105
1996 Physicians’ records 20 (kg) weight retention (kg) at 6 height (based on
weeks postpartum as the 1983 Metropolitan
Canada, Prenatal Total weight gain: G2: Weight gain weeks dependent variable and Life Insurance
Nutrition Counseling Measured 21-30 (kg) G1-G5 as independent Tables), pregravid
Program variables: weight above
G3: Weight gain weeks standard (difference
371 31- term G1: β = 0.86 (SE: 0.05) between actual
P< 0.001 weight and standard
All weight/BMI G4: Total weight gain weight), parity,
≤ 12 kg G2: β = 0.68 (SE: 0.07) gestational age,
Fair P< 0.001 infant sex
G5: Total weight gain
> 12 kg 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
Ohlin et al., 1990145 Pregravid weight: Gestational weight gain Regression model for Lactation score,
Self-report as a continuous variable weight change (kg), age, prepregnancy
Sweden, maternity (kg) defined as the difference BMI, parity
clinics Total weight gain: between prepregnancy
Maternity records and 1 year postpartum
1423 weights:
B = 0.32
All weight/BMI P< 0.001

Fair

118
Table 27. Gestational weight gain and postpartum weight retention (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Soltani et al., Pregravid weight: Pregravid weight G1: Patterns of changes in None
143
2000 Measured at 13 G1: Normal weight body weight (kg) and fat
weeks’ gestation G2: Underweight mass follow a monotonous
UK, Hospital G3: Overweight trend; body weight and
Total weight gain: G4: Obese fatness increased during
77 Measured gestation, decreased
substantially at 6 weeks
All weight/BMI postpartum, and then
stayed the same or slightly
Fair 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)
Walker et al., Pregravid weight: Continuous gestational Each kg of gestational Ethnicity, time,
141
2004 Self report weight gain (kg) weight gain was interaction of
associated with 0.314 ethnicity and time,
USA, Austin New Total weight gain: kg/m2 of postpartum BMI pregravid BMI,
Mothers Study Self report (P < 0.001) weight-related
distress, energy
382 intake

All weight/BMI

Fair

119
Table 27. Gestational weight gain and postpartum weight retention (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Parham et al., Pregravid weight: Gestational weight gain Change in BMI category None
140
1990 Self report for population in tertiles, between prepregnancy
mean (se): and 1-3months
USA, prenatal clinics Total weight gain: G1: 3.7 (2.9) postpartum:
serving low income Measured G2: 9.4 (1.3) G1, G2: 83% No change;
women G3: 16.0 (3.7) 7% Desirable change (i.e.
underweight women
158 becoming normal weight);
10% Undesirable change
All weight/BMI (~5% had an increase in
BMI category and ~5%
Poor had a decrease in BMI
category)
G3: 42% no change; 19%
desirable change; 39%
undesirable change (all
increases in BMI category)

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

120
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
121
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
122
 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.

123
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 Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
3
Saldana et al., 2006 Pregravid weight: G1: Normal Mean (SE) weight gain ratio Race, age,
Self-report glucose (defined as obeserved weight gestational
USA, hospital tolerance gain/IOM recommended weight age
Total weight gain: G2: Impaired gain):
952 Measured glucose G1: 1.43 (0.04)
tolerance G2: 1.48 (0.21)
All weight/BMI G3: Gestational G3: 1.88 (0.15)
diabetes P < 0.05
Good mellitus
AOR (95% CI) for weight gain
BMI IOM ratio:
G1: 1.0 (reference)
G3: 1.2 (0.9-1.4)
Edwards et al., 199655 Pregravid weight: Obese BMI > Gestational diabetes, % None
Self-report 29 (kg): G1: 13.3
USA, Hospital G1: Lost G2: 24.3
Total weight gain: weight/no G3: 11.9
1,443 Measured change G4: 16.7
G2: 0.5-6.5 G5: 17.3
Normal/obese G3: 7-11.5 P for linear trend (G1-G5) =
weight/BMI G4: 12-16 0.554
G5: > 16
Fair G6: 2.3
Normal weight G7: 3.3
BMI 19.8-26 G8: 2.9
G6: < 11.5 P for linear trend (G6-G8) =
G7: 11.5-16 0.759
G8: > 16
Thorsdottir 200253 Pregravid weight: Maternal Gestational diabetes, % None
Self-report weight gain G1: 2.9
Iceland, hospital categories (kg): G2: 0
records Total weight gain: G3: 0
Maternity records G1: < 11.5 G4: 0
614 G2: 11.5-16.0 P for trend < 0.015
G3: 16.1-20.0
Normal weight/BMI G4: > 20.0
19.5-25.5

Fair
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.

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

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
54
Bianco et al., 1998 Pregravid weight: Maternal Distribution of GDM, %: Race, parity, clinic
Self-report weight gain G1: 15.7 service, substance
USA, medical center categories G2: 15.0 abuse, preexisting
Total weight gain: among G3: 14.4 medical condition
11,926 Measured morbidly obese G4: 13.4
(BMI > 35): G5: 12.5
Nonobese (BMI 19-27) G1: Weight P = NS
and morbidly obese loss/no change
(BMI > 35) G2: 1-15 lbs
G3: 16-25 lbs
Poor G4: 26-35 lbs
G5: > 35 lbs

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.

125
 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 Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
25
Devader et al., 2007 Pregravid weight: Maternal weight AOR (95% CI) for Age, race,
Self-report gain categories preeclampsia: education, income,
USA, birth certificate (lbs): G1: 0.56 (0.49-0.64) alcohol use, height,
data Total weight gain: G2: 1.00 (reference) prior pregnancy,
Measured G1: < 25 G3: 1.88 (1.74-2.04) inadequate
94,696 G2: 25-35 prenatal care use,
G3: > 35 smoking, child's
Normal weight/BMI gender, birth year
19.8-26

Fair
Edwards et al., 199655 Pregravid weight: Obese BMI > 29 Preeclampsia None
Self-report (kg): G1: 10.7
USA, Hospital G2: 7.7
Total weight gain: G1: Lost weight/ G3: 8.3
1,443 Measured no change G4: 7.9
G2: 0.5-6.5 G5: 16.5
Normal/ Obese G3: 7-11.5 P for linear trend (for G1-
weight/BMI G4: 12-16 G5) = 0.076
G5: > 16
Fair G6: 2.8
Normal weight BMI G7: 2.9
19.8-26: G8: 6.6
G6: < 11.5 P for linear trend (for G6-
G7: 11.5-16.0 G8) = 0.048
G8: > 16.0
AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; g, gram; kg, kilogram; lbs, pounds; USA, United
States of America.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
4
Kiel et al., 2007 Pregravid weight: Maternal weight For Obese Class I: OR Age, race, parity,
Self-report gain categories (95% CI) for preeclampsia education, poverty
USA, Hospital stratified by were significantly lower (enrollment in
Total weight gain: prepregnancy (< 1.00, G6 was Medicaid, WIC, food
120,170 Medical record obesity status, reference) for G2-G5 and stamp programs),
Obese Class I significantly higher for G7- tobacco use, chronic
Obese BMI (BMI 30–34.9), G8. hypertension
Obese Class II
Fair (BMI 35–39.9), For Obese Class II: OR
Obese Class III (95% CI) for preeclampsia
(BMI ≥ 40): were significantly greater
G1: ≤ -10lbs (> 1.00, G6 was
G2: -2 to -9 lbs reference) for G1 and G3-
G3: No change G5 and significantly lower
G4: 2-9 lbs for G8.
G5: 10-14 lbs
G6: 15-25 lbs For Obese Class III: OR
G7: 26-35 lbs (95% CI) for preeclampsia
G8: > 35 lbs were significantly greater
(> 1.00, G6 was
reference) for G1-G3 and
G5 and significantly lower
for G7-G8
Thorsdottir et al., Pregravid weight: Maternal weight Preeclampsia,% None
200253 Self-report gain categories G1: 1.4
(kg): G2: 2.3
Iceland, hospital Total weight gain: G1: < 11.5 G3: 5.4
records Maternity record G2: 11.5-16.0 G4: 4.4
G3: 16.1-20.0 P for trend = 0.262
614 G4: > 20.0

Normal weight/BMI
19.5-25.5

Fair

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

127
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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Devader et al., Pregravid weight: G1: Gained less than AOR for cesarean delivery Age, race,
25
2007 Self-Report 25 lbs (additionally controlled for LGA education, income,
G2: Gained 25-35 lbs and cephalopelvic alcohol use,
USA-Missouri, Total weight gain: G3: Gained more disproportion) height, prior
birth certificate As reported on birth than 35 lbs G1: 0.82 (0.78–0.87) pregnancy,
data certificate G2: 1.0 inadequate
G3: 1.35 (1.29–1.40) prenatal care use,
94,696 smoking, child's
gender, birth year
Normal weight
BMI 19.8-26

Fair
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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Edwards et al., Pregravid weight: Obese Obese Age, parity,
55
1996 Self-reported G1: wt loss or 0 lbs G1: 30.7% pregravid BMI,
G2: 1-14 lbs G2: 21.6% GDM, pregnancy-
USA, hospital Total weight gain: G3: 15-25 lbs G3: 23.8% induced
Prenatal records G4: 26-35 lbs G4: 26.2% hypertension,
1,443 G5: > 35 lbs G5: 30.1% prenatal
Normal wt adequacy, alcohol
Normal BMI 19.8- Normal weight G1: 5.7% use, drug use,
26 G1: < 25 lbs G2: 12.1% smoking,
G2: 25-35 lbs G3: 8.6% gestational age
Obese BMI > 29 G3: > 35 lbs
No significant difference in
Fair 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
Jain et al., 200777 Pregravid weight: G1: ≤ 15 lbs Primipara (AOR, 95% CI) Pregravid BMI,
Self-reported G2: 16 - < 25 lbs G5: 0.71 (0.43-1.19) parity
USA, PRAMS G3: 25 - < 35 lbs
Total weight gain: G4: ≥ 35 lbs Multipara
7,661 Self-reported G5: interaction term G5: 0.77 (1.37-1.59)
overwt/obese and
All weight/BMIs gaining 25-35
(using IOM
definitions)

Fair
Kaiser and Kirby, Pregravid BMI: G1: Below IOM Crude OR 95% CI Age, race, pregravid
2001150 Self-reported G2: Within IOM G1: 0.82 (0.49-1.36) BMI, preeclampsia,
G3: Above IOM G3:1.0 (0.62-1.63) height, previous live
USA, university Total weight gain: births, failure to
nurse-midwifery Measured at last AOR for weight gain above progress, breech
system prenatal visit IOM recommendations: presentation,
2.04 (95% CI 1.02-4.05) placental abruption,
1,881 fetal bradycardia,
primigravidity,
All wt/BMI (using birthweight
IOM definitions)

Fair
Kiel et al., 20074 Pregravid BMI: G1: Wt loss > 10 lbs For all three classes of Age, race, parity,
Self-reported G2: Wt loss 2-9 lbs obese women, risks of education, poverty
USA-Missouri, G3: No change cesarean delivery rise (enrollment in
birth certificate Total weight gain: G4: 2-9 lbs above an OR of 1 when medicaid, WIC, food
Birth certificate G5: 10-14 lbs weight gain exceeds 25 stamp programs),
120,170 G6: 15-25 lbs pounds tobacco use,
G7: 26-35 lbs chronic
Obese BMI > 30 G8: > 35 lbs hypertension

Fair

129
Table 30. Weight change relative to IOM thresholds and cesarean delivery (continued)
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Parker and Pregravid weight: G1: Below IOM AOR for all women weight Age, race, parity,
Abrams, 1992118 Self reported G2: Above IOM gain > IOM (G2) = 1.48 pregravid BMI,
(1.25-1.76) height, maternal
USA, hospital data Total weight gain: high and low weight
base Measured weight in For overweight women, gain, smoking,
prenatal record there was no significant gestational age,
6,690 association between birthweight
cesarean delivery and
All wt/BMI (using weight gain (AOR = 0.71
IOM definitions) (0.40-1.26)

Fair For nonoverweight women,

the association between
cesarean delivery and
weight gain was 1.45 (1.21-
1.73)
Stotland et al., Pregravid weight: G1: Below IOM AOR with birthweight in Age, race, pregravid
2004149 No details reported G2: Above IOM model BMI, year of
G1: 0.99 (0.82-1.19) delivery, smoking,
USA, university Total weight gain: G2 :1.40 (1.22-1.59) gestational age,
hospital No details reported, birthweight, infant
possibly measured BMI < 19.8 G1 = 0.96 sex
9,788 weight in prenatal (0.67-1.37); G2 = 1.93
records (1.45-2.53)
All wt/BMI BMI 19.8-26 G1 = 1.04
(0.81-1.33); G2 = 1.26
Fair (1.06-1.50)
BMI > 26 G1 = 0.74 (0.38-
1.44); G2 = 1.21 (0.83-1.78)
Thorsdottir et al., Pregravid weight: G1 < 11.5 kg G1: 17.4% Age, parity, height,
200253 Self-reported G2 11.5-16 kg G2: 9.5% gestational age,
G3 16.1-20 kg G3: 12.9% birthweight
Iceland, hospital Total weight gain: G4 > 20 kg G4: 13.1%
records Measured weight in
prenatal records No significant differences in
614 cesarean delivery rates by
IOM weight gain categories
Normal wt/BMI in normal weight women
19.5-25.5

Fair
Bianco et al., Pregravid weight: G1: wt loss or 0 lbs G1: 25.5%
54
1998 Perinatal data base G2: 1-15 lbs G2: 26.8%
G3: 16-25 lbs G3: 28.8%
USA, hospital Total weight gain: G4: 26-35 lbs G4: 35.0%
Perinatal data base G5: > 35 lbs G5: 33.8%
11,926 No significant difference
Nonobese BMI 19 among morbidly obese
to 27 /morbidly women by weight gain
obese BMI > 35 categories

Poor OR for cesarean comparing Macrosomia

morbidly to nonobese = 2.3
(1.9-2.8)

130
 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 Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Hickey et al., Pregravid weight: G1: Low rate of weight OR (95% CI) for spontaneous Age, race,
151
1995 Self-reported gain in first trimester- preterm pregravid BMI,
underweight (BMI G1: 1.27 (0.7-2.3) height, alcohol
USA, university Total weight gain: < 19.8) & < 2.3 kg and G2: 1.23 (0.7-2.18) use, history of
prenatal clinics Prenatal records normal weight (BMI G3: 2.46 (1.53-3.92) previous infant
19.8-26) & < 1.6 kg less than 2,750
1,518 Pattern of weight gain g, number of
G2: Low rate of weight G1 only: 2.94 (0.73-11.98) days between
Under/normal wt gain in second G2 only: 1.08 (0.1-11.23) last weight
trimester (Underwt & G3 only: 11.54 (2.93-45.28) observation
Fair < 0.38 kg/wk or normal G1 & G2: 4.89 (0.85-28.14) and delivery,
wt & < 0.37 kg/wk) G1 & G3: 4.49 (0.96-20.96) smoking, infant
G2 & G3: 7.37 (1.66-32.76) sex
G3: Low rate of weight All trimesters: 4.18 (0.75-23.35)
gain in third trimester
(Underwt & < 0.38
kg/wk or normal wt &
< 0.37 kg/wk)
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.

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

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Schieve et al., Pregravid weight: G1: Low < 0.5 AOR for preterm birth Age, race,
152
2000 Self-reported less/week; Low BMI: G1 = 6.7 (1.1-40.6) parity, marital
baseline G2: Average Low BMI: G2 = 0.8 (0.4-1.4) status,
USA, nationally 0.5-1.5 lb/week Low BMI: G3 = 1.0 (0.4-2.6) education,
representative Weight gain: G3: High > 1.5 Average BMI: G1 = 3.6 (1.6-8.0) smoking
1988 births Rate of measured lb/week Average BMI: G2 (Reference)
weight between 14 Average BMI: G3 = 1.0 (0.6-1.9)
3,511 and 28 wks High BMI: G1 = 1.6 (0.7-3.5)
gestation High BMI: G2 = 1.1 (0.6-2.1)
All wt/BMI High BMI: G3 = 0.1 (0.03-0.6)
Low BMI < 19.8
Average BMI
19.8-26

High BMI > 26

Fair
Siega-Riz et al., Pregravid weight: Total weight Adequacy of weight gain in the third Pregravid BMI,
199422 self reported gain expressed trimester was predictive of preterm birth gestational age
as a ratio of - the data suggested a threshold effect
USA, public Total weight Gain: observed: for all weight status groups with a
health clinics Prenatal records expected based marked decrease in risk at 90-110% of
on the IOM the IOM recommendation
5,854 recommen-
dation for a With the rate of weight gain less than
All wt/BMI (using given 60% of the IOM value, women in all four
IOM definitions) gestational age. groups had more than double the risk of
delivering preterm, which was
Fair 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

132
Table 31. Weight change relative to IOM thresholds and preterm birth (< 37 weeks) (continued)

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Stotland et al., Pregravid weight: G1: low rate of Crude OR of spontaneous preterm birth Age, race,
85
2006 Self-reported weight gain G1: 2.6 (95% CI 2.1–3.2) parity,
< .27 kg/wk G3: 1.0 (95% CI 0.8–1.2) pregravid BMI,
USA, academic Total weight gain: G2: ref 0.27- history of
medical center prenatal records 0.52 kg/wk AOR of spontaneous preterm birth previous PTB,
G3: high rate of G1: 2.5 (95% CI 2.0–3.1) year of
15,101 weight gain > G3: 1.0 (95% CI 0.8–1.3) delivery,
0.52 kg/wk No differences in results by parity number of days
Underweight BMI combined with history of preterm birth between last
< 19.8 and normal weighing and
weight BMI 19.8- Slightly higher risks for Af Am and high DOB, smoking
26 wt gain close to sign for Af Am

Fair

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

133
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

134
Table 32. Weight change relative to IOM thresholds and birthweight

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
153
Nielsen 2006 Pregravid weight: G1: < IOM Adjusted birthweight Parity, pregravid
Self-reported G2: lower half IOM BMI < 19.8 BMI,
USA, prenatal range G1: 2,986 g preeclampsia,
clinics Total weight gain: G3: Upper half G2: 3,167 g time between last
Prenatal records, IOM range G3: 3,198 g weight measure
African-Americans measured G4: > IOM G4: 3,277 g and delivery,
only All significantly different from height, smoking,
each other except G2 & G3 infant sex
815
BMI 19.8-26
All weight/BMIs G1: 3,018 g
G2: 3,166 g
Good 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
&, 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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Hickey et al., Pregravid weight: G1: Below IOM BMI < 19.8 Age, education,
20
1997 Self-reported range G1: height, street
G2: Lower end of Black: 2,840 drugs, alcohol
USA, public Total weight gain: IOM range White: 3,002 use, time between
health programs Measured weights- G3: Upper end of last prenatal
prenatal records IOM range G2: weight observation
5,198 G4: Gain above Black: 2,995 and delivery,
IOM range White: 3,151 smoking,
All wt/BMI (using G3: gestational age,
IOM definitions) Black: 3,017 infant sex
White: 3,200
Fair
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

136
Table 32. Weight change relative to IOM thresholds and birthweight (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Hickey et al., Pregravid BMI: G1: First trimester Association of low trimester Age, race,
155
1996 Self-reported < 2.6 kg for gain with birthwt pregravid BMI,
underwt (BMI G1: all women -18 g P = .65 height, alcohol
USA, prenatal Total weight gain: < 19.8) & < 1.6 kg Black -15 g P = .76 use, third trimester
clinics Prenatal records for normal wt (BMI White -42 g P = .53 number of weeks
19.8-26) between last
415 G2: All women -166g weight observation
G2: Second P = < .001 and delivery,
Under & Normal trimester Black -164 g P = .005 history of previous
weight < 0.38 kg/wk for White -158 g P = .05 infant < 2,750 g,
underwt & < 0.37 smoking,
Fair kg/wk for normal G3: All women -111g P = .008 gestational age,
wt Black -77 g P = .14 infant sex
White -194 g P = .004
G3: < 0.38 kg/wk
for underwt & No association with low weight
< 0.37 kg/wk for gain in only the first or second
normal wt 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
Hickey et al., Pregravid BMI: BMI ≤ 29 Adjusted Birthwt Maternal height,
1993156 Self-reported G1: gain < range BMI ≤ 29 education, parity,
G2: gain in the G1: marital status,
USA, prenatal Total weight gain: range Black: 3,027 smoking, alcohol
clinics Prenatal records G3: gain > range White: 3,246 use, hypertension,
GDM, gestational
1,168 BMI > 29 G2: age at delivery,
G4: gain < 6.0 kg Black: 3,177 socioeconomic
All weight/BMIs G5: gain > 6.0 kg White: 3,233 status, time
between last
Fair G3: weight and
Black: 3,293 delivery
White: 3,523

137
Table 32. Weight change relative to IOM thresholds and birthweight (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Hickey et al., BMI > 29
156
1993 G4:
(continued) Black: 3,214
White: 3,500

G5:
Black: 3,553
White: 3,596
Luke et al., Pregravid weight: G1: Gain < IOM Adjusted birthweight Maternal age,
104
1996 Self-reported G2: gain equal to G1: parity, black
USA, clinic IOM BMI < 19.8 2,873 g* ethnicity, smoking,
Total weight gain: G3: gain > IOM BMI 19.8-26.0 3,157 g* gestational
487 Prenatal records, BMI > 26 3,138 g duration, fetal sex
measured
All weight/BMIs G2:
BMI < 19.8 3,190 g
Fair 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
May, 2007157 Pregravid weight: G1: Below IOM Betas from multiple linear Maternal BMI,
Self reported G2: Greater IOM regression smoking,
USA, WIC clinic G1: -162 g gestational age at
Total gestational weight G2: -153 g delivery
233 gain:
Self-reported
All weight/BMI

Fair
Ogunyemi et al., Pregravid weight: G1: Low < IOM Birthweight NR
199860 Self-reported G2: Normal = IOM G1: 3,029
G3: High > IOM G2: 3,210
USA, Hospital Total gestational weight G3: 3,283 (P < 0.01)
gain:
582 Prenatal records,
measured
All weight/BMIs
(using IOM
definitions)

Fair

138
Table 32. Weight change relative to IOM thresholds and birthweight (continued)
Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Scholl et al., Pregravid weight: Rate between 20- Birthweight (g): NR
1995158 Self-reported 36 wks G1: 3,049 (56.94) P < 0.05, low
G1: low rate < 0.34 vs. moderate plus excessive
USA Camden Total weight gain: kg/wk weight gain
Study Prenatal records, G2: moderate rate G2: 3,208 (36.33)
measured 0.34-0.68 kg/wk G3: 3,191 (49.46)
274 G3: Excessive rate
> 0.68 kg/wk
Normal weight
BMI 19.8-26

Fair
Stevens-Simon Pregravid weight: Birthweight (g): NR
and McAnarney, Self-reported G1: slow < 0.23 G1: 2,745 (694)
1992154 kg/wk G2: 3,097 (457)
Total weight gain: G2: average 0.23-4 G3: 3,351 (482) P < 0.0001
USA African- Prenatal records, kg/wk No difference in pregravid by
American measured G3: rapid > 0.4 weight gain groups
adolescent kg/wk
maternity
program

141

All BMI

Fair
Bianco et al., Pregravid weight: Maternal weight G1: 3,302 g NR
199854 Self-report gain categories G2: 3,192 g
among morbidly G3: 3,337 g
USA, medical Total weight gain: obese : G4: 3,506 g
center Measured G1: Weight loss/no G5: 3,453 g
change P = < 0.05
11,926 G2: 1-15 lbs
G3: 16-25 lbs
Nonobese (BMI G4: 26-35 lbs
19-27) and G5: > 35 lbs
morbidly obese
(BMI > 35)

Poor

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
139
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
140
Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Hellerstedt et al., Pregravid weight: Maternal weight gain G1: 17.3% Maternal age,
159
1997 Self-report categories stratified by G2: 10.0% pregravid BMI,
pregravid BMI and smoking G3: 12.3% infant sex, race,
USA, hospital Total weight gain: status: parity, prenatal
Measured G4: 10.5% alcohol use,
1,343 Obese (BMI > 29.0): G5: 7.8% prenatal illicit drug
G1: Smokers, < IOM G6: 2.6% use, adequacy of
Normal/obese BMI G2: Smokers, within IOM prenatal care,
G3: Smokers, > IOM G7: 17.5% gestational
Good G8: 3.5% hypertension,
G4: Nonsmokers, < IOM G9: 3.6% GDM, gestational
G5: Nonsmokers, within IOM age
G6: Nonsmokers, > IOM G10: 12.4%
G11: 6.0%
Normal weight (BMI 19.8- G12: 5.3%
26.0):
G7: Smokers, < IOM G13: 16.0%
G8: Smokers, within IOM G14: 11.1%
G9: Smokers, > IOM G15: 8.3%
G16: 4.0%
G10: Nonsmokers, < IOM G17: 6.0%
G11: Nonsmokers, within P = 0.003 for G13-G17
IOM
G12: Nonsmokers, > IOM G18: 14.2%
G19: 5.4%
Obese: G20: 4.9%
G13: Lost/no gain P = 0.001 for G18-G20
G14: 0.5-6.5 kg
G15: 7-11.5 kg For obese women,
G16: 12-16 kg compared to nonsmokers
G17: > 16 kg who gained 7-11.5 kg,
smokers who gained < 7
Normal weight: kg were at significantly
G18: < 11.5 kg higher risk of LBW:
G19: 11.5-16 kg AOR: 7.7 (95% CI, 1.5-
G20: > 16 kg 40.0)
Schieve et al., Pregravid weight: Maternal weight gain Within every BMI-race Age, height,
1998160 Self-report categories stratified by ethnicity stratum, the education,
pregravid BMI (IOM odds of delivering a LBW trimester of the
USA, Pregnancy Total weight gain: underweight, normal weight, infant tended to decrease special
Nutrition Self report overweight, and obese) and as weight gain increased. supplemental
Surveillance race (non-Hispanic white, This trend was nutrition program
System (WIC non-Hispanic black, and statistically significant for for WIC
clinics) Hispanic) all strata; however, the
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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Schieve et al., G1: ≥ 10 lbs below IOM trend diminished with
160
1998 (continued) G2: 1-9 lbs below IOM increasing BMI. Women
G3: Lower half of IOM with underweight and
173,006 G4: Upper half of IOM normal weight BMI in G2
G5: 1-9 lbs above IOM were 1.1–2.8 times more
All weight/BMI G6: ≥ 10 lbs above IOM likely to deliver a LBW
infant than women in G3;
Good women in G1 were 1.8 –
3.2 times more likely to
deliver a LBW infant
compared to G3.
Bracero and Byrne, Pregravid weight: Maternal weight gain G1: 10.1% Not applicable
1998127 Self-report categories: G2: 3.3%
G3: 2.5% (P < 0.001
USA, hospital, Total weight gain: G1: Maternal weight gain comparing G1-G3)
Brooklyn, NY Measured under the IOM guidelines G4: 4.9%
G2: Maternal weight gain G5: 1.8% (P < 0.001 vs.
20,971 within the IOM guidelines G4)
G3: Maternal weight gain
All weight/BMI over the IOM guidelines
G4: Optimal weight gain (36-
Fair 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)
Cogswell et al., Pregravid weight: Maternal weight gain AOR (95% CI) for low Age, race, height,
2
1995 Self-report categories (lbs) stratified by birthweight: smoking,
pregravid BMI: G1: 2.1 (1.6-2.6) gestational age,
USA, Pregnancy Total weight gain: G2: 1.4 (1.1-1.8) infant sex
Nutrition Self-report Normal weight (BMI 19.8- G3: 1.0 (0.8-1.3)
Surveillance 26.0): G4: 1.0 (reference)
System G1: < 15 G5: 0.8 (0.6-1.0)
G2: 15-19 G6: 0.6 (0.5-0.8)
53,541 G3: 20-24 G7: 0.5 (0.4-0.6)
G4: 25-29
Normal/ G5: 30-34 G8: 1.1 (0.7-1.9)
Overweight/Obese G6: 35-39 G9: 1.0 (reference)
G7: ≥ 40 G10: 0.7 (0.4-1.2)
Fair 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)

142
Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Cogswell et al., Overweight (BMI > 26.0- G15: 1.5 (0.9-2.4)
2
1994 (continued) 29.0): G16: 1.0 (reference)
G8: < 15 G17: 0.9 (0.5-1.6)
G9: 15-19 G18: 1.3 (0.8-2.3)
G10: 20-24 G19: 0.9 (0.5-1.7)
G11: 25-29 G20: 1.0 (0.5-1.8)
G12: 30-34 G21: 0.9 (0.5-1.5)
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
Edwards et al., Pregravid weight: Maternal weight gain G1:12.8% Age, parity,
55
1996 Self-report categories (kg) G2: 8.9% pregravid BMI,
G3: 7.9% GDM, pregnancy-
USA, Hospital Total weight gain: Obese BMI > 29: G4: 6.8% induced
Measured G1: Lost weight/no change G5: 8.7% hypertension,
1,443 G2: 0.5-6.5 P (for G1-G5) = 0.405 prenatal
G3: 7-11.5 adequacy, alcohol
Normal/Obese G4: 12-16 G6: 8.5% use, drug use,
weight/BMI G5: > 16 G7: 5.6% smoking,
Normal BMI 19.8-26: G8: 8.9% gestational age
Fair G6: < 11.5 kg P (for G6-G8) = 0.183
G7: 11.5-16
G8: > 16 kg 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)
Hickey et al., Pregravid weight: Maternal weight gain AOR (95% CI) Age, education,
20
1997 Self-report categories stratified by race: G1: 2.6 (1.2-5.6) height, drug use,
G2: 1.0 (reference) alcohol use, time
USA, public health Total weight gain: Black Women: G3: 1.2 (0.4-3.3) between last
programs Measured G1: Below range (< 12.5kg G4: 1.4 (0.6-3.6) prenatal weight
for BMI< 19.8; < 13.9kg for G5: 1.5 (0.8-2.6) observation and
5,198 BMI 19.8-26.0; < 7.0kg for G6: 1.0 (reference) delivery, smoking,
BMI > 26.0) G7: 0.4 (0.2-0.9) gestational age,
All weight/BMI G2: In lower range (12.5- G8: 0.7 (0.3-1.2) infant sex
15.2kg for BMI< 19.8; 11.5-
Fair 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)

143
Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Hickey et al., G4: Above range (> 18kg for
20
1997 (continued) 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., Pregravid weight: Maternal weight gain AOR (95% CI) for very Age, parity,
60
1999 Self-report categories: low birthweight: pregravid BMI,
G1: 1.8 (0.6-4.7) preeclampsia,
USA, Hospital Total weight gain: G1: < IOM G2: 1.1 (0.4-4.7) cesarean delivery,
Measured G2: Within IOM G3: 1.0 (Reference) previous cesarean,
582 G3: > IOM tobacco use,
previous fetal
All weight/BMI BMI IOM death,
hypertension,
Fair asthma, previous
LBW, vomiting,
NICU
Stevens-Simon Pregravid weight: Maternal weight gain Distribution of LBW, %: Not applicable
and McAnarney, Self-report categories (kg/wk): G1: 21.4
1992154 G2: 10.6
Total weight gain: G1: < 0.23 G3: 4.3
USA, adolescent Measured G2: 0.23-0.40 P = NS
maternity program G3: > 0.40

141

Fair
Strauss and Dietz, Pregravid weight: Maternal weight gain AOR (95% CI) for < Race, GDM,
1999161 Self-report categories stratified by 2,500g: toxemia, smoking
pregravid BMI: G1: 0.88 (0.50-1.57)
USA, National Total weight gain: G2: 2.68 (1.46-4.94)
Collaborative Measured BMI < 20.0: G3: 2.07 (1.22-3.51)
Perinatal Project G1: Low 1st trimester gain G4: 1.31 (0.88-1.95)
and the Child (< 0.1kg/wk) G5: 1.92 (1.29-2.87)
Health and G2: Low 2nd trimester gain G6: 2.12 (1.48-3.04)
Development (< 0.3kg/wk) G7: 1.02 (0.50-2.08)
Study G3: Low 3rd trimester gain G8: 1.88 (1.03-3.43)
(< 0.3kg/wk) G9: 1.53 (0.86-2.74)
10,756
BMI 20.0-25.0: Reference group-normal
All weight/BMI G4: Low 1st trimester gain rate of weight gain in the
G5: Low 2nd trimester gain trimester
Fair G6: Low 3rd trimester gain

BMI > 25.0:

G7: Low 1st trimester gain
G8: Low 2nd trimester gain
G9: Low 3rd trimester gain

144
Table 33. Weight change relative to IOM thresholds and low birthweight (< 2,500 g) (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Bianco et al., Pregravid weight: Maternal weight gain Distribution of LBW,%: Race, parity, clinic
54
1998 Self-report categories among morbidly G1: 2.0 service, substance
obese (BMI> 35): G2: 11.1 abuse, preexisting
USA, medical Total weight gain: G1: Weight loss/no change G3: 8.3 medical condition
center Measured G2: 1-15 lbs G4: 5.2
G3: 16-25 lbs G5: 3.8
11,926 G4: 26-35 lbs P = NS
G5: > 35 lbs
Nonobese (BMI 19-
27) and morbidly
obese (BMI > 35)

Poor
Hulsey et al., Pregravid weight: Pregravid BMI and AOR (95% CI) for very Ethnicity,
2005162 Self-report gestational weight gain low birthweight (500- intendedness of
categories: 1,499g): pregnancy,
USA, birth Total weight gain: G1: 2.06 (1.26-2.87) Medicaid status,
certificates linked Birth certificate G1: BMI < 19.8 and < IOM G2: 1.82 (1.22-2.29) WIC status,
to PRAMS data G2: BMI 19.8-26.0 and G3: 1.00 (reference) prenatal care,
< IOM G4: 2.05 (0.90-4.44) diabetes,
87,293 G3: BMI 19.8-26.0 and within G5: 1.25 (0.61-1.61) hypertension
IOM G6: 1.74 (1.23-2.42)
All weight/BMI G4: BMI 26.1-29.0 and
< IOM AOR (95% CI) for
Poor G5: BMI > 29.0 and < IOM moderately low
G6: BMI > 29.0 and within birthweight (1500-2499
IOM 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)
Nida et al., 1996163 Pregravid weight: G1: < IOM BMI < 19.8 Pregravid BMI
Self-report G2: within IOM G1: 10.2%
USA PRAMS G3: > IOM G2: 6%
Total weight gain: G3: 4.7
No sample size Self-report
BMI 19.8-25
All weight/BMI G1: 8.4%
G2: 3.9%
Poor G3: 4.5%

BMI > 26
G1: 6.1%
G2: 3.8%
G3: 5.1%
No statistical testing was
performed

145
 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

146
Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight

Author, Year
Country, Confounders
Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
LGA as > 90th percentile of birthweight for gestational age
Caulfield et al., Pregravid weight: G1: Underweight, BMI < 19.8 AOR (95% CI) for LGA and rate Age, race,
116
1998 Self report G2: Normal weight, BMI 19.8- of weight gain (per 50 g/wk): parity,
26.0 G1: 1.25 (1.11-1.41) pregravid BMI,
USA, university Total weight gain: G3: Overweight, BMI > 26.0 G2: 1.14 (1.08-1.20) height,
hospital Measured G3: 1.13 (1.07-1.20) hypertension,
Black women: provider type,
3,870 G4: No weight gain < IOM Expected absolute change (as % smoking,
G5: No weight gain > IOM of baseline) in incidence of LGA female infant
All weight/BMI associated with modifiable risk
White women: factor (G4-G7):
Good G6: No weight gain < IOM G4: +1.28 (+26)
G7: No weight gain > IOM G5: -0.77 (-16)
G6: +2.58 (+17)
G7: -2.87 (-19)
Hellerstedt et Pregravid weight: Maternal weight gain categories Frequencies of LGA,%: Maternal age,
159
al., 1997 Self-report stratified by pregravid BMI and G1: 5.3 pregravid BMI,
smoking status: G2: 10.0 infant sex,
USA, medical Total weight gain: G3: 12.3 race, parity,
center Measured Obese (BMI > 29.0): G4: 12.2 prenatal
G1: Smokers, < IOM G5: 11.7 alcohol use,
1,343 G2: Smokers, within IOM G6: 22.2 prenatal illicit
G3: Smokers, > IOM G7: 0 drug use,
Normal/obese G8: 1.8 adequacy of
BMI G4: Nonsmokers, < IOM G9: 9.1 prenatal care,
G5: Nonsmokers, within IOM G10: 4.4 gestational
Good G6: Nonsmokers, > IOM G11: 8.1 hypertension,
G12: 14.3 GDM,
Normal weight (BMI 19.8-26.0): gestational age
G7:Smokers, < IOM G13: 9.3
G8: Smokers within IOM G14: 10.5
G9:Smokers,> IOM G15: 11.3
G16: 17.5
G10: Nonsmokers < IOM G17: 21.8
G11: Nonsmokers, within IOM P = 0.001 for G13-G17
G12: Nonsmokers, > IOM
G18: 2.8
Obese: G19: 6.7
G13: Lost/no gain G20: 13.1
G14: 0.5-6.5 kg P < 0.001 for G18-G20
G15: 7-11.5 kg
G16: 12-16 kg Compared with infants of obese
G17: > 16 kg nonsmokers who gained 7-
11.5kg, the only group at
Normal weight: significantly higher risk of LGA
G18: < 11.5 kg was non smokers who gained
G19: 11.5-16 kg > 11.5kg: AOR: 2.3 (95% CI, 1.2-
G20: > 16 kg 4.5)

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.

147
Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued)

Author, Year
Country, Confounders
Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Devader et al., Pregravid weight: Maternal weight gain categories: AOR (95% CI) for LGA: Age, race,
200725 Self-report G1: < 25 lbs G1: 0.40 (0.37-0.44) education,
G2: 25-35 lbs G2: 1.00 (reference) income, alcohol
USA, birth Total weight gain: G3: > 35 lbs G3: 2.43 (2.30-2.56) use, height, prior
certificate data Measured pregnancy,
inadequate
94,696 prenatal care use,
smoking, child's
Normal gender, birth year
weight/BMI
19.8-26

Fair
Kiel et al., Pregravid weight: Maternal weight gain categories For Obese Class I: OR (95% Age, race, parity,
4
2007 Self-report stratified by prepregnancy CI) for LGA were significantly education,
obesity status, Obese Class lower (< 1.00, G6 was poverty
USA, birth Total weight gain: I(BMI 30–34.9), Obese Class II reference) for G1- G5 and (enrollment in
registry Medical record (BMI 35–39.9), Obese Class III significantly higher for G7- Medicaid, WIC,
(> = BMI 40): G8. food stamp
120,170 G1: ≤ -10 lbs programs),
G2: -2 to -9 lbs For Obese Class II: OR (95% tobacco use,
Obese BMI G3: No change CI) for LGA were significantly chronic
> 30 G4: 2-9 lbs lower (< 1.00, G6 was hypertension
G5: 10-14 lbs reference) for G1- G5 and
Fair G6: 15-25 lbs significantly higher for G7-
G7: 26-35 lbs G8.
G8: > 35 lbs
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
Parker and Pregravid weight: Maternal weight gain categories: AOR (95% CI) for LGA: Age, race, parity,
Abrams, Self-report G1: < IOM range G3: 1.92 (1.52-2.43) pregravid BMI,
118
1992 G2: Within IOM range G2: 1.00 (reference) height, maternal
Total weight gain: G3: > IOM high and low
USA, hospital Measured Incidence of LGA in weight gain,
BMI IOM nonobese women,%: smoking,
USA, Hospital G1: 3.25 gestational age,
database G2: 6.14 birthweight
(California) G3: 13.11

6,690 Incidence of LGA in obese

women,%:
All weight/BMI G1: 5.88
G2: 17.53
Fair

148
Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued)

Author, Year
Country, Confounders
Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Stevens-Simon Pregravid weight: Maternal weight gain categories Distribution of LGA,%: NA
and Self-report (kg/wk): G1: 3.6
McAnarney, G1:< 0.23 G2: 4.5
1992154 Total weight gain: G2: 0.23-0.40 G3: 12.8
Measured G3: > 0.40 P = NS
USA,
adolescent
maternity
program

141

Fair
Stotland et al., Pregravid weight: Maternal weight gain categories: Unadjusted Rates of LGA: Age, race, parity,
129
2006 Self-report G1: < IOM G1: 3.85 P< 0.001 vs. G2 pregravid BMI,
G2: Within IOM G2: 6.62 pregnancy-
USA, university Total weight gain: G3: > IOM G3:13.76 P< 0.001 vs. G2 induced
hospital Prenatal record G4: weight gain < 7kg G4: 5.26 hypertension,
G5: weight gain > 18kg G5: 14.60 P< 0.05 vs. G2 date of delivery,
20,465 mode of delivery,
BMI IOM AOR (95% CI) for LGA: length of first and
All weight/BMI G1: 0.58 (0.47-0.72) second stage of
G2: 1.00 (reference) labor, smoking,
Fair G3: 1.98 (1.74-2.25) gestational age,
G4: 0.50 (0.33-0.78) birthweight
G5: 2.28 (2.00-2.62)
Bianco et al., Pregravid weight: Maternal weight gain categories Distribution of LGA,%: Race, parity,
199854 Self-report among morbidly obese (BMI > G1: 12.0 clinic service,
35): G2: 11.8 substance abuse,
USA, Medical Total weight gain: G1: Weight loss/no change G3: 18.8 preexisting
Center Measured G2: 1-15 lbs G4: 25.8 medical condition
G3: 16-25 lbs G5: 23.8
11,926 G4: 26-35 lbs P < 0.01
G5: > 35 lbs
Nonobese (BMI
19-27) and
morbidly obese
(BMI > 35)

Poor

149
Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued)

Author, Year
Country, Confounders
Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
LGA as birthweight > 4,500 gm 275
Hedderson et Pregravid weight: Maternal weight gain categories: % Distribution of maternal Age, race,
110
al., 2006 Self-report G1: < IOM weight gain categories parity, pregravid
G2: Within IOM among women with BMI, screening
USA, Kaiser Total weight gain: G3: > IOM macrosomia: glucose value
Permanente Measured G1: 4.0 from 1 hour after
Medical Care BMI IOM G2: 16.3 the 50g oral
Program G3: 79.7 P < 0.05 (compared glucose
to controls) challenge test,
45,245 difference
AOR (95% CI) for between age at
All weight/BMI macrosomia: delivery and
G1: 0.38 (0.20-0.70) gestational age
Good G2: 1.00 reference at last weight
G3: 3.05 (2.19-4.26) measured

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)
Schieve et al., Pregravid weight: Maternal weight gain categories Within every BMI-race Age, height,
1998160 Self-report stratified by pregravid BMI (IOM- ethnicity stratum, the odds of education,
underweight, normal weight, delivering a > 4,500g infant trimester of the
USA Total weight gain: overweight, and obese) and race tended to increase as weight Special
Pregnancy Self report (non-Hispanic white, non- gain increased. This trend Supplemental
Nutrition Hispanic black, and Hispanic): was statistically significant for Nutrition
Surveillance all strata; however, the trend Program for
System - data G1: ≥ 10 lbs below IOM diminished with decreasing WIC
from WIC G2: 1-9 lbs below IOM BMI. Women in G6 were
clinics G3: Lower half of IOM 2.2–10.8 times more likely to
G4: Upper half of IOM deliver a > 4,500 g infant
173,006 G5: 1-9 lbs above IOM compared to women in G3,
G6 ≥ 10 lbs above IOM irrespective of BMI status.
All weight/BMI

Good

150
Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued)

Author, Year
Country, Confounders
Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Cogswell et al., Pregravid weight: Maternal weight gain categories AOR (95% CI) for high Age, race,
19952 Self-report (lbs) stratified by pregravid BMI: birthweight: height, smoking,
G1: 1.0 (0.5-2.0) gestational age,
USA, Total weight gain: Normal weight (BMI 19.8-26.0): G2: 0.4 (0.2-1.0) sex of infant
Pregnancy Self-report G1: < 15 G3: 0.6 (0.3-1.1)
Nutrition G2: 15-19 G4: 1.0 (reference)
Surveillance G3: 20-24 G5: 1.1 (0.7-1.8)
System G4: 25-29 G6: 1.5 (1.0-2.3)
G5: 30-34 G7: 3.3 (2.3-4.7)
53,541 G6: 35-39
G7: ≥= 40 G8: 0.8 (0.2-2.6)
Normal/ G9: 1.0 (reference)
Overweight/ Overweight (BMI > 26.0-29.0): G10: 1.1 (0.4-3.5)
Obese G8: < 15 G11: 2.1 (0.8-5.7)
G9: 15-19 G12: 2.4 (0.9-6.4)
Fair G10: 20-24 G13: 1.6 (0.6-4.6)
G11: 25-29 G14: 4.0 (1.6-10.1)
G12: 30-34
G13: 35-39 G15:0.7 (0.5-1.1)
G14: ≥ 40 G16: 1.0 (reference)
G17: 1.1 (0.7-1.7)
Obese (BMI > 29.0): G18: 1.3 (0.8-2.0)
G15: < 15 G19: 1.9 (1.3-2.9)
G16: 15-19 G20: 2.1 (1.3-3.2)
G17: 20-24 G21: 2.3 (1.6-3.3)
G18: 25-29
G19: 30-34
G20: 35-39
G21: ≥ 40
Thorsdottir Pregravid weight: Maternal weight gain categories: Birthweight > 4,500g,% Age, parity,
200253 Self-report G1: 4.3 height,
G1: < 11.5 kg G2: 4.1 (P< 0.05 between gestational age,
Iceland, Total weight gain: G2: 11.5-16.0 kg groups) birthweight
Hospital Maternity records G3: 16.1-20.0 kg G3: 9.1 (P< 0.05 between
records G4: > 20.0 kg groups)
G4: 10.2 (P< 0.05 between
614 G5: 12.5-15.5 kg groups)
G6: > 17.8-20.8 kg P for trend< 0.015
Normal
weight/BMI RR (95% CI) for > 4,500g:
19.5-25.5 G5: 1.00 (reference)
G6: 3.54 (1.26-9.97)
Fair

151
Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued)

Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and Effect
Baseline BMI Total Weight Gain Modifiers Included in
Quality (How Measured) Definition of Groups Results Analysis
LGA as birthweight > 4,000 gm
Edwards et al., Pregravid weight: Maternal weight gain Birthweight ≥ Age, parity, pregravid
199655 Self-report categories (kg) Obese > 29: 4,000g,%: BMI, GDM, pregnancy-
G1: Lost weight/no change G1:12.0 induced hypertension,
USA, Hospital Total weight gain: G2: 0.5-6.5 G2: 12.5 prenatal adequacy,
Measured G3: 7-11.5 G3: 13.3 alcohol use, drug use,
1,443 G4: 12-16 G4: 15.4 smoking, gestational age
G5: > 16 G5: 24.4
Normal/Obese Normal BMI 19.8-26 P (for G1-G5)
weight/BMI G6: < 11.5kg = 0.026
G7: 11.5-16
Fair G8: > 16kg 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)
Rode et al., 2007164 Pregravid weight: Maternal weight gain AOR (95% CI) for Preeclampsia, caffeine
Self report categories stratified by birthweight ≥ consumption, gestational
Denmark Smoke- pregravid BMI status: 4,000g: age, smoking
free Newborn Total weight gain: G1: 0.8 (0.4-1.6)
Study, University Self report BMI less than 19.8 G2: 1.0 (reference)
Hospital G1: < IOM G3: 1.7 (0.8-3.6)
G2: Within IOM
2,248 G3: > IOM G4: 0.7 (0.5-0.999)
G5: 1.0 (reference)
All weight/BMI BMI 19.8–26.0 G6: 1.9 (1.5-2.5)
G4: < IOM
Fair G5: Within IOM G7: 0.6 (0.1-3.1)
G6: > IOM G8: 1.0 (reference)
G9: 1.8 (0.8-3.9)
BMI 26.1–29.0
G7: < IOM G10: 0.8 (0.4-1.7)
G8: Within IOM G11: 1.0 (reference)
G9: > IOM G12: 0.9 (0.4-2.0)

152
Table 34. Weight change relative to IOM thresholds and large-for-gestational-age infant weight (continued)

Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Effect Modifiers
Quality (How Measured) Definition of Groups Results Included in Analysis
Rode et al., BMI greater than 29.0
164
2007 G10: < IOM
(continued) G11: Within IOM
G12: > IOM
Kabali et al., Pregravid weight: G1: < IOM AOR Maternal age, marital
165
2007 Self-report G2: within IOM G1: 1.0 (0.4, 1.9) status, race/ethnicity,
G3: > IOM G2: ref family income, years of
USA,/Canada, Total weight: G3: 1.5 (0.7, 2.5) education, smoking,
Pediatric practice Self-report BMI IOM alcohol, sex of child,
Combined effect with BMI OR parity, gestational age
815 (AOR similar but not all could
be calculated)
All weight/BMI Underweight/G1: 0.7 (0.2, 3.3)
Underweight/G2: 1.0 (0.3, 3.5)
Poor 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)

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.

153
 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.

154
Table 35. Weight change relative to IOM thresholds and small-for-gestational-age

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Caulfield et al., Pregravid weight: G1: Underweight, BMI AOR (95% CI) for SGA and Age, race,
116
1998 Self report < 19.8 rate of weight gain (per 50 parity,
G2: Normal weight, BMI g/wk): pregravid BMI,
USA, University Total weight gain: 19.8-26.0 G1: 0.87 (0.78-0.97) height,
Hospital Measured G3: Overweight, BMI G2: 0.90 (0.84-0.96) hypertension,
> 26.0 G3: 0.93 (0.86-1.01) provider type,
3,870 smoking,
Black women: Expected absolute change (as female infant
All weight/BMI G4: No weight gain < IOM % of baseline) in Incidence of
G5: No weight gain > IOM SGA associated with
Good modifiable risk factors (G4-
White women: G7):
G6: No weight gain < IOM G4: -1.17 (-16)
G7: No weight gain > IOM G5: +0.97 (+13)
G6: -0.44 (-11)
G7: +0.60 (+15)
Hellerstedt et al., Pregravid weight: Maternal weight gain Frequencies of SGA,%: Maternal age,
159
1997 Self-report categories stratified by G1: 13.3 pregravid BMI,
pregravid BMI and G2: 10.0 infant sex,
USA, medical Total weight gain: smoking status: G3: 7.7 race, parity,
center Measured G4: 5.5 prenatal
Obese (BMI > 29.0): G5: 4.7 alcohol use,
1,343 G1: Smokers, < IOM G6: 3.6 prenatal illicit
G2: Smokers, within IOM G7: 28.6 drug use,
Normal/obese BMI G3: Smokers, > IOM G8: 10.9 adequacy of
G9: 3.6 prenatal care,
Good G4: Nonsmokers, < IOM G10: 8.9 gestational
G5: Nonsmokers, within G11: 6.5 hypertension,
IOM G12: 6.4 GDM,
G6: Nonsmokers, > IOM gestational age
G13: 10.7
Normal weight (BMI 19.8- G14: 6.6
26.0): G15: 6.0
G7: Smokers, < IOM G16: 4.0
G8: Smokers, within IOM G17: 5.3
G9: Smokers, > IOM P = 0.115 for G13-G17

G10: Nonsmokers, < IOM G18: 15.9

G11: Nonsmokers, within G19: 7.5
IOM G20: 5.7
G12: Nonsmokers, > IOM P = 0.001 for G18-G20

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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Hellerstedt et al., Obese: For obese women, compared to
159
1997 (continued) G13: Lost/no gain nonsmokers who gained 7-11.5
G14: 0.5-6.5 kg kg, smokers who gained < 7 kg
G15: 7-11.5 kg were at significantly higher risk of
G16: 12-16 kg SGA OR: 3.2 (95% CI, 1.1-10.1)
G17: > 16 kg
For normal weight women,
Normal weight: compared to nonsmokers who
G18: < 11.5 kg gained 11.5-16 kg, smokers who
G19: 11.5-16 kg gained < 11.5 kg were at
G20: > 16 kg significantly higher risk of SGA
OR: 4.3 (95% CI, 1.8-10.3)
Nielsen et al., Pregravid weight: G1: BMI < 19.8 SGA,%: Parity,
153
2006 Self-report G2: BMI 19.8-26.0 G1: 22.3 pregravid BMI,
G3: BMI > 26.0 G2: 15.6 time between
USA, hospitals Total weight gain: G3: 11.5 last weight
(African American Measured G4: < IOM P < 0.01 for G1-G3 measure and
adolescents) G5: Lower half of IOM delivery, height
G6: Upper half of IOM AOR (95% CI) for SGA:
815 G7: > IOM G4: 2.31 (1.22-4.37)
G5: 1.00 (reference)
All weight/BMI G6: 0.88 (0.41-1.89)
G7: 0.68 (0.34-1.35)
Good P < 0.01 for G4-G7
Devader et al., Pregravid weight: Maternal weight gain AOR (95% CI) for SGA: Age, race,
25
2007 Self-report categories (lbs): G1: 2.14 (2.01-2.27) education,
G1: < 25 G2: 1.0 (reference) income,
USA, birth Total weight gain: G2: 25-35 G3: 0.48 (0.45-0.50) alcohol use,
certificate data Measured G3: > 35 height, prior
pregnancy,
94,696 inadequate
prenatal care
Normal weight/BMI use, smoking,
19.8-26 child's gender,
birth year
Fair

156
Table 35. Weight change relative to IOM thresholds and small-for-gestational-age (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Edwards et al., Pregravid weight: Obese BMI > 29 (kg): % SGA for obese: Age, parity,
55
1996 Self-report G1: Lost weight/no change G1: 10.7% pregravid BMI,
G2: 0.5-6.5 G2: 6.6% GDM, PIH,
USA, hospital Total weight gain: G3: 7-11.5 G3: 6.0% prenatal
Measured G4: 12-16 G4: 4.0% adequacy,
1,443 G5: > 16 G5: 5.3% alcohol use,
P = 0.11 drug use,
Normal/Obese Normal weight 19.8-26 smoking,
weight/BMI G6: < 11.5 For normal weight: gestational age
G7: 11.5-16 G6: 15.9%
Fair G8: > 16 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)
Kiel et al., 20074 Pregravid weight: Maternal weight gain For Obese Class I: AOR (95% Age, race,
Self-report categories stratified by CI) for SGA were significantly parity,
USA, birth registry prepregnancy obesity greater (> 1.00, G6 was education,
Total weight gain: status, Obese Class I (BMI reference) for G1- G5 and poverty
120,170 Medical record 30–34.9), Obese Class II significantly lower for G7-G8. (enrollment in
(BMI 35–39.9), Obese Medicaid, WIC,
Obese BMI > 30 Class III (BMI ≥ 40): For Obese Class II: AOR food stamp
G1: ≤ -10 lbs (95% CI) for SGA were programs),
Fair G2: -2 to -9 lbs significantly greater (> 1.00, tobacco use,
G3: No change G6 was reference) for G1- G5 chronic
G4: 2-9 lbs and significantly lower for G7- hypertension
G5: 10-14 lbs G8
G6: 15-25 lbs
G7: 26-35 lbs For Obese Class III: AOR
G8: > 35 lbs (95% CI) for SGA were
significantly greater (> 1.00,
G6 was reference) for G1 and
G3 and significantly lower for
G7-G8
Parker and Pregravid weight: Maternal weight gain AOR (95% CI) for SGA: Age, race,
118
Abrams, 1992 Self-report categories: G1: 1.78 (1.39-2.27) parity,
G2: 1.00 (reference) pregravid BMI,
USA, hospital Total weight gain: G1: < IOM height,
(California) Measured G2: Within IOM Incidence of SGA in maternal high
G3: > IOM nonobese women,%: and low weight
6,690 G1: 3.25 gain, smoking,
BMI IOM G2: 6.14 gestational
All weight/BMI G3: 13.11 age,
birthweight
Fair Incidence of SGA in obese
women,%:
G1: 11.76
G2: 3.09

157
Table 35. Weight change relative to IOM thresholds and small-for-gestational-age (continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Stevens-Simon and Pregravid weight: Maternal weight gain Distribution of SGA, %: None
McAnarney, Self-report categories (kg/wk): G1: 7.1
1992154 G2: 9.1
Total weight gain: G1: < 0.23 G3: 2.1
USA, adolescent Measured G2: 0.23-0.40 P = NS
maternity program G3: > 0.40

141

All weight/BMI

Fair
Stotland et al., Pregravid weight: Maternal weight gain Unadjusted rates of SGA: Age, race,
129
2006 Self-report categories: G1: 11.74 P< 0.001 vs. G2 parity,
G2: 7.05 pregravid BMI,
USA, university Total weight gain: G1: < IOM G3: 3.70 P< 0.001 vs. G2 PIH, date of
hospital Prenatal record G2: Within IOM G4: 13.99 P< 0.05 vs. G2 delivery, mode
G3: > IOM G5: 3.87 P< 0.05 vs. G2 of delivery,
20,465 G4: < 7 kg length of first
G5: > 18 kg AOR (95% CI) for SGA: and second
All weight/BMI G1: 1.66 (1.44-1.92) stages of labor,
G2: 1.00 (reference) smoking,
Fair G3: 0.51 (0.44-0.59) gestational
G4: 2.26 (1.76-2.90) age,
G5: 0.50 (0.42-0.60) birthweight
Bianco et al., Pregravid weight: Maternal weight gain Distribution of SGA,%: Race, parity,
199854 Self-report categories among morbidly G1: 4.0 clinic service,
obese (BMI > 35): G2: 3.9 substance
USA, medical Total weight gain: G1: Weight loss/no change G3: 5.6 abuse,
center Measured G2: 1-15 lbs G4: 3.1 preexisting
G3: 16-25 lbs G5: 3.8 medical
11,926 G4: 26-35 lbs P = No testing due to small condition
G5: > 35 lbs numbers in each cell
Nonobese (BMI 19-
27) and morbidly
obese (BMI > 35)

Poor

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

158
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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Nixon et al., 1998125 Pregravid weight: Gestational Maternal weight gain by IOM None
Self-report weight gain guidelines was not not a signigicant
USA, county nurse- categorized by predictor of Apgar scores (details-
midwifery services Total weight gain: IOM none reported)
Data records recommendations
2,228
BMI IOM
All weight/BMI

Fair
Stevens-Simon and Pregravid weight: Maternal weight Distribution of 1-minute Apgar score None
McAnarney, 1992154 Self-report gain categories ≤ 4,%:
(kg/wk): G1: 25.0
USA, adolescent Total weight gain: G2: 4.5
maternity program Measured G1: < 0.23 G3: 14.9
G2: 0.23-0.40 P = 0.02 for G1 vs. G2 or G3
141 G3: > 0.40
Distribution of 5-minute Apgar score
All weight/BMI ≤ 4,%:
G1: 3.5
Fair G2: 0
G3: 0
P = NS
BMI, body mass index; G, group; IOM, Institute of Medicine; kg/wk, kilogram per week; NS, not significant; USA, United
States of America.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Stotland et al., Pregravid weight: Maternal weight Unadjusted rates of 5-minute Apgar Age, race, parity,
129
2006 Self-report gain categories: score < 7: pregravid BMI,
G1: 1.94 pregnancy-induced
USA, university Total weight gain: G1: < IOM G2: 1.58 hypertension, date
hospital Prenatal records G2: Within IOM G3: 2.14 (P< 0.05, G3 vs. G2) of delivery, mode of
G3: > IOM delivery, length of
20,465 G4: < 7 kg G4: 2.39 first and second
G5: > 18 kg G5: 2.16 (P< 0.05, G5 vs. G2) stage of labor,
All weight/BMI smoking,
(using IOM AOR (95% CI) for 5-minute Apgar gestational age,
definitions) score < 7: birthweight
G1: 1.18 (0.84-1.66)
Fair 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)

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).

160
 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
161
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 singleton-
only 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

162
Table 37. Weight change relative to IOM thresholds and breastfeeding

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Baker et al., Pregravid weight: G1: < 8 kg Overall higher risk of BMI
166
2007 Prepregnant weight G2: 8-15.9 kg terminating full or any
Self reported G3: ≥ 16 kg breastfeeding with higher
Denmark-National pregravid BMI.
Birth Total weight gain:
Self-reported Unadjusted RR full BF G1:
37,459 1.13 (95% 1.08-1.18) G3:
1.05 (1.03-1.08).
All wt/BMI
Under wt BMI Any BF
< 18.5 G1: RR 1.16 (1.11-1.22)
Normal BMI 18.5- G3: 1.05 (1.03-1.08).
24.9
Overweight BMI GWG not a predictor of full or
25-29 any when BMI was in the
Obese BMI ≥ 30 model.

Fair
Li et al., 2003167 Pregravid weight: G1: < IOM Adjusted OR for failure to Age, race, parity,
Prepregnant weight G2: within IOM initiate BF by BMI: pregravid BMI,
USA WIC clinics Self reported G3: > IOM maternal education,
Under, normal and marital status,
51,329 Total weight gain: overweight G1: groups had a prenatal care,
Self-reported significant increased odds of poverty-income
All wt/BMI (using failure to initiate BF compared ratio, gestational
IOM definitions) to G2: within BMI strata. weight gain,
Obese women regardless of smoking, gestational
Fair weight gain had increased age, birthweight
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*
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.

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

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Included in
Quality (How Measured) Definition of Groups Results Analysis
Rasmussen et al., Pregravid weight: G1: < IOM OR unsuccessful initiation of Age, parity,
168
2002 Prepregnant weight G2: within IOM BF (normal wt G2: ref) participation in
Hilson et al., Self reported G3: > IOM Underweight no significant diff WIC/PCAP, type of
2006169 Normal wt G3: 1.66 (1.05- delivery, mother
Total weight gain: 2.63) attended college,
USA, hospital Prenatal records Overwt no significant diff smoking
Obese G3: 2.89 (1.78-4.69)
2,494
Hazard OR discontinuing
All wt/BMI (using exclusive BF
IOM definitions) (normal wt G2: ref)
Underwt G3: 1.39 (1.01-1.92)
Fair 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)

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

164
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
165
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 Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Luke et al., Pregravid weight: Maternal weight Mean (SEM) retained weight (defined as Age, parity,
1996104 Self-report gain < IOM 2-day postpartum weight minus race, smoking,
recommendations: pregravid weight, kg): gestation
USA, clinic Total weight gain: G1: BMI < 19.8 G1: 3.2 (0.5) P < 0.05 compared to G4 duration, fetal
Measured G2: BMI 19.8-26.0 G2: 0.8 (0.4) P < 0.05 compared to G5 sex
487 G3: BMI > 26.0 G3: -5.0 (0.7) P < 0.05 compared to G6

All weight/BMI Maternal weight G4: 8.2 (0.7)

gain within IOM G5: 7.0 (0.4)
Fair recommendations: G6: 1.4 (0.8)
G4: BMI < 19.8
G5: BMI 19.8-26.0 G7: 15.5 (0.9) P < 0.05 compared to G4
G6: BMI > 26.0 G8: 12.9 (0.4) P < 0.05 compared to G5
G9: 9.5 (0.5) P < 0.05 compared to G6
Maternal weight
gain > IOM
recommendations:
G7: BMI < 19.8
G8: BMI 19.8-26.0
G9: BMI > 26.0
Scholl et al., Pregravid weight: Maternal weight Mean (SEM) change in weight (kg) from Age, parity,
1995158 Self report gain categories pregravid to 6 weeks postpartum: race, height,
(kg/wk): G1: 3.1 (0.80) lactation
USA Camden Total weight gain: G2: 3.9 (0.51) status,
Study Measured G1: ≤ 0.34 G3: 9.4 (0.70) P < 0.001, G3 vs. G1,G2 smoking
G2: > 0.34-0.68
274 G3: > 0.68

Normal weight/BMI
19.8-26

Fair
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.

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

Author, Year Confounders

Country, Setting Pregravid Weight and Effect
Sample Size (How Measured) Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Stevens-Simon Pregravid weight: Maternal weight Short term weight retention (2-11 weeks Age, pregravid
and McAnarney, Self-report gain categories postpartum), total kg: BMI, level of
1992154 (kg/wk): G1: -1.7 (SD 2.9) physical
Total weight gain: G2: 2.9 (SD 2.9) activity, timing
USA, adolescent Measured G1:< 0.23 G3: 9.6 (SD 5.6) of first prenatal
maternity program G2: 0.23-0.40 P < 0.0001 and
G3: > 0.40 postpartum
141 AOR (95% CI) for subsequent maternal visits
obesity (> 120% ideal weight for height): substance
All weight/BMI G3: 190.94 (7.55-4,779.02) use, body
habitus
Fair
Walker et al., Pregravid weight: Maternal weight Mean (SD) weight (kg) retained at 6 Race, parity,
170
2004 Self-report gain categories: weeks postpartum: pregravid BMI,
G1: -0.34 (3.44) gestational
USA, Austin New Total weight gain: G1: < IOM G2: 3.86 (3.45) weight gain,
Mothers Study Self-report G2: Within IOM G3: 10.55 (6.14) gestational
G3: > IOM P = 0.000 age
419
% Women who attained pregravid
All weight/BMI weight at 6 weeks postpartum:
(using IOM G1: 48.8
definitions) G2: 14.3
G3: 2.3
Fair
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)

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

167
 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 Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Amorim et al., Pregravid weight: Maternal weight A mixed ANOVA with one repeated Pregravid BMI
2007171 Self-report gain categories: measures factor (weight before
< IOM pregnancy, 6 months, 1, and 15 years)
Sweden, hospital Total weight gain: Within IOM and one between-subjects factor
Obstetric records > IOM (< IOM, within IOM, > IOM) showed a
483 main effect of time [F (9.024) = 113.7,
P = 0.000] and a significant time group
All weight/BMI interaction [F(6,12) = 77.23, P = 0.000]

Fair 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]
Rooney et al., Pregravid weight: Maternal weight Average weight change between Duration of
174
2002 Measured at first gain categories: prepregnancy and 6 months breastfeeding,
visit postpartum (kg): postpartum aerobic
USA, hospital G1: < IOM G1: -0.61 exercise, weight
Total weight gain: G2: Within IOM G2: 1.8 loss by 6 months
540 Measured G3: > IOM G3: 4.2
P = 0.01
All weight/BMI BMI IOM
Regression coefficient (95% CI) for
Fair weight at 6 months postpartum:
G1: -1.53 (-3.36–0.30)
G2: Reference
G3: 1.24 (-0.63–3.11)
ANOVA, analysis of variance; BMI, body mass index; CI, confidence interval; G, group; kg, kilogram; kg/wk, kilogram per
week; SE, standard error.

168
Table 39. Weight change relative to IOM thresholds and weight retention during the first year postpartum
(continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
Scholl et al., Pregravid weight: Maternal weight Mean (SEM) change in weight (kg) Age, race, parity,
1995158 Self report gain categories from pregravid to 6 months postpartum: pregravid BMI,
(kg/wk): G1: 3.2 (0.95) lactation, height,
USA, Camden Total weight gain: G2: 3.8 (0.61) smoking
Study Measured G1: ≤ 0.34 G3: 7.9 (0.83) P < 0.001, G3 vs. G1,
G2: > 0.34-0.68 G2
274 G3: > 0.68
Mean (SEM) change in weight (kg)
Normal from 6 weeks to 6 months postpartum:
weight/BMI 19.8- G1: 0.13 (0.64)
26 G2: -0.05 (0.41)
G3: -1.48 (0.56) P < 0.05, G3 vs. G1,
Fair 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)
Walker, 1996172 Pregravid weight: Maternal weight Mean weight retention at 6 months Mode of delivery,
Self report gain categories: postpartum, lbs: infant sex,
USA, mail survey G1: 0.4 breastfeeding,
Total weight gain: G1: < IOM G2: 3.7 infant birthweight,
88 Self report G2: Within IOM G3: 13.5 pregravid BMI
G3: > IOM P < 0.001
Underweight/
Normal/ Maternal weight gain was significantly
Overweight (using related to weight at 6 months
IOM definitions) postpartum: r = 0.60, P < 0.001
Mean weight retention at 18 months
Fair 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

169
Table 39. Weight change relative to IOM thresholds and weight retention during the first year postpartum
(continued)

Author, Year
Country, Setting Pregravid Weight Confounders and
Sample Size (How Measured) Effect Modifiers
Baseline BMI Total Weight Gain Definition of Included in
Quality (How Measured) Groups Results Analysis
175
Olson 2002 Pregravid weight: Maternal weight Regression coefficient (SE) for weight Exercise, food
Measured during gain categories: change from early pregnancy to 1 year intake,
USA, hospital and first trimester postpartum (kg): breastfeeding,
primary care clinic G1: < IOM G1: -1.50 (0.62) P = 0.016 pregravid BMI, age,
system Total weight gain: G2: Within IOM G2: reference marital status,
Measured G3: > IOM G3: 0.32 (0.65) P = 0.621 income, postpartum
622 G4: Interaction G4: 3.41 (0.91) P < 0.001 month that weight
for > IOM and was measured
All weight/BMI income ≤ 185% AOR (95% CI) for major weight gain
federal poverty (≥ 10 lbs) at 1 year postpartum:
Fair line 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)
Keppel 1993173 Pregravid weight: Categories of The percent distribution of women in None
Self-report amount of G1-G5 stratified by maternal weight
USA, 1988 weight retained gain categories showed that both black
National Maternal Total weight gain: (lbs) at 10-18 and white women who gained < IOM or
and Infant Health Self-report months within the IOM guidelines retained less
Survey postpartum: weight (10-18 months postpartum) than
G1: Lost weight women who gained > IOM
2,944 G2: 0-3 recommendations. Irrespective of
G3: 4-8 maternal weight gain, black women
Non obese/BMI G4: 9-13 retained more weight than white
< 29 G5: ≥ 14 women

Poor

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

170
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 Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Definition of Effect Modifiers
Quality (How Measured) Groups Results Included in Analysis
Gunderson, Pregravid weight: Maternal weight AOR (95% CI) for becoming Smoking, PIH,
2000177 Self-report gain categories: overweight between baseline education, parity,
G1: < IOM/ within (pregravid weight at start of index marital status, age at
USA, hospital Total weight gain: IOM pregnancy) and start of second menarche, interval to
Measured G2: > IOM study pregnancy (median interval first birth
1,300 time = 1.5 years):
G1: Reference
All weight/BMI G2: 2.95 (1.67-5.24)
(using IOM
definitions)

Good
Rooney, 2005176 Pregravid weight: Categories of Multivariable regression Marital status at
Measured at first maternal weight coefficient (95% CI) for BMI at 15 delivery, change in
USA, hospital prenatal visit gain: years postpartum: marital status, current
G1: < IOM G1: -0.57 (-0.57-1.21) parity, insurance
484 Total weight gain: G2: within IOM G2: reference status at delivery,
Measured G3: > IOM G3: 1.69 (0.79-2.58) current insurance
All weight/BMI status, baseline BMI,
Multivariable regression weight gain at index
Fair coefficient (95% CI) for change in pregnancy, retained
weight between baseline and 15 weight at 6 months
years postpartum: postpartum,
G1: 0.43 (-1.87-2.73) participation in
G2: reference postpartum aerobic
G3: 4.19 (1.88-6.51) exercise, duration of
breastfeeding
Amorim et al., Pregravid weight: Maternal weight Mean (SD) change in weight at Education, lactation,
2007171 Self-report gain categories: 15 years postpartum, kg: weight retention at 6
G1: < IOM G1: 6.2 (6.8) months postpartum,
Sweden, hospital Total weight gain: G2: Within IOM G2: 6.7 (6.8) weight gain between
Obstetric records G3: > IOM G3: 10.3 (8.5) 6 months and 1 year
483 P = 0.000 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.

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

Author, Year
Country, Setting Pregravid Weight
Sample Size (How Measured) Confounders and
Baseline BMI Total Weight Gain Definition of Effect Modifiers
Quality (How Measured) Groups Results Included in Analysis
Amorim et al., Mean (SD) BMI at 15 years
171
2007 postpartum:
(continued) G1: 23.5 (3.7)
G2: 23.6 (3.0)
All weight/BMI G3: 25.9 (3.9)
(using IOM P = 0.000
definitions)
Multiple regression coefficient, B
Fair (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., Pregravid weight: Maternal weight Average weight change between Duration of
174
2002 Measured at first visit gain categories: prepregnancy and ~8.5 years breastfeeding,
postpartum (kg): postpartum aerobic
USA, hospital Total weight gain: G1: < IOM G1: 4.1 exercise, weight loss
Measured G2: Within IOM G2: 6.5 by 6 months
540 G3: > IOM G3: 8.4
P = 0.01
All weight/BMI
(using IOM Regression coefficients (95% CI)
definitions) for BMI at ~8.5 years postpartum:
G1: -3.86 (-5.56 - -2.16)
Fair G2: Reference
G3: -0.70 (-2.13-0.74)

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 long-
term 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.

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 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.

173
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.

175
 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.

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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

Source of Strength of
Outcome evidence 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
4,25,52,53,55,58-60 49,51,54,61
Hypertensive disorders KQ 1 Weak 8 fair, 4 poor,
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.

177
 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-than-
average 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 pregnancy-
induced 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.

178
Table 42. Strength of evidence: maternal intrapartum outcomes of gestational weight gain

Source of Number and Quality of

Outcome evidence Strength of Evidence Studies
Premature rupture of KQ 1 Weak 2 Fair64,65
membranes
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; 14 Fair,4,25,52,58,67,69-73,75-78
49,51,54,59,61,68,74
Weak for instrumental delivery 7 Poor
KQ 3 Moderate evidence for increased risk of 8 Fair,4,25,53,55,77,118,149,150
54
cesarean for weight gain above IOM 1 Poor
recommendations for underweight and
normal weight women
Weak inconsistent evidence for weight gain
above IOM recommendations for obese or
morbidly obese women
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 KQ 1 Weak 1 Fair,53
81
delivery 1 Poor
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

179
 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

180
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.

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 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 fourth-
degree 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 normal-
weight 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.

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

Source of
Outcome 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
59,83,87
3 Poor
KQ 3 Strong for association with weight gain below 4 Fair22,85,151,152
IOM recommendations;
Weak inconsistent for association with
weight gain above IOM recommendations
Birthweight KQ 1 Strong 4 Good,48,98,103,106
12 Fair,55,70,75,92,93,97,99-102,104,105
54,59,68,83,90,91,94-96
9 Poor
KQ 3 Strong for association between low gains 1 Good,153
20,60,104,154-158
and low birthweight 8 Fair,
Moderate for association between high gains 1 Poor54
and high birthweight only for underweight
and normal-weight women
Low birthweight KQ 1 Strong 1 Good,106
2,4,52,70,71,75,93,107,108
9 Fair,
3 Poor54,95,109
159,160
KQ 3 Strong for association between low gains 2 Good,
2,20,55,60,127,154,161
and low birthweight for underweight and 7 Fair,
54,162,163
normal weight mothers; weak for lack of 3 Poor
association between low gain and low
birthweight for overweight and obese women
Macrosomia KQ 1 Strong 1 Good,110
9 Fair,2,4,70,77,93,108,111-113
49,59
2 Poor
KQ 3 Moderate only for overweight and obese 2 Good,110,160
women 4 Fair,2,53,55,164
165
1 Poor
Large-for- KQ 1 Strong 1 Good,116
4,58,100,105,115,118,121,122
gestational-age 8 Fair,
5 Poor54,59,61,68,120
KQ 3 Strong for association between high gains 2 Good,116,159
4,25,118,129,154
and LGA infants, and moderate for protective 5 Fair,
effect of low gains and LGA infants 1 Poor54
Small-for- KQ 1 Strong 1 Good,116
gestational-age 12 Fair,4,58,89,105,108,111,114,118,119,122-124
51,54,59,61,66,68,95
7 Poor
KQ 3 Strong for the association between low gains 3 Good,116,153,159
and SGA infants 6 fair,4,25,55,118,129,154
54
1 Poor
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

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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 normal-
weight 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.

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 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

185
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

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 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).

187
Table 44. Strength of evidence: infant outcomes of gestational weight gain

Source of Strength of
Outcome Evidence 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 KQ 1 Weak 1 good,98 4 fair,92,93,117,122 1 poor68
characteristics
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.

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 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

189
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

Source of Strength of
Outcomes evidence 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 KQ 1 Weak 1 fair135
infectious diseases
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).

190
 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

Source of Number and Quality of

Outcomes Evidence Strength of Evidence Studies
Lactation KQ 1 No evidence
KQ 3 Breastfeeding initiation: 3 fair studies (4 articles),
166-169
Moderate for gains below guidelines 3 fair
Exclusive breastfeeding duration:
Weak
Any breastfeeding duration:
Weak
Fat accrual KQ 1 No evidence
KQ 3 Weak 2 fair16,97
Short-term weight KQ 1 Weak 1 fair105
retention (11 weeks or
less)
KQ 3 Moderate 4 fair104,154,158,170
Intermediate term weight KQ 1 Moderate 1 good,144
retention (3 months to 3 3 fair,141,143,145
140
years) 1 poor
KQ 3 Moderate for weight retention for gains 2 fair,171,172,174
158,173
within or above guidelines 2 poor
Weak for weight retention for gains below
guidelines
Inter-pregnancy weight KQ 1 Weak 3 fair137-139
retention
KQ 3 Weak 1 good177
Long-term weight KQ 1 Weak 1 good,146
retention (>3 years) 1 fair (2 articles)136,142
KQ 3 Moderate 3 fair,171,174,176
Premenopausal breast KQ 1 Weak 1 fair148
cancer
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.

191
 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

192
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.

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 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.

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• 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

195
Table 47. Age, gestational weight gain, and outcomes

Citations Addressing
Outcome Effect of Age Effect of Age
82,83,87-89 82
Preterm birth 5 of Higher risks of preterm birth with increased age
1223,59,65,66,71,82-89 Among women with prepregnancy weight < 48 kg, higher risk of preterm
87
birth for women < 21 years than for women ≥ 21 years
Higher risks of preterm delivery for women < 17 and > 25 than for 20-
89
25
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 572,73,76-78 of Higher risk of primary cesarean for women > 30 years than for women
4,25,49,51,52,54,58,59,61,67-78
delivery 21 20-29 years; lower risk for women < 20 years than for women 20-29
years72
73,76
Increased risk of cesarean delivery with increased age
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
683,93,98,99,101,102 of 93,98
Birthweight Increased birthweight associated with higher age
2548,54,55,59,68,70,75,83,90-106 Lower 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 2107,109 of Higher risk of LBW for women ≥40 than for women 20-29, no significant
2,4,52,54,70,71,75,93,95,106-109
birthweight 13 association for women 30-29 years compared with women 20-29
(specifically years109
107
< 2,500 g) No significant association between LBW and adolescence
Macrosomia 470,77,93,112 of Increased risk of macrosomia with higher age93,112
2,4,49,59,70,77,93,108,110-113 70,77
12 No significant association by age
Large-for- 0 of No abstractable data
gestational- 144,54,58,59,61,68,100,105,115,116,1
18,120-122
age (LGA)
Small-for- 366,89,124 of Higher risks of IUGR for women > 25 than for women 20-2589
gestational- 204,51,54,58,59,61,66,68,89,95,105, No significant association between SGA birth and age66,124
108,111,114,116,118,119,122-124
age (SGA)
Intermediate 3141,144,145 of 5140,141,143-145 Higher PPWR with higher age141,145
postpartum No significant association between postpartum weight retention and
weight age144
retention
(PPWR)
IUGR, intrauterine growth retardation; kg, kilogram; LBW, low birthweight; PPWR, postpartum weight retention; SGA, small-
for-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

196
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

Citations Addressing
Effect of Race and
Outcome Ethnicity Effect of Race and Ethnicity
82,85 23,59,65,71,82-89
Preterm 2 of 12 Significantly higher risks of preterm birth for blacks compared with
birth 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
85
a significantly higher risk of preterm birth but not high gain
Cesarean 177 of No significant association between race/ethnicity and primiparous or
delivery 214,25,49,51,52,54,58,59,61,67-78 multiparous cesarean delivery77
Birthweight 394,102,106 of Lower birthweight for infants of black women than for infants of white
48,54,55,59,68,70,75,83,90-106
25 women; no significant association for Puerto Rican ancestry compared
with white ancestry102
94,106
No effect of race and ethnicity on birthweight
LBW 2106,109 of LBW babies more likely among black than Hispanic women106
2,4,52,54,70,71,75,93,95,106-109
13 LBW babies more likely among black women and Hispanic women than
white women109
Macrosomia 270,77 of Lower risk of macrosomia for black women than for white women70
2,4,49,59,70,77,93,108,110-113
12 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
77
women or native-born Asian non-Hispanic women
LGA 1116 of Lower risk of LGA for black women with BMI 19.8-26 or BMI > 26 than
4,54,58,59,61,68,100,105,115,116,
14 white women at the same BMI levels; no significant association for race
118,120-122
at BMI < 19.8116
SGA 366,114,116 of Lower risk of SGA for black women with BMI 19.8-26 than white women
4,51,54,58,59,61,66,68,89,95,105,
20 at the same BMI level; no significant associations for race at BMI < 19.8
108,111,114,116,118,119,122-124
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 1141 of 5140,141,143-145 Risk of weight retention higher for black and Hispanic than white
PPWR 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

197
 • 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

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

Citations Addressing
Effect of Body Mass
Outcome Index Effect of Body Mass Index
65,71,82-84,86,88,89
Preterm 8 of Higher risks of preterm birth with baseline weight lower than reference
23,59,65,71,82-89
birth 12 pregravid weight of 100-149 pounds; no increased risks with higher than
reference weight71
82
Lower risks with increased BMI
Higher risks with decreased BMI86
84,88
Higher risks with BMI less than normal range (< 19.8-26)
Higher risks with pregravid weight < 73 kg than with ≥ 85 kg89
65
Higher risks of preterm birth with obesity (pregravid BMI > 30)
No significant association between pregravid weight and gestational age
1052,67,70-73,75-78 of 70,73,76
Cesarean Higher risk of cesarean delivery with higher BMI
delivery 214,25,49,51,52,54,58,59,61,67-78 Higher risks of cesarean delivery with higher pregravid weight75
Higher risks of primary cesarean with pregravid weight higher than 100–149
71
pounds; no increased risks with lower than reference weight
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
77
multiparous cesarean delivery
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 Higher birthweight associated with higher pregravid weight48,83,91,93,96,98,101
48,54,55,59,68,70,75,83,90-106
25 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
100
No significant association between birthweight and obesity
94
No difference in birthweight by pregravid BMI groups
102
No significant association between birthweight and low pregravid BMI
LBW 82,52,70,71,93,107-109 of Higher risks of LBW with pregravid weight less than 100–149 pounds,
132,4,52,54,70,71,75,93,95,106-109 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
2,93
Lower risk of LBW with increasing pregravid weight
70
Lower risk of LBW with increasing BMI
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.

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Table 49. Pregravid body mass index, gestational weight gain, and outcomes (continued)

Citations Addressing
Outcome Effect of Body Mass Index Effect of Body Mass Index
Macrosomia 72,70,83,93,108,112,113 of 93,112
Increased risk of macrosomia with higher pregravid weight
122,4,49,59,70,77,93,108,110-113 Increased risk of macrosomia with pregravid BMI 19.8-26 compared with
70
BMI < 19.8
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
2
Higher rates of macrosomia with higher pregravid weight
Higher risk of macrosomia with pregravid overweight or obese status
77
than with normal weight
LGA 4100,105,121,122 of Higher rates of LGA with higher pregravid BMI100
4,54,58,59,61,68,100,105,115,116,
14 Higher rates of LGA with higher pregravid weight-for-height (using
118,120-122 105
Metropolitan Life Insurance tables)
122
Lower risk of LGA with lower prepregnancy weight
No significant association between pregravid BMI (per 1 kg/meter2
ncrement) and LGA121
966,89,105,108,114,119,122-124 of 89
SGA Higher risks of SGA with pregravid weight < 73 kg than with ≥ 85 kg
204,51,54,58,59,61,66,68,89,95,105, Higher risk of growth retardation with BMI < 19.8 than with BMI 19.8-26
108,111,114,116,118,119,122-124
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
119
Higher risk of SGA with pregravid BMI < 20 than with BMI ≥ 20
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
124
than with normal weight
Higher risk of IUGR with lower prepregnancy weight122
114
Lower risk of IUGR with higher pregravid weight
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.

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 • 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

Citations Addressing Effect of

Outcome Parity Effect of Parity
82,83,87-89 23,59,65,71,72,82-89
Preterm birth 5 of 12 Lower gestational age with parity ≥ 5 compared with nulliparous; no
significant association for other parities83
82,87-89
No significant association between preterm birth and parity
Cesarean 467,70,72,76 of Higher risk of cesarean delivery with nulliparity67,70
4,25,49,51,52,54,58,59,61,67-78
delivery 21 Higher risk of cesarean delivery for nulliparity compared with parity
= 1; no increased risk of cesarean with parity > 1 compared with
72
parity =1
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-for-
gestational-age; PPWR, postpartum weight retention; SGA, small for gestational age.

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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 Higher birthweight associated with higher
48,54,55,59,68,70,75,83,90-106
25 parity48,70,83,92,98,101,102,105
Low 270,109 of Lower risk of LBW with increased parity70
2,4,52,54,70,71,75,93,95,106-109
birthweight 13 Lower 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
109
than with 1 or 2
Macrosomia 370,77,112 of Higher risk of macrosomia with multiparity than with
122,4,49,59,70,77,93,108,110-113 nulliparity70,112
Higher risk of macrosomia with nulliparity compared with
parity ≥ 2, no significant risks of macrosomia with parity = 1
77
compared with parity ≥ 2
LGA 3115,116,122 of Higher risks of LGA with multiparity for all BMI categories116
4,54,58,59,61,68,100,105,115,116,118,120-122 122
14 Higher risks of LGA with multiparity
No significant association between LGA and parity115
SGA 366,89,116 of Increased risk of IUGR for parity = 1 than with parity = 2; no
4,51,54,58,59,61,66,68,89,95,105,108,111,114,116, 89
20 increased risk of IUGR for parity ≥ 3 than with parity = 2
118,119,122-124
Lower risk of SGA with multiparity for normal BMI women; no
significant association between SGA and multiparity for
underweight and overweight women116
66
Higher risk of SGA with nulliparity than multiparity
Intermediate 1141 of Lower risk of PPWR for primiparous women than multiparous
140,141,143-145
PPWR 5 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

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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.

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 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

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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

205
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.

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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.

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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 No
(DEXA)
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.

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 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 self-
report 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

209
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;

210
 • 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

211
 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.

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patterns and spontaneous preterm birth among Apr;87(4):591-6.
nonobese black and white women. Obstet
Gynecol. 1995 Jun;85(6):909-14. 160. Schieve LA, Cogswell ME, Scanlon KS. An
empiric evaluation of the Institute of
152. Schieve LA, Cogswell ME, Scanlon KS, Perry Medicine's pregnancy weight gain guidelines
G, Ferre C, Blackmore-Prince C, et al. by race. Obstet Gynecol. 1998 Jun;91(6):878-
Prepregnancy body mass index and pregnancy 84.
weight gain: associations with preterm
delivery. The NMIHS Collaborative Study 161. Strauss RS, Dietz WH. Low maternal weight
Group. Obstet Gynecol. 2000 Aug;96(2):194- gain in the second or third trimester increases
200. the risk for intrauterine growth retardation. J
Nutr. 1999 May;129(5):988-93.
153. Nielsen JN, O'Brien KO, Witter FR, Chang
SC, Mancini J, Nathanson MS, et al. High 162. Hulsey TC, Neal D, Bondo SC, Hulsey T,
gestational weight gain does not improve birth Newman R. Maternal prepregnant body mass
weight in a cohort of African American index and weight gain related to low birth
adolescents. Am J Clin Nutr. 2006 weight in South Carolina. South Med J. 2005
Jul;84(1):183-9. Apr;98(4):411-5.

154. Stevens-Simon C, McAnarney ER. 163. Prenatal weight gain and birth weight among
Adolescent pregnancy. Gestational weight Oklahoma mothers. J Okla State Med Assoc.
gain and maternal and infant outcomes. Am J 1996 Dec;89(12):435-8.
Dis Child. 1992 Nov;146(11):1359-64.
164. Rode L, Hegaard HK, Kjaergaard H, Moller
155. Hickey CA, Cliver SP, McNeal SF, Hoffman LF, Tabor A, Ottesen B. Association between
HJ, Goldenberg RL. Prenatal weight gain maternal weight gain and birth weight. Obstet
patterns and birth weight among nonobese Gynecol. 2007 Jun;109(6):1309-15.
black and white women. Obstet Gynecol.
1996 Oct;88(4 Pt 1):490-6. 165. Kabali C, Werler MM. Pre-pregnant body
mass index, weight gain and the risk of
156. Hickey CA, Cliver SP, Goldenberg RL, delivering large babies among non-diabetic
Kohatsu J, Hoffman HJ. Prenatal weight gain, mothers. Int J Gynaecol Obstet. 2007
term birth weight, and fetal growth retardation May;97(2):100-4.
among high-risk multiparous black and white
women. Obstet Gynecol. 1993 Apr;81(4):529- 166. Baker JL, Michaelsen KF, Sorensen TI,
35. Rasmussen KM. High prepregnant body mass
index is associated with early termination of
157. May R. Prepregnancy weight, inappropriate full and any breastfeeding in Danish women.
gestational weight gain, and smoking: Am J Clin Nutr. 2007 Aug;86(2):404-11.
Relationships to birth weight. Am J Hum Biol.
2007 May-Jun;19(3):305-10. 167. Li R, Jewell S, Grummer-Strawn L. Maternal
obesity and breast-feeding practices. Am J
Clin Nutr. 2003 Apr;77(4):931-6.

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168. Rasmussen KM, Hilson JA, Kjolhede CL. 177. Gunderson EP, Abrams B, Selvin S. The
Obesity as a risk factor for failure to initiate relative importance of gestational gain and
and sustain lactation. Adv Exp Med Biol. maternal characteristics associated with the
2002;503:217-22. risk of becoming overweight after pregnancy.
Int J Obes Relat Metab Disord. 2000
169. Hilson JA, Rasmussen KM, Kjolhede CL. Dec;24(12):1660-8.
Excessive weight gain during pregnancy is
associated with earlier termination of breast- 178. Larciprete G, Valensise H, Vasapollo B,
feeding among White women. J Nutr. 2006 Altomare F, Sorge R, Casalino B, et al. Body
Jan;136(1):140-6. composition during normal pregnancy:
reference ranges. Acta Diabetol. 2003 Oct;40
170. Walker LO, Timmerman GM, Sterling BS, Suppl 1:S225-32.
Kim M, Dickson P. Do low-income women
attain their pre-pregnant weight by the 6th 179. Sohlstrom A, Wahlund LO, Forsum E. Total
week of postpartum? Ethn Dis. 2004 body fat and its distribution during human
Winter;14(1):119-26. reproduction as assessed by magnetic
resonance imaging. Basic Life Sci.
171. Amorim AR, Rossner S, Neovius M, 1993;60:181-4.
Lourenco PM, Linne Y. Does excess
pregnancy weight gain constitute a major risk 180. Paxton A, Lederman SA, Heymsfield SB,
for increasing long-term BMI? Obesity (Silver Wang J, Thornton JC, Pierson RN, Jr.
Spring). 2007 May;15(5):1278-86. Anthropometric equations for studying body
fat in pregnant women. Am J Clin Nutr. 1998
172. Walker LO. Predictors of weight gain at 6 and Jan;67(1):104-10.
18 months after childbirth: a pilot study. J
Obstet Gynecol Neonat Nurs. 1996;25(1):39- 181. Jovanovic-Peterson L, Crues J, Durak E,
48. Peterson CM. Magnetic resonance imaging in
pregnancies complicated by gestational
173. Keppel KG, Taffel SM. Pregnancy-related diabetes predicts infant birthweight ratio and
weight gain and retention: implications of the neonatal morbidity. Am J Perinatol. 1993
1990 Institute of Medicine guidelines. Am J Nov;10(6):432-7.
Pub Health.83(8):1100-3.
182. Bartha JL, Marin-Segura P, Gonzalez-
174. Rooney BL, Schauberger CW. Excess Gonzalez NL, Wagner F, Aguilar-Diosdado
pregnancy weight gain and long-term obesity: M, Hervias-Vivancos B. Ultrasound
one decade later. Obstet Gynecol. 2002 evaluation of visceral fat and metabolic risk
Aug;100(2):245-52. factors during early pregnancy. Obesity
(Silver Spring). 2007 Sep;15(9):2233-9.
175. Olson CM, Strawderman MS, Hinton PS,
Pearson TA. Gestational weight gain and 183. Williamson DF, Madans J, Anda RF,
postpartum behaviors associated with weight Kleinman JC, Giovino GA, Byers T. Smoking
change from early pregnancy to 1 y cessation and severity of weight gain in a
postpartum. Int J Obes Relat Metab Disord. national cohort. N Engl J Med. 1991 Mar
2003 Jan;27(1):117-27. 14;324(11):739-45.

176. Rooney BL, Schauberger CW, Mathiason 184. Viswanathan M, Visco AG, Hartmann K,
MA. Impact of perinatal weight change on Wechter ME, Gartlehner G, Wu JM, et al.
long-term obesity and obesity-related Cesarean delivery on maternal request. Evid
illnesses. Obstet Gynecol. 2005;106(6):1349- Rep Technol Assess (Full Rep). 2006
56. 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.

222
186. Johnston CS, Christopher FS, Kandell LA. 188. Cedergren MI. Optimal gestational weight
Pregnancy weight gain in adolescents and gain for body mass index categories. Obstet
young adults. J Am Coll Nutr. 1991 Gynecol. 2007 Oct;110(4):759-64.
Jun;10(3):185-9.
189. von Elm E, Altman DG, Egger M, Pocock SJ,
187. Groth S. Are the Institute of Medicine Gotzsche PC, Vandenbroucke JP. The
recommendations for gestational weight gain Strengthening the Reporting of Observational
appropriate for adolescents? J Obstet Gynecol Studies in Epidemiology (STROBE)
Neonatal Nurs. 2007 Jan-Feb;36(1):21-7. statement: guidelines for reporting
observational studies. J Clin Epidemiol. 2008
Apr;61(4):344-9.

223
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 287919
Outcome"[MeSH]) OR "Outcome and Process Assessment (Health
Care)"[MeSH] Limits: English, Humans
#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 97
Gain/genetics"[MeSH]) Limits: English, Humans
#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: 125469
English, Humans
#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, 22784
Female, Humans
#33 Search #32 AND #12 Limits: All Adult: 19+ years, English, Female, 131
Humans
#36 Search #9 OR #10 Limits: English, Publication Date from 1990, 1453
Humans
#38 Search "United States"[MeSH] Limits: English, Publication Date from 364130
1990, Humans
#39 Search #38 AND #36 Limits: English, Publication Date from 1990, 135
Humans
#42 Search iom 682
#43 Search #42 AND #12 19
#45 Search #43 OR #39 Limits: English, Publication Date from 1990, 150
Humans
#47 Search ("Counseling"[MeSH] OR "Directive Counseling"[MeSH]) 11733
Limits: English, Publication Date from 1990, Humans
#48 Search #47 AND #12 Limits: English, Publication Date from 1990, 13
Humans
#53 Search "Body Weights and Measures/instrumentation"[MeSH] Limits: 13
English, Publication Date from 1990, Humans
#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 287919
Outcome"[MeSH]) OR "Outcome and Process Assessment (Health
Care)"[MeSH] Limits: English, Humans
#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 97

Gain/genetics"[MeSH]) Limits: English, Humans
#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: 125469

English, Humans
#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, 22784
Female, Humans
#33 Search #32 AND #12 Limits: All Adult: 19+ years, English, Female, 131
Humans
#36 Search #9 OR #10 Limits: English, Publication Date from 1990, 1453
Humans
#38 Search "United States"[MeSH] Limits: English, Publication Date from 364130
1990, Humans
#39 Search #38 AND #36 Limits: English, Publication Date from 1990, 135
Humans
#42 Search iom 682
#43 Search #42 AND #12 19
#45 Search #43 OR #39 Limits: English, Publication Date from 1990, 150
Humans

KQ4: Recommendations

#47 Search ("Counseling"[MeSH] OR "Directive Counseling"[MeSH]) 11733

Limits: English, Publication Date from 1990, Humans
#48 Search #47 AND #12 Limits: English, Publication Date from 1990, 13
Humans

KQ5: Tools

#53 Search "Body Weights and Measures/instrumentation"[MeSH] Limits: 13

English, Publication Date from 1990, Humans
#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 1369412
OR circumferences OR BIA OR "body impedance analyzer" OR
ultrasound OR DEXA OR UWW OR "underwater weighing" OR "BOD
POD" OR CT OR MRI
#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, 24044
All Adult: 19+ years
#6 Search BMI OR "body mass index" OR skinfolds OR circumferences OR 247723
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
#7 Search #5 AND #6 Limits: Publication Date from 1990, Humans, English, 15336
All Adult: 19+ years
________________________________________________________________________
#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]) 148
Limits: Publication Date from 1990, Humans, English, All Adult: 19+ years
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, 98
English
#5 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Outcome and 395351
Process Assessment (Health Care)"[MeSH] OR "Pregnancy
Outcome"[MeSH]) OR "Reproductive History"[MeSH] OR "birth
outcomes" OR "infant health outcomes" OR "maternal health outcomes"
#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] 42873
AND"Anthropometry"[MeSH]
#10 Search #4 AND #9 34
#11 Search ("Pregnancy/physiology"[Majr]) AND ("Weight Gain"[Mesh]) 14
AND ("Adipose Tissue/anatomy and histology"[Mesh])
#12 Search ("Pregnancy/physiology"[Majr]) AND ("Weight Gain"[Mesh]) 0
AND ("Adipose Tissue/anatomy and histology"[Mesh]) Limits: added to
PubMed in the last 1 year, Humans, English

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

Appendix B. Sample Data Collection Forms

B-1
 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 Cannot
Yes No Determine
to editor, reviews, etc.)
2. Study published between January 1990 and Yes No Cannot
February 2007 Determine

3. Study published in English Cannot

Yes No Determine
4. Is this study located in a developed nation?
(US, Canada, Western Europe, Japan, New Cannot
Yes No Determine
Zealand, Australia)
5. Eligible Study type Yes No
Cannot
(Include RCTs, cohorts with comparisons, and Determine
case-controls with N40, case-series with
N100)
a. ___RCT (N =_____)
b. ___Cohorts with comparison (N =_____)
c. ___Case-control (N =_____)
d. ___Case series (N =_____)

6. Applies to research topic

(if not select one of the following
Cannot
reasons): Yes No Determine
a. ___Basic science
b. ___ Not “maternal weight gain”

No
7. Entirely or mostly singleton births (100% Cannot
Yes Determine
multi-
fetal)
Retain for (include meta-analyses and systematic reviews here as appropriate):
_____BACKGROUND/DISCUSSION
_____REVIEW OF REFERENCES
_____Other
COMMENTS:
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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: Submit Data
Anemia, Neonatal/blood/ prevention & control
1. Original research (no review articles, editorials, letters to the editor or commentaries)?

Increase Font Size n Yes

i
j
k
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Decrease Font Size j No
k
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n
n Cannot determine
j
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Abstract: Clear Selection
OBJECTIVE: Erythropoietin (EPO) is commonly used in 2. Study published after January 1, 1990?
very low birth weight neonates to minimize blood
transfusions during hospitalization. Data are limited i Yes
j
k
l
m
n
comparing the use of EPO along with a restricted
transfusion schedule versus a restricted transfusion j No
k
l
m
n
schedule alone. We compared the effects of a restricted
transfusion schedule with EPO versus a restricted j Cannot determine
k
l
m
n
transfusion schedule alone during two consecutive 6- Clear Selection
month periods. METHODS: In period I, infants born at <30
3. Study published in English?
weeks gestational age (GA) or <1,500 g birth weight (BW)
were treated prophylactically for six weeks with EPO 1,000 j Yes
k
l
m
n
U/kg/wk in three divided doses and blood transfusions
were given using a restricted transfusion schedule. This n No
j
k
l
m
was the called the EPO Group. In period II, a restricted
transfusion schedule was utilized, but EPO was not i Cannot determine
j
k
l
m
n
administered. This constituted the No EPO Group. No
Clear Selection
other changes in clinical practice were introduced in either
period. RESULTS: There were 30 neonates in the EPO 4. Study conducted in a developed nation? (for example- US, Canada, western Europe,
Group and 20 in the No EPO Group. There were no Japan, New Zealand, Australia)
significant differences in sex, race, mean birth weight
(1,074 +/- 283 versus 965 +/- 330 g), mean gestational age
j Yes
k
l
m
n
(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
j No- if not then where?
k
l
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n
(48.2% +/- 6.05 versus 48.6% +/- 6.31) at admission.
i Cannot determine
j
k
l
m
n
There were no significant differences in the total number of
transfusions between the two periods. In the EPO Group, Clear Selection
8/30 patients received 27 transfusions. Six transfusions 5. Study design is one of the following:
violated guidelines based on hematocrit level. EPO was
discontinued in three infants secondary to treatment- j RCT
k
l
m
n
related neutropenia. There were two deaths unassociated
with EPO treatment. Excluding deaths, 6 patients received i Cohort studies N => 40
j
k
l
m
n
16 transfusions. In the No EPO Group, 8/20 patients
received 13 transfusions. Two transfusions violated j Case control with N => 40
k
l
m
n
guidelines based on hematocrit. There were three deaths
and one patient transfer. Excluding these four patients, 6 j Case series N => 100
k
l
m
n
infants received 11 transfusions (P < or = 1.) Among
survivors, there were no significant differences in mean
j Cross sectional N => 100
k
l
m
n
total length of stay (49.3 +/- 22.7 versus 53.2 +/- 26.4 d),
j None of the above- so exclude
k
l
m
n
mean discharge weight (2,144 +/- 405 versus 2,358 +/- 458
g), or average weight gain/d (20.7 +/ - 5.44 versus 22.6 +/- j None of the above- but include (please provide
k
l
m
n
6.81 g), between the two groups respectively, nor were explanation)
there significant differences when all babies were included
in the analysis. There was a significant difference in mean j Cannot determine
k
l
m
n
hematocrit at discharge, respectively, (38.3% +/- 6.84
31 4% +/ 6 26 P 0 003) i i Clear Selection
6. Entirely or mostly singleton births?

https://srs.trialstat.com/d2d/ul1/review.asp?mode=reviewMode&articleid=1&level=1 12/4/2007
SRS Form Page 2 of 2

j Yes
k
l
m
n
n No (100% multi-fetal)
j
k
l
m
i Cannot determine
j
k
l
m
n
Clear Selection
7. Applies to research topic of maternal weight gain or the measurement body fat?

j Yes
k
l
m
n
i No- not maternal weight gain or the measurement of
j
k
l
m
n
body fat

n No - "basic science"
j
k
l
m
j No - other (please elucidate)
k
l
m
n
j Cannot determine
k
l
m
n
Clear Selection
8. Article should be marked and saved for background but not abstracted (This question
is optional).

n Yes
j
k
l
m
i No
j
k
l
m
n
n Cannot determine
j
k
l
m
Clear Selection
9. Population

j 100% healthy populations or mix of healthy

k
l
m
n
populations and "nonhealthy" populations

j 100% populations with health conditions (ie. drug

k
l
m
n
abuse or diabetes) Please define -
Clear Selection
Submit Data
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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?

j Yes
k
l
m
n
j No- so exclude
k
l
m
n
Clear Selection
2. Should the article be excluded for any of the following general reasons?

c Article should be excluded because (pick at least one of the following options)
d
e
f
g
c n < 40 for comparisons including cohort studies
d
e
f
g
c n < 100 for case -series
d
e
f
g
c Not published in english
d
e
f
g
c Wrong publication type (e.g. letter, commentary or editorial)
d
e
f
g
c Wrong design - please explain
d
e
f
g
c Includes only a population w/ a pre-existing condition - please list condition
d
e
f
g
c 100% multi-fetal
d
e
f
g
c Published before 1990
d
e
f
g
c Study not conducted in a developed nation? (Please provide country name)
d
e
f
g
g Study reported as an abstract only
c
d
e
f
c Not related to key questions
d
e
f
g
c Other reason- please explain briefly
d
e
f
g
c None of the above- should be included!
d
e
f
g
3. Regardless of inclusion/exclusion status, article should be retained for background.

j Yes
k
l
m
n
n No
j
k
l
m
Clear Selection
4. Which of the following key questions are addressed by the article

c 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
d
e
f
g
outcomes, and (3) maternal health outcomes?

c KQ2 What are the confounders and effect modifiers in examining the association between maternal weight gain (overall and patterns) and birth
d
e
f
g
outcomes?

c 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
d
e
f
g
pregnancy contribute to ante-partum or post-partum complications, or longer-term maternal and fetal complications?

c KQ4 What are the harms or benefits of offering the same weight gain recommendations to all pregnant women, irrespective of age and body weight
d
e
f
g
considerations (e.g., pregravid weight, actual body weight at a particular time point, or optimal body weight)?

c KQ5 What are the anthropometric tools for determining adiposity and their appropriateness for the pregnancy state?
d
e
f
g
g None of the above so exclude!
c
d
e
f
5. If study addresses KQ 1 -4 it must include pre-pregnancy weight or BMI measures.

j Pre-pregnancy weight or BMI is not in article so exclude

k
l
m
n
j Include!
k
l
m
n
Clear Selection

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SRS Form Page 2 of 2
6.
If article addresses KQ 3 it must includes the IOM guidelines.

j No IOM guidelines so exclude

k
l
m
n
j Include!
k
l
m
n
Clear Selection
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SRS Form Page 1 of 10
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

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1. First author et. al, year

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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.

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3. Source of funding to conduct study:

c Pharmaceutical company or other commercial source- please list name.

d
e
f
g
g Government or non-profit organization- please list name.
c
d
e
f
c Not reported
d
e
f
g
4. Research objective (Please be brief and concise):

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5. Which of the following key questions are addressed by the article

c 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
d
e
f
g
g KQ2 What are the confounders and effect modifiers in examining the association between maternal weight gain (overall and patterns) and birth outcom
c
d
e
f
c 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
d
e
f
g
maternal and fetal complications?

c 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
d
e
f
g
or optimal body weight)?

c KQ5 What are the anthropometric tools for determining adiposity and their appropriateness for the pregnancy state?
d
e
f
g
c None of the above so exclude!
d
e
f
g
6. Article reports on an observational study, check the applicable box -

j Case series
k
l
m
n
j Cohort
k
l
m
n
j Case-control
k
l
m
n

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j Cross-sectional
k
l
m
n
n Other observational
j
k
l
m
j No, not an observational study
k
l
m
n
Clear Selection
7. Observational study is-

j Prospective
k
l
m
n
j Retrospective
k
l
m
n
j Combination, please explain
k
l
m
n
n Other, please explain!
j
k
l
m
Clear Selection
8. Article reports on a RCT or meta-analysis, check appropiate box.

j RCT
k
l
m
n
j Meta-analysis
k
l
m
n
j Other controlled study design, please explain
k
l
m
n
j No, it is not a controlled trial
k
l
m
n
Clear Selection
9. Overall study n =

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10. Duration of study?

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11. How was pregravid weight collected?

c Self-reported
d
e
f
g
g Measured by study investigators
c
d
e
f
c Routine pre-natal care
d
e
f
g
c Other- please explain!
d
e
f
g
c Not reported
d
e
f
g
12. How was pregravid height collected?

c Self-reported
d
e
f
g
c Measured by study investigators
d
e
f
g
c Routine pre-natal care
d
e
f
g
c Other- please explain!
d
e
f
g
c Not reported
d
e
f
g
13. Was BMI imputed?

j Yes
k
l
m
n
j No
k
l
m
n
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14. How was BMI categorized?

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c Continuous
d
e
f
g
c IOM guidelines
d
e
f
g
c WHO International Taskforce
d
e
f
g
g Other- please define
c
d
e
f
c Not reported
d
e
f
g
15. Are any other anthrometric measures collected?

n Yes
j
k
l
m
j No
k
l
m
n
Clear Selection
16. How were weight gain measurements categorized?

g Continuous
c
d
e
f
c Quartiles
d
e
f
g
g According to IOM
c
d
e
f
c Other - please define
d
e
f
g
17. How were weight gain measurements collected?

c Self-reported
d
e
f
g
c Collected by study investigators
d
e
f
g
c Routine pre-natal care or maternity records
d
e
f
g
g Other - define or explain
c
d
e
f
18. How was total weight gain ascertained?

c Self-reported
d
e
f
g
c Based on last clinically measured weight prior to delivery
d
e
f
g
c Other- please explain!
d
e
f
g
c Not reported
d
e
f
g
19. Inclusion criteria

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20. Exclusion criteria

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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

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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?

c Self-reported
d
e
f
g
c Measured by study investigators
d
e
f
g
c Routine care
d
e
f
g
c Other- please explain!
d
e
f
g
g Not reported
c
d
e
f
39. What type of statistical analysis was used? Check all that apply.

c Bivariate
d
e
f
g
c Multivariate
d
e
f
g
c Risk ratios
d
e
f
g
c Odds ratios
d
e
f
g
c ANOVA
d
e
f
g
c Other- please explain
d
e
f
g
40. If relevant, define comparison or reference group.

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Outcomes- primarily bivariate

Group 1 Group 2 Group 3 G
41. Groups - if only one group please put in
first column. With intervention include p-
values 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!

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50. Additional infant outcomes of interest - please be brief!

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51. Maternal confounders accounted for in analysis:

c Age
d
e
f
g
c Race
d
e
f
g
c Parity
d
e
f
g
c Pre-gravid BMI
d
e
f
g
c GDM
d
e
f
g
c Pregnancy induced hypertension
d
e
f
g
c Pre-eclampsia
d
e
f
g
c Eclampsia
d
e
f
g
c C-section
d
e
f
g
c Post-partum weight retntion
d
e
f
g
g Lactation/ Breast feeding (Which one?)
c
d
e
f
c Obesity (How defined or categorized?)
d
e
f
g
c Type 1 Diabetes or pre-existing Type 2 Diabetes
d
e
f
g
g CVD
c
d
e
f
c Cancer
d
e
f
g
g Others- please list
c
d
e
f
c Smoking
d
e
f
g
c Pre-existing hypertension
d
e
f
g
52. Infant and child confounders accounted for in analysis:

c Pre-term birth
d
e
f
g
c Gestational age
d
e
f
g
c Birth weight
d
e
f
g
c SGA
d
e
f
g
c LGA
d
e
f
g
c Birth length
d
e
f
g
c Child weight/height
d
e
f
g
c Childhood obesity
d
e
f
g

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c Childhood diabetes (Type 1)

d
e
f
g
c Child with CVD
d
e
f
g
c Child's blood pressure
d
e
f
g
g Others- please list
c
d
e
f
53. More outcomes- mostly multivariate!

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Category or confounder Group 1 Group 2 Group 3 G

54. Groups - if
only one
group please
put in second
column
following
confounder. If c
d
e
f
g
result is an
odds
ratio (95% CI)
should be
included.
55. # in group
(n): c
d
e
f
g
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 c
d
e
f
g
following
characteristic
column. If
result is an
odds
ratio (95% CI)

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should be
included.
68. # in group
(n): c
d
e
f
g
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?

j Yes - why?
k
l
m
n
j No- why not?
k
l
m
n
j Can't tell...
k
l
m
n
Clear Selection

Quality Review
81. Randomization adequate?

j Yes
k
l
m
n
j No
k
l
m
n
j Not randomized
k
l
m
n
j Method not reported
k
l
m
n
Clear Selection
82. Allocation concealment adequate?

j Yes
k
l
m
n
j No
k
l
m
n
j Not randomized
k
l
m
n
j Method not reported
k
l
m
n
Clear Selection
83. Groups similar at baseline?

j Yes
k
l
m
n
j No
k
l
m
n

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Clear Selection
84. Outcome assessors masked?

j Yes
k
l
m
n
j No
k
l
m
n
j Yes, but method not described
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
85. Care provider masked?

j Yes
k
l
m
n
j No
k
l
m
n
j Yes, but method not described
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
86. Patient masked?

j Yes
k
l
m
n
j No
k
l
m
n
j Yes, but method not described
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
87. What was lost to follow-up (%)?

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88. How many dropped out (%)?

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89. Was the statistical analysis based on intention-to-treat (ITT)?

j Yes
k
l
m
n
j No
k
l
m
n
j Cannot tell
k
l
m
n
Clear Selection
90. Were there any post-randomization exclusions?

j Yes (how many?)

k
l
m
n
j No
k
l
m
n
j Cannot tell
k
l
m
n
Clear Selection
91. Quality rating for efficacy/effectiveness

c Good
d
e
f
g
g Fair
c
d
e
f
c Poor
d
e
f
g
Why?

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92. Were both groups selected from the same source population?

j Yes
k
l
m
n
j No
k
l
m
n
j Yes, but method not described
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
93. Did both groups have the same risk of having the outcome of interest at baseline?

j Yes
k
l
m
n
n No
j
k
l
m
j Not reported
k
l
m
n
Clear Selection
94. Were subjects in both groups recruited over the same time period?

j Yes
k
l
m
n
j No
k
l
m
n
j Yes, but method not described
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
95. Was there any obvious selection bias?

j Yes
k
l
m
n
j No
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
96. Were ascertainment methods adequate and equally applied to both groups?

j Yes
k
l
m
n
j No
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
97. Was an attempt made to blind the outcome assessors?

j Yes
k
l
m
n
j No
k
l
m
n
j Yes, but method not described
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
98. Was the time of follow-up equal in both groups?

j Yes
k
l
m
n
j No
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
99. What was lost to follow-up (%)?

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100. How many dropped out (%)?

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101. Did the statistical analysis consider potential confounders or adjust for different lengths of follow-up?

j Yes
k
l
m
n
n No
j
k
l
m
j Yes, but method not described
k
l
m
n
n Not reported
j
k
l
m
Clear Selection
102. Was the length of follow-up adequate to assess the outcome of interest?

j Yes
k
l
m
n
j No
k
l
m
n
j Not reported
k
l
m
n
Clear Selection
103. Quality rating for observational studies

c Good
d
e
f
g
c Fair
d
e
f
g
c Poor
d
e
f
g
Why?

104. Is the principle focus of this article maternal weight gain and associated outcomes

c Yes
d
e
f
g

g No then limit abstraction to MWG and associated outcomes and the confounders and effect modifiers
c
d
e
f
105. Time frame?

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Evidence Table Template
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
White
Country and setting: Total Study N: Pregravid BMI:
Black
Enrollment period: Group Description: Age (mean, yrs):
Hispanic
Group N: Parity:
Funding: Asian/Pacific Islander
Inclusion criteria:
Study Objective: Other
Exclusion criteria:
Time frame: x Smoking,%:
Duration of the study: Diabetes mellitus,%:
Hypertension,%:
Additional characteristics:
Evidence Table x
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
Total weight gain: Gestational Sample
diabetes, %: Groups: selection:
Categorized:
Cesarean Results: Definition of
Collected from: delivery,%: maternal
Maternal confounders and effect weight gain:
Ascertained by: Instrumental modifiers accounted for in analysis:
x delivery,%: Definition of
Infant and child confounders and effect outcomes:
Episiotomy,%: modifiers accounted for in analysis:
Source of
Other maternal information on
outcomes: exposure,
Other infant outcomes, and
outcomes: 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 case-
control 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 follow-
up 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

5
(excellent,
0 (poor, not clearly
defined 1 2 3 4 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 13

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22. Wilt TJ, Lederle FA, MacDonald R, Jonk YC, Rector TS, Kane RL. Appendix D.
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Quality Rating Form: maternal weight gain 14

Appendix C. Evidence Tables
Glossary
adj adjusted MWG maternal weight gain
AGA appropriate for gestational age N number
AOR adjusted odds ratio? NA not applicable
bf body fat NICU neonatal intensive care unit
BF breast feeding NIH National Institutes of Health
bp blood pressure NIMU neonatal intensive medical unit
BMI body mass index NR not reported
CI Confidence interval NVSD normal spontaneous vaginal delivery
CPD cardiopulmonary disease OGTT oral glucose tolerance test
CPS Collaborative Perinatal Study p P-value
ECW extra cellular water PE pulmonary embolism
g gram pg pregnancy?
ga gestational age PIH pregnancy induced hypertension
GDM gestational diabetes PNC prenatal care
gest gestational PPWR postpartum weight reduction
GWG gestational weigh gain Prepg prepregnancy
HDL high density lipoprotein PTB preterm birth
HDP hypertensive disorders of pregnancy RR relative risk
hg hemoglobin SD standard deviation
ICD-9-CM International Classification of Diseases, SE standard error
Ninth Revision, Clinical Modification SGA small for gestational age
IGT impaired glucose tolerance TBW total body water
IGUR intrauterine growth retardartion TSF triceps skinfold
IOM Institute of Medicine UCSF University of California at San Francisco
IUGR intrauterine growth restriction US United States
IVF in vitro fertilization VBAC vaginal birth after cesarean
kg kilogram VLBW very low birth weight
kg/wk kilogram per week WHO World Health Organization
lb pound WHR waist to hip ratio
LBW low birth weight WIC Women’s, Infant, and Children program
LGA large for gestational age
MCH maternal and child health

C-1
Evidence Table 1. Gestational weight gain and discomforts of pregnancy
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Atwal et al., 2006 • Cohort • Booking weight White
• Retrospective NR
Country and setting: Pregravid BMI:
United Kingdom, hospital Total Study N: NR Black
309 NR
Enrollment period: Imputed:
4-month period (1 March Group Description: • No Hispanic
2000 to 30 June 2000 NR NR
inclusive) Categorized:
Group N: NR Asian/Pacific Islander
Funding: NR NR
NR Age (mean, yrs):
Inclusion criteria: NR Other
Study Objective: • Primiparae who NR
To observe prevalence of Parity:
delivered after 28 Smoking,%:
striae gravidarum in NR
weeks of gestational NR
primiparae and identify age and had no
independent associated previous pregnancies Diabetes mellitus,%:
risk factors lasting more than 12 NR
Time frame: weeks
Hypertension,%:
4-month period (1 March Exclusion criteria: NR
2000 to 30 June 2000 • Multiple births
inclusive) Additional characteristics:
• Non-white women
NR
Duration of the study:
Duration of pregnancy

C-2
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Striae gravidum (%) Good
Total weight gain: Gestational Groups: Sample
G1: Odds ratio 1.08 diabetes, %: G1: MWG < 15 kg selection:
(95% CI 1.02- NR G2: MWG > 15 kg Poor
1.14) P =
0.0121 Cesarean Results: Definition of
delivery,%: G1: 47 maternal
Categorized: NR G2: 60 weight gain:
• Not clear Poor
Instrumental Maternal confounders and effect
Collected from: delivery,%: modifiers accounted for in analysis: Definition of
• Routine pre- NR NR outcomes:
natal care or Fair
Episiotomy,%: Infant and child confounders and effect
maternity
NR modifiers accounted for in analysis: Source of
records
NR information on
Other maternal exposure,
Ascertained by:
outcomes: outcomes, and
• Based on last
• Women with confounders:
clinically
largest weight Poor
measured
gain had
weight prior to Followup:
greatest
delivery Fair
incidence of
striae
Analysis
Other infant comparability:
outcomes: Fair
NR
Analysis of
outcomes:
Fair
Interpretation:
Poor
Sum of
Good/Fair/Poo
r:
1 Good, 4 Fair,
4 Poor
Final Quality
Score:
Poor

C-3
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Madlon-Kay DJ, 1993 • Cohort • NR White
• Retrospective G1: 98%
Country and setting: G2: NR
G2: 61.7kg
USA, hospital Total Study N: G3: 58.5kg
48 Black
Enrollment Period: NR
Pregravid BMI:
NR Group Description: NR
G1: All Hispanic
Funding: NR
G2: Abdominal Striae Imputed:
Grant from American
Present • No
Academy of Family Asian/Pacific Islander
G3: Abdominal Striae
Physicians and Ramsey Categorized: NR
Absent
Foundation • NR Other
Group N:
Study Objective: Age (mean, yrs): NR
G1: 48
To study factors G1: 26.7
G2: 22 Smoking,%:
associated with formation G2: 25 P < 0.05
G3: 26 NR
of striae gravidarum and G3: 28 P < 0.05
measures used by women Inclusion criteria: Diabetes mellitus,%:
to prevent them • Nulliparous women at Parity: NR
34-36 weeks’ NR
Time frame: Hypertension,%:
NR gestational age who
NR
planned to give birth
Duration of the study: at either of 2 study Additional characteristics:
From gestational weeks hospitals NR
34 to 36 until birth
Exclusion criteria:
• NR

C-4
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: NR Abdominal striae (kg) Good
Total weight gain: G2: NR
G1: 17.6kg P < 0.05 Groups: Sample
G2: 14kg P < 0.05 Gestational G1: Abdominal Striae Present selection:
diabetes, %: G2: Abdominal Striae Absent Poor
Categorized: NR
• Continuous Results: Definition of
Cesarean delivery, Pregnancy weight gain in abdominal striae maternal weight
Collected from: %: groups (kg) gain:
• Not stated NR G1: 14.9 Poor
Ascertained by: G2: 13.0
Instrumental P<0.05 Definition of
• Hospital charts delivery, %: outcomes:
NR Maternal confounders and effect modifiers Poor
accounted for in analysis:
Episiotomy, %: NA Source of
NR information on
Infant and child confounders and effect exposure,
Other maternal modifiers accounted for in analysis: outcomes, and
outcomes: NA confounders:
NR Poor
Other infant Followup:
outcomes: Fair
NR
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-5
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Marrero et al., 1992 • Cross-sectional • Self-reported White
• Retrospective G1: 65%
Country and setting: Pregravid BMI: G2: NR
UK, teaching hospital Total Study N:
Imputed: Black
607
Enrollment Period: • No G1: 14%
NR Group Description: G2: NR
G1: Total Categorized:
Funding: • Continuous Hispanic
G2: NR
NR NR
Group N: Age (mean, yrs):
Study Objective: G1: 29.5 Asian/Pacific Islander
G1: 607
To study prevalence and G2: NR G1: 16%
G2: NR
severity of reflux G2: NR
symptoms in pregnancy Inclusion criteria: Parity:

Time frame: • Consecutive patients % primigravid Other

in antenatal clinic G1: 37.2 NR
NR G2: NR
Exclusion criteria: Smoking,%:
Duration of the study: NR
91 were in first trimester, • incomplete survey
274 in second and 228 in responses Diabetes mellitus,%:
third NR
Hypertension,%:
NR
Additional characteristics:
NR

C-6
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Heartburn Good
Total weight gain:
Gestational Groups: Sample
Categorized: diabetes, %: NA, continuous weight gain measure selection:
• Continuous NR Poor
Results:
Collected from: Cesarean delivery, Weight gain in pregnancy not risk factor for Definition of
• Says record but %: heartburn in pregnancy maternal weight
not clearly stated NR gain:
Ascertained by: Poor
Instrumental Maternal confounders and effect modifiers
• Weight gain in delivery, %: accounted for in analysis: Definition of
this paper was NR • Age outcomes:
up until time of • Race Fair
questionnaire Episiotomy, %:
NR • Parity Source of
• NR • Pre-gravid BMI information on
Other maternal exposure,
outcomes: Infant and child confounders and effect
modifiers accounted for in analysis: outcomes, and
BMI before confounders:
pregnancy and • Gestational age
Poor
weight gain in
pregnancy were not Followup:
found to be risk Fair
factors for pregnancy
heartburn Analysis
comparability:
Other infant Fair
outcomes:
NR Analysis of
outcomes:
Fair
Interpretation:
Poor
Sum of
Good/Fair/Poor:
1 Good, 4 Fair, 4
Poor
Final Quality
Score:
Poor

C-7
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rodriguez et al., 2001 • Cohort • Routine pre-natal care White
• Prospective recorded at first prenatal NR
Country and setting:
care visit
Sweden, prenatal health Total Study N: Black
care centers 476 nulliparous Pregravid BMI: NR
Scandanavian women
Enrollment Period: Imputed: Hispanic
NR Group Description: • No NR
Funding: Group N: Categorized: Asian/Pacific Islander
Swedish Council of • Underweight BMI < 20; NR
Planning and Inclusion criteria:
normal weight BMI 20- Other
Coordination of Research • Nulliparous 24.99; overweight BMI >
and Knut and Alice • Scandinavian origin NR
25
Wallenberg Foundation • Solicited by midwives Smoking,%:
from 5 prenatal health Age (mean, yrs): NR
Study Objective: care centers (91% of NR
To document prevalence women agreed to Diabetes mellitus,%:
and frequency of 27 Parity: NR
participate and
pregnancy symptoms and NR
provided information
to sysematically Hypertension,%:
on at least one
investigate, cross NR
measure)
sectionally and Additional characteristics:
prospectively, effect of Exclusion criteria:
NR
psychosocial factors on • NA
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

C-8
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 3.457 (0.633) Pearson correlation coefficient (r) for Fair
Total weight gain: G2: NR prevalence of 27 pregnancy symptoms for
continuous weight gain measure Sample
Categorized: Gestational selection:
• Continuous Pearson correlation coefficient (r) for
diabetes, %: frequency of 27 pregnancy symptoms for Poor
Collected from: NR continuous weight gain measure Definition of
• Routine pre-natal Cesarean delivery, maternal weight
care or maternity %: Groups:
G1: Week 10 gain:
records NR Fair
G2: Week 12
Ascertained by: Instrumental G3: Week 20 Definition of
• Based on last delivery, %: G4: Week 28 outcomes:
clinically NR G5: Week 32 Good
measured weight G6: Week 36
prior to delivery: Episiotomy, %: Source of
weight at delivery NR Results information on
minus prepreg Prevalence exposure,
Other maternal G1: 0.05 outcomes, and
weight outcomes: G2: 0.03 confounders:
• Pregnancy G3: 0.13 (P < 0.05) Fair
symptoms: G4: 0.16 (P < 0.01)
urogenital, G5: 0.18 (P < 0.01) Followup:
gastrointestinal, G6: 0.19 (P < 0.001) Fair
musculoskeletal,
Analysis
miscellaneous Frequency comparability:
pregnancy G1: 0.09 Fair
symptoms G2: 0.04
G3: 0.11 (P < 0.05) Analysis of
Other infant
G4: 0.16 (P < 0.01) outcomes:
outcomes:
G5: 0.19 (P < 0.01) Fair
NR
G6: 0.24 (P < 0.001)
Interpretation:
Maternal confounders and effect modifiers Fair
accounted for in analysis:
Sum of
NR
Good/Fair/Poor:
Infant and child confounders and effect 1 Good, 7 Fair, 1
modifiers accounted for in analysis: Poor
NR
Final Quality
Score:
Fair

C-9
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Tulman et al., 1998 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
USA, obstetric and nurse- Total Study N: G1: 22.82 (SD 3.49) Black
midwifery practices 222 G2: NR NR
Enrollment Period: Group Description: Imputed: Hispanic
NR G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
NR Group N: • IOM guidelinesno obese NR
G1: 222 category - just > 26
Study Objective: Other
G2: NR
To examine relationship of Age (mean, yrs): NR
prepregnancy weight and Inclusion criteria: NR
pregnancy weight gain to • Smoking,%:
Englishspeaking, NR
functional status, physical married, pregnant Parity:
symptoms, and physical women at low risk NR Diabetes mellitus,%:
energy who were 18 years of NR
Time frame: age and older.
Hypertension,%:
NR • Participants could
NR
have no underlying
Duration of the study: medical problems Additional characteristics:
Recruited from practices (e.g., diabetes, NR
and had home visits chronic renal or
during pregnancy-thus cardiac disease) or
during pregnancy through preexisting factors in
delivery 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

C-10
Evidence Table 1. Gestational weight gain and discomforts of pregnancy (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 222 NR Inventory of Functional Status – Good
G2: NR Anteparturn Period, 1-3 point
Gestational diabetes, %: scale (mean, SD) Sample selection:
Total weight gain: NR Fair
G1: 13.93 kg (SD
4.63) Cesarean delivery, %: Groups: Definition of maternal weight
G2: NR NR G1: Excess weight gain gain:
G2: Weight gain within Fair
Categorized: Instrumental delivery,
%: recommended range Definition of outcomes:
• Continuous
NR Results: Good
Collected from: G1: 2.3
Episiotomy, %: Source of information on
• Collected by G2: 2.43
NR exposure, outcomes, and
study P < 0.014 confounders:
investigators Other maternal
Maternal confounders and Fair
• Percentage outcomes:
weight gain • There was a effect modifiers accounted Followup:
during pregnancy statistically significant for in analysis: Good
difference in NA
Ascertained by: Analysis comparability:
functional status Infant and child confounders Poor
• Based on last between women
clinically and effect modifiers
whose total weight accounted for in analysis: Analysis of outcomes:
measured weight gain for pregnancy NA Fair
prior to delivery: was more than
difference in recommended Interpretation:
pounds between amount based on Poor
prepg weight and prepregnancy BMI
weight at time of Sum of Good/Fair/Poor:
(n = 62) and those 3 Good, 4 Fair, 2 Poor
data collection who gained within
• Percentage recommended range Final Quality Score:
weight gain (n = 160), t(220) = Fair
during pregnancy 2.47, P = .014.
was calculatged • Women who gained
as weight gain in an excessive amount
pounds divided of weight had a lower
by prepregnancy third trimester level of
weight 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

C-11
Evidence Table 2. Gestational weight gain and hyperemesis
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Dodds et al., 2006 • Cohort • From records in database White
• Retrospective not mentioned whether it NR
Country and setting:
was self reported or not
Cananda, perinatal Total Study N: Black
G1: < 60kg: 45.4%
database 156,091 NR
60-69: 25.3%
Enrollment Period: Group Description: 70-79: 13.9% Hispanic
1988-2002 G1: Antepartum ≥ 80: 15.3% NR
admission for G2: < 60kg: 42.8%
Funding: 60-69: 27.6% Asian/Pacific Islander
hyperemesis
NR 70-79: 15.1% NR
G2: No antepartum
Study Objective: admission for ≥ 80: 14.5% Other
To evaluate maternal and hyperemesis Pregravid BMI: NR
neonatal outcomes
Group N: Imputed: Smoking,%:
among women with
G1: 1,270 • No G1: 21.4
hyperemesis during
G2: 154,821 G2: 30.2
pregnancy
Categorized:
Inclusion criteria: Diabetes mellitus,%:
Time frame: • NR
1988-2002 • Singleton NR
• 20 weeks or more Age (mean, yrs):
Duration of the study: Hypertension,%:
gestation G1: < 20 years: 12.1%
Prenatal to neonatal NR
• ≥ 500g at birth 20-29: 64.8%
• Hyperemetic 30-34: 17.8% Additional characteristics:
pregnancies defined 35-49: 5.4% NR
as those with 1 or G2: < 20 years: 8.0%
more antepartum 20-29: 56.7%
admissions for 30-34: 25.5%
hyperemesis first of 35-49: 9.8%
which occurred Parity:
before 24 completed G1: % nulliparous: 48.7
weeks gestation G2: 44.3
Exclusion criteria:
NA

C-12
Evidence Table 2. Gestational weight gain and hyperemesis (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Antepartum admission for hyperemesis (Kg) Good
Total weight gain:
Gestational Groups: Sample selection:
Categorized: diabetes, %: G1: No antepartum admission for Fair
• < 7kg and ≥ 7kf NR hyperemesis
Collected from: G2: Antepartum admission for hyperemesis Definition of
Cesarean delivery, maternal weight
• Routine pre-natal %: Results gain:
care or maternity NR Adjusted RR for pregnancy weight gain < 7kg Poor
records G1: 1.0 (ref)
Instrumental G2: 2.1 (1.8-2.5) Definition of
Ascertained by: delivery, %: outcomes:
• Based on last NR Maternal confounders and effect Fair
clinically modifiers accounted for in analysis:
measured weight Episiotomy, %: • Age
Source of
prior to delivery: NR information on
• Maternal prepregnancy weight
not specifically exposure,
Other maternal • Time period outcomes, and
stated by authors outcomes:
• Smoking confounders:
NA Poor
Infant and child confounders and effect
Other infant modifiers accounted for in analysis: Followup:
outcomes: NR Fair
NA
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-13
Evidence Table 2. Gestational weight gain and hyperemesis (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Dodds et al., 2006
(continued)

C-14
Evidence Table 2. Gestational weight gain and hyperemesis (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating

C-15
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference for
To compare pregnancy
G1: 613 women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and to Inclusion criteria: G1: 27.5
determine effect of Smoking,%:
• Singleton pregnancy G2: 28.7 (P = NS) NR
gestational weight gain on • Age 20 to 34 years
pregnancy outcome in Parity: Diabetes mellitus,%:
morbidly obese women Exclusion criteria: % multiparous: G1: 14.2%
• Multiple gestations G1: 66.7% G2: 4.3% (P < 0.01)
Time frame: • Extremes of age G2: 44.8% (P < 0.01)
NR • BMI between 27 and Hypertension,%:
Duration of the study: 34 G1: 5.4%
1988 to 1995 • Missing height G2: 0.3% (P < 0.01)
• Missing Additional characteristics:
prepregnancy weight % college education:
G1: 37.1%
G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-16
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes: Background:
G1: 613 G1: 3352 (598) Incidence of gestational Good
G2: 11,313 G2: 3269 (532) diabetes
(P < 0.05) Sample selection:
Total weight gain: Groups Fair
G1: 20 (16.2) Gestational Reported only for BMI >
G2: 31.4 (11.5) diabetes, %: 35: Definition of maternal
G1: 14.2% G1: weight loss or no gain weight gain:
Categorized: G2: 4.3% (P < G2: 1-15 lb gain Poor
Only calculated for 0.01) G3: 16-25 lb gain
morbidly obese: Definition of outcomes:
G4: 26-35 lb gain Good
0 or weight loss, 1- Cesarean
15 lbs, 16-25 lbs, delivery,%: Results Source of information on
26-35 lbs, >35 lbs G1: 31.3% G1: 15.7% exposure, outcomes, and
G2: 15.9% G2: 15.0% confounders:
Collected from: G3: 14.4% Poor
• Routine pre- Instrumental G4: 13.4%
natal care or delivery,%: G5: 12.5% Followup:
maternity NR (P =NS) Fair
records
Episiotomy,%: Maternal confounders Analysis comparability:
Ascertained by: NR and effect modifiers Poor
• Not stated - accounted for in
Other maternal Analysis of outcomes:
from medical analysis:
outcomes Fair
records • Race
• Preeclampsia
• Placental • Parity Interpretation:
abruption • Clinic service Poor
• Meconium • Substance abuse Sum of Good/Fair/Poor:
• Failure to • And preexisting 2 Good, 3 Fair, 4 Poor
progress medical conditions
• Shoulder Final Quality Score:
Infant and child Poor
dystocia confounders and effect
• Postpartum modifiers accounted for
hemorrhage in analysis:
• Endomyometrit NR
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-17
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Brennand et al., 2005 • Cohort • Routine pre-natal care White
• Retrospective • Medical records NR
Country and setting:
Canada, medical records Total Study N: • Measured within 14 Black
weeks of gestation NR
603
Enrollment Period: G1: 59.7 (5.0)
Prenatal to birth Group Description: G2: 73.0 (4.3) Hispanic
G1: Normal: G3: 93.6 (12.3) NR
Funding:
BMI 18.5 - 24.9 G4: 80.0 (16.9)
cree board of health and Asian/Pacific Islander
G2: Overweight:
social services of James Pregravid BMI: NR
BMI 25-29.9
Bay (Quebec) NR
G3: Obese: Other
Study Objective: BMI ≥ 30 Imputed: NR
To determine effect of G4: Total • Yes
pregravid weight and Smoking,%:
Group N: Categorized: NR
pregnancy weight gain on
G1: 139 • WHO International
pregnancy outcomes in Diabetes mellitus,%:
G2: 168 Taskforce
Cree women G1: 4.3
G3: 296
Time frame: G4: 603 Age (mean, yrs): G2: 14.9
Prenatal to birth G1: 20.8 (5.2) G3: 27.4
Inclusion criteria: G2: 23.8 (5.4) G4: 18.6
Duration of the study: • Used only Cree G3: 25.5 (5.5)
7 year period: January Hypertension,%:
women G4: 24.0 (5.7)
1994 to December 2000 • G1: 1.4
First birth observed
Parity: G2: 1.8
per woman during
NR G3: 4.8
study time period
G4: 3.2
• Must have first weight
recorded within first Additional characteristics:
14 weeks gestation % low weight gain:
and final weight G1: 20.1
recorded within 4 G2: 10.1
weeks of birth G3: 28.0
G4: 21.2
Exclusion criteria:
• Women with % acceptable weight gain:
secondary pregnancy G1: 28.8
in dataset (n = 792) G2: 32.1
• Women with first G3: 33.4
weight record > 14 G4: 32.0
weeks gestation
% excessive weight gain:
(n = 314)
G1: 51.1
• Women with final G2: 57.7
weight record > 4 G3: 38.5
weeks from birth G4: 46.6
(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)

C-18
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes: Background:
G1: 139 NR Incidence of gestational Good
G2: 168 diabetes and impaired
G3: 296 Gestational glucose tolerance Sample selection:
diabetes, %: Fair
Total weight gain: G1: 4.3 Groups:
G2: 14.9 G1: “Low weight gain” Definition of maternal
Categorized: G3: 27.4 G2: “Acceptable weight weight gain:
• 1999 Canadian G4: 18.6 gain” Fair
guidelines G3: “Excessive weight gain”
Cesarean Definition of outcomes:
Collected from: All categories per Canadian Poor
delivery,%: Guidelines
• Routine pre-natal G1: 10.8 Source of information on
care or maternity G2: 11.3 Results: exposure, outcomes, and
records G3: 24.1 (p < 0.001) Incidence of GDM confounders:
Ascertained by: G1: 38.6% Fair
Instrumental G2: 27.3%
• Based on last delivery,%: Followup:
clinically G3: 19.3%
Episiotomy,%: (P =0.011) Poor
measured weight
prior to delivery: NR Incidence IGT: Analysis comparability:
within 4 weeks of Other maternal G1: 12.0% Fair
birth outcomes: G2: 15.2% Analysis of outcomes:
• Definition of low, G3: 7.9% Fair
adequate, and (P = 0.249)
excessive weight Maternal confounders and Interpretation:
gains: Poor
effect modifiers
• For normal accounted for in analysis: Sum of Good/Fair/Poor:
weight women - NR 1 Good, 5 Fair, 3 Poor
adequate weight
gain is 11.5 to 16 Infant and child Final Quality Score:
kg confounders and effect Poor
• For overweight modifiers accounted for in
women, analysis:
adequate weight NR
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

C-19
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: • Pregnancies with
Brennand et al., 2005 factors that may have
(continued) 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-20
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating

C-21
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal weight G1: NR
To compare pregnancy
G1: 683 (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal weight Age (mean, yrs):
women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight change normal weight women
identified from Parity: Other
Time frame: NR G1: NR
1997-1993 pregnancy and
delivery summary G2: NR
Duration of the study: records (normal G3: 4.0 (Total sample)
1997-1993 weight matched to Smoking,%:
obese by race, age, NR
parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-22
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes: Background:
G1: 683 G1: 3420 Incidence of gestational Good
G2: 660 G2: 3285 P ≤ 0.001 diabetes
Sample selection:
Total weight gain: Gestational Groups Fair
G1: 9.5 diabetes,%: Pregravid wt 19.8-26.0 BMI:
G2: 14.5 P ≤ 0.001 NR G1: < 11.5 kg gain Definition of maternal
G2: 11.6-16 kg gain weight gain:
Categorized: Cesarean G3: > 16 kg gain Fair
• According to IOM delivery,%:
G1: 25.6 Pregravid wt > 29 kg Definition of outcomes:
Collected from: G2: 9.1 P < 0.001 G4: lost/gained nothing Fair
• Routine pre-natal G5: 0.5-6.5 kg gain Source of information on
care or maternity Instrumental G6: 7-11.5 kg gain
delivery,%: exposure, outcomes, and
records G7: 12-16 kg gain confounders:
Ascertained by: Episiotomy,%: G8: >16 kg gain Fair
• Based on last Other maternal Results Followup:
clinically outcomes: Incidence gestational Fair
measured weight NA diabetes:
prior to delivery G1: 2.3% Analysis comparability:
Other infant G2: 3.3% Good
outcomes: G3: 2.9%
NA Analysis of outcomes:
(P =.759) Fair
G4: 13.3% Interpretation:
G5: 24.3% Good
G6: 11.9%
Sum of Good/Fair/Poor:
G7: 16.7%
3 Good, 6 Fair, 0 Poor
G8: 17.3%
(P = .554) Final Quality Score:
Fair
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

C-23
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hackmon et al, 2007 • Cohort • Routine pre-natal care White
• Retrospective • NR G1: 22
Country and setting:
United States, Hospital Total Study N: Pregravid BMI: Black
75 G1: 27.4 G1: 31
Enrollment period:
2003 • Hispanic
Group Description:
G1: Study population Imputed: G1: 39
Funding:
NR • No Asian/Pacific Islander
Group N:
G1: 75 Categorized: G1: 5
Study Objective:
Aim was to determine Inclusion criteria: • Continuous Other
whether maternal age, • Consecutive, inner Age (mean, yrs): G1: 3
prepregnancy and mid- city, singleton G1: 31 (range: 19-43)
trimester body mass index Smoking,%:
pregnancies NR
(BMI), or excessive mid- Parity:
pregnancy weight gain Exclusion criteria: G1: 0.9 Diabetes mellitus,%:
predict abnormal glucose • Known gestational G1: Abnl GCT: 29.3%
challenge test (GCT) diabetes
results Hypertension,%:
NR
Time frame:
2003 Additional characteristics:
NR
Duration of the study:
Entry into prenatal care
through 24 to 28 weeks of
pregnancy

C-24
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes : Background:
NR NR Gestational diabetes Good
Total weight gain: Gestational Groups Sample selection:
• NR diabetes, %: NR Poor
G1: Abnl GCT: 29.3%
Categorized: Results Definition of maternal
• Continuous Cesarean There was no difference in weight gain:
delivery,%: maternal weight gain during Fair
Collected from: NR early pregnancy between
• Routine pre-natal patients with abnormal Definition of outcomes:
care or maternity Instrumental versus normal GCT values Good
records delivery,%: (mean+/-SD of 4.13+/-3.2
NR Source of information on
Ascertained by: and 4.16+/-1.67, exposure, outcomes, and
• NR Episiotomy,%: respectively). confounders:
NR Maternal confounders and Fair
Other maternal effect modifiers Followup:
outcomes accounted for in analysis: Fair
• No difference in • Gravidity
• Parity Analysis comparability:
maternal weight
Poor
gain during early • Ethnicity
pregnancy • BMI Analysis of outcomes:
between patients Fair
with abnormal Infant and child
versus normal confounders and effect Interpretation:
GCT values modifiers accounted for in Fair
(mean+SD of analysis:
NR Sum of Good/Fair/Poor:
4.13+/-3.2 and 2 Good, 5 Fair, 2 Poor
4.16+/-1.67,
respectively) Final Quality Score:
Fair
Other infant
outcomes
NR

C-25
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kabiru and Raynor, 2004 • Cohort • Measured at first prenatal White
• Retrospective visit G1: 1.9
Country and setting: G2: 2.6
USA, hospital Total Study N: Pregravid BMI: G3: 2.8
5,131
Enrollment Period: Imputed: Black
1999 to 2002 Group Description: • No G1: 84.1
G1: No change in BMI G2: 82.8
Funding: Categorized:
between first prenatal
NR
visit and delivery • 20-24.9, 25-29.9, 30-34.9, G3: 88.2
Study Objective: G2: 1 category increase in 35-39.9, ≥ 40 Hispanic
To investigate effect of BMI between first Age (mean, yrs): G1: 13.9
increase in body mass prenatal visit and G1: 24.7 (6.1) G2: 14.6
index category on delivery G2: 24.4 (5.7) G3: 9.0
obstetric outcomes G3: > 1 category increase G3: 25.2 (5.9) P < 0.001 Asian/Pacific Islander
in BMI between first
Time frame: Parity: NR
prenatal visit and
1999 to 2002 delivery G1: Gravidity (mean): 1.9 (1.9) Other
Duration of the study: G2: 1.5 (1.7) NR
Group N: G3: 1.2 (1.7) P < 0.001
Prenatal through birth G1: 2,556 Smoking,%:
G2: 2,252 NR
G3: 323
Diabetes mellitus,%:
Inclusion criteria: NR
• Singleton
Hypertension,%:
pregnancies
NR
Exclusion criteria:
Additional characteristics:
• Multiple pregnancies
Mean weight gain:
• BMI < 20
G1: 8.6 pounds (8.4)
• Missing BMI data G2: 22.2 pounds (10.2)
G3: 55.3 pounds (23.8)
Additional characteristics:
NR

C-26
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes description Background:
G1: 579 G1: 2886.0 (756) Incidence of gestational Good
G2: 942 G2: 3174.9 (600) diabetes
G3: 189 G3: 3099.5 (673) Sample selection:
G4: 819 P < 0.001 Fair
G5: 790 G4: 3116 (713) Groups:
BMI < 25 first assessment: Definition of maternal
G6: 104 G5: 3269 (698) weight gain:
G6: 3371 (733) G1: no change BMI
Total weight gain: category Poor
P = 0.015
G2: increase 1 category Definition of outcomes:
Categorized: Gestational G3; increase > 1 category Fair
• > 35 pounds for diabetes,%:
normal BMI, > 25 NR BMI≥25 first assessment Source of information on
pounds for G4: no change BMI exposure, outcomes, and
overweight BMI, Cesarean category confounders:
> 15 pounds for delivery,%: G5: increase 1 category Fair
obese BMI G1: 8.2 G6: increase >1 category
G2: 12.6 Followup:
Collected from: G3: 21.0 P < 0.001 Poor
• Routine pre-natal G4: 13.0 Results:
care or maternity G5: 14.3 Analysis comparability:
G1: 0.5% Poor
records G6: 19.3 P = 0.256 G2: 1.5%
Ascertained by: G3: 3.7% Analysis of outcomes:
Instrumental (P = .005) Fair
• Based on last delivery,%:
clinically Interpretation:
measured weight Episiotomy,%: G4: 1.0%
Poor
prior to delivery: Other maternal G5: 3.3%
not stated, most outcomes: G6: 1.9% Sum of Good/Fair/Poor:
likely difference NA (P = .005) 1 Good, 4 Fair, 4 Poor
between weight Final Quality Score:
at first prenatal Other infant Maternal confounders and Poor
visit and weight outcomes: effect modifiers
at delivery NA accounted for in analysis:
• Pregravid BMI

Infant and child

confounders and effect
modifiers accounted for in
analysis:
• NR

C-27
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kieffer et al., 2006 • Cohort • When unknown or Hispanic
• Prospective missing-used weight G1: 100%
Country and setting:
obtained within first 10
United States, community Total Study N: Smoking,%:
weeks of pregnancy
health center 1,041 G1: 9% before
G1: 63.4 ±12.9
2% during
Enrollment period: Group Description: Pregravid BMI:
Jan 1999 to Feb 2001 G1: Total Diabetes mellitus,%:
G1: 25.9 ±5.0
G1: 6.8
Funding: Group N: Imputed:
Study supported by G1: 1,041 Hypertension,%:
• Yes
National Institutes of NR
Diabetes and Digestive Inclusion criteria: Categorized:
and Kidney Diseases • Latino women Additional characteristics:
• IOM guidelines NR
(grant R18DK 062344); entering prenatal care
Biostatistics and during study period Age (mean, yrs):
Measurement Cores of G1: 25.2 ±5.1
Exclusion criteria:
Michigan Diabetes • Multiple gestation Parity:
Research and Training Multiparous, no. (%)
• Late entry into
Center(grant NIH5P60 G1: 0 429 (41.2)
prenatal care
DK20572); General Clinic 1- 574 (55.1)
• Previous participation
Center, National Institutes ≥4 38 (3.7)
in study
of Health (grant M01
RR00042); Maternal and • Miscarriage
Child Health Bureau • Stillbirth
(grant R40 MC00115-03); • Missing records
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.

C-28
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Bivariate Outcomes from
Gain Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: Total 933 NR GDM Good
Total weight gain: Gestational diabetes, %: Groups: Sample selection:
G1: Adjusted R2: G1: 6.8 NA, weight gain as Fair
0.30 kg [PE 8.2, continuous variable (study
SE 2.2, P < 0.01] Cesarean delivery,%: aim to determine Definition of maternal
NR relationship of weight gain:
Categorized: anthropometric and Fair
Instrumental delivery,%:
• Continuous metabolic variables on
NR Definition of outcomes:
according to IOM infant outcomes) Good
Episiotomy,%:
Collected from: Results
NR Source of information on
• Routine pre-natal Women with GDM had exposure, outcomes, and
care or maternity Other maternal outcomes: significantly lower average confounders:
records • Women with GDM had weight gain than those Good
significantly lower without GDM but weight
Ascertained by:
average weight gain gain was not significantly Followup:
• Based on last Good
than those without related to glucose category
clinically
GDM; weight gain not
measured weight Maternal confounders and Analysis comparability:
significantly related to
prior to delivery effect modifiers Good
glucose category
• Maternal waist, hip, and accounted for in analysis: Analysis of outcomes:
upper-arm • Parity Good
circumference and • Pregravid BMI
upper-arm fat area • Weight gain Interpretation:
associated with Good
Infant and child
increasingly abnormal Sum of Good/Fair/Poor:
confounders and effect
glucose categories 7 Good, 2 Fair, 0 Poor
modifiers accounted for in
among women with and
analysis: Final Quality Score:
without GDM
• Gestational age Good
• 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

C-29
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kieffer et al., 2001 • Cohort • Self-reported White
• Retrospective • if not selfreported, used NR
Country and setting:
weight measured weight
USA, city health system Total Study N: Black
within 10 weeks of
Latinas:661 G1: NR
Enrollment Period: gestation
African American: 673 G2: 100
Latinas: August 1996 -
Pregravid BMI:
December 1998 Group Description: Hispanic
African Americans: G1: Latina Imputed: G1: 100
January 1995 to February G2: African American • No G2: NR
1998
Group N: Categorized: Asian/Pacific Islander
Funding: G1: 661 • IOM guidelines: < 19.8, NR
Grants from Health G2: 673 19.8-26.0, > 26.0-29.0, >
Resources and Services Other
29.0-35.0, > 35.0 NR
Administration, Maternal Inclusion criteria:
and Child Health Bureau, • African American and Age (mean, yrs): Smoking,%:
and African American Latina women G1: NR G1: 3.8
health Initiative of Blue • Received at least 4 • < 20: 18.2% G2: 10.7
Cross Blue Shield of prenatal care visits • 20-29: 62.6%
Michigan Foundation • Delivery of single • ≥ 30: 19.1% Diabetes mellitus,%:
infant within large G2: NR NR
Study Objective: Detroit health system • < 20: 22.1% Hypertension,%:
To estimate prevalence of
Exclusion criteria: • 20-29: 49.1% NR
GDM, obesity, and
excessive weight gain • Documented diabetes • ≥ 30: 28.8%
Additional characteristics:
during pregnancy among prior to prenatal care Parity: Married:
Latinas and African • Information on infants % primiparous: G1: 60.3%
American women and to other than first G1: 39.7 G2: 31.5%
explore risk factors pregnancy within G2: 43.6
associated with GDM and study period Additional characteristics:
its implications NR
Time frame:
Latinas: August 1996 to
December 1998
African Americans:
January 1995 to February
1998
Duration of the study:
during prenatal care

C-30
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 661 NR GDM Good
G2: 673
Gestational Groups: Sample selection:
Total weight gain: diabetes, %: NR Fair
G1: 29.1 (14.6) NR
G2: 32.6 (12.1) Results Definition of maternal
P < 0.004 vs. Latinas Cesarean delivery, Multiple logistic regression weight gain:
%: analyses revealed Fair
Categorized: NR statistically significant risk
Definition of outcomes:
• According to IOM factors for GDM included
Instrumental weight gain during the first Good
Collected from: delivery, %: 28 wks gestation Source of information on
• Routine pre-natal NR
care or maternity Maternal confounders and exposure, outcomes, and
Episiotomy, %: effect modifiers confounders:
records
NR accounted for in analysis: Fair
Ascertained by: • Age
Other maternal Followup:
• Based on last outcomes: • Family history diabetes Fair
clinically NR • Parity
measured weight Analysis comparability:
• BMI
prior to delivery Other infant Good
• Weight gain first 28
outcomes:
weeks Analysis of outcomes:
NR
• Ethnicity Fair
Infant and child Interpretation:
confounders and effect Good
modifiers accounted for in
Sum of Good/Fair/Poor:
analysis:
4 Good, 5 Fair, 0 Poor
NR
Final Quality Score:
Fair

C-31
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Murakami et al., 2004 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Japan, hospital Total Study N: G1: 20.9 (2.8) Black
633 G2: NR NR
Enrollment Period:
2001 Group Description: Imputed: Hispanic
G1: Total cohort • No NR
Funding:
G2: NR
NR Categorized: Asian/Pacific Islander
Group N: • WHO International NR
Study Objective:
G1: 633 Taskforce
To estimate risk of Other
G2: NR
perinatal morbidity of Age (mean, yrs): NR
mother and infant with Inclusion criteria: G1: 29.1 (4.5)
respect to maternal Smoking,%:
• Live, singletons G2: NR G1: 8.5
prepregnancy BMI and delivered between 24 G2: NR
weight gain in Japanese to 42 weeks gestation Parity:
women G1: 0.6 (0.7) Diabetes mellitus,%:
Exclusion criteria: G2: NR G1: 2.1
Time frame:
2001 G2: NR

Duration of the study: Hypertension,%:

Prenatal through birth NR
Additional characteristics:
G1: Preeclampsia - mild:
5.4%; severe: 4.1%
G2: NR
Additional characteristics:
NR

C-32
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 633 G1: 3,052.6 (483.8) AORs (95% CI) of Good
G2: NR G2: NR gestational diabetes
Sample selection:
Total weight gain: Gestational Groups Fair
G1: 10.5 (3.4) diabetes, %: G1: < 8.5 kg gain
G2: NR G1: 2.1 G2: 8.5-12.5 kg gain Definition of maternal
G2: NR G3: >12.5 kg gain weight gain:
Categorized: Fair
• < 8.5kg, 8.5- Cesarean Results
delivery,%: G1: 5.14 (0.97-27.20) Definition of outcomes:
12.5, > 12.5
G1: 10.3 G2: Reference Fair
Collected from: G2: NR G3: 3.91 (0.61-24.73) Source of information on
• Routine pre-natal
care or maternity Instrumental Maternal confounders and exposure, outcomes, and
delivery,%: effect modifiers confounders:
records
NR accounted for in analysis: Fair
Ascertained by: • Maternal age
Episiotomy,%: Followup:
• Based on last • Parity Fair
clinically NR
• Smoking
measured weight Other maternal Analysis comparability:
• Weight gain
prior to delivery: outcomes: Fair
• Pregravid BMI
last NA Analysis of outcomes:
measurement Infant and child
Other infant Fair
was taken at confounders and effect
hospitalization outcomes: modifiers accounted for in Interpretation:
prior to delivery NA analysis: Fair
• Gestational age
Sum of Good/Fair/Poor:
1 Good, 8 Fair, 0 Poor
Final Quality Score:
Fair

C-33
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Saldana et al., 2006 • Cohort • Self-reported White
• Prospective G1: 58%
Country and setting: Pregravid BMI: G2: 73%
United States, hospital Total Study N: G1: 25 (0.24) G3: 69%
952 G2: 28 (1.1)
Enrollment period: Black
G3: 30 (0.82)
August 1,1995 through Group Description: G1: 42%
May 31, 2000 G1: Normal Glucose Imputed: G2: 27%
Tolerance • No G3: 31%
Funding:
G2: Impaired Glucose
Supported in part by Categorized: Hispanic
Tolerance
National Institute of • IOM guidelines NR
G3: GDM
General Medical Sciences
(Grant R25GM55336), Group N: Age (mean, yrs): Asian/Pacific Islander
National Institute of Child G1: 809 G1: 26 (0.22) NR
Health and Development G2: 48 G2: 29 (0.91)
(Grant 28684), and North G3: 28 (0.59) Other
G3: 95
Carolina Clinical Nutrition NR
Inclusion criteria: Parity:
Research (Grant G1: 0.9 (0.04) Smoking,%:
DK56350) • Singleton pregnancy G1: 25%
G2: 1.1 (0.16)
• More than 16 years of G2: 26%
Study Objective: G3: 0.9 (0.10)
age G3: 25%
Objective of study to • English speaking
examine weight and its • Access to phone Diabetes mellitus,%:
relationship to glucose • Planned to continue NR
intolerance during care at 1 of study
pregnancy Hypertension,%:
sites NR
Time frame: Exclusion criteria:
August 1,1995 through Additional characteristics:
• From non-white or Weight gain ratio
May 31, 2000
non-black racial (observed/recommended[compa
Duration of the study: group red with IOM range])
Entry into prenatal care • Having a second G1:: 1.43 (0.04)
through end of second pregnancy in cohort G2: 1.48 (0.21)
trimester • Pre-existing diabetes G3: 1.88 (0.15)
• No glucose screening
Quality: Additional characteristics:
data
Good NR
• High screen without
an oral glucose
tolerance test

C-34
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Impaired Glucose Tolerance Good
GDM
Total weight gain: Gestational Sample selection:
G1: 9.1 (0.19) diabetes, %: Groups: Good
G2: 8.1 (0.90) NR
G3: 9.4 (0.62) Weight gain ratio Definition of maternal weight
Cesarean (observed/recommended) gain:
Categorized: delivery,%: Good
• 2 weight gain NR
Results Definition of outcomes:
variables were
Instrumental OR for weight gain ratio on Good
created. Weight
delivery,%: Impaired Glucose Tolerance
gain was Source of information on
NR (95% CI)
calculated by exposure, outcomes, and
0.9 (0.7, 1.1)
subtracting Episiotomy,%: confounders:
prepregnancy NR Fair
OR for weight gain ratio on
weight from
Other maternal GDM (95% CI) Followup:
weight at end of
outcomes: 1.2 (0.9, 1.4) Good
second trimester
(G2 weeks). NR Maternal confounders and Analysis comparability:
Weight gain ratio Other infant effect modifiers Good
calculated as outcomes: accounted for in analysis:
ratio of observed Race Analysis of outcomes:
weight gain to Maternal age Fair
recommended Gestational age of weight Interpretation:
measurment Good
Collected from:
• Routine pre-natal Infant and child Sum of Good/Fair/Poor:
care or maternity confounders and effect 7 Good, 2 Fair, 0 Poor
records modifiers accounted for in
analysis: Final Quality Score:
Ascertained by:
NR
• NR Good

C-35
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Seghieri et al., 2005 • Cross-sectional • Not explained in Methods White
• Retrospective section G1: 100
Country and setting: G2: 100
Italy, outpatient clinic Total Study N: Pregravid BMI: G3: 100
1880 G1: 22.5 (3.4) G4: 100
Enrollment Period:
G2: 23.4 (4.1) G5: 100
January, 1997 to Group Description: G3: 23.7 (4.1) Group 6
December 2003 G1: Parity = 0 G4: 24.1 (5.3)
G2: Parity = 1 G5: 24.4 (6.1) (P Duncan’s Black
Funding:
G3: Parity = 2 test after anova = 0.0001, NR
NR
G4: Parity = 3 0 vs.3, > 3)
Study Objective: G5: Parity > 3 Hispanic
To study effect of parity Imputed: NR
Group N: • No
on impairment of insulin Asian/Pacific Islander
G1: 944
sensitivity during NR
G2: 604 Categorized:
pregnancy and on risk of
GDM
G3: 232 • Continuous Other
G4: 77
Age (mean, yrs): NR
Time frame: G5: 23
January, 1997 to G1: 29.2 (4.3) Smoking,%:
Inclusion criteria: G2: 31.4 (4.5)
December 2003 NR
• Women who tested G3: 31.9 (4.5)
Duration of the study: glucose intolerant by G4: 33.8 (4.3) Diabetes mellitus,%:
Caucasian pregnant glucose challenge or G5: 35.2 (4.2) (P Duncan’s NR
women who received a 3 who had an elevated test after anova = 0.0001,
hour OGTT at 24 to 28 Hypertension,%:
1 hour glucose or had 0 vs. 1,2,3, > 3)
weeks gestation; also 75 NR
other risk factors for
women whose glucose GDM (hx glucose Parity:
Additional characteristics:
levels were tested in 2 intolerance, NR
Weight increase (kg)
consecutive pregnancies macrosomic infants, G1: 7.4 (3.6)
diabetes of first G2: 7.2 (3.7)
degree relative G3: 6.8 (4.0)
Exclusion criteria: G4: 6.9 (3.5)
G5: 8.7 (8.6) (P Duncan’s test
• No criteria are
after anova = 0.0119, 0,
mentioned by authors
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-36
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1764 NR Weight gain as predictor of Good
G2: 124 GDM OR (95% CI)
Gestational Sample selection:
Total weight gain: diabetes, %: Groups Poor
G1: 7.3 (3.9) NR NA, weight gain continuous
G2: 7.2 (5.3) variable Definition of maternal
Cesarean delivery, weight gain:
Categorized: %: Results Poor
• Continuous NR 1.024 (0.974-1.077)
(P = NS) Definition of outcomes:
Collected from: Instrumental Fair
• Routine pre-natal delivery, %: Maternal confounders and
effect modifiers Source of information on
care or maternity NR
records accounted for in analysis: exposure, outcomes, and
Episiotomy, %: confounders:
• Parity
Ascertained by: NR Poor
• Age
• Not stated by Other maternal • Pregestational BMI Followup:
researchers - outcomes: • Weight gain Poor
appears that NR • Family history diabetes
weight gain was Analysis comparability:
computed at time Other infant Infant and child Fair
of testing which outcomes: confounders and effect
NR Analysis of outcomes:
was at 24-28 modifiers accounted for in
Fair
weeks rather analysis:
than total weight NR Interpretation:
gain Poor
Sum of Good/Fair/Poor:
1 Good, 3 Fair, 5 Poor
Final Quality Score:
Poor

C-37
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Thorsdottir et al., 2002 • Cohort • Self-reported White
• Retrospective G1: 63.1 (6.2) NR
Country and setting:
G2: 62.0 (5.6) P = 0.059
Maternity records, Total Study N: Black
G3: 61.7 (4.8) P = 0.174
Department of Obstetrics 614 NR
G4: 62.2 (6.1) P = 0.274
and Gynecology at
Landspitali University Group Description: Hispanic
Pregravid BMI:
Hospital, Iceland G1: No complication NR
G1: 22.2
G2: Complications in G2: 22.4 )1.6) P = 0.270
Enrollment Period: Asian/Pacific Islander
pregnancy or delivery G3: 22.4 (1.5) P = 0.338 NR
G3: Complications in G4: 22.3 P = 0.584
Funding:
pregnancy Other
NR
G4: Complications in Imputed: NR
Study Objective: delivery • No
To investigate relation Smoking,%:
Group N: Categorized: NR
between gestational
weight gain in women of
G1: 452 • Continuous
G2: 162 Diabetes mellitus,%:
normal prepregnant Age (mean, yrs): NR
G3: 56
weight and complications G1: 29
G4: 106 Hypertension,%:
during pregnancy and G2: 29 P = 0.857
delivery in a population Inclusion criteria: G3: 29 P = 0.404 NR
with high gestational • Women of normal G4: 29 P = 0.398 Additional characteristics:
weight gain and birth prepregnancy weight Proportional weight gain, %:
weight randomly selected Parity:
G1: 26.0
Time frame: within 1 year (1998) NR G2: 28.0 P = 0.018
NR • No history of G3: 30.0 P = 0.005
diabetes, G4: 27.0 P = 0.546
Duration of the study: hypertension, CVD,
1998 or thyroid problems Additional characteristics:
• Singleton births NR
• 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

C-38
Evidence Table 3. Maternal weight gain and abnormal glucose metabolism (continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 452 G1: 3789 (469) Incidence of gestational Good
G2: 162 G2: 3749 (565) P = 0.389 diabetes
G3: 56 G3: 3643 (526) P = 0.032 Sample selection:
G4: 106 G4: 3806 (578) P = 0.529 Groups: Fair
G1: <11.5 kg gain
Total weight gain: Gestational diabetes, %: G2: 11.5-16.0 kg gain Definition of maternal
G1: 16.6 (4.9) NR G3: 16.1-20.0 kg gain weight gain:
G2: 17.4 (5.1) P = G4: >20 kg gain Poor
0.080 Cesarean delivery, %:
NR Results: Definition of outcomes:
G3: 18.4 (5.1) P = Fair
0.013 G1: 2.9%
Instrumental delivery, G2: 0
G4: 16.9 (5.1) P = %: Source of information on
0.887 G3: 0 exposure, outcomes, and
NR G4: 0 confounders:
Categorized: Episiotomy, %: (P =.015) Fair
• According to IOM < NR
Maternal confounders and Followup:
11.5, 11.-16.0, ≥
Other maternal effect modifiers Good
16.1, also quintiles
outcomes: accounted for in analysis:
< 12.5, 12.5-15.5, Analysis comparability:
15.6-17.8, 17.9- NA • Age
• Parity Good
20.8, > 20.8 Other infant outcomes:
• Height Analysis of outcomes:
Collected from: NA
Good
• Routine pre-natal Infant and child
care or maternity confounders and effect Interpretation:
records modifiers accounted for in Good
analysis:
Ascertained by: • Gestational age Sum of Good/Fair/Poor:
• Based on last • Birth weight 5 Good, 3 Fair, 1 Poor
clinically measured Final Quality Score:
weight prior to Fair
delivery

C-39
Evidence Table 4. Gestational weight gain and hypertensive disorders
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-40
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Incidence of pregnancy Good
G2: 11,313 G2: 3269 (532) induced hypertension
(P < 0.05) Sample selection:
Total weight gain: Groups Fair
G1: 20 (16.2) Gestational Reported only for BMI >
G2: 31.4 (11.5) diabetes, %: 35: Definition of maternal
G1: 14.2% G1: weight loss or no gain weight gain:
Categorized: G2: 4.3% (P < G2: 1-15 lb gain Poor
Only calculated for 0.01) G3: 16-25 lb gain
morbidly obese: Definition of outcomes:
G4: 26-35 lb gain Good
0 or weight loss, 1- Cesarean G5: > 35 lb gain
15 lbs, 16-25 lbs, delivery,%: (P = NS) Source of information on
26-35 lbs, >35 lbs G1: 31.3% exposure, outcomes, and
G2: 15.9% Results confounders:
Collected from: G1: 11.8% Poor
• Routine pre- Instrumental G2: 13.7%
natal care or delivery,%: G3: 13.7% Followup:
maternity NR G4: 12.4% Fair
records G5: 21.3%
Episiotomy,%: Analysis comparability:
Ascertained by: NR Maternal confounders Poor
• Not stated - and effect modifiers
Other maternal Analysis of outcomes:
from medical accounted for in
outcomes Fair
records analysis:
• Preeclampsia
• Placental • Race Interpretation:
abruption • Parity Poor
• Meconium • Clinic service Sum of Good/Fair/Poor:
• Failure to • Substance abuse 2 Good, 3 Fair, 4 Poor
progress • Preexisting medical
• Shoulder conditions Final Quality Score:
dystocia Poor
Infant and child
• Postpartum confounders and effect
hemorrhage modifiers accounted for
• Endomyometrit in analysis:
is NR
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-41
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Brennand et al., 2005 • Cohort • Routine pre-natal care White
• Retrospective • Medical records NR
Country and setting:
Canada, medical • Measured within 14 Black
Total Study N:
records weeks of gestation NR
603
G1: 59.7 (5.0)
Enrollment Period: Group Description: G2: 73.0 (4.3) Hispanic
Prenatal to birth G1: Normal: G3: 93.6 (12.3) NR
BMI 18.5 - 24.9 G4: 80.0 (16.9)
Funding: Asian/Pacific Islander
G2: Overweight:
cree board of health and Pregravid BMI: NR
BMI 25-29.9
social services of James NR
G3: Obese: Other
Bay (Quebec)
BMI ≥ 30 Imputed: NR
Study Objective: G4: Total • Yes
To determine effect of Smoking,%:
Group N: Categorized: NR
pregravid weight and
G1: 139 • WHO International
pregnancy weight gain Diabetes mellitus,%:
G2: 168 Taskforce
on pregnancy outcomes G1: 4.3
G3: 296
in Cree women Age (mean, yrs): G2: 14.9
G4: 603
Time frame: G1: 20.8 (5.2) G3: 27.4
Inclusion criteria: G2: 23.8 (5.4) G4: 18.6
Prenatal to birth
• Used only Cree G3: 25.5 (5.5)
Duration of the study: Hypertension,%:
women G4: 24.0 (5.7)
G1: 1.4
7 year period: January • First birth observed
1994 to December 2000 Parity: G2: 1.8
per woman during
NR G3: 4.8
study time period
G4: 3.2
• Must have first
weight recorded Additional characteristics:
within first 14 % low weight gain:
weeks gestation G1: 20.1
and final weight G2: 10.1
recorded within 4 G3: 28.0
weeks of birth G4: 21.2
Exclusion criteria: % acceptable weight gain:
• Women with G1: 28.8
secondary G2: 32.1
pregnancy in G3: 33.4
dataset (n = 792) G4: 32.0
• Women with first
% excessive weight gain:
weight record > 14
G1: 51.1
weeks gestation
G2: 57.7
(n = 314)
G3: 38.5
• Women with final G4: 46.6
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)

C-42
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 139 NR hypertensive disorders, Good
G2: 168 PIH, preeclampsia
G3: 296 Gestational Sample selection:
diabetes, %: Groups Fair
Total weight gain: G1: 4.3 G1: “Low weight gain”
G2: 14.9 G2: “Acceptable weight Definition of maternal
Categorized: G3: 27.4 gain” weight gain:
• 1999 Canadian G4: 18.6 G3: “Excessive weight Fair
guidelines gain”
Cesarean Definition of outcomes:
Collected from: All categories per Poor
delivery,%: Canadian Guidelines
• Routine pre- G1: 10.8 Source of information on
natal care or G2: 11.3 Results exposure, outcomes, and
maternity G3: 24.1 (p < HTN Disorders confounders:
records 0.001) G1: 7.3% Fair
Ascertained by: G2: 12.5%
Instrumental G3: 19.3% Followup:
• Based on last delivery,%: Poor
clinically (P = 0.051)
measured Episiotomy,%: PIH: Analysis comparability:
weight prior to NR G1: 3.7% Fair
delivery: within Other maternal G2: 6.3% Analysis of outcomes:
4 weeks of outcomes: G3: 4.4%
birth Fair
• Definition of (P = 0.698)
low, adequate, Interpretation:
Preeclampsia Poor
and excessive G1: 3.7%
weight gains: G2: 6.3% Sum of Good/Fair/Poor:
• For normal G3: 14.9% 1 Good, 5 Fair, 3 Poor
weight women (P = 0.013)
- adequate Final Quality Score:
weight gain is Maternal confounders Poor
11.5 to 16 kg and effect modifiers
• For overweight accounted for in
women, analysis:
adequate NR
weight gain is 7 Infant and child
to 11.5 kg confounders and effect
• For obese modifiers accounted for
women, in analysis:
adequate NR
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

C-43
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: • Pregnancies with
Brennand et al., 2005 factors that may
(continued) 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-44
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis

C-45
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cedergren, 2006 • Cohort • Self-reported White
• Prospective • If unknown, G1: 96.6
Country and setting: G2: NR
standardized
Sweden, Medical Birth Total Study N: measurement is made
Registry 245,526 Black
during first visit to
NR
Enrollment Period: Group Description: maternity health care
January 1, 1994 - BMI center Hispanic
December 31, 2002 G1: < 20 NR
Pregravid BMI:
G2: 20 to 24.9
Funding: Asian/Pacific Islander
G3: 25 to 29.9 Imputed:
Ostergotland County G1: 1.4
Council
G4: 30 to 34.9 • No G2: NR
G5: ≥ 35
Study Objective: Categorized: Other
Group N: • < 20, 20.0-24.9, 25.0-
To estimate effects of G1: 2.0
G1: 28,186 29.9, 30-34.9, ≥ 35
high and low gestational G2: NR
G2: 143,365
weight gain in different Age (mean, yrs):
G3: 60,626 Smoking,%:
maternal BMI classes G1: 15 to 19 years: 3.8%
G4: 17,248 G1: % nonsmoking: 81.6
on obstetric and 20 to 24: 23.0%
G5: 6,296 G2: 85.2
neonatal outcomes 25 to 29: 38.7% G3: 83.1
Inclusion criteria: 30 to 34: 25.7%
Time frame: G4: 79.9
January 1, 1994 to • Singleton, term 35 to 39: 7.7% G5: 78.4
December 31, 2002 pregnancies ≥ 40: 1.1% Group 6
• Information on G2: 15 to 19 years: 1.9%
Duration of the study: maternal height, 20 to 24: 15.9% Diabetes mellitus,%:
First visit to maternity maternal weight in 25 to 29: 37.7% NR
health care center to early pregnancy, 30 to 34: 31.1%
delivery Hypertension,%:
and gestational 35 to 39: 11.3%
NR
weight gain ≥ 40: 1.9%
G3: 15 to 19 years: 1.5% Additional characteristics:
Exclusion criteria: 20 to 24: 15.7% NR
• NA 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%

C-46
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28,186 NR Preeclampsia Good
G2: 143,365
G3: 60,626 Gestational Groups Sample selection:
G4: 17,248 diabetes, %: G1:BMI < 20 Fair
G5: 6,296 NR G2:BMI 20-24.9
G3:BMI 25-29.9 Definition of maternal
Total weight gain: Cesarean delivery, G4:BMI 30-34.9 weight gain:
G1: < 8kg: 6.9% %: G5:BMI>35 Fair
8-15.9kg: 65.2% NR
Results Definition of outcomes:
≥ 16kg: 28.0% Instrumental Good
G2: < 8kg: 8.4% Preeclampsia by BMI for
delivery, %: weight gain < 8 kg
8-15.9kg: 67.1% NR Source of information on
≥ 16kg: 30.4% (reference gain 8-16 kg) exposure, outcomes, and
G3: < 8kg: 15.7% Episiotomy, %: OR (95% CI): confounders:
8-15.9kg: 54.4% NR G1: 0.90 (0.55-1.48) Good
≥ 16kg: 29.9% G2: 0.73 (0.61-0.89)
Other maternal G3: 0.64 (0.54-0.76) Followup:
G4: < 8kg: 30.2% outcomes: Fair
8-15.9kg: 48.7% G4: 0.52 (0.42-0.62)
NA G5: 0.63 (0.51-0.79)
≥ 16kg: 21.1% Analysis comparability:
G5: < 8kg: 44.6% Other infant Preeclampsia by BMI for Fair
8-15.9kg: 40.9% outcomes: weight gain >16 kg
NA Analysis of outcomes:
≥ 16kg (reference weight gain 8- Fair
Categorized: 16kg) OR (95% CI):
G1: 2.23 (1.83-2.71) Interpretation:
• < 8kg, 8-16, > 16 Good
G2: 2.31 (2.15-2.49)
Collected from: G3: 1.88 (1.72-2.06)
Sum of Good/Fair/Poor:
• Routine pre-natal G4: 1.65 (1.43-1.92)
4 Good, 5 Fair, 0 Poor
care or maternity G5: 1.50 (1.17-1.92)
records Final Quality Score:
Maternal confounders
Fair
Ascertained by: and effect modifiers
• Based on last accounted for in
clinically analysis:
measured weight • Age
prior to delivery: • Parity
difference • Smoking in early
between pregnancy
maternal weights
measured when Infant and child
woman attended confounders and effect
delivery unit and modifiers accounted for
maternal weight in analysis:
recorded at first • Year of birth
visit to maternity
health care
center

C-47
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
DeVader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained G1: 79.7
Country and setting: G2: 85.6
from mother during
United States, birth Total Study N: G3: 85.2
postpartum hospital stay
certificate data 94,696
Pregravid BMI: Black
Enrollment period: Group Description: G1: 15.7
NR
1999 to 2001 G1: Gained less than 25 G2: 10.8
lbs Imputed: G3: 12.1
Funding:
NR
G2: Gained 25 to 35 lbs • No
G3: Gained more than Hispanic
Study Objective: 35 lbs Categorized: NR
To investigate NR
Group N: Asian/Pacific Islander
relationship between Age (mean, yrs): NR
G1: 16,852
gestational weight gain G1: Maternal age (y)
G2: 37,292
and adverse pregnancy 18 to 24*: 42.3% Other
G3: 40,552
outcomes among 25 to 30: 36.2% G1: 4.6
women with normal Inclusion criteria: 31 to 35: 21.5% G2: 3.5
prepregnancy BMI • All mothers with G2: Maternal age (y) G3: 2.7
Time frame: normal 18 to 24*: 36.7% Smoking,%:
1999 to 2001 prepregnancy BMI 25 to 30: 39.5% G1: 20.5
(19.8 –26.0 kg/m2) 31 to 35: 23.8% G2: 14.9
Duration of the study: who were 18 to 35 G3: Maternal age (y) G3: 17.4
Entry into prenatal care years of age at time 18 to 24*: 44.7%
through delivery of delivery and who 25 to 30: 35.9% Diabetes mellitus,%:
delivered full-term 31 to 35: 19.4% NR
(37 weeks or more)
Parity: Hypertension,%:
singleton infant
during period NR NR
January 1, 1999, to Additional characteristics:
December 31, 2001 NR
Exclusion criteria:
• Women aged
younger than 18
years and older
than 35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-48
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Preeclampsia Good
Total weight gain: Gestational diabetes, %: Groups Sample selection:
NR NR G1: Weight gain < 25 lbs Fair
G2: Weight gain 25-35 lbs
Categorized: Cesarean delivery,%: G3: Gained > 35 lbs Definition of maternal
• According to NR weight gain:
IOM Results Fair
Instrumental delivery,%: AOR (95% CI)
Collected from: NR G1: 0.56 (0.49-0.64) Definition of
• Routine pre- G2: 1 outcomes:
Episiotomy,%: Good
natal care or G3: 1.88 (1.74-2.04)
NR
maternity
Maternal confounders Source of information
records Other maternal
and effect modifiers on exposure,
outcomes: outcomes, and
Ascertained by: accounted for in
• Figures 1 to 3 plot confounders:
NR analysis:
risk for each adverse Fair
pregnancy outcome • Maternal age
by 10-lb increments in • Race/ethnicity Followup:
gestational weight • Education Fair
gain. Women who • Medicaid status
Analysis
gained 25 to 34 lbs • Tobacco and alcohol
comparability:
during their use
Fair
pregnancy had lower • Maternal height
risks for most • Adequacy of prenatal Analysis of outcomes:
outcomes when care Fair
balancing risk for
SGA status and other Infant and child Interpretation:
adverse pregnancy confounders and effect Fair
outcomes modifiers accounted for
Sum of
• Women who gained in analysis:
Good/Fair/Poor:
15 to 24 lbs had • Child's sex 2 Good, 7 Fair, 0 Poor
lowest risks for most • Child’s birth year
outcomes, but Final Quality Score:
increased their risk of Fair
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

C-49
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal G1: NR
To compare pregnancy
G1: 683 weight (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal Age (mean, yrs):
weight women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight normal weight
change women identified Parity: Other
from pregnancy NR G1: NR
Time frame: G2: NR
1997-1993 and delivery
summary records G3: 4.0 (Total sample)
Duration of the study: (normal weight Smoking,%:
1997-1993 matched to obese NR
by race, age, parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-50
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 Preeclampsia, gestational Good
G2: 660 G2: 3285 P ≤ 0.001 hypertension
Sample selection:
Total weight gain: Gestational Groups Fair
G1: 9.5 diabetes,%: Pregravid wt 19.8-26.0 BMI:
G2: 14.5 P ≤ 0.001 NR G1: < 11.5 kg gain Definition of
G2: 11.6-16 kg gain maternal weight
Categorized: Cesarean G3: > 16 kg gain gain:
• According to delivery,%: Fair
IOM G1: 25.6 Pregravid wt > 29 kg
G2: 9.1 P < 0.001 G4: lost/gained nothing Definition of
Collected from: G5: 0.5-6.5 kg gain outcomes:
• Routine pre- Instrumental G6: 7-11.5 kg gain Fair
natal care or delivery,%: G7: 12-16 kg gain Source of
maternity
Episiotomy,%: Results information on
records
Preeclampsia: exposure,
Other maternal outcomes, and
Ascertained by: G1: 2.8%
outcomes: confounders:
• Based on last NA G2: 2.9%
clinically G3: 6.6% Fair
measured Other infant (P =. 048) Followup:
weight prior to outcomes: Fair
delivery NA G4:10.7%
G5: 7.7% Analysis
G6: 8.3% comparability:
G7: 7.9% Good
G8: 16.5% Analysis of
(P = .076) outcomes:
Gestational HTN: Fair
G1: 2.3% Interpretation:
G2: 3.8% Good
G3: 3.3%
(P = .607) Sum of
Good/Fair/Poor:
G4: 9.3% 3 Good, 6 Fair, 0
G5: 8.3% Poor
G6: 11.3%
Final Quality Score:
G7:10.3%
Fair
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

C-51
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of G1: 84.4
Country and setting: G2: 85.8
pregravid BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg G4: 32.7 (31.3-34.7)
Funding: Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain
G2: 134 • Continuous
in obese glucose Other
G3: 132
tolerant women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: ≥ 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance Parity:
test (OGTT) during NR Diabetes mellitus,%:
third trimester NR
(according to WHO
Hypertension,%:
criteria)
NR
• Only first
pregnancy during Additional characteristics:
study period NR
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)

C-52
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200- Gestational hypertension Good
G2: 134 3840)
G3: 132 G2: 3645 (3200- Groups Sample selection:
G4: 122 4000) G1: < 5kg gain Poor
G3: 3750 (3390- G2: 5.0-9.9 kg gain
Total weight gain: G3: 10.0-14.9 kg gain Definition of maternal
4125) weight gain:
G4: 3762 (3400- G4: ≥ 15.0 kg gain
Categorized: Poor
• < 5.0. 5.0-9.9, 4120) Results
OR (95% CI) Definition of outcomes:
10.0-14.9, ≥ Gestational
G1: 1 Fair
15.0 diabetes, %:
NR G2: 2.1 (0.8-5.7) Source of information on
Collected from: G3: 3.6 (1.3-9.8) exposure, outcomes, and
• Routine pre- Cesarean delivery, G4: 4.8 (1.7-13.1) confounders:
natal care or %: (P = 0.001 Poor
maternity NR
records Maternal confounders Followup:
Instrumental and effect modifiers Fair
Ascertained by: delivery, %: accounted for in
• Not stated by NR analysis: Analysis comparability:
authors • Results of 2 hour Fair
Episiotomy, %:
OGTT Analysis of outcomes:
NR
• Age Good
Other maternal • Pregravid BMI
outcomes: • Parity Interpretation:
NA • Smoking Fair

Other infant • Ethnicity and site of Sum of Good/Fair/Poor:

outcomes: prenatal care 2 Good, 4 Fair, 3 Poor
NA Infant and child Final Quality Score:
confounders and effect Poor
modifiers accounted for
in analysis:
• Gestational age

C-53
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kabiru and Raynor, • Cohort • Measured at first White
2004 • Retrospective prenatal visit G1: 1.9
G2: 2.6
Country and setting: Total Study N: Pregravid BMI: G3: 2.8
USA, hospital 5,131
Imputed: Black
Enrollment Period: Group Description: • No G1: 84.1
1999 to 2002 G1: No change in BMI G2: 82.8
between first Categorized:
Funding: • 20-24.9, 25-29.9, 30- G3: 88.2
prenatal visit and
NR 34.9, 35-39.9, ≥ 40 Hispanic
delivery
Study Objective: G2: 1 category increase Age (mean, yrs): G1: 13.9
To investigate effect of in BMI between first G1: 24.7 (6.1) G2: 14.6
increase in body mass prenatal visit and G2: 24.4 (5.7) G3: 9.0
index category on delivery G3: 25.2 (5.9) P < 0.001 Asian/Pacific Islander
obstetric outcomes G3: > 1 category
Parity: NR
increase in BMI
Time frame: between first G1: Gravidity (mean): 1.9 Other
1999 to 2002 prenatal visit and (1.9) NR
Duration of the study: delivery G2: 1.5 (1.7)
G3: 1.2 (1.7) P < 0.001 Smoking,%:
Prenatal through birth Group N: NR
G1: 2,556
G2: 2,252 Diabetes mellitus,%:
G3: 323 NR

Inclusion criteria: Hypertension,%:

• Singleton NR
pregnancies Additional characteristics:
Exclusion criteria: Mean weight gain:
G1: 8.6 pounds (8.4)
• Multiple
G2: 22.2 pounds (10.2)
pregnancies
G3: 55.3 pounds (23.8)
• BMI < 20
• Missing BMI data Additional characteristics:
NR

C-54
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 579 G1: 2886.0 (756) Incidence preeclampsia Good
G2: 942 G2: 3174.9 (600)
G3: 189 G3: 3099.5 (673) Groups Sample selection:
G4: 819 P < 0.001 BMI < 25 first assessment: Fair
G5: 790 G4: 3116 (713) G1: no change BMI
category Definition of maternal
G6: 104 G5: 3269 (698) weight gain:
G6: 3371 (733) G2: increase 1 category
Total weight gain: G3: increase > 1 category Poor
P = 0.015
Categorized: BMI>/=25 first assessment Definition of outcomes:
Gestational Fair
• > 35 pounds diabetes,%: G4: no change BMI
for normal BMI, NR category Source of information on
> 25 pounds G5: increase 1 category exposure, outcomes, and
for overweight Cesarean G6: increase >1 category confounders:
BMI, > 15 delivery,%: Fair
G1: 8.2 Results
pounds for
G2: 12.6 G1: 1.9% Followup:
obese BMI
G3: 21.0 P < 0.001 G2: 3.2% Poor
Collected from: G4: 13.0 G3: 1.6%
• Routine pre- (P = .203) Analysis comparability:
G5: 14.3 Poor
natal care or G6: 19.3 P = 0.256
maternity G4: 2.8% Analysis of outcomes:
records Instrumental G5: 3.7% Fair
delivery,%: (P = .002)
Ascertained by: Interpretation:
• Based on last Episiotomy,%: Maternal confounders Poor
clinically and effect modifiers
Other maternal accounted for in Sum of Good/Fair/Poor:
measured outcomes:
weight prior to analysis: 1 Good, 4 Fair, 4 Poor
NA
delivery: not • Pre-gravid weight Final Quality Score:
stated, most Other infant Poor
Infant and child
likely difference outcomes:
confounders and effect
between NA
modifiers accounted for
weight at first
in analysis:
prenatal visit
NR
and weight at
delivery

C-55
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
(BMI 35–39.9) (n = Categorized: NR
Study Objective:
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight G3: Obese Class III Age (mean, yrs): NR
change on pregnancy (BMI 40 and More) G1: <26: 46%
outcomes in obese (n = 19,025) 26-35: 47% Other
women Older than 35: 8% G1: 22
Group N:
Time frame: NR G2: <26: 44% Smoking,%:
1990 to 2001 26-35: 48% NR
Inclusion criteria: Older than 35: 8%
Duration of the study: • Obese women G3: <26: 40% Diabetes mellitus,%:
Entry into prenatal care residing in Missouri 26-35: 52% NR
through delivery who delivered (at Older than 35: 9%
Hypertension,%:
37 or more weeks
of gestation) Parity: NR
liveborn, singleton Nulliparous:
G1: 34% Additional characteristics:
infants during NR
1990–2001 G2: 33%
G3: 32%
Exclusion criteria:
• NR

C-56
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Preeclampsia Good
LGA:13%
Total weight gain: (P < 0.05) Groups Sample selection:
G1: GWG (lb) G2: SGA: 7% Analysis done by each Fair
Less than 2: 3% LGA:16% class of obesity and weight
2 to 14: 15% changes in gestation: Definition of maternal
(P < 0.05) weight gain:
15 to 25: 26% G3: SGA: 6% • Weight loss ≥ 10 lbs
More than 25: Fair
LGA:18% • Weight loss 2-9 lbs
56% (P < 0.05) • No weight change Definition of outcomes:
G2: GWG (lb) • Gain 2-9 lbs Good
Less than 2: 8% Gestational diabetes, • Gain 10-14 lbs
2 to 14: 22% %: Source of information on
• Gain 15-25 lbs exposure, outcomes, and
15 to 25: 27% NR • Gain 26-35 lbs
More than 25: confounders:
Cesarean delivery,%: • Gain > 35 lbs. Fair
43%
G3: GWG (lb)Less G1: 28
Results Followup:
than 2: 15% G2: 34
Data all presented in graph Fair
G3: 41
form:
Instrumental Using a gain of 15-25 Analysis comparability:
Categorized: Fair
delivery,%: pounds as reference for
• 10-lb or less loss each obesity class, OR of
NR Analysis of outcomes:
2 to 9 lbs loss, no preeclampsia lower with
weight change, Episiotomy,%: Fair
less weight gain and higher
2 to 9 lbs gain, NR with more weight gain. Interpretation:
10 to 14 lbs gain, Poor
15–25 lb gain, Maternal confounders
26–35 lb gain, and effect modifiers Sum of Good/Fair/Poor:
and greater than accounted for in 2 Good, 6 Fair, 1 Poor
35 lb gain analysis:
Final Quality Score:
• Age
Collected from: Fair
• Education
• Routine pre-natal
• Poverty (defined as
care or maternity
participation in one or
records
more subsidized
Ascertained by: programs)
NR • Tobacco use
• Parity
• Chronic hypertension
Infant and child
confounders and effect
modifiers accounted for
in analysis:
NR

C-57
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-58
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Bivariate
Gain 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-59
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Murakami et al., 2004 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Japan, hospital Total Study N: G1: 20.9 (2.8) Black
633 G2: NR NR
Enrollment Period:
2001 Group Description: Imputed: Hispanic
G1: Total cohort • No NR
Funding:
G2: NR
NR Categorized: Asian/Pacific Islander
Group N: • WHO International NR
Study Objective:
G1: 633 Taskforce
To estimate risk of Other
G2: NR
perinatal morbidity of Age (mean, yrs): NR
mother and infant with Inclusion criteria: G1: 29.1 (4.5)
respect to maternal Smoking,%:
• Live, singletons G2: NR G1: 8.5
prepregnancy BMI and delivered between
weight gain in Japanese Parity: G2: NR
24 to 42 weeks
women gestation G1: 0.6 (0.7) Diabetes mellitus,%:
G2: NR G1: 2.1
Time frame: Exclusion criteria:
2001 G2: NR
NR
Duration of the study: Hypertension,%:
Prenatal through birth NR
Additional characteristics:
G1: Preeclampsia - mild:
5.4%; severe: 4.1%
G2: NR
Additional characteristics:
NR

C-60
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 633 G1: 3,052.6 (483.8) Preeclampsia Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational diabetes, %: G1: < 8.5 kg gain Fair
G1: 10.5 (3.4) G1: 2.1 G2: 8.5-12.5 kg gain
G2: NR G2: NR G3: >12.5 kg gain Definition of maternal
weight gain:
Categorized: Cesarean delivery,%: Results Fair
• < 8.5kg, 8.5- G1: 10.3 Estimated OR (95% CI)
G2: NR G1: 0.74 (0.37-1.48) Definition of outcomes:
12.5, > 12.5
G2: 1 Fair
Collected from: Instrumental delivery,%: G3: 0.57 (0.24-1.32)
NR Source of information on
• Routine pre-
Maternal confounders exposure, outcomes, and
natal care or
Episiotomy,%: and effect modifiers confounders:
maternity
NR accounted for in Fair
records
Other maternal analysis: Followup:
Ascertained by: • Maternal age
outcomes: Fair
• Based on last NA • Parity
clinically Analysis comparability:
• Smoking
measured Other infant outcomes: Fair
• Weight gain
weight prior to NA
• Gestational weeks Analysis of outcomes:
delivery: last
measurement • Pregravid BMI Fair
was taken at Infant and child Interpretation:
hospitalization confounders and effect Fair
prior to delivery modifiers accounted for
Sum of Good/Fair/Poor:
in analysis:
1 Good, 8 Fair, 0 Poor
NR
Final Quality Score:
Fair

C-61
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ogunyemi et al., 1999 • Other observational: • Self-reported White
582 women NR
Country and setting: Pregravid BMI:
consecutive women
USA, hospital Black
who delivered Imputed: G1: 100
Enrollment Period: • Retrospective • No G2: 100
1990 to 1995 G3: 100
Total Study N: Categorized:
Funding: 582 • IOM guidelines G4: 100
NR Hispanic
Group Description: Age (mean, yrs):
Study Objective: G1: Underweight G1: 20.3 NR
To test IOM guidelines G2: Normal G2: 22.1 Asian/Pacific Islander
in a predominantly rural G3: Overweight G3: 23.7 NR
black population G4: Obese G4: 25.4 (P < 0.01)
Other
Time frame: Group N: Parity: NR
1990 to 1995 G1: 78 G1: # nulliparous: 53
G2: 223 G2: 54 Smoking,%:
Duration of the study: G3: 78 NR
582 women who G3: 42
G4: 203 G4: 26 (P < 0.01)
delivered and then their Diabetes mellitus,%:
medical record was Inclusion criteria: G1: n = 0
abstracted • Single child G2: n = 4
• > 37 weeks G3: n = 3
gestation G4: n = 8 (P = 0.02)
• Black
Hypertension,%:
• Registration for G1: n = 1
prenatal care within G2: n = 2
first trimester of G3: n = 4
pregnancy G4: n = 14 (P < 0.01)
Exclusion criteria: Additional characteristics:
• Difference between NR
recalled pregravid
weight and
measured first
trimester weight was
≥ 10%

C-62
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 196 G1: 3,029 Incidence preeclampsia Fair
G2: 181 G2: 3,210
G3: 205 G3: 3,283 (P < 0.01) Groups Sample selection:
G1: “low weight gain” Poor
Total weight gain: Gestational G2: “normal weight gain”
diabetes, %: G3: “high weight gain” Definition of maternal
Categorized: G1: n = 0 weight gain:
• According to G2: n = 4 Results Good
IOM G3: n = 3 G1: 10%
G2: 7% Definition of outcomes:
Collected from: G4: n = 8 (P = 0.02) Good
G3: 19%
• Routine pre- Cesarean (P = <.01) Source of information on
natal care or delivery,%:
Maternal confounders exposure, outcomes, and
maternity G1: n = 20
and effect modifiers confounders:
records G2: n = 10
accounted for in Fair
Ascertained by: G3: n = 17 (P =
0.02) analysis: Followup:
• Based on last • Age Fair
clinically Instrumental • Parity
measured delivery,%: Analysis comparability:
• Pregravid BMI
weight prior to Good
Episiotomy,%: • Tobacco use
delivery: weight
• Hypertension Analysis of outcomes:
at last prenatal Other maternal Fair
visit outcomes: Infant and child
• Asthma confounders and effect Interpretation:
• Preeclampsia modifiers accounted for Fair
in analysis:
• Vomiting Sum of Good/Fair/Poor:
NR
• C-section 3 Good, 5 Fair, 1 Poor
Other infant Final Quality Score:
outcomes: Fair
• Low birth weight
• Fetal distress
• NICU

C-63
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Thorsdottir et al., 2002 • Cohort • Self-reported White
• Retrospective G1: 63.1 (6.2) NR
Country and setting:
G2: 62.0 (5.6) P = 0.059
Maternity records, Total Study N: Black
G3: 61.7 (4.8) P = 0.174
Department of 614 NR
G4: 62.2 (6.1) P = 0.274
Obstetrics and
Gynecology at Group Description: Hispanic
Pregravid BMI:
Landspitali University G1: No complication NR
G1: 22.2
Hospital, Iceland G2: Complications in G2: 22.4 )1.6) P = 0.270 Asian/Pacific Islander
pregnancy or G3: 22.4 (1.5) P = 0.338
Enrollment Period: NR
delivery G4: 22.3 P = 0.584
G3: Complications in Other
Funding:
pregnancy Imputed: NR
NR
G4: Complications in • No
Study Objective: delivery Smoking,%:
Categorized: NR
To investigate relation
between gestational
Group N: • Continuous
G1: 452 Diabetes mellitus,%:
weight gain in women of Age (mean, yrs): NR
G2: 162
normal prepregnant G1: 29
G3: 56 Hypertension,%:
weight and G2: 29 P = 0.857
G4: 106 NR
complications during G3: 29 P = 0.404
pregnancy and delivery Inclusion criteria: G4: 29 P = 0.398 Additional characteristics:
in a population with high • Women of normal Proportional weight gain, %:
gestational weight gain prepregnancy Parity:
G1: 26.0
and birth weight weight randomly NR
G2: 28.0 P = 0.018
Time frame: selected within 1 G3: 30.0 P = 0.005
NR year (1998) G4: 27.0 P = 0.546
• No history of
Duration of the study: diabetes, Additional characteristics:
1998 hypertension, CVD, NR
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

C-64
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 452 G1: 3789 (469) Gestational hypertension, Good
G2: 162 G2: 3749 (565) P = preeclampsia
G3: 56 0.389 Sample selection:
G4: 106 G3: 3643 (526) P = Groups Fair
0.032 G1: <11.5 kg gain
Total weight gain: G2; 11.5-16.0 kg gain Definition of maternal
G4: 3806 (578) P = weight gain:
G1: 16.6 (4.9) 0.529 G3: 16.1-20.0 kg gain
G2: 17.4 (5.1) P = G4: >20 kg gain Poor
0.080 Gestational diabetes, Definition of outcomes:
G3: 18.4 (5.1) P = %: Results
% gestational htn Fair
0.013 NR
G4: 16.9 (5.1) P = G1: 1.5% Source of information on
0.887 Cesarean delivery, %: G2: 4.6% exposure, outcomes, and
NR G3: 5.1% confounders:
Categorized: G4: 9.2% Fair
Instrumental delivery,
• According to IOM (P = 0.026)
%: Followup:
< 11.5, 11.-16.0,
NR % preeclampsia Good
≥ 16.1, also
G1: 1.4%
quintiles < 12.5, Episiotomy, %: Analysis comparability:
G2: 2.3%
12.5-15.5, 15.6- NR Good
G3: 5.4%
17.8, 17.9-20.8, >
Other maternal G4: 4.4% Analysis of outcomes:
20.8
outcomes: (P = 0.262) Good
Collected from: NA Maternal confounders Interpretation:
• Routine pre-natal
Other infant and effect modifiers Good
care or maternity
outcomes: accounted for in
records Sum of Good/Fair/Poor:
NA analysis:
Ascertained by: • Age 5 Good, 3 Fair, 1 Poor
• Based on last • Parity Final Quality Score:
clinically • Height Fair
measured weight
prior to delivery Infant and child
confounders and effect
modifiers accounted for
in analysis:
• Gestational age

C-65
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Wataba et al., 2006 • Perinatal data base • In data base don’t know White
and look at medical if self reported NR
Country and setting:
records
Japan, academic Pregravid BMI: Black
retrospectively
medical center G1: 20.5 (2.6) NR
• Retrospective
G2: 21.1 (3.0)
Enrollment Period: Hispanic
Total Study N:
1981 to 1999 Imputed: NR
21,718
• No
Funding: Asian/Pacific Islander
Group Description:
NR Categorized: NR
G1: Nulliparous
Study Objective: G2: Parous women • Categorical in 2 kg/m2 Other
To analyze association point intervals from NR
Group N: prepregnancy weight;
of pregnancy
G1: 10,413 categorical into low, Smoking,%:
complications with
G2: 11,305 medium, high BMI NR
prepregnant body mass
index and weight gain groups (< 18, 18-23.9, >
Inclusion criteria: Diabetes mellitus,%:
during pregnancy in 24)
• Singleton NR
Japanese women pregnancy Age (mean, yrs):
Hypertension,%:
Time frame: delivering term G1: 27.8 (4.1)
baby at Osaka Med G2: 30.45 (3.9) NR
1981 to 1999
Center and Additional characteristics:
Duration of the study: Research Institute Parity:
NR NR
Entry into PNC up til for Maternal and
delivery Child Health in
19811999
Exclusion criteria:
• None reported

C-66
Evidence Table 4. Gestational weight gain and hypertensive disorders (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 10413 G1: SGA: 5.4% Preeclampsia Good
G2: 11305 LGA 5.2%
G2: SGA 6.5% LGA Groups Sample selection:
Total weight gain: 5.2% Separate analyses done Fair
G1: kg/wk: 0.25 for low, medium and high
(SD 0.09) Gestational pregravid weight groups by Definition of maternal
G2: kg/wk: 0.24 diabetes, %: following intervals of weight gain:
(0.09) P < 0.01 NR kg/week gain: Poor
• <0.15 Definition of outcomes:
Categorized: Cesarean delivery,
• 0.15-.20 Poor
• Categorical in %:
NR • 0.20-.25
kg/wk using Source of information on
prepregnancy • 0.25-.30
Instrumental exposure, outcomes, and
weight and • 0.30-.35
delivery, %: confounders:
weight at • 0.35-40 Poor
NR • >0.40
delivery divided
by gestational Episiotomy, %: Followup:
Results Fair
age of infant at NR No clear trends for
birth preeclampsia or severe Analysis comparability:
Other maternal
Collected from: outcomes: preeclampsia by pregravid Poor
• Rate of weight • NR weight status and kg/week
Analysis of outcomes:
gain weight gains. AOR
Fair
determined by: Other infant generally crossed 1.0 or
total weight outcomes: had wide confidence Interpretation:
gain divided by NR intervals Fair
weeks ga Maternal confounders Sum of Good/Fair/Poor:
Ascertained by: and effect modifiers 1 Good, 4 Fair, 4 Poor
• Based on last accounted for in
analysis: Final Quality Score:
clinically Poor
measured • Baseline BMI
weight prior to • Parity
delivery: and Infant and child
subtracting confounders and effect
prepregnancy modifiers accounted for
weight in analysis:
NR

C-67
Evidence Table 5. Gestational weight gain and gallstones
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ko, 2006 • Case-control • Self-reported White
• Retrospective G1: 71.3
Country and setting: Pregravid BMI: G2: 83.5
USA, hospital Total Study N: G1: < 25 32.8%, 25-29.9
26,680 26.8%, > 30 40.4% Black
Enrollment Period: G1: 3.6
G2: BMI < 25 62.8%, 25-29.9
1987-2001 Group Description: G2: 3.9
22.1%, > 30 15.1%
G1: Cases
Funding: Hispanic
G2: Controls Imputed:
NR G1: 17.5
• No
Group N: G2: 11.2
Study Objective:
G1: 6,670 Categorized:
Aim was to define Asian/Pacific Islander
incidence and risk factors
G2: 20,010 • WHO International
for postpartum Taskforce < 25, 25-29.9, > G1: 2.6
Inclusion criteria: G2: 6.4
hospitalization as a result 30
• Diagnosis of biliary
of gallstone-related tract-related diseases Age (mean, yrs): Other
disease either at delivery G1: 26.0 ± 5.9 G1: 17.8
hospitalization or on G2: 27.2 ± 6.0 P < 0.001 G2: 12.8
Time frame:
1987 to 2001 hospitalizations within Smoking,%:
1 year postpartum Parity:
G1: Median 1 (0–13) G1: 17.4
Duration of the study: • Women with acute G2: 15.0
Entry into prenatal care G2: Median 1 (0–14)
pancreatitis with
through the postpartum associated diagnosis Diabetes mellitus,%:
period of cholelithiasis, G1: 5.0
choledocholithiasis, G2: 3.0
or cholangitis. Cases
Hypertension,%:
were defined as any
Prepregnancy:
woman with a biliary
G1: 1.6%
tract diagnosis at
G2: 0.8%
delivery
hospitalization, or Additional characteristics:
with a primary NR
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

C-68
Evidence Table 5. Gestational weight gain and gallstones (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 6670 G1: 3,442 ± 767 • Hospitalization for gallstones at delivery Fair
G2: 20010 G2: 3,443 ± 718 or within the first year postpartum
Sample
Total weight gain: Gestational Groups: selection:
G1: 12.6 ± 7.1 diabetes, %: G1: Cases Fair
G2: 14.4 ± 6.0 P < G1: 5.0 G2: Controls
0.001 G2: 3.0 Definition of
Results: maternal weight
Categorized: Cesarean OR for pregnancy weight gain, per kg gain:
• Continuous delivery,%: G1: 0.98 (0.97- 0.99) P < 0.001 Poor
G1: 25.1 G2: NR
Collected from: G2: 21.3 Definition of
• Routine pre-natal Outcomes Set 2: outcomes:
care or maternity Instrumental NR Good
records delivery,%:
Maternal confounders and effect Source of
Ascertained by: Episiotomy,%: modifiers accounted for in analysis: information on
• birth certificate • Age exposure,
Other maternal outcomes, and
data outcomes: • Race
• Pre-gravid BMI confounders:
• “Risk of Poor
hospitalization • GDM
was inversely Infant and child confounders and effect Followup:
associated with modifiers accounted for in analysis: Poor
weight gain • Gestational age Analysis
during
comparability:
pregnancy, even
Good
after adjustment
for prepregnancy Analysis of
body mass outcomes:
index.” Fair
Other infant Interpretation:
outcomes: Fair
NR
Sum of
Good/Fair/Poor:
2 Good, 4 Fair, 3
Poor
Final Quality
Score:
Poor

C-69
Evidence Table 5. Gestational weight gain and gallstones (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Lindseth and Bird-Baker, • Cohort • Measured by study White
2004 • Prospective investigators G1: 76%
• Routine pre-natal care G2: NR
Country and setting: Total Study N:
USA, hospitals and clinics 128 Pregravid BMI: Black
G1: 26.5 (6.08) NR
Enrollment Period: Group Description: G2: NR
NR G1: total cohort Hispanic
G2: NR Imputed: NR
Funding:
NIH, NICHD • No Asian/Pacific Islander
Group N:
G1: 128 Categorized: NR
Study Objective:
G2: NR • 1990 National Academy of Other
To examine relationships
of demographics, Sciences Standards G1: 24% (Native American)
Inclusion criteria:
anthropometrics, prenatal • Within first 12 weeks Age (mean, yrs): G2: NR
physical activity, serum of pregnancy G1: 26.0 (4.78)
cholesterol, and nutrient • Smoking,%:
Consented to G2: NR NR
intakes to symptomatic participation
cholelithiasis occurrence • Parity: Diabetes mellitus,%:
18 to 40 years of age
Gravida: NR
Time frame: • Could understand,
G1: 2.7 (1.65)
NR read, and speak Hypertension,%:
G2: NR
English NR
Duration of the study:
14 weeks gestation to 1 Exclusion criteria: Additional characteristics:
month post-partum NR NR

C-70
Evidence Table 5. Gestational weight gain and gallstones (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • Cholelithiasis during pregnancy or upto 12 Good
Total weight gain:
weeks postpartum
Gestational Sample
Categorized: diabetes, %: selection:
Groups:
• Continuous NR NA, weight gain continuous variable Fair
Collected from: Cesarean delivery, G1: 128 Definition of
• Routine pre-natal %: G2: NR maternal weight
care or maternity NR gain:
records Results: Fair
Instrumental Prenatal weight gain
Ascertained by: delivery, %: Partial correlation = 0.33; B = 0.13; not Definition of
• Based on last NR statistically significant outcomes:
clinically Good
measured weight Episiotomy, %: Maternal confounders and effect modifiers
prior to delivery: NR accounted for in analysis: Source of
not specifically • Age information on
Other maternal exposure,
stated outcomes: • Parity
• Pre-gravid BMI outcomes, and
cholelithiasis in 16 confounders:
women (12.5%) • Prenatal physical activity
• Dietary fat Good
Other infant • Dietary iron supplement Followup:
outcomes: • History of gallbladder disease Fair
NA • Serum cholesterol
Analysis
Infant and child confounders and effect comparability:
modifiers accounted for in analysis: Fair
NR
Analysis of
outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
3 Good, 6 Fair, 0
Poor
Final Quality
Score:
Fair

C-71
Evidence Table 6. Gestational weight gain and premature rupture of membranes
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Gosselink et al., 1992 • Case-control • Self-reported White
• Retrospective G1: 36.6
Country and setting: Pregravid BMI: G2: 36.6
USA, university clinics Total Study N: G1: ≤ 20: 26.5%
Total n = 1,176 20-29: 65.0% Black
Enrollment Period: NR
• n = 184, preterm ≥ 30: 8.5%
September 1985-August
delivery (≤ 36 G2: ≤ 20: 19.4%
1987 (University of Iowa Hispanic
weeks) and PROM 20-29: 68.6%
Hospitals) NR
• n = 220, preterm ≥ 30: 12.0%
September 1987-April
1990 (University of delivery without Asian/Pacific Islander
Imputed:
Chicago) PROM NR
• No
• n = 184, fullterm
Funding: Other
delivery with PROM Categorized:
US Public Health NR
• n = 588, Controls • Underweight: < 20
Services, National • Normal weight: 20-29 Smoking,%:
Institute of Child Health Group Description: NR
(referent)
and Human G1: All cases
• Obese: > 30
Development G2: All controls Diabetes mellitus,%:
Age (mean, yrs): NR
Study Objective: Group N:
NR
To test hypothesis that G1: 588 Hypertension,%:
maternal prepregnancy G2: 588 Parity: NR
body weight, weight G1: % nulliparous: 44.4
Inclusion criteria: Additional characteristics:
gain during gestation, G2: % nulliparous: 44.4
• 15-45 years NR
and prepregnancy and
• Singleton delivery
pregnancy diet and
• Consented to
supplement status
interview while still
relate to PROM and
in hospital
preterm delivery
Exclusion criteria:
Time frame:
September 1985 to • Mothers with
August 1987 (University chronic conditions
of Iowa Hospitals) likely to adversely
September 1987 to April affect the course of
1990 (University of pregnancy such as
Chicago) cystic fibrosis,
emphysema,
Duration of the study: chronic heart
Interviewed within 72 failure, or poorly
hours of delivery to controlled diabetes
obtain retrospective mellitus
data • Women receiving
chemotherapy or
radiation treatments
• Mothers with limited
mental capacity

C-72
Evidence Table 6. Gestational weight gain and premature rupture of membranes (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes descriptions: Background:
G1: 588 NR AOR for premature rupture of Good
G2: 588 membrane (95% CI)
Gestational Sample selection:
Total weight gain: diabetes, %: Groups: Fair
G1: < 21 lbs: 36.7% NR G1: GWG: 21-30 lbs
21-30 lbs: G2 GWG: 31-40 lbs Definition of maternal
34.0% Cesarean delivery, G3 GWG: > 40 lbs weight gain:
31-40 lbs: %: G4 GWG: < 21 lbs or lost Fair
14.1% NR weight Definition of outcomes:
> 40 lbs: 15.1% Instrumental Good
G2: < 21 lbs: 19.6% Results:
delivery, %: Preterm, PROM moms and
21-30 lbs: NR Source of information
28.9% matched controls on exposure, outcomes,
31-40 lbs: Episiotomy, %: G1: 1.00 and confounders:
24.1% NR G2: 0.24 (0.09-0.61) Poor
> 40 lbs: 27.4% G3: 0.19 (0.07-0.57)
Other maternal G4 2.70 (1.14-6.36) Followup:
Categorized: outcomes: Fair
• < 21lbs NA Full term, PROM moms and Analysis comparability:
• 21-30 Other infant matched controls Fair
• 31-40 outcomes: G1 1.00
• > 40lbs NA G2: 0.56 (0.33-0.94) Analysis of outcomes:
G3 0.83 (0.48-1.46) Good
Collected from: G4 0.83 (0.44-1.57)
• Routine pre- Interpretation:
natal care or Poor
Preterm without PROM
maternity moms and matched controls Sum of Good/Fair/Poor:
recordsnot G1: 1.00 3 Good, 4 Fair, 2 Poor
stated G2: 0.42 (0.21-0.84)
G3: 0.37 (0.17-0.80) Final Quality Score:
Ascertained by: Fair
G4 1.34 (0.78-2.32)
• Not specifically
stated
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

C-73
Evidence Table 6. Gestational weight gain and premature rupture of membranes (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Nohr et al., 2007 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
Denmark, primary care Total Study N: NR Black
0 NR
Enrollment period: Imputed:
1996 to 2002 Group Description: • No Hispanic
G1: Total NR
Funding: Categorized:
Ellen Aagaard Nohr is Group N: • WHO International Asian/Pacific Islander
supported by a grant G1: 62,167 Taskforce NR
(No.2002B020) from
Health Insurance Inclusion criteria: Age (mean, yrs): Other
Foundation. Danish • Women with G1: < 25: 7,757 (12.5%) NR
National Research singleton 25 to 29: 26,152 (42.1%) Smoking,%:
Foundation established pregnancies who 30 to 34: 21,181 (34.1%) G1: 84.1% nonsmoker
Danish Epidemiology provided an 35+: 7,077 (11.4%)
Science Centre, which interview at Diabetes mellitus,%:
approximately 16 Parity: G1: 1.2%
initiated and created G1: 47% primiparous
Danish National Birth weeks gestation
Hypertension,%:
Cohort. Cohort is also Exclusion criteria: G1: 1.6%
result of major grant • Missing data on
from this Foundation. Additional characteristics:
weight gain in
Additional support for NR
pregnancy
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

C-74
Evidence Table 6. Gestational weight gain and premature rupture of membranes (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 62 167 NR Adjusted hazard of Good
G2: 2751 spontaneous preterm birth
G3: 41 991 Gestational with preterm premature Sample selection:
G4: 12 270 diabetes, %: rupture of membrane Fair
G5: 5155 G1: 1.2% (PPROM) Definition of maternal
Total weight gain: Cesarean Groups: weight gain:
G1: Weekly weight delivery,%: weekly weight gain Fair
gain (g) 8722;275g: NR G1: <275 g Definition of outcomes:
(15.3%) 276–675g: Instrumental G2: 276-675 g Good
(68.3%) 676g+ delivery,%: G2: >675 g
(16.4%) NR Source of information on
Results: exposure, outcomes, and
Categorized: Episiotomy,%: Spontaneous preterm confounders:
• Weekly weight NR birth with PPROM Poor
gain categorised G4: 1.5 [1.2, 1.7]
into 3 groups Other maternal G4: 1.0 Reference Followup:
(low, medium, outcomes: G4: 1.2 [1.0, 1.5] Good
high) using • Before 34 weeks
Maternal confounders and Analysis comparability:
cutpoints at 275 of gestation, risk
effect modifiers Fair
and 675 g, which of induced
preterm delivery accounted for in analysis: Analysis of outcomes:
were similar to
those used in potentiated • Age Fair
other studies among obese • Parity
women with high • Height Interpretation:
Collected from: weight gain, and • Alcohol use Good
• Does not specify- after 34 weeks, • Socio-occupational Sum of Good/Fair/Poor:
women self- risk was status 4 Good, 4 Fair, 1 Poor
reported weight potentiated at • Smoking
gain status extremes, Final Quality Score:
namely among Infant and child Fair
Ascertained by: confounders and effect
underweight
• Self-reported modifiers accounted for in
women with a
low weight gain analysis:
and obese NR
women with a
high weight gain
Other infant
outcomes:
NR

C-75
Evidence Table 7. Gestational weight gain and preterm labor
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Lang et al., 1996 • Cohort • Not stated by authors White
• Retrospective G1: NR G1: 5.3
Country and setting: G2: 9.1
• < 100 pounds: 11.2
USA, hospital Total Study N:
• 100-125: 5.9 Black
11,505
Enrollment period: • 126-160: 5.1 G1: 9.6
August 1977-March Group Description: • 161-180: 7.3 G2: 17.7
1980 G1: Prevalence of • > 180: 4.4
preterm labor G2: NR Hispanic
Funding: NR
G2: Prevalence of SGA • < 100 pounds: 24.9
NR
Group N: • 100-125: 12.6 Asian/Pacific Islander
Study Objective: • 126-160: 7.7 NR
To estimate effects of Inclusion criteria: • 161-180: 6.5
23 factors on • Singleton • > 180: 5.9 Other
prevalence of premature • Livebirths G1: 5.0
labor and fetal growth • Had data on Pregravid BMI: G2: 14.0
retardation across birthweight, Imputed: Smoking,%:
birthweight spectrum gestational age, • No % smoked throughout
Time frame: and sex pregnancy:
• Infants with Categorized:
August 1977 to March G1: 8.3
1980 gestational age • NR G2: 17.9
from 22 to 45 Age (mean, yrs):
Duration of the study: weeks Diabetes mellitus,%:
Pregnancy through G1: NR
• Birthweights no • < 15: 14.8
delivery more than 50%
• 16-19: 11.2 Hypertension,%:
higher than 90th NR
• 20-24: 8.2
percentile for sex
and gestational age • 25-34: 4.6 Additional characteristics:
• ≥ 35: 5.5 NR
Exclusion criteria: G2:
• Women with • < 15: 25.0
menstrual • 16-19: 17.6
abnormalities for • 20-24: 14.3
whom gestational • 25-34: 9.4
dating was • ≥ 35: 7.2
problematic
• Stillbirths Parity:
• Incomplete data G1: 6.4
• Preterm delivery G2: 12.3
• Women with
preexisting
diabetes mellitus,
hypertension,
epilepsy, asthma

C-76
Evidence Table 7. Gestational weight gain and premature labor (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • AOR for preterm labor Good
Total weight gain:
(95% CI)
Gestational Sample selection:
Categorized: diabetes, %: Fair
Groups
• Weekly rate of NR G1: Weekly weight gain ≤
weight gain Definition of maternal
0.40
Cesarean delivery, weight gain:
Collected from: G2: Weekly weight gain >
%: Poor
• Not stated by 0.40-0.65
NR
authors G3: Weekly weight gain > Definition of outcomes:
Instrumental 0.65-0.90 Poor
Ascertained by: delivery, %: G4: Weekly weight gain >
• NR NR 0.90 Source of information on
G5: Weekly weight gain exposure, outcomes, and
Episiotomy, %: missing confounders:
NR Poor
Results
Other maternal G1: 3.1 (2.3-4.2) Followup:
outcomes: G2: 1.6 (1.3-2.0) Fair
NA G3: 1.0 (ref) Analysis comparability:
Other infant G4: 1.3 (1.0-1.6) Good
outcomes: G5: 2.4 (1.1-5.0)
NA Analysis of outcomes:
Maternal confounders and Good
effect modifiers
accounted for in analysis: Interpretation:
• Age Fair
• Race Sum of Good/Fair/Poor:
• Parity 3 Good, 3 Fair, 3 Poor
• Maternal height
• Prepregnancy weight Final Quality Score:
• Maternal education Poor
• 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

C-77
Evidence Table 8. Maternal weight gain and post-term pregnancy
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cedergren, 2006 • Cohort • Self-reported White
• Prospective • If unknown, G1: 96.6
Country and setting: G2: NR
standardized
Sweden, Medical Birth Total Study N: measurement is made
Registry 245,526 Black
during first visit to
NR
Enrollment Period: Group Description: maternity health care
January 1, 1994 - BMI center Hispanic
December 31, 2002 G1: < 20 NR
Pregravid BMI:
G2: 20 to 24.9
Funding: Asian/Pacific Islander
G3: 25 to 29.9 Imputed:
Ostergotland County G1: 1.4
Council
G4: 30 to 34.9 • No G2: NR
G5: ≥ 35
Study Objective: Categorized: Other
Group N: • < 20, 20.0-24.9, 25.0-
To estimate effects of G1: 2.0
G1: 28,186 29.9, 30-34.9, ≥ 35
high and low gestational G2: NR
G2: 143,365
weight gain in different Age (mean, yrs):
G3: 60,626 Smoking,%:
maternal BMI classes G1: 15 to 19 years: 3.8%
G4: 17,248 G1: % nonsmoking: 81.6
on obstetric and 20 to 24: 23.0%
G5: 6,296 G2: 85.2
neonatal outcomes 25 to 29: 38.7% G3: 83.1
Inclusion criteria: 30 to 34: 25.7%
Time frame: G4: 79.9
January 1, 1994 to • Singleton, term 35 to 39: 7.7% G5: 78.4
December 31, 2002 pregnancies ≥ 40: 1.1% Group 6
• Information on G2: 15 to 19 years: 1.9%
Duration of the study: maternal height, 20 to 24: 15.9% Diabetes mellitus,%:
First visit to maternity maternal weight in 25 to 29: 37.7% NR
health care center to early pregnancy, 30 to 34: 31.1%
delivery Hypertension,%:
and gestational 35 to 39: 11.3%
NR
weight gain ≥ 40: 1.9%
G3: 15 to 19 years: 1.5% Additional characteristics:
Exclusion criteria: 20 to 24: 15.7% NR
• NA 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%

C-78
Evidence Table 8. Maternal weight gain and post-term pregnancy (continued)
Outcomes from
Maternal Weight Bivariate Outcomes from Multivariate
Gain Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28,186 NR Post-term pregnancy (>41 weeks) Good
G2: 143,365
G3: 60,626 Gestational Groups Sample selection:
G4: 17,248 diabetes, %: G1:BMI < 20 Fair
G5: 6,296 NR G2:BMI 20-24.9
G3:BMI 25-29.9 Definition of maternal
Total weight gain: Cesarean G4:BMI 30-34.9 weight gain:
G1: < 8kg: 6.9% delivery, %: G5:BMI>35 Fair
8-15.9kg: 65.2% NR
Results Definition of outcomes:
≥ 16kg: 28.0% Instrumental Good
G2: < 8kg: 8.4% Post-term pregnancy by BMI for
delivery, %: weight gain < 8 kg (reference gain
8-15.9kg: 67.1% NR Source of information
≥ 16kg: 30.4% 8-16 kg) on exposure, outcomes,
G3: < 8kg: 15.7% Episiotomy, %: OR (95% CI): and confounders:
8-15.9kg: 54.4% NR G1: 0.66 (0.27-1.63) Good
≥ 16kg: 29.9% G2: 0.86 (0.64-1.16)
Other maternal G3: 1.08 (0.87-1.42) Followup:
G4: < 8kg: 30.2% outcomes: Fair
8-15.9kg: 48.7% G4: 1.23 (0.84-1.79)
NA G5: 1.25 (0.66-2.37)
≥ 16kg: 21.1% Analysis comparability:
G5: < 8kg: 44.6% Other infant Post-term pregnancy by BMI for Fair
8-15.9kg: 40.9% outcomes: weight gain >16 kg (reference
NA Analysis of outcomes:
≥ 16kg weight gain 8-16kg) OR (95% CI): Fair
Categorized: G1: 0.88 (0.56-1.39)
G2: 0.87 (0.74-1.03) Interpretation:
• < 8kg, 8-16, > Good
G3: 0.82 (0.66-1.03)
16
G4: 0.78 (0.50-1.21)
Sum of Good/Fair/Poor:
Collected from: G5: 1.11 (0.51-2.41)
4 Good, 5 Fair, 0 Poor
• Routine pre-
Maternal confounders and effect
natal care or Final Quality Score:
modifiers accounted for in
maternity Fair
analysis:
records
• Age
Ascertained by: • Parity
• Based on last • Smoking in early pregnancy
clinically
measured Infant and child confounders
weight prior to and effect modifiers accounted
delivery: for in analysis:
difference • Year of birth
between
maternal
weights
measured when
woman attended
delivery unit and
maternal weight
recorded at first
visit to maternity
health care
center

C-79
Evidence Table 9. Gestational weight gain and induction of labor
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
DeVader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained G1: 79.7
Country and setting: G2: 85.6
from mother during
United States, birth Total Study N: G3: 85.2
postpartum hospital stay
certificate data 94,696
Pregravid BMI: Black
Enrollment period: Group Description: G1: 15.7
NR
1999 to 2001 G1: Gained less than 25 G2: 10.8
• Imputed:
lbs G3: 12.1
Funding: • No
G2: Gained 25 to 35 lbs
NR • Categorized: Hispanic
G3: Gained more than
35 lbs NR NR
Study Objective:
To investigate Age (mean, yrs): Asian/Pacific Islander
Group N:
relationship between G1: Maternal age (y) NR
G1: 16,852
gestational weight gain 18 to 24*: 42.3%
G2: 37,292
and adverse pregnancy 25 to 30: 36.2% Other
G3: 40,552
outcomes among 31 to 35: 21.5% G1: 4.6
women with normal Inclusion criteria: G2: Maternal age (y) G2: 3.5
prepregnancy BMI • All mothers with 18 to 24*: 36.7% G3: 2.7
normal 25 to 30: 39.5%
Time frame: Smoking,%:
prepregnancy BMI 31 to 35: 23.8%
1999 to 2001 G1: 20.5
(19.8 –26.0 kg/m2) G3: Maternal age (y)
G2: 14.9
Duration of the study: who were 18 to 35 18 to 24*: 44.7%
G3: 17.4
Entry into prenatal care years of age at time 25 to 30: 35.9%
through delivery of delivery and who 31 to 35: 19.4% Diabetes mellitus,%:
delivered full-term NR
Parity:
(37 weeks or more)
NR Hypertension,%:
singleton infant
during period NR
January 1, 1999, to Additional characteristics:
December 31, 2001 NR
Exclusion criteria:
• Women aged
younger than 18
years and older
than 35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-80
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR AOR for failed induction of labor Good
Total weight gain: Gestational diabetes, Groups Sample
NR %: G1: < 30 lbs selection:
NR G2: 30-35lbs Fair
Categorized: G3: > 35 lbs
• According to Cesarean delivery,%: Definition of
IOM NR Results maternal weight
G1: 0.68 gain:
Collected from: Instrumental Fair
• Routine pre- delivery,%: (95% CI, 0.59–0.78)
natal care or NR G2: 1.0 Definition of
maternity G3: 1.51 outcomes:
Episiotomy,%: (95% CI, 1.39–1.64) Good
records
NR
Ascertained by: Source of
Other maternal Maternal confounders and effect information on
NR
outcomes: modifiers accounted for in analysis: exposure,
• Figures 1 to 3 plot Maternal age, maternal race or ethnicity, outcomes, and
risk for each maternal education, Medicaid status, confounders:
adverse pregnancy tobacco use, alcohol use, maternal height, Fair
outcome by 10-lb prior pregnancy, adequacy of prenatal care
increments in Followup:
gestational weight Infant and child confounders and effect Fair
gain. Women who modifiers accounted for in analysis:
Child's gender, birth year Analysis
gained 25 to 34 lbs
comparability:
during their
Fair
pregnancy had
lower risks for most Analysis of
outcomes when outcomes:
balancing risk for Fair
SGA status and
other adverse Interpretation:
pregnancy Fair
outcomes Sum of
• Women who Good/Fair/Poor:
gained 15 to 24 lbs 2 Good, 7 Fair, 0
had lowest risks for Poor
most outcomes, but
increased their risk Final Quality
of having an SGA Score:
infant from 9.6% to Fair
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

C-81
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if White
1992 • Combination: self reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at G4: 65.0 (12.2) Hispanic
July 1, 1985 - delivery G5: 58.3 (6.5) NR
December 31, 1985 (6
Total Study N: Pregravid BMI: Asian/Pacific Islander
months)
Total n = 357 G1: 39.5 (3.4) NR
Funding: • 191 women with G2: 17.2 (0.9)
NR abnormal G3: 26.1 (6.1) Other
prepregnant weight G4: 23.6 (4.1) NR
Study Objective: G5: 21.6 (2.0)
(≥ 20% under or Smoking,%:
To evaluate effects of
over ideal weight for NR
abnormal maternal • Imputed:
height) or abnormal
weight or weight gain on pregnancy weight • No Diabetes mellitus,%:
pregnancy outcome NR
gain (≥ 20kg or ≤ • Categorized:
Time frame: 5kg) • Continuous ≥ 20% over Hypertension,%:
July 1, 1985 to • 166 controls or under normal weight NR
December 31, 1985 (6 for height
Group Description: Additional characteristics:
months)
G1: ≥ 20% over normal Age (mean, yrs): NR
Duration of the study: weight for height G1: 28 (5.1)
Prepregnancy to G2: ≥ 20% under normal G2: 25.5 (5.1)
delivery weight for height G3: 29.5 (5.1)
G3: weight gain ≤ 5kg G4: 28.7 (4.7)
G4: weight gain ≥ 20kg G5: 28.7 (4.4)
G5: control Group 6
Parity:
Group N: G1: prior deliveries: 1.0
G1: 77 (1.0)
G2: 28 G2: 0.8 (0.8)
G3: 30 G3: 1.2 (1.1)
G4: 56 G4: 0.8 (1.0)
G5: 166 G5: 0.9 (1.0)
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

C-82
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Maternal Weight Outcomes from Bivariate Outcomes from Multivariate
Gain Analysis Analysis Quality Grading
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Induction of labor (%) Fair
G2: 28 P < 0.05 compared to
G3: 30 controls Groups Sample
G4: 56 G2: 3293 (362) G1: weight gain ≤ 5kg selection:
G5: 166 P < 0.05 compared to G2: weight gain ≥ 20kg Poor
controls G3: reference (normal
Total weight gain: prepregnancy weight and Definition of
G3: 3284 (880) maternal weight
G1: 11.8 (6.2) G4: 3803 (538) normal weight gain [undefined])
P < 0.05 compared to gain:
P < 0.005 compared to Results Poor
controls controls
G2: 13.4 (4.5) G1: 23 %
G5: 3538 (535) G2: 43 % Definition of
G3: 3.0 (3.5) outcomes:
P < 0.0005 compared Gestational diabetes,%: G3: 24 %
P < 0.05 for G2 vs. G3 Poor
to controls NR
G4: 23.2 (22.8) Maternal confounders and effect Source of
P < 0.0005 compared Cesarean delivery,%: information on
G1: Elective 7% modifiers accounted for in
to controls analysis: exposure,
G5: 13.2 (3.4) Emergency 14% outcomes, and
Total 21% NA
confounders:
Categorized: G2: Elective 4% Infant and child confounders and Fair
• ≤ 5kg or ≥ 20kg Emergency 4% effect modifiers accounted for in
Total 8% analysis: Followup:
Collected from: G3: Elective 3% Fair
NA
• Routine pre-natal Emergency 3%
care or maternity Analysis
Total 6% comparability:
records G4: Elective 5% Poor
Ascertained by: Emergency 18%
Total 23% Analysis of
• Based on last
G5: Elective 13% outcomes:
clinically
Emergency 9% Fair
measured weight
prior to delivery Total 22%
Interpretation:
Instrumental delivery,%: Poor
NR
Sum of
Episiotomy,%: Good/Fair/Poor:
NR 0 Good, 4 Fair, 5
Poor
Other maternal outcomes:
NA Final Quality
Score:
Other infant outcomes: Poor
NA

C-83
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Graves et al., 2006 • Cohort • Actual prepregnant White
• Retrospective weight or early first G1: 26.9
Country and setting:
trimester weight
USA, midwifery Total Study N: Black
documented in medical
practices 1,500 G1: 18.7
records
Enrollment Period: Group Description: Hispanic
Pregravid BMI:
January 1, 1998- G1: Total cohort G1: 52.1
G1: < 19.8: 9.4%
December 31, 2000
Group N: 19.8-26.0: 52.1% Asian/Pacific Islander
Funding: G1: 1,500 26.1-29.0: 20.6% NR
NR > 29: 17.4%
Inclusion criteria: Other
Study Objective: • Non-diabetic • Imputed: G1: 2.2
To identify association • Entered labor after • No
between prepregnancy Smoking,%:
34 weeks gestation • Categorized: NR
BMI, weight gain in
pregnancy, and Exclusion criteria: • IOM guidelines
Diabetes mellitus,%:
newborn birth weight on • Planned cesarean Age (mean, yrs): NR
route of delivery and delivery (n = 8) G1: ≤ 19 years: 32.2%
induction of labor in • Unknown parity (in Hypertension,%:
20-34: 62.4%
patients receiving analyses in which NR
≥ 35: 4.9%
nurse-midwifery care parity was an Additional characteristics:
important Parity:
Time frame: NR
consideration, G1: % nulliparous: 42.3
January 1, 1998- n = 40)
December 31, 2000 • Hypertension
Duration of the study: • Diabetes
PRN care up til delivery

C-84
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Outcomes from Bivariate Outcomes from Multivariate
Maternal Weight Gain Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1500 G1: < 2500g: 3.5% OR induction of labor Good
G2: NR 2500-3999: 84.6%
4000-4449: 9.1% Groups Sample
Total weight gain: ≥ 4500: 1.4% G1: ≤ 45 pounds selection:
G1: < 15 pounds: G2: > 45 pounds Fair
12.7% Gestational diabetes,%:
15-25: 25.2% NR Results Definition of
26-35: 29.3% G2: 1.5 (95% CI, 1.0-2.4) maternal weight
36-45: 16.3% Cesarean delivery,%: gain:
G1: 8.8 Maternal confounders and Poor
> 45: 10.1% effect modifiers accounted
G2: NR
Categorized: for in analysis: Definition of
• ≤ 15 pounds 16-
Instrumental delivery,%: • Maternal BMI outcomes:
NR Fair
24, 25-35, 36-45, Infant and child confounders
> 45 Episiotomy,%: and effect modifiers Source of
NR accounted for in analysis: information on
Collected from:
• Gestational age exposure,
• Routine pre-natal Other maternal outcomes:
• Birth weight outcomes, and
care or maternity NA confounders:
records
Other infant outcomes: Fair
Ascertained by: NA Followup:
• Based on last Good
clinically
measured weight Analysis
prior to delivery comparability:
Fair
Analysis of
outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
2 Good, 6 Fair, 1
Poor
Final Quality
Score:
Fair

C-85
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of G1: 84.4
Country and setting: G2: 85.8
pregravid BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg G4: 32.7 (31.3-34.7)
Funding: Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain
G2: 134 • Continuous
in obese glucose Other
G3: 132
tolerant women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: ≥ 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance Parity:
test (OGTT) during NR Diabetes mellitus,%:
third trimester NR
(according to WHO
Hypertension,%:
criteria)
NR
• Only first
pregnancy during Additional characteristics:
study period NR
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)

C-86
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Maternal Outcomes from Outcomes from Multivariate
Weight Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200-3840) OR for induction of labor Good
G2: 134 G2: 3645 (3200-4000)
G3: 132 G3: 3750 (3390-4125) Groups Sample selection:
G4: 122 G4: 3762 (3400-4120) G1: GWG < 5.0 kg Poor
G2: GWG 5.0-9.9 kg
Total weight Gestational diabetes, G3: GWG 10.0-14.9 kg Definition of maternal weight
gain: %: G4: GWG ≥ 15.0 kg gain:
Categorized: NR Poor
Results
• < 5.0. 5.0- Definition of outcomes:
Cesarean delivery, G1: 1.0
9.9, 10.0- Fair
%: G2: 2.7 (95% CI, 1.3-5.7)
14.9, ≥ 15.0
NR G3: 2.8 (95% CI, 1.3-5.9) Source of information on
Collected from: G4: 3.7 (95% CI, 1.7-8.0) exposure, outcomes, and
Instrumental P for trend=0.002
• Routine pre- confounders:
delivery, %:
natal care or Poor
NR Maternal confounders and
maternity
effect modifiers accounted Followup:
records Episiotomy, %: for in analysis: Fair
NR
Ascertained by: • Age
• Analysis comparability:
• Not stated Other maternal Pre-gravid BMI
by authors outcomes: • 2 hour OGTT result Fair
NA • Smoking Analysis of outcomes:
Other infant Good
Infant and child confounders
outcomes: and effect modifiers Interpretation:
NA accounted for in analysis: Fair
• Gestational age
Sum of Good/Fair/Poor:
2 Good, 4 Fair, 3 Poor
Final Quality Score:
Poor

C-87
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kabiru and Raynor, • Cohort • Measured at first White
2004 • Retrospective prenatal visit G1: 1.9
G2: 2.6
Country and setting: Total Study N: Pregravid BMI: G3: 2.8
USA, hospital 5,131
Imputed: Black
Enrollment Period: Group Description: • No G1: 84.1
1999 to 2002 G1: No change in BMI G2: 82.8
between first Categorized:
Funding: • 20-24.9, 25-29.9, 30- G3: 88.2
prenatal visit and
NR 34.9, 35-39.9, ≥ 40 Hispanic
delivery
Study Objective: G2: 1 category increase Age (mean, yrs): G1: 13.9
To investigate effect of in BMI between first G1: 24.7 (6.1) G2: 14.6
increase in body mass prenatal visit and G2: 24.4 (5.7) G3: 9.0
index category on delivery G3: 25.2 (5.9) P < 0.001 Asian/Pacific Islander
obstetric outcomes G3: > 1 category
Parity: NR
increase in BMI
Time frame: between first G1: Gravidity (mean): 1.9 Other
1999 to 2002 prenatal visit and (1.9) NR
Duration of the study: delivery G2: 1.5 (1.7)
G3: 1.2 (1.7) P < 0.001 Smoking,%:
Prenatal through birth Group N: NR
G1: 2,556
G2: 2,252 Diabetes mellitus,%:
G3: 323 NR

Inclusion criteria: Hypertension,%:

• Singleton NR
pregnancies Additional characteristics:
Exclusion criteria: Mean weight gain:
G1: 8.6 pounds (8.4)
• Multiple
G2: 22.2 pounds (10.2)
pregnancies
G3: 55.3 pounds (23.8)
• BMI < 20
• Missing BMI data Additional characteristics:
NR

C-88
Evidence Table 9. Gestational weight gain and induction of labor (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 579 G1: 2886.0 (756) Percent failed induction of labor Good
G2: 942 G2: 3174.9 (600)
G3: 189 G3: 3099.5 (673) Groups Sample selection:
G4: 819 P < 0.001 G1: normal BMI, no change in BMI Fair
G5: 790 G4: 3116 (713) between first prenatal visit and
delivery Definition of maternal weight
G6: 104 G5: 3269 (698) gain:
G6: 3371 (733) G2: normal BMI, 1 category
Total weight gain: increase in BMI between first Poor
P = 0.015
prenatal visit and delivery Definition of outcomes:
Categorized: Gestational G3: normal BMI, > 1 category Fair
• > 35 pounds diabetes,%: increase in BMI between first
for normal BMI, NR prenatal visit and Source of information on
> 25 pounds G4: overweight BMI, no change in exposure, outcomes, and
for overweight Cesarean BMI between first prenatal visit confounders:
BMI, > 15 delivery,%: and delivery Fair
pounds for G1: 8.2 G5: overweight BMI, 1 category
obese BMI G2: 12.6 Followup:
increase in BMI between first Poor
G3: 21.0 P < 0.001 prenatal visit and delivery
Collected from: G4: 13.0
• Routine pre- G6: overweight BMI, > 1 category Analysis comparability:
G5: 14.3 increase in BMI between first Poor
natal care or G6: 19.3 P = 0.256
maternity prenatal visit and delivery
Analysis of outcomes:
records Instrumental Results Fair
delivery,%: G1: 4.7
Ascertained by: Interpretation:
• Based on last Episiotomy,%: G2: 9.2
Poor
clinically G3: 15.9
Other maternal P < 0.001 for difference in normal Sum of Good/Fair/Poor:
measured outcomes:
weight prior to BMI groups 1 Good, 4 Fair, 4 Poor
NA
delivery: not Final Quality Score:
stated, most Other infant G4: 7.9
G5: 10.3 Poor
likely difference outcomes:
between NA G6: 14.6
weight at first P < 0.001 for difference in normal
prenatal visit BMI groups
and weight at Maternal confounders and effect
delivery modifiers accounted for in
analysis:
NA
Infant and child confounders
and effect modifiers accounted
for in analysis:
NA

C-89
Evidence Table 10. Maternal weight gain and length of labor
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if White
1992 • Combination: self reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at G4: 65.0 (12.2) Hispanic
July 1, 1985 - delivery G5: 58.3 (6.5) NR
December 31, 1985 (6
Total Study N: Pregravid BMI: Asian/Pacific Islander
months)
Total n = 357 G1: 39.5 (3.4) NR
Funding: • 191 women with G2: 17.2 (0.9)
NR abnormal G3: 26.1 (6.1) Other
prepregnant weight G4: 23.6 (4.1) NR
Study Objective: G5: 21.6 (2.0)
(≥ 20% under or Smoking,%:
To evaluate effects of
over ideal weight for NR
abnormal maternal Imputed:
height) or abnormal
weight or weight gain on • No Diabetes mellitus,%:
pregnancy weight
pregnancy outcome NR
gain (≥ 20kg or ≤ Categorized:
Time frame: 5kg) • Continuous ≥ 20% over Hypertension,%:
July 1, 1985 to • 166 controls or under normal weight NR
December 31, 1985 (6 for height
Group Description: Additional characteristics:
months)
G1: ≥ 20% over normal Age (mean, yrs): NR
Duration of the study: weight for height G1: 28 (5.1)
Prepregnancy to G2: ≥ 20% under normal G2: 25.5 (5.1)
delivery weight for height G3: 29.5 (5.1)
G3: weight gain ≤ 5kg G4: 28.7 (4.7)
G4: weight gain ≥ 20kg G5: 28.7 (4.4)
G5: control Group 6
Parity:
Group N: G1: prior deliveries: 1.0
G1: 77 (1.0)
G2: 28 G2: 0.8 (0.8)
G3: 30 G3: 1.2 (1.1)
G4: 56 G4: 0.8 (1.0)
G5: 166 G5: 0.9 (1.0)
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

C-90
Evidence Table 10. Maternal weight gain and length of labor (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Labor patterns by stage in Fair
G2: 28 P < 0.05 compared minutes (SD)
G3: 30 to controls Sample selection:
G4: 56 G2: 3293 (362) Groups Poor
G5: 166 P < 0.05 compared G1: weight gain ≤ 5 kg
G2: weight gain ≥ 20 kg Definition of maternal weight
to controls gain:
Total weight gain: G3: 3284 (880) G3: reference (normal
G1: 11.8 (6.2) prepregnancy weight and Poor
G4: 3803 (538)
P < 0.05 compared P < 0.005 normal weight gain Definition of outcomes:
to controls compared to [undefined]) Poor
G2: 13.4 (4.5) controls
G3: 3.0 (3.5) Results Source of information on
G5: 3538 (535) I stage exposure, outcomes, and
P < 0.0005
compared to Gestational G1: 333 (208) confounders:
controls diabetes,%: G2: 374 (208) Fair
G4: 23.2 (22.8) NR G3: 346 (188)
Followup:
P < 0.0005 II stage Fair
compared to Cesarean
delivery,%: G1: 15 (18) P< 0.05 compared
controls to reference category Analysis comparability:
G5: 13.2 (3.4) G1: Elective 7% Poor
Emergency G2: 27 (25)
Categorized: 14% G3: 21 (18) Analysis of outcomes:
• ≤ 5kg or ≥ Total 21% III stage Fair
20kg G2: Elective 4% G1: 13 (13) Interpretation:
Emergency 4% G2: 13 (11)
Collected from: Poor
Total 8% G3: 12 (12)
• Routine pre- G3: Elective 3% Sum of Good/Fair/Poor:
natal care or Emergency 3% Maternal confounders and 0 Good, 4 Fair, 5 Poor
maternity Total 6% effect modifiers accounted
records G4: Elective 5% for in analysis: Final Quality Score:
Emergency NA Poor
Ascertained by:
• Based on last 18% Infant and child confounders
clinically Total 23% and effect modifiers
measured G5: Elective 13% accounted for in analysis:
weight prior to Emergency 9% NA
delivery Total 22%
Instrumental
delivery,%:
NR
Episiotomy,%:
NR
Other maternal
outcomes:
NA
Other infant
outcomes:
NA

C-91
Evidence Table 10. Maternal weight gain and length of labor (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Johnson et al., 1992 • Cohort • Self-reported White
• Retrospective G1: 64.5
Country and setting: Pregravid BMI: G2: 60.0
USA, prenatal clinics Total Study N: G3: 49.8
Imputed:
3,191 G4: 51.9
Enrollment Period: • No
January 1, 1987- Group Description: G5: 58.7
December 31, 1989 G1: BMI < 19.8 Categorized:
• National Academy of Black
G2: 19.8-26.0 G1: 33.6
Funding: Sciences
G3: 27-29 G2: 37.9
NR
G4: > 29 Age (mean, yrs): G3: 48.9
Study Objective: G5: All G1: NR G4: 47.5
To determine influences • < 20 years: 36.6% G5: 39.5
Group N:
of increased maternal • 20-26 years: 44.8%
G1: 755 Hispanic
prepregnancy weight • > 26 years: 18.7%
G2: 1,621 NR
and increased G2: NR
G3: 329
gestational weight gain • < 20 years: 30.8% Asian/Pacific Islander
G4: 486
on pregnancy outcome
G5: 3191 • 20-26 years: 46.5% NR
Time frame: • > 26 years: 22.6%
Inclusion criteria: Other
January 1, 1987 to G3:
• Delivery at or G1: 1.9
December 31, 1989 • < 20 years: 25.8% G2: 2.1
beyond 38 weeks
• 20-26 years: 48.9% G3: 1.2
Duration of the study: of gestation
• > 26 years: 25.2% G4: 0.6
Initiation of prenatal • Singletons
G4: G5: 1.7
care to delivery • Received prenatal
• < 20 years: 16.5%
care and delivered Smoking,%:
• 20-26 years: 53.9%
in Shands Hospital NR
• > 26 years: 29.6%
Exclusion criteria: G5: Diabetes mellitus,%:
• Fetal abnormalities • < 20 years: 29.5% G1: 1.9
• Oligohydramnios • 20-26 years: 47.5 % G2: 2.3
• Polyhydramnios • > 26 years: 23.0% G3: 6.1
• Medical or surgical G4: 5.3
Parity:
complications (GI G5: 3.1
G1: % first: 49.3
disorders, sickle
G2: 43.1 Hypertension,%:
cell
G3: 37.4 G1: 3.4
hemoglobinopathy,
G4: 31.1 G2: 4.6
hepatitis,
G5: 42.1 G3: 5.8
hematologic
disorders, G4: 10.7
malignant disease, G5: 5.4
renal disease, Additional characteristics:
neurologic disease, G1: % married: 42.6
pulmonary disease, G2: 46.1
psychiatric G3: 40.4
disorders, G4: 49.4
tuberculosis) G5: 45.2
• Incomplete risk
variable data or Additional characteristics:
outcome variable NR
information

C-92
Evidence Table 10. Maternal weight gain and length of labor (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 755 G1: Odds of labor Fair
G2: 1621 • < 2500g: 4.8% abnormalities
G3: 329 Sample selection:
• 2500-4000g:
G4: 486 Groups Fair
89.1%
G5: 3191 G1: total weight gain < 16
• > 4000g: 6.1% pounds Definition of maternal weight
Total weight gain: G2: G2: total weight gain 16- gain:
G1: • < 2500g: 2.0% 25 pounds Fair
• < 16kg: 7.8% • 2500-4000g: G3: total weight gain 26- Definition of outcomes:
• 16-25kg: 18.5% 85.2% 35 pounds Fair
• 26-35kg: 35.1% • > 4000g: 12.8% G4: total weight gain > 35
G3: pounds Source of information on
• > 35kg: 38.5%
• < 2500g: 1.5% exposure, outcomes, and
G2: Results
• 2500-4000g: confounders:
• < 16kg: 11.7% Elevated odds of labor
83.0% Fair
• 16-25kg: 18.0% abnormalities only in the
• > 4000g: 15.5% Followup:
• 26-35kg: 28.8% group gaining > 35
G4: Fair
• > 35kg: 41.5% pounds compared with
• < 2500g: 0.2%
G3: women gaining < 16 Analysis comparability:
• 2500-4000g:
• < 16kg: 19.8% pounds; not significant Fair
82.5%
• 16-25kg: 19.1% when adjusted for
• > 4000g: 17.3% Analysis of outcomes:
• 26-35kg: 28.3% confounders
• > 35kg: 32.8% Gestational Fair
G4: diabetes, %: Trend analysis showed
Interpretation:
• < 16kg: 32.3% G1: 1.9 risk of labor abnormalities
Fair
• 16-25kg: 22.0%; G2: 2.3 with increased weight
G3: 6.1 gain, a difference in 10 lb. Sum of Good/Fair/Poor:
Categorized: G4: 5.3 corresponds to OR: 2 (P< 0 Good, 9 Fair, 0 Poor
• Quartiles G5: 3.1 0.0001) after adjusting for
• National BMI, patient care (private Final Quality Score:
Academy of Cesarean vs. nonprivate), parity, Fair
Sciences (below, delivery,%: infant sex, hypertension,
within, or above G1: NR and macrosomia
recommended G2: NR
range) G3: NR Maternal confounders
G4: NR and effect modifiers
Collected from: G5: 11.9 accounted for in
• Routine pre-natal analysis:
care or maternity Instrumental • Prepregnancy weight
records delivery,%: quartile
NR • Height (tertile)
Ascertained by:
Episiotomy,%: • BMI category
• Based on last
clinically NR • Race/ethnicity
measured weight • Marital status
Other maternal
prior to delivery: • Private physician
outcomes:
difference • Parity
• Frequency of
between self • Maternal age
macrosomia =
report and weight 12.2% • Hypertension
at last prenatal • Frequency of Infant and child
visit (mean 6.1 cesarean = confounders and effect
days prior to 11.9% modifiers accounted for
delivery) • Frequency of in analysis:
LBW = 2.9% • Infant sex
• Birth weight

C-93
Evidence Table 10. Maternal weight gain and length of labor (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Johnson et al., 1992
(continued)

C-94
Evidence Table 10. Maternal weight gain and length of labor (continued)
Maternal Weight Outcomes from
Gain 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-95
Evidence Table 10. Maternal weight gain and length of labor (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Purfield and Morin, • Other observational • Self-reported White
1994 : convenience G1: 135.69 (15.43) NR
sample G2: 129.81 (14.83)
Country and setting: Black
• Retrospective
Tertiary care medical Pregravid BMI: NR
center, Pennsylvania Total Study N:
Imputed: Hispanic
104
Enrollment Period: • No NR
Group Description:
Funding: Categorized: Asian/Pacific Islander
G1: prepregnant weight
NR • Normal weight was NR
increased by 25% or
Study Objective: less defined as a weight Other
To determine whether a G2: prepregnant weight within 90-120% of NR
group of normal weight increased by more than standard weight for
women with a low risk 25% height based on Smoking,%:
pregnancy who Metropolitan Life NR
Group N: Insurance Company
increased prepregnancy Diabetes mellitus,%:
G1: 52 Table of 1983
weight by more than NR
G2: 52 • NR
25% experienced a
longer second stage of Inclusion criteria: Hypertension,%:
Age (mean, yrs):
labor or higher • Low risk NR
G1: 25.75 (4.83)
proportion of operative primiparous G2: 25.83 (4.81) Additional characteristics:
deliveries than a group pregnancy NR
of normal weight women • Normal Parity:
prepregnant weight NR
Time frame:
for height
Duration of the study: • 18 to 40 years of
August 1991 to June age
1992 • 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

C-96
Evidence Table 10. Maternal weight gain and length of labor (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 52 G1: 3266 (351.54) Length of second stage labor Good
G2: 52 G2: 3384 (327.47) t
= -2.33 P = 0.02 Groups Sample selection:
Total weight gain: G1: prepregnant weight Fair
G1: % of weight Gestational increased by 25% or less
gain (greater than diabetes, %: G2: prepregnant weight Definition of maternal weight
prepregnant NR increased by more than 25% gain:
weight): 20.60 Fair
(3.52) Cesarean delivery, Results
%: Normal weight primigravidas with Definition of outcomes:
G2: % of weight Good
gain (greater than NR a low risk pregnancy who gained
prepregnant an excessive amount of weight Source of information on
Instrumental had a longer mean length of
weight): 33.21 delivery, %: exposure, outcomes, and
(5.45) t = -14.02 P second stage labor than women confounders:
NR who gained less weight
= 0.001 Fair
Episiotomy, %: Length of second stage in
Categorized: NR Followup:
minutes by weight groups (SD) Fair
• > 25% of
Other maternal G1: 72.42 (46.69)
prepregnant Analysis comparability:
outcomes: G2: 93.28 (52.87)
weight and ≤ Poor
NA t=-2.05 P=0.02
25% of
prepregnant Other infant Maternal confounders and Analysis of outcomes:
weight outcomes: effect modifiers accounted for Fair
NA in analysis: Interpretation:
Collected from:
NA Fair
• Routine pre-
natal care or Infant and child confounders Sum of Good/Fair/Poor:
maternity and effect modifiers 2 Good, 6 Fair, 1 Poor
records accounted for in analysis:
NA Final Quality Score:
Ascertained by: Fair
• Based on last
clinically
measured
weight prior to
delivery:
difference
between self
report and
weight at
admission to
hospital for
birth

C-97
Evidence Table 11. Gestational weight gain and mode of delivery
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-98
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Percentage of cesarean Good
G2: 11,313 G2: 3269 (532) deliveries
(P < 0.05) Sample selection:
Total weight gain: Groups Fair
G1: 20 (16.2) Gestational G1: 0 or weight loss
G2: 31.4 (11.5) diabetes, %: G2: 1-15 lbs Definition of maternal
G1: 14.2% G3: 16-25 lbs weight gain:
Categorized: G2: 4.3% (P < G4: 26-35 lbs Poor
Only calculated for 0.01) G5: > 35 lbs
morbidly obese: Definition of outcomes:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 25.8% Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 26.8% exposure, outcomes, and
G2: 15.9% G3: 28.8% confounders:
Collected from: G4: 35.0% Poor
• Routine pre- Instrumental G5: 33.8%
natal care or delivery,%: P = NS Followup:
maternity NR Fair
records Maternal confounders and
Episiotomy,%: effect modifiers accounted Analysis comparability:
Ascertained by: NR for in analysis: Poor
• Not stated - NA
Other maternal Analysis of outcomes:
from medical
outcomes Infant and child Fair
records
• Preeclampsia confounders and effect
• Placental Interpretation:
modifiers accounted for in Poor
abruption analysis:
• Meconium NA Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-99
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Brennand et al., 2005 • Cohort • Routine pre-natal care White
• Retrospective • Medical records NR
Country and setting:
Canada, medical • Measured within 14 Black
Total Study N:
records weeks of gestation NR
603
G1: 59.7 (5.0)
Enrollment Period: Group Description: G2: 73.0 (4.3) Hispanic
Prenatal to birth G1: Normal: G3: 93.6 (12.3) NR
BMI 18.5 - 24.9 G4: 80.0 (16.9)
Funding: Asian/Pacific Islander
G2: Overweight:
cree board of health and Pregravid BMI: NR
BMI 25-29.9
social services of James NR
G3: Obese: Other
Bay (Quebec)
BMI ≥ 30 Imputed: NR
Study Objective: G4: Total • Yes
To determine effect of Smoking,%:
Group N: Categorized: NR
pregravid weight and
G1: 139 • WHO International
pregnancy weight gain Diabetes mellitus,%:
G2: 168 Taskforce
on pregnancy outcomes G1: 4.3
G3: 296
in Cree women Age (mean, yrs): G2: 14.9
G4: 603
Time frame: G1: 20.8 (5.2) G3: 27.4
Inclusion criteria: G2: 23.8 (5.4) G4: 18.6
Prenatal to birth
• Used only Cree G3: 25.5 (5.5)
Duration of the study: Hypertension,%:
women G4: 24.0 (5.7)
G1: 1.4
7 year period: January • First birth observed
1994 to December 2000 Parity: G2: 1.8
per woman during
NR G3: 4.8
study time period
G4: 3.2
• Must have first
weight recorded Additional characteristics:
within first 14 % low weight gain:
weeks gestation G1: 20.1
and final weight G2: 10.1
recorded within 4 G3: 28.0
weeks of birth G4: 21.2
Exclusion criteria: % acceptable weight gain:
• Women with G1: 28.8
secondary G2: 32.1
pregnancy in G3: 33.4
dataset (n = 792) G4: 32.0
• Women with first
% excessive weight gain:
weight record > 14
G1: 51.1
weeks gestation
G2: 57.7
(n = 314)
G3: 38.5
• Women with final G4: 46.6
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)

C-100
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 139 NR Percentage of cesarean Good
G2: 168 sections
G3: 296 Gestational Sample selection:
diabetes, %: Groups Fair
Total weight gain: G1: 4.3 Primigravid women
G2: 14.9 (maternal weight gain Definition of maternal
Categorized: G3: 27.4 outcomes by BMI presented weight gain:
• 1999 Canadian G4: 18.6 only for obese women) Fair
guidelines G1: Obese - low weight gain
Cesarean Definition of outcomes:
Collected from: (< 7 kg) Poor
delivery,%: G2: Obese - acceptable
• Routine pre- G1: 10.8 weight gain (7-11.5 kg) Source of information on
natal care or G2: 11.3 G3: Obese - excessive exposure, outcomes, and
maternity G3: 24.1 (p < weight gain (> 11.5 kg) confounders:
records 0.001) G4: Total Fair
Ascertained by: Instrumental Results Followup:
• Based on last delivery,%: Poor
clinically G1: 25.3
measured Episiotomy,%: G2: 23.5 Analysis comparability:
weight prior to NR G3: 23.7 χ2 P=0.952 Fair
delivery: within G4: 24
Other maternal Analysis of outcomes:
4 weeks of outcomes:
birth Fair
• Definition of Maternal confounders and
low, adequate, effect modifiers Interpretation:
and excessive accounted for in analysis: Poor
weight gains: NA
Sum of Good/Fair/Poor:
• For normal Infant and child 1 Good, 5 Fair, 3 Poor
weight women confounders and effect
- adequate Final Quality Score:
modifiers accounted for in
weight gain is Poor
analysis:
11.5 to 16 kg NA
• 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

C-101
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: • Pregnancies with
Brennand et al., 2005 factors that may have
(continued) 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-102
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis

C-103
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cedergren, 2006 • Cohort • Self-reported White
• Prospective • If unknown, G1: 96.6
Country and setting: G2: NR
standardized
Sweden, Medical Birth Total Study N: measurement is made
Registry 245,526 Black
during first visit to
NR
Enrollment Period: Group Description: maternity health care
January 1, 1994 - BMI center Hispanic
December 31, 2002 G1: < 20 NR
Pregravid BMI:
G2: 20 to 24.9
Funding: Asian/Pacific Islander
G3: 25 to 29.9 Imputed:
Ostergotland County G1: 1.4
Council
G4: 30 to 34.9 • No G2: NR
G5: ≥ 35
Study Objective: Categorized: Other
Group N: • < 20, 20.0-24.9, 25.0-
To estimate effects of G1: 2.0
G1: 28,186 29.9, 30-34.9, ≥ 35
high and low gestational G2: NR
G2: 143,365
weight gain in different Age (mean, yrs):
G3: 60,626 Smoking,%:
maternal BMI classes G1: 15 to 19 years: 3.8%
G4: 17,248 G1: % nonsmoking: 81.6
on obstetric and 20 to 24: 23.0%
G5: 6,296 G2: 85.2
neonatal outcomes 25 to 29: 38.7% G3: 83.1
Inclusion criteria: 30 to 34: 25.7%
Time frame: G4: 79.9
January 1, 1994 to • Singleton, term 35 to 39: 7.7% G5: 78.4
December 31, 2002 pregnancies ≥ 40: 1.1% Group 6
• Information on G2: 15 to 19 years: 1.9%
Duration of the study: maternal height, 20 to 24: 15.9% Diabetes mellitus,%:
First visit to maternity maternal weight in 25 to 29: 37.7% NR
health care center to early pregnancy, 30 to 34: 31.1%
delivery Hypertension,%:
and gestational 35 to 39: 11.3%
NR
weight gain ≥ 40: 1.9%
G3: 15 to 19 years: 1.5% Additional characteristics:
Exclusion criteria: 20 to 24: 15.7% NR
• NA 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%

C-104
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Outcomes from
Maternal Weight Bivariate Outcomes from Multivariate
Gain Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28,186 NR AOR for weight gain for weight gain Fair
G2: 143,365 groups by cesarean of instrumental
G3: 60,626 Gestational deliveries (95% CI) Sample selection:
G4: 17,248 diabetes, %: Good
G5: 6,296 NR Groups
Weight gain< 8 kg, 8-16 kg, and > Definition of maternal
Total weight gain: Cesarean 16 kg for each BMI class below weight gain:
G1: < 8kg: 6.9% delivery, %: G1: BMI < 20 Fair
8-15.9kg: 65.2% NR G2: BMI 20-24.9 Definition of outcomes:
≥ 16kg: 28.0% Instrumental G3: BMI 25-29.9 Good
G2: < 8kg: 8.4% delivery, %: G4: BMI 30-34.9
8-15.9kg: 67.1% NR G5: BMI ≥ 35 Source of information
≥ 16kg: 30.4% on exposure,
G3: < 8kg: 15.7% Episiotomy, %: AOR for weight gain< 8 kg for outcomes, and
8-15.9kg: 54.4% NR Cesarean section compared with confounders:
≥ 16kg: 29.9% weight gain 8-16 kg Good
Other maternal G1: 1.07 (0.89-1.29)
G4: < 8kg: 30.2% outcomes: Followup:
8-15.9kg: 48.7% G2: 0.98 (0.92-1.05)
NA G3: 0.88 (0.82-0.95) Fair
≥ 16kg: 21.1%
G5: < 8kg: 44.6% Other infant G4: 0.81 (0.73-0.90) Analysis
8-15.9kg: 40.9% outcomes: G5: 0.75 (0.66-0.87) comparability:
≥ 16kg NA AOR for weight gain< 8 kg for Fair
Categorized: instrumental delivery compared with Analysis of outcomes:
weight gain 8-16 kg Fair
• < 8kg, 8-16, >
G1: 0.89 (0.71-1.11)
16 Interpretation:
G2: 0.88 (0.80-0.96)
Collected from: G3: 0.85 (0.76-0.95) Good
• Routine pre- G4: 0.75 (0.63-0.88)
Sum of
natal care or G5: 0.83 (0.65-1.03)
Good/Fair/Poor:
maternity 4 Good, 5 Fair, 0 Poor
AOR for weight gain> 16 kg for
records
instrumental delivery compared with
Final Quality Score:
Ascertained by: weight gain 8-16 kg
Fair
• Based on last G1: 1.28 (1.15-1.43)
clinically G2: 1.19 (1.14-1.25)
measured G3: 1.14 (1.06-1.23)
weight prior to G4: 1.09 (0.93-1.27)
delivery: G5: 1.04 (0.77-1.40)
difference AOR for weight gain> 16 kg for
between Cesarean section compared with
maternal weight gain 8-16 kg
weights G1: 1.29 (1.17-1.43)
measured when G2: 1.24 (1.19-1.29)
woman attended G3: 1.23 (1.17-1.30)
delivery unit and G4: 1.22 (1.10-1.35)
maternal weight G5: 1.27 (1.05-1.52)
recorded at first
visit to maternity Maternal confounders and effect
health care modifiers accounted for in
center 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

C-105
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Chen et al., 2004 • Cohort • Self-reported White
• Retrospective • Weight taken at first NR
Country and setting:
prenatal visit if
USA, private practice Total Study N: Black
presented before 20
3,355 NR
Enrollment Period: weeks; if after 20
Feb 1993-June 2001 Group Description: weeks, self-reported Hispanic
G1: Total NR
Funding: Pregravid BMI:
G2: NR G1: BMI
NR Asian/Pacific Islander
Group N: < 20 16.3% NR
Study Objective: 20-25 48%
G1: 3,355
To develop an easily 25-30 21% Other
G2: NR
usable integrated 30-40 12.8% NR
formula for predicting Inclusion criteria: > 40 2%
probability of Smoking,%:
• All primaparous, G2: NR NR
cephalopelvic singleton births
disproportion/failure to between February Imputed: Diabetes mellitus,%:
progress (CPD) and 1993 and June 13, • No NR
cesarean delivery (CS) 2001
as function of Categorized: Hypertension,%:
demographic factors in Exclusion criteria: • Continuouscategorical NR
middle-class private • insufficent data for by 5 point increments (<
25, 20-25, etc.) Additional characteristics:
practice analysis with
NR
respect to all 5 Age (mean, yrs):
Time frame: demographic
Feb 1993-June 2001 G1: < 20: 8.9
factors 20-24: 25.8%
Duration of the study: 25-29: 36.7%
Entry into prenatal care 30-34: 20.2%
until delivery > 35 8.4%
G2: NR
Parity:

C-106
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 852 NR Progression of AOR of Good
G2: 1,383 cesarean delivery weight
G3: 1,120 Gestational gain (for every 5 lbs) Sample selection:
diabetes,%: Fair
Total weight gain: NR Groups
Gestational weight gain in Definition of maternal
Categorized: Cesarean lbs weight gain:
• Categorical, < delivery,%: Fair
25, 25-35, > 35 G1: 20.9 Results
G2: 19.3 1.094 (1.074 - 1.115) Definition of outcomes:
Collected from: G3: 25.4 Fair
• Routine pre- Maternal confounders
Instrumental and effect modifiers Source of information on
natal care or
delivery,%: accounted for in exposure, outcomes, and
maternity
analysis: confounders:
records
Episiotomy,%: Fair
• Maternal height
Ascertained by: • Body mass index
Other maternal Followup:
• Based on last outcomes: (BMI) Fair
clinically Progression of • Maternal height
measured Analysis comparability:
adjusted OR of • Maternal age
weight prior to Cephalopelvic Fair
• Pregnancy weight gain
delivery: Disproportion Analysis of outcomes:
subtracted (CPD): Every 5 lbs Infant and child
from weight at Fair
more weight gain confounders and effect
first prenatal during pregnancy = modifiers accounted for Interpretation:
visit 1.057 (1.005-1.110) in analysis: Fair
progression in OR. • Gestational age at
Sum of Good/Fair/Poor:
Progression of delivery
1 Good, 8 Fair, 0 Poor
adjusted OR of • Fetal birth weight
Cesearean Final Quality Score:
Delivery: Every 5 lb Fair
more weight gain
during pregnancy =
1.094 (1.074 -
1.115) progression
in OR
Other infant
outcomes:
NR

C-107
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
DeVader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained G1: 79.7
Country and setting: G2: 85.6
from mother during
United States, birth Total Study N: G3: 85.2
postpartum hospital stay
certificate data 94,696
Pregravid BMI: Black
Enrollment period: Group Description: G1: 15.7
NR
1999 to 2001 G1: Gained less than 25 G2: 10.8
lbs Imputed: G3: 12.1
Funding:
NR
G2: Gained 25 to 35 lbs • No
G3: Gained more than Hispanic
Study Objective: 35 lbs Categorized: NR
To investigate NR
Group N: Asian/Pacific Islander
relationship between Age (mean, yrs): NR
G1: 16,852
gestational weight gain G1: Maternal age (y)
G2: 37,292
and adverse pregnancy 18 to 24*: 42.3% Other
G3: 40,552
outcomes among 25 to 30: 36.2% G1: 4.6
women with normal Inclusion criteria: 31 to 35: 21.5% G2: 3.5
prepregnancy BMI • All mothers with G2: Maternal age (y) G3: 2.7
Time frame: normal 18 to 24*: 36.7% Smoking,%:
1999 to 2001 prepregnancy BMI 25 to 30: 39.5% G1: 20.5
(19.8 –26.0 kg/m2) 31 to 35: 23.8% G2: 14.9
Duration of the study: who were 18 to 35 G3: Maternal age (y) G3: 17.4
Entry into prenatal care years of age at time 18 to 24*: 44.7%
through delivery of delivery and who 25 to 30: 35.9% Diabetes mellitus,%:
delivered full-term 31 to 35: 19.4% NR
(37 weeks or more)
Parity: Hypertension,%:
singleton infant
during period NR NR
January 1, 1999, to Additional characteristics:
December 31, 2001 NR
Exclusion criteria:
• Women aged
younger than 18
years and older
than 35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-108
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Adjusted odds ratio of Good
mode of delivery by weight
Total weight gain: Gestational groups Sample selection:
NR diabetes, %: Fair
NR Groups
Categorized: G1: < 30 lbs Definition of maternal
• According to Cesarean G2: 30-35lbs weight gain:
IOM delivery,%: G3: > 35 lbs Fair
NR
Collected from: Results Definition of outcomes:
• Routine pre- Instrumental AOR for cesarean (95% Good
natal care or delivery,%: CI):
NR Source of information on
maternity G1: 0.82 (0.78–0.87) exposure, outcomes, and
records G2: 1.0
Episiotomy,%: confounders:
Ascertained by: NR G3: 1.35 (1.29–1.40) Fair
NR AOR for instrumental (95%
Other maternal Followup:
outcomes: CI): Fair
• Figures 1 to 3 G1: 0.97 (0.90–1.04)
G2: 1.0 Analysis comparability:
plot risk for each
G3: 1.03 (0.97–1.08) Fair
adverse
pregnancy Maternal confounders Analysis of outcomes:
outcome by 10-lb and effect modifiers Fair
increments in accounted for in
gestational Interpretation:
analysis: Fair
weight gain. • Maternal age
Women who Sum of Good/Fair/Poor:
• Maternal race or
gained 25 to 34 2 Good, 7 Fair, 0 Poor
ethnicity
lbs during their
• Maternal education Final Quality Score:
pregnancy had
lower risks for • Medicaid status Fair
most outcomes • Tobacco use
when balancing • Alcohol use
risk for SGA • Maternal height,
status and other • Prior pregnancy
adverse • Adequacy of prenatal
pregnancy care
outcomes
Infant and child
• Women who confounders and effect
gained 15 to 24 modifiers accounted for
lbs had lowest in analysis:
risks for most
• Child's gender
outcomes, but
• Birth year
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%

C-109
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if White
1992 • Combination: self reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at G4: 65.0 (12.2) Hispanic
July 1, 1985 - delivery G5: 58.3 (6.5) NR
December 31, 1985 (6
Total Study N: Pregravid BMI: Asian/Pacific Islander
months)
Total n = 357 G1: 39.5 (3.4) NR
Funding: • 191 women with G2: 17.2 (0.9)
NR abnormal G3: 26.1 (6.1) Other
prepregnant weight G4: 23.6 (4.1) NR
Study Objective: G5: 21.6 (2.0)
(≥ 20% under or Smoking,%:
To evaluate effects of
over ideal weight for NR
abnormal maternal Imputed:
height) or abnormal
weight or weight gain on • No Diabetes mellitus,%:
pregnancy weight
pregnancy outcome NR
gain (≥ 20kg or ≤ Categorized:
Time frame: 5kg) • Continuous ≥ 20% over Hypertension,%:
July 1, 1985 to • 166 controls or under normal weight NR
December 31, 1985 (6 for height
Group Description: Additional characteristics:
months)
G1: ≥ 20% over normal Age (mean, yrs): NR
Duration of the study: weight for height G1: 28 (5.1)
Prepregnancy to G2: ≥ 20% under normal G2: 25.5 (5.1)
delivery weight for height G3: 29.5 (5.1)
G3: weight gain ≤ 5kg G4: 28.7 (4.7)
G4: weight gain ≥ 20kg G5: 28.7 (4.4)
G5: control Group 6
Parity:
Group N: G1: prior deliveries: 1.0
G1: 77 (1.0)
G2: 28 G2: 0.8 (0.8)
G3: 30 G3: 1.2 (1.1)
G4: 56 G4: 0.8 (1.0)
G5: 166 G5: 0.9 (1.0)
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

C-110
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Percentage of vaginal, Fair
G2: 28 P < 0.05 compared forceps, vacuum, breech or
G3: 30 to controls cesarean deliveries by Sample selection:
G4: 56 G2: 3293 (362) weight gain categories Poor
G5: 166 P < 0.05 compared Definition of maternal
to controls Groups
Total weight gain: G1: weight gain ≤ 5 kg weight gain:
G3: 3284 (880) Poor
G1: 11.8 (6.2) G4: 3803 (538) G2: weight gain ≥ 20 kg
P < 0.05 compared P < 0.005 G3: reference (normal Definition of outcomes:
to controls compared to prepregnancy weight and Poor
G2: 13.4 (4.5) controls normal weight gain
G3: 3.0 (3.5) [undefined]) Source of information on
G5: 3538 (535) exposure, outcomes, and
P < 0.0005
compared to Gestational Normal vaginal delivery confounders:
controls diabetes,%: (%) Fair
G4: 23.2 (22.8) NR G1: 90 P < 0.05 compared
to controls Followup:
P < 0.0005 Fair
compared to Cesarean G2: 64
controls delivery,%: G3: 71 Analysis comparability:
G5: 13.2 (3.4) G1: Elective 7% Poor
Emergency Forceps or vacuum
Categorized: 14% delivery (%) Analysis of outcomes:
G1: 3 Fair
• ≤ 5kg or ≥ Total 21%
G2: Elective 4% G2: 13
20kg Interpretation:
Emergency 4% G3: 5
Collected from: Poor
Total 8% Breech (%)
• Routine pre- G3: Elective 3% Sum of Good/Fair/Poor:
G1: 1
natal care or Emergency 3% 0 Good, 4 Fair, 5 Poor
G2: 0
maternity Total 6% G3: 2
records G4: Elective 5% Final Quality Score:
Emergency Cesarean section - elective Poor
Ascertained by:
18% %
• Based on last G1: 3
clinically Total 23%
G5: Elective 13% G2: 5
measured G3: 13
weight prior to Emergency 9%
delivery Total 22% Cesarean section -
Instrumental emergency %
delivery,%: G1: 3
NR G2: 18
G3: 9
Episiotomy,%:
NR Maternal confounders
and effect modifiers
Other maternal accounted for in
outcomes: analysis:
NA NA
Other infant Infant and child
outcomes: confounders and effect
NA modifiers accounted for
in analysis:
NA

C-111
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Graves et al., 2006 • Cohort • Actual prepregnant White
• Retrospective weight or early first G1: 26.9
Country and setting:
trimester weight
USA, midwifery Total Study N: Black
documented in medical
practices 1,500 G1: 18.7
records
Enrollment Period: Group Description: Hispanic
Pregravid BMI:
January 1, 1998- G1: Total cohort G1: 52.1
G1: < 19.8: 9.4%
December 31, 2000
Group N: 19.8-26.0: 52.1% Asian/Pacific Islander
Funding: G1: 1,500 26.1-29.0: 20.6% NR
NR > 29: 17.4%
Inclusion criteria: Other
Study Objective: • Non-diabetic Imputed: G1: 2.2
To identify association • Entered labor after • No
between prepregnancy Smoking,%:
34 weeks gestation Categorized: NR
BMI, weight gain in
pregnancy, and Exclusion criteria: • IOM guidelines
Diabetes mellitus,%:
newborn birth weight on • Planned cesarean Age (mean, yrs): NR
route of delivery and delivery (n = 8) G1: ≤ 19 years: 32.2%
induction of labor in • Unknown parity (in Hypertension,%:
20-34: 62.4%
patients receiving analyses in which NR
≥ 35: 4.9%
nurse-midwifery care parity was an Additional characteristics:
important Parity:
Time frame: G1: % nulliparous: 42.3 NR
consideration,
January 1, 1998- n = 40)
December 31, 2000 • Hypertension
Duration of the study: • Diabetes
PRN care up til delivery

C-112
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1500 G1: < 2500g: 3.5% Association of weight gain Good
G2: NR 2500-3999: 84.6% on mode of delivery
4000-4449: 9.1% Sample selection:
Total weight gain: ≥ 4500: 1.4% Groups Fair
G1: < 15 pounds: 12.7% G1: ≤ 45 pounds
15-25: 25.2% Gestational Definition of maternal
G2: > 45 pounds weight gain:
26-35: 29.3% diabetes,%:
36-45: 16.3% NR Results Poor
> 45: 10.1% Greater weight gain in Definition of outcomes:
Cesarean delivery,%: pregnancy was not
Categorized: G1: 8.8 Fair
associated
• ≤ 15 pounds 16-24, G2: NR significantly with route of Source of information on
25-35, 36-45, > 45 delivery exposure, outcomes, and
Instrumental
delivery,%: confounders:
Collected from: Confounders and effect
NR Fair
• Routine pre-natal modifiers
care or maternity NR Followup:
Episiotomy,%:
records Good
NR Maternal confounders
Ascertained by: and effect modifiers Analysis comparability:
Other maternal
• Based on last outcomes: accounted for in Fair
clinically measured NA analysis: Analysis of outcomes:
weight prior to • Prepregnancy BMI
delivery Other infant Fair
category
outcomes: • Total prenatal weight Interpretation:
NA gain category Fair
• Induction of labor Sum of Good/Fair/Poor:
• Race/ethnicity 2 Good, 6 Fair, 1 Poor
Infant and child Final Quality Score:
confounders and effect Fair
modifiers accounted for
in analysis:
• Gestational age > 41
weeks
• Birth weight

C-113
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year: Design: Pregravid weight: Race,%:

Jain et al, • Cohort • Self-reported NR
2007 • Retrospective
Pregravid BMI: Smoking,%:
Country and setting: Total Study N: • NR NR
United States, hospitals 7661
Imputed: Diabetes mellitus,%:
Enrollment period: Group Description: • No NR
2002-2005 NR
Categorized: Hypertension,%:
Funding: Group N: • IOM guidelines NR
Not reported NR
Age (mean, yrs):
Study Objective: Inclusion criteria: NR
To analyze risks of • Term (> 37 weeks)
cesarean section, and singleton for Parity:
macrosomia, and macrosomia and NR
breastfeeding at 10 weeks breastfeeding
postpartum using logistic
regression to estimate Exclusion criteria:
independent effects of • Cesarean analysis
prepregnancy BMI and limited to to women
gestational weight gain with cephalic
presentation-records
Time frame: with missing data
2002-2005 excluded
Duration of the study:
Entry into prenatal care to
10 weeks postpartum

C-114
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from Multivariate Quality Rating
Gain Bivariate Analysis Analysis
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Cesarean delivery, primiparous Fair
and multiparous
Total weight gain: Gestational Sample selection:
• NR diabetes, %: Groups: Poor
NR G1: WG ≤ 15 lbs
Categorized: G2: WG 15-24 lbs Definition of maternal weight
• ≤ 15 lbs Cesarean G3: WG 25-35 lbs gain:
• 15-25 lbs delivery,%: G4: WG ≥ 35 lbs Poor
• 25-35 lbs NR
Results: Definition of outcomes:
• 35+ lbs Instrumental Fair
AOR for primiparous cesarean
Collected from: delivery,%: delivery (from model including
NR Source of information on
• Not outlined interaction term for exposure, outcomes, and
Episiotomy,%: overweight/obese + > 25 lbs confounders:
Ascertained by:
NR weight gain) Fair
• Birth certificate G1: 0.95 (0.59-1.52)
Other maternal G2: 1.0 (ref) Followup:
outcomes: G3: 1.10 (0.76-1.60) Fair
NR G4: 1.62 (1.10-2.39) Analysis comparability:
Other infant AOR for multiparous cesarean Fair
outcomes: delivery (from model including
NR Analysis of outcomes:
interaction term for Fair
overweight/obese + > 25 lbs
weight gain) Interpretation:
G1: 1.11 (0.60-2.04) Fair
G2: 1.0 (ref)
Sum of Good/Fair/Poor:
G3: 1.08 (0.63-1.85)
0 Good, 7 Fair, 2 Poor
G4: 1.95 (1.02-3.72)
Final Quality Score:
Maternal confounders and
Fair
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

C-115
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of G1: 84.4
Country and setting: G2: 85.8
pregravid BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg G4: 32.7 (31.3-34.7)
Funding: Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain
G2: 134 • Continuous
in obese glucose Other
G3: 132
tolerant women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: ≥ 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance Parity:
test (OGTT) during NR Diabetes mellitus,%:
third trimester NR
(according to WHO
Hypertension,%:
criteria)
NR
• Only first
pregnancy during Additional characteristics:
study period NR
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)

C-116
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200- OR for cesarean delivery Good
G2: 134 3840) (95% CI)
G3: 132 G2: 3645 (3200- Sample selection:
G4: 122 4000) Groups Poor
G3: 3750 (3390- G1: GWG 5.0-9.9 kg
Total weight gain: G2: GWG 10.0-14.9 kg Definition of maternal
4125) weight gain:
G4: 3762 (3400- G3: GWG ≥ 15 kg
Categorized: Poor
• < 5.0. 5.0-9.9, 4120) Results
G1: 1.0 Definition of outcomes:
10.0-14.9, ≥ Gestational
G2: 2.4 (1.1-5.3) Fair
15.0 diabetes, %:
NR G3: 3.0 (1.4-6.4) Source of information on
Collected from: G4: 3.6 (1.6-7.8) exposure, outcomes, and
• Routine pre- Cesarean delivery, P for trend = 0.002 confounders:
natal care or %:
Maternal confounders Poor
maternity NR
records and effect modifiers Followup:
Instrumental accounted for in Fair
Ascertained by: delivery, %: analysis:
• Not stated by NR • Age Analysis comparability:
authors • Pre-gravid BMI Fair
Episiotomy, %:
NR • 2h OGTT result Analysis of outcomes:
• Parity Good
Other maternal • Smoking
outcomes: Interpretation:
• Ethnic background
NA Fair
• Clinical center
Other infant Sum of Good/Fair/Poor:
Infant and child
outcomes: 2 Good, 4 Fair, 3 Poor
confounders and effect
NA modifiers accounted for Final Quality Score:
in analysis: Poor
• Gestational age

C-117
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Johnson et al., 1992 • Cohort • Self-reported White
• Retrospective G1: 64.5
Country and setting: Pregravid BMI: G2: 60.0
USA, prenatal clinics Total Study N: G3: 49.8
Imputed:
3,191 G4: 51.9
Enrollment Period: • No
January 1, 1987- Group Description: G5: 58.7
December 31, 1989 G1: BMI < 19.8 Categorized:
• National Academy of Black
G2: 19.8-26.0 G1: 33.6
Funding: Sciences
G3: 27-29 G2: 37.9
NR
G4: > 29 Age (mean, yrs): G3: 48.9
Study Objective: G5: All G1: NR G4: 47.5
To determine influences • < 20 years: 36.6% G5: 39.5
Group N:
of increased maternal • 20-26 years: 44.8%
G1: 755 Hispanic
prepregnancy weight • > 26 years: 18.7%
G2: 1,621 NR
and increased G2: NR
G3: 329
gestational weight gain • < 20 years: 30.8% Asian/Pacific Islander
G4: 486
on pregnancy outcome
G5: 3191 • 20-26 years: 46.5% NR
Time frame: • > 26 years: 22.6%
Inclusion criteria: Other
January 1, 1987 to G3:
• Delivery at or G1: 1.9
December 31, 1989 • < 20 years: 25.8% G2: 2.1
beyond 38 weeks
• 20-26 years: 48.9% G3: 1.2
Duration of the study: of gestation
• > 26 years: 25.2% G4: 0.6
Initiation of prenatal • Singletons
G4: G5: 1.7
care to delivery • Received prenatal
• < 20 years: 16.5%
care and delivered Smoking,%:
• 20-26 years: 53.9%
in Shands Hospital NR
• > 26 years: 29.6%
Exclusion criteria: G5: Diabetes mellitus,%:
• Fetal abnormalities • < 20 years: 29.5% G1: 1.9
• Oligohydramnios • 20-26 years: 47.5 % G2: 2.3
• Polyhydramnios • > 26 years: 23.0% G3: 6.1
• Medical or surgical G4: 5.3
Parity:
complications (GI G5: 3.1
G1: % first: 49.3
disorders, sickle
G2: 43.1 Hypertension,%:
cell
G3: 37.4 G1: 3.4
hemoglobinopathy,
G4: 31.1 G2: 4.6
hepatitis,
G5: 42.1 G3: 5.8
hematologic
disorders, G4: 10.7
malignant disease, G5: 5.4
renal disease, Additional characteristics:
neurologic disease, G1: % married: 42.6
pulmonary disease, G2: 46.1
psychiatric G3: 40.4
disorders, G4: 49.4
tuberculosis) G5: 45.2
• Incomplete risk
variable data or Additional characteristics:
outcome variable NR
information

C-118
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 755 G1: Adjusted odds ratio for Fair
G2: 1621 • < 2500g: 4.8% unscheduled cesarean
G3: 329 (95% CI) Sample selection:
• 2500-4000g:
G4: 486 Fair
89.1%
G5: 3191 Groups
• > 4000g: 6.1% G1: total weight gain < 16 Definition of maternal
Total weight gain: G2: pounds weight gain:
G1: • < 2500g: 2.0% G2: total weight gain 16-25 Fair
• < 16kg: 7.8% • 2500-4000g: pounds Definition of outcomes:
• 16-25kg: 18.5% 85.2% G3: total weight gain 26-35 Fair
• 26-35kg: 35.1% • > 4000g: pounds
12.8% G4: total weight gain > 35 Source of information on
• > 35kg: 38.5%
G3: pounds exposure, outcomes, and
G2:
• < 2500g: 1.5% confounders:
• < 16kg: 11.7% Results
• 2500-4000g: Fair
• 16-25kg: 18.0% G1: 1.0
83.0% Followup:
• 26-35kg: 28.8% G2: 0.95 (0.6-1.5)
• > 4000g: 15.5% Fair
• > 35kg: 41.5% G3: 1.3 (0.86-1.95)
G4:
G3: G4: 1.95 (1.32 - 2.87) Analysis comparability:
• < 2500g: 0.2%
• < 16kg: 19.8% Fair
• 2500-4000g: Maternal confounders
• 16-25kg: 19.1%
82.5% and effect modifiers Analysis of outcomes:
• 26-35kg: 28.3%
• > 4000g: 17.3% accounted for in Fair
• > 35kg: 32.8%
analysis:
G4: Gestational Interpretation:
• Prepregnancy weight
• < 16kg: 32.3% diabetes, %: Fair
quartile
• 16-25kg: 22.0%; G1: 1.9
G2: 2.3 • Height (tertile) Sum of Good/Fair/Poor:
Categorized: G3: 6.1 • BMI category 0 Good, 9 Fair, 0 Poor
• Quartiles G4: 5.3 • Private physician
• National Academy (yes/no) Final Quality Score:
G5: 3.1
of Sciences • Maternal age Fair
(below, within, or Cesarean • Parity
above delivery,%: • Diabetes
recommended G1: NR • Hypertension
range) G2: NR • Maternal education
G3: NR
Collected from: G4: NR Infant and child
• Routine pre-natal G5: 11.9 confounders and effect
care or maternity modifiers accounted for
records Instrumental in analysis:
delivery,%:
Ascertained by: • Birth weight
NR
• Based on last • Gestational age
clinically Episiotomy,%:
measured weight NR
prior to delivery: Other maternal
difference outcomes:
between self • Frequency of
report and weight macrosomia =
at last prenatal 12.2%
visit (mean 6.1 • Frequency of
days prior to cesarean =
delivery) 11.9%
• Frequency of
LBW = 2.9%

C-119
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Johnson et al., 1992
(continued)

C-120
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Bivariate
Gain 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-121
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Joseph et al., 2003 • Cohort • Data taken from White
• Retrospective standardized forms and NR
Country and setting:
hospital medical records
All deliveries that Total Study N: Black
- no mention of self-
occurred among 100,259 NR
report
residents of Nova
Group Description: G1: < 55: 30.1% Hispanic
Scotia, Canada - from
G1: Births 1988-1991 55-59: 21.2% NR
Nova Scotia Atlee
G2: Births 1998-2000 60-69: 27.3%
Perinatal Database Asian/Pacific Islander
G3: % Primary ≥ 70: 21.4%
Enrollment period: G2: < 55: 20.4% NR
Cesarean Rate
NR 1988-1991 55-59: 15.9% Other
G4: % Primary 60-69: 27.7% NR
Funding: ≥ 70: 36.0%
Cesarean Rate
NR G3: < 55: 12.3% Smoking,%:
1998-2000
Study Objective: 55-59: 12.6% G1: 32.6
Group N: 60-69: 11.8% G2: 23.4
To estimate contribution
G1: 44,317 ≥ 70: 16.9% G3: 27.1
of changes in maternal
G2: 24,901 G4: < 55: 13.2% G4: 28.8
characteristics (namely,
G3: 44,317 55-59: 13.6%
age, parity, Diabetes mellitus,%:
G4: 24,901 60-69: 14.7%
prepregnancy wieght, NR
weight gain in Inclusion criteria: ≥ 70: 18.7%
pregnancy, smoking Hypertension,%:
• All deliveries that Pregravid BMI:
status) and obstetric G1: 1.4
occurred to • NR
practice (namely labor G2: 1.2
residents of Nova
induction, epidural Imputed: G3: 38.7
Scotia
anesthesia, delivery by • No G4: 50.3
an obstetrician, Exclusion criteria:
Categorized: Additional characteristics:
midpelvic forceps • Women with
• NR NR
delivery) to recent previous cesarean
increases in primary delivery Age (mean, yrs):
cesarean delivery rates % Age: < 20yrs:
Time frame: G1: 9.4%
NR 20-29 yrs: 62.6%
30-34yrs: 21.4%
Duration of the study: 35-39 yrs: 5.9%
January 1, 1988 to ≥ 40yrs: 0.7%
December 31, 2000 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%

C-122
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR AOR for cesarean delivery Good
(95% CI)
Total weight gain: Gestational Sample selection:
• NR diabetes, %: Groups Fair
NR G1: < 5 kg
Categorized: G2: 5-9 kg Definition of maternal
• < 5, 5-9, 10- Cesarean G3: 10-14 kg weight gain:
14(ref), 15-19, delivery,%: G4: 15-19 kg Poor
≥ 20 NR G5: ≥ 20 kg Definition of outcomes:
Collected from: Instrumental Results Good
• Routine pre- delivery,%: G1: 1.10 (1.00, 1.20)
NR Source of information on
natal care or G2: 1.04 (0.99, 1.10) exposure, outcomes, and
maternity Episiotomy,%: G3: 1.00 confounders:
records NR G4: 1.09 (1.05,1.14) Poor
Ascertained by: G5: 1.41 (1.35,1.47)
Other maternal Followup:
• Not explained outcomes Maternal confounders Fair
by authors - NR and effect modifiers
data taken accounted for in Analysis comparability:
from maternity Other infant analysis: Good
records outcomes • Age
NR Analysis of outcomes:
• Parity Fair
• Prepregnancy weight
• Smoking Interpretation:
• Pregnancy (singleton Good
or multiple) Sum of Good/Fair/Poor:
• Hypertension 4 Good, 3 Fair, 2 Poor
• Diabetes
• Previous fetal death Final Quality Score:
Fair
• Induction
• Epidural
• Physician type
• Time
Infant and child
confounders and effect
modifiers accounted for
in analysis:
NR

C-123
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Parity:
Joseph et al., 2003 %Parity: Nulliparous:
(continued) 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-124
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis

C-125
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kabiru and Raynor, • Cohort • Measured at first White
2004 • Retrospective prenatal visit G1: 1.9
G2: 2.6
Country and setting: Total Study N: Pregravid BMI: G3: 2.8
USA, hospital 5,131
Imputed: Black
Enrollment Period: Group Description: • No G1: 84.1
1999 to 2002 G1: No change in BMI G2: 82.8
between first Categorized:
Funding: • 20-24.9, 25-29.9, 30- G3: 88.2
prenatal visit and
NR 34.9, 35-39.9, ≥ 40 Hispanic
delivery
Study Objective: G2: 1 category increase Age (mean, yrs): G1: 13.9
To investigate effect of in BMI between first G1: 24.7 (6.1) G2: 14.6
increase in body mass prenatal visit and G2: 24.4 (5.7) G3: 9.0
index category on delivery G3: 25.2 (5.9) P < 0.001 Asian/Pacific Islander
obstetric outcomes G3: > 1 category
Parity: NR
increase in BMI
Time frame: between first G1: Gravidity (mean): 1.9 Other
1999 to 2002 prenatal visit and (1.9) NR
Duration of the study: delivery G2: 1.5 (1.7)
G3: 1.2 (1.7) P < 0.001 Smoking,%:
Prenatal through birth Group N: NR
G1: 2,556
G2: 2,252 Diabetes mellitus,%:
G3: 323 NR

Inclusion criteria: Hypertension,%:

• Singleton NR
pregnancies Additional characteristics:
Exclusion criteria: Mean weight gain:
G1: 8.6 pounds (8.4)
• Multiple
G2: 22.2 pounds (10.2)
pregnancies
G3: 55.3 pounds (23.8)
• BMI < 20
• Missing BMI data Additional characteristics:
NR

C-126
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 579 G1: 2886.0 (756) Primary cesarean Good
G2: 942 G2: 3174.9 (600)
G3: 189 G3: 3099.5 (673) Groups Sample selection:
G4: 819 P < 0.001 Primary cesarean Fair
G5: 790 G4: 3116 (713) G1: normal BMI, no change in
BMI between first prenatal Definition of maternal
G6: 104 G5: 3269 (698) weight gain:
G6: 3371 (733) visit and delivery
Total weight gain: G2: normal BMI, 1 category Poor
P = 0.015
increase in BMI between Definition of
Categorized: Gestational first prenatal visit and outcomes:
• > 35 pounds diabetes,%: delivery Fair
for normal BMI, NR G3: normal BMI, > 1 category
> 25 pounds increase in BMI between Source of information
for overweight Cesarean first prenatal visit and on exposure,
BMI, > 15 delivery,%: G4: overweight BMI, no outcomes, and
pounds for G1: 8.2 change in BMI between confounders:
obese BMI G2: 12.6 first prenatal visit and Fair
G3: 21.0 P < 0.001 delivery
Collected from: G4: 13.0 Followup:
• Routine pre- G5: overweight BMI, 1 Poor
G5: 14.3 category increase in BMI
natal care or G6: 19.3 P = 0.256
maternity between first prenatal visit Analysis
records Instrumental and delivery comparability:
delivery,%: G6: overweight BMI, > 1 Poor
Ascertained by: category increase in BMI
Episiotomy,%: Analysis of outcomes:
• Based on last between first prenatal visit
Fair
clinically Other maternal and delivery
measured outcomes: Interpretation:
weight prior to Results
NA Poor
delivery: not Operative vaginal delivery
stated, most Other infant G1: 11.4 Sum of
likely difference outcomes: G2: 12.4 Good/Fair/Poor:
between NA G3: 12.2 P = 0.837 1 Good, 4 Fair, 4 Poor
weight at first G4: 8.4
G5: 11.4 Final Quality Score:
prenatal visit Poor
and weight at G6: 17.3 P < 0.001
delivery 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

C-127
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
(BMI 35–39.9) (n = Categorized: NR
Study Objective:
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight G3: Obese Class III Age (mean, yrs): NR
change on pregnancy (BMI 40 and More) G1: <26: 46%
outcomes in obese (n = 19,025) 26-35: 47% Other
women Older than 35: 8% G1: 22
Group N:
Time frame: NR G2: <26: 44% Smoking,%:
1990 to 2001 26-35: 48% NR
Inclusion criteria: Older than 35: 8%
Duration of the study: • Obese women G3: <26: 40% Diabetes mellitus,%:
Entry into prenatal care residing in Missouri 26-35: 52% NR
through delivery who delivered (at Older than 35: 9%
Hypertension,%:
37 or more weeks
of gestation) Parity: NR
liveborn, singleton Nulliparous:
G1: 34% Additional characteristics:
infants during NR
1990–2001 G2: 33%
G3: 32%
Exclusion criteria:
• NR

C-128
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Odds of preeclampsia, Good
LGA:13% cesarean delivery, LGA
Total weight gain: (P < 0.05) births, SGA births Sample selection:
G1: GWG (lb) G2: SGA: 7% Fair
Less than 2: 3% LGA:16% Groups
2 to 14: 15% All obese women Definition of maternal
(P < 0.05) weight gain:
15 to 25: 26% G3: SGA: 6% G1: Loss 10 lbs or more
More than 25: G2: Loss 2 to 9 lbs Fair
LGA:18%
56% (P < 0.05) G3: No change Definition of outcomes:
G2: GWG (lb) G4: Gain 2-9 lbs Good
Less than 2: 8% Gestational diabetes, G5: Gain 10-14 lbs
2 to 14: 22% %: G6: Gain 15-25 lbs Source of information on
15 to 25: 27% NR G7: Gain 25-35 lbs exposure, outcomes, and
More than 25: confounders:
43% Cesarean delivery,%: Results Fair
G3: GWG (lb)Less G1: 28 Compared with women
G2: 34 who gained 15–25 lb Followup:
than 2: 15% Fair
G3: 41 during their pregnancies,
Categorized: those who gained less Analysis comparability:
Instrumental
• 10-lb or less loss weight had significantly Fair
delivery,%: lower odds of
2 to 9 lbs loss, no
NR preeclampsia, cesarean Analysis of outcomes:
weight change,
2 to 9 lbs gain, Episiotomy,%: delivery, and LGA births, Fair
10 to 14 lbs gain, NR but higher odds for SGA
Interpretation:
15–25 lb gain, births.
Poor
26–35 lb gain,
Magnitude differed by
and greater than Sum of Good/Fair/Poor:
obesity classification, even
35 lb gain 2 Good, 6 Fair, 1 Poor
after adjusting for known or
Collected from: suspected confounders Final Quality Score:
• Routine pre-natal Fair
Maternal confounders
care or maternity
and effect modifiers
records
accounted for in
Ascertained by: analysis:
NR • 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

C-129
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-130
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Bivariate
Gain 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-131
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Murakami et al., 2004 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Japan, hospital Total Study N: G1: 20.9 (2.8) Black
633 G2: NR NR
Enrollment Period:
2001 Group Description: Imputed: Hispanic
G1: Total cohort • No NR
Funding:
G2: NR
NR Categorized: Asian/Pacific Islander
Group N: • WHO International NR
Study Objective:
G1: 633 Taskforce
To estimate risk of Other
G2: NR
perinatal morbidity of Age (mean, yrs): NR
mother and infant with Inclusion criteria: G1: 29.1 (4.5)
respect to maternal Smoking,%:
• Live, singletons G2: NR G1: 8.5
prepregnancy BMI and delivered between
weight gain in Japanese Parity: G2: NR
24 to 42 weeks
women gestation G1: 0.6 (0.7) Diabetes mellitus,%:
G2: NR G1: 2.1
Time frame: Exclusion criteria:
2001 G2: NR

Duration of the study: Hypertension,%:

Prenatal through birth NR
Additional characteristics:
G1: Preeclampsia - mild:
5.4%; severe: 4.1%
G2: NR
Additional characteristics:
NR

C-132
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 633 G1: 3,052.6 (483.8) AOR for cesarean delivery Good
G2: NR G2: NR (95% CI)
Sample selection:
Total weight gain: Gestational Groups Fair
G1: 10.5 (3.4) diabetes, %: G1: < 8.5 kg
G2: NR G1: 2.1 G2: 8.5-12.5 kg Definition of maternal
G2: NR G3: > 12.5 kg weight gain:
Categorized: Fair
• < 8.5kg, 8.5- Cesarean Results
delivery,%: G1: 1.08 (0.56-2.07) Definition of outcomes:
12.5, > 12.5
G1: 10.3 G2: 1.00 Fair
Collected from: G2: NR G3: 1.23 (0.61-2.48) Source of information on
• Routine pre-
Instrumental Maternal confounders exposure, outcomes, and
natal care or
delivery,%: and effect modifiers confounders:
maternity
NR accounted for in Fair
records
analysis: Followup:
Ascertained by: Episiotomy,%:
• Age Fair
• Based on last NR
• Parity
clinically Analysis comparability:
Other maternal • Pre-gravid BMI
measured Fair
outcomes: • Smoking
weight prior to NA Analysis of outcomes:
delivery: last Infant and child
measurement Other infant Fair
confounders and effect
was taken at outcomes: modifiers accounted for Interpretation:
hospitalization NA in analysis: Fair
prior to delivery • Gestational age
Sum of Good/Fair/Poor:
1 Good, 8 Fair, 0 Poor
Final Quality Score:
Fair

C-133
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Purfield and Morin, • Other observational • Self-reported White
1994 : convenience G1: 135.69 (15.43) NR
sample G2: 129.81 (14.83)
Country and setting: Black
• Retrospective
Tertiary care medical Pregravid BMI: NR
center, Pennsylvania Total Study N:
Imputed: Hispanic
104
Enrollment Period: • No NR
Group Description:
Funding: Categorized: Asian/Pacific Islander
G1: prepregnant weight
NR • Normal weight was NR
increased by 25% or
Study Objective: less defined as a weight Other
To determine whether a G2: prepregnant weight within 90-120% of NR
group of normal weight increased by more than standard weight for
women with a low risk 25% height based on Smoking,%:
pregnancy who Metropolitan Life NR
Group N: Insurance Company
increased prepregnancy Diabetes mellitus,%:
G1: 52 Table of 1983
weight by more than NR
G2: 52 • NR
25% experienced a
longer second stage of Inclusion criteria: Hypertension,%:
Age (mean, yrs):
labor or higher • Low risk NR
G1: 25.75 (4.83)
proportion of operative primiparous G2: 25.83 (4.81) Additional characteristics:
deliveries than a group pregnancy NR
of normal weight women • Normal Parity:
prepregnant weight NR
Time frame:
for height
Duration of the study: • 18 to 40 years of
August 1991 to June age
1992 • 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

C-134
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 52 G1: 3266 (351.54) Rates of different modes of Good
G2: 52 G2: 3384 (327.47) t delivery by weight gain
= -2.33 P = 0.02 Sample selection:
Total weight gain: Groups Fair
G1: % of weight Gestational G1: prepregnant weight
gain (greater than diabetes, %: increased by 25% or less Definition of maternal
prepregnant NR G2: prepregnant weight weight gain:
weight): 20.60 increased by more than Fair
(3.52) Cesarean delivery, 25%
%: Definition of outcomes:
G2: % of weight Good
gain (greater than NR Results
prepregnant Higher rate of vacuum Source of information on
Instrumental extraction and cesarean
weight): 33.21 delivery, %: exposure, outcomes, and
(5.45) t = -14.02 P delivery and lower rate of confounders:
NR spontaneous vaginal
= 0.001 Fair
Episiotomy, %: delivery. with excessive
Categorized: NR weight gain Followup:
• > 25% of Fair
Other maternal No difference in forceps
prepregnant Analysis comparability:
outcomes: delivery and vaginal
weight and ≤ Poor
NA delivery by weight gain
25% of
status Analysis of outcomes:
prepregnant Other infant
weight outcomes: Vaginal delivery Fair
NA G1: n=27 Interpretation:
Collected from:
G2: n=9 Fair
• Routine pre-
natal care or Vacuum extraction Sum of Good/Fair/Poor:
maternity G1: n=14 2 Good, 6 Fair, 1 Poor
records G2: n=25
Final Quality Score:
Ascertained by: Low forceps Fair
• Based on last G1: n=8
clinically G2: n=8
measured
weight prior to Cesarean section
G1: n=3
delivery:
difference G2: n=10
between self χ2=15.87, P=0.001 for all 4
report and modes of delivery by
weight at weight groups
admission to
hospital for Maternal confounders
birth and effect modifiers
accounted for in
analysis:
NA
Infant and child
confounders and effect
modifiers accounted for
in analysis:
NA

C-135
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rosenberg et al., 2005 • Cohort • Self-reported White
• Retrospective G1: < 100 pounds: 1.7% NR
Country and setting:
100-149: 49.1%
USA, vital statistics data Total Study N: Black
150-199: 37.5%
329988 NR
Enrollment Period: 200-299: 11.2%
Bbirth certificates with Group Description: ≥ 300: 0.5% Hispanic
self reported pregravid G1: Non-hispanic G2: < 100 pounds: 1.8% NR
weight and weight gain blacks 100-149: 69.5%
150-199: 24.0% Asian/Pacific Islander
G2: Non-hispanic
Funding: 200-299: 4.7% NR
whites
NR ≥ 300: 0.1%
G3: Non-hispanic Other
Study Objective: asians G3: < 100 pounds: 8.1% NR
To examine G4: Hispanics 100-149: 79.5%
associations between G5: Total 150-199: 11.6% Smoking,%:
obesity, diabetes, and 3 200-299: 0.8% NR
Group N: ≥ 300
adverse pregnancy Diabetes mellitus,%:
G1: 86,908
outcomes (primary Pregravid BMI: G1: 3.7
G2: 96,581
cesarean section, G2: 2.6
G3: 38,570 Imputed:
preterm birth, and LBW) G3: 6.6
G4: 107,612 • No
by race/ethnic groups G4: 3.5
G5: 329,988
Time frame: Categorized: G5: 3.7 P < 0.001
Inclusion criteria:
Birth certificates with • NR Hypertension,%:
self reproted pregravid • Live singleton births
G1: 1.7
weight and weight gain • Information on Age (mean, yrs):
G1: 27.5 G2: 0.6
maternal
Duration of the study: G2: 30.6 G3: 0.5
prepregnancy
Birth certificates from G4: 0.7
weight and G3: 29.7
1999, 2000, and 2001 G4: 26.4 P < 0.001 G5: 0.9 P < 0.001
maternal weight
gain during G5: 28.3 Additional characteristics:
pregnancy G1: PIH 1.9
Parity:
G2: 1.2
Exclusion criteria: NR
G3: 0.7
• NA
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-136
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 86,908 NR AOR for primary cesarean Fair
G2: 96,581 (95% CI)
G3: 38,570 Gestational Sample selection:
G4: 107,612 diabetes, %: Groups Fair
G5: 329,988 G1: 3.7 G1: < 41 pounds
G2: 2.6 Definition of maternal
G2: ≥ 41 pounds weight gain:
Total weight gain: G3: 6.6
G1: < 41pounds: G4: 3.5 Poor
Results
79.7% G5: 3.7 P < 0.001 1.38 (1.34-1.41) Definition of outcomes:
≥ 41 pounds: Poor
20.3% Cesarean
G2: < 41pounds: delivery,%: Maternal confounders Source of information on
83.2% G1: 16.2 and effect modifiers exposure, outcomes, and
≥ 41 pounds: G2: 14.7 P < 0.001 accounted for in confounders:
16.8% P < 0.001 G3: 14.4 analysis: Fair
G4: 13.8
G3: < 41pounds: • Age Followup:
89.2% G5: 14.7
• Parity Fair
≥ 41 pounds: Instrumental • GDM
10.8% delivery,%: • Pregnancy induced Analysis comparability:
G4: < 41pounds: NR hypertension Fair
79.1% • Pre-eclampsia
Episiotomy,%: Analysis of outcomes:
≥ 41 pounds: • Prepregnancy weight
NR Fair
20.9% • Chronic diabetes
G5: < 41pounds: Other maternal Interpretation:
• Chronic hypertension
81.6% outcomes: Fair
• Marital status
≥ 41 pounds: NA
18.4% • Maternal education Sum of Good/Fair/Poor:
Other infant • Mother’s birthplace 0 Good, 7 Fair, 2 Poor
Categorized: outcomes: • Prenatal care payer
• < 41, ≥ 41 Final Quality Score:
• Preterm birth • Social risk
pounds Fair
10.5, 5.1, 5.9, • Trimester prenatal
Collected from: 7.8, 7.5 care began
• Routine pre-natal P < 0.001 Infant and child
care or maternity (groups confounders and effect
records defined above) modifiers accounted for
• LBW 9.7, 4.1, in analysis:
Ascertained by: 5.7, 6.1, 6.4 NR
• Based on last P < 0.001
clinically (groups
measured weight defined above)
prior to delivery

C-137
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Description Study Design, Patient Baseline Characteristics Baseline Characteristics
Population, Inclusion/ (continued)
Exclusion Criteria

Author, year: Design: Pregravid weight: Race,%:

Sherrard, 2007 • Cohort • Self-reported NR
• Retrospective
Country and setting: Pregravid BMI: Smoking,% (none):
Total Study N:
Canada, hospital Imputed: G1: 81%
63,930
Enrollment Period: • Yes G2: 81%
Group Description:
1978 to 2001 Categorized: G3: 82.1%
G1: Primary caeserean
Funding: • < 18.5, 18.5-24.9. 25- G4: 82.6%
w/o labor
NR 29.9, >30
G2: Primary caeserean
Study Objective: w/ labour Age (mean, yrs): Diabetes mellitus,%:
To quantify the effects G3: Repeat w/o labour Categories by group NA
of pre-gravid BMI and <20: 1.9%, 1.9%, 0.2%,
G4: Repeat w/ labour Hypertension,%:
gestational weight gain 0.2%
on caeserian delivery NR
20 to 34: 82.2%,
Time frame: Group N: 82.4%,70%, 72% Additional characteristics:
1978 to 2001 G1: 58039 35 or more: 15.9%, 15.7%, NR
Duration of the study: 29.8%, 27.8%
G2: 57468
22 years Parity:
G3: 5351
Nulliparous- Yes
G4: 2206
G1: 51.5%
G2: 51.3%
G3: NA
Inclusion criteria:
G4: NA
• Singleton term
births
Exclusion criteria:
• NR

C-138
Evidence Table
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
Cesarean delivery, primary and Good
Total weight gain: Gestational repeat, labored and
Weight gain rate diabetes, %: unlabored Sample selection:
Low (<0.18) Fair
G1: 18.9% Groups:
G2: 18.9% Cesarean Definition of maternal weight
G3: 19.5% delivery,%: Rate of weight gain (kg/wk) gain:
G4: 19.6% NR G1: Low (≤0.17) Fair
G2: Normal (0.18-0.50)
Instrumental G3: High (>0.50 Definition of outcomes:
Normal (0.18-0.5) delivery, %: Good
G1: 75.4% NR
G2: 75.4% Results: Source of information on
G3: 74.3% Episiotomy, %: exposure, outcomes, and
G4: 74.8% NR AOR for unlabored cesarean, confounders:
primary Poor
Other maternal G1: 0.79 (0.59-1.05)
High (>0.5) outcomes: Followup:
G1: 5.7% G2: 1.00 (ref)
NR G3: 1.03 (0.64-1.64) Good
G2: 5.7%
G3: 6.2% Other infant AOR for labored cesarean, Analysis comparability:
G4: 5.6% outcomes: primary Good
NR G1: 0.77 (0.68-0.86) Analysis of outcomes:
G2: 1.00 (ref) Good
G3: 1.40 (1.23-1.60)
Interpretation:
AOR for unlabored cesarean, Fair
repeat
G1: 0.91 (0.76-1.09) Sum of Good/Fair/Poor:
G2: 1.00 (ref) 5 Good, 3 Fair, 1 Poor
G3: 1.38 (1.04-1.83) Final Quality Score:
AOR for labored cesarean, Fair
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

C-139
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Shepard et al., 1998 • Cohort • Self-reported White
• Prospective G1: 140.9 (28.6) G1: 88.4
Country and setting: G2: 91.2
G2: 136.3 (25.2) P = 0.007
Obstetrical practices in Total Study N:
New Haven, CT 2,301 Pregravid BMI: Black
G1: 24.3 (4.6) G1: 5.8
Enrollment Period: Group Description: G2: 4.9
G2: 22.9 (3.9) P < 0.0001
1988 to 1992 G1: Cesarean delivery
G2: Vaginal delivery Imputed: Hispanic
Funding: G1: 3.5
• No
Grants NIH Group N: G2: 2.3
G1: 312 Categorized:
Study Objective: Asian/Pacific Islander
To examine absolute
G2: 1,989 • NHANES II: ≤ 19.4;
19.5-22.4; 22.5-28.5; > G1: 1.3
and proportional Inclusion criteria: G2: 1.1
gestational weight gain 28.5
• Privately insured
and prepregnancy BMI women who Age (mean, yrs): Other
as predictors of primary received prenatal NR G1: 1.0
cesarean delivery care from 13 G2: 0.4
largest obstetrical Parity:
Time frame: NR Smoking,%:
1988 to 1992 practices and % never smokers:
health maintenance G1: 82.3
Duration of the study: organizations in G2: 85.9
First prenatal visit to greater New
delivery Haven, CT region Diabetes mellitus,%:
(part of a larger NR
study of selected
Hypertension,%:
environmental risk
NR
factors on
pregnancy) Additional characteristics:
• Singleton deliveries %married:
at Yale-New Haven G1: 95.8
Hospital G2: 92.1
Exclusion criteria: Additional characteristics:
• Repeat cesareans NR
births
• Missing information
on key variables

C-140
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 312 NR Adjusted relative risk (95% CI) of Good
G2: 1989 cesarean delivery based on types of
Gestational weight gain Sample selection:
Total weight gain: diabetes, %: Fair
G1: 35.4 (11.9) NR Groups
G2: 33.3 (11.9) P = G1: Proportional Weight Gain (total Definition of maternal
0.005 Cesarean delivery, weight gain/ prepregnancy weight) weight gain:
%: G2: Absolute Weight Gain Poor
Categorized: NR
Definition of
• Proportional Results
Instrumental Underweight (< 19.4), ≤ median outcomes:
weight gain
delivery, %: G1: 1.00 Fair
based on
NR G2: 1.00
prepregnancy Source of information
weight and Episiotomy, %: on exposure,
Underweight (< 19.4), > median
weight change NR outcomes, and
G1: 2.08 (0.86-5.04)
during confounders:
Other maternal G2: 1.20 (0.56-2.59)
pregnancy Poor
outcomes: Low-Average (19.5-22.4), ≤ median
Collected from: • Propotional Followup:
G1: 1.62 (0.90-3.67)
• Routine pre- weight gain, lb, Good
G2: 1.00 (0.54-1.84)
natal care or mean:
maternity Low-Average (19.5-22.4), > median Analysis
cesarean
records G1: 2.35 (1.06-5.21) comparability:
delivery - 26.5
G2: 1.62 (0.94-3.02) Fair
(10.0); vaginal
Ascertained by:
delivery - 25.2 Analysis of outcomes:
• Based on last High-Average(22.5-28.4), ≤ median
(9.3) P = 0.048 Good
clinically G1: 2.78 (1.26-6.12)
measured Other infant G2: 1.80 (1.01-3.21) Interpretation:
weight prior to outcomes: Fair
High-Average (22.5-28.4), > median
delivery • Low birth
G1: 3.06 (1.40-6.73) Sum of
weight rate =
G2: 2.02 (1.14-3.57) Good/Fair/Poor:
3.3% for entire
study Obese (> 28.5), ≤ median 3 Good, 4 Fair, 2 Poor
population G1: 3.25 (1.40-7.54) Final Quality Score:
G2: 2.13 (1.12-4.08) Fair
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

C-141
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Wataba et al., 2006 • Perinatal data base • Not stated White
and look at medical NR
Country and setting: Pregravid BMI:
records
Japan, academic G1: 20.5 (2.6) Black
retrospectively
medical center G2: 21.1 (3.0) NR
• Retrospective
Enrollment Period: Imputed: Hispanic
Total Study N:
1981 to 1999 • No NR
21,718
Funding: Categorized: Asian/Pacific Islander
Group Description:
NR • Categorical in 2 kg/m2 NR
G1: Nulliparous
Study Objective: G2: Parous women point intervals from Other
To analyze association prepregnancy weight; NR
Group N: categorical into low,
of pregnancy
G1: 10413 medium, high BMI Smoking,%:
complications with
G2: 11305 groups (< 18, 18-23.9, > NR
prepregnant body mass
index and weight gain 24)
Inclusion criteria: Diabetes mellitus,%:
during pregnancy in • Singleton Age (mean, yrs): NR
Japanese women pregnancy G1: 27.8 (4.1)
Hypertension,%:
Time frame: delivering term G2: 30.45 (3.9)
baby at Osaka Med NR
1981 to 1999 Parity:
Center and Additional characteristics:
Duration of the study: Research Institute NR
NR
Entry into PNC up til for Maternal and
delivery Child Health in
19811999
Exclusion criteria:
• None reported

C-142
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 10413 G1: SGA: 5.4% Adjusted odds ratio for Good
G2: 11305 LGA 5.2% cesarean deliveries by
G2: SGA 6.5% LGA weight gain categories Sample selection:
Total weight gain: 5.2% Fair
G1: kg/wk: 0.25 Groups
(SD 0.09) Gestational Rate of weight gain, Definition of maternal
G2: kg/wk: 0.24 diabetes, %: categorized differently weight gain:
(0.09) P < 0.01 NR across different BMI Poor
groups Definition of outcomes:
Categorized: Cesarean delivery,
Poor
• Categorical in %: Results
kg/wk using NR For nulliparous, low BMI Source of information on
prepregnancy women: exposure, outcomes, and
Instrumental Higher risk of cesarean
weight and confounders:
delivery, %: delivery for women with
weight at Poor
NR weight gain ≥ 0.4 kg/week
delivery divided
by gestational Episiotomy, %: (AOR: 2.30 [95% CI 1.06- Followup:
age of infant at NR 4.98] compared with Fair
birth women gaining 0.25-0.3 Analysis comparability:
Other maternal kg/week)
Collected from: outcomes: Poor
• Rate of weight • NR For nulliparous, medium Analysis of outcomes:
gain BMI women: Fair
determined by: Other infant
outcomes: Higher risk of cesarean
total weight Interpretation:
NR delivery for women with
gain divided by Fair
weight gain ≥ 0.4 kg/week
weeks ga (AOR: 1.61 [[95% CI 1.21- Sum of Good/Fair/Poor:
Ascertained by: 2.14] compared with 1 Good, 4 Fair, 4 Poor
• Based on last women gaining 0.25-0.3
kg/week) and for women Final Quality Score:
clinically Poor
measured with weight gain 0.35-0.4
weight prior to kg/week (AOR: 1.68 [95%
delivery: and CI 1.22-2.30] compared
subtracting with women gaining 0.25-
prepregnancy 0.3 kg/week)
weight
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

C-143
 Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Wataba et al., 2006
(Continued)

C-144
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis 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-145
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Witter et al., 1995 • Cohort • Self-reported White
• Retrospective • NR G1: 40.3
Country and setting: G2: 29.0
Obstetric database, Total Study N: Pregravid BMI:
Johns Hopkins Hospital, 4,346 G1: 24.7 (5.9) Black
MD G2: 23.1 (4.7) G1: 59.7
Group Description: G2: 71.0
Enrollment period: G1: Cesarean deliveries Imputed:
NR G2: Vaginal deliveries • No Hispanic
NR
Funding: Group N: Categorized:
NR G1: 1,086 • Continuous Asian/Pacific Islander
G2: 3,260 NR
Study Objective: Age (mean, yrs):
To determine whether Group 3Inclusion G1: 26.9 (6.7) Other
greater weight gain criteria: G2: 24.3 (6.1) NR
during pregnancy is • Women who
associated with an Parity: Smoking,%:
delivered infants ≥ G1: 27.3
increased risk of 28 weeks gestation NR
cesarean delivery and, if G2: 29.6
so, whether this effect is Exclusion criteria: Diabetes mellitus,%:
explained by positive • Incomplete data G1: 6.1
influence of weight gain G2: 2.6
on birth weight and if
there is a threshold of Hypertension,%:
pregnancy weight gain NR
above which risk of Additional characteristics:
cesarean delivery is NR
increased differentially
Time frame:
NR
Duration of the study:
1987 to 1989

C-146
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1,086 G1: 3,128 (841) AOR for cesarean (95% Good
G2: 3,260 G2: 3,181 (618) CI)
Sample selection:
Total weight gain: Gestational Groups Fair
G1: 14.56 (6.53) * diabetes, %: NA, continuous pregnancy
P < 0.05 G1: 6.1 weight gain (kg) Definition of maternal
compared to G2: 2.6 weight gain:
vaginal Results Fair
deliveries Cesarean 1.04 (1.02-1.05)
delivery,%: Definition of outcomes:
G2: 13.49 (6.44) Maternal confounders Good
NR
Categorized: and effect modifiers
Instrumental accounted for in Source of information on
• Continuous exposure, outcomes, and
delivery,%: analysis:
confounders:
Collected from: NR • Age
Fair
• Routine pre- • Pre-gravid BMI
Episiotomy,%:
natal care or
NR • Height Followup:
maternity • At least 1 previous Fair
records Other maternal viable pregnancy
outcomes Analysis comparability:
Ascertained by: • Diagnosis of
Good
• Incidence of preeclampsia during
• Based on last
cesarean in the current pregnancy Analysis of outcomes:
clinically
study • Previous cesarean Fair
measured
population was delivery
weight prior to Interpretation:
25%
delivery: used Infant and child Good
weight Other infant confounders and effect
recorded at last outcomes Sum of Good/Fair/Poor:
modifiers accounted for
visit prior to • NA 4 Good, 5 Fair, 0 Poor
in analysis:
delivery • Gestational age Final Quality Score:
• Birth weight Fair

C-147
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Young et al., 2002 • Cohort • Self-reported Routine White
• Retrospective pre-natal care G1: NR
Country and setting: G2: NR
USA, private practice Total Study N: Pregravid BMI: G3: NR
3,375 (hard to tell from G1: 16.3% G4: NR
Enrollment Period:
tables however as #’s G2: 47.8% G5: 90.6%
Feb 1993 to June 2001
don’t add up to this) G3: 21%
Funding: G4: 14.8% Black
Group Description: G1: NR
NR
G1: BMI < 20 Imputed: G2: NR
Study Objective: G2: BMI 20-25 • No G3: NR
To examine body mass G3: BMI 25-30 G4: NR
G4: BMI > 30 Categorized:
index and pregnancy G5: 7.56%
weight gain as risk G5: All • Categorical based on
factors for primary American Bariatric Hispanic
Group N: Society definition of NR
cesarean delivery in
G1: 551 obesity and categories
nulliparous women in Asian/Pacific Islander
G2: 1616 used by Cnattingius et
middle-class private G1: NR
G3: 709 al
practice G2: NR
G4: 500
Time frame: G5: 3361 Age (mean, yrs): G3: NR
Feb 1993 to June 2001 G1: NR G4: NR
Inclusion criteria: G2: NR G5: 1.88%
Duration of the study: • Primiparous G3: NR
From entry into prenatal deliveries between G4: NR Other
care up til delivery Feb 1993 and June G5: < 20: 8.91%, NR
13,2001 in large 20-29: 62.57%, Smoking,%:
private practice 30-34: 20.1%, NR
obstetric clinic > 35: 8.43%
Diabetes mellitus,%:
Exclusion criteria: Parity: NR
• Missing BMI data NR
on mother Hypertension,%:
NR
Additional characteristics:
NR

C-148
Evidence Table 11. Gestational weight gain and mode of delivery (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 551 NR Rate of cesarean deliveries Poor
G2: 1616 by weight gain categories
G3: 709 Gestational Sample selection:
G4: 500 diabetes,%: Groups Poor
NR G1: < 30 lbs
Total weight gain: G2: 30-35lbs Definition of maternal
G1: * (computed Cesarean G3: > 35 lbs weight gain:
these delivery,%: Poor
percentages G1: 12.7 Results
G2: 18.44 Increase in overall Definition of outcomes:
from n values) Poor
< 30#: 40.7% G3: 24.96 cesarean delivery rate with
30-35#:27.2% G4: 37.6 increased weight gain was Source of information on
> 35#: 32.1% significant at all BMI levels exposure, outcomes, and
Instrumental
G2: < 30#: 35.5% delivery,%: Maternal confounders confounders:
30-35#:27.6% and effect modifiers Fair
> 35#: 36.9% Episiotomy,%: accounted for in Followup:
G3: < 30#: 44.6% Other maternal analysis: Fair
30-35#: 21.6% outcomes: • BMI
> 35#: 33.8% Analysis comparability:
• CPD rate Infant and child
G4: < 30#: 63.6% Poor
doubles in confounders and effect
30-35#: 12.8% women with modifiers accounted for Analysis of outcomes:
> 35#: 23.6% BMI of < 25 in analysis: Fair
Categorized: kg/m2 with NR
excessive Interpretation:
• Less than 30#, Poor
30-35#, > 35# weight gain
Other infant Sum of Good/Fair/Poor:
Collected from: 0 Good, 3 Fair, 6 Poor
• Routine pre- outcomes:
natal care or NR Final Quality Score:
maternity Poor
records
Ascertained by:
• Based on last
clinically
measured
weight prior to
delivery: last
weight minus
first wt

C-149
Evidence Table 12. Gestational weight gain and vaginal birth after cesarean
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Juhasz et al., 2005 • Cohort • Self-reported White
• Retrospective G1: 75.6
Country and setting: Pregravid BMI: G2: 63.9
USA, hospital Total Study N: G3: 48.2
Imputed:
1,213 G4: 31.3
Enrollment Period: • No
Prepregnancy weight as Group Description: Black
defined by patient and G1: BMI < 19.8 Categorized:
• IOM guidelines G1: 6.9
weight at last prenatal G2: BMI 19.8-26.0 G2: 9.1
visit G3: BMI 26.1-29.0 Age (mean, yrs): G3: 22.6
G4: BMI > 29.0 G1: 32.4 G4: 32.8
Funding:
NR Group N: G2: 31.8
G3: 31.1 Hispanic
G1: 160 G1: 10.0
Study Objective: G4: 29.9 P < 0.001
G2: 715 G2: 20.6
To estimate whether
G3: 137 Parity: G3: 24.8
excessive weight gain
G4: 201 G1: gravidity (mean) 3.4 G4: 34.8
or obesity are risk
factors affecting Inclusion criteria: G2: 3.6
G3: 4.0 Asian/Pacific Islander
success for vaginal birth • Women attempting G1: 7.5
after cesarean (VBAC) VBAC per chart G4: 4.7
G2: 5.2
Time frame: entry G3: 2.9
Prepregnancy weight as Exclusion criteria: G4: 1.0
defined by patient and • Multiple gestation Other
weight at last prenatal • More than one G1: 0
visit previous cesarean G2: 1.3
Duration of the study: delivery G3: 1.5
January 1, 1996 to • Previous uterine G4: 0 P for race < 0.001
December 31, 2000 scar other than low
transverse Smoking,%:
• Malpresentation in NR
current pregnancy Diabetes mellitus,%:
• Presence of an G1: diabetes: 4.0
intrauterine fetal G2: 6.0
demise G3: 16.0
• Delivery at less G4: 20.0 P < 0.001
than 36 weeks of
gestation Hypertension,%:
• Incomplete NR
information for a Additional characteristics:
patient NR

C-150
Evidence Table 12. Gestational weight gain and vaginal birth after cesarean (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 160 G1: 3,345.0 Vaginal birth after cesarean Good
G2: 715 G2: 3,367.8
G3: 137 G3: 3,486.6 Groups: Sample selection:
G4: 201 G4: 3,448.9 G1: ≤ 40 pounds Fair
P = 0.004 G2: > 40 pounds
Total weight gain: Definition of maternal
Categorized: Gestational Results: weight gain:
• ≤ 40 pounds, diabetes, %: • Adjusted odds of VBAC success Fair
> 40 pounds G1: Diabetes: 4.0 with respect to excessive weight
Definition of
G2: 6.0 gain, adjusted for previous
outcomes:
Collected from: G3: 16.0 NSVD, previous VBAC,
Fair
• Routine pre- G4: 20.0 P < 0.001 diabetes, induction, birth weight
natal care or > 4000g, recurrent indication, Source of information
maternity Cesarean one-layer closure, and on exposure,
records delivery,%: complications with respect to outcomes, and
NR pregnancy weight gain, VBAC confounders:
Ascertained by: success rate was 79.1% in those
Instrumental Fair
• Based on last who gained < 40 pounds and
clinically delivery,%: Followup:
66.8% for those who gained
measured NR Poor
more than 40 pounds during the
weight prior to Episiotomy,%: pregnancy, P < 0.001 Analysis
delivery: NR • A higher VBAC success rate was comparability:
difference still noted in group gaining less
Other maternal Poor
between self- than 40 pounds when controlling
reported outcomes: for previous normal spontaneous Analysis of outcomes:
prepregnancy NA vaginal delivery (NSVD), Fair
weight and previous VBAC, indication for
Other infant Interpretation:
weight at last previous cesarean, birth weight,
outcomes: Poor
prenatal visit and diabetes, OR 1.58 (1.04-
NA
2.40) Sum of
• Those who were successful at Good/Fair/Poor:
VBAC gained significantly less 1 Good, 5 Fair, 3 Poor
weight than those who failed
Final Quality Score:
VBAC (29 +/-10.1 pounds and
Poor
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)

C-151
Evidence Table 12. Gestational weight gain and vaginal birth after cesarean (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Juhasz et al., 2005
(continued)

C-152
Evidence Table 12. Gestational weight gain and vaginal birth after cesarean (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis 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-153
Evidence Table 13. Gestational weight gain and vaginal lacerations
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kabiru and Raynor, • Cohort • Measured at first White
2004 • Retrospective prenatal visit G1: 1.9
G2: 2.6
Country and setting: Total Study N: Pregravid BMI: G3: 2.8
USA, hospital 5,131
Imputed: Black
Enrollment Period: Group Description: • No G1: 84.1
1999 to 2002 G1: No change in BMI G2: 82.8
between first Categorized:
Funding: • 20-24.9, 25-29.9, 30- G3: 88.2
prenatal visit and
NR 34.9, 35-39.9, ≥ 40 Hispanic
delivery
Study Objective: G2: 1 category increase Age (mean, yrs): G1: 13.9
To investigate effect of in BMI between first G1: 24.7 (6.1) G2: 14.6
increase in body mass prenatal visit and G2: 24.4 (5.7) G3: 9.0
index category on delivery G3: 25.2 (5.9) P < 0.001 Asian/Pacific Islander
obstetric outcomes G3: > 1 category
Parity: NR
increase in BMI
Time frame: between first G1: Gravidity (mean): 1.9 Other
1999 to 2002 prenatal visit and (1.9) NR
Duration of the study: delivery G2: 1.5 (1.7)
G3: 1.2 (1.7) P < 0.001 Smoking,%:
Prenatal through birth Group N: NR
G1: 2,556
G2: 2,252 Diabetes mellitus,%:
G3: 323 NR

Inclusion criteria: Hypertension,%:

• Singleton NR
pregnancies Additional characteristics:
Exclusion criteria: Mean weight gain:
G1: 8.6 pounds (8.4)
• Multiple
G2: 22.2 pounds (10.2)
pregnancies
G3: 55.3 pounds (23.8)
• BMI < 20
• Missing BMI data Additional characteristics:
NR

C-154
Evidence Table 13. Gestational weight gain and vaginal lacerations (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 579 G1: 2886.0 (756) Third/fourth degree lacerations Good
G2: 942 G2: 3174.9 (600)
G3: 189 G3: 3099.5 (673) Groups Sample selection:
G4: 819 P < 0.001 Primary cesarean Fair
G5: 790 G4: 3116 (713) G1: normal BMI, no change in BMI
between first prenatal visit and Definition of maternal
G6: 104 G5: 3269 (698) weight gain:
G6: 3371 (733) delivery
Total weight gain: G2: normal BMI, 1 category increase in Poor
P = 0.015
BMI between first prenatal visit and Definition of outcomes:
Categorized: Gestational delivery Fair
• > 35 pounds for diabetes,%: G3: normal BMI, > 1 category increase
normal BMI, > 25 NR in BMI between first prenatal visit Source of information on
pounds for and exposure, outcomes, and
overweight BMI, Cesarean G4: overweight BMI, no change in BMI confounders:
> 15 pounds for delivery,%: between first prenatal visit and Fair
obese BMI G1: 8.2 delivery
G2: 12.6 Followup:
Collected from: G5: overweight BMI, 1 category Poor
G3: 21.0 P < 0.001 increase in BMI between first
• Routine pre-natal G4: 13.0
care or maternity G5: 14.3 prenatal visit and delivery Analysis comparability:
records G6: overweight BMI, > 1 category Poor
G6: 19.3 P = 0.256 increase in BMI between first
Ascertained by: Analysis of outcomes:
Instrumental prenatal visit and delivery
Fair
• Based on last delivery,%:
clinically Results
Interpretation:
measured weight Episiotomy,%: Third/fourth degree lacerations (%)
Poor
prior to delivery: Other maternal G1: 24.0
not stated, most outcomes: G2: 29.3 Sum of Good/Fair/Poor:
likely difference NA G3: 31.7 P < 0.001 1 Good, 4 Fair, 4 Poor
between weight G4: 26.3
G5: 27.5 Final Quality Score:
at first prenatal Other infant Poor
visit and weight outcomes: G6: 30.8 P = 0.780
at delivery NA Maternal confounders and effect
modifiers accounted for in analysis:
• Pre-gravid BMI
Infant and child confounders and
effect modifiers accounted for in
analysis:
NR

C-155
Evidence Table 13. Gestational weight gain and vaginal lacerations (continued)
Study Design, Patient Baseline
Population, Inclusion/ Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if self White
1992 • Combination: reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at G4: 65.0 (12.2) Hispanic
July 1, 1985 - delivery G5: 58.3 (6.5) NR
December 31, 1985 (6
Total Study N: Pregravid BMI: Asian/Pacific Islander
months)
Total n = 357 G1: 39.5 (3.4) NR
Funding: • 191 women with G2: 17.2 (0.9)
NR abnormal G3: 26.1 (6.1) Other
prepregnant weight G4: 23.6 (4.1) NR
Study Objective: G5: 21.6 (2.0)
(≥ 20% under or Smoking,%:
To evaluate effects of
over ideal weight NR
abnormal maternal Imputed:
for height) or
weight or weight gain on • No Diabetes mellitus,%:
abnormal
pregnancy outcome NR
pregnancy weight Categorized:
Time frame: gain (≥ 20kg or ≤ • Continuous ≥ 20% over or Hypertension,%:
July 1, 1985 to 5kg) under normal weight for NR
December 31, 1985 (6 • 166 controls height
months) Additional
Group Description: Age (mean, yrs): characteristics:
Duration of the study: G1: ≥ 20% over normal G1: 28 (5.1) NR
Prepregnancy to weight for height G2: 25.5 (5.1)
delivery G2: ≥ 20% under G3: 29.5 (5.1)
normal weight for height G4: 28.7 (4.7)
G3: weight gain ≤ 5kg G5: 28.7 (4.4)
G4: weight gain ≥ 20kg
G5: control Group 6 Parity:
G1: prior deliveries: 1.0 (1.0)
Group N: G2: 0.8 (0.8)
G1: 77 G3: 1.2 (1.1)
G2: 28 G4: 0.8 (1.0)
G3: 30 G5: 0.9 (1.0)
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

C-156
Evidence Table 13. Gestational weight gain and vaginal lacerations (continued)
Maternal Outcomes from Bivariate Outcomes from Multivariate
Weight Gain Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Vaginal repair II/ III % Fair
G2: 28 P < 0.05 compared to
G3: 30 controls Groups Sample selection:
G4: 56 G2: 3293 (362) G1: weight gain ≤ 5 kg Poor
G5: 166 P < 0.05 compared to G2: weight gain ≥ 20 kg
G3: reference (normal prepregnancy Definition of maternal
controls weight gain:
Total weight G3: 3284 (880) weight and normal weight gain
gain: [undefined]) Poor
G4: 3803 (538)
G1: 11.8 (6.2) P < 0.005 compared to Definition of outcomes:
P < 0.05 Results
controls G1: 4/0 Poor
compared to G5: 3538 (535)
controls G2: 5/0 Source of information
G2: 13.4 (4.5) Gestational diabetes,%: G3: 2/0 on exposure,
G3: 3.0 (3.5) NR Maternal confounders and effect outcomes, and
P < 0.0005 modifiers accounted for in analysis: confounders:
compared to Cesarean delivery,%: Fair
G1: Elective 7% NA
controls Followup:
G4: 23.2 (22.8) Emergency 14% Infant and child confounders and
Total 21% effect modifiers accounted for in Fair
P < 0.0005
compared to G2: Elective 4% analysis: Analysis comparability:
controls Emergency 4% NA Poor
G5: 13.2 (3.4) Total 8%
G3: Elective 3% Analysis of outcomes:
Categorized: Emergency 3% Fair
• ≤ 5kg or ≥ Total 6%
Interpretation:
20kg G4: Elective 5%
Poor
Emergency 18%
Collected from: Total 23% Sum of Good/Fair/Poor:
• Routine pre- G5: Elective 13% 0 Good, 4 Fair, 5 Poor
natal care or Emergency 9%
maternity Total 22% Final Quality Score:
records Poor
Instrumental delivery,%:
Ascertained by: NR
• Based on
last clinically Episiotomy,%:
measured NR
weight prior Other maternal
to delivery outcomes:
NA
Other infant outcomes:
NA

C-157
Evidence Table 14. Maternal weight gain and shoulder dystocia
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if White
1992 • Combination: self reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at G4: 65.0 (12.2) Hispanic
July 1, 1985 - delivery G5: 58.3 (6.5) NR
December 31, 1985 (6
Total Study N: Pregravid BMI: Asian/Pacific Islander
months)
Total n = 357 G1: 39.5 (3.4) NR
Funding: • 191 women with G2: 17.2 (0.9)
NR abnormal G3: 26.1 (6.1) Other
prepregnant weight G4: 23.6 (4.1) NR
Study Objective: G5: 21.6 (2.0)
(≥ 20% under or Smoking,%:
To evaluate effects of
over ideal weight for NR
abnormal maternal Imputed:
height) or abnormal
weight or weight gain on • No Diabetes mellitus,%:
pregnancy weight
pregnancy outcome NR
gain (≥ 20kg or ≤ Categorized:
Time frame: 5kg) • Continuous ≥ 20% over Hypertension,%:
July 1, 1985 to • 166 controls or under normal weight NR
December 31, 1985 (6 for height
Group Description: Additional characteristics:
months)
G1: ≥ 20% over normal Age (mean, yrs): NR
Duration of the study: weight for height G1: 28 (5.1)
Prepregnancy to G2: ≥ 20% under normal G2: 25.5 (5.1)
delivery weight for height G3: 29.5 (5.1)
G3: weight gain ≤ 5kg G4: 28.7 (4.7)
G4: weight gain ≥ 20kg G5: 28.7 (4.4)
G5: control Group 6
Parity:
Group N: G1: prior deliveries: 1.0
G1: 77 (1.0)
G2: 28 G2: 0.8 (0.8)
G3: 30 G3: 1.2 (1.1)
G4: 56 G4: 0.8 (1.0)
G5: 166 G5: 0.9 (1.0)
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

C-158
Evidence Table 14. Maternal weight gain and shoulder dystocia (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Percentage of shoulder Fair
G2: 28 P < 0.05 compared dystocia cases by weight
G3: 30 to controls gain categories Sample selection:
G4: 56 G2: 3293 (362) Poor
G5: 166 P < 0.05 compared Groups
G1: weight gain ≤ 5 kg Definition of maternal
to controls weight gain:
Total weight gain: G3: 3284 (880) G2: weight gain ≥ 20 kg
G1: 11.8 (6.2) G3: reference (normal Poor
G4: 3803 (538)
P < 0.05 compared P < 0.005 prepregnancy weight Definition of outcomes:
to controls compared to and normal weight gain Poor
G2: 13.4 (4.5) controls [undefined])
G3: 3.0 (3.5) Source of information on
G5: 3538 (535) Results exposure, outcomes, and
P < 0.0005
compared to Gestational G1: 3 confounders:
controls diabetes,%: G2: 2 Fair
G4: 23.2 (22.8) NR G3: 0.6
Followup:
P < 0.0005 Maternal confounders Fair
compared to Cesarean
delivery,%: and effect modifiers
controls accounted for in Analysis comparability:
G5: 13.2 (3.4) G1: Elective 7% Poor
Emergency analysis:
Categorized: 14% NA Analysis of outcomes:
• ≤ 5kg or ≥ Total 21% Infant and child Fair
20kg G2: Elective 4% confounders and effect Interpretation:
Emergency 4% modifiers accounted for
Collected from: Poor
Total 8% in analysis:
• Routine pre- G3: Elective 3% Sum of Good/Fair/Poor:
NA
natal care or Emergency 3% 0 Good, 4 Fair, 5 Poor
maternity Total 6%
records G4: Elective 5% Final Quality Score:
Emergency Poor
Ascertained by:
• Based on last 18%
clinically Total 23%
measured G5: Elective 13%
weight prior to Emergency 9%
delivery Total 22%
Instrumental
delivery,%:
NR
Episiotomy,%:
NR
Other maternal
outcomes:
NA
Other infant
outcomes:
NA

C-159
Evidence Table 14. Maternal weight gain and shoulder dystocia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Geary et al., 1995 • Case-control • not stated White
• Prospective G1: < 90 kg: 98.5% NR
Country and setting:
G2: 98.0
Ireland, hospital Total Study N: Black
363 Pregravid BMI: NR
Enrollment Period:
March 1991 - December Group Description: Imputed: Hispanic
1992 G1: Cases • No NR
G2: Controls
Funding: Categorized: Asian/Pacific Islander
NR Group N: • NR NR
G1: 66
Study Objective: Age (mean, yrs): Other
G2: 297
To determine if routine G1: ≥ 30: 48.5% NR
clinical indicators are Inclusion criteria: G2: 42.1
useful predictors for Smoking,%:
• All cases of NR
shoulder dystocia shoulder dystocia Parity:
during study period G1: %Multiparous: 89.4 Diabetes mellitus,%:
Time frame: G2: 56.6
March 1991 - December • Controlofs NR
1992 consisted
Hypertension,%:
consecutive women
Duration of the study: NR
recruited mid-way
Pregnancy through through study Additional characteristics:
delivery period: must have NR
had delivery in
same hospital,
singleton births and
cephalic, vaginal
delivery at term
Exclusion criteria:
• NA

C-160
Evidence Table 14. Maternal weight gain and shoulder dystocia (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 66 G1: ≥ 4000g: Shoulder dystocia by Good
G2: 297 87.9% weight gain categories
G2: 16.8 Sample selection:
Total weight gain: Groups Fair
G1: < 12kg: 59.1% Gestational Weight gain < 12 kg and ≥
G2: 74.1 diabetes, %: 12 kg for cases with Definition of maternal
NR shoulder dystocia and weight gain:
Categorized: controls Poor
• < 12kg and ≥ Cesarean delivery, G1: Cases with shoulder
%: Definition of outcomes:
12kg dystocia
NR Good
Collected from: G2: Controls
Instrumental Source of information on
• Routine pre- Results
delivery, %: exposure, outcomes, and
natal care or maternal weight gain < 12
NR confounders:
maternity kg Poor
records G1: 59.1%
Episiotomy, %:
NR G2: 74.1% Followup:
Ascertained by:
OR 2.0 (1.6-2.2) Fair
• Not stated Other maternal
outcomes: Maternal confounders Analysis comparability:
NA and effect modifiers Fair
accounted for in Analysis of outcomes:
Other infant analysis:
outcomes: Fair
• Parity
NA • Previous birth ≥ 4000g Interpretation:
Good
Infant and child
confounders and effect Sum of Good/Fair/Poor:
modifiers accounted for 3 Good, 4 Fair, 2 Poor
in analysis: Final Quality Score:
NR Poor

C-161
Evidence Table 14. Maternal weight gain and shoulder dystocia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kabiru and Raynor, • Cohort • Measured at first White
2004 • Retrospective prenatal visit G1: 1.9
G2: 2.6
Country and setting: Total Study N: Pregravid BMI: G3: 2.8
USA, hospital 5,131
Imputed: Black
Enrollment Period: Group Description: • No G1: 84.1
1999 to 2002 G1: No change in BMI G2: 82.8
between first Categorized:
Funding: • 20-24.9, 25-29.9, 30- G3: 88.2
prenatal visit and
NR 34.9, 35-39.9, ≥ 40 Hispanic
delivery
Study Objective: G2: 1 category increase Age (mean, yrs): G1: 13.9
To investigate effect of in BMI between first G1: 24.7 (6.1) G2: 14.6
increase in body mass prenatal visit and G2: 24.4 (5.7) G3: 9.0
index category on delivery G3: 25.2 (5.9) P < 0.001 Asian/Pacific Islander
obstetric outcomes G3: > 1 category
Parity: NR
increase in BMI
Time frame: between first G1: Gravidity (mean): 1.9 Other
1999 to 2002 prenatal visit and (1.9) NR
Duration of the study: delivery G2: 1.5 (1.7)
G3: 1.2 (1.7) P < 0.001 Smoking,%:
Prenatal through birth Group N: NR
G1: 2,556
G2: 2,252 Diabetes mellitus,%:
G3: 323 NR

Inclusion criteria: Hypertension,%:

• Singleton NR
pregnancies Additional characteristics:
Exclusion criteria: Mean weight gain:
G1: 8.6 pounds (8.4)
• Multiple
G2: 22.2 pounds (10.2)
pregnancies
G3: 55.3 pounds (23.8)
• BMI < 20
• Missing BMI data Additional characteristics:
NR

C-162
Evidence Table 14. Maternal weight gain and shoulder dystocia (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 579 G1: 2886.0 (756) Rates of shoulder dystocia by Good
G2: 942 G2: 3174.9 (600) weight gain categories (%)
G3: 189 G3: 3099.5 (673) Sample selection:
G4: 819 P < 0.001 Groups Fair
G5: 790 G4: 3116 (713) G1: normal BMI, no change in
BMI between first prenatal Definition of maternal
G6: 104 G5: 3269 (698) weight gain:
G6: 3371 (733) visit and delivery
Total weight gain: G2: normal BMI, 1 category Poor
P = 0.015
increase in BMI between Definition of
Categorized: Gestational first prenatal visit and outcomes:
• > 35 pounds diabetes,%: delivery Fair
for normal BMI, NR G3: normal BMI, > 1 category
> 25 pounds increase in BMI between Source of information
for overweight Cesarean first prenatal visit and on exposure,
BMI, > 15 delivery,%: delivery outcomes, and
pounds for G1: 8.2 G4: overweight BMI, no confounders:
obese BMI G2: 12.6 change in BMI between Fair
G3: 21.0 P < 0.001 first prenatal visit and
Collected from: G4: 13.0 Followup:
• Routine pre- delivery Poor
G5: 14.3 G5: overweight BMI, 1
natal care or G6: 19.3 P = 0.256
maternity category increase in BMI Analysis
records Instrumental between first prenatal visit comparability:
delivery,%: and delivery Poor
Ascertained by: G6: overweight BMI, > 1
Episiotomy,%: Analysis of outcomes:
• Based on last category increase in BMI
Fair
clinically Other maternal between first prenatal visit
measured outcomes: and delivery Interpretation:
weight prior to NA Poor
delivery: not Preeclampsia
stated, most Other infant Sum of
likely difference outcomes: Good/Fair/Poor:
Results
between NA 1 Good, 4 Fair, 4 Poor
G1: 0.5
weight at first G2: 1.4 Final Quality Score:
prenatal visit G3: 1.1 Poor
and weight at P = 0.278 for associations
delivery 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

C-163
Evidence Table 15. Gestational weight gain and cephalopelvic disproportion
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Devader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained G1: 79.7
Country and setting: G2: 85.6
from mother during
United States, birth Total Study N: G3: 85.2
postpartum hospital stay
certificate data 94,696
Pregravid BMI: Black
Enrollment period: Group Description: G1: 15.7
NR
1999 to 2001 G1: Gained less than 25 G2: 10.8
lbs Imputed: G3: 12.1
Funding:
NR
G2: Gained 25 to 35 lbs • No
G3: Gained more than Hispanic
Study Objective: 35 lbs Categorized: NR
To investigate NR
Group N: Asian/Pacific Islander
relationship between Age (mean, yrs): NR
G1: 16,852
gestational weight gain G1: Maternal age (y)
G2: 37,292
and adverse pregnancy 18 to 24*: 42.3% Other
G3: 40,552
outcomes among 25 to 30: 36.2% G1: 4.6
women with normal Inclusion criteria: 31 to 35: 21.5% G2: 3.5
prepregnancy BMI • All mothers with G2: Maternal age (y) G3: 2.7
Time frame: normal 18 to 24*: 36.7% Smoking,%:
1999 to 2001 prepregnancy BMI 25 to 30: 39.5% G1: 20.5
(19.8 –26.0 kg/m2) 31 to 35: 23.8% G2: 14.9
Duration of the study: who were 18 to 35 G3: Maternal age (y) G3: 17.4
Entry into prenatal care years of age at time 18 to 24*: 44.7%
through delivery of delivery and who 25 to 30: 35.9% Diabetes mellitus,%:
delivered full-term 31 to 35: 19.4% NR
(37 weeks or more)
Parity: Hypertension,%:
singleton infant
during period NR NR
January 1, 1999, to Additional characteristics:
December 31, 2001 NR
Exclusion criteria:
• Women aged
younger than 18
years and older
than 35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-164
Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Adjusted Odds Ratios for Good
Women With Normal
Total weight gain: Gestational diabetes, Prepregnancy BMI (19.8 –26.0 Sample selection:
NR %: kg/m2) by GWG Category for Fair
NR cephalopelvic disproportion
Categorized: Definition of maternal weight
• According to Cesarean delivery,%: (95% CI) gain:
IOM NR Groups: Fair
Collected from: Instrumental G1: Gained less than 25 lbs Definition of outcomes:
• Routine pre- delivery,%: G2: Gained 25 to 35 lbs Good
natal care or NR G3: Gained more than 35 lbs
Source of information on
maternity Results:
Episiotomy,%: exposure, outcomes, and
records CPD
NR confounders:
Ascertained by: G1: 0.64 (0.55–0.75) Fair
Other maternal G2: 1.0
NR
outcomes: G3: 1.58 (1.44–1.75) Followup:
• Figures 1 to 3 plot Fair
risk for each Maternal confounders and
effect modifiers accounted Analysis comparability:
adverse
for in analysis: Fair
pregnancy
outcome by 10-lb • Age Analysis of outcomes:
increments in • Race Fair
gestational weight • Education
gain. Women who • Income Interpretation:
gained 25 to 34 • Alcohol use Fair
lbs during their • Height Sum of Good/Fair/Poor:
pregnancy had • Prior pregnancy 2 Good, 7 Fair, 0 Poor
lower risks for • Inadequate prenatal care
most outcomes use Final Quality Score:
when balancing Fair
• Smoking
risk for SGA
status and other Infant and child confounders
adverse and effect modifiers
pregnancy accounted for in analysis:
outcomes • Child's gender
• Women who • Birth year
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%

C-165
Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Devader et al., 2007
(combined)

C-166
Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
•
Other infant
outcomes:
NR

C-167
Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Young et al., 2002 • Cohort • Self-reportedRoutine White
• Retrospective pre-natal care G1: NR
Country and setting: G2: NR
USA, private practice Total Study N: Pregravid BMI: G3: NR
3,375 (computed) G1: 16.3% G4: NR
Enrollment Period:
G2: 47.8% G5: 90.6%
Feb 1993 to June 2001 Group Description: G3: 21%
G1: BMI < 20 G4: 14.8% Black
Funding:
G2: BMI 20-25 G1: NR
NR
G3: BMI 25-30 Imputed: G2: NR
Study Objective: G4: BMI > 30 • No G3: NR
To examine body mass G5: All G4: NR
Categorized:
index and pregnancy G5: 7.56%
weight gain as risk
Group N: • Categorical based on
G1: 551 American Bariatric Hispanic
factors for primary
G2: 1616 Society definition of NR
cesarean delivery in
G3: 709 obesity and categories
nulliparous women in Asian/Pacific Islander
G4: 500 used by Cnattingius et
middle-class private G1: NR
G5: 3361 al
practice G2: NR
Inclusion criteria: Age (mean, yrs): G3: NR
Time frame:
Feb 1993 to June 2001 • Primiparous G1: NR G4: NR
deliveries between G2: NR G5: 1.88%
Duration of the study: Feb 1993 and June G3: NR
From entry into prenatal 13,2001 in large G4: NR Other
care up til delivery private practice G5: < 20: 8.91%, NR
obstetric clinic 20-29: 62.57%, Smoking,%:
30-34: 20.1%, NR
Exclusion criteria: > 35: 8.43%
• Missing BMI data Diabetes mellitus,%:
on mother Parity: NR
NR
Hypertension,%:
NR
Additional characteristics:
NR

C-168
Evidence Table 15. Gestational weight gain and cephalopelvic disproportion (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 551 NR OR for cephalopelvic disproportion (95% CI) Poor
G2: 1616
G3: 709 Gestational Groups: Sample selection:
G4: 500 diabetes,%: G1: < 30 pounds Poor
NR G2: 30-35 pounds
Total weight gain: G3: > 35 pounds Definition of
G1: (computed these Cesarean maternal weight
percentages from delivery,%: BMI < 20: gain:
n values) < 30 G1: 12.7 G1: 1.0 Poor
lbs: 40.7% 30-35 G2: 18.44 G2: -
G3: 24.96 G3: 3.8 (3-4.6) P < 0.01 Definition of
lbs:27.2% > outcomes:
35lbs: 32.1% G4: 37.6
BMI 20-25: Poor
G2: < 30 lbs: 35.5% Instrumental G1: 1.0
30-35 lbs:27.6% > delivery,%: G2: - Source of
35 lbs: 36.9% G3: 1.85 (1.63-2.06) P < 0.0001 information on
G3: < 30 lbs: 44.6% Episiotomy,%: exposure, outcomes,
30-35 lbs: 21.6% BMI 25-30: and confounders:
Other maternal G1: 1.0 Fair
> 35 lbs: 33.8% outcomes:
G4: < 30 lbs: 63.6% G2: -
• CPD rate doubles G3: NS Followup:
30-35 lbs: 12.8% in women with Fair
> 35 lbs: 23.6% BMI of < 25 BMI > 30:
G1: 1.0 Analysis
Categorized: kg/m2 with
G2: - comparability:
• Less than 30 lbs, excessive weight
G3: NS Poor
30-35 lbs, > 35 gain
lbs Other infant Maternal confounders and effect modifiers Analysis of
accounted for in analysis: outcomes:
Collected from: outcomes:
Fair
• Routine pre-natal NR • Obesity: BMI at first prenatal visit
care or maternity Interpretation:
records Poor
Infant and child confounders and effect
Ascertained by: modifiers accounted for in analysis: Sum of
• Based on last NR Good/Fair/Poor:
clinically 0 Good, 3 Fair, 6 Poor
measured weight Final Quality Score:
prior to delivery: Poor
last weight minus
first wt

C-169
Evidence Table 16. Gestational weight gain and complications of labor and delivery
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Marshall, 1991 • Cohort • Medical records White
• Retrospective G1: 77
Country and setting: Pregravid BMI: G2: NR
USA, hospital Total Study N:
Imputed: Black
493
Enrollment Period: • No G1: 18
not stated Group Description: G2: NR
G1: total cohort Categorized:
Funding: • Weight for height < 110% Hispanic
G2: NR
NR of ideal and > 111% of NR
Group N: ideal
Study Objective: Asian/Pacific Islander
G1: 493
To examine relationships Age (mean, yrs): NR
G2: NR
between a healthful G1: < 18 years: 4%
lifestyle, demonstrated by Inclusion criteria: 18-25: 68% Other
selected health practices, • Women who had 26-34: 25% G1: 5
and complications in term reached but not > 34: 3% G2: NR
labor exceeded term (37- G2: NR Smoking,%:
Time frame: 41 weeks) NR
Parity:
Not stated Exclusion criteria: Diabetes mellitus,%:
Duration of the study: • Women who NR
Initiation of prenatal care delivered at an
to delivery outside hospital Hypertension,%:
NR
Additional characteristics:
% married:
G1: 44
G2: NR

C-170
Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Risk of complications (dystocia, Fair
Total weight gain: retained placenta, pp hemorrhage
Gestational PIH, fetal distress and neonatal Sample selection:
Categorized: diabetes, %: Fair
• 20-40 lbs and < distress
NR
20/ > 40 lbs Groups: Definition of maternal weight
Cesarean delivery, G1: <20 lbs gain:
Collected from: %: Poor
• Routine pre-natal NR G2: 20-40 lbs
care or maternity G3: > 40 lbs Definition of outcomes:
records Instrumental Results: Good
delivery, %: In multivariate analysis a gestational
Ascertained by: NR Source of information on
• Based on last weight gain of > 40 pounds exposure, outcomes, and
clinically Episiotomy, %: increased the risk of complications confounders:
measured weight NR (dystocia, retained placenta, pp Fair
prior to delivery: Other maternal hemorrhage PIH, fetal distress and
neonatal distress) by 40%; Followup:
from medical outcomes: Good
records Specific Three variables, smoking, weight for Analysis comparability:
complications that height, and gestational weight gain
were examined: Poor
explain 15% of the outcome; of
dystocia, retained note: smoking was associated with Analysis of outcomes:
placenta, postpartum a protective effect (with a beta Fair
hemorrhage, PIH coefficient of .593 (p=.021)
Interpretation:
Other infant Poor
outcomes: Maternal confounders and effect
Specific Sum of Good/Fair/Poor:
modifiers accounted for in
complications that 2 Good, 4 Fair, 3 Poor
analysis:
were examined: fetal • Pre-gravid BMI Final Quality Score:
distress and neonatal • Exercise Poor
distress • Alcohol
• Drugs
• Sleep
• Breakfast
• Snacks
• Smoking
Infant and child confounders and
effect modifiers accounted for in
analysis:
NR

C-171
Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Thorsdottir et al., 2002 • Cohort • Self-reported White
• Retrospective G1: 63.1 (6.2) NR
Country and setting:
G2: 62.0 (5.6) P = 0.059
Maternity records, Total Study N: Black
G3: 61.7 (4.8) P = 0.174
Department of Obstetrics 614 NR
G4: 62.2 (6.1) P = 0.274
and Gynecology at
Landspitali University Group Description: Hispanic
Pregravid BMI:
Hospital, Iceland G1: No complication NR
G1: 22.2
G2: Complications in G2: 22.4 )1.6) P = 0.270
Enrollment Period: Asian/Pacific Islander
pregnancy or delivery G3: 22.4 (1.5) P = 0.338 NR
G3: Complications in G4: 22.3 P = 0.584
Funding:
pregnancy Other
NR
G4: Complications in Imputed: NR
Study Objective: delivery • No
To investigate relation Smoking,%:
Group N: Categorized: NR
between gestational
weight gain in women of
G1: 452 • Continuous
G2: 162 Diabetes mellitus,%:
normal prepregnant Age (mean, yrs): NR
G3: 56
weight and complications G1: 29
G4: 106 Hypertension,%:
during pregnancy and G2: 29 P = 0.857
delivery in a population Inclusion criteria: G3: 29 P = 0.404 NR
with high gestational • Women of normal G4: 29 P = 0.398 Additional characteristics:
weight gain and birth prepregnancy weight Proportional weight gain, %:
weight randomly selected Parity:
G1: 26.0
Time frame: within 1 year (1998) NR G2: 28.0 P = 0.018
NR • No history of G3: 30.0 P = 0.005
diabetes, G4: 27.0 P = 0.546
Duration of the study: hypertension, CVD,
1998 or thyroid problems Additional characteristics:
• Singleton births NR
• 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

C-172
Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued)
Outcomes from Outcomes from Multivariate
Maternal Weight Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 452 G1: 3789 (469) • Rates of complications in Good
G2: 162 G2: 3749 (565) P = 0.389 pregnancy and delivery and
G3: 56 G3: 3643 (526) P = 0.032 Sample selection:
neonatal outcome by maternal
G4: 106 G4: 3806 (578) P = 0.529 Fair
weight gian categories based on
IOM recommendations for Definition of maternal
Total weight gain: Gestational diabetes, %:
women of normal weight before weight gain:
G1: 16.6 (4.9) NR
pregnancy and additionally at Poor
G2: 17.4 (5.1) P =
Cesarean delivery, %: 20.0kg (G1 to G4)
0.080 Definition of outcomes:
NR • Relative risk for complications in
G3: 18.4 (5.1) P = Fair
pregnancy and delivery by
0.013 Instrumental delivery, quartiles of weight gain in Source of information
G4: 16.9 (5.1) P = %: pregnancy adjusted for age, on exposure, outcomes,
0.887 NR height, parity, gestational length, and confounders:
Categorized: Episiotomy, %: and birth weight (G5-G9) Fair
• According to IOM < NR
Groups: Followup:
11.5, 11.-16.0,
Other maternal G1: < 11.5 Good
16.1-20, ≥20, also
outcomes: G2: 11.-16.0
quintiles < 12.5, Analysis comparability:
NA G3: 16.1-20
12.5-15.5, 15.6- Good
G4: ≥ 20 kg
17.8, 17.9-20.8, Other infant outcomes:
> 20.8 NA Analysis of outcomes:
G5: < 12.5 kg Good
Collected from: G6: 12.5-15.5kg
• Routine pre-natal G7: > 15.5-17.8 Interpretation:
care or maternity G8: > 17.8-20.8 Good
records G9: > 20.8
Sum of Good/Fair/Poor:
Ascertained by: Results for quartiles: 5 Good, 3 Fair, 1 Poor
• Based on last Complications in pregnancy or Final Quality Score:
clinically measured delivery Fair
weight prior to G1: 29
delivery 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)

C-173
Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Thorsdottir et al., 2002
(continued)

C-174
Evidence Table 16. Gestational weight gain and complications of labor and delivery (continued)
Outcomes from Outcomes from Multivariate
Maternal Weight Gain Bivariate Analysis 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-175
Evidence Table 17. Gestational weight gain and preterm birth
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Carmichael et al., 1997 • Cohort • Self-reported White
• Retrospective G1: 52
Country and setting: Pregravid BMI: G2: NR
USA, hospital Total Study N:
Imputed: Black
7,259
Enrollment Period: • No G1: 10
1980 to 1990 Group Description: G2: NR
G1: Total cohort Categorized:
Funding: • Continuous Hispanic
G2: NR
Grant HD27347-05 from G1: 12
National Institute of Group N: Age (mean, yrs):
G1: 28.0 G2: NR
Child Health and G1: 7,259
Human Development G2: NR G2: NR Asian/Pacific Islander
Parity: G1: 26
Study Objective: Inclusion criteria: G2: NR
To investigate • All deliveries during G1: Nulliparous: 55%
usefulness of monitoring time study period at G2: NR Other
weight gain during study hospital NR
pregnancy and • Spontaneous
mechanisms by which Smoking,%:
preterm deliveries G1: 16
weight gain pattern
relate to preterm Exclusion criteria: G2: NR
delivery • Multiple births Diabetes mellitus,%:
(n = 642) NR
Time frame: • Randomly selected
1980 to 1990 1 delivery for those Hypertension,%:
Duration of the study: women who NR
Initiation of prenatal experienced more Additional characteristics:
care to delivery than 1 pregnancy NR
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

C-176
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Gain Outcomes from Outcomes from Multivariate
Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 7,259 NR AOR (95% CI) of spontaneous Poor
G2: NR preterm birth/ kg increase in
Gestational diabetes, total weight gain Sample selection:
Total weight gain: %: Fair
G1: Mean estimated NR Groups
total weight gain 16.8 kg Total gestational weight gain Definition of maternal weight
G2: NR Cesarean delivery, %: (continuous) gain:
NR Fair
Categorized: Results
Instrumental delivery, Definition of outcomes:
• Continuous Linear regression analysis of
%: Good
Collected from: NR gestational age (days) as
dependent variable and Source of information on
• Routine pre-natal
Episiotomy, %: gestational weight gain (kg) as exposure, outcomes, and
care or maternity
NR independent variable: confounders:
records
Regression coefficient= 0.51; t- Fair
Other maternal
Ascertained by: statistic=13.1; P < 0.001
outcomes: Followup:
• Based on last NA Good
clinically measured AOR (95% CI) of spontaneous
weight prior to Other infant outcomes: preterm birth/ kg increase in Analysis comparability:
delivery: difference • Spontaneous total weight gain: 0.84 (0.82- Fair
between self preterm birth 0.87)
Analysis of outcomes:
reported • Gestational age Maternal confounders and Good
prepregnancy effect modifiers accounted
weight and last for in analysis: Interpretation:
measured weight BMI, maternal age, infant sex Fair
cigarettes per day maternal
Sum of Good/Fair/Poor:
height, parity, race, pattern of
3 Good, 5 Fair, 1 Poor
gain derived from quadratic
curves Final Quality Score:
Fair
Infant and child confounders
and effect modifiers
accounted for in analysis:
Infant sex

C-177
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Dietz et al., 2006 • Cross-sectional • Self-reported White
• Retrospective G1: 67
Country and setting: Pregravid BMI: G2: NR
USA, PRAMS data Total Study N: G1: Underweight < 19.8
113,019 16% (20,352) Normal 19.8– Black
Enrollment Period: G1: 18
26 54% (59,088) Overweight
1996-2001 Group Description: G2: NR
26.1–28.9 12% (12,928)
G1: Total Obese 29–34.9 12%
Funding: Hispanic
G2: NR (13,910) Very obese > 35
NR G1: 11
Group N: 6% (6744)
Study Objective: G2: NR
G1: 113,019 G2: NR
Objective of study to Asian/Pacific Islander
G2: NR Imputed:
estimate combined NR
effects of prepregnancy Inclusion criteria: • No
BMI and pregnancy • New mothers Other
Categorized:
weight gain on preterm delivering live birth G1: 4
delivery of singleton • IOM guidelines G2: NR
in states redefined obese as
births participating in 29.0-34.9 and added Smoking,%:
Time frame: PRAMS with additional category for G1: 17
1996-2001 annual reponse very obese: BMI > 35 G2: NR
rate of 70% or
Duration of the study: higher during 1996- Age (mean, yrs): Diabetes mellitus,%:
Cross-sectional 2001 G1: < 20: 13% (13,258) G1: 5 (pre-existing or
• Stratified, 20–34: 75% (81,157) gestational)
systematic sample 35+: 12% (18,586) G2: NR
G2: NR
Exclusion criteria: Hypertension,%:
• Missing or Parity: G1: 11 (pre-existing or
Implausible G1: 0: 43% (51,918) during pg)
estimates of birth 1–2: 49% (50,648) G2: NR
weight, pre- > 3: 8% (10,050)
G2: NR Additional characteristics:
pregnancy BMI,
NR
weight gain during
pg, gestational age;
multiple births

C-178
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 20,352 G1: Moderately Risk of preterm birth Good
G2: 59,088 Preterm (32-36
G3: 12,928 weeks) 4188 Groups Sample selection:
G4: 13,910 Very Preterm (20- Categories of mean rate of Fair
G5: 6,744 31 weeks) 1,753 gestational weight gain Definition of maternal
G2: Moderately (kg/wk) during second and weight gain:
Total weight gain: Preterm (32-36 third trimesters stratified by
G1: Weight gain Fair
weeks): 9,495 pregravid BMI and type of
during second and Very Preterm (20- preterm birth (very preterm, Definition of outcomes:
third trimesters of 31 weeks): 4291 20-31 weeks; moderate Poor
pregnancy: < 0.12 G3: Moderately preterm, 32-36 weeks):
21% (763) 0.12–0.22 Source of information on
Preterm (32-36 G1: < 0.12 exposure, outcomes, and
4.4% (1299) 0.23– weeks): 2047 G2: 0.12-0.22
0.68 75.6% (14,905) confounders:
Very Preterm (20- G3: 0.23-0.68 Poor
0.69–0.79 9.1% 31 weeks): 1,143 G4: 0.69-0.79
(1632) > 0.79 8.8% G4: Moderately G5: > 0.79 Followup:
(1753) Fair
G2: Weight gain Gestational Results
during second and diabetes, %: Analysis comparability:
In general, in comparison to
third trimesters of G1: 5 (pre-existing or Fair
women with normal BMI in G3:
pregnancy: < 0 gestational) underweight women in G1- G5 Analysis of outcomes:
G2: NR and normal weight women in
Categorized: Good
• Based on weight Cesarean G1, G2, and G5 were at
increased risk of very preterm Interpretation:
gain second and delivery,%:
births (AOR: 1.5-9.8). Good
third trimesters of NR
pregnancy Underweight women in G1-G3 Sum of Good/Fair/Poor:
Instrumental and G5 and normal women in
(kg/wk) 3 Good, 4 Fair, 2 Poor
delivery, %: G1, G2, and G5 were at
Collected from: NR increased risk moderate Final Quality Score:
• Weight gain data preterm births (AOR: 1.4-3.1). Fair
Episiotomy, %:
from birth Overweight and obese women
NR
certificate - in G1 and G5 were at
presumably Other maternal increased risk of very preterm
measured at outcomes: birth (AOR: 2.3-2.5) but had
prenatal visits, NR no elevated risk of moderate
self report- preterm birth. Very obese
however rates Other infant
women with G1, G4, G5 had
were determined outcomes:
increased risks of very
by formula NR
preterm births (AOR: 2.1-2.8)
Ascertained by: and with G4 had increased
risks of moderate preterm birth
• Birth certificate
(AOR: 1.3)
data and PRAMS
survey
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

C-179
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of G1: 84.4
Country and setting: G2: 85.8
pregravid BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg G4: 32.7 (31.3-34.7)
Funding: Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain
G2: 134 • Continuous
in obese glucose Other
G3: 132
tolerant women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: ≥ 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance Parity:
test (OGTT) during NR Diabetes mellitus,%:
third trimester NR
(according to WHO
Hypertension,%:
criteria)
NR
• Only first
pregnancy during Additional characteristics:
study period NR
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)

C-180
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Gain Outcomes from Outcomes from Multivariate
Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200-3840) Percentage of preterm delivery Good
G2: 134 G2: 3645 (3200-4000)
G3: 132 G3: 3750 (3390-4125) Groups: Sample selection:
G4: 122 G4: 3762 (3400-4120) Total gestational weight gain Poor
categories (kg): Definition of maternal weight
Total weight gain: Gestational diabetes, %: G1: < 5.0
NR gain:
Categorized: G2: 5.0-9.9 Poor
• < 5.0. 5.0-9.9, Cesarean delivery, %: G3: 10.0-14.9
NR G4: > 15.0 Definition of outcomes:
10.0-14.9,
Fair
≥ 15.0
Instrumental delivery, %: Results
NR Source of information on
Collected from: Percent (%) preterm delivery exposure, outcomes, and
• Routine pre-natal by weight gain categories:
Episiotomy, %: confounders:
care or maternity G1: 6.5
NR Poor
records G2: 6.0
Other maternal G3: 4.6 Followup:
Ascertained by:
outcomes: G4: 2.5 Fair
• Not stated by NA P for trend = 0.11
authors Analysis comparability:
Other infant outcomes: Maternal confounders and Fair
NA effect modifiers accounted
Analysis of outcomes:
for in analysis:
Good
NA
Interpretation:
Infant and child confounders
Fair
and effect modifiers
accounted for in analysis: Sum of Good/Fair/Poor:
NA 2 Good, 4 Fair, 3 Poor
Final Quality Score:
Poor

C-181
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kramer et al., 1995 • Case-control • Self-reported White
• Retrospective G1: 72.5
Country and setting: Pregravid BMI: G2: 79.7
Canada, university Total Study N: G1: 21.8 (4.2)
hospitals 555 G2: 22.7 (4.0) Black
G1: 13.9
Enrollment Period: Group Description: Imputed: G2: 10.9
July 1990- July 1992 G1: Cases • No
G2: Controls Hispanic
Funding: Categorized: NR
National Health Group N: • IOM guidelines < 19.8
Research and G1: 244 vs. ≥ 19.8 Asian/Pacific Islander
Development Program, G2: 311 NR
Health Canada Age (mean, yrs):
Inclusion criteria: G1: < 20: 7.8%; 20-34: Other
Study Objective: • Women with 79.1%; ≥ 35: 13.1% G1: 13.5
To assess etiologic role spontaneous onset of G2: < 20: 2.6%; 20-34: G2: 9.3
of maternal short labor before 37 75.8%; ≥ 35: 21.6%
stature, low Smoking,%:
weeks - 1 subsample G1: 24.6 during pregnancy
prepregnancy BMI, and composed of women Parity:
low rate of gestational %primiparous: G2: 25.7
with spontaneous
weight gain in idiopathic onset of labor before G1: 44.3% Diabetes mellitus,%:
preterm labor 34 weeks and G2: 41.2% NR
Time frame: another subsample
Hypertension,%:
July 1990 to July 1992 with spontaneous
onset of labor before NR
Duration of the study: 37 weeks in index Additional characteristics:
Initiation of prenatal pregnancy plus a G1: % married: 73.4
care to delivery history of prior G2: 80.7
preterm delivery or
second trimester Additional characteristics:
miscarriage NR
• 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

C-182
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 244 NR AOR (95% CI) for cases Good
G2: 311 with preterm delivery
Gestational versus controls Sample selection:
Total weight gain: diabetes, %: Good
G1: 0.35 (0.15) NR Groups
kg/wk Gestational weight gain Definition of maternal
G2: 0.37 (0.13) Cesarean delivery, categories (kg/wk): weight gain:
kg/wk %: G1: < 0.27 Fair
NR G2: ≥ 0.27
Categorized: Definition of outcomes:
Instrumental Good
• Rate of weight
delivery, %:
gain < Source of information on
NR Results
0.27kg/wk exposure, outcomes, and
G1: 1.56 (0.94-2.58)
Episiotomy, %: G2: 1.00 (reference) confounders:
Collected from:
NR labor subsample Fair
• Self-reported
Other maternal Maternal confounders Followup:
Ascertained by:
outcomes: and effect modifiers Good
• Based on last NA
clinically accounted for in Analysis comparability:
measured Other infant analysis: Fair
weight prior to outcomes: • Age
NA • Parity Analysis of outcomes:
delivery: used
rate of weight • Marital status Good
gain since • English-speaking Interpretation:
cases had • Education Fair
preterm labor • Matched on smoking
Sum of Good/Fair/Poor:
history
5 Good, 4 Fair, 0 Poor
Infant and child
Final Quality Score:
confounders and effect
Good
modifiers accounted for
in analysis:
NR

C-183
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Exclusion criteria:
Kramer et al., 1995 • Multifetal gestation
(continued) • 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-184
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis

C-185
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Nohr et al., 2007 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
Denmark, primary care Total Study N: NR Black
0 NR
Enrollment period: Imputed:
1996 to 2002 Group Description: • No Hispanic
G1: Total NR
Funding: Categorized:
Ellen Aagaard Nohr is Group N: • WHO International Asian/Pacific Islander
supported by a grant G1: 62,167 Taskforce NR
(No.2002B020) from
Health Insurance Inclusion criteria: Age (mean, yrs): Other
Foundation. Danish • Women with G1: < 25: 7,757 (12.5%) NR
National Research singleton 25 to 29: 26,152 (42.1%) Smoking,%:
Foundation established pregnancies who 30 to 34: 21,181 (34.1%) G1: 84.1% nonsmoker
Danish Epidemiology provided an 35+: 7,077 (11.4%)
Science Centre, which interview at Diabetes mellitus,%:
approximately 16 Parity: G1: 1.2%
initiated and created G1: 47% primiparous
Danish National Birth weeks gestation
Hypertension,%:
Cohort. Cohort is also Exclusion criteria: G1: 1.6%
result of major grant • Missing data on
from this Foundation. Additional characteristics:
weight gain in
Additional support for NR
pregnancy
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

C-186
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 62 167 NR Rate of gestational weight Good
G2: 2751 gain for women with early
G3: 41 991 Gestational or late preterm birth by Sample selection:
G4: 12 270 diabetes, %: PPROM Fair
G5: 5155 G1: 1.2%
Definition of maternal
Cesarean Groups weight gain:
Total weight gain: Rate of gestational weight
G1: Weekly weight delivery,%: Fair
NR gain (g/wk) for women with
gain (g) >275g: early preterm birth (22-33 Definition of outcomes:
(15.3%) 276–675g: Instrumental weeks) with PPROM : Good
(68.3%) 676g+ delivery,%: G1: < 275
(16.4%) NR Source of information on
G2: 276-675 exposure, outcomes, and
Categorized: Episiotomy,%: G3: ≥ 676 confounders:
• Weekly weight NR Poor
gain Rate of gestational weight
categorised Other maternal gain (g/wk) for women with Followup:
into 3 groups outcomes: early preterm birth (22-33 Good
(low, medium, • Before 34 weeks) without PPROM :
Analysis comparability:
high) using weeks of G4: < 275
Fair
cutpoints at gestation, risk G5: 276-675
275 and 675 g, of induced G6: ≥ 676 Analysis of outcomes:
which were preterm Fair
similar to those delivery Rate of gestational weight
potentiated gain (g/wk) for women with Interpretation:
used in other Good
studies among obese late preterm birth (34-36
women with weeks) with PPROM: Sum of Good/Fair/Poor:
Collected from: high weight G7: < 275 4 Good, 4 Fair, 1 Poor
• Does not gain, and after G8: 276-675
specify-women 34 weeks, risk G9: ≥ 676 Final Quality Score:
self-reported was Fair
weight gain potentiated at Rate of gestational weight
status extremes, gain (g/wk) for women with
namely among late preterm birth (34-36
Ascertained by:
underweight weeks) without PPROM:
• Self-reported
women with a G10: < 275
low weight gain G11: 276-675
and obese G12: ≥ 676
women with a
high weight Results
gain HR (95% CI):
G1: 2.1 (1.5-3.0)
Other infant
G2: 1.0 (ref)
outcomes:
G3: 1.2 (0.8-1.8)
NR
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)

C-187
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Nohr et al., 2007
(continued)

C-188
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis 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-189
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rosenberg et al., 2005 • Cohort • Self-reported White
• Retrospective G1: < 100 pounds: 1.7% NR
Country and setting:
100-149: 49.1%
USA, vital statistics data Total Study N: Black
150-199: 37.5%
329988 NR
Enrollment Period: 200-299: 11.2%
Birth certificates with Group Description: ≥ 300: 0.5% Hispanic
self reported pregravid G1: Non-hispanic G2: < 100 pounds: 1.8% NR
weight and weight gain blacks 100-149: 69.5%
150-199: 24.0% Asian/Pacific Islander
G2: Non-hispanic
Funding: 200-299: 4.7% NR
whites
NR ≥ 300: 0.1%
G3: Non-hispanic Other
Study Objective: asians G3: < 100 pounds: 8.1% NR
To examine G4: Hispanics 100-149: 79.5%
associations between G5: Total 150-199: 11.6% Smoking,%:
obesity, diabetes, and 3 200-299: 0.8% NR
Group N: ≥ 300
adverse pregnancy Diabetes mellitus,%:
G1: 86,908
outcomes (primary Pregravid BMI: G1: 3.7
G2: 96,581
cesarean section, G2: 2.6
G3: 38,570 Imputed:
preterm birth, and LBW) G3: 6.6
G4: 107,612 • No
by race/ethnic groups G4: 3.5
G5: 329,988
Time frame: Categorized: G5: 3.7 P < 0.001
Inclusion criteria:
Birth certificates with • NR Hypertension,%:
self reproted pregravid • Live singleton births
G1: 1.7
weight and weight gain • Information on Age (mean, yrs):
G1: 27.5 G2: 0.6
maternal
Duration of the study: G2: 30.6 G3: 0.5
prepregnancy
Birth certificates from G4: 0.7
weight and G3: 29.7
1999, 2000, and 2001 G4: 26.4 P < 0.001 G5: 0.9 P < 0.001
maternal weight
gain during G5: 28.3 Additional characteristics:
pregnancy G1: PIH 1.9
Parity:
G2: 1.2
Exclusion criteria: NR
G3: 0.7
• NA
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-190
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 86,908 NR AOR (95% CI) for Preterm Fair
G2: 96,581 Birth
G3: 38,570 Gestational Sample selection:
G4: 107,612 diabetes, %: Groups Fair
G5: 329,988 G1: 3.7 Categories of total
G2: 2.6 Definition of maternal
gestational weight gain weight gain:
Total weight gain: G3: 6.6 (lbs):
G1: < 41pounds: 79.7% G4: 3.5 Poor
G1: <41
≥ 41 pounds: 20.3% G5: 3.7 P < 0.001 G2: ≥ 41 Definition of outcomes:
G2: < 41pounds: 83.2% Poor
≥ 41 pounds: 16.8% Cesarean
delivery,%: Results Source of information on
P < 0.001 AOR (95% CI) for Preterm
G3: < 41pounds: 89.2% G1: 16.2 exposure, outcomes, and
G2: 14.7 P < 0.001 Birth: confounders:
≥ 41 pounds: 10.8% G1: 1.00 (reference)
G4: < 41pounds: 79.1% G3: 14.4 Fair
G4: 13.8 G2: 0.54 (0.52-0.57)
≥ 41 pounds: 20.9% Followup:
G5: < 41pounds: 81.6% G5: 14.7
Fair
≥ 41 pounds: 18.4% Instrumental Maternal confounders
delivery,%: and effect modifiers Analysis comparability:
Categorized: accounted for in Fair
NR
• < 41, ≥ 41 pounds analysis:
Episiotomy,%: Analysis of outcomes:
Collected from: Pregravid weight, chronic
NR Fair
• Routine pre-natal diabetes, GDM, chronic
care or maternity Other maternal hypertension, PIH Interpretation:
records outcomes: preeclampsia, maternal Fair
NA age marital status maternal
Ascertained by: education maternal Sum of Good/Fair/Poor:
• Based on last Other infant birthplace, prenatal care 0 Good, 7 Fair, 2 Poor
clinically measured outcomes: payer, social risk, parity, Final Quality Score:
weight prior to • Preterm birth trimester that prenatal care Fair
delivery 10.5, 5.1, 5.9, began
7.8, 7.5
P < 0.001
(groups Infant and child
defined above) confounders and effect
modifiers accounted for
• LBW 9.7, 4.1,
in analysis:
5.7, 6.1, 6.4
NR
P < 0.001
(groups
defined above)

C-191
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Schieve et al., 1999 • Cohort • Self-reported White
• Prospective G1: 63.4
Country and setting: Pregravid BMI: G2: NR
USA, Pregnancy Total Study N: G1: 12.0-19.7: 17.0%
Nutrition Surveillance 266,172 19.8-26.0: 50.9% Black
System of women 26.1-29.0: 12.7% G1: 20.5
participating in federally Group Description: 29.1-61.0 : 19.5% G2: NR
funded prenatal public G1: Total sample G2: NR
health programs G2: NR Hispanic
Imputed: G1: 16.1
Enrollment Period: Group N: • No G2: NR
1990 to 1993 G1: 266,172
G2: NR Categorized: Asian/Pacific Islander
Funding: • IOM guidelines NR
NR Inclusion criteria:
• White, black, or Age (mean, yrs): Other
Study Objective: hispanic women G1: 10-14y: 0.7% NR
To examine • Women attending 15-19y: 24.8%
associations between Smoking,%:
WIC clinics both 20-29y: 58.3% NR
weight gain per week of prenatally and 30-34y: 11.5%
pregnancy and net postnatally 35-39y: 3.9% Diabetes mellitus,%:
weight gain per week of • Liveborn, 40-55y: 0.7% NR
pregnancy and preterm singletons delivered G2: NR
delivery Hypertension,%:
between 26 to 42
Parity: NR
Time frame: weeks gestation
Primiparous:
1990 to 1993 G1: 40.9% Additional characteristics:
Exclusion criteria:
G2: NR NR
Duration of the study: • Missing data for
First prenatal visit to prepregnancy BMI,
delivery pregnancy weight
gain, or infant birth
weight
• Incompatible birth
weight for
gestational age

C-192
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 266,172 NR RD of preterm birth Fair
G2: 45,142
G3: 135,390 Gestational Groups Sample selection:
G4: 33,697 diabetes, %: Rate of weight gain Good
G5: 51943 NR (kg/week) in percentiles Definition of maternal
Cesarean delivery, stratified by Low, Average, weight gain:
Total weight gain: High, and Obese pregravid
G1: 14.19 (6.70) kg %: Fair
NR BMI:
G2: 15.15 (5.75) G1: 5th,0.10 Definition of outcomes:
G3: 14.97 (6.27) Instrumental G2: 10th, 0.16 Good
G4: 13.78 (6.94) delivery, %: G3: 25th,0.26
G5: 11.56 (7.62) NR Source of information on
G4: 50th,0.35 exposure, outcomes, and
Categorized: Episiotomy, %: G5: 75th, 0.46 confounders:
• Weight NR G6: 90th, 0.57 Poor
gain/week was G7: 95th, 0.65
calculated as Other maternal Followup:
weight gain outcomes: Results Fair
(kg) divided by • Mean weight Reference category of rate
Analysis comparability:
completed gain rate of weight gain: 0.35-<0.46
Fair
weeks (kg/wk) for total kg/wk
gestation sample: 0.36 Analysis of outcomes:
• Weight (0.17) RD of preterm birth varied Fair
gain/week and • Mean net by prepregnant BMI and
weight gain ( = gestational weight gain. Interpretation:
net weight Fair
gain/week weight gain- Overall, women gaining
were birth weight) 0.26-0.46 kg/wk had the Sum of Good/Fair/Poor:
categorized on (kg) for total lowest RD of preterm birth. 2 Good, 6 Fair, 1 Poor
basis of sample: 10.86 The highest RD occurred for
(6.60) women gaining the least and Final Quality Score:
percentile
• Mean net most amount of weight, Fair
distributions in
total sample weight gain irrespective of prepregnant
rate (kg/wk) for BMI; however, the highest
Collected from: total sample: RD of preterm births were
• Self-reported 0.28 (0.17) among women of low BMI
Ascertained by: Other infant Maternal confounders and
• Self-reported outcomes: effect modifiers accounted
• 6.8% delivered for in analysis:
at 32-36 weeks None
gestation
Infant and child
• 0.7% delivered confounders and effect
at 20-31 weeks modifiers accounted for in
gestation analysis:
NR

C-193
Evidence Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Siega-Riz et al., 1996 • Cohort • Self-reported White
• Prospective G1: 57.6 (0.53) G1: 8.7
Country and setting: G2: 8.9
G2: 59.0 (0.15)
USA, public health Total Study N:
clinics 7589 Pregravid BMI: Black
G1: 23.7 (0.22) G1: 10.3
Enrollment Period: Group Description: G2: 4,9
G2: 24.5 (0.06)
1983 to 1987 G1: Preterm
G2: Term Imputed: Hispanic
Funding: G1: 76.1
• No
State of California Group N: G2: 82.8
Maternal and Child G1: 517 Categorized:
Health Branch, March of G2: 7072 • IOM guidelines Asian/Pacific Islander
Dimes, and University of G1: 4.0
North Carolina Inclusion criteria: Age (mean, yrs): G2: 3.3
Department of Nutrition • Pregnant women G1: 24.9 (0.25)
attending public G2: 24.9 (0.06) Other
Study Objective: health clinics who NR
To examine differences were eligible to Parity:
in pattern of weight gain %primiparous: Smoking,%:
participate in G1: 5.4
according to trimesters Prematurity G1: 36.9
of pregnancy and G2: 34.4 G2: 3.8
Prevention Project
analyze effects on Diabetes mellitus,%:
preterm delivery Exclusion criteria: NR
• Mismatched
Time frame: prenatal and birth Hypertension,%:
1983 to 1987 outcome files G1: 4.8
Duration of the study: • Unreasonable G2: 2.5
Prenatal through birth gestational age
Additional characteristics:
• Stillbirths NR
• Missing data
• Multiple gestations
• Medical inductions
• Inability to
determine timing of
PPROM or PTL

C-194
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR AOR (95% CI) for rate of Good
Total weight gain: preterm birth, preterm labor,
Gestational PPROM Sample selection:
Categorized: diabetes, %: Fair
• According to IOM NR Groups
Categories of 3rd trimester Definition of maternal
Collected from: Cesarean delivery, weight gain:
• Routine pre-natal %: weekly weight gain rates
(kg/week): Good
care or maternity NR
records G1: Inadequate (Underweight, Definition of outcomes:
Instrumental < 0.34; Normal weight, < 0.35; Good
Ascertained by: delivery, %: Overweight/ Obese, < 0.30)
• Based on last NR G2: Adequate Source of information on
clinically (Underweight, > 0.34; Normal, exposure, outcomes, and
measured weight Episiotomy, %: > 0.35; Overweight/Obese, confounders:
prior to delivery NR > 0.30) Good
Other maternal Results Followup:
outcomes: Preterm birth: Good
NA G1: 1.91 (1.40-2.61) Analysis comparability:
Other infant G2: 1.00 (reference) Good
outcomes:
NA Preterm labor: Analysis of outcomes:
G1:1.75 (1.15-2.64) Good
G2: 1.00 (reference)
Interpretation:
Good
PPROM:
G1: 2.70 (1.35-5.42) Sum of Good/Fair/Poor:
G2: 1.00 (reference) 8 Good, 1 Fair, 0 Poor
Maternal confounders and Final Quality Score:
effect modifiers accounted Good
for in analysis:
Iron status, parity combined
with maternal age, ethnicity,
hypertension (chronic or
pregnancy induced), smoking
status, week prenatal care
began

C-195
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Spinillo et al., 1998 • Case-control • Self-reported White
• Prospective G1: 55.7 (10.3) NR
Country and setting:
G2: 57.7 (9.7)
Italy, University Hospital Total Study N: Black
690 Pregravid BMI: NR
Enrollment Period:
G1: 21.3 (3.7)
1988 to 1995 Group Description: Hispanic
G2: 21.8 (3.4)
G1: Cases NR
Funding:
G2: Controls Imputed:
NR Asian/Pacific Islander
• No
Group N: NR
Study Objective:
Categorized:
To investigate whether Inclusion criteria: Other
maternal anthropometric • ≤ 19,5 or > 19.5 NR
• Cases were
factors interact with 1 patients with Age (mean, yrs):
another or with other Smoking,%:
spontaneous G1: 28.7+/- 5.2 NR
risk factors, thus preterm delivery G2: 29.6+/-4.6
modifying risk of between 24 and 35 Diabetes mellitus,%:
spontaneous preterm weeks gestation Parity: NR
delivery NR
Exclusion criteria: Hypertension,%:
Time frame: • PROM indicated NR
1988 to 1995 premature delivery
Additional characteristics:
Duration of the study: associated with
NR
NR abruptio placentae,
placenta previa,
preeclampsia,
impaired fetal
growth, diabetes, or
other severe
maternal diseases
prior to pregnancy
• Severe fetal
malformations
• Missing data

C-196
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR AOR for spontaneous preterm Poor
Total weight gain: delivery
Categorized: Gestational Sample selection:
• Dichotomized diabetes, %: Groups Poor
into second/third NR G1: Prepregnancy BMI ≤ 19.5 Definition of maternal
trimester weight and 2nd/3rd trimester weight
Cesarean delivery, weight gain:
gain ≤ 0.37 gain ≤ 0.37 kg/wk
%: Fair
kg/wk and > 0.37 G2: Prepregnancy BMI>19.5
NR
kg/wk. Also, net and 2nd/3rd trimester weight Definition of outcomes:
weight gain Instrumental gain ≤ 0.37 kg/wk Good
≤ 0.135 kg/wk or delivery, %: G3: Prepregnancy BMI ≤ 48
> 0.135 kg/wk NR Source of information on
kg and 2nd/3rd trimester exposure, outcomes, and
Collected from: Episiotomy, %: weight gain ≤ 0.37 kg/wk confounders:
• Routine pre-natal NR G4: Prepregnancy BMI > 48 Fair
care or maternity kg and 2nd/3rd trimester
records Other maternal weight gain ≤ 0.37 kg/wk Followup:
outcomes: Good
Ascertained by: • Crude ORs for Results
Analysis comparability:
• Based on last spontaneous AOR (95% CI) for cases with
Poor
clinically preterm delivery: spontaneous preterm delivery
measured weight BMI < 19.5 = versus controls: Analysis of outcomes:
prior to delivery 1.68(1.20-2.38) G1: 5.63 (2.35-13.8) Good
• Second/third G2: 2.45 (1.60-3.75)
trimester weight P = 0.06 for interaction Interpretation:
gain ≤ 0.37 between G1 and G2 Poor
kg/wk: 2.40 (1.69 G3: 5.29 (1.45-20.90) Sum of Good/Fair/Poor:
- 3.42): Net G4: 2.42 (1.65-3.55) 3 Good, 2 Fair, 4 Poor
weight gain ≤ P = 0.21 for interaction
0.135 kg/wk 2.31 between G3 and G4 Final Quality Score:
(1.45-3/68) Poor

Other infant Maternal confounders and

outcomes: effect modifiers accounted
NR 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

C-197
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Perinatal data base • Self-reporteddata base White
review NR
Country and setting: Pregravid BMI:
• Retrospective
USA, academic medical G1: Low 29.6%; Normal Black
center Total Study N: 70.4% NR
15,101 G2: Low25.9%; Normal
Enrollment Period: Hispanic
74.1%
1976 to 2001 Group Description: NR
G3: Low 23.0%; Normal
G1: Total 77%
Funding: Asian/Pacific Islander
G2: White G4: Low 19%; Normal 81%
NIH NR
G3: African American G5: Low 42.2%; 57.9%
Study Objective: G4: Latina Other
To study how G5: Asian Imputed: NR
relationship between • No
Group N: Smoking,%:
gestational weight gain
G1: 15,101 Categorized: G1: 10.9%
and spontaneous
preterm birth interacts
G2: 6,513 • IOM guidelines G2: 14.5%
G3: 1,533 Low (< 19.8) G3: 21.4%
with maternal race or
G4: 1,614 Normal (19.8-25.9) but G4: 6.7%
ethnicity and previous
G5: 3,440 this is not explicitly G5: 4.5%
preterm birth status
stated
Inclusion criteria: Diabetes mellitus,%:
Time frame:
1976 to 2001 • Women of low or Age (mean, yrs): NR
normal G1: 28.19
Duration of the study: G2: 29.43 Hypertension,%:
prepregnancy BMI
From entry into prenatal delivering singleton G3: 24.25 NR
care until delivery during study period G4: 26.17 Additional characteristics:
(actually used a with complete data G5: 29.10 Previous preterm birth (%)
perinatal data base and on all variables G1: NR
looked at info) considered Parity:
G2: 4.4
Nulliparous
G3: 4.1
Exclusion criteria: G1: 53.8%
G4: 8.3
• Multiple gestations G2: 57.5
G5: 5.58
• Hypertension G3: 48.0
G4: 49.0 G6: 2.91
• Diabetes
• Delivery before 24 G5: 52.9 Additional characteristics:
weeks of gestation NR
• Congenital
anomalies
• Missing data on
any key variables
• Prepregnancy BMI
of 26 or greater
• Transport from
another hospital

C-198
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Outcomes from
Maternal Weight Bivariate Outcomes from Multivariate
Gain Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 15,101 NR Rates of preterm delivery at 34 and 37 Good
G2: 6513 weeks
G3: 1533 Gestational Sample selection:
G4: 1614 diabetes, %: Groups Fair
G5: 3440 NR Categories of rate of gestational Definition of maternal
Group 6 Cesarean weight gain (kg/wk): weight gain:
delivery, %: G1: < 0.27 Fair
Total weight gain: G2: 0.27 to 0.52
G1: Below IOM: 20.5; NR
G3: > 0.52 Definition of outcomes:
% Within IOM Instrumental Good
39.1%; delivery, %: Results
Above 40.4% NR Source of information
AOR (95% CI) for preterm delivery < on exposure,
P < .001 37 weeks:
G2: Below 15.5%; Episiotomy, %: outcomes, and
NR G1: 2.6 (2.1-3.2) confounders:
Within 38.5%; G2: 1.0 (reference)
above 46.1% Fair
Other maternal G3: 1.0 (0.8-1.2)
P < .001 outcomes: Followup:
G3: Below 16.9%; • Spontaneous AOR (95% CI) for preterm delivery < Fair
Within 30.9%; PTB for all 34 weeks:
Above 41.2% Analysis comparability:
women 4.0% G1: 3.0 (2.0-4.8)
P < .001 Fair
white 3.6%, G2: 1.0 (ref)
G4: Below 21.1%; blacks 6.8%, Analysis of outcomes:
Within 37.4%; latinas 4.4% Maternal confounders and effect
Fair
Above 41.5% asians 3.6% modifiers accounted for in analysis:
P < .001 Race, age pregravid BMI, year of Interpretation:
G5: Below 25.4%; Other infant delivery, parity, previous preterm birth, Good
Within outcomes: number of days between last weighing
NR and delivery, smoking Sum of
Categorized: Good/Fair/Poor:
• Continuous 3 Good, 6 Fair, 0 Poor
• According to Infant and child confounders and
effect modifiers accounted for in Final Quality Score:
IOM3-way
analysis: Fair
categorical
variable, low NR
(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

C-199
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Velonakis et al., 1997 • Cohort • Self-reported White
NR
Country and setting: Total Study N: Pregravid BMI:
France, hospital 2,040 Black
Imputed: NR
Enrollment Period: Group Description: • No
1988 Hispanic
Group N: Categorized: NR
Funding: • NR
NR Inclusion criteria: Asian/Pacific Islander
• Women with Age (mean, yrs): NR
Study Objective: regular cycle not NR
To identify impact of exceeding 32 days Other
various biological, • Last menstrual Parity: NR
occupational, and period was not NR
socioeconomic factors Smoking,%:
withdrawal bleed NR
on gestational age and from pill
birth weight Diabetes mellitus,%:
Exclusion criteria: NR
Time frame: • NA
1988 Hypertension,%:
Duration of the study: NR
First prenatal visit Additional characteristics:
through delivery NR

C-200
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Risk for preterm birth Poor
Total weight gain:
Gestational Groups Sample selection:
Categorized: diabetes, %: Poor
• Continuous NA, total gestational weight gain
NR (continuous) Definition of maternal
Collected from: Cesarean delivery, weight gain:
• Routine pre- %: Results Fair
natal care or NR Regression analysis with
maternity gestational age (weeks) as the Definition of outcomes:
records Instrumental dependent variable and net Fair
delivery, %: gestational weight gain as the
Ascertained by: NR Source of information on
independent variable: exposure, outcomes, and
• Based on last
Episiotomy, %: Β = 0.191 (SE, 0.06) confounders:
clinically
NR P = 0.001 Fair
measured
weight prior to Other maternal Followup:
delivery: outcomes: Maternal confounders and Fair
calculated by NA effect modifiers accounted for
subtracting in analysis: Analysis comparability:
prepregnancy Other infant Age, race, gravidity, previous Poor
weight, fetal outcomes: diseases, parity, abortions, marital
NA Analysis of outcomes:
and placental status, pathology of index
weight from Fair
pregnancy, , height, pregravid
final weight weight, job classification, alcohol, Interpretation:
smoking, duration of pregnancy Fair
Infant and child confounders Sum of Good/Fair/Poor:
and effect modifiers accounted 0 Good, 6 Fair, 3 Poor
for in analysis:
Infant sex, APGAR score Final Quality Score:
Poor

C-201
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Wen et al., 1990 • Cohort • Routine pre-natal White
• Retrospective careweight at first G1: 29.7
Country and setting: G2: NR
prenatal visit was used
USA, hospital Total Study N: G1: (Prepregnancy?)
17,149 Black
Enrollment Period: Maternal weight (kg) <
G1: 70.3
January 1983 to Group Description: 50: 10.6%, 50-60:
G2: NR
December 1987 G1: Total 32.6%, 61-72: 28.7%,
G2: IUGR 73-84: 14.5%, > 85: Hispanic
Funding: 13.6% NR
G3: Preterm delivery
NIH contract N01-HD-4- G2: (Prepregnancy?)
2811 Group N: Maternal weight (kg) < Asian/Pacific Islander
G1: 100% 50: 12.9%, 50-60: 8.5%, NR
Study Objective:
G2: 7.4% 61-72: 6.4%, 73-84:
To determine effect of Other
G3: 12.6% 5.5%, > 85: 4.8%
factors related to LBW NR
on IUGR and preterm Inclusion criteria: G3: (Prepregnancy?)
delivery Maternal wei Smoking,%:
• Women seen for G1: 29.4
Time frame: prenatal care and Pregravid BMI: G2: 10.3
January 1983 to delivered of infants G3: 13.3
at study location Imputed:
December 1987 • No Diabetes mellitus,%:
Duration of the study: Exclusion criteria: NR
• Diabetes Categorized:
Entry into prenatal care • NR
through delivery • Pregnancies Hypertension,%:
involving multiple Age (mean, yrs): NR
births G1: < 17: 7.5%, Additional characteristics:
• Fetal death 17-19: 22.7%, G1: Married: 38.0%
• Congenital 20-25: 43.1%, G2: Married: 6.6%
malformation 26-30: 17.5%, G3: Married: 10.6%
31-35: 7.0%,
> 36: 2.3% Additional characteristics:
G2: < 17: 8.0%, Education:
17-19: 6.6%, G1: < 12: 41.1%,
20-25: 7.4%, 12: 41.6%,
26-30: 7.6%, > 12: 15.8%
31-35: 8.2%, G2: < 12: 7.7%,
> 36: 8.6% 12: 7.3%,
G3: < 17: 15.4%, > 12: 7.6%
17-19: 13.0%, G3: < 12: 12.8%,
20-25: 11.6%, 12: 12.1%,
26-30: 12.9%, > 12: 12.2%
31-35: 14.3%, Additional characteristics:
> 36: 13.4% NR
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

C-202
Evidence Table 17. Gestational weight gain and preterm birth (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Risk for preterm birth Fair
Total weight gain:
G1: Weight Gestational Groups Sample selection:
gain/week diabetes, %: Rate of weight gain (kg/wk) after Poor
(after the 20th NR 20 weeks gestation
week) in kg: Definition of maternal
Cesarean delivery, G1: < 0.24 weight gain:
< 0.24: 12.2%, G2: 0.24-0.57
0.24-0.57: %: Poor
NR G3: 0.58-0.74
54.4%, G4: ≥0.75 Definition of outcomes:
0.58-0.74: Instrumental Good
19.2%, delivery, %: Results
≥ 0.75: 14.3% NR Source of information on
AOR for preterm birth: exposure, outcomes, and
G2: Weight G1: 1.52 (P < 0.05)
gain/week Episiotomy, %: confounders:
NR G2: 1.11 (NS) Fair
(after the 20th G3: 1.00 (ref)
week) in kg: Other maternal G4: 1.71 (P < 0.05) Followup:
< 0.24: 9.9%, outcomes: Fair
0.24-0.57: NR
7.9%, Maternal confounders and Analysis comparability:
0.58-0.74: Other infant effect modifiers accounted for Fair
5.2%, outcomes: in analysis:
NR Analysis of outcomes:
≥ 0.75: 5.7% Race, parity, infant sex, marital
Good
G3: Weight gain/ status, education, age, previous
preterm delivery, smoking, alcohol Interpretation:
Categorized: consumption, drug use, height, Fair
• Ave weight pregravid weight
gain per week Sum of Good/Fair/Poor:
after 20th week 2 Good, 5 Fair, 2 Poor
Infant and child confounders
Collected from: and effect modifiers accounted Final Quality Score:
• Routine pre- for in analysis: Fair
natal care or Gender
maternity
records
Ascertained by:
• Maternal
weight at
delivery not
available, so
total weight
gain not
calculated

C-203
Evidence Table 18. Gestational weight gain and birthweight
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Abrams et al., 1995 • Cohort • Self-reported White
• Retrospective G1: 58.5 (7.8) kg G1: 100
Country and setting: G2: NR
G2: NR
USA, university hospital Total Study N:
4,420 Pregravid BMI: Black
Enrollment Period: NR
G1: 21.5 (2.5)
1980-1990 Group Description: G2: NR
G1: total sample Hispanic
Funding: NR
G2: NR Imputed:
NICHD grant
• No
Group N: Asian/Pacific Islander
Study Objective: NR
G1: 2994 Categorized:
To determine
relationship between
G2: NR • IOM guidelines Other
maternal weight gain Inclusion criteria: Age (mean, yrs): NR
pattern and birth weight • White women G1: 28.8 (5.4) Smoking,%:
Time frame: delivering at G2: NR G1: cigarettes per day: 2.0
1980-1990 hospital (5.6)
Parity:
Exclusion criteria: G1: 0.6 (0.9) G2: NR
Duration of the study:
initiation of prenatal • Multiple gestation G2: NR Diabetes mellitus,%:
care to delivery • Fetal congenital NR
abnormalities
• Maternal diabetes Hypertension,%:
• Hypertensive NR
disorders Additional characteristics:
• Maternal obesity NR
(BMI > 29.0)
• Missing data

C-204
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 2994 G1: 3485.8 (523.1) Infant weight gain Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational NA, weight gain as continuous variable Good
G1: 16.7 (0.5) diabetes, %:
G2: NR NR Results Definition of maternal
Infant BW among nonobese women weight gain:
Categorized: Cesarean delivery, 3,485.8g ± 523.1 Fair
• Weight gain by %:
NR Definition of outcomes:
trimester - 25th Increase in birth weight per 1 kg Good
percentile was increase in total pregnancy weight gain
Instrumental
used to define β = 22.6g Source of information on
delivery, %:
low (L) vs. not (P < 0.001) exposure, outcomes, and
NR
low (N) maternal confounders:
gain in each Episiotomy, %: Increase in birth weight per 1 kg Fair
trimester (i.e. NR increase in first trimester weight gain
below 25th Followup:
Other maternal β = 18.0g ± 2.4 Fair
percentile and
outcomes: (P < 0.001)
above 25th Analysis comparability:
percentile) • First trimester,
Increase in birth weight per 1 kg Fair
25th percentile
Collected from: value (kg) = increase in second trimester weight Analysis of outcomes:
• Routine pre-natal -0.05 gain Fair
care or maternity • Second β = 32.8g ± 2.8
records trimester, 25th (P < 0.001) Interpretation:
percentile value Fair
Ascertained by: Increase in birth weight per 1 kg
(kg) = 5.7 Sum of Good/Fair/Poor:
• Based on last increase in third trimester weight gain
clinically • Third trimester, 3 Good, 6 Fair, 0 Poor
25th percentile β = 17.0g ± 2.9
measured weight (P < 0.001) Final Quality Score:
prior to delivery: value (kg) = 4.8
• First-trimester Fair
using weight at
last prenatal visit gain (kg): 2.1 Maternal confounders and effect
prior to delivery (3.3) modifiers accounted for in analysis:
• Second-trimester Maternal age, parity, pregravid BMI,
gain (kg): 7.7 height, smoking, difference in weeks
(2.9) between the last measured weight and
• Third-trimester delivery
gain (kg): 6.6
(2.7) Infant and child confounders and
effect modifiers accounted for in
Other infant analysis:
outcomes: Infant sex, gestational age
NA

C-205
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-206
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Increase in birthweight Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: Weight loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: Definition of maternal weight
G3: 16-25 lbs gain:
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P < Poor
Only calculated for G5: >35 lbs
0.01) Definition of outcomes:
morbidly obese:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 3,302 Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 3,192 exposure, outcomes, and
G2: 15.9% G3: 3,337 confounders:
Collected from: G4: 3,506 Poor
• Routine pre- Instrumental G5: 3,453
natal care or delivery,%: (P < 0.05) Followup:
maternity NR Fair
records Maternal confounders and
Episiotomy,%: effect modifiers accounted Analysis comparability:
Ascertained by: NR for in analysis: Poor
• Not stated - NR
Other maternal Analysis of outcomes:
from medical
outcomes Infant and child confounders Fair
records
• Preeclampsia and effect modifiers
• Placental Interpretation:
accounted for in analysis:
abruption Poor
NR
• Meconium Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-207
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Brown et al., 2002 • Cohort • Measured by study White
• Prospective investigators G1: 97
Country and setting: G2: NR
• Weight was measured
USA, primary care Total Study N: < 6 months before
clinics 389 Black
conception for 364
NR
Enrollment Period: Group Description: women by study
1989 to 1993 G1: Total investigators Hispanic
G2: NR G1: 61.2 ± 9.4 (50.7, 73.2) NR
Funding: G2: NR
NIH Group N: Asian/Pacific Islander
G1: 389 Pregravid BMI: NR
Study Objective: G1: 22.5 ± 3.2 (19.2, 26.9)
G2: NR
To identify effects of G2: NR Other
maternal weight change Inclusion criteria: NR
by trimester of • Women aged 22-35 Imputed:
Smoking,%:
pregnancy on weight, years enrolled in • No
length, head NR
Group Health Categorized:
circumference, and managed care Diabetes mellitus,%:
ponderal index (PI; in • Continuous
organization NR
kg/m3) of newborns • Intended to become Age (mean, yrs):
Hypertension,%:
Time frame: pg within G1: 29.4 ± 3.1 (25.3, 33.7)
NR
1989 - 1993 enrollment period G2: NR
• Had not been Additional characteristics:
Duration of the study: Parity:
attempting pg for NR
From preconception or G1: 0.5 ± 0.7 (0, 1)
> 3 mo
entry into prenatal care G2: NR
• Had delivered last
through 6 to 8 weeks infant > 12 mo
postpartum 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

C-208
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 389 G1: 3575g ± 448 Increase in birthweight Good
G2: NR (3033–4167)
G2: NR Groups Sample selection:
Total weight gain: NA, weight gain as continuous Good
G1: 15.6 ± 4.1 Gestational variable
(10.5–21.4)2 diabetes, %: Definition of maternal weight
G2: NR NR gain:
Results Fair
Categorized: Cesarean delivery, Increase in birth weight per 1 kg
increase in total pregnancy Definition of outcomes:
• Continuous %:
NR weight gain Good
Collected from: β = 20g
Instrumental Source of information on
• Collected by (P < 0.0001)
delivery, %: exposure, outcomes, and
study
NR confounders:
investigatorsRo Increase in birth weight per 1 kg Good
utine pre-natal increase in first trimester weight
Episiotomy, %:
care or gain Followup:
NR
maternity β = 31g Good
records Other maternal (P < 0.0007)
outcomes: Analysis comparability:
Ascertained by: Good
NR Increase in birth weight per 1 kg
• Based on last
Other infant increase in second trimester Analysis of outcomes:
clinically
measured outcomes: weight gain Good
weight prior to Although β = 26g
Interpretation:
delivery nonsignificant, a (P < 0.007)
Good
trend was noted
that suggested, Increase in birth weight per 1 kg Sum of Good/Fair/Poor:
among women with increase in third trimester 8 Good, 1 Fair, 0 Poor
lower weight gain
Final Quality Score:
preconception β = 7g
Good
weight, an (P < 0.40)
increased effect of
first-trimester Maternal confounders and
weight gain on effect modifiers accounted
weight of their for in analysis:
newborns (51 kg Maternal age, parity, pregravid
preconception BMI, height
weight, 51 g/kg
weight gain; 62 kg Infant and child confounders
preconceptional and effect modifiers
accounted for in analysis:
Gestational age, sex (female)

C-209
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Butte et al., 2003 • Cohort • Measured by study White
• Prospective investigators G1: 77
Country and setting: G2: NR
USA, children’s nutrition Total Study N: Pregravid BMI:
center 63 Black
Imputed: G1: 10
Enrollment Period: Group Description: • No G2: NR
NR G1: Total cohort
G2: NR Categorized: Hispanic
Funding: • IOM guidelines G1: 10
US Department of Army Group N: G2: NR
and US Department of G1: 63 Age (mean, yrs):
Agriculture/Agriculture G2: NR G1: 31 (4) Asian/Pacific Islander
Research Service G2: NR G1: 3
Inclusion criteria: G2: NR
Study Objective: • Nonsmokers Parity:
To evaluate how NR Other
• 18-40 years
changes in gestational • parity ≤ 4 NR
weight and body • Physically active
composition affect infant Smoking,%:
(20 to 30 minutes of NR
birth weight and moderate exercise
maternal fat retention at least 3 Diabetes mellitus,%:
after delivery in times/week) NR
underweight, normal • No long term
weight and overweight Hypertension,%:
medicine use NR
women
• No alcohol/drug
Time frame: abuse Additional characteristics:
NR NR
Exclusion criteria:
Duration of the study: • Multiparous
Prior to preg through pp • Preterm deliveries
• Miscarriage
• Preeclampsia

C-210
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Infant birthweight Good
Total weight gain:
G1: 15.0 (3.8) kg Gestational Groups Sample selection:
G2: 14.5 (4.5) kg diabetes, %: G1: Correlation coefficient Fair
G3: 17.9 (5.4) kg NR G2: Variability in BW accounted for Definition of maternal
Categorized: Cesarean delivery, by gestational age, pregravid weight, weight gain:
• Continuous %: and total pregnancy weight gain Fair
NR
Collected from: Results Definition of outcomes:
• Collected by Instrumental G1: 0.28 Good
study delivery, %: G2: 37.9%
NR Source of information on
investigators
Maternal confounders and effect exposure, outcomes, and
Ascertained by: Episiotomy, %: modifiers accounted for in confounders:
• NR NR analysis: Good
Other maternal Race, pre-gravid BMI Followup:
outcomes: Infant and child confounders and Poor
NA effect modifiers accounted for in Analysis comparability:
Other infant analysis: Fair
outcomes: Gestational age
Analysis of outcomes:
• Birth weight
Fair
Interpretation:
Fair
Sum of Good/Fair/Poor:
3 Good, 5 Fair, 1 Poor
Final Quality Score:
Fair

C-211
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cherry et al., 1993 • RCT • Measured by study White
investigators NR
Country and setting: Total Study N: G1: 53% were 90-110%
USA, hospital 599 Black
Expected Weight (EW); 26%
NR
Enrollment Period: Group Description: < 90% EW; 21% were >
NR G1: Total 110% EW Hispanic
G2: NR G2: NR NR
Funding:
NR Group N: Pregravid BMI: Asian/Pacific Islander
G1: 599 NR
Study Objective: Imputed:
G2: NR
NR-to examine effect of • No Other
zinc on birth outcomes Inclusion criteria: NR
Categorized:
• Adolescents in
Time frame: • Calculated weight for Smoking,%:
prenatal clinic at
NR age and height NR
Charity Hospital of
Duration of the study: New Orleans Age (mean, yrs): Diabetes mellitus,%:
9 months-from time of NR NR
Exclusion criteria:
enrollment in to prenatal
care up to delivery • NR Parity: Hypertension,%:
NR NR
Additional characteristics:
NR

C-212
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Infant BW by Quartiles of Poor
Total weight gain: weight gain
Gestational Sample selection:
Categorized: diabetes, %: Poor
• Grams gained Groups
NR Quartiles defined as weekly
per week per cm Definition of maternal weight gain:
height Cesarean delivery, weight gain in g per cm height Poor
%: G1: Quartile 1 (≤ 1.87g)
Collected from: NR G2: Quartile 2 (1.88-2.68g) Definition of outcomes:
• Routine pre-natal G3: Quartile 3 (2.69-3.58g) Good
care or maternity Instrumental G4: Quartile 4 (≥ 3.59g)
delivery, %: Source of information on exposure,
records
NR Results outcomes, and confounders:
Ascertained by: G1: 2,829g Fair
• NR Episiotomy, %: G2: 2,990g
NR Followup:
G3: 3,112g Fair
Other maternal G4: 3,189g
outcomes: Analysis comparability:
Table 1 provided data Poor
Maternal confounders and
above-LBW, wt for effect modifiers accounted Analysis of outcomes:
length of infant, % of for in analysis: Fair
infants in high risk NA
nursery Interpretation:
Infant and child confounders Poor
Other infant and effect modifiers
outcomes: Sum of Good/Fair/Poor:
accounted for in analysis:
NA 1 Good, 3 Fair, 5 Poor
NA
Final Quality Score:
Poor

C-213
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cianni et al., 2003 • Cohort • Not stated White
• Prospective G1: 64 (11) NR
Country and setting:
G2: NR
Italy, clinic Total Study N: Black
180 Pregravid BMI: NR
Enrollment Period:
G1: 23.6 (4)
not stated Group Description: Hispanic
G2: NR
G1: Total cohort NR
Funding:
G2: NR Imputed:
NR Asian/Pacific Islander
• No
Group N: NR
Study Objective:
G1: 180 Categorized:
To determine predictive Other
value of serum
G2: NR • Continuous NR
triglyceride levels for Inclusion criteria: Age (mean, yrs):
neonatal weight in Smoking,%:
• Positive diabetic G1: 33 (4) NR
pregnant women with screening G2: NR
positive diabetic performed at 24- Diabetes mellitus,%:
screening but normal 30th week of Parity: NR
glucose tolerance gestation NR
Hypertension,%:
Time frame: Exclusion criteria: NR
Not stated • Hypertensive
Additional characteristics:
Duration of the study: disorders
NR
24 to 30 weeks GA to • Thyroid disorder
birth • Lupus
• Antiphospholipid
syndrome

C-214
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 180 G1: 3,442 (440) Infant birthweight Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational NA continuos measure Poor
G1: 8 (3) diabetes, %:
G2: NR NR Definition of maternal weight
Results gain:
Categorized: Cesarean delivery, F statistic = 3.16, P = 0.08 Poor
• Continuous %: Maternal confounders and
NR Definition of outcomes:
Collected from: effect modifiers accounted Fair
• Not stated Instrumental for in analysis:
delivery, %: • Pre-gravid BMI Source of information on
Ascertained by: NR • Maternal triglycerides exposure, outcomes, and
• Based on last confounders:
• Plasma glucose
clinically Episiotomy, %: Poor
measured NR Infant and child confounders
Followup:
weight prior to and effect modifiers
Other maternal Fair
delivery: not accounted for in analysis:
outcomes:
stated NR Analysis comparability:
NA
Fair
Other infant
outcomes: Analysis of outcomes:
NA Fair
Interpretation:
Poor
Sum of Good/Fair/Poor:
1 Good, 4 Fair, 4 Poor
Final Quality Score:
Poor

C-215
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal G1: NR
To compare pregnancy
G1: 683 weight (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal Age (mean, yrs):
weight women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight normal weight
change women identified Parity: Other
from pregnancy NR G1: NR
Time frame: G2: NR
1997-1993 and delivery
summary records G3: 4.0 (Total sample)
Duration of the study: (normal weight Smoking,%:
1997-1993 matched to obese NR
by race, age, parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-216
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 Infant birthweight Good
G2: 660 G2: 3285 P ≤ 0.001
Groups Sample selection:
Total weight gain: Gestational G1: Increase in birth weight per Fair
G1: 9.5 diabetes,%: 1 kg increase in total pregnancy
G2: 14.5 P ≤ 0.001 NR Definition of maternal weight
weight gain for obese women gain:
Categorized: Cesarean G2: Increase in birth weight per Fair
• According to delivery,%: 1 kg increase in total pregnancy
G1: 25.6 weight gain for normal weight Definition of outcomes:
IOM
G2: 9.1 P < 0.001 women Fair
Collected from:
Instrumental Source of information on
• Routine pre- Results
delivery,%: exposure, outcomes, and
natal care or G1: β = 11g ± 2 confounders:
maternity (P ≤ 0.001)
Episiotomy,%: Fair
records G2: β = 15g ± 2
Other maternal (P ≤ 0.001) Followup:
Ascertained by:
outcomes: Fair
• Based on last NA Maternal confounders and
clinically effect modifiers accounted for Analysis comparability:
measured Other infant in analysis: Good
weight prior to outcomes: Age, parity, pregravid BMI,
NA Analysis of outcomes:
delivery pregnancy-induced Fair
hypertension, adequacy of
prenatal care, alcohol use, drug Interpretation:
use, smoking Good
Infant and child confounders Sum of Good/Fair/Poor:
and effect modifiers 3 Good, 6 Fair, 0 Poor
accounted for in analysis:
Final Quality Score:
Gestational age
Fair

C-217
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if White
1992 • Combination: self reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at G4: 65.0 (12.2) Hispanic
July 1, 1985 - delivery G5: 58.3 (6.5) NR
December 31, 1985 (6
Total Study N: Pregravid BMI: Asian/Pacific Islander
months)
Total n = 357 G1: 39.5 (3.4) NR
Funding: • 191 women with G2: 17.2 (0.9)
NR abnormal G3: 26.1 (6.1) Other
prepregnant weight G4: 23.6 (4.1) NR
Study Objective: G5: 21.6 (2.0)
(≥ 20% under or Smoking,%:
To evaluate effects of
over ideal weight NR
abnormal maternal Imputed:
for height) or
weight or weight gain on • No Diabetes mellitus,%:
abnormal
pregnancy outcome NR
pregnancy weight Categorized:
Time frame: gain (≥ 20kg or • Continuous ≥ 20% over Hypertension,%:
July 1, 1985 to ≤ 5kg) or under normal weight NR
December 31, 1985 (6 • 166 controls for height
months) Additional characteristics:
Group Description: Age (mean, yrs): NR
Duration of the study: G1: ≥ 20% over normal G1: 28 (5.1)
Prepregnancy to weight for height G2: 25.5 (5.1)
delivery G2: ≥ 20% under G3: 29.5 (5.1)
normal weight for height G4: 28.7 (4.7)
G3: weight gain ≤ 5kg G5: 28.7 (4.4)
G4: weight gain ≥ 20kg
G5: control Group 6 Parity:
G1: prior deliveries: 1.0 (1.0)
Group N: G2: 0.8 (0.8)
G1: 77 G3: 1.2 (1.1)
G2: 28 G4: 0.8 (1.0)
G3: 30 G5: 0.9 (1.0)
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

C-218
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Infant birthweight Fair
G2: 28 P < 0.05 compared
G3: 30 to controls Groups Sample selection:
G4: 56 G2: 3293 (362) G1: Normal prepregnancy Poor
G5: 166 P < 0.05 compared weight and normal weight gain Definition of maternal weight
to controls G2: Weight gain ≤5 kg gain:
Total weight gain: G3: 3284 (880) G3: Weight gain ≥20 kg
G1: 11.8 (6.2) Poor
G4: 3803 (538)
P < 0.05 compared P < 0.005 Results Definition of outcomes:
to controls compared to G1: 3,538g ± 535 Poor
G2: 13.4 (4.5) controls G2: 3,284g ± 880
G3: 3.0 (3.5) Source of information on
G5: 3538 (535) G3: 3,803g ± 538 exposure, outcomes, and
P < 0.0005 (P < 0.005 compared to G1)
compared to Gestational confounders:
controls diabetes,%: Fair
G4: 23.2 (22.8) NR Maternal confounders and Followup:
P < 0.0005 effect modifiers accounted Fair
compared to Cesarean for in analysis:
controls delivery,%: NA Analysis comparability:
G5: 13.2 (3.4) G1: Elective 7% Poor
Emergency Infant and child confounders
Categorized: 14% and effect modifiers Analysis of outcomes:
• ≤ 5kg or Total 21% accounted for in analysis: Fair
≥ 20kg G2: Elective 4% NA
Interpretation:
Emergency 4%
Collected from: Poor
Total 8%
• Routine pre- G3: Elective 3% Sum of Good/Fair/Poor:
natal care or Emergency 3% 0 Good, 4 Fair, 5 Poor
maternity Total 6%
records G4: Elective 5% Final Quality Score:
Emergency Poor
Ascertained by:
• Based on last 18%
clinically Total 23%
measured G5: Elective 13%
weight prior to Emergency 9%
delivery Total 22%
Instrumental
delivery,%:
NR
Episiotomy,%:
NR
Other maternal
outcomes:
NA
Other infant
outcomes:
NA

C-219
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Groff et al., 1997 • Cohort • Self-reported White
• Prospective • Routine pre-natal care G1: 100%
Country and setting: G2: NR
first prenatal visit for
USA, multispecialty Total Study N: 18%, self-report for 82%
clinics 341 Black
Pregravid BMI: NR
Enrollment Period: Group Description: G1: 23.9
1991-1993 G1: Total Hispanic
G2: NR
G2: NR NR
Funding:
Imputed:
National Cancer Group N: Asian/Pacific Islander
Institute grant • No NR
G1: 341
G2: NR Categorized:
Study Objective: Other
To determine effects of • IOM guidelines NR
Inclusion criteria:
smoking status and • Adult, white, non- Age (mean, yrs):
maternal weight gain on Smoking,%:
Hispanic pregnant G1: 26.4 G1: 32% Never smoked
infant birthweight women beginning G2: NR G2: NR
Time frame: prenatal care
before 14 weeks Parity: Diabetes mellitus,%:
1991-1993 G1: Nulliparous: 52.8%
gestation who self- NR
Duration of the study: identified as never G2: NR
Entry into prenatal care Hypertension,%:
smokers,
to delivery continuing NR
smokers, and Additional characteristics:
women who Married/living with partner:
stopped smoking G1: 73.9%
during pregnancy G2: NR
• First or second
pregnancies, Additional characteristics:
singletons with NR
recorded weights at
12,26, and 39
weeks (+/- 2
weeks)
• Documented infant
birth weight
Exclusion criteria:
• Gestation > 42
weeks
• Black women
• Diabetics
• Hispanics

C-220
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Bivariate Outcomes from
Gain Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 3732 g (501) Increase in birthweight Good
Total weight gain: G2: 3440 g (465)
G1: 39.68 lb G3: 3693 g (443) Groups Sample selection:
(15.42) G1: Increase in birth weight Good
G2: 32.75 lb Gestational diabetes, %: per 1 lb increase in total
(13.23) NR Definition of
pregnancy weight gain maternal weight
G3: 34.16 lb
(11.77) Cesarean delivery, %: gain:
NR Results Fair
Categorized: G1: β = 10.1g ± 1.76
Instrumental delivery, %: (P ≤ 0.001) Definition of
• Continuous
NR outcomes:
Collected from: Maternal confounders and Good
Episiotomy, %: effect modifiers accounted
• Routine pre-
NR for in analysis: Source of
natal care or
• Pre-gravid BMI information on
maternity Other maternal outcomes: exposure,
records • Significant effects were found • Smoking
outcomes, and
for weight gain by smoking Infant and child confounders:
Ascertained by:
status @ < 0.001) and weight confounders and effect Good
• NR
gain over time (P < 0.001) modifiers accounted for in
• First trimester slopes differed Followup:
analysis:
slightly, but not significantly, Good
• Gender
among 3 groups (P = 0.075)
Analysis
• Second trimester slopes comparability:
differed significantly Fair
(P = 0.013), with women who
reported stopping smoking Analysis of
gaining more weight than outcomes:
never smokers during this Fair
period (difference of 2.57 Ib,
Interpretation:
99% CI = 0.46, 8.07)
Fair
• Third trimester slopes also
differed significantly (P = Sum of
0.003). Pairwise contrasts Good/Fair/Poor:
revealed significant differences 5 Good, 4 Fair, 0
in weight gain during third Poor
trimester between women who
stopped smoking and Final Quality Score:
continuing smokers (difference Good
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

C-221
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Guihard-Costa et al., • Cohort • Routine pre-natal care White
2004 • Retrospective NR
Pregravid BMI:
Country and setting: Total Study N: Black
France, hospital Imputed: NR
13,972
database • No
Group Description: Hispanic
Enrollment Period: Categorized: NR
1980-1990 Group N: • Continuous
Asian/Pacific Islander
Funding: Inclusion criteria: Age (mean, yrs): NR
NR • Liveborn singletons NR
• Term infants (37 to Other
Study Objective: Parity: NR
41 weeks)
To deterine relative NR
• Both parents born Smoking,%:
influences of maternal in Ffrance
factors on infant skinfold NR
• No maternal
thickness and other smoking during Diabetes mellitus,%:
outcomes gestation NR
Time frame: • All data available, Hypertension,%:
1980-1990 specifically NR
subscapular
Duration of the study: skinfold thickness Additional characteristics:
Pregnancy to birth • French NR
metropolitan
mothers
Exclusion criteria:
• French mothers
born in French
Caribbean Islands
or outside of
France

C-222
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Effect of pregnancy weight gain Good
Total weight gain: on infant birth weight
Gestational Sample selection:
Categorized: diabetes, %: Fair
• Continuous Groups
NR G1: Standardized coefficient for Definition of maternal weight
Collected from: Cesarean delivery, effect of pregnancy weight gain gain:
• Routine pre- %: on infant birth weight. Poor
natal care or NR
maternity Standardized coefficients are Definition of outcomes:
records Instrumental regression coefficients Good
delivery, %: calculated as if all of the
Ascertained by: NR Source of information on
independent variables had a exposure, outcomes, and
• Not stated -
Episiotomy, %: variance of 1 confounders:
from database
NR Fair
Results
Other maternal G1: SC = 0.199 Followup:
outcomes: Fair
NA
Maternal confounders and Analysis comparability:
Other infant effect modifiers accounted Fair
outcomes: for in analysis:
NA Analysis of outcomes:
• Age Good
• Parity
• Pre-gravid BMI Interpretation:
• Height Fair

Infant and child confounders Sum of Good/Fair/Poor:

and effect modifiers 3 Good, 5 Fair, 1 Poor
accounted for in analysis: Final Quality Score:
NR Fair

C-223
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hediger et al., 1994 • Cohort • Self-reported White
• Prospective G1: 56.00 (0.84) kg G1: 7.6
Country and setting: G2: 9.2
G2: 59.95 (0.82)
USA, setting NR Total Study N: G3: 8.8
G3: 60.91 (0.82)
608
Enrollment Period: Black
Pregravid BMI:
1985 Group Description: G1: 69.5
G1: 21.81 (0.30)
G1: Teenagers 13-15 G2: 23.02 (0.29) G2: 57.5
Funding:
years G3: 23.18 (0.29) G3: 61.8
NICHD grant
G2: Teenagers 16-18
Study Objective: years Imputed: Hispanic
To study relationship G3: Adults 19-29 • No G1: 22.8
between changes in G2: 33.3
Group N: Categorized: G3: 29.4
maternal subcutaneous
fat and infant birth
G1: 197 • Continuous
G2: 207 Asian/Pacific Islander
weight Age (mean, yrs): NR
G3: 204
Time frame: G1: 14.49 (0.14)
Inclusion criteria: G2: 17.41 (0.13) Other
1985 NR
• Primigravid and G3: 22.63 (0.14)
Duration of the study: multigravid teenagers Smoking,%:
Initiation of prenatal (< 19 years) with first Parity:
% primiparous: G1: 20.8
care to 4 to 6 weeks pregnancy at < 16 y G2: 34.8
G1: 93.9
postpartum • Older women ages 18 G3: 40.2
G2: 37.2
to 29 years at first
G3: 36.3 Diabetes mellitus,%:
pregnancy
NR
Exclusion criteria:
• History of serious Hypertension,%:
nonobstetric problems NR
(seizure disorders,
Additional characteristics:
leukemia or drug or
Mean change in arm muscle
alcohol abuse)
area, cm2:
• Fetal demise G1: 2.19 (0.44)
• Multiple pregnancy G2: 1.78 (0.38)
• Missing data on study G3: 2.00 (0.39)
variables
• Women who breast Change in arm fat area,
fed after delivery or cm2:
who were still G1: -0.46 (0.48)
breastfeeding at 4 to G2: -1.18 (0.43)
6 weeks postpartum 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-224
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 197 NR Infant birthweight by maternal Good
G2: 207 weight gain
G3: 204 Gestational Sample selection:
diabetes, %: Groups Fair
Total weight gain: NR G1: Increase in birth weight per 1
G1: 14.85 (0.54) kg Definition of maternal
Cesarean delivery, kg increase in total pregnancy weight gain:
G2: 13.82 (0.47) weight gain
G3: 14.12 (0.48) %: Fair
NR
Categorized: Results Definition of outcomes:
Instrumental G1: β = 16.7g ± 2.5 Good
• Continuous
delivery, %: (P = 0.001)
NR Source of information on
Collected from:
Maternal confounders and effect exposure, outcomes, and
• Routine pre-
Episiotomy, %: modifiers accounted for in confounders:
natal care or
NR analysis: Fair
maternity
records Other maternal Age, race/ethnicity, parity, Followup:
outcomes: pregravid weight, height, prior poor Good
Ascertained by: outcome, fat loss, pregravid weight:
• Anthropometric
• Based on last low weight, fat accretion, smoking Analysis comparability:
measurements
clinically Fair
taken were: mid-
measured
upper arm Infant and child confounders Analysis of outcomes:
weight prior to
circumference, and effect modifiers accounted Fair
delivery
triceps, and for in analysis:
, infant sex Interpretation:
subscapular Gestational age
skinfold thickness Fair
from left side of Sum of Good/Fair/Poor:
body - upper arm 3 Good, 6 Fair, 0 Poor
muscle and fat
area Final Quality Score:
Fair
Other infant
outcomes:
NA

C-225
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hickey et al., 1990 • Cohort • Self-reported White
• Prospective G1: NR NR
Country and setting:
• < 90% standard: 27.3%
United States, prenatal Total Study N: Black
clinics • 90-119%: 44.2% NR
325
• ≥ 120%standard: 21.5%
Enrollment Period: Group Description: G2: NR Hispanic
Does not state G1: Black • < 90% standard: 15.7% NR
Funding:
G2: Hispanic • 90-119%: 38.6% Asian/Pacific Islander
Supported by Garry A • ≥ 120%standard: 9.8% NR
Group N:
Weber Graduate G1: 172 Pregravid BMI:
Fellowship in Other
G2: 153
Anthropology, Southern Imputed: NR
Methodist University, Inclusion criteria: • No Smoking,%:
and through University • Black and Hispanic NR
pregnant women Categorized:
Affiliated Center,
aged ≥ 17 who • NR Diabetes mellitus,%:
Department of
Pediatrics, University of subsequently Age (mean, yrs): NR
Texas Southwestern delivered singleton G1: 22.65 ± 4.48 Hypertension,%:
Medical Center at infants free from G2: 23. 18 ± 4.78
congenital NR
Dallas, Maternal and
Child Health Training malformations Parity: Additional characteristics:
Grant MCJ-2000, G1: 0.98± 1.23 NR
Exclusion criteria: G2: 1.10± 1.50
Department of Health • Women whose last
and Human Services prenatal weight was
Study Objective: recorded > 14 days
Present study was before delivery,
designed to (1) gestational
determine prevalence of diabetes, other
low maternal weight-for- medical or
height near term among obstetrical
low income black and conditions, missing
Hispanic women records, moved to
attending public another city before
prenatal clinics, and (2) delivery
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

C-226
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Weight gain Good
Total weight gain:
Gestational Groups Sample selection:
Categorized: diabetes, %: Good
• % of standard Infant BW for groups
NR defined by maternal weight
weight for Definition of maternal
height by use Cesarean delivery, near term (% of standard weight gain:
of nomogram %: weight-for-height) Fair
and chart NR G1: > 135%, Black
G2: > 135%, Hispanic Definition of outcomes:
developed by
Instrumental G3: 120-135%, Black Good
Rosso
delivery, %: G4: 120-135%, Hispanic
NR Source of information on
Collected from: G5: 110-119%, Black exposure, outcomes, and
• Routine pre- G6: 110-119%, Hispanic
Episiotomy, %: confounders:
natal care or G7: 100-109%, Black
NR Good
maternity G8: 100-109%, Hispanic
records Other maternal G9: < 100%, Black Followup:
outcomes: G10: < 100%, Hispanic Good
Ascertained by:
NR
• Based on last Results Analysis comparability:
clinically Other infant G1: 3,325g ± 460 Fair
measured outcomes: G2: 3,543g ± 410
NR Analysis of outcomes:
weight prior to G3: 3,200g ± 389
delivery Good
G4: 3,381g ± 385
G5: 3,157g ± 373 Interpretation:
G6: 3,282g ± 400 Good
G7: 3,025g ± 494
G8: 3,154g ± 375 Sum of Good/Fair/Poor:
G9: 2,813g ± 289 7 Good, 2 Fair, 0 Poor
G10: 3,205g ± 472 Final Quality Score:
Maternal confounders Good
and effect modifiers
accounted for in
analysis:
NA
Infant and child
confounders and effect
modifiers accounted for
in analysis:
NA

C-227
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of G1: 84.4
Country and setting: G2: 85.8
pregravid BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg G4: 32.7 (31.3-34.7)
Funding: Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain
G2: 134 • Continuous
in obese glucose Other
G3: 132
tolerant women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: ≥ 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance Parity:
test (OGTT) during NR Diabetes mellitus,%:
third trimester NR
(according to WHO
Hypertension,%:
criteria)
NR
• Only first
pregnancy during Additional characteristics:
study period NR
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)

C-228
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200-3840) Infant birthweight Good
G2: 134 G2: 3645 (3200-4000)
G3: 132 G3: 3750 (3390-4125) Groups Sample selection:
G4: 122 G4: 3762 (3400-4120) G1: MWG < 5.0 kg Poor
G2: MWG 5.0-9.9 kg Definition of maternal
Total weight gain: Gestational diabetes, %: G3: MWG 10-14.9 kg
NR weight gain:
Categorized: G4: MWG ≥ 15.0 kg Poor
• < 5.0. 5.0-9.9, Cesarean delivery, %:
NR Results Definition of outcomes:
10.0-14.9, ≥
G1: 3,456g ± 620 Fair
15.0
Instrumental delivery, %: G2: 3,624g ±675
NR Source of information on
Collected from: G3: 3,757g ± 582 exposure, outcomes, and
• Routine pre- G4: 3,784g ± 597
Episiotomy, %: confounders:
natal care or P < 0.0001
NR Poor
maternity
records Other maternal outcomes: Increase in birth weight per 1 Followup:
NA kg increase in total pregnancy Fair
Ascertained by:
weight gain
• Not stated by Other infant outcomes: Analysis comparability:
authors NA Fair
G1: β = 18.4g
(P < 0.001) Analysis of outcomes:
Good
Interpretation:
Maternal confounders and Fair
effect modifiers accounted
for in analysis: Sum of Good/Fair/Poor:
Maternal age, pregravid BMI, 2 Good, 4 Fair, 3 Poor
smoking, gestational age, Final Quality Score:
result of 2-hour oral glucose Poor
tolerance test

Infant and child confounders

and effect modifiers
accounted for in analysis:
NA

C-229
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Johnson et al., 1992 • Cohort • Self-reported White
• Retrospective G1: 64.5
Country and setting: Pregravid BMI: G2: 60.0
USA, prenatal clinics Total Study N: G3: 49.8
Imputed:
3,191 G4: 51.9
Enrollment Period: • No
January 1, 1987- Group Description: G5: 58.7
December 31, 1989 G1: BMI < 19.8 Categorized:
• National Academy of Black
G2: 19.8-26.0 G1: 33.6
Funding: Sciences
G3: 27-29 G2: 37.9
NR
G4: > 29 Age (mean, yrs): G3: 48.9
Study Objective: G5: All G1: NR G4: 47.5
To determine influences • < 20 years: 36.6% G5: 39.5
Group N:
of increased maternal • 20-26 years: 44.8%
G1: 755 Hispanic
prepregnancy weight • > 26 years: 18.7%
G2: 1,621 NR
and increased G2: NR
G3: 329
gestational weight gain • < 20 years: 30.8% Asian/Pacific Islander
G4: 486
on pregnancy outcome
G5: 3191 • 20-26 years: 46.5% NR
Time frame: • > 26 years: 22.6%
Inclusion criteria: Other
January 1, 1987 to G3:
• Delivery at or G1: 1.9
December 31, 1989 • < 20 years: 25.8% G2: 2.1
beyond 38 weeks
• 20-26 years: 48.9% G3: 1.2
Duration of the study: of gestation
• > 26 years: 25.2% G4: 0.6
Initiation of prenatal • Singletons
G4: G5: 1.7
care to delivery • Received prenatal
• < 20 years: 16.5%
care and delivered Smoking,%:
• 20-26 years: 53.9%
in Shands Hospital NR
• > 26 years: 29.6%
Exclusion criteria: G5: Diabetes mellitus,%:
• Fetal abnormalities • < 20 years: 29.5% G1: 1.9
• Oligohydramnios • 20-26 years: 47.5 % G2: 2.3
• Polyhydramnios • > 26 years: 23.0% G3: 6.1
• Medical or surgical G4: 5.3
Parity:
complications (GI G5: 3.1
G1: % first: 49.3
disorders, sickle
G2: 43.1 Hypertension,%:
cell
G3: 37.4 G1: 3.4
hemoglobinopathy,
G4: 31.1 G2: 4.6
hepatitis,
G5: 42.1 G3: 5.8
hematologic
disorders, G4: 10.7
malignant disease, G5: 5.4
renal disease, Additional characteristics:
neurologic disease, G1: % married: 42.6
pulmonary disease, G2: 46.1
psychiatric G3: 40.4
disorders, G4: 49.4
tuberculosis) G5: 45.2
• Incomplete risk
variable data or Additional characteristics:
outcome variable NR
information

C-230
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 755 G1: Infant birthweight by Fair
G2: 1621 • < 2500g: 4.8% maternallweight gain
G3: 329 Sample selection:
• 2500-4000g:
G4: 486 Groups Fair
89.1%
G5: 3191 • > 4000g: 6.1% G1: Increase in birth weight per 1 Definition of maternal weight
G2: lb increase in net pregnancy weight gain:
Total weight gain: gain
G1: • < 2500g: 2.0% Fair
• < 16kg: 7.8% • 2500-4000g:
Results Definition of outcomes:
• 16-25kg: 85.2%
G1: β = 15.4g ± 2.2 Fair
18.5% • > 4000g:
12.8% (P < 0.0001) Source of information on
• 26-35kg:
G3: Maternal confounders and effect exposure, outcomes, and
35.1%
• < 2500g: 1.5% modifiers accounted for in confounders:
• > 35kg: 38.5%
• 2500-4000g: analysis: Fair
G2:
• < 16kg: 11.7% 83.0% Race, parity, pregravid BMI, height, Followup:
• 16-25kg: • > 4000g: pregravid weight, marital status, Fair
18.0% 15.5% education, tobacco/alcohol/drug
G4: use, pregnancy-induced Analysis comparability:
• 26-35kg:
• < 2500g: 0.2% hypertension, macrosomia Fair
28.8%
• > 35kg: 41.5% • 2500-4000g: Analysis of outcomes:
82.5% Infant and child confounders
G3: and effect modifiers accounted Fair
• < 16kg: 19.8% • > 4000g:
for in analysis: Interpretation:
17.3%
• 16-25kg: Gestational age, infant sex, Fair
19.1% Gestational macrosomia
• 26-35kg: diabetes, %: Sum of Good/Fair/Poor:
28.3% G1: 1.9 0 Good, 9 Fair, 0 Poor
• > 35kg: 32.8% G2: 2.3
Final Quality Score:
G4: G3: 6.1
Fair
• < 16kg: 32.3% G4: 5.3
• 16-25kg: G5: 3.1
22.0%;
Cesarean
Categorized: delivery,%:
• Quartiles G1: NR
• National G2: NR
Academy of G3: NR
Sciences G4: NR
(below, within, G5: 11.9
or above Instrumental
recommended delivery,%:
range) NR
Collected from: Episiotomy,%:
• Routine pre- NR
natal care or
maternity
records

C-231
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Johnson et al., 1992
(continued)

C-232
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Ascertained by: Other maternal
• Based on last outcomes:
clinically • Frequency of
measured macrosomia =
weight prior to 12.2%
delivery: • Frequency of
difference cesarean =
between self 11.9%
report and
weight at last • Frequency of
prenatal visit LBW = 2.9%
(mean 6.1 days • Frequency of
prior to postdate
delivery) 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-233
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kieffer et al., 2006 • Cohort • Self-reported when White
• Prospective unknown or missing - NR
Country and setting:
used weight obtained
United States, Total Study N: Black
within first 10 weeks of
community health 1,041 NR
pregnancy
center
Group Description: G1: 63.4 ¡±12.9 Hispanic
Enrollment Period: G1: Total G2: NR G1: 100%
Jan 1999 to Feb 2001 G2: NR G2: NR
Pregravid BMI:
Funding: Group N: G1: 25.9 ±5.0 Asian/Pacific Islander
This study was G1: 1041 G2: NR NR
supported by National G2: NR Imputed: Other
Institutes of Diabetes
Inclusion criteria: • Yes NR
and Digestive and
Kidney Diseases (grant • Latino women Categorized: Smoking,%:
R18DK 062344); entering prenatal • IOM guidelines G1: 9%before; 2% during
Biostatistics and care during study G2: NR
Measurement Cores of period Age (mean, yrs):
Michigan Diabetes G1: 25.2 ±5.1 Diabetes mellitus,%:
Exclusion criteria: G2: NR G1: 6.8
Research and Training • Multiple gestation
Center (grant NIH5P60 G2: NR
• Late entry into Parity:
DK20572); General G1: Multiparous, no. (%)0 Hypertension,%:
prenatal care
Clinic Center, National 429 (41.2) 1¨C3 574 (55.1) NR
• Previous
Institutes of Health ¡Ý4 38 (3.7)
participation in Additional characteristics:
(grant M01 RR00042); G2: NR
study NR
the Maternal and Child
Health Bureau (grant • Miscarriage
R40 MC00115-03); and • Stillbirth
Detroit Community • Missing records
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

C-234
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: total n = 933 NR Infant birth weight Good
G2: NR
Gestational diabetes, Groups Sample selection:
Total weight gain: %: G1: Increase in birth weight per Fair
G1: Adjusted R2: G1: 6.8 1 kg increase in total pregnancy
0.30 kg [PE 8.2, SE G2: NR Definition of maternal weight
weight gain gain:
2.2, P < 0.01]
G2: NR Cesarean delivery,%: Fair
Results
Categorized: Instrumental G1: β = 19.7g ± 2.8 Definition of outcomes:
delivery,%: (P < 0.01) Good
• Continuous
According to IOM Episiotomy,%: Maternal confounders and Source of information on
effect modifiers accounted for exposure, outcomes, and
Collected from: Other maternal
in analysis: confounders:
• Routine pre-natal outcomes:
Good
care or maternity • Women with GDM Parity, pregravid BMI, height, 1-
records had significantly hour glucose value Followup:
lower average Infant and child confounders Good
Ascertained by:
weight gain than and effect modifiers
• Based on last Analysis comparability:
those without accounted for in analysis:
clinically Good
GDM, but weight Gestational age
measured weight
gain was not Analysis of outcomes:
prior to delivery
significantly Good
related to glucose
category Interpretation:
• Maternal waist, Good
hip, and upper- Sum of Good/Fair/Poor:
arm 7 Good, 2 Fair, 0 Poor
circumference
and upper-arm fat Final Quality Score:
area were Good
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

C-235
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kirchengast and • Cohort Estimated by means of White
Hartmann, 2003 • Retrospective retrospective method and first NR
weight determination, which
Country and setting: Total Study N: was carried out at first prenatal Black
Singleton births that took 8,011 visit (8th week of gestation) NR
place at University Clinic G1: 56.0
for Gynecology and Group Description: Hispanic
G1: 12 to 16 years G2: 57.2 NR
Obstetrics in Vienna, G3: 59.2
Austria G2: 17 to 19 years
Asian/Pacific Islander
G3: 20 to 29 years Pregravid BMI:
Enrollment period: NR
Group N: G1: 21.45
NR G2: 21.59 Other
G1: 215
Funding: G3: 22.10 NR
G2: 1,336
NR G3: 6,460 Imputed: Smoking,%:
Study Objective: • Yes NR
Inclusion criteria:
Examine impact of • Women ages 12 to Diabetes mellitus,%:
Categorized:
biological factors such as 29 NR
• Continuous
young maternal age and • All prenatal check-
maternal somatic Age (mean, yrs): Hypertension,%:
ups of mother-child
characteristics on G1: 14.5 NR
passport were
pregnancy outcome performed G2: 17.8 Additional characteristics:
among group of • Delivery of single G3: 24.1 Age at menarche:
adolescent mothers who infant without G1: 12.2
gave birth between 39th Parity:
congenital NR G2: 12.9
and 41st week of malformations G3: 13.3
gestation after period of • Receiving
intensive psychological Gynecological age:
psychosocial support
support G1: 3.4
by family and/or
G2: 5.3
Time frame: specially trained
G3: 10.8
NR social worker within
young adolescent
Duration of the study: group (12 to 16
1985 to 1995 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

C-236
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 215 G1: 3237.6 Increase in birth weight per 1 Good
G2: 1,336 (significantly kg increase in total pregnancy
G3: 6,460 different from 17- weight gain Sample selection:
19 and 20-29) Fair
Total weight gain: G2: 3298.3 Groups
G1: 13.1 Definition of maternal weight
(significantly NA, weight gain as continuous gain:
G2: 13.1 different from variable
G3: 13.1 (P = .10) Fair
< 17 and 20-29)
Categorized: G3: 3368.9 Results Definition of outcomes:
(significantly Increase in birth weight per 1 Good
• Continuous
different from kg increase in total pregnancy Source of information on
Collected from: < 17 and 17-19) weight gain (95% CI) exposure, outcomes, and
• Routine pre-natal (F = 24.1, G1: β = 17.32 (14.62, 20.03) confounders:
care or maternity P < .0001)
Maternal confounders and Fair
records
Gestational effect modifiers accounted Followup:
Ascertained by: diabetes, %: for in analysis: Good
• Based on last NR Maternal age, age at
clinically menarche, pregravid weight, Analysis comparability:
measured weight Cesarean height, distantia cristarum Good
prior to delivery delivery,%:
NR Infant and child confounders Analysis of outcomes:
and effect modifiers Fair
Instrumental
accounted for in analysis: Interpretation:
delivery,%:
NR Fair
NR
Episiotomy,%: Sum of Good/Fair/Poor:
NR 4 Good, 5 Fair, 0 Poor
Other maternal Final Quality Score:
outcomes Fair
• 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

C-237
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Luke et al., 1996 • Cohort • Self-reported White
• Prospective G1: 47.9 (5.1) NR
Country and setting:
G2: 58.7 (6.3)
USA, clinic Total Study N: Black
G3: 83.9 (16.9)
487 G1: 48.1
Enrollment Period: G2: 48.8
Pregravid BMI:
March 1, 1974 to June 15, Group Description: G3: 63.5
G1: 18.3 (1.0)
1979 G1: BMI < 19.8 G2: 22.6 (1.7)
G2: BMI 19.8-26.0 Hispanic
Funding: G3: 31.7 (5.3)
G3: BMI > 26.0 NR
NR
Imputed:
Group N: Asian/Pacific Islander
Study Objective: • No
G1: 104 NR
Reanalysis of original data
G2: 268 Categorized:
to examine contribution of Other
maternal weight gain to
G3: 115 • IOM guidelines NR
infant birth weight and Inclusion criteria: Age (mean, yrs):
retained maternal weight • Smoking,%:
Referred for nutrition G1: 23.1 (5.5) G1: 17.3
in immediate postpartum counseling G2: 23.8 (5.5)
period, and effect of G2: 15.3
• > 37- < 43 weeks G3: 27.4 (6.2) G3: 13.0
weight gains below, at, gestation
and above IOM guidelines • Parity: Diabetes mellitus,%:
Singleton pregnancy
on both infant birt % primipara: NR
Exclusion criteria: G1: 60.6
Time frame: • Women with history G2: 48.1 Hypertension,%:
March 1, 1974 to June 15, of or concurrent G3: 27.0 NR
1979 metabolic disease, Additional characteristics:
Duration of the study: such as diabetes, NR
Prenatal visit through 2 seizure disorder,
days postpartum hypertension, cardiac
disease, asthma, or
drug dependence
• Women developing
antepartum
complications such
as preeclampsia,
GDM, or multiple
gestation

C-238
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 104 G1: 3,067 (44) Infant birthweight for total Good
G2: 268 P < 0.05 weight gain and net weight gain
G3: 115 significantly Sample selection:
different from Groups Fair
Total weight gain: mean for normal G1: Underweight
G1: 12.6 (0.7) Definition of maternal weight
BMI G2: Normal weight gain:
G2: 13.2 (0.4) G2: 3308 (27) G3: Overweight
G3: 11.7 (0.7) Fair
G3: 3300 (43)
Significantly different Results Definition of outcomes:
from mean for normal Gestational Increase in birth weight per 1 Good
BMI group at P < 0.05 diabetes, %: kg increase in total pregnancy
NR Source of information on
Categorized: weight gain for BMI categories exposure, outcomes, and
• According to IOM Cesarean delivery, G1: β = 44.9g ±6.8 confounders:
%: (P < 0.01) Fair
Collected from: NR G2: β = 22.9g ± 3.9
• Routine pre-natal (P < 0.01) Followup:
care or maternity Instrumental G3: β = 11.9g ± 5.2 Fair
records delivery, %:
(P < 0.05) Analysis comparability:
NR
Ascertained by: Good
• Based on last Episiotomy, %: Increase in birth weight per 1
NR kg increase in net pregnancy Analysis of outcomes:
clinically
weight gain for BMI categories: Fair
measured weight Other maternal
prior to delivery: outcomes: G1: β = 41.9g ± 7.5 Interpretation:
total weight gain: (P < 0.01) Poor
• Net gain (kg): 9.5 G2: β = 19.2g ± 3.9
difference
(0.6), 9.9 (0.4), (P < 0.01) Sum of Good/Fair/Poor:
between last
7.8 (0.6) G3: β = 9.1g ± 5.3 3 Good, 5 Fair, 1 Poor
measurement
significantly
and pregravid Final Quality Score:
different from Maternal confounders and
weight; net Fair
mean for normal effect modifiers accounted
weight gain:
BMI group at P < for in analysis:
difference
0.05 Age, parity, black ethnicity,
between
• Retained weight smoking
pregravid weight
(kg): 6.6 (0.6),
and last Infant and child confounders
6.6 (0.4), 4.2
measured weight and effect modifiers
(0.6) significantly
minus infant birth accounted for in analysis:
different from
weight Gestational age, infant sex
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

C-239
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Muscati et al., 1996 • Cohort Family physicians’ records White
• Retrospective G1: 62.8 +/- 16.0 kg NR
Country and setting: G2: NR
Canada, public health Total Study N: Black
department 371 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1979 to 1989 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
NR Group N: • Pregravid weight status NR
G1: 371 categorized into 3 groups
Study Objective: Other
G2: NR as a percentage of
To examine association of NR
standard weight:
extent and timing of Inclusion criteria: underweight < 90%, Smoking,%:
pregnancy weight gain • White, low income, normal 90-120%, and NR
with infant birth weight non-smoking women overweight > 120%
and postpartum weight • Pregnant women Diabetes mellitus,%:
retention Age (mean, yrs): NR
Exclusion criteria: G1: 24.5 +/- 5.6
Time frame: • Prematurity < 37 Hypertension,%:
G2: NR
1979 to 1989 weeks NR
• Adolescents < 16 Parity:
Duration of the study: Additional characteristics:
years G1: Primiparous 52%
Pregnancy through 6 G1: PPWR: 5.3 +/- 5.7 kg
• Women > 40 years G2: NR
weeks postpartum G2: NR
• Maternal health
problems Additional characteristics:
• Women who NR
consume alcohol or
drugs
• Pregnancy
complications such
as proteinuria,
hypertension,
diabetes, negative
weight gain, missing
values

C-240
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Infant birthweight Good
Total weight gain:
G1: 16.1 +/- 6.4 kg Gestational diabetes, Groups Sample selection:
G2: NR %: G1: Increase in birth weight per 1 kg Fair
NR increase in total weight gain up to
Categorized: Definition of maternal
• Continuous Cesarean delivery, %: week 20 weight gain:
NR G2: Increase in birth weight per 1 kg Fair
Collected from: increase in total weight gain from
• Collected by Instrumental delivery, weeks 21 to 30 Definition of outcomes:
study %: G3: Increase in birth weight per 1 kg Fair
investigators NR increase in total weight gain from Source of information
Episiotomy, %: weeks 31 to term on exposure,
Ascertained by:
• Based on last NR outcomes, and
Results confounders:
clinically Other maternal G1: β = 22g ± 6 Fair
measured outcomes:
weight prior to (P < 0.01)
From Table 1: G2: β = 31g ± 7 Followup:
delivery Pearson’s Correlation Poor
(P < 0.001)
Coefficient and G3: β = 12g ± 6
determination Analysis
(P < 0.05) comparability:
coefficient of maternal
weight gain with PP Fair
weight retention and Maternal confounders and effect Analysis of outcomes:
Infant BW. Maternal PP modifiers accounted for in analysis: Good
weight retention and • Parity
Preg weight gain: [Total • Pregravid standard weight Interpretation:
amount r = 0.808, R • Pregravid excess weight, Poor
square 65.3%, P < Sum of
0.001], [Up to week 20 r Infant and child confounders and effect
modifiers accounted for in analysis: Good/Fair/Poor:
= 0.682, R square 2 Good, 5 Fair, 2 Poor
46.5%, P < 0.001], • Birth length
[Weeks 21-30 r = • Infant gender Final Quality Score:
0.411, R square 16.9%, Fair
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]

C-241
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Paauw et al., 2005 • Cohort • Self-reported White
• Prospective G1: 65.2 (1.2) kg G1: 83.7
Country and setting: G2: 67.4 (P < .05 vs controls)
G2: 66.7 (3.3)
USA, hospital Total Study N:
351 Pregravid BMI: Black
Enrollment Period: NR
1995 to 1998 Group Description: Imputed:
G1: Controls • No Hispanic
Funding: NR
G2: HG patients
NR Categorized:
Group N: • NR Asian/Pacific Islander
Study Objective: NR
G1: 306
To evaluate relationship of Age (mean, yrs):
G2: 45
maternal hyperemesis G1: 25.9 (0.3) Other
gravidarum to neonatal Inclusion criteria: G2: 25.5 (0.7) NR
birth weight, infant • Singleton pregnancy
hospital length of stay, Parity: Smoking,%:
and other birth outcomes Exclusion criteria: NR G1: 21.9
• Multiple or molar G2: 11.1
Time frame: gestation
1995 to 1998 Diabetes mellitus,%:
• Diabetes or GDM G1: 0.7
Duration of the study: • Causes of nausea G2: 2.2
Initiation of prenatal care such as appendicitis
to delivery (+any time in or pyleonephritis Hypertension,%:
NICU or NIMU) G1: 3.6
G2: 4.4
Additional characteristics:
NR

C-242
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 306 G1: 3523 (29) Infant birthweight by maternal Good
G2: 45 G2: 3232 (88) (P < weight gain
0.05) Sample selection:
Total weight gain: Groups Poor
G1: 14.9 (0.3) Gestational G1: Increase in birth weight per 1
G2: 10.6 (1.3) diabetes, %: Definition of maternal weight
kg increase in total pregnancy gain:
G1: 0.7 weight gain
Categorized: G2: 2.2 Poor
• Continuous
Cesarean Results Definition of outcomes:
Collected from: delivery,%: G1: β = 21.0g Fair
• Self-reported
Instrumental Source of information on
Ascertained by: delivery,%: Maternal confounders and exposure, outcomes, and
• Based on last effect modifiers accounted for confounders:
clinically Episiotomy,%: in analysis: Poor
measured weight Other maternal • Race Followup:
prior to delivery: outcomes: • Prepravid weight Fair
not explained by NA • Marital status
authors • Smoking Analysis comparability:
Other infant Fair
outcomes: Infant and child confounders
NA and effect modifiers accounted Analysis of outcomes:
for in analysis: Fair
• Gestational age Interpretation:
Poor
Sum of Good/Fair/Poor:
1 Good, 4 Fair, 4 Poor
Final Quality Score:
Poor

C-243
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Pezzarossa et al., 1996 • Cohort • Self-reported White
• Prospective G1: 100
Country and setting: Pregravid BMI: G2: 100
Italy, not stated Total Study N: G1: 25.7 (0.5)
192 G2: 25.4 (0.8) Black
Enrollment Period: NR
Not stated Group Description: Imputed:
G1: Normal • No Hispanic
Funding: NR
G2: GDM
NR Categorized:
Group N: • Continuous Asian/Pacific Islander
Study Objective: NR
G1: 132
To evaluate effects of Age (mean, yrs):
G2: 60
gestational weight gain on G1: 29.1 (0.4) Other
neonatal birthweight in Inclusion criteria: G2: 28.07 (0.6) NR
women who were • Caucasian women
diagnosed with Parity: Smoking,%:
who had 1 or more NR
gestational diabetes after risk factors for GDM: NR
3second week gestation BMI > 28.6, Diabetes mellitus,%:
Time frame: gestational weight NR
Not stated gain > 12kg, previous
Hypertension,%:
GDM, or previous
Duration of the study: NR
neonatal macrosomia
Initiation of prenatal care and underwent a Additional characteristics:
to delivery diagnostic oral NR
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

C-244
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 132 G1: 3576.8 (41.3) Infant birthweight by maternal weight Fair
G2: 60 G2: 3678.7 (69.3) gain
Sample selection:
Total weight gain: Gestational Groups Fair
G1: 13.4 (0.5) diabetes, %: Increase in birth weight per 1 kg
G2: 12.2 (0.6) NR Definition of maternal
increase in total pregnancy weight gain weight gain:
Categorized: Cesarean delivery, for: Fair
• Continuous %: G1: Controls (normal glucose
NR tolerance) Definition of outcomes:
Collected from: G2: GDM Good
• Routine pre-natal Instrumental
Source of information
care or maternity delivery, %: Results
NR on exposure, outcomes,
records G1: β = 27.8g (P = 0.0001) and confounders:
Ascertained by: Episiotomy, %: G2: β = 39.5 Fair
• Based on last NR (P = 0.0001)
Followup:
clinically Other maternal Maternal confounders and effect Good
measured weight outcomes: modifiers accounted for in analysis:
prior to delivery: NR • Pre-gravid BMI Analysis comparability:
used weight at • Fasting plasma glucose Poor
last prenatal visit Other infant
outcomes: Infant and child confounders and Analysis of outcomes:
macrosomia effect modifiers accounted for in Good
analysis: Interpretation:
NR Fair
Sum of Good/Fair/Poor:
3 Good, 5 Fair, 1 Poor
Final Quality Score:
Fair

C-245
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Shapiro et al., 2000 • Cohort • Routine pre-natal care White
• Retrospective G1: 144.4 (36.0) NR
Country and setting:
G2: NR
USA, community hospital Total Study N: Black
159 Pregravid BMI: NR
Enrollment Period:
G1: 24.5 (5.7)
NR Group Description: Hispanic
G2: NR
G1: total cohort NR
Funding:
G2: NR Imputed:
NR Asian/Pacific Islander
• No
Group N: NR
Study Objective:
G1: 159 Categorized:
To ascertain whether Other
increased weight gain
G2: NR • < 25 > 25 NR
during pregnancy resulted Inclusion criteria: Age (mean, yrs): Smoking,%:
in higher birth weight • Randomly selected G1: 27.8 (4.6)
infants in women NR
from hospital G2: NR
delivering at a community database Diabetes mellitus,%:
hospital Parity:
• Ages 19 to 37 NR
G1: 1.3
Time frame: • Term delivery
G2: NR Hypertension,%:
NR Exclusion criteria: NR
Duration of the study: • Smokers Additional characteristics:
First prenatal visit (0-15 • Drug abusers NR
wks of gestation) to 2 • Chronic
weeks after birth hypertensivers
• Preeclampsia
requiring magnesium
sulfate
• Underlying systemic
disease such as
lupus or diabetes
• Patients not screened
for GDM

C-246
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 159 G1: 3513.4 gms Infant birthweight Good
G2: NR (468.8)
G2: NR Groups Sample selection:
Total weight gain: G1: Low BMI (< 25), Low gain (< Poor
G1: 30.3 lbs (11.4) Gestational 35lbs)
G2: NR diabetes, %: Definition of maternal weight
G2: Low BMI (< 25), High gain gain:
NR (> 35lbs)
Categorized: Fair
• < 35, > 35 Cesarean delivery, G3: High BMI (> 25), Low gain
%: (< 35lbs) Definition of outcomes:
Collected from: NR G4: High BMI (> 25), High gain Good
• Routine pre-natal (> 35lbs) Source of information on
care or maternity Instrumental
delivery, %: exposure, outcomes, and
records Results
NR confounders:
G1: 3,363g Fair
Ascertained by:
Episiotomy, %: G2: 3,636g
• Based on last Followup:
NR G3: 3,565g
clinically Fair
G4: 3,774g
measured weight Other maternal
prior to delivery: outcomes: Maternal confounders and Analysis comparability:
difference NA effect modifiers accounted for Poor
between weight in analysis:
Analysis of outcomes:
measured at first Other infant NA
Poor
visit (0-15 weeks outcomes:
gestation) and NA Infant and child confounders
Interpretation:
weight at last and effect modifiers
Poor
visit (35-41 accounted for in analysis:
weeks) NA Sum of Good/Fair/Poor:
2 Good, 3 Fair, 4 Poor
Final Quality Score:
Poor

C-247
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Shepard et al., 1998 • Cohort • Self-reported White
• Prospective G1: 140.9 (28.6) G1: 88.4
Country and setting: G2: 91.2
G2: 136.3 (25.2) P = 0.007
Obstetrical practices in Total Study N:
New Haven, CT 2,301 Pregravid BMI: Black
G1: 24.3 (4.6) G1: 5.8
Enrollment Period: Group Description: G2: 4.9
G2: 22.9 (3.9) P < 0.0001
1988 to 1992 G1: Cesarean delivery
G2: Vaginal delivery Imputed: Hispanic
Funding: G1: 3.5
• No
Grants NIH Group N: G2: 2.3
G1: 312 Categorized:
Study Objective:
To examine absolute and
G2: 1,989 • NHANES II: ≤ 19.4; 19.5- Asian/Pacific Islander
22.4; 22.5-28.5; > 28.5 G1: 1.3
proportional gestational Inclusion criteria: G2: 1.1
weight gain and • Privately insured Age (mean, yrs):
prepregnancy BMI as women who received NR Other
predictors of primary prenatal care from 13 G1: 1.0
cesarean delivery largest obstetrical Parity: G2: 0.4
practices and health NR
Time frame: Smoking,%:
1988 to 1992 maintenance % never smokers:
organizations in G1: 82.3
Duration of the study: greater New Haven, G2: 85.9
First prenatal visit to CT region (part of a
delivery larger study of Diabetes mellitus,%:
selected NR
environmental risk
Hypertension,%:
factors on pregnancy)
NR
• Singleton deliveries
at Yale-New Haven Additional characteristics:
Hospital %married:
G1: 95.8
Exclusion criteria:
G2: 92.1
• Repeat cesareans
births Additional characteristics:
• Missing information NR
on key variables

C-248
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 312 NR Infant birthweight Good
G2: 1989
Gestational Groups Sample selection:
Total weight gain: diabetes, %: Infant BW for mothers with: Fair
G1: 35.4 (11.9) NR G1: Low average BMI (19.5 to 22.4),
G2: 33.3 (11.9) P = Definition of maternal
Cesarean delivery, proportional weight gained > median weight gain:
0.005 G2: Low average BMI (19.5 to 22.4),
%: Poor
Categorized: NR gained < median
G3: High average BMI (22.5 to 28.5), Definition of outcomes:
• Proportional
Instrumental gained > median Fair
weight gain
delivery, %: G4: High average BMI (22.5 to 28.5),
based on Source of information on
NR gained < median
prepregnancy exposure, outcomes, and
weight and Episiotomy, %: G5: Obese (> 28.5 BMI), gained > confounders:
weight change NR median Poor
during pregnancy G6: Obese (> 28.5 BMI), gained <
Other maternal median Followup:
Collected from: outcomes: Good
• Routine pre-natal • Propotional Results
care or maternity Analysis comparability:
weight gain, lb, G1: 3,231g
records Fair
mean: cesarean G2: 3,553g
delivery - 26.5 G3: 3,395g Analysis of outcomes:
Ascertained by:
(10.0); vaginal G4: 3,620g Good
• Based on last
delivery - 25.2 G5: 3,685g
clinically Interpretation:
(9.3) P = 0.048 G6: 3,453g
measured weight Fair
prior to delivery Other infant
outcomes: Maternal confounders and effect Sum of Good/Fair/Poor:
• Low birth weight modifiers accounted for in 3 Good, 4 Fair, 2 Poor
rate = 3.3% for analysis: Final Quality Score:
entire study NA Fair
population
Infant and child confounders and
effect modifiers accounted for in
analysis:
NA

C-249
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Springer et al., 1992 • Other observational • Self-reported White
• Retrospective • Listed on medical record NR
Country and setting:
G1: Underweight 96.1 lbs
USA, university hospital Total Study N: Black
Normal weight 128.4 lbs
107 NR
Enrollment Period: Overwt 188.5 lbs
Sept 1988 Group Description: G2: NR Hispanic
NR
Funding: Group N: Pregravid BMI:
NIH-nursing G1: 107 Asian/Pacific Islander
Imputed:
G2: NR NR
Study Objective: • No
Purpose of study to Inclusion criteria: Other
examine relationship Categorized: NR
• Women giving birth
between early weight gain • Weight standards
during September Smoking,%:
and other nutrition-related published by Metropolitan
1988 at University of G1: 32%
risk factors and 2 Life Insurance Company
Michigan Women’s G2: NR
pregnancy outcomes: Hospital Age (mean, yrs):
length of gestation G1: 28 Diabetes mellitus,%:
and birth weight Exclusion criteria: NR
G2: NR
• NA
Time frame: Parity: Hypertension,%:
Sept 1988 NR NR
Duration of the study: Additional characteristics:
Entry into prenatal care up NR
to delivery

C-250
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Infant birthweight by maternal Good
Total weight gain: weight gain
Gestational Sample selection:
Categorized: diabetes, %: Fair
• Continuous Groups
NR G1: Increase in birth weight per Definition of maternal weight
Collected from: Cesarean delivery, 1 lb increase in total pregnancy gain:
• Routine pre-natal %: weight gain Poor
care or maternity NR
records Results Definition of outcomes:
Instrumental G1: β = 20.1g Poor
Ascertained by: delivery, %:
• Weight gain at NR Maternal confounders and Source of information on
10 and 20 weeks effect modifiers accounted for exposure, outcomes, and
ascertained to Episiotomy, %: in analysis: confounders:
within 5 weeks NR Maternal age, pregravid weight, Fair
• NR Other maternal length of gestation, smoking, Followup:
outcomes: weight gain at 20 weeks Fair
NR Infant and child confounders Analysis comparability:
Other infant and effect modifiers Poor
outcomes: accounted for in analysis:
Estimated weight NR Analysis of outcomes:
gain at 20 weeks’ Fair
gestation was Interpretation:
positively related to Poor
both length of
gestation and birth Sum of Good/Fair/Poor:
weight; this 1 Good, 4 Fair, 4 Poor
association was Final Quality Score:
statistically significant Poor
(P = .02) for birth
weight, as shown by
a simple regression.

C-251
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Velonakis et al., 1997 • Cohort • Self-reported White
NR
Country and setting: Total Study N: Pregravid BMI:
France, hospital 2,040 Black
Imputed: NR
Enrollment Period: Group Description: • No
1988 Hispanic
Group N: Categorized: NR
Funding: • NR
NR Inclusion criteria: Asian/Pacific Islander
• Women with regular Age (mean, yrs): NR
Study Objective: cycle not exceeding NR
To identify impact of 32 days Other
various biological, • Last menstrual period Parity: NR
occupational, and was not withdrawal NR
socioeconomic factors on Smoking,%:
bleed from pill NR
gestational age and birth
weight Exclusion criteria: Diabetes mellitus,%:
• NA NR
Time frame:
1988 Hypertension,%:
Duration of the study: NR
First prenatal visit through Additional characteristics:
delivery NR

C-252
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Infant birthweight Poor
Total weight gain:
Gestational Groups Sample selection:
Categorized: diabetes, %: G1: Increase in birth weight for Poor
• Continuous NR net pregnancy weight gain
Definition of maternal weight
Collected from: Cesarean delivery, gain:
• Routine pre-natal %: Results
G1: β = 111.17g ± 12.94 Fair
care or maternity NR
records (P = 0.000) Definition of outcomes:
Instrumental Maternal confounders and Fair
Ascertained by: delivery, %:
• Based on last effect modifiers accounted for Source of information on
NR in analysis:
clinically exposure, outcomes, and
measured weight Episiotomy, %: Maternal age, parity, pathology of confounders:
prior to delivery: NR previous/current pregnancy, Fair
calculated by previous diseases, reproductive
Other maternal history, marital status, Followup:
subtracting outcomes: Fair
prepregnancy employment, height weight,
NA smoking, alcohol use, nationality
weight, fetal and Analysis comparability:
placental weight Other infant Infant and child confounders Poor
from final weight outcomes: and effect modifiers accounted
NA Analysis of outcomes:
for in analysis: Fair
Infant sex, APGAR score,
gestational age Interpretation:
Fair
Sum of Good/Fair/Poor:
0 Good, 6 Fair, 3 Poor
Final Quality Score:
Poor

C-253
Evidence Table 18. Gestational weight gain and birthweight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Zaren et al., 1997 • Cohort • Self-reported White
• Prospective G1: ≤ 55: 30.9%; NR
Country and setting:
56-66: 45.8%;
Norway and Sweden, Total Study N: Black
≥ 67: 23.3%
university hospitals 1,099 NR
G2: NR
Enrollment Period: Group Description: Hispanic
Pregravid BMI:
January 1986 to March G1: Total cohort NR
G1: ≤ 19.8: 26.6%;
1988 G2: NR 19.9-23.4: 48.5%; Asian/Pacific Islander
Funding: Group N: ≥ 23.5: 24.9% NR
NR G1: 1,099 G2: NR
Other
G2: NR Imputed:
Study Objective: NR
To assess effects of Inclusion criteria: • No
Smoking,%:
maternal smoking on • 10% random sample Categorized: G1: 70.4%
birthweight in term of nonsmoking
pregnancies among • ≤ 19.8, 19.9-23.4, ≥ 23.5 G2: NR
mothers
mothers with different • 50% random sample Age (mean, yrs): Diabetes mellitus,%:
anthropometric stature of smokers from G1: 15-19 years: 0.5%; NR
Time frame: Successive Small for 20-24: 13.7%;
Hypertension,%:
January 1986 to March Gestational Age 25-29: 42.4%;
NR
1988 Births 30-34: 32.2%;
• Women speaking ≥ 35: 11.2% Additional characteristics:
Duration of the study: Swedish or G2: NR NR
Initiation of prenatal care Norwegian
to delivery Parity:
• Para 1 and 2 NR
• First prenatal visit
before 17 weeks
Exclusion criteria:
• Preterm delivery
• Incomplete
information

C-254
Evidence Table 18. Gestational weight gain and birthweight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1099 NR β is estimated change in infant BW (g) Good
G2: NR
Gestational Sample selection:
Groups
Total weight gain: diabetes, %: Poor
G1: MWG ≤ 11 kg:
G1: ≤ 11kg: 30.8%; NR
G2: MWG ≥ 17 kg Definition of maternal
12-16kg: 45.6%; ≥
17: 23.6% Cesarean delivery, weight gain:
%: Results Fair
G2: NR
NR G1: β = -131 (P = 0.0001)
Definition of
Categorized: G2: β = 164 (P = 0.0001)
Instrumental outcomes:
• ≤ 11, 12-16, ≥
delivery, %: Maternal confounders and effect Fair
17 kg
NR modifiers accounted for in analysis:
Source of information
Collected from: Maternal age, height, pregravid weight,
Episiotomy, %: on exposure,
• Routine pre-natal smoking
NR outcomes, and
care or maternity
confounders:
records Other maternal
Infant and child confounders and Fair
outcomes:
Ascertained by: effect modifiers accounted for in
NA Followup:
• Based on last analysis:
Good
clinically Other infant NR
measured weight outcomes: Analysis
prior to delivery NA comparability:
Fair
Analysis of outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
2 Good, 6 Fair, 1 Poor
Final Quality Score:
Fair

C-255
Evidence Table 19. Gestational weight gain and low birth weight
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-256
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) LBW (%) Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: Weight loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: Definition of maternal weight
G3: 16-25 lbs gain:
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P < Poor
Only calculated for G5: >35 lbs
0.01) Definition of outcomes:
morbidly obese:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 2.0 Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 11.1 exposure, outcomes, and
G2: 15.9% G3: 8.3 confounders:
Collected from: G4: 5.2 Poor
• Routine pre- Instrumental G5: 3.8
natal care or delivery,%: Followup:
maternity NR Maternal confounders and Fair
records effect modifiers accounted
Episiotomy,%: for in analysis: Analysis comparability:
Ascertained by: NR NR Poor
• Not stated -
Other maternal Infant and child confounders Analysis of outcomes:
from medical
outcomes and effect modifiers Fair
records
• Preeclampsia accounted for in analysis:
• Placental Interpretation:
NR
abruption Poor
• Meconium Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-257
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cherry et al., 1993 • RCT • Measured by study White
investigators NR
Country and setting: Total Study N: G1: 53% were 90-110%
USA, hospital 599 Black
Expected Weight (EW); 26% <
NR
Enrollment Period: Group Description: 90% EW; 21% were > 110%
NR G1: Total EW Hispanic
G2: NR G2: NR NR
Funding:
NR Group N: Pregravid BMI: Asian/Pacific Islander
G1: 599 NR
Study Objective: Imputed:
G2: NR
NR-to examine effect of • No Other
zinc on birth outcomes Inclusion criteria: NR
Categorized:
• Adolescents in
Time frame: • Calculated weight for age Smoking,%:
prenatal clinic at
NR and height NR
Charity Hospital of
Duration of the study: New Orleans Age (mean, yrs): Diabetes mellitus,%:
9 months-from time of NR NR
Exclusion criteria:
enrollment in to prenatal
care up to delivery • NR Parity: Hypertension,%:
NR NR
Additional characteristics:
NR

C-258
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Percentage of low birth weight Poor
Total weight gain: for each shifting of EW category.
Gestational Sample selection:
Categorized: diabetes, %: Poor
• Grams gained Groups
NR Light: < 90% EW
per week per cm Definition of maternal weight
height Cesarean delivery, Normal: 90 to 110% of EW gain:
%: Heavy: > 110% EW Poor
Collected from: NR G1: Heavy to normal
• Routine pre-natal G2: Normal to light Definition of outcomes:
care or maternity Instrumental G3: Normal to heavy Good
records delivery, %: G4: Light to normal
NR Source of information on
Ascertained by: exposure, outcomes, and
Episiotomy, %: Results confounders:
• NR
NR G1: 5% Fair
G2: 32%
Other maternal G3: 3.1% Followup:
outcomes: G4: 2.7% Fair
Table 1 provided data
above-LBW, wt for Maternal confounders and Analysis comparability:
length of infant, % of effect modifiers accounted for Poor
infants in high risk in analysis:
Analysis of outcomes:
nursery NA
Fair
Other infant Infant and child confounders
Interpretation:
outcomes: and effect modifiers
Poor
NA accounted for in analysis:
NA Sum of Good/Fair/Poor:
1 Good, 3 Fair, 5 Poor
Final Quality Score:
Poor

C-259
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cogswell et al., 1994 • Cohort • Self-reported White
• Retrospective G1: 75.1
Country and setting: Pregravid BMI: G2: 72.4
USA, Pregnancy Nutrition Total Study N: G3: 74.5
Surveillance System Imputed:
53,541
• No Black
Enrollment Period: Group Description: G1: 13.8
1990-1991 G1: Average weight Categorized:
• IOM guidelines G2: 14.1
G2: Overweight G3: 16.1
Funding:
G3: Very overweight Age (mean, yrs):
NR Hispanic
Group N: G1: 11-17 yr: 11.9%
Study Objective: 18-34yr: 85.0% G1: 11.1
G1: 33,809 G2: 13.5
To determine association 35-54 yr: 3.1%
G2: 7,661 G3: 9.4
between increased G2: 11-17 yr: 6.9%
G3: 12,071
gestational weight gain 18-34yr: 88.7% Asian/Pacific Islander
and birth weight outcomes Inclusion criteria: 35-54 yr: 4.4% NR
for low income women • White, black and G3: 11-17 yr: 4.0%
hispanic women who 18-34yr: 90.1% Other
Time frame: NR
1990-1991 delivered single, 35-54 yr: 6.0%
liveborn, term infants Smoking,%:
Duration of the study: Parity:
Exclusion criteria: NR G1: 29.9
Women in WIC but G2: 28.3
everything is self reported • Low or high values
for; birth weight, G3: 25.7
so it is when they were
first enrolled in WIC until prepregnancy BMI, or Diabetes mellitus,%:
delivery weight gain during NR
pregnancy
• Missing data on one Hypertension,%:
or more study NR
variables
Additional characteristics:
• Underweight women NR
• Only 1 infant was
used in analysis for
women who delivered
more than once
during study period

C-260
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 33,809 G1: < 2500g: 2.7% Odds ratio (95% CI) for LBW by MWG and Good
G2: 7,661 2500-4000g: 87.5% prepregnancy BMI
G3: 12,071 > 4000-4500: 8.5% Sample selection:
> 4500g: 1.4% Groups Fair
Total weight gain: G2: < 2500g: 2.5% G1: Normal BMI, MWG < 15lbs
G1: < 15 lb: 6.2% Definition of
2500-4000g: 83.9% G2: Normal BMI, MWG ≥40lbs maternal weight
15-19: 5.8% > 4000-4500: 11.7% G3: Normal BMI, MWG 25-29lbs (Reference
20-24: 11.2% gain:
> 4500g: 2.0% for Normal BMI) Fair
25-29: 14.4% G3: < 2500g: 2.1% G4: Overweight BMI, MWG 30-34lbs
30-34: 17.1% 2500-4000g: 81.1% G5: Overweight BMI, MWG 35-39 Definition of
35-39: 13.9% > 4000-4500: 13.2% G6: Overweight BMI, MWG ≥40lbs outcomes:
≥ 40: 31.4% > 4500g: 3.6% G7: Overweight BMI, MWG 15-19lbs Good
G2: < 15 lb: 11.4% (Reference for Overweight BMI)
15-19: 7.8% Gestational diabetes, %: Source of
20-24: 13.0% NR information on
Results exposure,
25-29: 12.7% G1: 2.1 (1.6-2.6)
30-34: 15.9% Cesarean delivery, %: outcomes, and
NR G2: 0.5 (0.4-0.6) confounders:
35-39: 11.2% G3: 1.0
≥ 40: 28.1% Instrumental delivery, Poor
G4: 0.5 (0.3-0.8)
G3: < 15 lb: 25.1% %: G5: 0.6 (0.3-1.1) Followup:
15-19: 10.1% NR G6: 0.4 (0.3-0.7) Fair
20-24: 1 G7: 1.0
Episiotomy, %: Analysis
Categorized: NR Maternal confounders and effect comparability:
• 4 lbs increments modifiers accounted for in analysis: Fair
starting at 15 lbs Other maternal • Age
outcomes: Analysis of
Collected from: NA • Race outcomes:
• Self-reported • height Good
Other infant outcomes: • Smoking
Ascertained by: NA Interpretation:
• Self-reported Infant and child confounders and effect Good
modifiers accounted for in analysis:
• Gestational age Sum of
• Sex of infant Good/Fair/Poor:
4 Good, 4 Fair, 1
Poor
Final Quality
Score:
Fair

C-261
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Desjardins and Hardwick, • Cohort • Self-reported White
1999 • Prospective G1: % underweight: 20.5 NR
G2: % underweight: 8.8
Country and setting: Total Study N: Black
Canada, Healthiest 1,892 (1883 completed Pregravid BMI: NR
Babies Possible Program program to delivery - used
Imputed: Hispanic
in regression analyses)
Enrollment Period: • No NR
January 1, 1987 - Group Description:
December 31, 1996 Categorized: Asian/Pacific Islander
G1: N - total sample
• Dichotomized as NR
G2: LBW - 6.8% of total
Funding: prepregnancy BMI < 20
sample Other
Health Information and (underweight) and ≥ 20,
Research Services, NR
Group N: done for women older
Toronto Public Health G1: 1892 than 19 years women Smoking,%:
G2: 128 younger than 19 years G1: 29.0
Study Objective:
were determined to be G2: 9.1
To evaluate HBP program Inclusion criteria:
as mediator of impact of • underweight or not by
Singleton births Diabetes mellitus,%:
smoking, adolescence, program nurse/dietitian
• Women who NR
prepregnancy remained in HBP Age (mean, yrs):
underweight, and erratic Hypertension,%:
program until delivery G1: % less than 19 years: 19.1
weight gain/initial weight NR
(31% did not G2: % less than 19 years: 8.3
loss on LBW complete program - Additional characteristics:
Parity:
Time frame: mainly because they % Inadequate weight gain
NR
January 1, 1987 - moved out of area) G1: 39.9
December 31, 1996 G2: 7.3
Exclusion criteria:
Duration of the study: • Women for whom Additional characteristics:
number of visits for NR
HBP program was
missing

C-262
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 793 % < 2500g: Odds ratio (95% CI) for LBW and inadequate Fair
G2: 528 G1: 8.8 weight gain
G3: 562 G2: 5.1 Sample
G3: 5.5 Groups selection:
Total weight gain: G1: LBW and inadequate weight gain Fair
Gestational (defined by dietician)
Categorized: diabetes, %: Definition of
• NR NR maternal
Results weight gain:
Collected from: Cesarean delivery, G1: 1.15 (0.78-1.67) Fair
• Home visitor’s %:
scale NR Definition of
Maternal confounders and effect outcomes:
Ascertained by: Instrumental modifiers accounted for in analysis: Good
• Dichotomized as delivery, %: Gestational age, adolescence, pregravid
inadequate NR underweight, number of Healthiest Baby Source of
(determined by Possible visits information on
nurse/dietitan as Episiotomy, %: exposure,
weight loss, lack NR Infant and child confounders and effect outcomes, and
of weight gain, or modifiers accounted for in analysis: confounders:
Other maternal NR Fair
very inadequate outcomes:
weight gain since NA Followup:
conception) or Good
not Other infant
outcomes: Analysis
NA 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-263
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hickey et al., 1990 • Cohort • Self-reported White
• Prospective G1: NR NR
Country and setting:
• < 90% standard: 27.3%
United States, prenatal Total Study N: Black
clinics • 90-119%: 44.2% NR
325
• ≥ 120%standard: 21.5%
Enrollment Period: Group Description: G2: NR Hispanic
Does not state G1: Black • < 90% standard: 15.7% NR
Funding: G2: Hispanic • 90-119%: 38.6% Asian/Pacific Islander
Supported by Garry A • ≥ 120%standard: 9.8% NR
Group N:
Weber Graduate G1: 172 Pregravid BMI:
Fellowship in Other
G2: 153
Anthropology, Southern Imputed: NR
Methodist University, and Inclusion criteria: • No Smoking,%:
through University • Black and Hispanic NR
pregnant women Categorized:
Affiliated Center,
aged ≥ 17 who • NR Diabetes mellitus,%:
Department of Pediatrics,
University of Texas subsequently Age (mean, yrs): NR
Southwestern Medical delivered singleton G1: 22.65 ± 4.48 Hypertension,%:
Center at Dallas, Maternal infants free from G2: 23. 18 ± 4.78 NR
and Child Health Training congenital
Grant MCJ-2000, malformations Parity: Additional characteristics:
Department of Health and G1: 0.98± 1.23 NR
Exclusion criteria: G2: 1.10± 1.50
Human Services • Women whose last
Study Objective: prenatal weight was
Present study was recorded > 14 days
designed to (1) determine before delivery,
prevalence of low gestational diabetes,
maternal weight-for-height other medical or
near term among low obstetrical conditions,
income black and missing records,
Hispanic women attending moved to another city
public prenatal clinics, and before delivery
(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

C-264
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Infant birthweight Good
Total weight gain:
Gestational Groups Sample
Categorized: diabetes, %: selection:
• % of standard G1: Percent BW < 3,000, Low weight gain
NR < 120% of standard Good
weight for height
by use of Cesarean delivery, G2: Percent BW ≥ 3,000, Low weight gain Definition of
nomogram and %: < 120% of standard maternal weight
chart developed NR G3: Percent BW < 3,000, Acceptable gain:
by Rosso weight gain ≥120% of standard Fair
Instrumental G4: Percent BW ≥ 3,000, Acceptable
Collected from: delivery, %: weight gain ≥120% of standard Definition of
• Routine pre-natal NR outcomes:
care or maternity Results Good
Episiotomy, %:
records G1: 38.2
NR Source of
G2: 61.8 information on
Ascertained by:
Other maternal G3: 22.1 exposure,
• Based on last outcomes: G4: 77.9 outcomes, and
clinically NR
measured weight Maternal confounders and effect confounders:
prior to delivery Other infant modifiers accounted for in analysis: Good
outcomes: NA Followup:
NR
Infant and child confounders and effect Good
modifiers accounted for in analysis: Analysis
NA comparability:
Fair
Analysis of
outcomes:
Good
Interpretation:
Good
Sum of
Good/Fair/Poor:
7 Good, 2 Fair, 0
Poor
Final Quality
Score:
Good

C-265
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Johnson et al., 1992 • Cohort • Self-reported White
• Retrospective G1: 64.5
Country and setting: Pregravid BMI: G2: 60.0
USA, prenatal clinics Total Study N: G3: 49.8
Imputed:
3,191 G4: 51.9
Enrollment Period: • No
January 1, 1987- Group Description: G5: 58.7
December 31, 1989 G1: BMI < 19.8 Categorized:
• National Academy of Black
G2: 19.8-26.0 G1: 33.6
Funding: Sciences
G3: 27-29 G2: 37.9
NR
G4: > 29 Age (mean, yrs): G3: 48.9
Study Objective: G5: All G1: NR G4: 47.5
To determine influences • < 20 years: 36.6% G5: 39.5
Group N:
of increased maternal • 20-26 years: 44.8%
G1: 755 Hispanic
prepregnancy weight and • > 26 years: 18.7%
G2: 1,621 NR
increased gestational G2: NR
G3: 329
weight gain on pregnancy • < 20 years: 30.8% Asian/Pacific Islander
G4: 486
outcome
G5: 3191 • 20-26 years: 46.5% NR
Time frame: • > 26 years: 22.6%
Inclusion criteria: Other
January 1, 1987 to G3:
• Delivery at or beyond • G1: 1.9
December 31, 1989 < 20 years: 25.8% G2: 2.1
38 weeks of gestation
• 20-26 years: 48.9% G3: 1.2
Duration of the study: • Singletons
• > 26 years: 25.2% G4: 0.6
Initiation of prenatal care • Received prenatal G4: G5: 1.7
to delivery care and delivered in
• < 20 years: 16.5%
Shands Hospital Smoking,%:
• 20-26 years: 53.9%
Exclusion criteria: • > 26 years: 29.6% NR
• Fetal abnormalities G5: Diabetes mellitus,%:
• Oligohydramnios • < 20 years: 29.5% G1: 1.9
• Polyhydramnios • 20-26 years: 47.5 % G2: 2.3
• Medical or surgical • > 26 years: 23.0% G3: 6.1
complications (GI G4: 5.3
Parity:
disorders, sickle cell G5: 3.1
G1: % first: 49.3
hemoglobinopathy,
G2: 43.1 Hypertension,%:
hepatitis, hematologic
G3: 37.4 G1: 3.4
disorders, malignant
G4: 31.1 G2: 4.6
disease, renal
G5: 42.1 G3: 5.8
disease, neurologic
disease, pulmonary G4: 10.7
disease, psychiatric G5: 5.4
disorders, Additional characteristics:
tuberculosis) G1: % married: 42.6
• Incomplete risk G2: 46.1
variable data or G3: 40.4
outcome variable G4: 49.4
information G5: 45.2
Additional characteristics:
NR

C-266
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 755 G1: Odds ratio (95% CI) for LBW Fair
G2: 1621 • < 2500g: 4.8%
G3: 329 Groups Sample selection:
• 2500-4000g:
G4: 486 G1: Net WG < 14.9 lbs (Reference) Fair
89.1%
G5: 3191 • > 4000g: 6.1% G2: Net WG 14.9-23.5 lbs Definition of
G2: G3: Net WG 24-33 lbs maternal weight
Total weight gain: G4: Net WG > 33 lbs
G1: • < 2500g: 2.0% gain:
• 2500-4000g: Fair
• < 16kg: 7.8% Results
• 16-25kg: 18.5% 85.2%
G1: 1.0 (Reference) Definition of
• 26-35kg: 35.1% • > 4000g: 12.8% outcomes:
G3: G2: 0.51 (0.27-0.98)
• > 35kg: 38.5% G3: 0.54 (0.28-1.04) Fair
G2: • < 2500g: 1.5%
G4: 0.38 (0.2-0.8) Source of
• < 16kg: 11.7% • 2500-4000g:
83.0% Maternal confounders and effect information on
• 16-25kg: 18.0% exposure,
• > 4000g: 15.5% modifiers accounted for in analysis:
• 26-35kg: 28.8% outcomes, and
G4: Maternal race, parity, pregravid BMI,
• > 35kg: 41.5% confounders:
• < 2500g: 0.2% height, pregravid weight, marital status,
G3: Fair
• 2500-4000g: education, tobacco/alcohol/drug use,
• < 16kg: 19.8%
82.5% pregnancy-induced hypertension Followup:
• 16-25kg: 19.1%
• > 4000g: 17.3% Fair
• 26-35kg: 28.3%
• > 35kg: 32.8% Gestational Infant and child confounders and Analysis
G4: diabetes, %: effect modifiers accounted for in comparability:
• < 16kg: 32.3% G1: 1.9 analysis: Fair
• 16-25kg: 22.0%; G2: 2.3 • Gestational age
G3: 6.1 • Infant sex Analysis of
Categorized: G4: 5.3 • Macrosomia outcomes:
• Quartiles G5: 3.1 Fair
• National
Cesarean Interpretation:
Academy of
Fair
Sciences (below, delivery,%:
within, or above G1: NR Sum of
recommended G2: NR Good/Fair/Poor:
range) G3: NR 0 Good, 9 Fair, 0
G4: NR Poor
Collected from: G5: 11.9
• Routine pre-natal Final Quality
care or maternity Instrumental Score:
records delivery,%: Fair
NR
Ascertained by:
• Based on last Episiotomy,%:
clinically NR
measured weight Other maternal
prior to delivery: outcomes:
difference • Frequency of
between self macrosomia =
report and weight 12.2%
at last prenatal • Frequency of
visit (mean 6.1 cesarean =
days prior to 11.9%
delivery) • Frequency of
LBW = 2.9%

C-267
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Johnson et al., 1992
(continued)

C-268
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain 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-269
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
Categorized: NR
Study Objective: (BMI 35–39.9) (n =
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight change G3: Obese Class III Age (mean, yrs): NR
on pregnancy outcomes in (BMI 40 and More) (n G1: <26: 46%
obese women = 19,025) 26-35: 47% Other
Older than 35: 8% G1: 22
Time frame: Group N:
1990 to 2001 NR G2: <26: 44% Smoking,%:
26-35: 48% NR
Duration of the study: Inclusion criteria: Older than 35: 8%
Entry into prenatal care • Obese women G3: <26: 40% Diabetes mellitus,%:
through delivery residing in Missouri 26-35: 52% NR
who delivered (at 37 Older than 35: 9%
Hypertension,%:
or more weeks of
Parity: NR
gestation) liveborn,
singleton infants Nulliparous:
G1: 34% Additional characteristics:
during 1990–2001 NR
G2: 33%
Exclusion criteria: G3: 32%
• NR

C-270
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Odds of low birth weight Good
LGA:13%
Total weight gain: (P < 0.05) Groups Sample selection:
G1: GWG (lb) G2: SGA: 7% G1: Odds of LBW for weight gain > 25 lbs Fair
Less than 2: 3% LGA:16% G2: OR of LBW for weight gain < 15 lbs
2 to 14: 15% Definition of
(P < 0.05) G3: Reference Weight gain 15-25 lbs maternal weight
15 to 25: 26% G3: SGA: 6%
More than 25: 56% gain:
LGA:18% Results Fair
G2: GWG (lb) (P < 0.05) G1: Lower for women in this group
Less than 2: 8% G2: Higher for women in this group Definition of
2 to 14: 22% Gestational diabetes, Numerical value for ORs not reported in study outcomes:
15 to 25: 27% %: Good
More than 25: 43% NR
G3: GWG (lb)Less than Maternal confounders and effect modifiers Source of
2: 15% Cesarean delivery,%: accounted for in analysis: information on
G1: 28 exposure,
• Age
G2: 34 outcomes, and
• Race
Categorized: G3: 41 confounders:
• Parity
• 10-lb or less loss Fair
2 to 9 lbs loss, no
Instrumental • Education
delivery,%: • Poverty (enrollment in Medicaid, WIC, food Followup:
weight change,
NR stamp programs) Fair
2 to 9 lbs gain,
10 to 14 lbs gain, Episiotomy,%: • Smoking
Analysis
15–25 lb gain, NR • Chronic hypertension
comparability:
26–35 lb gain, and Infant and child confounders and effect Fair
greater than 35 lb modifiers accounted for in analysis:
gain Analysis of
NR
outcomes:
Collected from: Fair
• Routine pre-natal
care or maternity Interpretation:
records Poor

Ascertained by: Sum of

NR Good/Fair/Poor:
2 Good, 6 Fair, 1
Poor
Final Quality
Score:
Fair

C-271
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-272
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from Bivariate
Gain 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-273
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kirchengast and • Cohort Estimated by means of White
Hartmann, 2003 • Retrospective retrospective method and first NR
weight determination, which
Country and setting: Total Study N: was carried out at first prenatal Black
Singleton births that took 8,011 visit (8th week of gestation) NR
place at University Clinic G1: 56.0
for Gynecology and Group Description: Hispanic
G1: 12 to 16 years G2: 57.2 NR
Obstetrics in Vienna, G3: 59.2
Austria G2: 17 to 19 years
Asian/Pacific Islander
G3: 20 to 29 years Pregravid BMI:
Enrollment period: NR
Group N: G1: 21.45
NR G2: 21.59 Other
G1: 215
Funding: G3: 22.10 NR
G2: 1,336
NR G3: 6,460 Imputed: Smoking,%:
Study Objective: • Yes NR
Inclusion criteria:
Examine impact of • Women ages 12 to Diabetes mellitus,%:
Categorized:
biological factors such as 29 NR
• Continuous
young maternal age and • All prenatal check-
maternal somatic Age (mean, yrs): Hypertension,%:
ups of mother-child
characteristics on G1: 14.5 NR
passport were
pregnancy outcome performed G2: 17.8 Additional characteristics:
among group of • Delivery of single G3: 24.1 Age at menarche:
adolescent mothers who infant without G1: 12.2
gave birth between 39th Parity:
congenital NR G2: 12.9
and 41st week of malformations G3: 13.3
gestation after period of • Receiving
intensive psychological Gynecological age:
psychosocial support
support G1: 3.4
by family and/or
G2: 5.3
Time frame: specially trained
G3: 10.8
NR social worker within
young adolescent
Duration of the study: group (12 to 16
1985 to 1995 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

C-274
Evidence Table 18. Gestational weight gain and low birthweight (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 215 G1: 3237.6 OR and 95% CI, for LBW Good
G2: 1,336 (significantly
G3: 6,460 different from 17- Groups Sample selection:
19 and 20-29) NA, weight gain as continuous Fair
Total weight gain: G2: 3298.3 variable
G1: 13.1 Definition of maternal weight
(significantly gain:
G2: 13.1 different from Results
G3: 13.1 (P = .10) Fair
< 17 and 20-29) 0.90 (0.85-0.95)
Categorized: G3: 3368.9 Definition of outcomes:
(significantly Maternal confounders and Good
• Continuous effect modifiers accounted
different from Source of information on
Collected from: < 17 and 17-19) for in analysis:
Maternal age, age at exposure, outcomes, and
• Routine pre-natal (F = 24.1,
menarche, pregravid weight, confounders:
care or maternity P < .0001)
height, distantia cristarum Fair
records
Gestational Followup:
Ascertained by: diabetes, %: Infant and child confounders
and effect modifiers Good
• Based on last NR
clinically accounted for in analysis: Analysis comparability:
measured weight Cesarean NR Good
prior to delivery delivery,%:
NR Analysis of outcomes:
Fair
Instrumental
delivery,%: Interpretation:
NR Fair
Episiotomy,%: Sum of Good/Fair/Poor:
NR 4 Good, 5 Fair, 0 Poor
Other maternal Final Quality Score:
outcomes Fair
• 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

C-275
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Lasker et al., 2005 • Cohort • NR White
• Retrospective G1: 74.1
Country and setting: Pregravid BMI: G2: NR
USA, hospital Total Study N:
Imputed: Black
5,528
Enrollment period: • No G1: 3.3
November 1997 to Group Description: G2: NR
October 1999 G1: Total cohort Categorized:
G2: NR • WHO International Hispanic
Funding: Taskforce G1: 11.0
NR Group N: • BMI at delivery G2: NR
G1: 5,528
Study Objective: Age (mean, yrs): Asian/Pacific Islander
G2: NR
To investigate predictors G1: NR
of LBW in population of Inclusion criteria: • < 15: 0.5%
Eastern Pennsylvania • Women delivering in • 15-19.9: 8.2% Other
1 of 2 hospitals in a • 20-24.9: 17.2% G1: 11.5
Time frame: G2: NR
November 1997 to single hospital • 25-29.9: 34.7%
October 1999 network • 30-34.9: 23.6% Smoking,%:
Exclusion criteria: • 35-39.9: 13.5% NR
Duration of the study:
• NA • 40-50: 2.3%
NA, retrospective Diabetes mellitus,%:
G2: NR
NR
Parity:
Hypertension,%:
NR
NR
Additional characteristics:
NR

C-276
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Odds ratio (95% CI) for LBW Good
Total weight gain:
Gestational Groups Sample selection:
Categorized: diabetes, %: Poor
• < 10, 11-20, 21- G1: MWG < 10 lbs
NR G2: MWG > 30 lbs
30, > 30 Definition of
Cesarean delivery, G3: MWG 21-30 lbs (Reference) maternal weight
Collected from: %: gain:
• Routine pre-natal NR Results Poor
care or maternity G1: 2.43 (1.45-4.05)
records Instrumental G2: 0.63 (0.47-0.85) Definition of
delivery, %: G3: 1.00 outcomes:
Ascertained by: NR Fair
• Based on last Maternal confounders and effect
clinically Episiotomy, %: modifiers accounted for in analysis: Source of
measured weight NR Maternal age, maternal race, marital status, information on
prior to delivery Other maternal prenatal care, prior term births, prior exposure,
abortions, prior preterm births, BMI at outcomes, and
outcomes: confounders:
NA delivery, preeclampsia, bleeding, smoking,
multiple births, premature birth, congenital Poor
Other infant anomaly, incompetent cervix, smoking Followup:
outcomes: Fair
• 490 (8.9%) Infant and child confounders and effect
delivered LBW modifiers accounted for in analysis: Analysis
babies (< 2500g) NR comparability:
• 103 (1.9%) Good
delivered VLBW
Analysis of
babies (< 1500g)
outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
2 Good, 4 Fair, 3
Poor
Final Quality
Score:
Poor

C-277
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Murakami et al., 2004 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Japan, hospital Total Study N: G1: 20.9 (2.8) Black
633 G2: NR NR
Enrollment Period:
2001 Group Description: Imputed: Hispanic
G1: Total cohort • No NR
Funding:
G2: NR
NR Categorized: Asian/Pacific Islander
Group N: • WHO International NR
Study Objective:
G1: 633 Taskforce
To estimate risk of Other
G2: NR
perinatal morbidity of Age (mean, yrs): NR
mother and infant with Inclusion criteria: G1: 29.1 (4.5) Smoking,%:
respect to maternal • Live, singletons G2: NR
prepregnancy BMI and G1: 8.5
delivered between 24 G2: NR
weight gain in Japanese to 42 weeks gestation Parity:
women G1: 0.6 (0.7) Diabetes mellitus,%:
Exclusion criteria: G2: NR G1: 2.1
Time frame:
2001 G2: NR

Duration of the study: Hypertension,%:

Prenatal through birth NR
Additional characteristics:
G1: Preeclampsia - mild:
5.4%; severe: 4.1%
G2: NR
Additional characteristics:
NR

C-278
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 633 G1: 3,052.6 (483.8) Odds ratio (95% CI) for LBW Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational G1: MWG < 8.5 kg Fair
G1: 10.5 (3.4) diabetes, %: G2: MWG 8.5-12.5 kg
G2: NR G1: 2.1 Definition of
G3: MWG > 12.5 kg maternal weight
G2: NR
Categorized: gain:
• < 8.5kg, 8.5- Cesarean Results Fair
12.5, > 12.5 delivery,%: G1: 1.26 (0.57-2.75)
G1: 10.3 G2: Reference Definition of
Collected from: G2: NR G3: 0.62 (0.24-1.62) outcomes:
• Routine pre- Fair
natal care or Instrumental Maternal confounders and effect modifiers
delivery,%: accounted for in analysis: Source of
maternity
NR • Age information on
records
• Parity exposure, outcomes,
Ascertained by: Episiotomy,%: and confounders:
• Pre-gravid BMI
• Based on last NR • Smoking
Fair
clinically Other maternal Followup:
measured Infant and child confounders and effect
outcomes: Fair
weight prior to NA modifiers accounted for in analysis:
delivery: last • Gestational age Analysis
measurement Other infant comparability:
was taken at outcomes: Fair
hospitalization NA
Analysis of
prior to
outcomes:
delivery
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
1 Good, 8 Fair, 0 Poor
Final Quality Score:
Fair

C-279
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rosenberg et al., 2005 • Cohort • Self-reported White
• Retrospective G1: < 100 pounds: 1.7% NR
Country and setting:
100-149: 49.1%
USA, vital statistics data Total Study N: Black
150-199: 37.5%
329988 NR
Enrollment Period: 200-299: 11.2%
Bbirth certificates with self Group Description: ≥ 300: 0.5% Hispanic
reported pregravid weight G1: Non-hispanic blacks G2: < 100 pounds: 1.8% NR
and weight gain G2: Non-hispanic whites 100-149: 69.5%
150-199: 24.0% Asian/Pacific Islander
G3: Non-hispanic asians
Funding: 200-299: 4.7% NR
G4: Hispanics
NR ≥ 300: 0.1%
G5: Total Other
Study Objective: G3: < 100 pounds: 8.1% NR
Group N: 100-149: 79.5%
To examine associations
G1: 86,908 150-199: 11.6% Smoking,%:
between obesity,
G2: 96,581 200-299: 0.8% NR
diabetes, and 3 adverse
G3: 38,570 ≥ 300
pregnancy outcomes Diabetes mellitus,%:
G4: 107,612
(primary cesarean Pregravid BMI: G1: 3.7
G5: 329,988
section, preterm birth, and G2: 2.6
LBW) by race/ethnic Inclusion criteria: Imputed: G3: 6.6
groups • Live singleton births • No G4: 3.5
Time frame: • Information on Categorized: G5: 3.7 P < 0.001
Birth certificates with self maternal • NR Hypertension,%:
reproted pregravid weight prepregnancy weight
G1: 1.7
and weight gain and maternal weight Age (mean, yrs):
G2: 0.6
gain during G1: 27.5
Duration of the study: G3: 0.5
pregnancy G2: 30.6
G4: 0.7
Birth certificates from G3: 29.7
1999, 2000, and 2001 Exclusion criteria: G5: 0.9 P < 0.001
G4: 26.4 P < 0.001
• NA G5: 28.3 Additional characteristics:
G1: PIH 1.9
Parity:
G2: 1.2
NR
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-280
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 86,908 NR Odds ration (95% CI) for LBW Fair
G2: 96,581
G3: 38,570 Gestational Groups Sample
G4: 107,612 diabetes, %: G1: MWG ≥ 41 lbs selection:
G5: 329,988 G1: 3.7 G2: MGW < 41 lbs Fair
G2: 2.6
Total weight gain: G3: 6.6 Definition of
Results maternal weight
G1: < 41pounds: 79.7% G4: 3.5 G1: 0.41 (0.39-0.43)
≥ 41 pounds: 20.3% G5: 3.7 P < 0.001 gain:
G2: Reference Poor
G2: < 41pounds: 83.2%
≥ 41 pounds: 16.8% Cesarean Definition of
delivery,%: Maternal confounders and effect modifiers
P < 0.001 outcomes:
G3: < 41pounds: 89.2% G1: 16.2 accounted for in analysis: Poor
≥ 41 pounds: 10.8% G2: 14.7 P < 0.001 Maternal age, parity, GDM, pregnancy-induced
G4: < 41pounds: 79.1% G3: 14.4 hypertension, preeclampsia, pregravid weight, Source of
G4: 13.8 chronic diabetes, chronic hypertension, marital information on
≥ 41 pounds: 20.9%
G5: < 41pounds: 81.6% G5: 14.7 status, maternal education, mother’s birthplace, exposure,
≥ 41 pounds: 18.4% Instrumental prenatal care payer, social risk, trimester outcomes, and
delivery,%: prenatal care began confounders:
Categorized: Fair
NR
• < 41, ≥ 41 pounds Infant and child confounders and effect
Episiotomy,%: modifiers accounted for in analysis: Followup:
Collected from: NR Fair
NR
• Routine pre-natal
care or maternity Other maternal Analysis
records outcomes: comparability:
NA Fair
Ascertained by:
Analysis of
• Based on last Other infant
outcomes:
clinically measured outcomes:
Fair
weight prior to • Preterm birth
delivery 10.5, 5.1, 5.9, Interpretation:
7.8, 7.5 Fair
P < 0.001
(groups defined Sum of
above) Good/Fair/Poor:
• LBW 9.7, 4.1, 0 Good, 7 Fair, 2
5.7, 6.1, 6.4 Poor
P < 0.001 Final Quality
(groups defined Score:
above) Fair

C-281
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Shepard et al., 1998 • Cohort • Self-reported White
• Prospective G1: 140.9 (28.6) G1: 88.4
Country and setting: G2: 91.2
G2: 136.3 (25.2) P = 0.007
Obstetrical practices in Total Study N:
New Haven, CT 2,301 Pregravid BMI: Black
G1: 24.3 (4.6) G1: 5.8
Enrollment Period: Group Description: G2: 4.9
G2: 22.9 (3.9) P < 0.0001
1988 to 1992 G1: Cesarean delivery
G2: Vaginal delivery Imputed: Hispanic
Funding: G1: 3.5
• No
Grants NIH Group N: G2: 2.3
G1: 312 Categorized:
Study Objective:
To examine absolute and
G2: 1,989 • NHANES II: ≤ 19.4; 19.5- Asian/Pacific Islander
22.4; 22.5-28.5; > 28.5 G1: 1.3
proportional gestational Inclusion criteria: G2: 1.1
weight gain and • Privately insured Age (mean, yrs):
prepregnancy BMI as women who received NR Other
predictors of primary prenatal care from 13 G1: 1.0
cesarean delivery largest obstetrical Parity: G2: 0.4
practices and health NR
Time frame: Smoking,%:
1988 to 1992 maintenance % never smokers:
organizations in G1: 82.3
Duration of the study: greater New Haven, G2: 85.9
First prenatal visit to CT region (part of a
delivery larger study of Diabetes mellitus,%:
selected NR
environmental risk
Hypertension,%:
factors on pregnancy)
NR
• Singleton deliveries
at Yale-New Haven Additional characteristics:
Hospital %married:
G1: 95.8
Exclusion criteria:
G2: 92.1
• Repeat cesareans
births Additional characteristics:
• Missing information NR
on key variables

C-282
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 312 NR Percent low birth weight Good
G2: 1989
Gestational Groups Sample
Total weight gain: diabetes, %: G1: Proportional WG < median, underweight selection:
G1: 35.4 (11.9) NR (BMI < 19.4) Fair
G2: 33.3 (11.9) P = G2: Proportional WG < median, obese
0.005 Cesarean delivery, Definition of
%: (BMI > 28.5) maternal weight
Categorized: NR G3: Proportional WG > median, underweight gain:
• Proportional (BMI < 19.4) Fair
Instrumental G4: Proportional WG > median, Low-average
weight gain
delivery, %: BMI (19.5-22.4) Definition of
based on
NR G5: Proportional WG > median, High-average outcomes:
prepregnancy
BMI (22.5-28.5) Good
weight and Episiotomy, %:
weight change NR G6: Proportional WG > median, obese (BMI > Source of
during pregnancy 28.5) information on
Other maternal exposure,
Collected from: outcomes: Results outcomes, and
• Routine pre-natal • Propotional G1: 3.5% confounders:
care or maternity weight gain, lb, G2: 7.4% Fair
records mean: cesarean G3: 2.1%
delivery - 26.5 G4: 2.8% Followup:
Ascertained by:
(10.0); vaginal G5: 2.1% Good
• Based on last
delivery - 25.2 G6: 4.6%
clinically Analysis
(9.3) P = 0.048
measured weight comparability:
prior to delivery Other infant Maternal confounders and effect modifiers Fair
outcomes: accounted for in analysis:
Analysis of
• Low birth weight NA
outcomes:
rate = 3.3% for
Infant and child confounders and effect Fair
entire study
modifiers accounted for in analysis:
population Interpretation:
NA
Fair
Sum of
Good/Fair/Poor:
3 Good, 6 Fair, 0
Poor
Final Quality
Score:
Fair

C-283
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Zhou and Olsen, 1997 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Denmark, two Total Study N: G1: % < 19.8: 27.2; %19.8-26: Black
communities 7122 63.7; %26+: 9.1 NR
G2: NR
Enrollment Period: Group Description: Hispanic
April 1984 to April 1987 G1: Entire study Imputed: NR
G2: NR • No
Funding: Asian/Pacific Islander
Danish National Research Group N: Categorized: NR
Foundation and G1: 7122 • IOM guidelines
Sygekassernes Helsefond G2: NR Other
Age (mean, yrs): NR
Study Objective: Inclusion criteria: % < 25: Smoking,%:
To study association • Women who provided G1: 30.3
between gestational %non-smoking:
detailed information G2: NR G1: 60.0
weight gain and different on lifestyle during
birth weight indicators Parity: G2: NR
pregnancy
considering prepregnancy • %nulliparous: Diabetes mellitus,%:
Singletons
BMI G1: 48.9 G1: 0
• Non-diabetic women
G2: NR G2: NR
Time frame: who gave birth
April 1984 to April 1987 between weeks 37
Hypertension,%:
and 42 for whom
Duration of the study: NR
weight gain was
Initiation of prenatal care reported Additional characteristics:
to delivery NR
Exclusion criteria:
• NA

C-284
Evidence Table 19. Gestational weight gain and low birth weight (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 7122 G1: %LBW: 1.7; Odds ratio (95% CI) for LBW for MWG Fair
G2: NR %normal: 96.8; categories by BMI
%HBW: 1.5 Sample
Total weight gain: G2: NR Groups selection:
G1: % < 11kg: 35.2; G1: MWG < 11 kg, Underweight (Reference) Fair
%12-15: 35.5; Gestational G2: MWG < 11 kg, Normal weight
%16+: 29.3 diabetes, %: Definition of
G3: MWG < 11 kg, Overweight maternal weight
G2: NR G1: 0 G4: MWG 12-15 kg, Underweight,
G2: NR gain:
Categorized: G5: MWG 12-15 kg, Normal weight Fair
• ≤ 11, 12-15, Cesarean G6: MWG 12-15 kg, Overweight
delivery,%: G7: MWG ≥16 kg, Underweight Definition of
≥ 16 kg
NR G8: MWG ≥16 kg, Normal weight outcomes:
Collected from: G9: MWG ≥16 kg, Overweight Good
• Routine pre-natal Instrumental
Source of
care or maternity delivery,%: Results
NR information on
records G1: 1.0 exposure,
Episiotomy,%: G2: 0.9 (0.5-1.5) outcomes, and
Ascertained by:
NR G3: 0.8 (0.3-2.0) confounders:
• Based on last
G4: 0.5 (0.2-1.0) Fair
clinically Other maternal G5: 0.8 (0.4-1.5)
measured weight outcomes: Followup:
G6: 0.9 (0.2-3.8)
prior to delivery: NA Good
G7: 0.3 (0.1-1.0)
difference
G8: 0.4 (0.2-0.8)
between last Other infant Analysis
G9: 0.0 (0.0-2500)
measured weight outcomes: comparability:
prior to delivery • Low birth weight Maternal confounders and effect modifiers Fair
and (< 2500g) accounted for in analysis:
Analysis of
prepregnancy • High birth weight • Age outcomes:
weight (> 4500g) • Parity Fair
• Growth retarded • Alcohol
were newborns • No diabetes Interpretation:
with a birth • Term delivery Fair
weight below • Smoking Sum of
3000g in spite of
Infant and child confounders and effect Good/Fair/Poor:
a placenta
weight higher modifiers accounted for in analysis: 2 Good, 7 Fair, 0
than 66 • Gestational age Poor
percentile (491g) • Infant sex Final Quality
Score:
Fair

C-285
Evidence Table 20. Gestational weight gain and macrosomia
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bergmann, 2003 • Cohort • Hospital records White
• Retrospective NR
Country and setting: Pregravid BMI:
Hospital deliveries in Total Study N: G1: % ≥ 20-26 Black
Berlin collected by Berlin 206,308 ≥ 26: 62.3, 17.8 NR
Medical Board G2: 62.1, 19.0
Group Description: Hispanic
G3: 62.4, 19.7
Enrollment period: G1: 1993 NR
G4: 62.2, 20.6
NR G2: 1994 G5: 63.1, 20.6 Asian/Pacific Islander
G3: 1995 G6: 61.4, 21.5 (61.2,21.1)
Funding: NR
G4: 1996
NR
G5: 1997 Imputed: Other
Study Objective: G6: 1998 (1999) • No NR
To investigate trend in
Group N: Categorized: Smoking,%:
prevalence of neonatal
macrosomia and to
G1: 25,449 • ≥ 20-26, ≥ 26 G1: 18.9
G2: 25,070 G2: 18.8
evaluate influences of Age (mean, yrs):
G3: 24,784 G3: 19.2
potential determinants, % ≥ 30:
G4: 27,100 G4: 17.2
key features of 206,308 G1: 34.9
G5: 27,753 G5: 17.9
hospital deliveries (97% of G2: 37.5
G6: 27,653 (27,513) G6: 18.0 (18.3)
all) in Berlin in years 1993 G3: 40.6
to 1999, collected by Inclusion criteria: G4: 43.4 Diabetes mellitus,%:
Berlin Medical Board • Recorded hospital G5: 45.7 NR
Time frame: birth by Berlin G6: 47.7 (48.5)
Hypertension,%:
NR Perinatal ReGistry
Parity: NR
Duration of the study: Exclusion criteria: Multiparity:
Additional characteristics:
1993 to 1999 • Multiple births G1: % 49.2
G2: 51.1 NR
• Preterm infants
G3: 50.4
G4: 49.9
G5: 49.1
G6: 50.3 (49.2)

C-286
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 25,449 % ≥ 4000g: Odds ratio (95% CI) of macrosomia Good
G2: 25,070 G1: 10.0
G3: 24,784 G2: 10.2 Groups Sample
G4: 27,100 G3: 10.6 G1: WG < 10 kg (Reference) selection:
G5: 27,753 G4: 10.9 G2: WG 10-16 kg Fair
G6: 27,653 G5: 11.0 G3: WG ≥ 16 kg Definition of
G6: 11.3 maternal
Total weight gain: Results
%10-16kg: Gestational weight gain:
G1: 1.0 Poor
G1: 62.3 diabetes, %: G2: 1.85 (1.77-1.93)
G2: 62.1 NR G3: 3.37 (3.22-3.53) Definition of
G3: 62.4 outcomes:
G4: 62.2 Cesarean Maternal confounders and effect modifiers
delivery,%: Good
G5: 63.1 accounted for in analysis:
G6: 61.4 NR Pregravid BMI, height, parity, smoking, diabetes, Source of
Instrumental postterm delivery information on
Categorized: exposure,
10-16kg and ≥ 16kg delivery,%: Infant and child confounders and effect
NR outcomes, and
modifiers accounted for in analysis: confounders:
Collected from: NR
Episiotomy,%: Poor
• Routine pre-natal
NR
care or maternity Followup:
records Other maternal Fair
outcomes
Ascertained by: Analysis
• % weight gain:
• Method not comparability:
≥ 26: 21.0, 21.0,
mentioned by Fair
21.4, 22.3, 22.2,
authors
24.2 Analysis of
1999: n = 27513 outcomes:
% birthweight ≥ Fair
4000g, 11.3%
% weight gain ≥ Interpretation:
10-16kg, 45.3 Good
% weight gain ≥ Sum of
16kg, 25.0% Good/Fair/Poor
Other infant :
outcomes 3 Good, 4 Fair, 2
NR Poor
Final Quality
Score:
Fair

C-287
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Brennand et al., 2005 • Cohort • Routine pre-natal care White
• Retrospective • Medical records NR
Country and setting:
Canada, medical records Total Study N: • Measured within 14 Black
weeks of gestation NR
603
Enrollment Period: G1: 59.7 (5.0)
Prenatal to birth Group Description: G2: 73.0 (4.3) Hispanic
G1: Normal: G3: 93.6 (12.3) NR
Funding: G4: 80.0 (16.9)
BMI 18.5 - 24.9
cree board of health and Asian/Pacific Islander
G2: Overweight:
social services of James Pregravid BMI: NR
BMI 25-29.9
Bay (Quebec) NR
G3: Obese: Other
Study Objective: BMI ≥ 30 Imputed: NR
To determine effect of G4: Total • Yes
Smoking,%:
pregravid weight and
Group N: Categorized: NR
pregnancy weight gain on
G1: 139 • WHO International
pregnancy outcomes in Diabetes mellitus,%:
G2: 168 Taskforce
Cree women G1: 4.3
G3: 296
Time frame: G4: 603 Age (mean, yrs): G2: 14.9
Prenatal to birth G1: 20.8 (5.2) G3: 27.4
Inclusion criteria: G2: 23.8 (5.4) G4: 18.6
Duration of the study: • Used only Cree G3: 25.5 (5.5)
7 year period: January Hypertension,%:
women G4: 24.0 (5.7)
G1: 1.4
1994 to December 2000 • First birth observed
Parity: G2: 1.8
per woman during
NR G3: 4.8
study time period
G4: 3.2
• Must have first weight
recorded within first Additional characteristics:
14 weeks gestation % low weight gain:
and final weight G1: 20.1
recorded within 4 G2: 10.1
weeks of birth G3: 28.0
G4: 21.2
Exclusion criteria:
• Women with % acceptable weight gain:
secondary pregnancy G1: 28.8
in dataset (n = 792) G2: 32.1
• Women with first G3: 33.4
weight record > 14 G4: 32.0
weeks gestation
% excessive weight gain:
(n = 314)
G1: 51.1
• Women with final G2: 57.7
weight record > 4 G3: 38.5
weeks from birth G4: 46.6
(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)

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Evidence Table 20. Gestational weight gain and macrosomia (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 139 NR Percentage of macrosomia among obese women Good
G2: 168 only
G3: 296 Gestational Sample
diabetes, %: Groups selection:
Total weight gain: G1: 4.3 G1: Low WG, < 7 kg Fair
G2: 14.9 G2: Acceptable WG, 7-11.5 kg
Categorized: G3: 27.4 Definition of
• 1999 Canadian G3: Excessive WG, > 11.5 kg maternal
G4: 18.6
guidelines weight gain:
Cesarean Results Fair
Collected from: delivery,%: >4500g
• Routine pre-natal G1: 10.8 G1: 16.9% Definition of
care or maternity G2: 11.3 G2: 15.3% outcomes:
records G3: 24.1 (p < 0.001) G3: 18.4% Poor
(P = 0.834) Source of
Ascertained by: Instrumental
• Based on last delivery,%: information on
>4000g exposure,
clinically
Episiotomy,%: G1: 47.0% outcomes, and
measured weight
NR G2: 42.9% confounders:
prior to delivery:
G3: 54.4% Fair
within 4 weeks of Other maternal (P = 0.234)
birth outcomes: Followup:
• Definition of low, Maternal confounders and effect modifiers Poor
adequate, and accounted for in analysis:
NA Analysis
excessive weight
comparability:
gains: Infant and child confounders and effect Fair
• For normal modifiers accounted for in analysis:
weight women - NA Analysis of
adequate weight outcomes:
gain is 11.5 to 16 Fair
kg
Interpretation:
• For overweight
women, Poor
adequate weight Sum of
gain is 7 to 11.5 Good/Fair/Poor
kg :
• For obese 1 Good, 5 Fair, 3
women, Poor
adequate weight
gain is 7 to 11.5 Final Quality
kg Score:
• Weight gain Poor
below specified
range is “low”
and weight gain
above specified
range is
“excessive”
Other infant
outcomes:
> 4000g, > 4500g

C-289
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: • Pregnancies with
Brennand et al., 2005 factors that may have
(continued) 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-290
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating

C-291
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Clausen et al., 2005 • Case-control • Routine pre-natal careNR White
• Combination: G1: 65.0 (11.2) NR
Country and setting:
prospective cohort G2: 64.7 (11.0)
Norway, university Black
and retrospective G3: 72.2 (13.9)***P, 0.001
hospital NR
nested case control
Pregravid BMI:
Enrollment Period: Hispanic
Total Study N: G1: 23.0 (3.7)
1995-1996 (21 months) NR
2,50 and 219 G2: 22.9 (3.7)
Funding: G3: 24.8 (4.3) *** P, 0.001 Asian/Pacific Islander
Group Description:
NR NR
G1: Cohort study Imputed:
Study Objective: G2: Birth weight < 4500 g • No Other
To investigate G3: Birth weight > 4500 g NR
Categorized:
prospectively if maternal
metabolic parameters
Group N: • WHO International Smoking,%:
G1: 2050 Taskforce G1: 22.2%
associated with maternal
G2: 1962 Lan < 20 G2: 22.5%
weight were independent
G3: 88 Nrmal weight 20-25 G3: 17.0%
determinants of large
baby size at term Ovrweight 25-30
Inclusion criteria: Diabetes mellitus,%:
Obse > 30
Time frame: • All pregnant women G1: 2.1%
of norwegian decent Age (mean, yrs): G2: 1.9
1995-1996 (21 months)
receiving care at Aker G1: 29.9 (4.4) G3: 5.7
Duration of the study: Hospital G2: 29.9 (4.5) *P, 0.05,
Dring pregnancy until G3: 30.6 (4.2)
delivery Exclusion criteria: Hypertension,%:
• Pre-gestational Parity: NR
diabetes G1: 50.3% nullipara
Additional characteristics:
• Mltiple pregnancy G2: 51% nullipara
G3: 34.1% nullipara NR
• Peterm births
• Mssing medical **P, 0.001
records
• Mssing information
on birth weight

C-292
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 2050 NR Odds ratios (95% CIs) for macrosomia Good
G2: 1962
G3: 88 Gestational diabetes, %: Groups Sample selection:
G1: 2.1% G1: WG, Quartile 1 (Reference) Good
Total weight gain: G2: 1.9 G2: WG, Quartile 2
G1: 15.4 (9.7) G3: 5.7 Definition of
G3: WG, Quartile 3 maternal weight
G2: 15.3 (9.8) *P, 0.05 G4: WG, Quartile 4
G3: 18.2 (5.7)**P, gain:
0.001, Cesarean delivery,%: Poor
NR Results
G1: 1.0 Definition of
Categorized:
Instrumental delivery, G2: 2.1 (0.8-5.1) outcomes:
• Continuous
%: G3: 3.5 (1.5-8.0) Good
Quartiles
NR G4: 4.3 (1.9-9.8) Source of
Collected from:
Episiotomy, %: information on
• Routine pre-natal
NR Maternal confounders and effect exposure,
care or maternity
modifiers accounted for in analysis: outcomes, and
records Other maternal
outcomes: Maternal age, parity, smoking, placental confounders:
Ascertained by:
NR weight, gestational diabetes, first trimester Poor
• Based on last BMI Followup:
clinically Other infant outcomes: Good
measured weight NR Infant and child confounders and
prior to delivery effect modifiers accounted for in Analysis
analysis: comparability:
NR Good
Analysis of
outcomes:
Fair
Interpretation:
Good
Sum of
Good/Fair/Poor:
6 Good, 1 Fair, 2
Poor
Final Quality
Score:
Fair

C-293
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cogswell et al., 1994 • Cohort • Self-reported White
• Retrospective G1: 75.1
Country and setting: Pregravid BMI: G2: 72.4
USA, Pregnancy Nutrition Total Study N: G3: 74.5
Surveillance System Imputed:
53,541
• No Black
Enrollment Period: Group Description: G1: 13.8
1990-1991 G1: Average weight Categorized:
• IOM guidelines G2: 14.1
G2: Overweight G3: 16.1
Funding:
G3: Very overweight Age (mean, yrs):
NR Hispanic
Group N: G1: 11-17 yr: 11.9%
Study Objective: 18-34yr: 85.0% G1: 11.1
G1: 33,809 G2: 13.5
To determine association 35-54 yr: 3.1%
G2: 7,661 G3: 9.4
between increased G2: 11-17 yr: 6.9%
G3: 12,071
gestational weight gain 18-34yr: 88.7% Asian/Pacific Islander
and birth weight outcomes Inclusion criteria: 35-54 yr: 4.4% NR
for low income women • White, black and G3: 11-17 yr: 4.0%
hispanic women who 18-34yr: 90.1% Other
Time frame: NR
1990-1991 delivered single, 35-54 yr: 6.0%
liveborn, term infants Smoking,%:
Duration of the study: Parity:
Exclusion criteria: NR G1: 29.9
Women in WIC but G2: 28.3
everything is self reported • Low or high values
for; birth weight, G3: 25.7
so it is when they were
first enrolled in WIC until prepregnancy BMI, or Diabetes mellitus,%:
delivery weight gain during NR
pregnancy
• Missing data on one Hypertension,%:
or more study NR
variables
Additional characteristics:
• Underweight women NR
• Only 1 infant was
used in analysis for
women who delivered
more than once
during study period

C-294
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 33,809 G1: < 2500g: 2.7% Odds ratios (95% CIs) for macrosomia by Good
G2: 7,661 2500-4000g: 87.5% MWG and prepregnancy BMI
G3: 12,071 > 4000-4500: 8.5% Sample selection:
> 4500g: 1.4% Groups Fair
Total weight gain: G2: < 2500g: 2.5% G1: Normal BMI, MWG 25-29 lbs
G1: < 15 lb: 6.2% Definition of
2500-4000g: 83.9% (Reference for normal BMI) maternal weight
15-19: 5.8% > 4000-4500: 11.7% G2: Normal BMI, MWG 35-39 lbs gain:
20-24: 11.2% > 4500g: 2.0% G3: Normal BMI, MWG ≥ 40 lbs
25-29: 14.4% Fair
G3: < 2500g: 2.1% G4: Overweight BMI, MWG 15-19 lbs
30-34: 17.1% 2500-4000g: 81.1% (Reference for overweight BMI) Definition of
35-39: 13.9% > 4000-4500: 13.2% G5: Overweight BMI, MWG ≥ 40 lbs outcomes:
≥ 40: 31.4% > 4500g: 3.6% G6: Obese, MWG 15-19 lbs (Reference Good
G2: < 15 lb: 11.4% for obese GMI)
15-19: 7.8% Gestational diabetes, %: G7: Obese BMI, MWG 30-34 lbs Source of
20-24: 13.0% NR information on
G8: Obese BMI, MWG 35-39 lbs exposure,
25-29: 12.7% G9: Obese BMI, MWG ≥ 40 lbs
30-34: 15.9% Cesarean delivery, %: outcomes, and
35-39: 11.2% NR confounders:
Results Poor
≥ 40: 28.1% Instrumental delivery, G1: 1.0
G3: < 15 lb: 25.1% %: G2: 1.5 (1.0-2.3) Followup:
15-19: 10.1% NR G3: 3.3 (2.3-4.7) Fair
20-24: 1 G4: 1.0
Episiotomy, %: Analysis
Categorized: NR G5: 4.0 (1.6-10.1)
comparability:
• 4 lbs increments G6: 1.0
Fair
starting at 15 lbs Other maternal G7: 1.9 (1.3-2.9)
outcomes: G8: 2.1 (1.3-3.2) Analysis of
Collected from: NA G9: 2.3 (1.6-3.3) outcomes:
• Self-reported Good
Other infant outcomes:
Ascertained by: NA Maternal confounders and effect Interpretation:
• Self-reported modifiers accounted for in analysis: Good
• Age
Sum of
• Race
Good/Fair/Poor:
• Height
4 Good, 4 Fair, 1
• Smoking Poor
Infant and child confounders and Final Quality
effect modifiers accounted for in Score:
analysis: Fair
• Gestational age
• Sex of infant

C-295
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hedderson et al., 2006 • Case-control • Self-reported in some White
• Retrospective cases used measured G1: 54.0
Country and setting: G2: 67.8
weight recorded in chart
USA, Kaiser Permanente Total Study N: G3: 47.6
closes to woman’s last
Medical Care Program 45,245 G4: 42.6
menstrual period but no
Enrollment Period: Group Description: more than 12 months
Black
January 1, 1996 - June G1: Controls before her last menstrual
G1: 10.0
31, 1998 G2: Macrosomia period
G2: 5.1
G3: Hypoglycemia Pregravid BMI: G3: 11.3
Funding:
G4: Hyperbilirubinemia G1: < 19.8: 13.5% G4: 4.4
R01 DK 54834 from
National Institute of Group N: 19.8-24.9: 56.4%
Hispanic
Diabetes and Digestive G1: 652 25.0-29.0: 12.4%
G1: 17.2
and Kidney Diseases, G2: 391 > 29.0: 17.6%
G2: 15.1
grant from American G3: 328 G2: < 19.8: 5.1%
G3: 20.4
Diabetes Association and G4: 432 19.8-24.9: 51.2%
G4: 15.5
Kaiser Community Benefit 25.0-29.0: 16.6%
research support Inclusion criteria: > 29.0: 27.1% Asian/Pacific Islander
• Singleton livebirth G3: < 19.8: 10.1% G1: 8.1
Study Objective: 19.8-24.9: 50.0% G2: 3.6
To examine whether Exclusion criteria:
25.0-29.0: 17.1% G3: 6.7
pregnancy weight gains • No pregestational
> 29.0: 22.9% G4: 20.1
outside IOM diabetes or history of
G4: < 19.8: 13.9%
recommendations and gestational diabetes Other
19.8-24.9: 57.9%
rates of maternal weight (screened at 24-28 G1: 10.7
25.0-29.0: 13.2%
gain are associated with weeks gestation - G2: 8.4
> 29.0: 57.1%
neonatal complications meeting National G3: 14.0
Diabetes Data Group Imputed: G4: 17.4
Time frame: criteria for GDM) • No
January 1, 1996 to June Smoking,%:
31, 1998 Categorized: G1: %nonsmoking during
• IOM guidelines pregnancy: 92.0; %smoked
Duration of the study: but quit: 4.2; %smoked 3.9
First prenatal care visit to Age (mean, yrs): G2: %nonsmoking during
30 days post delivery G1: < 25 years: 22.1% pregnancy: 90.8; %smoked
25-29: 24.2% but quit: 5.3; %smoked 4.0
30-34: 33.6% G3: %nonsmoking during
≥ 35: 20.1% pregnancy: 92.6; %smoked
G2: < 25 years: 15.9% but quit: 1.5; %smoked 5.8
25-29: 28.0% G4: %nonsmoking during
30-34: 31.7% pregnancy: 94.2; %smoked
≥ 35: 24.3% but quit: 4.9; %smoked 1.0
G3: < 25 years: 24.1%
25-29: 25.3% Diabetes mellitus,%:
30-34: 26.8% NR
≥ 35: 23.8%
G4: < 25 years: 17.1% Hypertension,%:
NR
25-29: 29.4%
30-34: 32.6% Additional characteristics:
≥ 35: 20.8% Screening glucose value less
Parity: than 140:
G1: 85.0%: > 140: 15.0%
% primiparous:
G1: 56.9 G2: 81.6%: > 140: 18.4%
G3: 81.4%: > 140: 18.6%
G2: 31.2
G4: 83.3%: > 140: 16.7%
G3: 50.0
G4: 59.3

C-296
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Odds ratio (95% CI) for macrosomia based on Good
Total weight gain: rate of weight gain
Gestational Sample selection:
Categorized: diabetes, %: Good
• According to IOM NR Groups
Rate of gain kg/wk: Definition of
Collected from: Cesarean delivery, G1: -0.26 to 0.21 maternal weight
• Routine pre-natal %: G2: 0.22 to 0.31 (Reference) gain:
care or maternity NR G3: 0.32 to 0.39 Fair
recordsrate of G4: 0.40 to 1.03
maternal weight Instrumental Definition of
gain was delivery, %: Results outcomes:
calculated as NR G1: 0.52 (0.34-0.79) Good
total pregnancy G2: 1.00
Episiotomy, %: Source of
weight gain G3: 0.99 (0.67-1.47)
NR information on
minus infant birth G4: 2.23 (1.54-3.22) exposure,
weight divided by Other maternal
Maternal confounders and effect modifiers outcomes, and
weeks of outcomes:
accounted for in analysis: confounders:
gestation when NA
Age, race/ethnicity, parity, pregravid BMI, Fair
last weight was
measured; rate Other infant screening glucose value Followup:
of maternal outcomes: Fair
NA Infant and child confounders and effect
weight gain modifiers accounted for in analysis:
before the third Analysis
Gestational age comparability:
trimester was
calculated using Good
the weight Analysis of
measured at or outcomes:
before the Fair
screening test for
GDM (24-28 wks Interpretation:
of gestation) Good
minus Sum of
prepregnancy Good/Fair/Poor:
weight divided by 5 Good, 4 Fair, 0
weeks of Poor
gestation
Final Quality
Ascertained by: Score:
• Based on last Good
clinically
measured weight
prior to delivery:
difference
between final
recorded weight
at last prenatal
visit (within 2
weeks of delivery
date) and
prepregnancy
weight

C-297
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jain et al, • Cohort • Self-reported NR
2007 • Retrospective
Pregravid BMI: Smoking,%:
Country and setting: Total Study N: • NR NR
United States, hospitals 7661
Imputed: Diabetes mellitus,%:
Enrollment period: Group Description: • No NR
2002-2005 NR
Categorized: Hypertension,%:
Funding: Group N: • IOM guidelines NR
Not reported NR
Age (mean, yrs):
Study Objective: Inclusion criteria: NR
To analyze risks of • Term (> 37 weeks)
cesarean section, and singleton for Parity:
macrosomia, and macrosomia and NR
breastfeeding at 10 weeks breastfeeding
postpartum using logistic
regression to estimate Exclusion criteria:
independent effects of • Cesarean analysis
prepregnancy BMI and limited to to women
gestational weight gain with cephalic
presentation-records
Time frame: with missing data
2002-2005 excluded
Duration of the study:
Entry into prenatal care to
10 weeks postpartum

C-298
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Odds ratios (95% CIs) for macrosomia Fair
Total weight gain: Gestational diabetes, %: Groups Sample selection:
• NR NR G1: WG ≤ 15 lbs Poor
Categorized: Cesarean delivery,%: G2: WG 15-24 lbs Definition of
• ≤ 15 lbs NR G3: WG 25-35 lbs maternal weight
• 15-25 lbs G4: WG ≥ 35 lbs gain:
Instrumental delivery,%: Poor
• 25-35 lbs NR Results
• 35+ lbs Definition of
Episiotomy,%: G1: 0.49 (0.30-0.82)
Collected from: G2: 1.0 outcomes:
NR Fair
• Not outlined G3: 1.17 (0.82-1.65)
Other maternal G4: 2.83 (2.04-3.92) Source of
Ascertained by: outcomes:
• Birth certificate Maternal confounders and effect information on
NR exposure,
modifiers accounted for in analysis:
Other infant outcomes: Maternal age, pregravid BMI, parity, outcomes, and
NR education, race/ethnicity, US/foreign confounders:
origin Fair

Infant and child confounders and Followup:

effect modifiers accounted for in Fair
analysis: Analysis
NR comparability:
Fair
Analysis of
outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
0 Good, 7 Fair, 2
Poor
Final Quality
Score:
Fair

C-299
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of pregravid G1: 84.4
Country and setting: G2: 85.8
BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg
Funding: G4: 32.7 (31.3-34.7)
Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain in
G2: 134 • Continuous
obese glucose tolerant Other
G3: 132
women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI ≥ G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance test Parity:
(OGTT) during third NR Diabetes mellitus,%:
trimester (according NR
to WHO criteria)
Hypertension,%:
• Only first pregnancy
NR
during study period
included Additional characteristics:
NR
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)

C-300
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200-3840) Odds ratios (95% CIs) for macrosomia Good
G2: 134 G2: 3645 (3200-4000)
G3: 132 G3: 3750 (3390-4125) Groups Sample selection:
G4: 122 G4: 3762 (3400-4120) G1: MWG < 5.0 kg (Reference) Poor
G2: MWG 5.0-9.9 kg Definition of
Total weight gain: Gestational diabetes, G3: MWG 10.0-14.9 kg
%: maternal weight
Categorized: G4: MWG ≥ 15.0 kg gain:
NR
• < 5.0. 5.0-9.9, Poor
10.0-14.9, ≥ 15.0 Cesarean delivery, %: Results
NR G1: 1.0 Definition of
Collected from: G2: 1.8 (0.8-3.8) outcomes:
• Routine pre-natal Instrumental delivery, G3: 2.2 (1.0-4.7) Fair
care or maternity %: G4: 4.0 (1.8-9.0)
NR Source of
records
Maternal confounders and effect information on
Ascertained by: Episiotomy, %: modifiers accounted for in analysis: exposure,
• Not stated by NR • Age outcomes, and
authors • Pregravid BMI confounders:
Other maternal Poor
outcomes: • 2h OGTT result
NA • Parity Followup:
• Smoking Fair
Other infant outcomes:
• Ethnicity
NA Analysis
• Clinical Center
comparability:
Infant and child confounders and effect Fair
modifiers accounted for in analysis:
Analysis of
Gestational age
outcomes:
Good
Interpretation:
Fair
Sum of
Good/Fair/Poor:
2 Good, 4 Fair, 3
Poor
Final Quality
Score:
Poor

C-301
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Johnson et al., 1992 • Cohort • Self-reported White
• Retrospective G1: 64.5
Country and setting: Pregravid BMI: G2: 60.0
USA, prenatal clinics Total Study N: G3: 49.8
Imputed:
3,191 G4: 51.9
Enrollment Period: • No
January 1, 1987- Group Description: G5: 58.7
December 31, 1989 G1: BMI < 19.8 Categorized:
• National Academy of Black
G2: 19.8-26.0 G1: 33.6
Funding: Sciences
G3: 27-29 G2: 37.9
NR
G4: > 29 Age (mean, yrs): G3: 48.9
Study Objective: G5: All G1: NR G4: 47.5
To determine influences • < 20 years: 36.6% G5: 39.5
Group N:
of increased maternal • 20-26 years: 44.8%
G1: 755 Hispanic
prepregnancy weight and • > 26 years: 18.7%
G2: 1,621 NR
increased gestational G2: NR
G3: 329
weight gain on pregnancy • < 20 years: 30.8% Asian/Pacific Islander
G4: 486
outcome
G5: 3191 • 20-26 years: 46.5% NR
Time frame: • > 26 years: 22.6%
Inclusion criteria: Other
January 1, 1987 to G3:
• Delivery at or beyond • G1: 1.9
December 31, 1989 < 20 years: 25.8% G2: 2.1
38 weeks of gestation
• 20-26 years: 48.9% G3: 1.2
Duration of the study: • Singletons
• > 26 years: 25.2% G4: 0.6
Initiation of prenatal care • Received prenatal G4: G5: 1.7
to delivery care and delivered in
• < 20 years: 16.5%
Shands Hospital Smoking,%:
• 20-26 years: 53.9%
Exclusion criteria: • > 26 years: 29.6% NR
• Fetal abnormalities G5: Diabetes mellitus,%:
• Oligohydramnios • < 20 years: 29.5% G1: 1.9
• Polyhydramnios • 20-26 years: 47.5 % G2: 2.3
• Medical or surgical • > 26 years: 23.0% G3: 6.1
complications (GI G4: 5.3
Parity:
disorders, sickle cell G5: 3.1
G1: % first: 49.3
hemoglobinopathy,
G2: 43.1 Hypertension,%:
hepatitis, hematologic
G3: 37.4 G1: 3.4
disorders, malignant
G4: 31.1 G2: 4.6
disease, renal
G5: 42.1 G3: 5.8
disease, neurologic
disease, pulmonary G4: 10.7
disease, psychiatric G5: 5.4
disorders, Additional characteristics:
tuberculosis) G1: % married: 42.6
• Incomplete risk G2: 46.1
variable data or G3: 40.4
outcome variable G4: 49.4
information G5: 45.2
Additional characteristics:
NR

C-302
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 755 G1: Odds ratio ( 95% CI) for macrosomia Fair
G2: 1621 • < 2500g: 4.8%
G3: 329 Groups Sample
• 2500-4000g:
G4: 486 G1: Net WG < 14.9 lbs (Reference) selection:
89.1%
G5: 3191 G2: Net WG 14.9-23.5 lbs Fair
• > 4000g: 6.1%
G2: G3: Net WG 24-33 lbs Definition of
Total weight gain: G4: Net WG > 33 lbs
G1: • < 2500g: 2.0% maternal weight
• 2500-4000g: gain:
• < 16kg: 7.8% Results
85.2% Fair
• 16-25kg: 18.5% G1: 1.0
• 26-35kg: 35.1% • > 4000g: 12.8% Definition of
G3: G2: 1.20 (0.83-1.75)
• > 35kg: 38.5% G3: 1.77 (1.24-2.52) outcomes:
G2: • < 2500g: 1.5% Fair
G5: 2.86 (2.02-4.02)
• < 16kg: 11.7% • 2500-4000g:
83.0% Source of
• 16-25kg: 18.0% information on
• > 4000g: 15.5% Maternal confounders and effect
• 26-35kg: 28.8% exposure,
G4: modifiers accounted for in analysis:
• > 35kg: 41.5% outcomes, and
• < 2500g: 0.2% • Race
G3: confounders:
• 2500-4000g: • Parity
• < 16kg: 19.8% Fair
82.5% • Pre-gravid BMI
• 16-25kg: 19.1%
• > 4000g: 17.3% • Pregnancy induced hypertension Followup:
• 26-35kg: 28.3%
• > 35kg: 32.8% Gestational • Height Fair
G4: diabetes, %: • Prepregnancy weight
Analysis
• < 16kg: 32.3% G1: 1.9 • Marital status
comparability:
• 16-25kg: 22.0%; G2: 2.3 • Education Fair
G3: 6.1 • Tobacco/alcohol/drug use
Categorized: G4: 5.3 Analysis of
• Quartiles Infant and child confounders and effect outcomes:
G5: 3.1 modifiers accounted for in analysis:
• National Fair
Academy of Cesarean • Gestational age
• Infant sex Interpretation:
Sciences (below, delivery,%:
• Fair
within, or above G1: NR Macrosomia
recommended G2: NR Sum of
range) G3: NR Good/Fair/Poor:
G4: NR 0 Good, 9 Fair, 0
Collected from: G5: 11.9 Poor
• Routine pre-natal
care or maternity Instrumental Final Quality
records delivery,%: Score:
NR Fair
Ascertained by:
• Based on last Episiotomy,%:
clinically NR
measured weight Other maternal
prior to delivery: outcomes:
difference • Frequency of
between self macrosomia =
report and weight 12.2%
at last prenatal • Frequency of
visit (mean 6.1 cesarean =
days prior to 11.9%
delivery) • Frequency of
LBW = 2.9%

C-303
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Johnson et al., 1992
(continued)

C-304
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain 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-305
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
Categorized: NR
Study Objective: (BMI 35–39.9) (n =
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight change G3: Obese Class III Age (mean, yrs): NR
on pregnancy outcomes in (BMI 40 and More) (n G1: <26: 46%
obese women = 19,025) 26-35: 47% Other
Older than 35: 8% G1: 22
Time frame: Group N:
1990 to 2001 NR G2: <26: 44% Smoking,%:
26-35: 48% NR
Duration of the study: Inclusion criteria: Older than 35: 8%
Entry into prenatal care • Obese women G3: <26: 40% Diabetes mellitus,%:
through delivery residing in Missouri 26-35: 52% NR
who delivered (at 37 Older than 35: 9%
Hypertension,%:
or more weeks of
Parity: NR
gestation) liveborn,
singleton infants Nulliparous:
G1: 34% Additional characteristics:
during 1990–2001 NR
G2: 33%
Exclusion criteria: G3: 32%
• NR

C-306
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Odds of macrosomia Good
LGA:13%
Total weight gain: (P < 0.05) Groups Sample selection:
G1: GWG (lb) G2: SGA: 7% G1: Odds of macrosomia for WG > 2 5lbs Fair
Less than 2: 3% LGA:16% G2: OR of macrosomia for WG < 15 lbs
2 to 14: 15% Definition of
(P < 0.05) G3: Reference WG 15-25 lbs maternal weight
15 to 25: 26% G3: SGA: 6%
More than 25: gain:
LGA:18% Results Fair
56% (P < 0.05) G1: higher for women in this group
G2: GWG (lb) G2: lower for women in this group Definition of
Less than 2: 8% Gestational diabetes, outcomes:
2 to 14: 22% %: Good
15 to 25: 27% NR Maternal confounders and effect modifiers
More than 25: accounted for in analysis: Source of
Cesarean delivery,%: information on
43% • Age
G3: GWG (lb)Less G1: 28 exposure,
• Race
than 2: 15% G2: 34 outcomes, and
G3: 41 • Parity
confounders:
• Education
Instrumental Fair
Categorized: • Poverty (enrollment in Medicaid, WIC,
delivery,%: food stamp programs) Followup:
• 10-lb or less loss
NR • Smoking Fair
2 to 9 lbs loss, no
weight change, Episiotomy,%: • Chronic hypertension
Analysis
2 to 9 lbs gain, NR Infant and child confounders and effect comparability:
10 to 14 lbs gain, modifiers accounted for in analysis: Fair
15–25 lb gain, NR
26–35 lb gain, Analysis of
and greater than outcomes:
35 lb gain Fair

Collected from: Interpretation:

• Routine pre-natal Poor
care or maternity Sum of
records Good/Fair/Poor:
Ascertained by: 2 Good, 6 Fair, 1
NR Poor
Final Quality
Score:
Fair

C-307
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-308
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from Bivariate
Gain 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-309
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kirchengast and • Cohort Estimated by means of White
Hartmann, 2003 • Retrospective retrospective method and first NR
weight determination, which
Country and setting: Total Study N: was carried out at first prenatal Black
Singleton births that took 8,011 visit (8th week of gestation) NR
place at University Clinic G1: 56.0
for Gynecology and Group Description: Hispanic
G1: 12 to 16 years G2: 57.2 NR
Obstetrics in Vienna, G3: 59.2
Austria G2: 17 to 19 years
Asian/Pacific Islander
G3: 20 to 29 years Pregravid BMI:
Enrollment period: NR
Group N: G1: 21.45
NR G2: 21.59 Other
G1: 215
Funding: G3: 22.10 NR
G2: 1,336
NR G3: 6,460 Imputed: Smoking,%:
Study Objective: • Yes NR
Inclusion criteria:
Examine impact of • Women ages 12 to Diabetes mellitus,%:
Categorized:
biological factors such as 29 NR
• Continuous
young maternal age and • All prenatal check-
maternal somatic Age (mean, yrs): Hypertension,%:
ups of mother-child
characteristics on G1: 14.5 NR
passport were
pregnancy outcome performed G2: 17.8 Additional characteristics:
among group of • Delivery of single G3: 24.1 Age at menarche:
adolescent mothers who infant without G1: 12.2
gave birth between 39th Parity:
congenital NR G2: 12.9
and 41st week of malformations G3: 13.3
gestation after period of • Receiving
intensive psychological Gynecological age:
psychosocial support
support G1: 3.4
by family and/or
G2: 5.3
Time frame: specially trained
G3: 10.8
NR social worker within
young adolescent
Duration of the study: group (12 to 16
1985 to 1995 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

C-310
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 215 G1: 3237.6 OR and 95% CI, for Good
G2: 1,336 (significantly Macrosomia
G3: 6,460 different from 17- Sample selection:
19 and 20-29) Groups Fair
Total weight gain: G2: 3298.3 NA, weight gain as continuous
G1: 13.1 Definition of maternal weight
(significantly variable gain:
G2: 13.1 different from
G3: 13.1 (P = .10) Fair
< 17 and 20-29) Results
Categorized: G3: 3368.9 G1: 1.07 (1.05-1.10) Definition of outcomes:
(significantly Good
• Continuous Maternal confounders and
different from Source of information on
Collected from: < 17 and 17-19) effect modifiers accounted
for in analysis: exposure, outcomes, and
• Routine pre-natal (F = 24.1,
Maternal age, age at confounders:
care or maternity P < .0001)
menarche, pregravid weight, Fair
records
Gestational height, distantia cristarum Followup:
Ascertained by: diabetes, %:
• Based on last NR Infant and child confounders Good
clinically and effect modifiers Analysis comparability:
measured weight Cesarean accounted for in analysis: Good
prior to delivery delivery,%: NR
NR Analysis of outcomes:
Fair
Instrumental
delivery,%: Interpretation:
NR Fair
Episiotomy,%: Sum of Good/Fair/Poor:
NR 4 Good, 5 Fair, 0 Poor
Other maternal Final Quality Score:
outcomes Fair
• 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

C-311
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Takimoto et al., 2006 • Cross-sectional • Taken from records not White
stated whether it was self- NR
Country and setting: Total Study N: reported or measured
Japan, obstetric units 112,257 Black
Pregravid BMI: NR
Enrollment Period: Group Description:
2001 to 2002 G1: Study cohort Imputed: Hispanic
G2: NR • No NR
Funding:
Ministry of Health, Labour, Group N: Categorized: Asian/Pacific Islander
and Welfare, Health, and G1: 46,659 • NR NR
Labour Research Grant, G2: NR
Research on Children and Age (mean, yrs): Other
Families Inclusion criteria: G1: 29.9 (4.8) NR
• Vaginal birth G2: NR
Study Objective: Smoking,%:
• Singleton pregnancy G1: 6.3
To identify adequate Parity:
• Low risk G2: NR
weight gain ranges during • % primiparous:
Term
pregnancy in Japanese G1: 53.5 Diabetes mellitus,%:
women Exclusion criteria: G2: NR G1: 1.2
• Cesarean deliveries G2: NR
Time frame: (n = 30,559)
2001 to 2002 • Delivery method Hypertension,%:
Duration of the study: unknown (n = 2258) G1: 2.0
• Multiple gestations (n G2: NR
Pregnancy through
delivery (all info derived = 8387) Additional characteristics:
from delivery records) • Preterm deliveries NR
< 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)

C-312
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 46,659 G1: 2982 (472) Odds ratio (95% CI) for macrosomia Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational diabetes,G1: Total MWG < 25th percentile for GA Fair
G1: 9.9 (4.3) %: G2: Total MWG 25-49th percentile for GA
G2: NR G1: 1.2 Definition of maternal
G3: Total MWG 50-74th percentile for GA weight gain:
G2: NR (Reference)
Categorized: Poor
• Gestational age Cesarean delivery,%: G4: Total MWG 75-89th percentile for GA
G5: Total MWG ≥90th percentile for GA Definition of outcomes:
specific percentile NR
Fair
values of weight
Instrumental Results
gain: under the Source of information
delivery,%: G1: 0.31 (0.20,-0.47)
25th, 25th-49th, on exposure, outcomes,
NR G2: 0.49 (0.34-0.70)
50th-74th, 75th- and confounders:
89th, ≥ 90th Episiotomy,%: G3: 1.0 Poor
NR G4: 1.62 (1.24-2.12)
Collected from: G5: 2.41 (1.83-3.17) Followup:
• Routine pre-natal Other maternal Fair
care or maternity outcomes:
records NA Maternal confounders and effect Analysis comparability:
modifiers accounted for in analysis: Fair
Ascertained by: Other infant • Age Analysis of outcomes:
• Based on last outcomes: • Parity Fair
clinically • Macrosomia • Pre-pregnancy weight
measured weight • IUGR Interpretation:
prior to delivery: Infant and child confounders and effect Fair
not stated modifiers accounted for in analysis:
• Gestational age Sum of Good/Fair/Poor:
• Infant sex 1 Good, 6 Fair, 2 Poor
Final Quality Score:
Fair

C-313
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Zhou and Olsen, 1997 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Denmark, two Total Study N: G1: % < 19.8: 27.2; %19.8-26: Black
communities 7122 63.7; %26+: 9.1 NR
G2: NR
Enrollment Period: Group Description: Hispanic
April 1984 to April 1987 G1: Entire study Imputed: NR
G2: NR • No
Funding: Asian/Pacific Islander
Danish National Research Group N: Categorized: NR
Foundation and G1: 7122 • IOM guidelines
Sygekassernes Helsefond G2: NR Other
Age (mean, yrs): NR
Study Objective: Inclusion criteria: % < 25: Smoking,%:
To study association • Women who provided G1: 30.3
between gestational %non-smoking:
detailed information G2: NR G1: 60.0
weight gain and different on lifestyle during
birth weight indicators Parity: G2: NR
pregnancy
considering prepregnancy • %nulliparous: Diabetes mellitus,%:
Singletons
BMI G1: 48.9 G1: 0
• Non-diabetic women
G2: NR G2: NR
Time frame: who gave birth
April 1984 to April 1987 between weeks 37
Hypertension,%:
and 42 for whom
Duration of the study: NR
weight gain was
Initiation of prenatal care reported Additional characteristics:
to delivery NR
Exclusion criteria:
• NA

C-314
Evidence Table 20. Gestational weight gain and macrosomia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 7122 G1: %LBW: 1.7; Odds ratios (95% CI) for macrosomia by MWG Fair
G2: NR %normal: 96.8; categories and BMI
%HBW: 1.5 Sample selection:
Total weight gain: G2: NR Groups Fair
G1: % < 11kg: G1: MWG < 11 kg, underweight (Reference)
35.2; Gestational Definition of
G2: MWG < 11 kg, normal weight maternal weight
%12-15: 35.5; diabetes, %: G3: MWG < 11 kg, overweight
%16+: 29.3 G1: 0 gain:
G4: MWG 12-15 kg, underweight, Fair
G2: NR G2: NR G5: MWG 12-15 kg, normal weight
Categorized: Cesarean G6: MWG 12-15 kg, overweight Definition of
G7: MWG ≥ 16 kg, underweight outcomes:
• ≤ 11, 12-15, delivery,%:
NR G8: MWG ≥ 16 kg, normal weight Good
≥ 16 kg
G9: MWG ≥ 16 kg, overweight Source of
Collected from: Instrumental
delivery,%: information on
• Routine pre- Results
NR exposure, outcomes,
natal care or G1: 1.0 and confounders:
maternity G2: 52.8 (0.3-22.9)
Episiotomy,%: Fair
records G3: 9.7 (1.2-81.8)
NR
G4: 0.0 (0.0-7x105) Followup:
Ascertained by:
Other maternal G5: 6.8 (0.9-51) Good
• Based on last outcomes: G6: 27.1 (3.3-220)
clinically NA Analysis
G7: 6.1 (0.7-52.5)
measured comparability:
G8: 15.7 (2.2-114)
weight prior to Other infant Fair
G9: 45.6 (6.0-349)
delivery: outcomes:
Analysis of
difference • Low birth
outcomes:
between last weight (< Maternal confounders and effect modifiers
Fair
measured 2500g) accounted for in analysis:
weight prior to • High birth • Age Interpretation:
delivery and weight (> • Parity Fair
prepregnancy 4500g) • Alcohol
weight Sum of
• Growth • No diabetes Good/Fair/Poor:
retarded were • Term delivery
newborns with 2 Good, 7 Fair, 0 Poor
• Smoking
a birth weight Final Quality Score:
below 3000g in Infant and child confounders and effect Fair
spite of a modifiers accounted for in analysis:
placenta • Gestational age
weight higher Infant sex
than 66
percentile
(491g)

C-315
Evidence Table 21. Gestational weight gain and large-for-gestational age
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-316
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Percentage of LGA for MWG Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: Weight loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: Definition of maternal weight
G3: 16-25 lbs gain:
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P < Poor
Only calculated for G5: > 35 lbs
0.01) Definition of outcomes:
morbidly obese:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 12.0 Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 11.8 exposure, outcomes, and
G2: 15.9% G3: 18.8 confounders:
Collected from: G4: 25.8 Poor
• Routine pre- Instrumental G5: 23.8
natal care or delivery,%: (P < 0.01) Followup:
maternity NR Fair
records Maternal confounders and
Episiotomy,%: effect modifiers accounted Analysis comparability:
Ascertained by: NR for in analysis: Poor
• Not stated - NA
Other maternal Analysis of outcomes:
from medical
outcomes Infant and child confounders Fair
records
• Preeclampsia and effect modifiers
• Placental Interpretation:
accounted for in analysis:
abruption Poor
NA
• Meconium Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-317
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bo et al., 2003 • Cohort • Self-reported White
• Prospective G1: 100
Country and setting: Pregravid BMI: G2: 100
Italy, university clinic Total Study N: G1: 21.2 G3: 100
700 G2: 29.9 G4: 100
Enrollment Period:
G3: 21.5
April 1999 to February Group Description: Black
G4: 29.9
2001 G1: Normal wieight, NR
normal OGTT Imputed:
Funding: Hispanic
G2: Overweight/Obese, • No
NR NR
normal OGTT
G3: Normal Weight, Categorized:
Study Objective: Asian/Pacific Islander
IGT/GDM NR
To evaluate pregnancy NR
outcomes in cohort of G4: Overweight/Obese, Age (mean, yrs):
caucasian pregnant IGT/GDM G1: 31.7 Other
women in relation to G2: 31.1 NR
Group N:
BMI and glucose G3: 32.9
G1: 333 Smoking,%:
toleranc status; role of G4: 32.6
G2: 117 G1: 11.4
central fat distribution,
G3: 133 Parity: G2: 15.4
as indicated by waist to
G4: 117 G1: Nulliparous (%): 63.7 G3: 15.0
hip circumference ratio
also considered G2: 53.0 G4: 18.8
Inclusion criteria:
G3: 62.4
Time frame: • Caucasian Diabetes mellitus,%:
G4: 51.3
April 1999 to February pregnant women NR
2001 attending
Hypertension,%:
Gynecological and
Duration of the study: G1: 1.2
Obstetrical
Screened during G2: 10.3
Department of
pregnancy at 24 to 28 G3: 4.5
University of Torino
weeks, recall data on G4: 11.1
screened with 50g
pregravid weight oral glucose test at Additional characteristics:
24 to 28 weeks Waist-to-hip ratio:
gestation G1: 0.86
Exclusion criteria: G2: 0.87
G3: 0.89
• Women known to
G4: 0.90
have preexistent
diabetes mellitus, a Additional characteristics:
disease affecting Preterm delivery (%):
glucose G1: 6.9
metabolism, or G2: 6.7
hypertension G3: 9.2
G4: 8.5
Additional characteristics:
LGA (%):
G1: 13.1
G2: 27.6
G3: 13.3
G4: 27.4

C-318
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 333 G1: 3271+/-446 Odds ratio (95% CI) for LGA Fair
G2: 117 (P < 0.05 vs. G2)
G3: 133 G2: 3413+/-589 Groups Sample selection:
G4: 117 (P < 0.01 vs. G3) G1: for each 1 kg increase in MWG Fair
G3: 3186+/-578 Definition of
Total weight gain: (P < 0.01 vs. G4) Results
G1: 13.2+/-4.1 maternal weight
G4: 3389+/-447 G1: 1.08 (1.03-1.12) gain:
(P < 0.01 vs. G2) (P < 0.05 vs. G1)
G2: 10.5+/-6.1 Maternal confounders and effect modifiers Poor
(overall P = 0.001)
G3: 11.8+/-5.7 accounted for in analysis: Definition of
(P < 0.05 vs. G2, Gestational Age, pregravid BMI, smoking, gestational outcomes:
P < 0.05 vs. G4) diabetes,%: hyperglycaemia Fair
G4: 9.5+/-6.8 NR
(P < 0.01 vs. G1) Infant and child confounders and effect Source of
(overall P < 0.0001) Cesarean modifiers accounted for in analysis: information on
delivery,%: NR exposure,
Categorized: G1: 30.5 outcomes, and
• Continuous G2: 38.1 confounders:
G3: 39.2 Fair
Collected from: G4: 44.3 (P < 0.01
• Gains during vs. G1) (overall P = Followup:
pregnancy not 0.044) Fair
collected
Instrumental Analysis
Ascertained by: delivery,%: comparability:
• Not explained by NR Good
researchers, may
Episiotomy,%: Analysis of
be difference
NR outcomes:
between
Fair
prepregnancy Other maternal
weight and outcomes: Interpretation:
weight measured Fair
• Height
at 24 to 28
• Parental Sum of
weeks gestation
diabetes Good/Fair/Poor:
• Waist 1 Good, 7 Fair, 1
• Systolic bp Poor
• Diastolic bp
Final Quality
• Hypertension
Score:
• Triglycerides
Fair
• HDL
Other infant
outcomes:
• Weeks of
delivery
• SGA
• Neonatal
pathologies

C-319
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Caulfield et al., 1998 • Cohort • Self-reported White
• Retrospective G1: 13.3 (5.7) NR
Country and setting:
G2: 14.6 (5.1)
USA, hospital obstetric Total Study N: Black
G3: 13.6 (6.7)
database 3,870 NR
G4: 15.3 (5.4)
Enrollment Period: Group Description: G5: 12.4 (7.7) Hispanic
1987 to 1989 G1: BMI < 19.8 Black G6: 14.5 (7.3) NR
G2: BMI < 19.8 White Pregravid BMI:
Funding: Asian/Pacific Islander
G3: BMI 19.8 to 26.0 Black G1: 18.4 (1.0)
NR NR
G4: BMI 19.8 to 26.0 White G2: 18.5 (1.0)
Study Objective: G5: BMI > 26.0 Black G3: 22.7 (1.8) Other
To examine relation G6: BMI > 26.0 White G4: 22.1 (1.8) NR
between gestational
Group N: Imputed: Smoking,%:
weight gain and risk of
G1: 523 • No G1: 32.8
delivering a small for
G2: 267 G2: 20.6
gestational age and large
G3: 1,479 Categorized: G3: 35.4
for gestational age infant
by race
G4: 796 • IOM guidelines G4: 20.0
G5: 615 G5: 28.8
Time frame: G6: 190 Age (mean, yrs): G6: 25.4
1987-1989 G1: 21.7 (4.8)
Inclusion criteria: G2: 27.1 (6.6) Diabetes mellitus,%:
Duration of the study: • Singleton pregnancies G3: 22.7 (5.3) NR
Entry into pn care until • White or black ethnicity G4: 29.8 (5.8)
delivery Hypertension,%:
• At least 28 weeks’ G5: 24.9 (6.0)
G1: 4.3
gestation G6: 28.2 (5.5)
G2: 3.0
• One delivery per Parity: G3: 6.0
woman (randomly G1: % primiparous: 52.4 G4: 5.7
chosen) G2: 55.4 G5: 11.9
• Information on G3: 50.1 G6: 17.0
anthropometric data G4: 48.0
Additional characteristics:
Exclusion criteria: G5: 36.9
G6: 46.9 NR
• Missing data
• Improbable data
• Non-black or non-white
ethnicity

C-320
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR ORs and 95% CIs for LGA per 50g/wk increase in Good
rate of weight gain by BMI
Total weight gain: Gestational Sample
G1: 13.3 (5.7) diabetes, %: G1: Underweight selection:
G2: 14.6 (5.1) NR G2: Normal weight Fair
G3: 13.6 (6.7) G3: Overweight
G4: 15.3 (5.4) Cesarean delivery, Definition of
G5: 12.4 (7.7) %: maternal weight
NR G1: 1.25 (1.11-1.41) gain:
G6: 14.5 (7.3) G2: 1.14 (1.08,-1.20) Fair
Categorized: Instrumental G3: 1.13 (1.07-1.20)
delivery, %: Definition of
• According to IOM
NR Maternal age, race, parity, pregravid BMI, height, outcomes:
Collected from: hypertension, provider type, smoking, infant sex Good
Episiotomy, %:
• Routine pre-natal
NR Maternal confounders and effect modifiers Source of
care or maternity
accounted for in analysis: information on
records Other maternal
• Age exposure,
outcomes: outcomes, and
Ascertained by: • Race
NR confounders:
• Based on last • Parity
clinically Other infant Fair
• Pre-gravid BMI
measured weight outcomes: • Height Followup:
prior to delivery: NR • Hypertension Good
difference
• Provider type
between Analysis
• Smoking comparability:
selfreport
prepregnancy Infant and child confounders and effect Good
weight and last modifiers accounted for in analysis: Analysis of
recorded weight Female infant outcomes:
Good
Interpretation:
Good
Sum of
Good/Fair/Poor:
6 Good, 3 Fair, 0
Poor
Final Quality
Score:
Good

C-321
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cedergren, 2006 • Cohort • Self-reported White
• Prospective • If unknown, standardized G1: 96.6
Country and setting: G2: NR
measurement is made
Sweden, Medical Birth Total Study N: during first visit to
Registry 245,526 Black
maternity health care
NR
Enrollment Period: Group Description: center
January 1, 1994 - BMI Hispanic
Pregravid BMI:
December 31, 2002 G1: < 20 NR
G2: 20 to 24.9 Imputed:
Funding: Asian/Pacific Islander
Ostergotland County
G3: 25 to 29.9 • No G1: 1.4
G4: 30 to 34.9
Council Categorized: G2: NR
G5: ≥ 35
Study Objective: • < 20, 20.0-24.9, 25.0- Other
Group N: 29.9, 30-34.9, ≥ 35
To estimate effects of high G1: 2.0
G1: 28,186
and low gestational weight Age (mean, yrs): G2: NR
G2: 143,365
gain in different maternal G1: 15 to 19 years: 3.8%
G3: 60,626 Smoking,%:
BMI classes on obstetric 20 to 24: 23.0%
G4: 17,248 G1: % nonsmoking: 81.6
and neonatal outcomes 25 to 29: 38.7%
G5: 6,296 G2: 85.2
Time frame: 30 to 34: 25.7% G3: 83.1
Inclusion criteria: 35 to 39: 7.7%
January 1, 1994 to G4: 79.9
December 31, 2002 • Singleton, term ≥ 40: 1.1% G5: 78.4
pregnancies G2: 15 to 19 years: 1.9% Group 6
Duration of the study: • Information on 20 to 24: 15.9%
First visit to maternity maternal height, 25 to 29: 37.7% Diabetes mellitus,%:
health care center to maternal weight in 30 to 34: 31.1% NR
delivery early pregnancy, and 35 to 39: 11.3%
Hypertension,%:
gestational weight ≥ 40: 1.9%
NR
gain G3: 15 to 19 years: 1.5%
20 to 24: 15.7% Additional characteristics:
Exclusion criteria: 25 to 29: 36.1% NR
• NA 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%

C-322
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28,186 NR Odds ratio (95% CIs) for LGA (> 2 SD above the Good
G2: 143,365 mean)
G3: 60,626 Gestational Sample
G4: 17,248 diabetes, %: Groups selection:
G5: 6,296 NR Weight gain < 8 kg Fair
Cesarean delivery, G1: BMI < 20 Definition of
Total weight gain: G2: BMI 20-24.9
G1: < 8kg: 6.9% %: maternal weight
NR G3: BMI 25-29.9 gain:
8-15.9kg: 65.2% G4: BMI 30-34.9
≥ 16kg: 28.0% Fair
Instrumental G5: BMI ≥ 35
G2: < 8kg: 8.4% delivery, %: Definition of
8-15.9kg: 67.1% NR Weight gain > 16 kg outcomes:
≥ 16kg: 30.4% G6: BMI < 20 Good
G3: < 8kg: 15.7% Episiotomy, %:
NR G7: BMI 20-24.9 Source of
8-15.9kg: 54.4% G8: BMI 25-29.9
≥ 16kg: 29.9% information on
Other maternal G9: BMI 30-34.9 exposure,
G4: < 8kg: 30.2% outcomes: G10: BMI ≥ 35
8-15.9kg: 48.7% outcomes, and
NA confounders:
≥ 16kg: 21.1% Weight gain 8-16 kg (Reference)
G5: < 8kg: 44.6% Other infant Good
8-15.9kg: 40.9% outcomes: Followup:
Results
≥ 16kg NA Fair
G1: 0.43 (0.24-0.75)
Categorized: G2: 0.53 (0.47-0.61)
Analysis
• < 8kg, 8-16, > 16 G3: 0.48 (0.43-0.53)
comparability:
G4: 0.66 (0.59-0.75)
Collected from: Fair
G5: 0.54 (0.46-0.63)
• Routine pre-natal Analysis of
care or maternity G6: 3.26 (2.76-3.86) outcomes:
records G7: 2.73 (2.60-2.88) Fair
G8: 2.14 (2.01-2.28)
Ascertained by: Interpretation:
G9: 2.24 (2.00-2.51)
• Based on last Good
G10: 1.54 (1.24-1.90)
clinically
measured weight Maternal confounders and effect modifiers Sum of
prior to delivery: accounted for in analysis: Good/Fair/Poor:
difference • Age 4 Good, 5 Fair, 0
between Poor
• Parity
maternal weights • Smoking Final Quality
measured when Score:
woman attended Infant and child confounders and effect modifiers
Fair
delivery unit and accounted for in analysis:
maternal weight Year of birth
recorded at first
visit to maternity
health care
center

C-323
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if self White
1992 • Combination: reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at delivery G4: 65.0 (12.2) Hispanic
July 1, 1985 - December G5: 58.3 (6.5) NR
Total Study N:
31, 1985 (6 months)
Total n = 357 Pregravid BMI: Asian/Pacific Islander
Funding: • 191 women with G1: 39.5 (3.4) NR
NR abnormal G2: 17.2 (0.9)
G3: 26.1 (6.1) Other
prepregnant weight
Study Objective: G4: 23.6 (4.1) NR
(≥ 20% under or over
To evaluate effects of G5: 21.6 (2.0)
ideal weight for Smoking,%:
abnormal maternal weight height) or abnormal
or weight gain on Imputed: NR
pregnancy weight
pregnancy outcome • No Diabetes mellitus,%:
gain (≥ 20kg or ≤ 5kg)
Time frame: • 166 controls Categorized: NR
July 1, 1985 to December • Continuous ≥ 20% over or Hypertension,%:
Group Description:
31, 1985 (6 months) under normal weight for NR
G1: ≥ 20% over normal
height
Duration of the study: weight for height Additional characteristics:
Prepregnancy to delivery G2: ≥ 20% under normal Age (mean, yrs): NR
weight for height G1: 28 (5.1)
G3: weight gain ≤ 5kg G2: 25.5 (5.1)
G4: weight gain ≥ 20kg G3: 29.5 (5.1)
G5: control Group 6 G4: 28.7 (4.7)
G5: 28.7 (4.4)
Group N:
G1: 77 Parity:
G2: 28 G1: prior deliveries: 1.0 (1.0)
G3: 30 G2: 0.8 (0.8)
G4: 56 G3: 1.2 (1.1)
G5: 166 G4: 0.8 (1.0)
G5: 0.9 (1.0)
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

C-324
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Percentage of Infant BW by maternal weight Fair
G2: 28 P < 0.05 compared to gain groups
G3: 30 controls Sample selection:
G4: 56 G2: 3293 (362) Groups Poor
G5: 166 P < 0.05 compared to Infant weight percentile for mothers with normal Definition of maternal
controls pregravid weight and normal weight gain weight gain:
Total weight gain: G3: 3284 (880) G1: < 2.5%
G1: 11.8 (6.2) Poor
G4: 3803 (538) G2: 2.5-10%
P < 0.05 compared to P < 0.005 compared G3: 10-50% Definition of
controls to controls G4: 50-90% outcomes:
G2: 13.4 (4.5) G5: 3538 (535) G5: 90-97.5% Poor
G3: 3.0 (3.5) G6: > 97.5%
P < 0.0005 compared Gestational Source of information
to controls diabetes,%: on exposure,
Infant weight percentile for mothers with weight outcomes, and
G4: 23.2 (22.8) NR gain ≤5 kg
P < 0.0005 compared confounders:
Cesarean G7: < 2.5% Fair
to controls G8: 2.5-10%
G5: 13.2 (3.4) delivery,%:
G1: Elective 7% G9: 10-50% Followup:
Categorized: Emergency 14% G10: 50-90% Fair
• ≤ 5kg or ≥ 20kg Total 21% G11: 90-97.5%
Analysis
G2: Elective 4% G12: > 97.5%
Collected from: comparability:
Emergency 4% Poor
• Routine pre-natal Total 8% Infant weight percentile for mothers with weight
care or maternity G3: Elective 3% gain ≥20 kg Analysis of outcomes:
records Emergency 3% G13: < 2.5% Fair
Total 6% G14: 2.5-10%
Ascertained by: Interpretation:
G4: Elective 5% G15: 10-50%
• Based on last Poor
Emergency 18% G16: 50-90%
clinically
Total 23% G17: 90-97.5% Sum of
measured weight
G18: > 97.5%
prior to delivery G5: Elective 13% Good/Fair/Poor:
Emergency 9% 0 Good, 4 Fair, 5 Poor
Total 22% Results
G1: 1% Final Quality Score:
Instrumental G2: 6% Poor
delivery,%: G3: 35%
NR G4: 43%
Episiotomy,%: G5: 13%
NR G6: 2%

Other maternal G7: 3%

outcomes: G8: 14%
NA G9: 32%
G10: 34%
Other infant
G11: 14%
outcomes:
G12: 3%
NA
G13: 0%
G14: 2%
G15: 42%
G16: 29%
G17: 20%
G18: 7%

C-325
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Ekblad and Grenman,
1992 (continued)

C-326
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain 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-327
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of pregravid G1: 84.4
Country and setting: G2: 85.8
BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg G4: 32.7 (31.3-34.7)
Funding: Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain in
G2: 134 • Continuous
obese glucose tolerant Other
G3: 132
women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI ≥ G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance test Parity:
(OGTT) during third NR Diabetes mellitus,%:
trimester (according NR
to WHO criteria)
Hypertension,%:
• Only first pregnancy
NR
during study period
included Additional characteristics:
NR
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)

C-328
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200-3840) Odds ratios (95% CIs) for LGA Good
G2: 134 G2: 3645 (3200-4000)
G3: 132 G3: 3750 (3390-4125) Groups Sample
G4: 122 G4: 3762 (3400-4120) G1: MWG < 5.0 kg (Reference) selection:
G2: MWG 5.0-9.9 kg Poor
Total weight gain: Gestational diabetes, G3: MWG 10.0-14.9 kg
%: Definition of
Categorized: G4: MWG ≥ 15.0 kg maternal weight
NR
• < 5.0. 5.0-9.9, gain:
10.0-14.9, ≥ 15.0 Cesarean delivery, Results Poor
%: G1: 1.0
Collected from: NR G2: 2.4 (1.1-5.3) Definition of
• Routine pre-natal G3: 2.1 (1.1-4.8) outcomes:
care or maternity Instrumental G4: 4.7 (2-11) Fair
records delivery, %:
NR Maternal confounders and effect modifiers accounted Source of
Ascertained by: for in analysis: information on
• Not stated by Episiotomy, %: • Age exposure,
authors NR • Pregravid BMI outcomes, and
confounders:
Other maternal • 2h OGTT result
Poor
outcomes: • Parity
NA • Smoking Followup:
• Ethnicity Fair
Other infant
• Clinical Center
outcomes: Analysis
NA Infant and child confounders and effect modifiers comparability:
accounted for in analysis: Fair
Gestational age
Analysis of
outcomes:
Good
Interpretation:
Fair
Sum of
Good/Fair/Poor:
2 Good, 4 Fair, 3
Poor
Final Quality
Score:
Poor

C-329
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
(BMI 35–39.9) (n = Categorized: NR
Study Objective:
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight G3: Obese Class III Age (mean, yrs): NR
change on pregnancy (BMI 40 and More) G1: < 26: 46%
outcomes in obese (n = 19,025) 26-35: 47% Other
women Older than 35: 8% G1: 22
Group N:
Time frame: NR G2: < 26: 44% Smoking,%:
1990 to 2001 26-35: 48% NR
Inclusion criteria: Older than 35: 8%
Duration of the study: • Obese women G3: < 26: 40% Diabetes mellitus,%:
Entry into prenatal care residing in Missouri 26-35: 52% NR
through delivery who delivered (at Older than 35: 9%
Hypertension,%:
37 or more weeks
Parity: NR
of gestation)
liveborn, singleton Nulliparous:
G1: 34% Additional characteristics:
infants during NR
1990–2001 G2: 33%
G3: 32%
Exclusion criteria:
• NR

C-330
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Odds of LGA by maternal weight gain groups Good
LGA:13%
Total weight (P < 0.05) Groups Sample
gain: G2: SGA: 7% G1: Odds of LGA for weight gain > 25lbs selection:
G1: GWG (lb) LGA:16% G2: OR of LGA for weight gain < 15lbs Fair
Less than 2: (P < 0.05) G3: Reference weight gain 15-25 lbs
3% Definition of
G3: SGA: 6% maternal
2 to 14: 15% LGA:18% Results
15 to 25: 26% weight gain:
(P < 0.05) G1: Odds of LGA are higher for women in this Fair
More than 25: group
56% Gestational diabetes, G2: Odds of LGA are lower for women in this Definition of
G2: GWG (lb) %: group outcomes:
Less than 2: NR Numerical value for ORs not reported in study Good
8%
2 to 14: 22% Cesarean delivery,%: Maternal confounders and effect modifiers Source of
15 to 25: 27% G1: 28 accounted for in analysis: information on
G2: 34 exposure,
More than 25: • Age
43% G3: 41 outcomes, and
• Race
G3: GWG (lb)Less confounders:
Instrumental • Parity
than 2: 15% Fair
delivery,%: • Education
NR • Poverty (enrollment in Medicaid, WIC, Followup:
Categorized: food stamp programs) Fair
Episiotomy,%:
• 10-lb or less NR • Smoking
Analysis
loss • Chronic hypertension
comparability:
2 to 9 lbs Infant and child confounders and effect Fair
loss, no modifiers accounted for in analysis:
weight Analysis of
NR
change, outcomes:
2 to 9 lbs Fair
gain, Interpretation:
10 to 14 lbs Poor
gain, 15–25 lb
gain, Sum of
26–35 lb gain, Good/Fair/Poo
and greater r:
than 35 lb 2 Good, 6 Fair,
gain 1 Poor
Collected from: Final Quality
• Routine pre- Score:
natal care or Fair
maternity
records
Ascertained by:
NR

C-331
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-332
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Outcomes from Bivariate
Weight Gain 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-333
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Baseline Characteristics
Study Description Exclusion Criteria Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kitajima et al., 2001 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
Japan, university Total Study N: G1: 21.2 +/-2.7 Black
hospital 146 G2: NR NR
Enrollment period: Group Description: Imputed: Hispanic
1992 to 1999 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
NR Group N: • Continuous NR
G1: 146
Study Objective: Age (mean, yrs): Other
G2: NR
To determine whether G1: 32+/1 4 NR
elevated midpregnancy Inclusion criteria: G2: NR
maternal serum lipid Smoking,%:
• Japanese pregnant NR
levels predict newborn women who had Parity:
weight at term and risk positive diabetic screen G1: Nulliparous 44% Diabetes mellitus,%:
of LGA infants in test results (at least 135 G2: NR NR
women with positive mg/dL of plasma
diabetic screen but Hypertension,%:
glucose level at 1 hour
normal glucose after 50-g oral glucose NR
tolerance test challenge) and a normal Additional characteristics:
Time frame: 75-g oral GTT at 24 to NR
1992 to 1999 32 weeks’ gestation at
Nagasaki University
Duration of the study: Hospital between
Entry of pn care to November 1992 and
delivery 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

C-334
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 3012g+/- 359 Odds ratio (95% CI) for LGA Good
Total weight G2: NR
gain: Groups Sample
G1: 9.6+/- 3.3 kg Gestational diabetes, %: G1: for each 1 kg increase in MWG selection:
G2: NR NR Good
Categorized: Cesarean delivery, %: Results Definition of
• Continuous NR G1: 1.08 (0.81-1.44) maternal weight
gain:
Collected from: Instrumental delivery, %: Poor
• Routine pre- NR Maternal confounders and effect
natal care or modifiers accounted for in analysis: Definition of
Episiotomy, %: • Pre-gravid BMI outcomes:
maternity
NR • Maternal plasma glucose levels Good
records
Other maternal outcomes: Infant and child confounders and effect Source of
Ascertained by:
NR modifiers accounted for in analysis: information on
• Based on last
clinically Other infant outcomes: • Gestational age exposure,
measured NR • Infant sex outcomes, and
weight prior to confounders:
delivery 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-335
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kramer et al., 1990 • Cohort • Self-reportedNR White
• Prospective G1: 57.8 kg (10.8) NR
Country and setting:
G2: NR
Canada, university Total Study N: Black
hospital 8,719 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1980 to 1986 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
National Health Research Group N: • They used prepregnancy NR
and Development G1: 8715 wt and ht separately
Program, Health and Other
G2: NR • NR
Welfare Canada NR
Inclusion criteria: Age (mean, yrs):
Study Objective: Smoking,%:
• Live-born, singleton G1: 28.6 (4.7) Cigarettes/d:
(1) Which maternal and infants without G2: NR
fetal variables appear to G1: 3.2 (7.5)
evidence of G2: NR
have independent causal congenital Parity:
impacts on intrauterine intrauterine infection, G1: 0.72 (0.86) Diabetes mellitus,%:
growth? (2) For a given chromosomal G2: NR NR
fetal growth status, which anomalies, or other
maternal and fetal Hypertension,%:
major malformations
variables affect and for whom Pg related HTN:
proportionality? G1: 7.7%
gestational age
G2: NR
Time frame: calculated from last
1980 to 1986 normal menstrual Additional characteristics:
period agreed within Education, y completed:
Duration of the study: ±7 days with an early G1: 13.0 (3.3)
Entry in to prenatal care second-trimester G2: NR
up to delivery (usually 16 to 18
weeks) Marital status:
• Ultrasonographic G1: 90.6%
estimate based on G2: NR
fetal biparietal Parity % primaparas:
diameter G1: 48.0
Exclusion criteria: G2: NR
• See above

C-336
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 8715 G1: 3385g (547) Odds ratio (95% CI) for LGA Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational diabetes, %: G1: for each 5 kg decrease in net Fair
G1: 14.2kg (5.5) NR gestational WG
G2: NR Definition of
Cesarean delivery, %: maternal weight
Categorized: NR Results gain:
• Continuous G1: 0.73 (0.68-0.79) Poor
Instrumental delivery, %:
Collected from: NR Definition of
• Routine pre-natal Maternal confounders and effect outcomes:
Episiotomy, %: modifiers accounted for in analysis: Good
care or maternity
NR Pregravid weight, smoking, parity, maternal
records
diabetes, height, previous LBW infant, Source of
Other maternal information on
Ascertained by: severe pregnancy-induced hypertension
outcomes: exposure,
• Based on last
• Bivariate asssociations outcomes, and
clinically
between selected Infant and child confounders and effect confounders:
measured weight
maternal and fetal modifiers accounted for in analysis: Poor
prior to delivery,
variables and fetal • Sex of the infant
using net weight Followup:
growth and
gain (total weight Fair
proportionality:
minus wt of
Correlation coefficient
infant) Analysis
for net gestational
comparability:
weight gain (kg)and
Fair
fetal growth ratio =
0.12 (P < 0.001); for Analysis of
prepregnancy weight outcomes:
(kg) 0.21 (P < 0.001) Fair
Other infant outcomes: Interpretation:
• Correlation coefficients Fair
for Net prepregnancy
weight gain (kg) and Sum of
length = -0.04 (P < Good/Fair/Poor:
0.01) 2 Good, 5 Fair, 2
• Head circumference = Poor
-0.01 (NS); BMI 0.04 Final Quality
(P < 0.001); Ponderal Score:
index = 0.04 (P < Fair
0.001)
• Weight/height
circumference = 0.01
(NS)

C-337
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Muscati et al., 1996 • Cohort Family physicians’ records White
• Retrospective G1: 62.8 +/- 16.0 kg NR
Country and setting: G2: NR
Canada, public health Total Study N: Black
department 371 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1979 to 1989 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
NR Group N: • Pregravid weight status NR
G1: 371 categorized into 3 groups
Study Objective: Other
G2: NR as a percentage of
To examine association of NR
standard weight:
extent and timing of Inclusion criteria: underweight < 90%, Smoking,%:
pregnancy weight gain • White, low income, normal 90-120%, and NR
with infant birth weight non-smoking women overweight > 120%
and postpartum weight • Pregnant women Diabetes mellitus,%:
retention Age (mean, yrs): NR
Exclusion criteria: G1: 24.5 +/- 5.6
Time frame: • Prematurity < 37 Hypertension,%:
G2: NR
1979 to 1989 weeks NR
• Adolescents < 16 Parity:
Duration of the study: Additional characteristics:
years G1: Primiparous 52%
Pregnancy through 6 G1: PPWR: 5.3 +/- 5.7 kg
• Women > 40 years G2: NR
weeks postpartum G2: NR
• Maternal health
problems Additional characteristics:
• Women who NR
consume alcohol or
drugs
• Pregnancy
complications such
as proteinuria,
hypertension,
diabetes, negative
weight gain, missing
values

C-338
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Odds ratio for LGA per weight gain increase Good
Total weight gain:
G1: 16.1 +/- 6.4 kg Gestational diabetes, Groups Sample
G2: NR %: G1: OR for LGA per 1 kg increase in WG up to week 20 selection:
NR G2: OR for LGA per 1 kg increase in WG from weeks Fair
Categorized:
• Continuous Cesarean delivery, %: 21 to 30 Definition of
NR G3: OR for LGA per 1 kg increase in WG from weeks maternal weight
Collected from: 31 to term gain:
• Collected by Instrumental delivery, Fair
study %: Results
investigators NR G1: 1.17 (P < 0.001) Definition of
G2: 1.16 (P < 0.01) outcomes:
Ascertained by: Episiotomy, %: Fair
NR G3: 1.02 (P = NS)
• Based on last
clinically Source of
Other maternal information on
measured outcomes: Maternal confounders and effect modifiers
weight prior to accounted for in analysis: exposure,
From Table 1: outcomes, and
delivery Pearson’s Correlation Parity, pregravid standard weight, pregravid excess
weight confounders:
Coefficient and Fair
determination Infant and child confounders and effect modifiers
coefficient of maternal accounted for in analysis: Followup:
weight gain with PP Birth length, infant sex Poor
weight retention and
Infant BW. Maternal PP Analysis
weight retention and comparability:
Preg weight gain: [Total Fair
amount r = 0.808, R Analysis of
square 65.3%, P < outcomes:
0.001], [Up to week 20 r Good
= 0.682, R square
46.5%, P < 0.001], Interpretation:
[Weeks 21-30 r = Poor
0.411, R square 16.9%, Sum of
P < 0.001], [Week 31 - Good/Fair/Poor:
term r = 0.414, R 2 Good, 5 Fair, 2
square 17.1%, P < Poor
0.001]
Final Quality
Other infant Score:
outcomes: Fair
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]

C-339
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Parker and Abrams, 1992 • Cohort • Self-reported White
• Retrospective G1: 56.8 kg(SD 11.0) G1: 44.0
Country and setting: G2: NR
G2: NR
USA, hospital Total Study N:
6,690 Pregravid BMI: Black
Enrollment Period: G1: 8.3
G1: Underweight: 27.7%,
Sept 1980 to Dec 1988 Group Description: G2: NR
Normal weight 61.8%,
G1: Overall Overweight: 5.6%,
Funding: Hispanic
G2: NR Obese 4.9%
UC Committee on G1: 9.4
Research & MCH and Group N: G2: NR
G2: NR
Resources Development, G1: 6,690
Imputed:
Health Resources and G2: NR Asian/Pacific Islander
• No
Services Administration G1: 21.4
Inclusion criteria: Categorized: G2: NR
Study Objective: • Consecutive live
To test whether gains • IOM guidelines Other
singleton births at
outside IOM reference Moffitt Hospital Age (mean, yrs): G1: 12.0
ranges were associated between September G1: 27.7 (5.5) G2: NR
with increased risks of 1980 and December G2: NR
suboptimal pregnancy Smoking,%:
1988 with gestational G1: 12.0
outcome (SGA, LGA, ages of 37 to 42 Parity:
cesarean delivery) and to Primiparous: G2: NR
weeks
determine whether locally G1: 58.8% Diabetes mellitus,%:
developed ranges were Exclusion criteria: G2: NR NR
more applicable to study • Maternal transfers or
population transports and Hypertension,%:
deliveries NR
Time frame: complicated by fetal
Sept 1980 to Dec 1988 Additional characteristics:
malformations,
NR
Duration of the study: maternal diabetes, or
From entry into prenatal maternal
care until delivery hypertension

C-340
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 6690 G1: 3408g (462) Odds ratios (95% CIs) of LGA by weight gain Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational G1: Compared to UCSF Cohort 25-75th percentile Fair
G1: 15.2kg (5.2) diabetes, %: of WG
G2: NR NR th
Definition of
G2: Compared to UCSF 10-90 percentile of WG maternal weight
Categorized: Cesarean delivery, gain:
• According to IOM %: Results Fair
Weight gain NR G1: 1.89 (1.51-2.37)
G2: 1.87 (1.39-2.52) Definition of
ranges based on
Instrumental outcomes:
percentiles from
delivery, %: Good
previous study of Maternal confounders and effect modifiers
NR
UC population accounted for in analysis: Source of
with good Episiotomy, %: • Age information on
pregnancy NR exposure,
• Race
outcomes: 25th - outcomes, and
Other maternal • Parity
75th, 10-90th confounders:
percentiles. For outcomes: • Pre-gravid BMI
Fair
25-75th, weight NR • Height
gain range = 12- • Smoking Followup:
Other infant Fair
17kg for outcomes: Infant and child confounders and effect
underweight NR modifiers accounted for in analysis: Analysis
women (BMI < • Gestational age comparability:
19.8); Fair
Collected from: Analysis of
• Routine pre-natal outcomes:
care or maternity Good
records
Interpretation:
Ascertained by: Poor
• Based on last
clinically Sum of
measured weight Good/Fair/Poor:
prior to delivery 3 Good, 5 Fair, 1
Poor
Final Quality Score:
Fair

C-341
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Pezzarossa et al., 1996 • Cohort • Self-reported White
• Prospective G1: 100
Country and setting: Pregravid BMI: G2: 100
Italy, not stated Total Study N: G1: 25.7 (0.5)
192 G2: 25.4 (0.8) Black
Enrollment Period: NR
Not stated Group Description: Imputed:
G1: Normal • No Hispanic
Funding: NR
G2: GDM
NR Categorized:
Group N: • Continuous Asian/Pacific Islander
Study Objective: NR
G1: 132
To evaluate effects of Age (mean, yrs):
G2: 60
gestational weight gain on G1: 29.1 (0.4) Other
neonatal birthweight in Inclusion criteria: G2: 28.07 (0.6) NR
women who were • Caucasian women
diagnosed with Parity: Smoking,%:
who had 1 or more NR
gestational diabetes after risk factors for GDM: NR
3second week gestation BMI > 28.6, Diabetes mellitus,%:
Time frame: gestational weight NR
Not stated gain > 12kg, previous
Hypertension,%:
GDM, or previous
Duration of the study: NR
neonatal macrosomia
Initiation of prenatal care and underwent a Additional characteristics:
to delivery diagnostic oral NR
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

C-342
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 132 G1: 3576.8 (41.3) Relative risks for LGA Fair
G2: 60 G2: 3678.7 (69.3)
Groups Sample selection:
Total weight gain: Gestational diabetes, %: G1: MWG < 9 kg Fair
G1: 13.4 (0.5) NR G2: MWG 9-14 kg
G2: 12.2 (0.6) Definition of
Cesarean delivery, %: maternal weight
Categorized: NR Results gain:
• Continuous G1: similar between non-diabetic and GDM Fair
Instrumental delivery, %: groups
Collected from: NR G2: GDM group has 2 times higher risk that Definition of
• Routine pre-natal non-diabetics outcomes:
Episiotomy, %: Good
care or maternity Numerical results not reported
NR
records
Maternal confounders and effect Source of
Other maternal information on
Ascertained by: modifiers accounted for in analysis:
outcomes: exposure,
• Based on last NR • Pre-gravid BMI
clinically • Fasting plasma glucose outcomes, and
measured weight Other infant outcomes: confounders:
prior to delivery: macrosomia Infant and child confounders and effect Fair
used weight at modifiers accounted for in analysis:
NR Followup:
last prenatal visit 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-343
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Sunehag et al., 1991 • Cohort • Not stated - records? White
• Retrospective NR
Country and setting: Pregravid BMI:
Sweden, prenatal clinics Total Study N: G1: 25.6 (4.7) Black
133 women confirmed to G2: NR NR
Enrollment Period:
have GDM
October 1994 to Imputed: Hispanic
December 1987 Group Description: • No NR
G1: Total cohort
Funding: Categorized: Asian/Pacific Islander
G2: NR
Grants from Gillberg • Continuous > 23.9 NR
Foundation, Swedish Group N:
Diabetes Association, and G1: 133 Age (mean, yrs): Other
Family Ernfors Foundation G2: NR G1: 32 (range 19-43) NR
G2: NR Smoking,%:
Study Objective: Inclusion criteria:
To assess perinatal Parity: NR
• Women at risk for
morbidity in clinic with GDM % primiparous: Diabetes mellitus,%:
policy of liberal insulin G1: 30.8% NR
treatment in pregnancies Exclusion criteria: G2: NR
complicated by diabetes • Twin pregnancies Hypertension,%:
and to find predictive • Incomplete case G1: 30.8
factors for adverse records G2: NR
perinatal outcome Additional characteristics:
Time frame: NR
October 1994 to
December 1987
Duration of the study:
Initiation of prenatal care
to delivery

C-344
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 133 G1: 3.7 (0.6) Association between LGA and MWG Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational G1: LGA vs MWG > 18 kg Fair
G1: 12.5 (6.3) kg diabetes,%:
G2: NR NR Definition of
Results maternal weight
Categorized: Cesarean G1: χ2 = 8.2 (P < 0.005) gain:
• Continuous delivery,%:
Maternal confounders and effect modifiers
Poor
G1: 27
Collected from: accounted for in analysis: Definition of
G2: NR
• Not stated - NA outcomes:
records? Instrumental Fair
Infant and child confounders and effect
delivery,%:
Ascertained by: modifiers accounted for in analysis: Source of
NR
• Not stated NA information on
Episiotomy,%: exposure,
NR outcomes, and
confounders:
Other maternal Poor
outcomes:
NA Followup:
Fair
Other infant
outcomes: Analysis
NA comparability:
Fair
Analysis of
outcomes:
Fair
Interpretation:
Poor
Sum of
Good/Fair/Poor:
1 Good, 5 Fair, 3
Poor
Final Quality Score:
Poor

C-345
Evidence Table 21. Maternal weight and large for gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Wataba et al., 2006 • Perinatal data base • In data base, but don’t White
and look at medical know if self reported NR
Country and setting:
records
Japan, academic medical Pregravid BMI: Black
retrospectively
center G1: 20.5 (2.6) NR
• Retrospective
G2: 21.1 (3.0)
Enrollment Period: Hispanic
Total Study N:
1981 to 1999 Imputed: NR
21,718
• No
Funding: Asian/Pacific Islander
Group Description:
NR Categorized: NR
G1: Nulliparous
Study Objective: G2: Parous women • Categorical in 2 kg/m2 Other
To analyze association of point intervals from NR
Group N: prepregnancy weight;
pregnancy complications
G1: 10413 categorical into low, Smoking,%:
with prepregnant body
G2: 11305 medium, high BMI groups NR
mass index and weight
gain during pregnancy in Inclusion criteria: (< 18, 18-23.9, > 24)
Diabetes mellitus,%:
Japanese women • Singleton pregnancy Age (mean, yrs): NR
Time frame: delivering term baby G1: 27.8 (4.1)
Hypertension,%:
1981 to 1999 at Osaka Med Center G2: 30.45 (3.9)
NR
and Research
Duration of the study: Institute for Maternal Parity:
Additional characteristics:
Entry into PNC up til and Child Health in NR
NR
delivery 19811999
Exclusion criteria:
• None reported

C-346
Evidence Table 21. Maternal weight and large for gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 10413 G1: SGA: 5.4% Odds ratio for LGA (95% CIs) Good
G2: 11305 LGA 5.2%
G2: SGA 6.5% LGA Groups Sample selection:
Total weight gain: 5.2% Nulliparous Fair
G1: kg/wk: 0.25 G1: Low BMI (< 18), WG > 0.40 kg/wk
(SD 0.09) Gestational Definition of maternal
G2: Medium BMI (18-23.9), WG 0.20-0.25 weight gain:
G2: kg/wk: 0.24 diabetes, %: kg/wk
(0.09) P < 0.01 NR Poor
G3: WG 0.25-0.30 kg/wk (Reference)
Categorized: Cesarean delivery, G4: Medium BMI, WG 0.30-0.35 kg/wk Definition of
G5: Medium BMI, WG 0.35-0.40 kg/wk outcomes:
• Categorical in %:
NR G6: Medium BMI, WG > 0.40 kg/wk Poor
kg/wk using
prepregnancy Source of
Instrumental Parous
weight and information on
delivery, %: G7: Low BMI (< 18), WG > 0.40 kg/wk
weight at exposure, outcomes,
NR G8: WG 0.20-0.25 kg/wk (Reference for
delivery divided and confounders:
by gestational Episiotomy, %: low/med BMI) Poor
age of infant at NR G9: Medium BMI (18-23.9), WG 0.25-0.30
birth kg/wk Followup:
Other maternal G10: Medium BMI, WG 0.30-0.35 kg/wk Fair
Collected from: outcomes: G11: Medium BMI, WG 0.35-0.40 kg/wk
• Rate of weight Analysis
• NR G12: Medium BMI, WG > 0.40 kg/wk
gain comparability:
G13: High BMI (≥24), WG 0.15-0.20 kg/wk
determined by: Other infant Poor
G14: WG ≥ 0.30 kg/wk (Reference for high
total weight outcomes:
BMI) Analysis of
gain divided by NR
outcomes:
weeks ga Results Fair
G1: 2.25 (1.03-4.94)
Ascertained by: Interpretation:
G2: 1.41 (1.31-1.76)
• Based on last Fair
G3: 1.0
clinically
G4: 1.76 (1.38-2.23) Sum of
measured
G5: 2.34 (1.77-3.10) Good/Fair/Poor:
weight prior to
G6: 2.58 (1.71-3.89) 1 Good, 4 Fair, 4 Poor
delivery: and
G7: 2.16 (0.63-/7.44)
subtracting Final Quality Score:
G8: 1.0
prepregnancy Poor
G9: 1.48 (1.15-2.33)
weight
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

C-347
Evidence Table 22. Gestational weight gain and small-for-gestational age
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-348
Evidence Table 22. Gestational weight gain and small-for-gestational age(continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) SGA (%) Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: Weight loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: Definition of maternal weight
G3: 16-25 lbs gain:
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P < Poor
Only calculated for G5: >35 lbs
0.01) Definition of outcomes:
morbidly obese:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 4 Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 3.9 exposure, outcomes, and
G2: 15.9% G3: 5.6 confounders:
Collected from: G4: 3.1 Poor
• Routine pre- Instrumental G5: 3.8
natal care or delivery,%: Followup:
maternity NR Maternal confounders and Fair
records effect modifiers accounted
Episiotomy,%: for in analysis: Analysis comparability:
Ascertained by: NR NR Poor
• Not stated -
Other maternal Infant and child confounders Analysis of outcomes:
from medical
outcomes and effect modifiers Fair
records
• Preeclampsia accounted for in analysis:
• Placental Interpretation:
NR
abruption Poor
• Meconium Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-349
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Caulfield et al., 1998 • Cohort • Self-reported White
• Retrospective G1: 13.3 (5.7) NR
Country and setting:
G2: 14.6 (5.1)
USA, hospital obstetric Total Study N: Black
G3: 13.6 (6.7)
database 3,870 NR
G4: 15.3 (5.4)
Enrollment Period: Group Description: G5: 12.4 (7.7) Hispanic
1987 to 1989 G1: BMI < 19.8 Black G6: 14.5 (7.3) NR
G2: BMI < 19.8 White Pregravid BMI:
Funding: Asian/Pacific Islander
G3: BMI 19.8 to 26.0 Black G1: 18.4 (1.0)
NR NR
G4: BMI 19.8 to 26.0 White G2: 18.5 (1.0)
Study Objective: G5: BMI > 26.0 Black G3: 22.7 (1.8) Other
To examine relation G6: BMI > 26.0 White G4: 22.1 (1.8) NR
between gestational
Group N: Imputed: Smoking,%:
weight gain and risk of
G1: 523 • No G1: 32.8
delivering a small for
G2: 267 G2: 20.6
gestational age and large
G3: 1,479 Categorized: G3: 35.4
for gestational age infant
by race
G4: 796 • IOM guidelines G4: 20.0
G5: 615 G5: 28.8
Time frame: G6: 190 Age (mean, yrs): G6: 25.4
1987-1989 G1: 21.7 (4.8)
Inclusion criteria: G2: 27.1 (6.6) Diabetes mellitus,%:
Duration of the study: • Singleton pregnancies G3: 22.7 (5.3) NR
Entry into pn care until • White or black ethnicity G4: 29.8 (5.8)
delivery Hypertension,%:
• At least 28 weeks’ G5: 24.9 (6.0)
G1: 4.3
gestation G6: 28.2 (5.5)
G2: 3.0
• One delivery per Parity: G3: 6.0
woman (randomly G1: % primiparous: 52.4 G4: 5.7
chosen) G2: 55.4 G5: 11.9
• Information on G3: 50.1 G6: 17.0
anthropometric data G4: 48.0
Additional characteristics:
Exclusion criteria: G5: 36.9
G6: 46.9 NR
• Missing data
• Improbable data
• Non-black or non-white
ethnicity

C-350
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Odds ratio (95% CI) for SGA per 50g/wk Good
increase in rate of weight gain by BMI
Total weight gain: Gestational Sample selection:
G1: 13.3 (5.7) diabetes, %: Groups Fair
G2: 14.6 (5.1) NR G1: Underweight
G3: 13.6 (6.7) Definition of
Cesarean delivery, G2: Normal weight maternal weight
G4: 15.3 (5.4) G3: Overweight
G5: 12.4 (7.7) %: gain:
G6: 14.5 (7.3) NR Fair
Results
Categorized: Instrumental G1: 0.87 (0.78-0.97) Definition of
delivery, %: G2: 0.90 (0.84-0.96) outcomes:
• According to IOM
NR G3: 0.93 (0.86-1.01) Good
Collected from:
Episiotomy, %: Maternal confounders and effect Source of
• Routine pre-natal
NR modifiers accounted for in analysis: information on
care or maternity
• Age exposure, outcomes,
records Other maternal
• Race and confounders:
outcomes: Fair
Ascertained by: • Parity
NR
• Based on last • Pregravid BMI Followup:
clinically Other infant • Height Good
measured weight outcomes: • Hypertension
prior to delivery: NR Analysis
• Provider type
difference comparability:
• Smoking Good
between
selfreport Infant and child confounders and effect Analysis of
prepregnancy modifiers accounted for in analysis: outcomes:
weight and last Infant sex
recorded weight Good
Interpretation:
Good
Sum of
Good/Fair/Poor:
6 Good, 3 Fair, 0 Poor
Final Quality Score:
Good

C-351
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cedergren, 2006 • Cohort • Self-reported White
• Prospective • If unknown, standardized G1: 96.6
Country and setting: G2: NR
measurement is made
Sweden, Medical Birth Total Study N: during first visit to
Registry 245,526 Black
maternity health care
NR
Enrollment Period: Group Description: center
January 1, 1994 - BMI Hispanic
Pregravid BMI:
December 31, 2002 G1: < 20 NR
G2: 20 to 24.9 Imputed:
Funding: Asian/Pacific Islander
Ostergotland County
G3: 25 to 29.9 • No G1: 1.4
G4: 30 to 34.9
Council Categorized: G2: NR
G5: ≥ 35
Study Objective: • < 20, 20.0-24.9, 25.0- Other
Group N: 29.9, 30-34.9, ≥ 35
To estimate effects of high G1: 2.0
G1: 28,186
and low gestational weight Age (mean, yrs): G2: NR
G2: 143,365
gain in different maternal G1: 15 to 19 years: 3.8%
G3: 60,626 Smoking,%:
BMI classes on obstetric 20 to 24: 23.0%
G4: 17,248 G1: % nonsmoking: 81.6
and neonatal outcomes 25 to 29: 38.7%
G5: 6,296 G2: 85.2
Time frame: 30 to 34: 25.7% G3: 83.1
Inclusion criteria: 35 to 39: 7.7%
January 1, 1994 to G4: 79.9
December 31, 2002 • Singleton, term ≥ 40: 1.1% G5: 78.4
pregnancies G2: 15 to 19 years: 1.9% Group 6
Duration of the study: • Information on 20 to 24: 15.9%
First visit to maternity maternal height, 25 to 29: 37.7% Diabetes mellitus,%:
health care center to maternal weight in 30 to 34: 31.1% NR
delivery early pregnancy, and 35 to 39: 11.3%
Hypertension,%:
gestational weight ≥ 40: 1.9%
NR
gain G3: 15 to 19 years: 1.5%
20 to 24: 15.7% Additional characteristics:
Exclusion criteria: 25 to 29: 36.1% NR
• NA 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%

C-352
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28,186 NR Odds ratios (95% CIs) for SGA (< 2 SD Good
G2: 143,365 below the mean)
G3: 60,626 Gestational Sample selection:
G4: 17,248 diabetes, %: Groups Fair
G5: 6,296 NR Weight gain < 8 kg Definition of maternal
Cesarean delivery, G1: BMI < 20 weight gain:
Total weight gain: G2: BMI 20-24.9
G1: < 8kg: 6.9% %: Fair
G3: BMI 25-29.9
8-15.9kg: 65.2% NR G4: BMI 30-34.9 Definition of
≥ 16kg: 28.0% Instrumental G5: BMI ≥ 35 outcomes:
G2: < 8kg: 8.4% delivery, %: Good
8-15.9kg: 67.1% NR Weight gain > 16 kg
≥ 16kg: 30.4% Source of information
Episiotomy, %: G6: BMI < 20 on exposure,
G3: < 8kg: 15.7% G7: BMI 20-24.9
8-15.9kg: 54.4% NR outcomes, and
G8: BMI 25-29.9 confounders:
≥ 16kg: 29.9% Other maternal G9: BMI 30-34.9
G4: < 8kg: 30.2% Good
outcomes: G10: BMI ≥ 35
8-15.9kg: 48.7% NA Followup:
≥ 16kg: 21.1% Weight gain 8-16 kg (Reference) Fair
G5: < 8kg: 44.6% Other infant
8-15.9kg: 40.9% outcomes: Results
Analysis
≥ 16kg NA comparability:
G1: 2.35 (1.92-2.88)
Fair
Categorized: G2: 1.99 (1.77-2.23)
• < 8kg, 8-16, > 16 G3: 1.75 (1.48-2.07) Analysis of outcomes:
G4: 1.68 (1.26-2.25) Fair
Collected from: G5: 1.71 (1.03-2.85)
• Routine pre-natal Interpretation:
care or maternity G6: 0.50 (0.41-0.61) Good
records G7: 0.50 (0.45-0.56) Sum of
G8: 0.57 (0.47-0.68) Good/Fair/Poor:
Ascertained by:
G9: 0.61 (0.40-0.93) 4 Good, 5 Fair, 0 Poor
• Based on last
G10: 0.50 (0.20-1.24)
clinically Final Quality Score:
measured weight Maternal confounders and effect Fair
prior to delivery: modifiers accounted for in analysis:
difference • Age
between • Parity
maternal weights • Smoking
measured when
woman attended Infant and child confounders and effect
delivery unit and modifiers accounted for in analysis:
maternal weight Year of birth
recorded at first
visit to maternity
health care
center

C-353
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cheng et al., 2004 • Case-control • Self-reported White
• Retrospective • NR G1: 86
Country and setting: G2: 85
Missouri - birth certificate Total Study N: Pregravid BMI:
data • Cases: 6,973 (8,062 G1: < 19.8: 26% Black
used but percentages 19.8 to 26.0: 47% G1: 13
Enrollment period: G2: 13
based on those with >26: 22%
Funding: information) G2: < 19.8: 14%
Hispanic
NR • Controls: 7,141 19.8 to 26.0: 51%
NR
(8,062 used but >26: 30%
Study Objective: Asian/Pacific Islander
percentages based
To estimate whether Imputed:
on those with NR
maternal weight changes • No
information)
between pregnancy Other
influence risk for small for Group Description: Categorized: NR
gestational age births IOM Guidelines
G1: Cases
Smoking,%:
G2: Controls Age (mean, yrs):
Time frame: G1: 40
NR G1: < 20: 15% G2: 17
Group N:
20 to 34: 80%
G1: 8,062
Duration of the study: ≥ 35: 5% Diabetes mellitus,%:
G2: 8,062
1989 to 1997 G2: < 20: 10 % G1: 2
Inclusion criteria: 20 to 34: 83% G2: 2
• Second born infants: ≥ 35: 6%
Hypertension,%:
cases had second
Parity: NR
born SGA infants
NR
(less than the 10th Additional characteristics:
percentile of birth % married:
weight) G1: 67%
• Controls were G2: 77%
randomly selected by
year of birth from
remaining cohort of
mothers with 2 live
births during study
period
Exclusion criteria:
• Missing data

C-354
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 8,062 NR Odds ratio (95% CI) for SGA by weight gain Good
G2: 8,062 categories
Gestational Sample selection:
Total weight gain: diabetes, %: Groups Good
G1: < 0.2kg/wk: 17% G1: 2 SGA
≥ 0.2kg/wk: 78% G2: 2 Definition of
G1: WG < 0.2 kg/wk maternal weight
G2: < 0.2kg/wk: 11% G2: WG ≥ 0.2 kg/wk (Reference)
Group 3Cesarean gain:
≥ 0.2kg/wk: 86%
P < 0.001 cases delivery,%: SGA for low weight gain (< 0.2 kg/wk) by BMI
Poor
vs. controls NR
G1: Underweight Definition of
Categorized: Instrumental G2: Normal weight outcomes:
delivery,%: G3: Overweight Good
Rate - kG/wk
NR G4: Obese
Collected from: Source of
Episiotomy,%: information on
• Routine pre-natal Results
NR exposure,
care or maternity SGA outcomes, and
records Other maternal G1: 1.9 (1.8-2.2) confounders:
• Birth certificate outcomes G2: 1.022% Poor
• NA
Ascertained by:
SGA by BMI Followup:
• NR Other infant Fair
G1: (1.2-2.4)
outcomes
G2: (1.9-2.7)
• NA Analysis
G3: (1.6-2.9)
comparability:
G4: (1.4-2.1)
Good
Maternal confounders and effect modifiers
Analysis of
accounted for in analysis:
outcomes:
Maternal age, education, Medicaid status,
Fair
pregravid BMI, smoking, previous SGA,
adequacy of prenatal care, maternal cardiac Interpretation:
disease, preeclampsia, year of birth of second Good
infant
Sum of
Infant and child confounders and effect Good/Fair/Poor:
modifiers accounted for in analysis: 5 Good, 2 Fair, 2
NR Poor
Final Quality
Score:
Fair

C-355
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cherry et al., 1993 • RCT • Measured by study White
investigators NR
Country and setting: Total Study N: G1: 53% were 90-110%
USA, hospital 599 Black
Expected Weight (EW); 26% <
NR
Enrollment Period: Group Description: 90% EW; 21% were > 110%
NR G1: Total EW Hispanic
G2: NR G2: NR NR
Funding:
NR Group N: Pregravid BMI: Asian/Pacific Islander
G1: 599 NR
Study Objective: Imputed:
G2: NR
NR-to examine effect of • No Other
zinc on birth outcomes Inclusion criteria: NR
Categorized:
• Adolescents in
Time frame: • Calculated weight for age Smoking,%:
prenatal clinic at
NR and height NR
Charity Hospital of
Duration of the study: New Orleans Age (mean, yrs): Diabetes mellitus,%:
9 months-from time of NR NR
Exclusion criteria:
enrollment in to prenatal
care up to delivery • NR Parity: Hypertension,%:
NR NR
Additional characteristics:
NR

C-356
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Percentage SGA for each shifting of EW Poor
Total weight gain: category.
Gestational Sample selection:
Categorized: diabetes, %: Poor
• Grams gained Groups
NR Light:: < 90% EW
per week per cm Definition of
height Cesarean delivery, Normal: 90 to 110% of EW maternal weight
%: Heavy: > 110% EW gain:
Collected from: NR Poor
• Routine pre-natal G1: Normal to Heavy
care or maternity Instrumental G2: Light to Normal Definition of
records delivery, %: G3: Heavy to Heavy outcomes:
NR G4: Normal to Normal Good
Ascertained by:
Episiotomy, %: G5: Light to Light Source of
• NR
NR G6: Heavy to Normal information on
G7: Normal to Light exposure,
Other maternal outcomes, and
outcomes: Results confounders:
Table 1 provided data G1: 22% Fair
above-LBW, wt for G2: 39%
length of infant, % of G3: 38% Followup:
infants in high risk G4: 41% Fair
nursery G5: 62%
Analysis
G6: 60%
Other infant comparability:
G7: 65%
outcomes: Poor
NA Maternal confounders and effect modifiers
Analysis of
accounted for in analysis:
outcomes:
NA
Fair
Infant and child confounders and effect
Interpretation:
modifiers accounted for in analysis:
Poor
NA
Sum of
Good/Fair/Poor:
1 Good, 3 Fair, 5
Poor
Final Quality
Score:
Poor

C-357
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cnattingius et al., 1998 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Sweden, Medical birth Total Study N: G1: < 20: 13.5% Black
register 167,750 20-24.9: 60.4% NR
25-29.9: 19.9%
Enrollment Period: Group Description: Hispanic
≥ 30: 6.2%
1992-1993 G1: Total sample NR
G2: NR
G2: NR
Funding: Asian/Pacific Islander
Imputed:
NR Group N: NR
• No
G1: 167750
Study Objective: Other
G2: NR Categorized:
To examine effect of NR
prepregnancy BMI on risk Inclusion criteria: • < 20.0
of late fetal death, early 20-24.9 Smoking,%:
• Singleton births 25-29.9 G1: Nonsmoking: 77.4%
neonatal death, preterm • Registered on
delivery, and delivery of ≥ 30.0 G2: NR
Swedish Birth
an infant who was SGA Registry Age (mean, yrs): Diabetes mellitus,%:
Time frame: • Women with G1: ≤ 19: 2.3% NR
1992-1993 information on 20-24: 20.3%
Hypertension,%:
prepregnancy BMI 25-29: 39.9%
Duration of the study: NR
info 30-34: 25.9%
Immediately after birth • Women born in ≥ 35: 11.7% Additional characteristics:
(from birth register) Sweden, Denmark, G2: NR NR
Norway, Finland, or Parity:
Iceland G1: Nulliparous: 40.6%
Exclusion criteria: G2: NR
• NA

C-358
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 91,484 NR Odds ratios (95% CIs) for SGA Good
G2: NR
Gestational Groups Sample selection:
Total weight gain: diabetes, %: G1: WG < 0.25 kg/wk Fair
G1: < 0.25 kg/wk: NR G2:WG 0.25-0.34 kg/wk
9.3%; 0.25-0.34 Definition of
Cesarean delivery, G3: WG 0.35-0.44 kg/wk maternal weight
kg/wk: 32.9%; 0.35- G4: ≥ 0.45 kg/wk (Reference)
0.44: 29.4%; ≥ 0.45: %: gain:
20.6% NR Fair
Results
G2: NR Instrumental G1: 3.0 (2.5-3.5) Definition of
Categorized: delivery, %: G2: 1.9 (1.6-2.2) outcomes:
NR G3: 1.3 (1.1-1.5) Good
• Rate: kg/wk
Episiotomy, %: G4: 1.0 Source of
Collected from:
NR Maternal confounders and effect modifiers information on
• Routine pre-natal
accounted for in analysis: exposure,
care or maternity Other maternal
• Age outcomes, and
records outcomes:
• Parity confounders:
NR Fair
Ascertained by: • Pre-gravid BMI
• Based on last Other infant • Height Followup:
clinically outcomes: • Education Fair
measured weight • % late fetal • Mother living with father
prior to delivery: death: 0.28% Analysis
• Smoking
difference • % early noenatal comparability:
between death: 0.18% Infant and child confounders and effect Fair
prepregnancy modifiers accounted for in analysis:
Analysis of
weight and NR
outcomes:
weight at delivery
Fair
Interpretation:
Good
Sum of
Good/Fair/Poor:
3 Good, 6 Fair, 0
Poor
Final Quality
Score:
Fair

C-359
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Dawes and Grudzinskas, • Cohort • Routine pre-natal White
1991 • Retrospective careweight measured at NR
first visit
Country and setting: Total Study N: Black
G1: 62.7 (11.15)
UK, hospital 988 NR
G2: NR
Enrollment Period: Group Description: Hispanic
Pregravid BMI:
12 months G1: Total cohort NR
G2: NR Imputed:
Funding: Asian/Pacific Islander
• No
Grant from Royal College Group N: NR
of General Practitioners G1: 988 Categorized:
Other
Study Objective:
G2: NR • Continuous NR
To examine patterns of Inclusion criteria: Age (mean, yrs):
maternal weight gain in Smoking,%:
• Alternate women who G1: 26.6 (5.1) NR
relation to delivered at Radcliffe G2: NR
sociodemographic factors Hospital within 12 Diabetes mellitus,%:
and pregnancy outcome month period Parity: NR
Time frame: Exclusion criteria: Hypertension,%:
12 months • Not stated NR
Duration of the study: Additional characteristics:
Initiation of prenatal care NR
to delivery

C-360
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 988 G1: 3.32 (0.54) Average weekly weight gain < 0.20 Good
G2: NR G2: NR kg as a predictor of SGA
Sample selection:
Total weight gain: Gestational Groups Poor
G1: 10.71 (4.3) diabetes, %: G1: Sensitivity
average weekly NR Definition of maternal weight
G2: Specificity gain:
weight gain: 0.38
(0.16) Cesarean delivery, Fair
%: Results
G2: NR G1: 12.9% Definition of outcomes:
NR
Categorized: G2: 91.3% Fair
Instrumental
• Continuous Maternal confounders and effect Source of information on
delivery, %:
NR modifiers accounted for in exposure, outcomes, and
Collected from:
analysis: confounders:
• Routine pre-natal
Episiotomy, %: Maternal age, parity, pre-gravid Fair
care or maternity
NR BMI, weight, smoking
records Followup:
Other maternal Infant and child confounders Fair
Ascertained by:
outcomes: and effect modifiers accounted
• Based on last NA Analysis comparability:
clinically for in analysis: Fair
measured weight Other infant Gestational age
Analysis of outcomes:
prior to delivery outcomes:
NA Fair
Interpretation:
Poor
Sum of Good/Fair/Poor:
1 Good, 6 Fair, 2 Poor
Final Quality Score:
Fair

C-361
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if self White
1992 • Combination: reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at delivery G4: 65.0 (12.2) Hispanic
July 1, 1985 - December G5: 58.3 (6.5) NR
Total Study N:
31, 1985 (6 months)
Total n = 357 Pregravid BMI: Asian/Pacific Islander
Funding: • 191 women with G1: 39.5 (3.4) NR
NR abnormal G2: 17.2 (0.9)
G3: 26.1 (6.1) Other
prepregnant weight
Study Objective: G4: 23.6 (4.1) NR
(≥ 20% under or over
To evaluate effects of G5: 21.6 (2.0)
ideal weight for Smoking,%:
abnormal maternal weight height) or abnormal
or weight gain on Imputed: NR
pregnancy weight
pregnancy outcome • No Diabetes mellitus,%:
gain (≥ 20kg or ≤ 5kg)
Time frame: • 166 controls Categorized: NR
July 1, 1985 to December • Continuous ≥ 20% over or Hypertension,%:
Group Description:
31, 1985 (6 months) under normal weight for NR
G1: ≥ 20% over normal
height
Duration of the study: weight for height Additional characteristics:
Prepregnancy to delivery G2: ≥ 20% under normal Age (mean, yrs): NR
weight for height G1: 28 (5.1)
G3: weight gain ≤ 5kg G2: 25.5 (5.1)
G4: weight gain ≥ 20kg G3: 29.5 (5.1)
G5: control Group 6 G4: 28.7 (4.7)
G5: 28.7 (4.4)
Group N:
G1: 77 Parity:
G2: 28 G1: prior deliveries: 1.0 (1.0)
G3: 30 G2: 0.8 (0.8)
G4: 56 G3: 1.2 (1.1)
G5: 166 G4: 0.8 (1.0)
G5: 0.9 (1.0)
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

C-362
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Infant birthweight by maternal weight gain group Fair
G2: 28 P < 0.05 compared to
G3: 30 controls Groups Sample selection:
G4: 56 G2: 3293 (362) Infant weight percentile for mothers with normal Poor
G5: 166 P < 0.05 compared to prepregnancy weight and normal weight gain Definition of
controls G1: < 2.5% maternal weight
Total weight gain: G3: 3284 (880) G2: 2.5-10%
G1: 11.8 (6.2) gain:
G4: 3803 (538) G3: 10-50% Poor
P < 0.05 compared to P < 0.005 compared G4: 50-90%
controls to controls G5: 90-97.5% Definition of
G2: 13.4 (4.5) G5: 3538 (535) G6: > 97.5% outcomes:
G3: 3.0 (3.5) Poor
P < 0.0005 compared Gestational Infant weight percentile for mothers with weight
to controls diabetes,%: Source of
gain ≤5 kg information on
G4: 23.2 (22.8) NR G7: < 2.5%
P < 0.0005 compared exposure, outcomes,
Cesarean G8: 2.5-10% and confounders:
to controls G9: 10-50%
G5: 13.2 (3.4) delivery,%: Fair
G1: Elective 7% G10: 50-90%
Categorized: Emergency 14% G11: 90-97.5% Followup:
• ≤ 5kg or ≥ 20kg Total 21% G12: > 97.5% Fair
G2: Elective 4% Analysis
Collected from: Emergency 4% Infant weight percentile for mothers with weight
• Routine pre-natal comparability:
Total 8% gain ≥20 kg
care or maternity G3: Elective 3% Poor
G13: < 2.5%
records Emergency 3% G14: 2.5-10% Analysis of
Ascertained by: Total 6% G15: 10-50% outcomes:
G4: Elective 5% G16: 50-90% Fair
• Based on last
Emergency 18% G17: 90-97.5%
clinically Interpretation:
Total 23% G18: > 97.5%
measured weight Poor
prior to delivery G5: Elective 13%
Emergency 9% Results Sum of
Total 22% G1: 1% Good/Fair/Poor:
G2: 6% 0 Good, 4 Fair, 5 Poor
Instrumental G3: 35%
delivery,%: G4: 43% Final Quality Score:
NR G5: 13% Poor
Episiotomy,%: G6: 2%
NR
G7: 3%
Other maternal G8: 14%
outcomes: G9: 32%
NA G10: 34%
G11: 14%
Other infant
G12: 3%
outcomes:
NA
G13: 0%
G14: 2%
G15: 42%
G16: 29%
G17: 20%
G18: 7%

C-363
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Ekblad and Grenman,
1992 (continued)

C-364
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain 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-365
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jensen et al., 2005 • Cohort • Records White
• Retrospective • Patient report of pregravid G1: 84.4
Country and setting: G2: 85.8
BMI
Denmark, university Total Study N: G3: 82.7
hospitals 481 Pregravid BMI: G4: 89.9
G1: 34.3 (32.2-39.9)
Enrollment Period: Group Description: Black
G2: 33.9 (31.5-36.5)
Gestation through birth G1: GWG < 5.0 kg NR
G3: 32.9 (31.2-35.6)
G2: GWG 5.0-9.9kg G4: 32.7 (31.3-34.7)
Funding: Hispanic
G3: GWG 10.0-14.9 kg
Many different funds NR
G4: GWG ≥ 15.0kg Imputed:
Study Objective: • No Asian/Pacific Islander
Group N:
To investigate effect of NR
G1: 93 Categorized:
gestational weight gain in
G2: 134 • Continuous
obese glucose tolerant Other
G3: 132
women Age (mean, yrs): NR
G4: 122
Time frame: G1: 29.8 (26.4-33.1) Smoking,%:
Inclusion criteria: G2: 29.1 (26.3-33.1)
Gestation through birth G1: 29.7
• Prepregnancy BMI ≥ G3: 30.0 (26.6-33.2) G2: 25.8
Duration of the study: 30 G4: 27.9 (24.8-31.8) G3: 30.2
NR • Normal 2h 75g oral G4: 26.8
glucose tolerance test Parity:
(OGTT) during third NR Diabetes mellitus,%:
trimester (according NR
to WHO criteria)
Hypertension,%:
• Only first pregnancy
NR
during study period
included Additional characteristics:
NR
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)

C-366
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 93 G1: 3500 (3200-3840) Rates of SGA by weight gain groups Good
G2: 134 G2: 3645 (3200-4000)
G3: 132 G3: 3750 (3390-4125) Groups Sample selection:
G4: 122 G4: 3762 (3400-4120) G1: MWG < 5.0 kg (Reference) Poor
G2: MWG 5.0-9.9 kg Definition of
Total weight gain: Gestational diabetes, G3: MWG 10.0-14.9 kg
%: maternal weight
Categorized: G4: MWG ≥ 15.0 kg gain:
NR
• < 5.0. 5.0-9.9, Poor
10.0-14.9, ≥ 15.0 Cesarean delivery, Results
%: No significant difference in rates of SGA by maternal Definition of
Collected from: NR weight gain group. Numerical results not reported in outcomes:
• Routine pre-natal article Fair
care or maternity Instrumental
delivery, %: Maternal confounders and effect modifiers Source of
records
NR accounted for in analysis: information on
Ascertained by: • Age exposure,
• Not stated by Episiotomy, %: • Pregravid BMI outcomes, and
authors NR confounders:
• 2h OGTT result
Poor
Other maternal • Parity
outcomes: • Smoking Followup:
NA • Ethnicity Fair
• Clinical Center
Other infant Analysis
outcomes: Infant and child confounders and effect modifiers comparability:
NA accounted for in analysis: Fair
Gestational age
Analysis of
outcomes:
Good
Interpretation:
Fair
Sum of
Good/Fair/Poor:
2 Good, 4 Fair, 3
Poor
Final Quality
Score:
Poor

C-367
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kabiru and Raynor, 2004 • Cohort • Measured at first prenatal White
• Retrospective visit G1: 1.9
Country and setting: G2: 2.6
USA, hospital Total Study N: Pregravid BMI: G3: 2.8
5,131
Enrollment Period: Imputed: Black
1999 to 2002 Group Description: • No G1: 84.1
G1: No change in BMI G2: 82.8
Funding: Categorized:
between first prenatal
NR
visit and delivery • 20-24.9, 25-29.9, 30-34.9, G3: 88.2
Study Objective: G2: 1 category increase in 35-39.9, ≥ 40 Hispanic
To investigate effect of BMI between first Age (mean, yrs): G1: 13.9
increase in body mass prenatal visit and G1: 24.7 (6.1) G2: 14.6
index category on delivery G2: 24.4 (5.7) G3: 9.0
obstetric outcomes G3: > 1 category increase G3: 25.2 (5.9) P < 0.001 Asian/Pacific Islander
in BMI between first
Time frame: Parity: NR
prenatal visit and
1999 to 2002 delivery G1: Gravidity (mean): 1.9 (1.9) Other
Duration of the study: G2: 1.5 (1.7) NR
Group N: G3: 1.2 (1.7) P < 0.001
Prenatal through birth G1: 2,556 Smoking,%:
G2: 2,252 NR
G3: 323
Diabetes mellitus,%:
Inclusion criteria: NR
• Singleton
Hypertension,%:
pregnancies
NR
Exclusion criteria:
Additional characteristics:
• Multiple pregnancies
Mean weight gain:
• BMI < 20
G1: 8.6 pounds (8.4)
• Missing BMI data G2: 22.2 pounds (10.2)
G3: 55.3 pounds (23.8)
Additional characteristics:
NR

C-368
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 579 G1: 2886.0 (756) Percentage SGA by BMI category Good
G2: 942 G2: 3174.9 (600)
G3: 189 G3: 3099.5 (673) Groups Sample selection:
G4: 819 P < 0.001 G1: No change in BMI category Fair
G5: 790 G4: 3116 (713) G2: 1 category increase in BMI Definition of
G6: 104 G5: 3269 (698) G3: > 1 category increase in BMI maternal weight
G6: 3371 (733) gain:
Total weight gain: P = 0.015 % SGA among overweight Poor
Categorized: G4: No change in BMI category
Gestational G5: 1 category increase in BMI Definition of
• > 35 pounds for diabetes,%: G6: > 1 category increase in BMI outcomes:
normal BMI, > 25 NR Fair
pounds for
overweight BMI, Cesarean Results Source of
> 15 pounds for delivery,%: G1: 19.5% information on
obese BMI G1: 8.2 G2: 13.5% exposure,
G2: 12.6 G3: 9.5% outcomes, and
Collected from: G3: 21.0 P < 0.001 G4: 14.2% confounders:
• Routine pre-natal G4: 13.0 G5: 9.9% Fair
care or maternity G5: 14.3 G6: 11.5%
records G6: 19.3 P = 0.256 Followup:
Poor
Ascertained by: Instrumental Maternal confounders and effect modifiers
• Based on last delivery,%: accounted for in analysis: Analysis
clinically NA comparability:
measured weight Episiotomy,%: Poor
prior to delivery: Other maternal Infant and child confounders and effect
modifiers accounted for in analysis: Analysis of
not stated, most outcomes:
NA outcomes:
likely difference NA
Fair
between weight
at first prenatal Other infant Interpretation:
visit and weight outcomes: Poor
at delivery NA
Sum of
Good/Fair/Poor:
1 Good, 4 Fair, 4
Poor
Final Quality Score:
Poor

C-369
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
(BMI 35–39.9) (n = Categorized: NR
Study Objective:
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight change G3: Obese Class III Age (mean, yrs): NR
on pregnancy outcomes in (BMI 40 and More) (n G1: <26: 46%
obese women = 19,025) 26-35: 47% Other
Older than 35: 8% G1: 22
Time frame: Group N:
1990 to 2001 NR G2: <26: 44% Smoking,%:
26-35: 48% NR
Duration of the study: Inclusion criteria: Older than 35: 8%
Entry into prenatal care • Obese women G3: <26: 40% Diabetes mellitus,%:
through delivery residing in Missouri 26-35: 52% NR
who delivered (at 37 Older than 35: 9%
Hypertension,%:
or more weeks of
Parity: NR
gestation) liveborn,
singleton infants Nulliparous:
G1: 34% Additional characteristics:
during 1990–2001 NR
G2: 33%
Exclusion criteria: G3: 32%
• NR

C-370
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Odds of SGA for weight gain groups Good
LGA:13%
Total weight gain: (P < 0.05) Groups Sample selection:
G1: GWG (lb) G2: SGA: 7% G1: Odds of SGA for weight gain > 25lbs Fair
Less than 2: 3% LGA:16% G2: OR of SGA for weight gain < 15lbs
2 to 14: 15% Definition of
(P < 0.05) G3: Reference Weight gain 15-25 lbs maternal weight
15 to 25: 26% G3: SGA: 6%
More than 25: 56% gain:
LGA:18% Results Fair
G2: GWG (lb) (P < 0.05) G1: lower for women in this group
Less than 2: 8% G2: higher for women in this group Definition of
2 to 14: 22% Gestational diabetes, %: Numerical value for ORs not reported in study outcomes:
15 to 25: 27% NR Good
More than 25: 43% Maternal confounders and effect modifiers
G3: GWG (lb)Less than Cesarean delivery,%: accounted for in analysis: Source of
G1: 28 information on
2: 15% • Age
G2: 34 exposure,
• Race
G3: 41 outcomes, and
Categorized: • Parity
confounders:
• 10-lb or less loss
Instrumental delivery,%: • Education
NR Fair
2 to 9 lbs loss, no • Poverty (enrollment in Medicaid, WIC, food
weight change, stamp programs) Followup:
Episiotomy,%:
2 to 9 lbs gain, NR • Smoking Fair
10 to 14 lbs gain, • Chronic hypertension
Analysis
15–25 lb gain, Infant and child confounders and effect comparability:
26–35 lb gain, and modifiers accounted for in analysis: Fair
greater than 35 lb NR
gain Analysis of
outcomes:
Collected from: Fair
• Routine pre-natal
care or maternity Interpretation:
records Poor

Ascertained by: Sum of

NR Good/Fair/Poor:
2 Good, 6 Fair, 1
Poor
Final Quality Score:
Fair

C-371
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-372
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from Bivariate
Gain 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-373
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kramer et al., 1990 • Cohort • Self-reportedNR White
• Prospective G1: 57.8 kg (10.8) NR
Country and setting:
G2: NR
Canada, university Total Study N: Black
hospital 8,719 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1980 to 1986 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
National Health Research Group N: • They used prepregnancy NR
and Development G1: 8715 wt and ht separately
Program, Health and Other
G2: NR • NR
Welfare Canada NR
Inclusion criteria: Age (mean, yrs):
Study Objective: Smoking,%:
• Live-born, singleton G1: 28.6 (4.7) Cigarettes/d:
(1) Which maternal and infants without G2: NR
fetal variables appear to G1: 3.2 (7.5)
evidence of G2: NR
have independent causal congenital Parity:
impacts on intrauterine intrauterine infection, G1: 0.72 (0.86) Diabetes mellitus,%:
growth? (2) For a given chromosomal G2: NR NR
fetal growth status, which anomalies, or other
maternal and fetal Hypertension,%:
major malformations
variables affect and for whom Pg related HTN:
proportionality? G1: 7.7%
gestational age
G2: NR
Time frame: calculated from last
1980 to 1986 normal menstrual Additional characteristics:
period agreed within Education, y completed:
Duration of the study: ±7 days with an early G1: 13.0 (3.3)
Entry in to prenatal care second-trimester G2: NR
up to delivery (usually 16 to 18
weeks) Marital status:
• Ultrasonographic G1: 90.6%
estimate based on G2: NR
fetal biparietal Parity % primaparas:
diameter G1: 48.0
Exclusion criteria: G2: NR
• See above

C-374
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 8715 G1: 3385g (547) Odds ratio (95% CI) for SGA for weight gain Good
G2: NR G2: NR groups
Sample selection:
Total weight gain: Gestational diabetes, Groups Fair
G1: 14.2kg (5.5) %: G1: OR and 95% CI, for SGA for each 5 kg
G2: NR NR Definition of
decrease in net gestational WG maternal weight
Categorized: Cesarean delivery, %: gain:
• Continuous NR Results Poor
G1: 1.32 (1.20-1.44)
Collected from: Instrumental delivery, Definition of
• Routine pre- %: Maternal confounders and effect modifiers outcomes:
natal care or NR accounted for in analysis: Good
maternity Pregravid weight, infant sex, smoking, parity,
Episiotomy, %: maternal diabetes, height, previous LBW infant, Source of
records
NR severe pregnancy-induced hypertension information on
Ascertained by: exposure, outcomes,
Other maternal Infant and child confounders and effect and confounders:
• Based on last outcomes:
clinically modifiers accounted for in analysis: Poor
• Bivariate • Sex of the infant
measured Followup:
asssociations
weight prior to Fair
between selected
delivery, using
maternal and fetal
net weight Analysis
variables and fetal
gain (total comparability:
growth and
weight minus Fair
proportionality:
wt of infant)
Correlation Analysis of
coefficient for net outcomes:
gestational weight Fair
gain (kg)and fetal
growth ratio = 0.12 Interpretation:
(P < 0.001); for Fair
prepregnancy Sum of
weight (kg) 0.21 (P Good/Fair/Poor:
< 0.001) 2 Good, 5 Fair, 2 Poor
Other infant Final Quality Score:
outcomes: Fair
• 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)

C-375
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Lang et al., 1996 • Cohort • Not stated by authors White
• Retrospective G1: NR G1: 5.3
Country and setting: G2: 9.1
• < 100 pounds: 11.2
USA, hospital Total Study N:
• 100-125: 5.9 Black
11,505
Enrollment period: • 126-160: 5.1 G1: 9.6
August 1977-March 1980 Group Description: • 161-180: 7.3 G2: 17.7
Funding:
G1: Prevalence of • > 180: 4.4
preterm labor G2: NR Hispanic
NR NR
G2: Prevalence of SGA • < 100 pounds: 24.9
Study Objective: • 100-125: 12.6 Asian/Pacific Islander
Group N:
To estimate effects of 23 • 126-160: 7.7 NR
factors on prevalence of Inclusion criteria: • 161-180: 6.5
premature labor and fetal • Singleton • > 180: 5.9 Other
growth retardation across • Livebirths G1: 5.0
birthweight spectrum • Had data on Pregravid BMI: G2: 14.0
Time frame: birthweight, Imputed: Smoking,%:
August 1977 to March gestational age, and • No % smoked throughout
1980 sex pregnancy:
• Infants with Categorized:
G1: 8.3
Duration of the study: gestational age from • NR G2: 17.9
Pregnancy through 22 to 45 weeks
delivery Age (mean, yrs): Diabetes mellitus,%:
• Birthweights no more G1:
than 50% higher than NR
• < 15: 14.8
90th percentile for Hypertension,%:
• 16-19: 11.2
sex and gestational NR
• 20-24: 8.2
age
• 25-34: 4.6 Additional characteristics:
Exclusion criteria: • ≥ 35: 5.5 NR
• Women with G2:
menstrual • < 15: 25.0
abnormalities for • 16-19: 17.6
whom gestational • 20-24: 14.3
dating was • 25-34: 9.4
problematic • ≥ 35: 7.2
• Stillbirths
• Incomplete data Parity:
• Preterm delivery G1: 6.4
• Women with G2: 12.3
preexisting diabetes
mellitus,
hypertension,
epilepsy, asthma

C-376
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Odds ratios (95% CIs) for SGA be weight gain Good
Total weight gain: groups
Gestational Sample
Categorized: diabetes, %: selection:
• Weekly rate of Groups
NR G1: WG ≤ 0.40 lbs/wk Fair
weight gain
Cesarean delivery, G2: WG 0.40-0.65 lbs/wk Definition of
Collected from: %: G3: WG 0.65-0.90 lbs/wk (Reference) maternal weight
• Not stated by NR G4: WG > 0.90 lbs/wk gain:
authors Poor
Instrumental Results
Ascertained by: delivery, %: Definition of
G1: 2.8 (2.2-3.6)
• NR NR outcomes:
G2: 1.6 (1.4-1.9)
G3: 1.0 (Reference) Poor
Episiotomy, %:
NR G4: 0.6 (0.5-0.7) Source of
Maternal confounders and effect modifiers information on
Other maternal exposure,
outcomes: accounted for in analysis:
• Age outcomes, and
NA confounders:
• Race
Other infant • Parity Poor
outcomes: • Maternal height Followup:
NA • Prepregnancy weight Fair
• Maternal education
Analysis
• Health insurance
comparability:
• Planned pregnancy Good
• Previous induced abortion
• Previous spontaneous abortion Analysis of
• Previous still birth outcomes:
• Maternal morbidity Good
• Caffeine intake Interpretation:
• Marijuana Fair
• prenatal care
• smoking Sum of
Good/Fair/Poor:
3 Good, 3 Fair, 3
Infant and child confounders and effect Poor
modifiers accounted for in analysis:
Infant sex Final Quality
Score:
Poor

C-377
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Muscati et al., 1996 • Cohort Family physicians’ records White
• Retrospective G1: 62.8 +/- 16.0 kg NR
Country and setting: G2: NR
Canada, public health Total Study N: Black
department 371 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1979 to 1989 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
NR Group N: • Pregravid weight status NR
G1: 371 categorized into 3 groups
Study Objective: Other
G2: NR as a percentage of
To examine association of NR
standard weight:
extent and timing of Inclusion criteria: underweight < 90%, Smoking,%:
pregnancy weight gain • White, low income, normal 90-120%, and NR
with infant birth weight non-smoking women overweight > 120%
and postpartum weight • Pregnant women Diabetes mellitus,%:
retention Age (mean, yrs): NR
Exclusion criteria: G1: 24.5 +/- 5.6
Time frame: • Prematurity < 37 Hypertension,%:
G2: NR
1979 to 1989 weeks NR
• Adolescents < 16 Parity:
Duration of the study: Additional characteristics:
years G1: Primiparous 52%
Pregnancy through 6 G1: PPWR: 5.3 +/- 5.7 kg
• Women > 40 years G2: NR
weeks postpartum G2: NR
• Maternal health
problems Additional characteristics:
• Women who NR
consume alcohol or
drugs
• Pregnancy
complications such
as proteinuria,
hypertension,
diabetes, negative
weight gain, missing
values

C-378
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Odds ratios for SGA by weight gain groups Good
Total weight gain:
G1: 16.1 +/- 6.4 kg Gestational diabetes, Groups Sample selection:
G2: NR %: G1: per 1 kg increase in WG up to week 20 Fair
NR G2: per 1 kg increase in WG from weeks 21 to
Categorized: Definition of
• Continuous Cesarean delivery, %: 30 maternal weight
NR G3: per 1 kg increase in WG from weeks 31 to gain:
Collected from: term Fair
• Collected by Instrumental delivery,
study %: Results Definition of
investigators NR G1: 0.93 (P = NS) outcomes:
G2: 0.85 (P < 0.01) Fair
Ascertained by: Episiotomy, %:
NR G3: 0.89 (P < 0.01) Source of
• Based on last
clinically Maternal confounders and effect modifiers information on
Other maternal exposure,
measured weight outcomes: accounted for in analysis:
prior to delivery From Table 1: • Parity outcomes, and
• Pregravid standard weight confounders:
Pearson’s Correlation Fair
Coefficient and • Pregravid excess weight,
determination coefficient Followup:
Infant and child confounders and effect
of maternal weight gain Poor
modifiers accounted for in analysis:
with PP weight retention
• Birth length Analysis
and Infant BW. Maternal
• Infant sex comparability:
PP weight retention and
Preg weight gain: [Total Fair
amount r = 0.808, R Analysis of
square 65.3%, P < outcomes:
0.001], [Up to week 20 r Good
= 0.682, R square
46.5%, P < 0.001], Interpretation:
[Weeks 21-30 r = 0.411, Poor
R square 16.9%, P < Sum of
0.001], [Week 31 - term Good/Fair/Poor:
r = 0.414, R square 2 Good, 5 Fair, 2
17.1%, P < 0.001] Poor
Other infant Final Quality
outcomes: Score:
Pregnancy Weight Gain Fair
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]

C-379
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Parker and Abrams, 1992 • Cohort • Self-reported White
• Retrospective G1: 56.8 kg(SD 11.0) G1: 44.0
Country and setting: G2: NR
G2: NR
USA, hospital Total Study N:
6,690 Pregravid BMI: Black
Enrollment Period: G1: 8.3
G1: Underweight: 27.7%,
Sept 1980 to Dec 1988 Group Description: G2: NR
Normal weight 61.8%,
G1: Overall Overweight: 5.6%,
Funding: Hispanic
G2: NR Obese 4.9%
UC Committee on G1: 9.4
Research & MCH and Group N: G2: NR
G2: NR
Resources Development, G1: 6,690
Imputed:
Health Resources and G2: NR Asian/Pacific Islander
• No
Services Administration G1: 21.4
Inclusion criteria: Categorized: G2: NR
Study Objective: • Consecutive live
To test whether gains • IOM guidelines Other
singleton births at
outside IOM reference Moffitt Hospital Age (mean, yrs): G1: 12.0
ranges were associated between September G1: 27.7 (5.5) G2: NR
with increased risks of 1980 and December G2: NR
suboptimal pregnancy Smoking,%:
1988 with gestational G1: 12.0
outcome (SGA, LGA, ages of 37 to 42 Parity:
cesarean delivery) and to Primiparous: G2: NR
weeks
determine whether locally G1: 58.8% Diabetes mellitus,%:
developed ranges were Exclusion criteria: G2: NR NR
more applicable to study • Maternal transfers or
population transports and Hypertension,%:
deliveries NR
Time frame: complicated by fetal
Sept 1980 to Dec 1988 Additional characteristics:
malformations,
NR
Duration of the study: maternal diabetes, or
From entry into prenatal maternal
care until delivery hypertension

C-380
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 6690 G1: 3408g (462) Odds ratios (95% CIs) of SGA for low WG Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational G1: Compared to UCSF Cohort 25-75th Fair
G1: 15.2kg (5.2) diabetes, %: percentile of WG
G2: NR NR th
Definition of
G2: Compared to UCSF 10-90 percentile of maternal weight
Categorized: Cesarean delivery, WG gain:
• According to IOM %: Fair
Weight gain NR Results
G1: 2.06 (1.62-2.63) Definition of
ranges based on
Instrumental G2: 1.82 (1.35-2.47)) outcomes:
percentiles from
delivery, %: Good
previous study of
NR
UC population Maternal confounders and effect modifiers Source of
with good Episiotomy, %: accounted for in analysis: information on
pregnancy NR • Age exposure,
outcomes: 25th - outcomes, and
Other maternal • Race
75th, 10-90th confounders:
outcomes: • Parity
percentiles. For Fair
25-75th, weight NR • Pregravid BMI
gain range = 12- • Height Followup:
Other infant
17kg for • Smoking Fair
outcomes:
underweight NR Infant and child confounders and effect Analysis
women (BMI modifiers accounted for in analysis: comparability:
< 19.8); • Gestational age Fair
Collected from: Analysis of
• Routine pre-natal outcomes:
care or maternity Good
records
Interpretation:
Ascertained by: Poor
• Based on last
clinically Sum of
measured weight Good/Fair/Poor:
prior to delivery 3 Good, 5 Fair, 1
Poor
Final Quality
Score:
Fair

C-381
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Steward and Moser, 2004 • Cross-sectional • Birth statistics White
• Retrospective G1: 144.4 (33.3) G1: 77.9
Country and setting: G2: 61.0 P < 0.001
G2: 134.4 (31.0)
USA, vital statistics data Total Study N:
2,933 (from 14,463 births Pregravid BMI: Black
Enrollment Period: G1: 18.4
in county in 1993)
1993 Imputed: G2: 33.7
Group Description: • No
Funding: Hispanic
G1: Normal birth weight
Ohio State University Categorized: NR
G2: IUGR
Graduate School and • Continuous
College of Nursing Group N: Asian/Pacific Islander
G1: 1569 Age (mean, yrs): G1: 3.6
Study Objective: G1: 27.0 (5.8) G2: 5.3
G2: 1364
To determine prevalence G2: 25.4 (5.9)
of IUGR in full term infants Inclusion criteria: Other
and to identify • Birth weight > 2500g Parity: NR
sociodemographic and NR
• Reported gestational Smoking,%:
maternal characteristics age ≥ 38 weeks
associated with IUGR G1: 19.6
• Singleton birth G2: 34.5 P < 0.001
Time frame: Exclusion criteria:
1993 Diabetes mellitus,%:
• Chromosomal NR
Duration of the study: abnormality
Prenatal to birth • Congenital anomaly 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-382
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 3484.9 (414.9) Odds ratio (95% CI) for SGA Good
Total weight gain: G2: 2781.4 (131.9)
G1: 32.3 pounds Groups Sample selection:
G2: 29.2 P < 0.001 Gestational SGA defined as FGR < 0.85 Fair
diabetes, %:
Categorized: NR Definition of
• Continuous Results maternal weight
Cesarean delivery, G1: 0.98 (0.97-0.98) gain:
Collected from: %: Poor
• Self-reported Maternal confounders and effect modifiers
NR accounted for in analysis:
• Routine pre- Definition of
natal care or Instrumental • Age outcomes:
maternity delivery, %: • Race Fair
records NR • Maternal education
Source of
• Marital status
Ascertained by: Episiotomy, %: information on
• Prepregnancy weight
• Self-reported NR exposure,
• Adequacy of prenatal care outcomes, and
• Birth certificate Other maternal • Smoking
data confounders:
outcomes: Poor
NA Infant and child confounders and effect
modifiers accounted for in analysis: Followup:
Other infant • Infant sex Fair
outcomes:
IUGR in full term Analysis
newborn infants with comparability:
birth weights > Fair
2500g
Analysis of
outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
1 Good, 6 Fair, 2
Poor
Final Quality Score:
Fair

C-383
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Takimoto et al., 2006 • Cross-sectional • Taken from records not White
stated whether it was self- NR
Country and setting: Total Study N: reported or measured
Japan, obstetric units 112,257 Black
Pregravid BMI: NR
Enrollment Period: Group Description:
2001 to 2002 G1: Study cohort Imputed: Hispanic
G2: NR • No NR
Funding:
Ministry of Health, Labour, Group N: Categorized: Asian/Pacific Islander
and Welfare, Health, and G1: 46,659 • NR NR
Labour Research Grant, G2: NR
Research on Children and Age (mean, yrs): Other
Families Inclusion criteria: G1: 29.9 (4.8) NR
• Vaginal birth G2: NR
Study Objective: Smoking,%:
• Singleton pregnancy G1: 6.3
To identify adequate Parity:
• Low risk G2: NR
weight gain ranges during • % primiparous:
Term
pregnancy in Japanese G1: 53.5 Diabetes mellitus,%:
women Exclusion criteria: G2: NR G1: 1.2
• Cesarean deliveries G2: NR
Time frame: (n = 30,559)
2001 to 2002 • Delivery method Hypertension,%:
Duration of the study: unknown (n = 2258) G1: 2.0
Pregnancy through • Multiple gestations (n G2: NR
delivery (all info derived = 8387) Additional characteristics:
from delivery records) • Preterm deliveries NR
< 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)

C-384
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 46,659 G1: 2982 (472) Odds ratios (95% CI) for SGA by weight gain Good
G2: NR G2: NR groups
Sample selection:
Total weight gain: Gestational Groups Fair
G1: 9.9 (4.3) diabetes, %: G1: Total MWG < 25th percentile for GA
G2: NR G1: 1.2 th
Definition of
G2: Total MWG 25-49 percentile for GA maternal weight
G2: NR G3: Total MWG 50-74th percentile for GA
Categorized: gain:
• Gestational age Cesarean (Reference) Poor
specific delivery,%: G4: Total MWG 75-89th percentile for GA
NR
th
G5: Total MWG ≥90 percentile for GA Definition of
percentile values
outcomes:
of weight gain:
Instrumental Results Fair
under the 25th,
delivery,%: G1: 2.87 (2.56-3.21)
25th-49th, 50th- Source of
NR G2: 1.49 (1.35-1.66)
74th, 75th-89th, information on
≥ 90th Episiotomy,%: G3: 1.0 exposure,
NR G4: 0.55 (0.55-0.72) outcomes, and
Collected from: G5: 0.45 (0.45-0.63) confounders:
• Routine pre-natal Other maternal
Maternal confounders and effect modifiers Poor
care or maternity outcomes:
records NA accounted for in analysis: Followup:
• Age Fair
Ascertained by: Other infant • Parity
• Based on last outcomes: • Pre-pregnancy weight Analysis
clinically • Macrosomia comparability:
measured weight • IUGR Infant and child confounders and effect Fair
prior to delivery: modifiers accounted for in analysis:
• Gestational age Analysis of
not stated
• Infant sex outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
1 Good, 6 Fair, 2
Poor
Final Quality
Score:
Fair

C-385
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Wataba et al., 2006 • Perinatal data base • In data base but don’t White
and look at medical know if self reported NR
Country and setting:
records
Japan, academic medical Pregravid BMI: Black
retrospectively
center G1: 20.5 (2.6) NR
• Retrospective
G2: 21.1 (3.0)
Enrollment Period: Hispanic
Total Study N:
1981 to 1999 Imputed: NR
21,718
• No
Funding: Asian/Pacific Islander
Group Description:
NR Categorized: NR
G1: Nulliparous
Study Objective: G2: Parous women • Categorical in 2 kg/m2 Other
To analyze association of point intervals from NR
Group N: prepregnancy weight;
pregnancy complications
G1: 10413 categorical into low, Smoking,%:
with prepregnant body
G2: 11305 medium, high BMI groups NR
mass index and weight
gain during pregnancy in Inclusion criteria: (< 18, 18-23.9, > 24)
Diabetes mellitus,%:
Japanese women • Singleton pregnancy Age (mean, yrs): NR
Time frame: delivering term baby G1: 27.8 (4.1)
Hypertension,%:
1981 to 1999 at Osaka Med Center G2: 30.45 (3.9)
NR
and Research
Duration of the study: Institute for Maternal Parity:
Additional characteristics:
Entry into PNC up til and Child Health in NR
NR
delivery 19811999
Exclusion criteria:
• None reported

C-386
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 10413 G1: SGA: 5.4% LGA Odds ratios (95% CIs) for SGA by weight gain Good
G2: 11305 5.2% categories
G2: SGA 6.5% LGA Sample selection:
Total weight gain: 5.2% Groups Fair
G1: kg/wk: 0.25 (SD Parous, Low BMI (< 18)
0.09) Gestational Definition of
G1: WG < 0.15 kg/wk maternal weight
G2: kg/wk: 0.24 diabetes, %: G2: WG 0.15-0.20 kg/wk
(0.09) P < 0.01 NR gain:
G3: WG 0.20-0.25 kg/wk Poor
Categorized: Cesarean delivery, G4: WG 0.25-0.30 kg/wk (Reference
Definition of
• Categorical in %:
NR Parous, Medium BMI (18-23.9) outcomes:
kg/wk using
G5: WG < 0.15 kg/wk Poor
prepregnancy
Instrumental G6: WG 0.15-0.20 kg/wk
weight and Source of
delivery, %: G7: WG 0.20-0.25 kg/wk (Reference)
weight at delivery information on
NR
divided by exposure,
gestational age Episiotomy, %: Parous, High BMI (> 24) outcomes, and
of infant at birth NR G8: WG < 0.15 kg/wk confounders:
G9: WG 0.15-0.20 kg/wk (Reference) Poor
Collected from: Other maternal
• Rate of weight outcomes: Nulliparous, Low BMI (< 18) Followup:
gain determined • NR G10: WG < 0.15 kg/wk Fair
by: total weight G11: WG 0.15-0.20 kg/wk
gain divided by Other infant Analysis
G12: WG 0.20-0.25 kg/wk
weeks ga outcomes: comparability:
G13: WG 0.25-0.30 kg/wk (Reference
NR Poor
Ascertained by:
Nulliparous, Medium BMI (18-23.9) Analysis of
• Based on last
G14: WG < 0.15 kg/wk outcomes:
clinically
G15: WG 0.15-0.20 kg/wk Fair
measured weight
G16: WG 0.20-0.25 kg/wk
prior to delivery: Interpretation:
G17: WG 0.25-0.30 (Reference)
and subtracting Fair
prepregnancy
Nulliparous, High BMI (> 24) Sum of
weight
G18: WG < 0.05 kg/wk Good/Fair/Poor:
G19: WG 0.15-0.20 kg/wk 1 Good, 4 Fair, 4
(Reference) Poor

Results Final Quality

G1: 5.42 (2.86-10.27) Score:
G2: 2.78 (1.53-5.06) Poor
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

C-387
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Wataba et al., 2006
(continued)

C-388
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain 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-389
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Wen et al., 1990 • Cohort • Routine pre-natal White
• Retrospective careweight at first prenatal G1: 29.7
Country and setting: G2: NR
visit was used
USA, hospital Total Study N: G1: Prepregnancy weight (kg)
17,149 Black
Enrollment Period: < 50: 10.6%, 50-60:
G1: 70.3
January 1983 to Group Description: 32.6%, 61-72: 28.7%, 73-
G2: NR
December 1987 G1: Total 84: 14.5%, > 85: 13.6%
G2: IUGR G2: (Prepregnancy?) Maternal Hispanic
Funding: weight (kg) < 50: 12.9%, NR
G3: Preterm delivery
NIH contract N01-HD-4- 50-60: 8.5%, 61-72: 6.4%,
2811 Group N: 73-84: 5.5%, > 85: 4.8% Asian/Pacific Islander
G1: 100% G3: (Prepregnancy?) Maternal NR
Study Objective:
G2: 7.4% wei
To determine effect of Other
G3: 12.6%
factors related to LBW on Pregravid BMI: NR
IUGR and preterm Inclusion criteria: Imputed:
delivery Smoking,%:
• Women seen for • No G1: 29.4
Time frame: prenatal care and G2: 10.3
delivered of infants at Categorized:
January 1983 to G3: 13.3
study location • NR
December 1987
Diabetes mellitus,%:
Exclusion criteria: Age (mean, yrs):
Duration of the study: G1: < 17: 7.5%, NR
Entry into prenatal care • Diabetes
• Pregnancies involving 17-19: 22.7%, Hypertension,%:
through delivery 20-25: 43.1%,
multiple births NR
• Fetal death 26-30: 17.5%,
31-35: 7.0%, Additional characteristics:
• Congenital G1: Married: 38.0%
malformation > 36: 2.3%
G2: < 17: 8.0%, G2: Married: 6.6%
17-19: 6.6%, G3: Married: 10.6%
20-25: 7.4%, Additional characteristics:
26-30: 7.6%, Education:
31-35: 8.2%, G1: < 12: 41.1%,
> 36: 8.6% 12: 41.6%,
G3: < 17: 15.4%, > 12: 15.8%
17-19: 13.0%, G2: < 12: 7.7%,
20-25: 11.6%, 12: 7.3%,
26-30: 12.9%, > 12: 7.6%
31-35: 14.3%, G3: < 12: 12.8%,
> 36: 13.4% 12: 12.1%,
Parity: > 12: 12.2%
G1: Parity 0: 44.1, 1: 29.9, > 1: Additional characteristics:
26.0 NR
G2: Parity 0: 8.4, 1: 6.3, > 1:
6.6
G3: Parity 0: 12.5, 1: 12.3, > 1:
12.8

C-390
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Odds ratios for SGA by weight gain groups Fair
Total weight gain:
G1: Weight Gestational Groups Sample selection:
gain/week (after diabetes, %: G1: MWG < 0.24 kg/wk Poor
the 20th week) in NR G2: MWG 0.24-0.57 kg/wk
kg: Definition of
Cesarean delivery, G3: MWG 0.58-0.74 kg/wk (Reference) maternal weight
< 0.24: 12.2%, G4: MWG ≥ 0.75 kg/wk
0.24-0.57: 54.4%, %: gain:
0.58-0.74: 19.2%, NR Poor
Results
≥ 0.75: 14.3% Instrumental G1: 2.24 (P < 0.05) Definition of
G2: Weight delivery, %: G2: 1.55 (P < 0.05) outcomes:
gain/week (after NR G3: 1.0 Good
the 20th week) in G4: 1.25 (NS)
kg: Episiotomy, %: Source of
< 0.24: 9.9%, NR Maternal confounders and effect modifiers information on
0.24-0.57: 7.9%, accounted for in analysis: exposure,
Other maternal outcomes, and
0.58-0.74: 5.2%, outcomes: • Age
≥ 0.75: 5.7% • Race confounders:
NR Fair
G3: Weight gain/ • Parity
Other infant • Marital status Followup:
Categorized: outcomes:
• Ave weight gain • Eucation Fair
NR
per week after • Previous preterm delivery
Analysis
20th week • Alcohol use
comparability:
• Drug use Fair
Collected from: • Maternal height
• Routine pre-natal • Maternal weight Analysis of
care or maternity • Smoking outcomes:
records Good
Infant and child confounders and effect
Ascertained by: modifiers accounted for in analysis: Interpretation:
• Maternal weight Infant sex Fair
at delivery not
available, so total Sum of
weight gain not Good/Fair/Poor:
calculated 2 Good, 5 Fair, 2
Poor
Final Quality
Score:
Fair

C-391
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Zhou and Olsen, 1997 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Denmark, two Total Study N: G1: % < 19.8: 27.2; %19.8-26: Black
communities 7122 63.7; %26+: 9.1 NR
G2: NR
Enrollment Period: Group Description: Hispanic
April 1984 to April 1987 G1: Entire study Imputed: NR
G2: NR • No
Funding: Asian/Pacific Islander
Danish National Research Group N: Categorized: NR
Foundation and G1: 7122 • IOM guidelines
Sygekassernes Helsefond G2: NR Other
Age (mean, yrs): NR
Study Objective: Inclusion criteria: % < 25:
To study association Smoking,%:
• Women who provided G1: 30.3 %non-smoking:
between gestational detailed information G2: NR
weight gain and different G1: 60.0
on lifestyle during G2: NR
birth weight indicators pregnancy Parity:
considering prepregnancy %nulliparous:
• Singletons Diabetes mellitus,%:
BMI G1: 48.9 G1: 0
• Non-diabetic women
G2: NR G2: NR
Time frame: who gave birth
April 1984 to April 1987 between weeks 37
Hypertension,%:
and 42 for whom
Duration of the study: NR
weight gain was
Initiation of prenatal care reported Additional characteristics:
to delivery NR
Exclusion criteria:
• NA

C-392
Evidence Table 22. Gestational weight gain and small-for-gestational age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 7122 G1: %LBW: 1.7; Percentage growth retardation (birth weight < Fair
G2: NR %normal: 96.8; 3,000g and placental weight > 490g) by weight gain
%HBW: 1.5 category and BMI Sample selection:
Total weight gain: G2: NR Fair
G1: % < 11kg: 35.2; Groups
%12-15: 35.5; Gestational Definition of
Weight gain < 11 kg maternal weight
%16+: 29.3 diabetes, %: G1: Underweight (Reference)
G2: NR G1: 0 gain:
G2: Normal Fair
G2: NR G3: Overweight
Categorized:
Definition of
• ≤ 11, 12-15, Cesarean
delivery,%: Weight gain 12-15 kg outcomes:
≥ 16 kg
NR G4: Underweight Good
Collected from: G5: Normal Source of
• Routine pre-natal Instrumental G6: Overweight information on
care or maternity delivery,%:
NR exposure, outcomes,
records Weight gain > 16 kg and confounders:
Episiotomy,%: G7: Underweight Fair
Ascertained by:
NR G8: Normal
• Based on last Followup:
G9: Overweight
clinically Other maternal Good
measured weight outcomes: Results
prior to delivery: NA Analysis
G1: 1.0
difference comparability:
G2: 0.6 (0.4-0.8)
between last Other infant Fair
G3: 0.6 (0.4-1.1)
measured weight outcomes:
Analysis of
prior to delivery • Low birth weight
G4: 0.3 (0.2-0.5) outcomes:
and (< 2500g)
G5: 0.4 (0.3-0.6) Fair
prepregnancy • High birth weight G6: 0.4 (0.1-1.0)
weight (> 4500g) Interpretation:
• Growth retarded G7: 0.3 (0.2-0.5) Fair
were newborns G8: 0.2 (0.1-0.3) Sum of
with a birth G9: 0.2 (0.1-0.6) Good/Fair/Poor:
weight below
3000g in spite of Maternal confounders and effect modifiers 2 Good, 7 Fair, 0 Poor
a placenta accounted for in analysis: Final Quality Score:
weight higher • Age Fair
than 66 • Parity
percentile (491g) • Alcohol
• Diabetes
• Term delivery
• Smoking
Infant and child confounders and effect
modifiers accounted for in analysis:
• Gestational age
• Infant sex

C-393
Evidence Table 23. Gestational weight gain and Apgar Scores
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cedergren, 2006 • Cohort • Self-reported White
• Prospective • If unknown, G1: 96.6
Country and setting: G2: NR
standardized
Sweden, Medical Birth Total Study N: measurement is made
Registry 245,526 Black
during first visit to
NR
Enrollment Period: Group Description: maternity health care
January 1, 1994 - BMI center Hispanic
December 31, 2002 G1: < 20 NR
Pregravid BMI:
G2: 20 to 24.9
Funding: Asian/Pacific Islander
G3: 25 to 29.9 Imputed:
Ostergotland County G1: 1.4
Council
G4: 30 to 34.9 • No G2: NR
G5: ≥ 35
Study Objective: Categorized: Other
Group N: • < 20, 20.0-24.9, 25.0-
To estimate effects of G1: 2.0
G1: 28,186 29.9, 30-34.9, ≥ 35
high and low gestational G2: NR
G2: 143,365
weight gain in different Age (mean, yrs):
G3: 60,626 Smoking,%:
maternal BMI classes G1: 15 to 19 years: 3.8%
G4: 17,248 G1: % nonsmoking: 81.6
on obstetric and 20 to 24: 23.0%
G5: 6,296 G2: 85.2
neonatal outcomes 25 to 29: 38.7% G3: 83.1
Inclusion criteria: 30 to 34: 25.7%
Time frame: G4: 79.9
January 1, 1994 to • Singleton, term 35 to 39: 7.7% G5: 78.4
December 31, 2002 pregnancies ≥ 40: 1.1% Group 6
• Information on G2: 15 to 19 years: 1.9%
Duration of the study: maternal height, 20 to 24: 15.9% Diabetes mellitus,%:
First visit to maternity maternal weight in 25 to 29: 37.7% NR
health care center to early pregnancy, 30 to 34: 31.1%
delivery Hypertension,%:
and gestational 35 to 39: 11.3%
NR
weight gain ≥ 40: 1.9%
G3: 15 to 19 years: 1.5% Additional characteristics:
Exclusion criteria: 20 to 24: 15.7% NR
• NA 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%

C-394
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Outcomes from
Maternal Weight Bivariate Outcomes from
Gain Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28,186 NR Association of weight gain Fair
G2: 143,365 and Apgar scores
G3: 60,626 Gestational Sample selection:
G4: 17,248 diabetes, %: Groups Good
G5: 6,296 NR 5 minute Apgar Score < 7
Weight gain< 8 kg, 8-16 kg, Definition of maternal
Total weight gain: Cesarean and > 16 kg for each BMI weight gain:
G1: < 8kg: 6.9% delivery, %: class below Fair
8-15.9kg: 65.2% NR G1: BMI < 20 Definition of outcomes:
≥ 16kg: 28.0% Instrumental G2: BMI 20-24.9 Good
G2: < 8kg: 8.4% delivery, %: G3: BMI 25-29.9
8-15.9kg: 67.1% NR G4: BMI 30-34.9 Source of information on
≥ 16kg: 30.4% G5: BMI ≥ 35 exposure, outcomes, and
G3: < 8kg: 15.7% Episiotomy, %: confounders:
8-15.9kg: 54.4% NR Results Good
≥ 16kg: 29.9% No association between
Other maternal low weight gain and Apgar Followup:
G4: < 8kg: 30.2% outcomes: Fair
8-15.9kg: 48.7% score, despite BMI of
NA mother
≥ 16kg: 21.1% Analysis comparability:
G5: < 8kg: 44.6% Other infant Maternal confounders Fair
8-15.9kg: 40.9% outcomes: and effect modifiers
NA Analysis of outcomes:
≥ 16kg accounted for in Fair
Categorized: analysis:
• BMI Interpretation:
• < 8kg, 8-16, > Good
16 • Age
• Parity Sum of Good/Fair/Poor:
Collected from: • Smoking in early 4 Good, 5 Fair, 0 Poor
• Routine pre- pregnancy
natal care or Final Quality Score:
maternity Infant and child Fair
records confounders and effect
modifiers accounted for
Ascertained by: in analysis:
• Based on last • Year of birth
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

C-395
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Johnson et al., 1992 • Cohort • Self-reported White
• Retrospective G1: 64.5
Country and setting: Pregravid BMI: G2: 60.0
USA, prenatal clinics Total Study N: G3: 49.8
Imputed:
3,191 G4: 51.9
Enrollment Period: • No
January 1, 1987- Group Description: G5: 58.7
December 31, 1989 G1: BMI < 19.8 Categorized:
• National Academy of Black
G2: 19.8-26.0 G1: 33.6
Funding: Sciences
G3: 27-29 G2: 37.9
NR
G4: > 29 Age (mean, yrs): G3: 48.9
Study Objective: G5: All G1: NR G4: 47.5
To determine influences • < 20 years: 36.6% G5: 39.5
Group N:
of increased maternal • 20-26 years: 44.8%
G1: 755 Hispanic
prepregnancy weight • > 26 years: 18.7%
G2: 1,621 NR
and increased G2: NR
G3: 329
gestational weight gain • < 20 years: 30.8% Asian/Pacific Islander
G4: 486
on pregnancy outcome
G5: 3191 • 20-26 years: 46.5% NR
Time frame: • > 26 years: 22.6%
Inclusion criteria: Other
January 1, 1987 to G3:
• Delivery at or G1: 1.9
December 31, 1989 • < 20 years: 25.8% G2: 2.1
beyond 38 weeks
• 20-26 years: 48.9% G3: 1.2
Duration of the study: of gestation
• > 26 years: 25.2% G4: 0.6
Initiation of prenatal • Singletons
G4: G5: 1.7
care to delivery • Received prenatal
• < 20 years: 16.5%
care and delivered Smoking,%:
• 20-26 years: 53.9%
in Shands Hospital NR
• > 26 years: 29.6%
Exclusion criteria: G5: Diabetes mellitus,%:
• Fetal abnormalities • < 20 years: 29.5% G1: 1.9
• Oligohydramnios • 20-26 years: 47.5 % G2: 2.3
• Polyhydramnios • > 26 years: 23.0% G3: 6.1
• Medical or surgical G4: 5.3
Parity:
complications (GI G5: 3.1
G1: % first: 49.3
disorders, sickle
G2: 43.1 Hypertension,%:
cell
G3: 37.4 G1: 3.4
hemoglobinopathy,
G4: 31.1 G2: 4.6
hepatitis,
G5: 42.1 G3: 5.8
hematologic
disorders, G4: 10.7
malignant disease, G5: 5.4
renal disease, Additional characteristics:
neurologic disease, G1: % married: 42.6
pulmonary disease, G2: 46.1
psychiatric G3: 40.4
disorders, G4: 49.4
tuberculosis) G5: 45.2
• Incomplete risk
variable data or Additional characteristics:
outcome variable NR
information

C-396
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 755 G1: Rate of 1-minute and 5- Fair
G2: 1621 • < 2500g: 4.8% minute Apgar Scores ≤ 7
G3: 329 by weight gain categories Sample selection:
• 2500-4000g:
G4: 486 Fair
89.1%
G5: 3191 Groups
• > 4000g: 6.1% 1-minute and 5-minute Definition of maternal
Total weight gain: G2: Apgar score ≤ 7 weight gain:
G1: • < 2500g: 2.0% G1: total weight gain < 16lb Fair
• < 16kg: 7.8% • 2500-4000g: G2: total weight gain 16 - Definition of outcomes:
• 16-25kg: 18.5% 85.2% 25lb Fair
• 26-35kg: 35.1% • > 4000g: 12.8% G3: total weight gain 26-
G3: 35lb Source of information on
• > 35kg: 38.5%
• < 2500g: 1.5% G4: total weight gain >35lb exposure, outcomes, and
G2:
• 2500-4000g: confounders:
• < 16kg: 11.7% Results
83.0% Fair
• 16-25kg: 18.0% Increased OR for
• > 4000g: 15.5% Followup:
• 26-35kg: 28.8% gestational weight gain,
G4: Fair
• > 35kg: 41.5% persists after adjusting (no
• < 2500g: 0.2%
G3: further details provided) Analysis comparability:
• 2500-4000g:
• < 16kg: 19.8% Fair
82.5% Maternal confounders
• 16-25kg: 19.1%
• > 4000g: 17.3% and effect modifiers Analysis of outcomes:
• 26-35kg: 28.3%
accounted for in Fair
• > 35kg: 32.8%
analysis:
G4: Interpretation:
Gestational • Race
• < 16kg: 32.3% Fair
diabetes, %: • Parity
• 16-25kg: 22.0%;
G1: 1.9 • BMI category Sum of Good/Fair/Poor:
Categorized: G2: 2.3 • GDM 0 Good, 9 Fair, 0 Poor
• Quartiles G3: 6.1 • Hypertension
• National Academy G4: 5.3 • Height (tertile) Final Quality Score:
of Sciences G5: 3.1 • Prepregnancy weight Fair
(below, within, or Cesarean quartile
above delivery,%: • Other variables
recommended G1: NR entered by stepwise
range) G2: NR regression model
Collected from: G3: NR Infant and child
• Routine pre-natal G4: NR confounders and effect
care or maternity G5: 11.9 modifiers accounted for
records Instrumental in analysis:
delivery,%: • NR
Ascertained by:
• Based on last NR
clinically Episiotomy,%:
measured weight NR
prior to delivery:
difference Other maternal
between self outcomes:
report and weight • Frequency of
at last prenatal macrosomia =
visit (mean 6.1 12.2%
days prior to • Frequency of
delivery) cesarean =
11.9%
• Frequency of
LBW = 2.9%

C-397
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Johnson et al., 1992
(continued)

C-398
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Maternal Weight Outcomes from
Gain 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-399
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Nixon et al., 1998 • Cohort • Self-reported White
• Retrospective G1: 138 (31) NR
Country and setting:
G2: 158 (36) (P < 0.0001)
USA, county nurse- Total Study N: Black
midwifery services 2,228 Pregravid BMI: NR
G1: 24 (5)
Enrollment Period: Group Description: Hispanic
G2: 26 (5.8) (P < 0.0001)
January 1991 to G1: 2500 - 3999g NR
December 1994 G2: ≥ 4000g Imputed:
Asian/Pacific Islander
• No
Funding: Group N: NR
American College of G1: 1906 Categorized:
Nurse Midwives Other
G2: 322 • Continuous IOM NR
Study Objective: guidelines
Inclusion criteria:
To compare outcomes Smoking,%:
• Gestational age Age (mean, yrs): NR
of term infants of ≥ 37 weeks G1: 25 (6)
average birth weight • Birth weight G2: 27.5 (6) (P < 0.0001) Diabetes mellitus,%:
with outcomes of large ≥ 2500g NR
infants using computer Parity:
• Live infant at onset
database % parous: Hypertension,%:
of labor
G1: 56.3 NR
Time frame: • Birth occurred in G2: 69.9 (P < 0.00001)
January 1991 to hospital Additional characteristics:
December 1994 % shoulder dystocia:
Exclusion criteria: G1: 0.6
Duration of the study: • Women with G2: 5.9 (P < 0.001)
First prenatal visit gestational
through birth collected diabetes that % NICU:
retrospectively required insulin G1: 4.3
therapy G2: 6.6 (P = ns)

C-400
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1906 NR Apgar scores less than 7 Good
G2: 322
Gestational Groups Sample selection:
Total weight gain: diabetes, %: 1-minute Apgar score < 7 Fair
G1: 30.7+/-15 NR Continuous weight gain
G2: 37.2+/-15 measure Definition of maternal
(P < 0.0001) Cesarean delivery, weight gain:
%: Results Fair
Categorized: NR Gestational weight gain not
Definition of outcomes:
• Continuous a predictor of Apgar scores
Instrumental < 7 (details NR) Good
According to
delivery, %:
IOM Source of information on
NR Maternal confounders
and effect modifiers exposure, outcomes, and
Collected from:
Episiotomy, %: accounted for in confounders:
• Routine pre-
NR analysis: Fair
natal care or
maternity Other maternal • Age Followup:
records outcomes: • Parity Good
NA • BMI
Ascertained by: Analysis comparability:
• Based on last Other infant Infant and child Fair
clinically outcomes: confounders and effect
Analysis of outcomes:
measured • Apgar scores modifiers accounted for
in analysis: Fair
weight prior to
delivery NR Interpretation:
Fair
Sum of Good/Fair/Poor:
3 Good, 6 Fair, 0 Poor
Final Quality Score:
Fair

C-401
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Wataba et al., 2006 • Perinatal data base • In data base, on’t know White
and look at medical if self reported NR
Country and setting:
records
Japan, academic Pregravid BMI: Black
retrospectively
medical center G1: 20.5 (2.6) NR
• Retrospective
G2: 21.1 (3.0)
Enrollment Period: Hispanic
Total Study N:
1981 to 1999 Imputed: NR
21,718
• No
Funding: Asian/Pacific Islander
Group Description:
NR Categorized: NR
G1: Nulliparous
Study Objective: G2: Parous women • Categorical in 2 kg/m2 Other
To analyze association point intervals from NR
Group N: prepregnancy weight;
of pregnancy
G1: 10413 categorical into low, Smoking,%:
complications with
G2: 11305 medium, high BMI NR
prepregnant body mass
index and weight gain groups (< 18, 18-23.9, >
Inclusion criteria: Diabetes mellitus,%:
during pregnancy in 24)
• Singleton NR
Japanese women pregnancy Age (mean, yrs):
Hypertension,%:
Time frame: delivering term G1: 27.8 (4.1)
baby at Osaka Med G2: 30.45 (3.9) NR
1981 to 1999
Center and Additional characteristics:
Duration of the study: Research Institute Parity:
NR NR
Entry into PNC up til for Maternal and
delivery Child Health in
19811999
Exclusion criteria:
• None reported

C-402
Evidence Table 23. Gestational weight gain and Apgar Scores (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 10413 G1: SGA: 5.4% Rate of 1 minute Apgar Good
G2: 11305 LGA 5.2% scores <4 by weight gain
G2: SGA 6.5% LGA categories Sample selection:
Total weight gain: 5.2% Fair
G1: kg/wk: 0.25 Groups
(SD 0.09) Gestational 1 minute Apgar score < 4 Definition of maternal
G2: kg/wk: 0.24 diabetes, %: Rate of weight gain, weight gain:
(0.09) P < 0.01 NR categorized differently Poor
across different BMI Definition of outcomes:
Categorized: Cesarean delivery, groups Poor
• Categorical in %:
kg/wk using NR Results Source of information on
prepregnancy AOR for nulliparous exposure, outcomes, and
Instrumental women with low BMI with
weight and confounders:
delivery, %: weekly weight gain of <
weight at Poor
NR 15kg/wk versus women
delivery divided
by gestational Episiotomy, %: with weight gain of 0.25- Followup:
age of infant at NR 0.3kg/wk: Fair
birth 12.24 (2.04 - 73.43) Analysis comparability:
Other maternal
Collected from: outcomes: AOR for parous women Poor
• Rate of weight • NR with medium BMI, with Analysis of outcomes:
gain weekly weight gain of Fair
determined by: Other infant 0.35-0.4kg/wk versus
total weight outcomes: women with weight gain Interpretation:
gain divided by NR 0.2-0.25kg/wk: Fair
weeks ga 2.21 (1.08-4.53)
Sum of Good/Fair/Poor:
Ascertained by: No other relationships were 1 Good, 4 Fair, 4 Poor
• Based on last significant
Final Quality Score:
clinically Maternal confounders Poor
measured and effect modifiers
weight prior to accounted for in
delivery: and analysis:
subtracting
• Parity
prepregnancy
• Baseline BMI
weight
Infant and child
confounders and effect
modifiers accounted for
in analysis:
NR

C-403
Evidence Table 24. Gestational weight gain and perinatal mortality
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bracero and Byrne, • Cohort • Self-reported White
1997 • Retrospective G1: 92.1
Pregravid BMI: G2: NR
Country and setting: Total Study N: G1: median BMI = 23.19
Hospital charts - 20,971 (range 14.46-40.07) Black
Maimonides Medical G2: NR G1: 4.2
Center, Brooklyn, NY Group Description: G2: NR
G1: Total population Imputed:
Enrollment Period: G2: NR • No Hispanic
NR
Funding: Group N: Categorized:
NR G1: 20,971 • IOM guidelines Asian/Pacific Islander
G2: NR G1: 0.9
Study Objective: Age (mean, yrs): G2: NR
To determine optimal Inclusion criteria: G1: % < 15 years: < 0.1;
weight gain in singleton • Delivery at 15-19 yrs: 4.8; Other
pregnancy and evaluate Maimonides 20-24: 25.1; G1: 2.1
current Medical Center 25-29: 31.1; G2: NR
recommendations • Singleton 30-34: 24.3; Smoking,%:
Time frame: pregnancy 35-39: 11.8; NR
• No documentation 40-44: 2.8;
Duration of the study: of congenital 45-49: 0.1; Diabetes mellitus,%:
Jan 1, 1987 to Jan 1, anomaly, > 50: < 0.1 NR
1993 pregnancy was not G2: NR
Hypertension,%:
terminated by
Parity: NR
abortion
% primigravida:
• Documentation on G1: 25.1
Additional characteristics:
chart of G2: NR % married:
prepregnancy G1: 12.4
maternal weight, G2: NR
amount of maternal
Additional characteristics:
weight gain during
Type of service:
pregnancy, and
G1: Ward, 22.5%
gender of infant
Private: 77.5%
Exclusion criteria: G2: NR
• Infants with any
Additional characteristics:
type of congenital
NR
anomaly
(international
classification of
diseases (ICD-9-
CM) codes 740.0-
759.9

C-404
Evidence Table 24. Gestational weight gain and perinatal mortality (continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: r = .210 Perinatal mortality % Fair
Total weight gain: correlation with
G1: % weight gain: lost maternal weight Groups: Sample selection:
weight, 0.4; gain G1: Suboptimal weight gain Fair
1 to 5lbs, 0.9; G2: NR G2: Optimal weight gain
6 to 10, 2.3; Definition of maternal weight gain:
11 to 15, 5.4; Gestational Results: Fair
16 to 20, 12.0; diabetes, %: G1: 0.6
G2: 0.2 Definition of outcomes:
21 to 25, 17.2; NR Good
26 to 30, 21.1; P < 0.0001
31 to 35, 14.8; Cesarean Source of information on exposure,
delivery, %: Maternal confounders and
36 to 40, 11.5; effect modifiers accounted outcomes, and confounders:
41 to 45, 6.1; NR Fair
for in analysis:
≥ 46, 8.3 Instrumental NA Followup:
G2: NR delivery, %: Fair
NR Infant and child
Categorized: confounders and effect Analysis comparability:
• According to IOM Episiotomy, %: modifiers accounted for in Fair
ordinal categories NR analysis:
in 5 pound NA Analysis of outcomes:
intervals Other maternal Fair
outcomes:
Collected from: Optimal weight gain Interpretation:
• Routine prenatal defined as 36 to 40 Fair
care or maternity pounds for Sum of Good/Fair/Poor:
records underweight 1 Good, 8 Fair, 0 Poor
women, 31 to 40
Ascertained by: Final Quality Score:
pounds for women
• Based on last of ideal Fair
clinically prepregnancy
measured weight weight, 26 to 30
prior to delivery: pounds for
using last overweight women
measurement
obtained as an Other infant
outpatient outcomes:
Adverse outcomes:
• Still birth
• Neonatal death
• Preterm
delivery/low
birth weight
• Perinatal
morbidity

C-405
Evidence Table 24. Gestational weight gain and perinatal mortality (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Naeye, 1990 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
USA, hospitals affiliated Total Study N: Black
with medical schools Imputed: G1: 34.7
56,857
• No G2: 45.8
Enrollment Period: Group Description: G3: 55.3
1959 to 1966 G1: BMI < 20 Categorized:
• < 20, 20-24, 25-30, > 30 G4: 54.1
G2: BMI 20-24
Funding: Hispanic
G3: BMI 25-30 Age (mean, yrs):
NR NR
G4: BMI > 30 G1: 10-18: 19.3%
Study Objective: 35-50: 2.4% Asian/Pacific Islander
Group N:
To evaluate relationship G2: 10-18: 17.8% NR
G1: 12,669
of maternal pregravid 35-50: 5.9%
G2: 28,810
BMI to pregnancy G3: 10-18: 9.8% Other
G3: 10,160
outcome 35-50: 12.9% NR
G4: 5,218
Time frame: G4: 10-18: 7.8% Smoking,%:
Inclusion criteria: 35-50: 16.3%
1959 to 1966 G1: 49.1
• Data from G2: 44.9
Duration of the study: Collaborative Parity:
NR G3: 40.0
First prenatal visit to Perinatal Study G4: 39.8
delivery
Exclusion criteria: Diabetes mellitus,%:
• Deliveries taking G1: (GDM and preexisting
place outside of DM) 0.6
CPS hospitals 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-406
Evidence Table 24. Gestational weight gain and perinatal mortality (continued)
Maternal Weight Outcomes from Outcomes from Multivariate Quality Rating
Gain Bivariate Analysis Analysis
Groups (N): Birth weight: Outcomes Description: Background:
NR Attributable risk estimates for Fair
Total weight gain: perinatal death for low
Gestational diabetes, pregnancy weight gain Sample selection:
Categorized: %: Poor
• Low weight G1: (GDM and Groups:
gain defined as preexisting DM) 0.6 Low weight gain defined as < Definition of maternal weight
< 0.8 kg/month G2: 1.0 0.8 kg/week after the first gain:
after first G3: 1.1 trimester for pregravid BMI Poor
trimester G4: 5.0 groups below: Definition of outcomes:
Collected from: G1: BMI < 20 Poor
Cesarean delivery,%: G2: BMI 20-24
• Routine pre- NR G3: BMI 25-30 Source of information on
natal care or
Instrumental G4: BMI > 30 exposure, outcomes, and
maternity
delivery, %: confounders:
records Results:
NR Good
Ascertained by: G1: 0.03 (95% CI, 0.02-0.05)
Episiotomy, %: G2: 0.02 (95% CI, 0.01-0.03) Followup:
• NR Good
NR G3: 0.01 (95% CI, 0.00-0.02)
G4: 0.00 Analysis comparability:
Other maternal
outcomes: Maternal confounders and Good
NR effect modifiers accounted Analysis of outcomes:
for in analysis: Fair
Other infant • Age 35-40
outcomes: • Diabetes mellitus Interpretation:
% preterm births: BMI • Hypertensive disorders Poor
< 20: 20.8%, BMI 20-
• Black Sum of Good/Fair/Poor:
24: 19.6% (P < 0.01
• Preterm birth 3 Good, 2 Fair, 4 Poor
compared to BMI <
20), BMI 25-30: 22.5 • Major congenital
malformations Final Quality Score:
(P < 0.005 compared Poor
to BMI < 20), BMI > • Twins
30: 30.7% (P < 0.001 • Neonatal respiratory
compared to BMI < 20) distress syndrome
Infant and child confounders
and effect modifiers
accounted for in analysis:
NR

C-407
Evidence Table 24. Gestational weight gain and perinatal mortality (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Nohr et al., 2005 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Denmark, National Birth Total Study N: Black
Cohort Imputed: NR
55432
• No
Enrollment Period: Group Description: Hispanic
May, 1998 to April, 2001 G1: < 18.5 Categorized: NR
G2: 18.5-24.9 • WHO International
Funding: Taskforce Asian/Pacific Islander
G3: 25-29.9
NR NR
G4: ≥ 30 Age (mean, yrs):
Study Objective: G1: < 25 years: 19.0% Other
Group N:
To examine association 25-29: 42.2% NR
G1: 2458
between high 30-34: 29.5%
G2: 36986 Smoking,%:
prepregnancy BMI and ≥ 35: 9.3%
G3: 10650 G1: % non-smoking: 72.5
fetal death, allowing for G2: < 25 years: 11.9%
G4: 4411 G2: 84.1
the effects of gestational 25-29: 41.2%
age, weight gain, and G3: 83.3
Inclusion criteria: 30-34: 34.9%
maternal dieases in G4: 82.1
• Women who had ≥ 35: 12.0%
pregnancy participated in first G3: < 25 years: 13.9% Diabetes mellitus,%:
Time frame: telephone interview 25-29: 41.8% G1: 0.3
May, 1998 to April, 2001 30-34: 33.3% G2: 0.6
Exclusion criteria: ≥ 35: 10.9% G3: 1.6
Duration of the study: • Missing information G4: < 25 years: 16.8% G4: 5.0
Approximately 16 weeks on BMI (n = 886) 25-29: 40.9%
gestational age through • Missing information Hypertension,%:
30-34: 32.3%
end of pregnancy on gestational age NR
≥ 35: 10.0%
(n = 30)
Additional characteristics:
• Termination of Parity:
G1: %primiparous: 46.8 NR
pregnancy after first
telephone interview G2: 46.7
or at an estimated G3: 43.6
gestational age less G4: 42.7
than 28 days (n =
11)

C-408
Evidence Table 24. Gestational weight gain and perinatal mortality (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 2,458 NR Adjusted odds ratio for perinatal Good
G2: 36,986 mortality
G3: 10,650 Gestational Sample selection:
G4: 4,411 diabetes, %: Groups: Fair
G1: 0.3 Weight per week for BMI groups:
Total weight G2: 0.6 G1: Underweight <18.5 Definition of maternal weight
gain: G3: 1.6 G2: 18.5 ≤ normal weight < 25 gain:
G1: 459 g/wk G4: 5.0 G3: 25 ≤ overweight < 30 Fair
G2: 487 g/wk G4: Obese ≥ 30 Definition of outcomes:
G3: 462 g/wk Cesarean
delivery,%: Results: Fair
G4: 347 g/wk
Weight gain in pregnancy was not Source of information on
Categorized: Instrumental significantly associated with the
delivery,%: exposure, outcomes, and
• Weight gain risk of stillbirth for any BMI groups confounders:
was defined Episiotomy,%: Poor
Maternal confounders and
as average
Other maternal effect modifiers accounted for Followup:
weekly
outcomes: in analysis: Fair
increase
between self NA • Age
• Height Analysis comparability:
reported Other infant Fair
weights in • Parity
outcomes:
first and • Socio-occupational status Analysis of outcomes:
NA
second • Physical exercise Fair
pregnancy • Smoking
Interpretation:
interviews for • Alcohol and coffee
Fair
women who consumption
provided a Sum of Good/Fair/Poor:
Infant and child confounders
first interview 1 Good, 7 Fair, 1 Poor
and effect modifiers accounted
between 9-
for in analysis: Final Quality Score:
24 weeks,
NR Fair
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

C-409
Evidence Table 25. Gestational weight gain and neonatal distress
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cedergren, 2006 • Cohort • Self-reported White
• Prospective • If unknown, standardized G1: 96.6
Country and setting: G2: NR
measurement is made
Sweden, Medical Birth Total Study N: during first visit to
Registry 245,526 Black
maternity health care
NR
Enrollment Period: Group Description: center
January 1, 1994 - BMI Hispanic
Pregravid BMI:
December 31, 2002 G1: < 20 NR
G2: 20 to 24.9 Imputed:
Funding: Asian/Pacific Islander
Ostergotland County
G3: 25 to 29.9 • No G1: 1.4
G4: 30 to 34.9
Council Categorized: G2: NR
G5: ≥ 35
Study Objective: • < 20, 20.0-24.9, 25.0- Other
Group N: 29.9, 30-34.9, ≥ 35
To estimate effects of high G1: 2.0
G1: 28,186
and low gestational weight Age (mean, yrs): G2: NR
G2: 143,365
gain in different maternal G1: 15 to 19 years: 3.8%
G3: 60,626 Smoking,%:
BMI classes on obstetric 20 to 24: 23.0%
G4: 17,248 G1: % nonsmoking: 81.6
and neonatal outcomes 25 to 29: 38.7%
G5: 6,296 G2: 85.2
Time frame: 30 to 34: 25.7% G3: 83.1
Inclusion criteria: 35 to 39: 7.7%
January 1, 1994 to G4: 79.9
December 31, 2002 • Singleton, term ≥ 40: 1.1% G5: 78.4
pregnancies G2: 15 to 19 years: 1.9% Group 6
Duration of the study: • Information on 20 to 24: 15.9%
First visit to maternity maternal height, 25 to 29: 37.7% Diabetes mellitus,%:
health care center to maternal weight in 30 to 34: 31.1% NR
delivery early pregnancy, and 35 to 39: 11.3%
Hypertension,%:
gestational weight ≥ 40: 1.9%
NR
gain G3: 15 to 19 years: 1.5%
20 to 24: 15.7% Additional characteristics:
Exclusion criteria: 25 to 29: 36.1% NR
• NA 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%

C-410
Evidence Table 25. Gestational weight gain and neonatal distress (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28,186 NR • AOR for fetal distress (95% CI) Good
G2: 143,365
G3: 60,626 Gestational Groups Sample
G4: 17,248 diabetes, %: GWG<8 g, 8-15.9 kg, ≥ 16kg for BMI groups (8.- selection:
G5: 6,296 NR 15.9 ref) Fair
G1: BMI < 20
Total weight gain: Cesarean delivery, Definition of
G2: BMI 20-24.9
G1: < 8kg: 6.9% %: maternal weight
G3: BMI 25-29.9
8-15.9kg: 65.2% NR gain:
G4: BMI 30-34.9
≥ 16kg: 28.0% Fair
Instrumental G5: BMI ≥ 35
G2: < 8kg: 8.4% delivery, %: Definition of
8-15.9kg: 67.1% NR Results
outcomes:
≥ 16kg: 30.4% GWG<8kg
Good
G3: < 8kg: 15.7% Episiotomy, %: G1: 1.05 (0.54-2.03)
8-15.9kg: 54.4% NR G2: 1.06 (0.81-1.40) Source of
≥ 16kg: 29.9% G3: 0.96 (0.70-1.32) information on
Other maternal G4: 1.21 (0.79-1.85) exposure,
G4: < 8kg: 30.2% outcomes:
8-15.9kg: 48.7% NA G5: 0.59 (0.28-1.25) outcomes, and
≥ 16kg: 21.1% confounders:
G5: < 8kg: 44.6% Other infant GWG≥ 16kg Good
8-15.9kg: 40.9% outcomes: G1: 0.86 (0.57-1.29)
G2: 1.08 (0.92-1.26) Followup:
≥ 16kg NA Fair
G3: 1.31 (1.05-1.53)
Categorized: G4: 1.02 (0.65-1.62) Analysis
• < 8kg, 8-16, > 16 G5: 2.15 (1.10-4.20) comparability:
Collected from: Maternal confounders and effect modifiers Fair
• Routine pre-natal accounted for in analysis: Analysis of
care or maternity • Age outcomes:
records • Parity Fair
• Smoking
Ascertained by: Interpretation:
• Based on last Infant and child confounders and effect Good
clinically modifiers accounted for in analysis:
measured weight Year of birth Sum of
prior to delivery: Good/Fair/Poor:
difference 4 Good, 5 Fair, 0
between Poor
maternal weights Final Quality
measured when Score:
woman attended Fair
delivery unit and
maternal weight
recorded at first
visit to maternity
health care
center

C-411
Evidence Table 26. Gestational weight gain and neonatal hypoglycemia
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hedderson et al., 2006 • Case-control • Self-reported in some White
• Retrospective cases used measured G1: 54.0
Country and setting: G2: 67.8
weight recorded in chart
USA, Kaiser Permanente Total Study N: G3: 47.6
closes to woman’s last
Medical Care Program 45,245 G4: 42.6
menstrual period but no
Enrollment Period: Group Description: more than 12 months
Black
January 1, 1996 - June G1: Controls before her last menstrual
G1: 10.0
31, 1998 G2: Macrosomia period
G2: 5.1
G3: Hypoglycemia Pregravid BMI: G3: 11.3
Funding:
G4: Hyperbilirubinemia G1: < 19.8: 13.5% G4: 4.4
R01 DK 54834 from
National Institute of Group N: 19.8-24.9: 56.4%
Hispanic
Diabetes and Digestive G1: 652 25.0-29.0: 12.4%
G1: 17.2
and Kidney Diseases, G2: 391 > 29.0: 17.6%
G2: 15.1
grant from American G3: 328 G2: < 19.8: 5.1%
G3: 20.4
Diabetes Association and G4: 432 19.8-24.9: 51.2%
G4: 15.5
Kaiser Community Benefit 25.0-29.0: 16.6%
research support Inclusion criteria: > 29.0: 27.1% Asian/Pacific Islander
• Singleton livebirth G3: < 19.8: 10.1% G1: 8.1
Study Objective: 19.8-24.9: 50.0% G2: 3.6
To examine whether Exclusion criteria:
25.0-29.0: 17.1% G3: 6.7
pregnancy weight gains • No pregestational
> 29.0: 22.9% G4: 20.1
outside IOM diabetes or history of
G4: < 19.8: 13.9%
recommendations and gestational diabetes Other
19.8-24.9: 57.9%
rates of maternal weight (screened at 24-28 G1: 10.7
25.0-29.0: 13.2%
gain are associated with weeks gestation - G2: 8.4
> 29.0: 57.1%
neonatal complications meeting National G3: 14.0
Diabetes Data Group Imputed: G4: 17.4
Time frame: criteria for GDM) • No
January 1, 1996 to June Smoking,%:
31, 1998 Categorized: G1: %nonsmoking during
• IOM guidelines pregnancy: 92.0; %smoked
Duration of the study: but quit: 4.2; %smoked 3.9
First prenatal care visit to Age (mean, yrs): G2: %nonsmoking during
30 days post delivery G1: < 25 years: 22.1% pregnancy: 90.8; %smoked
25-29: 24.2% but quit: 5.3; %smoked 4.0
30-34: 33.6% G3: %nonsmoking during
≥ 35: 20.1% pregnancy: 92.6; %smoked
G2: < 25 years: 15.9% but quit: 1.5; %smoked 5.8
25-29: 28.0% G4: %nonsmoking during
30-34: 31.7% pregnancy: 94.2; %smoked
≥ 35: 24.3% but quit: 4.9; %smoked 1.0
G3: < 25 years: 24.1%
25-29: 25.3% Diabetes mellitus,%:
30-34: 26.8% NR
≥ 35: 23.8%
G4: < 25 years: 17.1% Hypertension,%:
NR
25-29: 29.4%
30-34: 32.6% Additional characteristics:
≥ 35: 20.8% Screening glucose value less
Parity: than 140:
G1: 85.0%: > 140: 15.0%
% primiparous:
G1: 56.9 G2: 81.6%: > 140: 18.4%
G3: 81.4%: > 140: 18.6%
G2: 31.2
G4: 83.3%: > 140: 16.7%
G3: 50.0
G4: 59.3

C-412
Evidence Table 26. Gestational weight gain and neonatal hypoglycemia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • AOR for neonatal hypoglycemia (95% CI) Good
Total weight gain:
Gestational Groups: Sample selection:
Categorized: diabetes, %: Good
G1: Rate of maternal weight gain (kg/wk): -0.26-
• According to IOM NR 0.21
Definition of
Collected from: G2: Rate of maternal weight gain (kg/wk): 0.22-
Cesarean delivery, maternal weight
• Routine pre-natal %: 0.31
gain:
care or maternity NR G3: Rate of maternal weight gain (kg/wk): 0.32-
Fair
recordsrate of 0.39
maternal weight Instrumental G4: Rate of maternal weight gain (kg/wk): 0.40- Definition of
gain was delivery, %: 1.03 outcomes:
calculated as NR Good
Results:
total pregnancy G1: 0.87 (0.57-1.32)
Episiotomy, %: Source of
weight gain G2: 1.00
NR information on
minus infant birth G3: 0.74 (0.49-1.14) exposure,
weight divided by Other maternal G4: 1.91 (1.33-2.82) outcomes, and
weeks of outcomes: confounders:
gestation when NA Below IOM recommendations Fair
last weight was 0.91 (0.59-1.41)
measured; rate Other infant Within IOM recommendations Followup:
of maternal outcomes: Fair
NA 1.00
weight gain Above IOM recommendations
before the third Analysis
1.39 (1.02-1.90) comparability:
trimester was
calculated using Maternal confounders and effect modifiers Good
the weight accounted for in analysis: Analysis of
measured at or • Age outcomes:
before the • Race Fair
screening test for • Parity
GDM (24-28 wks • Pre-gravid BMI Interpretation:
of gestation) Good
• Screening glucose value from 1 hour after
minus 50g oral glucose challenge test Sum of
prepregnancy • Difference between age at delivery and Good/Fair/Poor:
weight divided by gestational age at last weight measured 5 Good, 4 Fair, 0
weeks of Poor
gestation Infant and child confounders and effect
modifiers accounted for in analysis: Final Quality
Ascertained by: NR Score:
• Based on last Good
clinically
measured weight
prior to delivery:
difference
between final
recorded weight
at last prenatal
visit (within 2
weeks of delivery
date) and
prepregnancy
weight

C-413
Evidence Table 26. Gestational weight gain and neonatal hypoglycemia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Cohort • Self-reported White
• Retrospective G1: 16.2
Country and setting: Pregravid BMI: G2: 35.8
USA, university hospital Total Study N: G1: < 19.8: 25.8% G3: 48.0
20465 19.8-26.0: 19.4%
Enrollment Period: Black
26.1-29.0: 9.2%
1980 to 2001 Group Description: G1: 25.5
> 29.0: 20.6%
G1: Gain below IOM G2: < 19.8: 49.1% G2: 29.4
Funding:
recommendations 19.8-26.0: 34.8% G3: 45.1
NR
G2: Gain within IOM 26.1-29.0: 23.3%
Study Objective: recommendations Hispanic
> 29.0: 25.5%
To examine relationship G3: Gain above IOM G1: 19.2
G3: < 19.8: 25.0%
between gestational recommendations G2: 34.8
19.8-26.0: 45.8%
weight gain and adverse G3: 46.0
Group N: 26.1-29.0: 67.5%
neonatal outcomes > 29.0: 53.9% Asian/Pacific Islander
G1: 4,114
among infants born at P < 0.001 G1: 24.3
G2: 7,490
term (37 weeks or more) G2: 43.3
G3: 8,861 Imputed:
Time frame: G3: 32.4
Inclusion criteria: • No
1980 to 2001 Other
• Singleton Categorized:
Duration of the study: G1: 21.7
Exclusion criteria: • IOM guidelines G2: 37.9
Entry into PN care up till
delivery • Pregnancies Age (mean, yrs): G3: 40.4
complicated by G1: < 20 years: 23.4% P for all race categories <
multiple gestations, 20-29 years: 19.3% 0.001
congenital anomalies, 30-39 years: 19.9%
chronic hypertension, Smoking,%:
> 40 years: 25.3% G1: 23.5
gestational or G2: < 20 years: 31.3%
pregestational G2: 30.8
20-29 years: 36.6% G3: 45.8 P < 0.001
diabetes 30-39 years: 37.6%
• Birth before 37 weeks > 40 years: 36.3% Diabetes mellitus,%:
• Maternal transport G3: < 20 years: 45.4% NR
• Missing data on any 20-29 years: 44.0%
of variables Hypertension,%:
30-39 years: 42.5%
considered in > 40 years: 38.4% NR
multivariable analysis P < 0.001 Additional characteristics:
Parity: NR
% Nulliparous:
G1: 17.3
G2: 36.2
G3: 46.6
P < 0.001

C-414
Evidence Table 26. Gestational weight gain and neonatal hypoglycemia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4114 G1: %SGA: 36.1; AOR for neonatal hypoglycemia (95% CI) Good
G2: 7490 %AGA: 20.2;
G3: 8861 %LGA: 8.5 Groups: Sample
G2: %SGA: 39.4; G1: GWG > 7 kg selection:
Total weight gain: %AGA: 37.5; G2: GWG 11.5-16 kg Fair
%LGA: 26.5 G3: GWG >18 kg
Categorized: Definition of
• According to G3: %SGA: 24.5; maternal
IOMpercentiles %AGA: 42.4; Results weight gain:
and dichotomous %LGA: 65.1 Hypoglycemia Fair
P < 0.001 G1: 1.86 (0.91-3.81)
Collected from: G2: 1.0 Definition of
• Routine pre-natal Gestational G3: 1.67 (1.13-2.46) outcomes:
care or maternity diabetes,%: Good
records NR Maternal confounders and effect modifiers
accounted for in analysis: Source of
Ascertained by: Cesarean delivery,%: information on
G1: 14.7 • Age
• Based on last exposure,
G2: 32.1 • Race
clinically outcomes, and
• Parity
measured weight G3: 53.2 confounders:
• Pre-gravid BMI Fair
prior to delivery Instrumental • Pregnancy induced hypertension
delivery,%: • Date of delivery Followup:
Operative vaginal • Mode of delivery Fair
delivery:
• Length of first stage of labor Analysis
G1: 18.0%
• Length of second stage of labor comparability:
G2: 37.5%
G3: 44.5% • Smoking Fair

Episiotomy,%: Infant and child confounders and effect modifiers Analysis of

NR accounted for in analysis: outcomes:
• Gestational age Fair
Other maternal Birth weight
outcomes: Interpretation:
NA Good

Other infant Sum of

outcomes: Good/Fair/Poo
• Birth trauma r:
• 5 min Apgar score 3 Good, 6 Fair,
less than 7 0 Poor
• Assisted ventilation Final Quality
• SGA Score:
• LGA Fair
• NICU admission
• SCN admission
• Neonatal infection
• Seizure
• Hypoglycemia
• Polycythemia
• MAS
• RDS
• Tachypnea
• Hospital stay > 5
days
• Hospital stay > 10
days

C-415
Evidence Table 27. Gestational weight gain and hyperbilirubinemia
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hedderson et al., 2006 • Case-control • Self-reported in some White
• Retrospective cases used measured G1: 54.0
Country and setting: G2: 67.8
weight recorded in chart
USA, Kaiser Permanente Total Study N: G3: 47.6
closes to woman’s last
Medical Care Program 45,245 G4: 42.6
menstrual period but no
Enrollment Period: Group Description: more than 12 months
Black
January 1, 1996 - June G1: Controls before her last menstrual
G1: 10.0
31, 1998 G2: Macrosomia period
G2: 5.1
G3: Hypoglycemia Pregravid BMI: G3: 11.3
Funding:
G4: Hyperbilirubinemia G1: < 19.8: 13.5% G4: 4.4
R01 DK 54834 from
National Institute of Group N: 19.8-24.9: 56.4%
Hispanic
Diabetes and Digestive G1: 652 25.0-29.0: 12.4%
G1: 17.2
and Kidney Diseases, G2: 391 > 29.0: 17.6%
G2: 15.1
grant from American G3: 328 G2: < 19.8: 5.1%
G3: 20.4
Diabetes Association and G4: 432 19.8-24.9: 51.2%
G4: 15.5
Kaiser Community Benefit 25.0-29.0: 16.6%
research support Inclusion criteria: > 29.0: 27.1% Asian/Pacific Islander
• Singleton livebirth G3: < 19.8: 10.1% G1: 8.1
Study Objective: 19.8-24.9: 50.0% G2: 3.6
To examine whether Exclusion criteria:
25.0-29.0: 17.1% G3: 6.7
pregnancy weight gains • No pregestational
> 29.0: 22.9% G4: 20.1
outside IOM diabetes or history of
G4: < 19.8: 13.9%
recommendations and gestational diabetes Other
19.8-24.9: 57.9%
rates of maternal weight (screened at 24-28 G1: 10.7
25.0-29.0: 13.2%
gain are associated with weeks gestation - G2: 8.4
> 29.0: 57.1%
neonatal complications meeting National G3: 14.0
Diabetes Data Group Imputed: G4: 17.4
Time frame: criteria for GDM) • No
January 1, 1996 to June Smoking,%:
31, 1998 Categorized: G1: %nonsmoking during
• IOM guidelines pregnancy: 92.0; %smoked
Duration of the study: but quit: 4.2; %smoked 3.9
First prenatal care visit to Age (mean, yrs): G2: %nonsmoking during
30 days post delivery G1: < 25 years: 22.1% pregnancy: 90.8; %smoked
25-29: 24.2% but quit: 5.3; %smoked 4.0
30-34: 33.6% G3: %nonsmoking during
≥ 35: 20.1% pregnancy: 92.6; %smoked
G2: < 25 years: 15.9% but quit: 1.5; %smoked 5.8
25-29: 28.0% G4: %nonsmoking during
30-34: 31.7% pregnancy: 94.2; %smoked
≥ 35: 24.3% but quit: 4.9; %smoked 1.0
G3: < 25 years: 24.1%
25-29: 25.3% Diabetes mellitus,%:
30-34: 26.8% NR
≥ 35: 23.8%
G4: < 25 years: 17.1% Hypertension,%:
NR
25-29: 29.4%
30-34: 32.6% Additional characteristics:
≥ 35: 20.8% Screening glucose value less
Parity: than 140:
G1: 85.0%: > 140: 15.0%
% primiparous:
G1: 56.9 G2: 81.6%: > 140: 18.4%
G3: 81.4%: > 140: 18.6%
G2: 31.2
G4: 83.3%: > 140: 16.7%
G3: 50.0
G4: 59.3

C-416
Evidence Table 27. Gestational weight gain and hyperbilirubinemia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • AOR for hyperbilirubinemia (95% CI) Good
Total weight gain:
Gestational Groups: Sample selection:
Categorized: diabetes, %: Good
G1: Rate of maternal weight gain (kg/wk): -0.26-
• According to IOM NR 0.21
Definition of
Collected from: G2: Rate of maternal weight gain (kg/wk): 0.22-
Cesarean delivery, maternal weight
• Routine pre-natal %: 0.31
gain:
care or maternity NR G3: Rate of maternal weight gain (kg/wk): 0.32-
Fair
recordsrate of 0.39
maternal weight Instrumental G4: Rate of maternal weight gain (kg/wk): 0.40- Definition of
gain was delivery, %: 1.03 outcomes:
calculated as NR Good
Results:
total pregnancy G1: 0.74 (0.49-1.11)
Episiotomy, %: Source of
weight gain G2: 1.00
NR information on
minus infant birth G3: 0.91 (0.62-1.34) exposure,
weight divided by Other maternal G4: 1.58 (1.10-2.28) outcomes, and
weeks of outcomes: confounders:
gestation when NA Below IOM recommendations Fair
last weight was 0.98 (0.65-1.47)
measured; rate Other infant Within IOM recommendations Followup:
of maternal outcomes: Fair
NA 1.00
weight gain Above IOM recommendations
before the third Analysis
1.43 (1.06-1.93) comparability:
trimester was
calculated using Maternal confounders and effect modifiers Good
the weight accounted for in analysis: Analysis of
measured at or • Age outcomes:
before the • Race Fair
screening test for • Parity
GDM (24-28 wks • Pre-gravid BMI Interpretation:
of gestation) Good
• Screening glucose value from 1 hour after
minus 50g oral glucose challenge test Sum of
prepregnancy • Difference between age at delivery and Good/Fair/Poor:
weight divided by gestational age at last weight measured 5 Good, 4 Fair, 0
weeks of Poor
gestation Infant and child confounders and effect
modifiers accounted for in analysis: Final Quality
Ascertained by: NR Score:
• Based on last Good
clinically
measured weight
prior to delivery:
difference
between final
recorded weight
at last prenatal
visit (within 2
weeks of delivery
date) and
prepregnancy
weight

C-417
Evidence Table 28. Gestational weight gain and neonatal hospitalization
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Murakami et al., 2004 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
Japan, hospital Total Study N: G1: 20.9 (2.8) Black
633 G2: NR NR
Enrollment Period:
2001 Group Description: Imputed: Hispanic
G1: Total cohort • No NR
Funding:
G2: NR
NR Categorized: Asian/Pacific Islander
Group N: • WHO International NR
Study Objective:
G1: 633 Taskforce
To estimate risk of Other
G2: NR
perinatal morbidity of Age (mean, yrs): NR
mother and infant with Inclusion criteria: G1: 29.1 (4.5) Smoking,%:
respect to maternal • Live, singletons G2: NR
prepregnancy BMI and G1: 8.5
delivered between 24 G2: NR
weight gain in Japanese to 42 weeks gestation Parity:
women G1: 0.6 (0.7) Diabetes mellitus,%:
Exclusion criteria: G2: NR G1: 2.1
Time frame:
2001 G2: NR

Duration of the study: Hypertension,%:

Prenatal through birth NR
Additional characteristics:
G1: Preeclampsia
Mild: 5.4%
Severe: 4.1%
G2: NR
Additional characteristics:
NR

C-418
Evidence Table 28. Gestational weight gain and neonatal hospitalization (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 633 G1: 3,052.6 (483.8) Adjusted ORs of hospitalization of infant (95% CI) Good
G2: NR G2: NR
Groups: Sample selection:
Total weight gain: Gestational Gesational weight gain Fair
G1: 10.5 (3.4) diabetes, %: G1: < 8.5 kg
G2: NR G1: 2.1 G2: 8.5-12.5 kg Definition of
G2: NR G3: > 12.5 kg maternal weight
Categorized: gain:
• < 8.5kg, 8.5- Cesarean Hospitalization of infant Fair
12.5, > 12.5 delivery,%: G1: 1.60 (0.88-2.88)
G1: 10.3 G2: 1.00 Definition of
Collected from: G2: NR G3: 0.93 (0.46-1.88) outcomes:
• Routine pre-natal Fair
care or maternity Instrumental Outcomes Set 2:
delivery,%: NR Source of
records
NR information on
Ascertained by: Maternal confounders and effect modifiers exposure,
• Based on last Episiotomy,%: accounted for in analysis: outcomes, and
clinically NR • Age confounders:
measured weight Other maternal • Parity Fair
prior to delivery: outcomes: • Pre-gravid BMI Followup:
last NA • Smoking Fair
measurement
was taken at Other infant Infant and child confounders and effect Analysis
hospitalization outcomes: modifiers accounted for in analysis: comparability:
prior to delivery NA • Gestational age Fair
Analysis of
outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
1 Good, 8 Fair, 0
Poor
Final Quality
Score:
Fair

C-419
Evidence Table 29. Gestational weight gain and other infant morbidity
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Spector et al., 2007 • Case-control • Self-reported White
• Retrospective G1: 79.5
Country and setting: Pregravid BMI: G2: 85.5
United States, hospital Total Study N: G1: 25.2 (5.07) G3: 0.003
495 G2: 25.1 (5.52)
Enrollment period: Black
G3: 0.83
January 1, 1996 and Group Description: G1: 2.1
August 20, 2002 G1: Cases Imputed: G2: 5.5
G2: Controls • No
Funding: Hispanic
G3: P value
National Cancer Institute Categorized: G1: 10.5
grant R01CA79940. Group N: • WHO International G2: 3.5
University of Minnesota G1: 240 Taskforce
supported by Children’s G2: 255 Asian/Pacific Islander
Cancer Research Fund Age (mean, yrs): G1: 8.0
(Minneapolis, MN) and Inclusion criteria: G1: 29 (5.54) G2: 5.5
grants U10CA13539 and • Infants diagnosed G2: 30 (5.58)
U10CA98543 with leukemia at < 1 G3: 0.06 Other
year of age. NR
Study Objective: Parity:
Report association Exclusion criteria: NR Smoking,%:
between birth • No telephone NR
characteristics and • Down syndrome Diabetes mellitus,%:
maternal reproductive • Biological mother not NR
history with infant available for interview
luekemia in English Hypertension,%:
NR
Time frame:
January 1, 1996 and Additional characteristics:
August 20, 2002 NR

Duration of the study:

Entry to prenatal care until
child's first birthday

C-420
Evidence Table 29. Gestational weight gain and other infant morbidity (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 240 NR AORs for acute lymphoblastic Fair
G2: 255 leukemia (95% CI)
Gestational Sample selection:
Total weight gain: diabetes, %: Groups: Fair
G1: 15.3 (7.52) NR G1: GWG≤ 9.07 kg
G2: 14.6 (7.62) G2: GWG 9.53-13.61 kg Definition of maternal weight
G3: 0.31 Cesarean G3: GWG: 13.61-18.14 kg gain:
delivery,%: G4: GWG: > 18.14 kg Poor
Categorized: NR
Definition of outcomes:
• Quartiles Results:
Instrumental G1: 1.0 Fair
Collected from: delivery,%: G2: 1.16 (0.68-1.99)
NR Source of information on
• Self-reported G3: 1.25 (0.71-2.21) exposure, outcomes, and
Ascertained by: Episiotomy,%: G4: 1.50 (0.84-2.68) confounders:
• Self-reported NR P for trend=0.23 Poor
Other maternal Maternal confounders and Followup:
outcomes: effect modifiers accounted for Fair
• Finally, no in analysis: Analysis comparability:
observation • Maternal education Fair
observed
between infant Infant and child confounders Analysis of outcomes:
leukemia and and effect modifiers Fair
maternal accounted for in analysis:
prepregnancy NR Interpretation:
• BMI or weight Fair
gain during Sum of Good/Fair/Poor:
pregnancy 0 Good, 7 Fair, 2 Poor
Other infant Final Quality Score:
outcomes: Fair
NR

C-421
Evidence Table 29. Gestational weight gain and other infant morbidity (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Cohort • Self-reported White
• Retrospective G1: 16.2
Country and setting: Pregravid BMI: G2: 35.8
USA, university hospital Total Study N: G1: < 19.8: 25.8% G3: 48.0
20465 19.8-26.0: 19.4%
Enrollment Period: Black
26.1-29.0: 9.2%
1980 to 2001 Group Description: G1: 25.5
> 29.0: 20.6%
G1: Gain below IOM G2: < 19.8: 49.1% G2: 29.4
Funding:
recommendations 19.8-26.0: 34.8% G3: 45.1
NR
G2: Gain within IOM 26.1-29.0: 23.3%
Study Objective: recommendations Hispanic
> 29.0: 25.5%
To examine relationship G3: Gain above IOM G1: 19.2
G3: < 19.8: 25.0%
between gestational recommendations G2: 34.8
19.8-26.0: 45.8%
weight gain and adverse G3: 46.0
Group N: 26.1-29.0: 67.5%
neonatal outcomes > 29.0: 53.9% Asian/Pacific Islander
G1: 4,114
among infants born at P < 0.001 G1: 24.3
G2: 7,490
term (37 weeks or more) G2: 43.3
G3: 8,861 Imputed:
Time frame: G3: 32.4
Inclusion criteria: • No
1980 to 2001 Other
• Singleton Categorized:
Duration of the study: G1: 21.7
Exclusion criteria: • IOM guidelines G2: 37.9
Entry into PN care up till
delivery • Pregnancies Age (mean, yrs): G3: 40.4
complicated by G1: < 20 years: 23.4% P for all race categories <
Quality: multiple gestations, 20-29 years: 19.3% 0.001
Fair congenital anomalies, 30-39 years: 19.9%
chronic hypertension, Smoking,%:
> 40 years: 25.3% G1: 23.5
gestational or G2: < 20 years: 31.3%
pregestational G2: 30.8
20-29 years: 36.6% G3: 45.8 P < 0.001
diabetes 30-39 years: 37.6%
• Birth before 37 weeks > 40 years: 36.3% Diabetes mellitus,%:
• Maternal transport G3: < 20 years: 45.4% NR
• Missing data on any 20-29 years: 44.0%
of variables Hypertension,%:
30-39 years: 42.5%
considered in > 40 years: 38.4% NR
multivariable analysis P < 0.001 Additional characteristics:
Parity: NR
% Nulliparous:
G1: 17.3
G2: 36.2
G3: 46.6
P < 0.001

C-422
Evidence Table 29. Gestational weight gain and other infant morbidity (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4114 G1: %SGA: 36.1; AOR for morbidity (95% CI) Good
G2: 7490 %AGA: 20.2;
G3: 8861 %LGA: 8.5 Groups: Sample
G2: %SGA: 39.4; G1: GWG > 7 kg selection:
Total weight gain: %AGA: 37.5; G2: GWG 11.5-16 kg Fair
%LGA: 26.5 G3: GWG >18 kg
Categorized: Definition of
• According to G3: %SGA: 24.5; Results maternal
IOMpercentiles %AGA: 42.4; Seizure weight gain:
and dichotomous %LGA: 65.1 G1: 10.66 (2.17-52.36) Fair
P < 0.001 G3: 6.19 (1.32-28.96)
Collected from: Definition of
• Routine pre-natal Gestational Polycythemia outcomes:
care or maternity diabetes,%: G1: 1.32 (0.66-2.62) Good
records NR G3: 1.59 (1.13-2.22)
Source of
Ascertained by: Cesarean delivery,%: MAS (meconium aspiration syndrome)/ RDS information on
• Based on last G1: 14.7 (respiratory distress syndrome) or tachypnea exposure,
clinically G2: 32.1 G1: 1.93 (0.82-4.53) outcomes, and
measured weight G3: 53.2 G3: 1.86 (1.13-3.05) confounders:
prior to delivery Instrumental Fair
RDS (respiratory distress syndrome) or tachypnea
delivery,%: G1: 0.56 (0.29-1.06) Followup:
Operative vaginal G3: 1.04 (0.79-1.38) Fair
delivery:
G1: 18.0% Hospital stay more than 5 days/ Hospital stay more Analysis
G2: 37.5% than 10 days comparability:
G3: 44.5% G1: 1.44 (1.02-2.04) Fair
G3: 1.07 (0.90-1.28)
Episiotomy,%: Analysis of
NR Hospital stay more than 10 days outcomes:
G1: 1.13 (0.51-2.53) Fair
Other maternal G3: 1.22 (0.81-1.84)
outcomes: Interpretation:
NA Maternal confounders and effect modifiers Good
accounted for in analysis:
Other infant Sum of
• Age
outcomes: Good/Fair/Poo
• Race
• Birth trauma r:
• Parity 3 Good, 6 Fair,
• 5 min Apgar score • Pre-gravid BMI
less than 7 0 Poor
• Pregnancy induced hypertension
• , Aassisted • Date of delivery Final Quality
ventilation • Mode of delivery Score:
• SGA • Length of first stage of labor Fair
• LGA • Length of second stage of labor
• NICU admission • Smoking
• SCN admission
• Neonatal infection Infant and child confounders and effect modifiers
• Seizure accounted for in analysis:
• Hypoglycemia Gestational age
• Polycythemia Birth weight
• MAS
• RDS
• Tachypnea
• Hospital stay > 5
days
• Hospital stay > 10
days

C-423
Evidence Table 30. Gestational weight gain and infant BMI
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kramer et al., 1990 • Cohort • Self-reportedNR White
• Prospective G1: 57.8 kg (10.8) NR
Country and setting:
G2: NR
Canada, university Total Study N: Black
hospital 8,719 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1980 to 1986 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
National Health Research Group N: • They used prepregnancy NR
and Development G1: 8715 wt and ht separately
Program, Health and Other
G2: NR • NR
Welfare Canada NR
Inclusion criteria: Age (mean, yrs):
Study Objective: Smoking,%:
• Live-born, singleton G1: 28.6 (4.7) Cigarettes/d:
(1) Which maternal and infants without G2: NR G1: 3.2 (7.5)
fetal variables appear to evidence of
have independent causal Parity: G2: NR
congenital
impacts on intrauterine intrauterine infection, G1: 0.72 (0.86) Diabetes mellitus,%:
growth? (2) For a given chromosomal G2: NR NR
fetal growth status, which anomalies, or other
maternal and fetal Hypertension,%:
major malformations
variables affect Pg related HTN:
and for whom
proportionality? G1: 7.7%
gestational age
G2: NR
Time frame: calculated from last
1980 to 1986 normal menstrual Additional characteristics:
period agreed within Education, y completed:
Duration of the study: ±7 days with an early G1: 13.0 (3.3)
Entry in to prenatal care second-trimester G2: NR
up to delivery (usually 16 to 18
weeks) Marital status:
• Ultrasonographic G1: 90.6%
estimate based on G2: NR
fetal biparietal Parity % primaparas:
diameter G1: 48.0
Exclusion criteria: G2: NR
• See above

C-424
Evidence Table 30. Gestational weight gain and infant BMI (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 8715 G1: 3385g (547) • Infant BMI (kg/m2) Good
G2: NR G2: NR
Sample selection:
Total weight gain: Gestational Groups: Fair
G1: 14.2kg (5.5) diabetes, %: NA, net gestational weight (total
G2: NR NR Definition of maternal weight
weight gain minus weight of
gain:
infant) as continuous variable
Categorized: Cesarean delivery, Poor
• Continuous %: Results:
NR Definition of outcomes:
Correlation of net gestational
Collected from: Good
weight gain with infant BMI
• Routine pre- Instrumental
R=0.037, P<0.01 Source of information on
natal care or delivery, %:
NR exposure, outcomes, and
maternity Net gestational weight gain did confounders:
records not meet criterion threshold for
Episiotomy, %: Poor
Ascertained by: NR stepwise regression
Followup:
• Based on last Other maternal Maternal confounders and Fair
clinically outcomes: effect modifiers accounted for
measured in analysis: Analysis comparability:
• Bivariate
weight prior to • NA Fair
asssociations
delivery, using
between selected Analysis of outcomes:
net weight gain Infant and child confounders
maternal and Fair
(total weight and effect modifiers accounted
fetal variables
minus wt of for in analysis: Interpretation:
and fetal growth
infant) • NA Fair
and
proportionality: Sum of Good/Fair/Poor:
Correlation 2 Good, 5 Fair, 2 Poor
coefficient for net
gestational Final Quality Score:
weight gain Fair
(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)

C-425
Evidence Table 30. Gestational weight gain and infant BMI (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Vohr et. al, • Case-control Self-reported Black
1995 • Prospective G1: 67 kg (14) G1: 5.7% of total study
G2: 61 kg (12) population
Country and setting: Total Study N: G3: 71 kg (17)
USA, hospital 262 G4: 71 kg (18) Smoking,%:
NR
Enrollment period: Group Description: Pregravid BMI:
G1: Controls - LGA G1: 25 (5) Diabetes mellitus,%:
Funding: NR
G2: Controls - AGA G2: 23 (4)
National Institute of Child
G3: GDM mothers- LGA G3: 27 (6)
Health and Human Hypertension,%:
G4: GDM mothers - AGA G4: 28 (7)
Development Grant 2P50- NR
Group 5Group 6
HD11343 Imputed:
Group N: No
Study Objective:
G1: 74
To determine effects of Categorized:
G2: 69
maternal factors, including Continuous
G3: 57
prepregnancy maternal
G4: 62
adiposity, weight gain Age (mean, yrs):
Group 5Group 6
during pregnancy, degree G1: 29 (5)
of abnormality of oral Inclusion criteria: G2: 27 (6)
glucose tolerance test, • GDM criteria based G3: 30 (6)
glycemia during on screen at 24-28 G4: 31 (5)
pregnancy, and treatment weeks of gestation.
with insulin vs. diet Parity:
Women were NR
therapy, on neonatal body diagnosed with GDM
weight, adiposity, and if an initial 1-hour 50 -
blood pressure on IGDM g glucose screen
and control infants value > 130 mg/dl
Time frame: followed by two
NR abnormal values in a
100-g oral glucose
Duration of the study: tolerance test. An
21 months 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

C-426
Evidence Table 30. Gestational weight gain and infant BMI (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 74 NR • Infant BMI (kg/m2) Good
G2: 69
G3: 57 Gestational Groups: Sample selection:
G4: 62 diabetes, %: Weight gain as a continuous Fair
NR variable for
Total weight gain: Definition of maternal weight
G1: GDM mothers
G1: 18 kg (7) Cesarean gain:
G2: Control mothers
P < 0.05 delivery,%: Fair
G2: 15 kg (6) NR Results:
Definition of outcomes:
G3: 15 kg (7) Estimates of 1-kg increase in
Instrumental Good
P < 0.05 gestational weight on infant BMI
delivery,%:
G4: 11 kg (7) G1: 0.06, P=0.001 Source of information on
NR
P < 0.05 G2: 0.05, P=0.003 exposure, outcomes, and
Episiotomy,%: confounders:
Categorized: NR Correlation between weight gain Fair
• Continuous and infant BMI overall: .022,
Other maternal P=0.01 Followup:
Collected from: outcomes: Fair
• Does not state NR Maternal confounders and
effect modifiers accounted for Analysis comparability:
Ascertained by: Other infant in analysis: Fair
• Based on last outcomes: • NR
NR Analysis of outcomes:
clinically
measured Infant and child confounders Fair
weight prior to and effect modifiers accounted Interpretation:
delivery for in analysis: Fair
• NR
Sum of Good/Fair/Poor:
2 Good, 7 Fair, 0 Poor
Final Quality Score:
Fair

C-427
Evidence Table 31. Gestational weight gain and other infant growth characteristics
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Brown et al., 2002 • Cohort • Measured by study White
• Prospective investigators G1: 97
Country and setting: G2: NR
• Weight was measured < 6
USA, primary care clinics Total Study N:
months before conception
389 Black
Enrollment Period: for 364 women by study
NR
1989 to 1993 Group Description: investigators
G1: Total G1: 61.2 ± 9.4 (50.7, 73.2) Hispanic
Funding: G2: NR NR
G2: NR
NIH
Group N: Pregravid BMI: Asian/Pacific Islander
Study Objective: G1: 22.5 ± 3.2 (19.2, 26.9) NR
G1: 389
To identify effects of G2: NR
G2: NR
maternal weight change Other
by trimester of pregnancy Inclusion criteria: Imputed: NR
on weight, length, head • Women aged 22-35 • No
circumference, and Smoking,%:
years enrolled in Categorized: NR
ponderal index (PI; in Group Health
kg/m3) of newborns • Continuous
managed care Diabetes mellitus,%:
Time frame: organization Age (mean, yrs): NR
1989 - 1993 • Intended to become G1: 29.4 ± 3.1 (25.3, 33.7)
Hypertension,%:
pg within enrollment G2: NR
Duration of the study: NR
period
From preconception or Parity:
• Had not been Additional characteristics:
entry into prenatal care G1: 0.5 ± 0.7 (0, 1)
attempting pg for > 3 NR
through 6 to 8 weeks G2: NR
mo
postpartum • 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

C-428
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 389 G1: 3575g ± 448 • Ponderal index, beta coefficients Good
G2: NR (3033–4167)
G2: NR Groups: Sample selection:
Total weight gain: G1: Increase in Ponderal Index per 1 kg Good
G1: 15.6 ± 4.1 Gestational increase in first trimester weight gain
(10.5–21.4)2 diabetes, %: Definition of
G2: Increase in Ponderal Index per 1 kg
G2: NR NR maternal weight
increase in second trimester weight gain
gain:
G3: Increase in Ponderal Index per 1 kg
Categorized: Cesarean delivery, Fair
increase in third trimester weight gain
• Continuous %:
NR Definition of
Results:
Collected from: outcomes:
G1: β = 0.21
• Collected by Instrumental Good
(P < 0.0003)
study delivery, %:
NR Source of
investigatorsRout G2: β = 0.05 PI information on
ine pre-natal (P < 0.4)
Episiotomy, %: exposure,
care or maternity
NR outcomes, and
records G3: β = 0.12 confounders:
Other maternal (P < 0.03) Good
Ascertained by:
outcomes:
• Based on last NR Maternal confounders and effect modifiers Followup:
clinically accounted for in analysis: Good
measured weight Other infant • Age
prior to delivery outcomes: Analysis
• Parity
Although comparability:
• Pre-gravid BMI
nonsignificant, a Good
• Mother’s height
trend was noted that
suggested, among Analysis of
Infant and child confounders and effect
women with lower outcomes:
modifiers accounted for in analysis:
preconception weight, Good
• Gestational age
an increased effect of • Sex (female) Interpretation:
first-trimester weight Good
gain on weight of
their newborns (51 kg Sum of
preconception weight, Good/Fair/Poor:
51 g/kg weight gain; 8 Good, 1 Fair, 0
62 kg preconce Poor
Final Quality
Score:
Good

C-429
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ekblad and Grenman, • Cohort • Records - not stated if self White
1992 • Combination: reported NR
retrospective data G1: 83.9 (10.1)
Country and setting: Black
from records, G2: 46.7 (3.4)
Finland, hospital NR
prospective weight G3: 73.1 (16.5)
Enrollment Period: and height at delivery G4: 65.0 (12.2) Hispanic
July 1, 1985 - December G5: 58.3 (6.5) NR
Total Study N:
31, 1985 (6 months)
Total n = 357 Pregravid BMI: Asian/Pacific Islander
Funding: • 191 women with G1: 39.5 (3.4) NR
NR abnormal G2: 17.2 (0.9)
G3: 26.1 (6.1) Other
prepregnant weight
Study Objective: (≥ 20% under or over G4: 23.6 (4.1) NR
To evaluate effects of ideal weight for G5: 21.6 (2.0) Smoking,%:
abnormal maternal weight height) or abnormal
or weight gain on Imputed: NR
pregnancy weight
pregnancy outcome • No Diabetes mellitus,%:
gain (≥ 20kg or ≤ 5kg)
Time frame: • 166 controls Categorized: NR
July 1, 1985 to December • Continuous ≥ 20% over or Hypertension,%:
Group Description:
31, 1985 (6 months) under normal weight for NR
G1: ≥ 20% over normal
height
Duration of the study: weight for height Additional characteristics:
Prepregnancy to delivery G2: ≥ 20% under normal Age (mean, yrs): NR
weight for height G1: 28 (5.1)
G3: weight gain ≤ 5kg G2: 25.5 (5.1)
G4: weight gain ≥ 20kg G3: 29.5 (5.1)
G5: control Group 6 G4: 28.7 (4.7)
G5: 28.7 (4.4)
Group N:
G1: 77 Parity:
G2: 28 G1: prior deliveries: 1.0 (1.0)
G3: 30 G2: 0.8 (0.8)
G4: 56 G3: 1.2 (1.1)
G5: 166 G4: 0.8 (1.0)
G5: 0.9 (1.0)
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

C-430
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3712 g (614) Mean symphysis-fundus height: Fair
G2: 28 P < 0.05 compared to
G3: 30 controls Group: Sample selection:
G4: 56 G2: 3293 (362) G1: weight gain ≤ 5kg Poor
G5: 166 P < 0.05 compared to G2: weight gain ≥ 20kg
G3: control: 5-20 kg Definition of maternal
controls weight gain:
Total weight gain: G3: 3284 (880)
G1: 11.8 (6.2) Results Poor
G4: 3803 (538)
P < 0.05 compared to P < 0.005 compared G1: 30.8 cm ± 4.0 Definition of
controls to controls G2: 32.8 cm ± 3.4 outcomes:
G2: 13.4 (4.5) G5: 3538 (535) G3: 35.0 cm ± 3.9 Poor
G3: 3.0 (3.5)
P < 0.0005 compared Gestational Maternal confounders and effect Source of information
to controls diabetes,%: modifiers accounted for in analysis: on exposure,
G4: 23.2 (22.8) NR NR outcomes, and
P < 0.0005 compared
Cesarean Infant and child confounders and effect confounders:
to controls modifiers accounted for in analysis: Fair
G5: 13.2 (3.4) delivery,%:
G1: Elective 7% NR Followup:
Categorized: Emergency 14% Fair
• ≤ 5kg or ≥ 20kg Total 21% Analysis
G2: Elective 4% comparability:
Collected from: Emergency 4%
• Routine pre-natal Poor
Total 8%
care or maternity G3: Elective 3% Analysis of outcomes:
records Emergency 3% Fair
Ascertained by: Total 6%
Interpretation:
• Based on last G4: Elective 5%
Poor
clinically Emergency 18%
measured weight Total 23% Sum of
prior to delivery G5: Elective 13% Good/Fair/Poor:
Emergency 9% 0 Good, 4 Fair, 5 Poor
Total 22%
Final Quality Score:
Instrumental Poor
delivery,%:
NR
Episiotomy,%:
NR
Other maternal
outcomes:
NA
Other infant
outcomes:
NA

C-431
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Guihard-Costa et al., 2004 • Cohort • Routine pre-natal care White
• Retrospective NR
Country and setting: Pregravid BMI:
France, hospital database Total Study N: Black
Imputed: NR
13,972
Enrollment Period: • No
1980-1990 Group Description: Hispanic
Categorized: NR
Funding: Group N: • Continuous
NR Asian/Pacific Islander
Inclusion criteria: Age (mean, yrs): NR
Study Objective: • Liveborn singletons NR
To deterine relative • Term infants (37 to Other
influences of maternal Parity: NR
41 weeks)
factors on infant skinfold NR
• Both parents born in Smoking,%:
thickness and other Ffrance
outcomes NR
• No maternal smoking
Time frame: during gestation Diabetes mellitus,%:
1980-1990 • All data available, NR
specifically Hypertension,%:
Duration of the study: subscapular skinfold
Pregnancy to birth NR
thickness
• French metropolitan Additional characteristics:
mothers NR
Exclusion criteria:
• French mothers born
in French Caribbean
Islands or outside of
France

C-432
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Crown-heel length, head circumference, Good
Total weight gain: subscapular skinfold thickness
Gestational Sample selection:
Categorized: diabetes, %: Groups: Fair
• Continuous NR NA, weight gain continuous variable, results
reported in standardized coefficients (SC). Definition of
Collected from: Cesarean delivery, maternal weight
• Routine pre-natal %: SCs are regression coefficients calculated as
if all of the independent variables had a gain:
care or maternity NR Poor
records variance of 1
Instrumental Results: Definition of
Ascertained by: delivery, %: outcomes:
• Not stated - from NR G1: SC for effect of MWG on crown-heel
length Good
database
Episiotomy, %: G2: SC for effect of MWG on head Source of
NR circumference information on
G3: SC for effect of MWG on subscapular exposure,
Other maternal skinfold thickness outcomes, and
outcomes: confounders:
NA G1: SC 0.142 Fair
Other infant G2: SC 0.120
G3: SC 0.146 Followup:
outcomes: Fair
NA
Maternal confounders and effect modifiers Analysis
accounted for in analysis: comparability:
• Age Fair
• Parity Analysis of
• Pre-gravid BMI outcomes:
• Height Good
Infant and child confounders and effect Interpretation:
modifiers accounted for in analysis: Fair
NR
Sum of
Good/Fair/Poor:
3 Good, 5 Fair, 1
Poor
Final Quality
Score:
Fair

C-433
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kirchengast and • Cohort Estimated by means of White
Hartmann, 2003 • Retrospective retrospective method and first NR
weight determination, which
Country and setting: Total Study N: was carried out at first prenatal Black
Singleton births that took 8,011 visit (8th week of gestation) NR
place at University Clinic G1: 56.0
for Gynecology and Group Description: Hispanic
G1: 12 to 16 years G2: 57.2 NR
Obstetrics in Vienna, G3: 59.2
Austria G2: 17 to 19 years
Asian/Pacific Islander
G3: 20 to 29 years Pregravid BMI:
Enrollment period: NR
Group N: G1: 21.45
NR G2: 21.59 Other
G1: 215
Funding: G3: 22.10 NR
G2: 1,336
NR G3: 6,460 Imputed: Smoking,%:
Study Objective: • Yes NR
Inclusion criteria:
Examine impact of • Women ages 12 to Diabetes mellitus,%:
Categorized:
biological factors such as 29 NR
• Continuous
young maternal age and • All prenatal check-
maternal somatic Age (mean, yrs): Hypertension,%:
ups of mother-child
characteristics on G1: 14.5 NR
passport were
pregnancy outcome performed G2: 17.8 Additional characteristics:
among group of • Delivery of single G3: 24.1 Age at menarche:
adolescent mothers who infant without G1: 12.2
gave birth between 39th Parity:
congenital NR G2: 12.9
and 41st week of malformations G3: 13.3
gestation after period of • Receiving
intensive psychological Gynecological age:
psychosocial support
support G1: 3.4
by family and/or
G2: 5.3
Time frame: specially trained
G3: 10.8
NR social worker within
young adolescent
Duration of the study: group (12 to 16
1985 to 1995 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

C-434
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 215 G1: 3237.6 Change in infant size Good
G2: 1,336 (significantly characteristics per 1 kg
G3: 6,460 different from 17- increase in MWG Sample selection:
19 and 20-29) Fair
Total weight gain: G2: 3298.3 Groups
G1: 13.1 Definition of maternal weight
(significantly NA, weight gain as continuous gain:
G2: 13.1 different from variable
G3: 13.1 (P = .10) Fair
< 17 and 20-29)
Categorized: G3: 3368.9 Results Definition of outcomes:
(significantly G1: Birth length (cm) Good
• Continuous
different from G2: Head circumference (cm) Source of information on
Collected from: < 17 and 17-19) G3: Acromial circumference exposure, outcomes, and
• Routine pre-natal (F = 24.1, (cm) confounders:
care or maternity P < .0001) G4: Diameter frontoccipitalis Fair
records (cm)
Gestational Followup:
Ascertained by: diabetes, %:
G1: β = 0.55 (0.43-0.68) Good
• Based on last NR
clinically G2: β = 0.33 (0.23-0.42) Analysis comparability:
measured weight Cesarean G3: β = 0.47 (0.39-0.55) Good
prior to delivery delivery,%: G4: β = 0.12 (0.07-0.18)
NR Analysis of outcomes:
Fair
Instrumental Maternal confounders and
delivery,%: effect modifiers accounted Interpretation:
NR for in analysis: Fair
Maternal age, age at Sum of Good/Fair/Poor:
Episiotomy,%:
menarche, pregravid weight, 4 Good, 5 Fair, 0 Poor
NR
height, distantia cristarum
Other maternal Final Quality Score:
Infant and child confounders Fair
outcomes
and effect modifiers
• Chronological
accounted for in analysis:
age
NR
• 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

C-435
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kramer et al., 1990 • Cohort • Self-reportedNR White
• Prospective G1: 57.8 kg (10.8) NR
Country and setting:
G2: NR
Canada, university Total Study N: Black
hospital 8,719 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1980 to 1986 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
National Health Research Group N: • They used prepregnancy NR
and Development G1: 8715 wt and ht separately
Program, Health and Other
G2: NR • NR
Welfare Canada NR
Inclusion criteria: Age (mean, yrs):
Study Objective: Smoking,%:
• Live-born, singleton G1: 28.6 (4.7) Cigarettes/d:
(1) Which maternal and infants without G2: NR G1: 3.2 (7.5)
fetal variables appear to evidence of
have independent causal Parity: G2: NR
congenital
impacts on intrauterine intrauterine infection, G1: 0.72 (0.86) Diabetes mellitus,%:
growth? (2) For a given chromosomal G2: NR NR
fetal growth status, which anomalies, or other
maternal and fetal Hypertension,%:
major malformations
variables affect Pg related HTN:
and for whom
proportionality? G1: 7.7%
gestational age
G2: NR
Time frame: calculated from last
1980 to 1986 normal menstrual Additional characteristics:
period agreed within Education, y completed:
Duration of the study: ±7 days with an early G1: 13.0 (3.3)
Entry in to prenatal care second-trimester G2: NR
up to delivery (usually 16 to 18
weeks) Marital status:
• Ultrasonographic G1: 90.6%
estimate based on G2: NR
fetal biparietal Parity % primaparas:
diameter G1: 48.0
Exclusion criteria: G2: NR
• See above

C-436
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 8715 G1: 3385g (547) Length, head circumference, Good
G2: NR G2: NR BMI, Ponderal Index,
weight/head circumference Sample selection:
Total weight gain: Gestational diabetes, Fair
G1: 14.2kg (5.5) %: Groups:
G2: NR NR NA, weight gain continuous Definition of maternal weight
variable gain:
Categorized: Cesarean delivery, %: Poor
• Continuous NR Results:
Correlation coefficients between Definition of outcomes:
Collected from: Instrumental delivery, MWG and: Good
• Routine pre-natal %: G1: Length
NR Source of information on
care or maternity G2: Head circumference exposure, outcomes, and
records G3: BMI
Episiotomy, %: confounders:
Ascertained by: NR G4: Ponderal Index Poor
• Based on last G5: Weight/Head circumference
Other maternal G1: -0.04 Followup:
clinically outcomes: Fair
measured weight (P < 0.01)
• Bivariate G2: -0.01
prior to delivery, Analysis comparability:
asssociations G3: 0.04
using net weight Fair
between selected (P < 0.01)
gain (total weight
maternal and fetal G4: 0.04 Analysis of outcomes:
minus wt of
variables and fetal (P < 0.01) Fair
infant)
growth and G5: 0.01
proportionality: Interpretation:
Correlation Fair
Net gestational weight gain was
coefficient for net associated with correlation Sum of Good/Fair/Poor:
gestational weight coefficients of -0.04 for length, - 2 Good, 5 Fair, 2 Poor
gain (kg)and fetal 0.01 for head circumference,
growth ratio = 0.12 0.04 for BMI, 0.04 for Ponderal Final Quality Score:
(P < 0.001); for Index, and 0.01 for weight/head Fair
prepregnancy circumference. Results were
weight (kg) 0.21 (P significant
< 0.001) (P < 0.01) for length, BMI, and
Other infant Ponderal Index
outcomes: Maternal confounders and
• Correlation effect modifiers accounted for
coefficients for Net in analysis:
prepregnancy • Parity
weight gain (kg) • GDM
and length = -0.04 • Pregnancy induced
(P < 0.01) hypertension
• Head • Obesity (How defined or
circumference = - categorized?)
0.01 (NS); BMI • previous lbw,
0.04 (P < 0.001); • Smoking
Ponderal index =
0.04 (P < 0.001) Infant and child confounders
• Weight/height and effect modifiers
circumference = accounted for in analysis:
0.01 (NS) • Birth weight
• Sex of the infant

C-437
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Shepard et al., 1996 • Cohort • records White
• Combination: G1: 53.1 (0.6) NR
Country and setting:
Retrospective records G2: 59.8 (0.5)
Norway and Sweden, Black
for pregravid weight, G3: 72.3 (0.7) P = 0.0001
multicenter study NR
prospective for fetal
Pregravid BMI:
Enrollment Period: growth Hispanic
January 1, 1986 to March Imputed: NR
Total Study N:
31, 1988 • No
369 Asian/Pacific Islander
Funding: Categorized: NR
Group Description:
NICHHD • Quetelet’s Index: ≤ 19.9;
G1: Low BMI, ≤ 19.9 Other
Study Objective: G2: Average BMI, 20-23.3 20-23.3; > 23.3 NR
To examine impact of G3: High BMI, > 23.3 Age (mean, yrs): Smoking,%:
BMI, proportional weight G1: 29.1 (0.3)
Group N: G1: # daily cigarette, 17
gain, and other variables G2: 29.9 (0.4)
on fetal growth weeks: 3.7 (0.5)
Inclusion criteria: G3: 30.0 (0.4) P = 0.14 G2: 2.5 (0.4)
Time frame: • Random 10% sample G3: 3.3 (0.1) P = 0.17
January 1, 1986 to March of NICHD SGA study Parity:
cohort (n = 571) of NR Diabetes mellitus,%:
31, 1988
women with data on NR
Duration of the study: prepregnant weight
Early pregnancy (before Hypertension,%:
and weight gain and
17 wks gestation) through NR
ultrasound
37 wks gestation measurements Additional characteristics:
NR
Exclusion criteria:
NR

C-438
Evidence Table 31. Gestational weight gain and other infant growth characteristics (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 3517.1 (50.9) • Estimates of fetal growth rate in 3 time Good
Total weight gain: G2: 3677.9 (37.5) periods, model for weeks 17 to 25 adjusted
G1: Overall G3: 3837.1 (52.0) Sample selection:
for maternal BMI; model for weeks 25 to 33
proportional weight P = 0.0001 Fair
adjusted for maternal BMI, maternal age,
gain (%): 23.1
previous SGA, and male infant; model for Definition of
G2: 20.3 Gestational
33-37 weeks adjusted for maternal BMI maternal weight
G3: 16.7 P = 0.0001 diabetes, %:
and female infant gain:
NR
Categorized: Fair
Groups:
• Measured at 3 Cesarean delivery,
NA, continuous weight gain measure
%: Definition of
study time
NR outcomes:
periods - Results:
Good
expressed as a Increase in mean abdominal fetal growth rate
Instrumental
proportion of (mm/day) per 5% increase in proportional Source of
delivery, %:
prepregnant weight gain in this period: information on
NR
weight gained • Weeks 17-25, β = 0.35 (P = 0.49) exposure,
during that time Episiotomy, %: • Weeks 25-33, β = 0.88 (P = 0.02) outcomes, and
Collected from:
NR • Weeks 33-37, β = 1.53 (P = 0.02) confounders:
Fair
• Collected by Other maternal
study outcomes: Maternal confounders and effect modifiers Followup:
investigators NA accounted for in analysis: Good
Ascertained by: • Age
Other infant Analysis
• Overall outcomes: • Pre-gravid BMI comparability:
proportional NA • Previous SGA Fair
weight gain Infant and child confounders and effect Analysis of
modifiers accounted for in analysis: outcomes:
• Infant sex Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
3 Good, 6 Fair, 0
Poor
Final Quality
Score:
Fair

C-439
Evidence Table 32. Gestational weight gain and childhood weight status
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Li, 2007 • Cohort • Self-reported White
• Prospective 77.8
Country and setting: Pregravid BMI:
USA, national survey Total Study N: Black
Imputed: 15.3
1739
Enrollment Period: • Yes
1959 to 1966 Group Description: Hispanic
G1: Early overweight Categorized: 6.9
Funding: • < 25, 25-29, > 29
G2: Late overweight
NR Smoking,%:
G3: Never overweight Age (mean, yrs): NR
Study Objective: Age at birth
To evaluate <25: 40.9%% Diabetes mellitus,%:
Group N:
developmental trajectories 25 to 29: 50.5% NA
G1: 10.9%
of overweight in children 30 or more: 8.6%
G2: 5.2% Hypertension,%:
and assess early life
G3: 83.9% Parity: NR
influences
Birth order Additional characteristics:
Time frame: 1: 41.1%
Inclusion criteria: NR
1986 to 2000 2: 36.9%
• Data from National
Duration of the study: Longitudinal Survey 3 or more: 22.0%
20 years 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.

C-440
Evidence Table 32. Gestational weight gain and childhood weight status (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
<2500 : 3.5% Overweight status for children for upto 12 Good
Total weight gain: 2500-3999: 81.6% years
• NR 4000 or more: 12.9% Sample selection:
Groups: Fair
Gestational Maternal weight gain categories (kg):
diabetes, %: G1: < 15 lbs Definition of
0% G2: 15-24 lbs maternal weight
G3: 25-34 lbs gain:
Cesarean G4: 35-44 lbs Fair
delivery,%: G5: > 45 lbs
NR Definition of
Results: outcomes:
Instrumental AOR (95% CI) for early onset overweight Good
delivery, %: (early onset of overweight
NR Source of
that persisted throughout childhood) information on
Episiotomy, %: compared with normal (low exposure, outcomes,
NR probability of overweight throughout and confounders:
childhood and was Poor
Other maternal characterized as the never overweight
outcomes: class) Followup:
NR G5: 1.7 (1.0-2.9) Good
Other infant G3: 1.0 (reference) Analysis
outcomes: comparability:
NR Other AOR for weight gain categories for Fair
early onset overweight not significant
compared with weight gain 25-34 lbs Analysis of
outcomes:
No association between maternal weight Good
gain and risk of late onset overweight
Interpretation:
(moderately high probability of overweight
Fair
at age 2 years, low probability of
overweight at age 4 and 6 years, but Sum of
growing probability of overweight after age Good/Fair/Poor:
8 years) 4 Good, 4 Fair, 1 Poor
Maternal confounders and effect Final Quality Score:
modifiers accounted for in analysis: Fair
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

C-441
Evidence Table 32. Gestational weight gain and childhood weight status (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Oken et al., 2007 • Cohort • Self-reported White
• Prospective G1: 74%
Country and setting: Pregravid BMI:
Reported elsewhere Total Study N: G1: 24.6 (SD 5.0) Black
1,044 G1: 11%
Enrollment period: Imputed:
NR Group Description: • No Hispanic
G1: Total G1: 6%
Funding: Categorized:
Supported by grants from Group N: • IOM guidelines Other
US National Institutes of G1: 1,044 G1: 10%
Health (HD 34568, HL Age (mean, yrs):
64925, HL68041, HD Inclusion criteria: G1: 15-24: 6% Smoking,%:
44807), the Robert Wood Women delivering live 25-34: 62% G1: Never: 67%
Johnson Foundation, singleton infant and 35-44: 32% Quit before pregnancy 20%
Harvard Medical School, enrolled for continuation Smoked in early pregnancy 10%
and Harvard Pilgrim of study beyond 6 months Parity:
G1: Nulliparous: 48% Diabetes mellitus,%:
Health Care Foundation after delivery
Parous: 52% G1: 4%
Study Objective: Exclusion criteria:
Purpose of study to • Missing information
examine associations of on prepregnancy
gestational weight gain weight, parental BMI,
with child adiposity or infant birthweight,
or who did not have a
Time frame: weight recorded
NR within 4 weeks
Duration of the study: preceding delivery
Entry to prenatal care thru
delivery

C-442
Evidence Table 32. Gestational weight gain and childhood weight status (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR • Association of MWG with Good
child adiposity-related
Total weight gain: Gestational Sample selection:
outcomes at age 3 years,
G1: 15.6 kg (5.4) diabetes, %: Fair
before and after adjustment
G1: 4%
Categorized: for potential confounding Definition of maternal weight
• Continuous Cesarean and pathway variables. gain:
According to IOM delivery,%: Effect increments are for a 5 Fair
G1: 23% kg increment in total weight
Collected from: G2: 12% gain. Definition of outcomes:
• Routine pre-natal G3: 35% Good
care or maternity G4: 53% Groups:
MWG for 5 kg increments Source of information on
records
Instrumental exposure, outcomes, and
Ascertained by: Results: confounders:
delivery,%:
• Based on last AOR (95%CI) BMI≥95th Good
NR
clinically percentile vs BMI<50th
percentile associated with a 5 kg Followup:
measured weight Episiotomy,%: Fair
prior to delivery NR increase in gestational weight
gain: Analysis comparability:
Other maternal 1.52 (1.19-1.94)
outcomes: Fair
NR Child BMI z-score at age 3 years Analysis of outcomes:
Other infant for AOR listed above (95% CI): Fair
outcomes: 0.11 (0.05, 0.17)Maternal Interpretation:
NR confounders and effect Good
modifiers accounted for in Sum of Good/Fair/Poor:
analysis: 4 Good, 5 Fair, 0 Poor
• Breastfeeding
• Education Final Quality Score:
• Time between last Fair
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

C-443
Evidence Table 32. Gestational weight gain and childhood weight status (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ong et al., 2000 • Cohort • Obstetric records, not White
• Combination: stated whether it was self NR
Country and setting:
Maternal data reported
UK, Avon longitudinal Black
retrospective, infant
study of pregnancy and Pregravid BMI: NR
prospective
childhood
Imputed: Hispanic
Total Study N:
Enrollment Period: • No NR
848
Births from April 1991-
December 1992 followed Categorized: Asian/Pacific Islander
Group Description:
to age 5 years • Continuous NR
Group N:
Funding: Age (mean, yrs): Other
Medical Research Inclusion criteria: NR NR
Council, Wellcome Trust, • 10% sample of births
Parity: Smoking,%:
Department of Health, in longitudinal study NR
cohort with NR
Department of the
Environment information on weight Diabetes mellitus,%:
measurements NR
Study Objective:
To identify predictors of Exclusion criteria: Hypertension,%:
postnatal catch up growth • NA NR
from birth to 2 years and Additional characteristics:
its relation to size and NR
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

C-444
Evidence Table 32. Gestational weight gain and childhood weight status (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • Catch-up and catch-down Fair
Total weight gain:
growth
Gestational Sample selection:
Categorized: diabetes, %: Fair
Groups:
• Continuous NR Maternal weight gain, continuous
Definition of maternal weight
Collected from: measure
Cesarean delivery, gain:
• Routine pre-natal %: Result: Poor
care or maternity NR Children were grouped into three
records Definition of outcomes:
growth categories (catch-up, no
Instrumental Good
Ascertained by: change, and catch-down) based
delivery, %:
• Based on last on a gain in weight (SD score > Source of information on
NR
clinically 0.67 for catch-up; SD score < exposure, outcomes, and
measured weight Episiotomy, %: 0.67 for catch-down. confounders:
prior to delivery: NR Fair
obstetric records Other maternal Maternal weight gain was not a
- not stated significant predictor of catch-up Followup:
outcomes: growth between 0 and 2 years Fair
NA
Maternal confounders and Analysis comparability:
Other infant effect modifiers accounted for Fair
outcomes: in analysis:
NA Analysis of outcomes:
NR Fair
Infant and child confounders Interpretation:
and effect modifiers Fair
accounted for in analysis:
NR Sum of Good/Fair/Poor:
1 Good, 7 Fair, 1 Poor
Final Quality Score:
Fair

C-445
Evidence Table 32. Gestational weight gain and childhood weight status (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Sowan and Stember, • Cohort • Self-reported White
2000 • Prospective NR
Pregravid BMI:
Country and setting: Total Study N: Black
USA, sample from Infant Imputed: NR
630
Growth Study Database • No
Group Description: Hispanic
Enrollment Period: NR Categorized: NR
NR • Continuous
Group N: Asian/Pacific Islander
Funding: NR Age (mean, yrs): NR
AAUW, NRSA, NIH, NINR NR
Inclusion criteria: Other
Study Objective: • Normal infant at birth Parity: NR
To facilitate an (i.e. no organic NR
understanding of influence Smoking,%:
etiology) NR
of parental characteristics • Mother able to
on development of infant communicate in Diabetes mellitus,%:
obesity English NR
Time frame: Exclusion criteria: Hypertension,%:
NR • Infants weighing less NR
Duration of the study: than 2500g at birth
Additional characteristics:
Birth through 15 months • Preterm infants (< 37 NR
postpartum weeks)

C-446
Evidence Table 32. Gestational weight gain and childhood weight status (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • Infant obesity (BMI> gender Good
Total weight gain:
and age specific 84th
Gestational Sample selection:
Categorized: percentile based on Infant
diabetes, %: Fair
• Continuous, 5 Growth Study population
NR
pound Definition of maternal weight
Groups:
increments Cesarean delivery, gain:
Maternal weight gain in 5 pound
%: Poor
Collected from: increments
NR
• Self-reported Definition of outcomes:
Results:
Instrumental Good
Ascertained by: Model AOR (95%CI) for infant
delivery, %:
• Self-reported obesity (BMI> gender and age Source of information on
NR th
specific 84 percentile based on exposure, outcomes, and
Episiotomy, %: Infant Growth Study population confounders:
NR norms) at 1, 4, 7, and 10 months: Poor
NS
Other maternal Followup:
outcomes: AOR (95%CI) for obesity at 14 Fair
NA months: .8 (0.7-1.0) Analysis comparability:
Other infant Maternal confounders and Fair
outcomes: effect modifiers accounted for
NA Analysis of outcomes:
in analysis: Fair
• Age
• Race Interpretation:
• Pre-gravid BMI Poor
• Marital status Sum of Good/Fair/Poor:
• Psychosocial factors 2 Good, 4 Fair, 3 Poor
• Sociocultural factors
• Smoking Final Quality Score:
Poor
Infant and child confounders
and effect modifiers accounted
for in analysis:
• Infant gender
• Birth BMI
• BMI at previous month

C-447
Evidence Table 33. Gestational weight gain and childhood hospitalization
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Yuan et al., 2001 • Cohort • Self-reported, may be White
• Retrospective from hospital records - not NR
Country and setting:
specifically stated
Denmark, birth cohort Total Study N: Black
from midwife centers 10,440 Pregravid BMI: NR
G1: < 18: 5.8%;
Enrollment Period: Group Description: Hispanic
18-20: 42.8%;
April 1984 to April 1987 G1: Cohort NR
21-23: 33.5%;
G2: NR ≥ 24: 17.9%
Funding: Asian/Pacific Islander
Grant from Medical Group N: G2: NR NR
Research Council G1: 10,400 Imputed: Other
G2: NR •
Study Objective: No NR
To examine whether Inclusion criteria: Categorized: Smoking,%:
maternal prenatal lifestyle • Children born to
factors were associated • < 18, 18-20, 21-23, > 24 G1: 44.3
mothers attending G2: NR
with risk of hospitalization midwife centers at Age (mean, yrs):
with infectious disease approximately 36th NR Diabetes mellitus,%:
during early childhood and week gestation in 2 NR
whether a possible study areas in Parity:
association was modified NR Hypertension,%:
Denmark
by fetal growth reduction NR
Exclusion criteria:
Time frame: Additional characteristics:
• Stillbirths
April 1984 to April 1987 NR
• Multiple births
Duration of the study: • Children with
Prenatal period through congenital
early childhood (6 to 12 malformations
yrs)

C-448
Evidence Table 33. Gestational weight gain and childhood hospitalization (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 7550 NR • Adjusted incidence rate ratio (IRR) of Fair
G2: NR hospitalization with infectious disease
Gestational Sample
(95% CI)
Total weight gain: diabetes, %: selection:
G1: < 10kg: 19.1%; NR Groups: Fair
10-12: 24.6%; G1: < 13kg
13-15: 26.0%; Cesarean delivery, Definition of
G2: ≥ 13kg
%: maternal weight
≥ 16: 30.3%
G2: NR NR Results: gain:
G1: 1.05 (0.76-1.47) Poor
Instrumental
Categorized: G2: 1.42 (1.09-1.86)
delivery, %: Definition of
• < 10, 10-12, 13-
NR All gestational weight gain outcomes:
15, ≥ 16 kg
1.29 (1.05-1.59) Good
Episiotomy, %:
Collected from:
NR Source of
• Routine pre-natal Stratification of analyses by either
information on
care or maternity Other maternal prepregnancy BMI or gestational weight gain
exposure,
records outcomes: did not show any difference in associations
outcomes, and
NR between maternal smoking, alcohol, tea, and
Ascertained by: confounders:
fruit intake and hospitalization with infectious
• Based on last Other infant Poor
disease (of child from 6 months to 12 years)
clinically outcomes: Followup:
measured weight NR Good
prior to delivery Maternal confounders and effect modifiers
accounted for in analysis: Analysis
• Age comparability:
• Paternal age Fair
• Social group
Analysis of
• Maternal cohabitation status
outcomes:
• Number of siblings at birth for infant Good
• Smoking
Interpretation:
Infant and child confounders and effect Good
modifiers accounted for in analysis:
NR Sum of
Good/Fair/Poor:
4 Good, 3 Fair, 2
Poor
Final Quality
Score:
Fair

C-449
Evidence Table 34. Gestational weight gain and postpartum weight retention
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Callaway et al., 2007 • Cohort • Correlated with first White
• Prospective prenatal visit weight G1: 94.9%
Country and setting: G2: 89.8%
r = 0.95
Australia, hospital Total Study N: G3: < 0.001
3,572 Pregravid BMI:
Enrollment period: Black
G1: 21.9 (3.8)
Received antenatal care Group Description: NR
G2: 22.0 (4.1)
between 1981 and G1: Included G3: 0.1
1984, then followed 21 G2: Excluded Hispanic
years later G3: P value Imputed: NR
• No
Funding: Group N: Asian/Pacific Islander
Authors thank National G1: 3,572 Categorized: NR
Health and Medical G2: 3,651 • Continuous
Research Council and Other
Queensland Health for Inclusion criteria: Age (mean, yrs): NR
funding this project. L. • Women delivered G1: 25.0 (5.1) Smoking,%:
K. C. was supported by live singleton baby, G2: 24.1 (5.2) G1: 46.9%
a National Health and who neither died G3: < 0.001 G2: 53.0%
Medical Research nor was adopted G3: < 0.001
prior to leaving Parity:
Council Postgraduate G1: nulliparous 35.7%
Medical Scholarship at hospital, and Diabetes mellitus,%:
completed both G2: nulliparous 30.8% NR
commencement of this G3: < 0.001
work. D. A. L. is initial phases of
Hypertension,%:
fundedby a United data collection
NR
Kingdom Department of Exclusion criteria:
Health Career Scientist Additional characteristics:
NR
Award NR
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

C-450
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 3,572 G1: 3,388 (518) Postpartum weight Good
G2: 3,651 G2: 3,382 (523) retention
G3: 0.7 Sample selection:
Total weight gain: Groups Good
G1: 14.8 (6.03? vs Gestational G1: Maternal weight gain
14.6) diabetes, %: <=15kg Definition of maternal
G2: 14.9 (14.7) NR G2: Maternal weight gain weight gain:
G3: 0.3 >15kg Fair
Cesarean
Categorized: delivery,%: Results Definition of outcomes:
Good
• Continuous NR G1: Mean change (95%CI)
in BMI at 21 years Source of information on
Collected from: Instrumental postpartum: 5.06 kg/m2
delivery,%: exposure, outcomes, and
• Routine pre- (4.85-5.27)
NR confounders:
natal care or G2: Mean change (95%CI) Poor
maternity in BMI at 21 years
Episiotomy,%:
records postpartum: 6.40 kg/m2 Followup:
NR
(6.19-6.61) Good
Ascertained by:
Other maternal P < 0.001
NR Analysis comparability:
outcomes: G2 was associated with a Good
• Univariable mean change in BMI
association of over 21 years of 0.19 Analysis of outcomes:
MWG with 2
kg/m (95%CI: 0.16- Good
mean change 0.22)
in BMI over 21 Interpretation:
years: MWG < Maternal confounders Good
= 15: 5.06 and effect modifiers
Sum of Good/Fair/Poor:
(4.85, 5.27), accounted for in
7 Good, 1 Fair, 1 Poor
MWG >15: 6.4 analysis:
(6.19, 6.61) • Baseline income Final Quality Score:
< 0.001. • Secondary school Fair
Women with completion
HDP gained on • Ethnicity
average 2.01 • Maternal age at birth
kg (95% CI, • Parity
1.41 kg, 2.61 • Birth weight
kg) more than • Gestational age
women without • Infant sex
HDP • Maternal smoking
Other infant during pregnancy
outcomes: • Smoking at 21 years
NR • 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

C-451
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Harris et al., 1999 • Cohort • Measured during first White
• Prospective trimester of NR
Country and setting:
pregnancy at prenatal
UK, antenatal care Total Study N: Black
visit
project 74 NR
G1: NR
Enrollment Period: Group Description: G2: NR Hispanic
Not stated G1: Women with long- G3: 66.23 (1.25) NR
term weight gains < Pregravid BMI:
Funding: Asian/Pacific Islander
0.4kg G1: 25.0 (0.6)
DevR fund of University NR
G2: Women with long- G2: 24.2 (0.7)
of Greenwich; NHS
term weight gains > Other
Executive, South
0.4kg Imputed: NR
Thames
G3: Total sample • No
Study Objective: Smoking,%:
Group N: Categorized: G1: % continual smokers:
To assess relative
importance of heritable
G1: 37 • Continuous 18.9
G2: 37 G2: % continual smokers:
characteristics and Age (mean, yrs):
G3: 74 18.9
lifestyle in development G1: 33.4 (0.8)
of maternal obesity after G3: % smokers at first
Inclusion criteria: G2: 33.7 (0.8)
pregnancy antenatal visit: 43.2
• Women who had G3: 33.54 (0.56)
Time frame: been enrolled in Diabetes mellitus,%:
Antenatal Care Parity: NR
Not stated G1: NR
Project who had been
Duration of the study: G2: NR Hypertension,%:
weighed during first
First antenatal visit to trimester of G3: % nulliparous: 37.8 NR
2.5 years post delivery pregnancy and had Additional characteristics:
not become pregnant G1: % married: 54.1
since birth of child G2: 56.8
carried during ANC G3: 55.4
project
Additional characteristics:
Exclusion criteria: G1: Duration of followup
• Women with missing (days): 1141.2 (20.0)
data G2: 1181.8 (20.6)

C-452
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 37 NR Postpartum weight Good
G2: 37 retention
G3: 74 Gestational Sample selection:
diabetes, %: Groups Good
Total weight gain: NR Continuous maternal
G1: 13.14 (1.07) kg Definition of maternal
Cesarean delivery, weight gain, kg weight gain:
G2: 12.73 (0.82)
G3: 12.93 (0.67) %: Fair
NR Results
Categorized: ANCOVA model with Definition of outcomes:
Instrumental weight (kg) at 2.5 years Fair
• Continuous
delivery, %: postpartum as dependent
NR Source of information on
Collected from: variable and maternal exposure, outcomes, and
• Self-reported weight gain (kg) as
Episiotomy, %: confounders:
NR independent variable: Fair
Ascertained by:
B = -0.031
• Self-reported Other maternal Followup:
β = -0.029
outcomes: SEM = 0.120 Good
Mean long term P = 0.796
weight gain in Analysis comparability:
association with Maternal confounders Good
pregnancy was and effect modifiers
Analysis of outcomes:
0.50 (0.71)kg, accounted for in
Good
overall the mothers analysis:
in sample not • Marital status Interpretation:
significantly heavier • Increased Fair
after pregnancy dissatisfaction with
Sum of Good/Fair/Poor:
than were before body
5 Good, 4 Fair, 0 Poor
(95%CI: -0.89- • Increased access to
1.89); however, food increased energy Final Quality Score:
these long term intake Good
weight gains were • Decreased activity
very variable • Smoking status
ranging from 13.6kg
Infant and child
in weight loss to
confounders and effect
17.7 kg in weight
modifiers accounted for
gain
in analysis:
Other infant • Gestational age
outcomes:
NR

C-453
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Harris et al., 1997 • Cohort • Abstracted from each White
• Retrospective mother’s obstetric notes NR
Country and setting:
UK, city hospital Total Study N: Pregravid BMI: Black
1,637 (523 included and G1: 23.45 (0.17) NR
Enrollment Period:
694 excluded) G2: 23.59 (0.18)
1992-1993 Hispanic
Group Description: Imputed: NR
Funding:
G1: Included women • No
DevR fund of University Asian/Pacific Islander
G2: Excluded women
of Greenwich Categorized: NR
Study Objective:
Group N: • Continuous Other
G1: 523
Investigated Age (mean, yrs): NR
G2: 694
independent G1: 29.6 (0.2)
associations between Smoking,%:
Inclusion criteria: G2: 28.9 (0.2)
parity and maternal G1: 22.4
• Women who had G2: 27.0
body mass index and singleton births at Parity:
between parity and hospital between G1: % parity = 1: 73.4% Diabetes mellitus,%:
maternal weight gain 1992 and 1993 with G2: 54.5% NR
Time frame: obstetric notes
Hypertension,%:
1992 to 1993 available for their
G1: 0
previous pregnancy
G2: 0
Duration of the study: • Women who were
Previous pregnancy weighed regularly Additional characteristics:
through current during pregnancy NR
pregnancy and birth • 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)

C-454
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 523 G1: 3384.1 (21.2) Postpartum weight Poor
G2: 694 G2: 3338.8 (20.2) retention
Sample selection:
Total weight gain: Gestational Groups Fair
G1: Rate of weight diabetes, %: G1: Maternal weight gain
gain: 0.47 (0.01) NR during previous Definition of maternal
G2: 0.44 (0.1) pregnancy(kg), continuous weight gain:
Cesarean delivery, G2: Interpregnancy weight Fair
Categorized: %: change (kg), defined Definition of outcomes:
• Continuous NR as the difference Good
Collected from: Instrumental between weight at start
delivery, %: of index pregnancy Source of information on
• Routine pre-
NR and weight at start of exposure, outcomes, and
natal care or
previous pregnancy confounders:
maternity
Episiotomy, %: Fair
records Results
NR
ANCOVA model with G2 Followup:
Ascertained by:
Other maternal as dependent variable and Good
• Based on last outcomes:
clinically G1 as independent Analysis comparability:
NA variable:
measured Fair
weight prior to Other infant B = 0.262
outcomes: β = 0.227, Analysis of outcomes:
delivery: based
on difference NA SEM = 0.52 Good
between first P < 0.001
Interpretation:
antenatal Maternal confounders Fair
weight and effect modifiers
measurement Sum of Good/Fair/Poor:
accounted for in
and last 3 Good, 5 Fair, 1 Poor
analysis:
antenatal • Marital status Final Quality Score:
measurement • Smoking status Fair
usually • Alcohol
recorded within
• Parity
1 week of
• Age
delivery
• 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

C-455
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Harris et al., 1997 • Cohort • Used weight White
• Retrospective measurements recorded NR
Country and setting:
during first trimester of
UK, hospital Total Study N: Black
pregnancy (up to 13
243 NR
Enrollment Period: weeks gestation)
1990-1993 Group Description: Hispanic
Pregravid BMI:
G1: Mothers included in NR
Funding: G1: 24.2 (0.5)
study G2: 23.5 (0.1)
DevR Fund of University Asian/Pacific Islander
G2: Mothers excluded
of Greenwich NR
from study Imputed:
Study Objective: • No Other
Group N:
To investigate impact of NR
G1: 243 Categorized:
pregnancy on long term
weight gain of
G2: 2,154 • Continuous Smoking,%:
primiparous mothers G1: Nonsmoker: 76.6%
Inclusion criteria: Age (mean, yrs):
and to identify potential G2: Nonsmoker: 70.0%
• Singleton births G1: 26.2 (0.4)
risk factors for maternal • Multiparous women G2: 24.5 (0.1) Diabetes mellitus,%:
obesity with 2 consecutive NR
Parity:
Time frame: births at hospital
NR Hypertension,%:
1990 to 1993 Exclusion criteria: G1: PIH: 23.4%
Duration of the study: • Incomplete G2: 24.5%
Initiation of prenatal obstetric records for
Additional characteristics:
care during first 1 or more previous
Married:
pregnancy to beginning pregnancy
G1: 79.8%
of second pregnancy (n = 863)
G2: 66.9%
• Not weighed
regularly during Left hospital breast feeding:
both first and G1: 59.1%
second G2: 53.4%
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)

C-456
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 243 G1: 3.3338 (0.0533) Postpartum weight Good
G2: 2154 G2: 3.2886 (0.017) retention
Sample selection:
Total weight gain: Gestational Groups Good
G1: rate of weight diabetes,%: G1: Maternal weight gain
gain (kg/week): NR during first pregnancy Definition of maternal
0.48 (0.01) as a continuous weight gain:
G2: 0.48 (0.01) Cesarean measure (kg) Fair
delivery,%: G2: Interpregnancy weight
Categorized: G1: 18.1 Definition of outcomes:
change (kg), Good
• Continuous G2: 14.1 defined as the difference
Instrumental between weight at start Source of information on
Collected from:
delivery,%: of first pregnancy and exposure, outcomes, and
• Routine pre-
Assisted Non- weight at start of the confounders:
natal care or
Cesarean: second pregnancy Fair
maternity
records G1: 13.8% Results Followup:
G2: 13.3% ANCOVA model with G2 as Fair
Ascertained by:
• Based on last Episiotomy,%: dependent variable and G1 Analysis comparability:
clinically as independent variable: Fair
Other maternal B = 0.176
measured outcomes: β = 0.169 Analysis of outcomes:
weight prior to
• Examining SEM = 0.070 Fair
delivery
change in P < 0.013
maternal body Interpretation:
weight from Maternal confounders Fair
beginning of first and effect modifiers
Sum of Good/Fair/Poor:
pregnancy to accounted for in
3 Good, 6 Fair, 0 Poor
beginning of analysis:
second • Marital status Final Quality Score:
pregnancy • Lactation Fair
(interpregnancy • Smoking status
weight change) • Alcohol
and gestational • Height
weight gain • Nulliparous BMI
during first • Birth weight
pregnancy • Gestational age at
Other infant start of previous
outcomes: pregnancy
NA • Terminations between
pregnancy
• Interpregnancy interval
Infant and child
confounders and effect
modifiers accounted for
in analysis:
• Gestational age

C-457
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hunt et al., 1995 • Cohort • Self-reportedvalidated White
• Prospective by hospital records NR
Country and setting:
G1: at ages 20-24: 64.4
USA, 2 separate Total Study N: Black
(9.0)
sources: population- Controls = 115 NR
G2: at ages 20-24: 55.8
based family history Morbidly obese = 96 (7.0) Hispanic
database and
participation in a study Group Description: NR
Pregravid BMI:
on obesity G1: Morbidly obese G1: at ages 20-24: 23.3 Asian/Pacific Islander
G2: Random control (2.9)
Enrollment Period: NR
Group N: G2: at ages 20-24: 20.6
1991-1992 Other
G1: 96 (2.2)
Funding: NR
G2: 115 Imputed:
NIH grant DK44655 Smoking,%:
Inclusion criteria: • No
Study Objective: NR
• Women with 1 or Categorized:
To examine impact of more pregnancies Diabetes mellitus,%:
pregnancy during • NR
• Ages 30-59 NR
weight gain on later • Living in Utah Age (mean, yrs):
weight status in G1: 48.1 (8.6) Hypertension,%:
morbidly obese women; Exclusion criteria: G2: 44.0 (5.2) NR
i.e. to study role of • Morbidly obese Additional characteristics:
pregnancy in women were Parity:
G1: Number of pregnancies: Weight at 6 weeks after last
development of obesity excluded if more delivery (kg):
than 13.6 kg over 4.2 (2.0)
Time frame: G1: 90.8 (18.8)
ideal weight G2: Number of pregnancies:
1991 to 1992 G2: 65.0 (12.9)
between ages 20 4.3 (1.8)
Duration of the study: and 24 or prior to Additional characteristics:
Beginning of first first pregnancy NR
pregnancy up to time of occurring before
study recruitment age 20
(includes multiple • Controls were
pregnancies per excluded if not less
woman) than 13.6kg over
ideal weight at ages
20-24 or prior to
first pregnancy
occurring before
age 20

C-458
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Postpartum weight Fair
Total weight gain: retention
Gestational Sample selection:
Categorized: diabetes, %: Groups Good
• Other - please NR G1: Population-based
define sample Definition of maternal
Cesarean delivery, G2: Morbidly obese women weight gain:
Collected from: %: Fair
• not collected who were normal weight at
NR age 20-24 years or prior to Definition of outcomes:
Ascertained by: Instrumental first pregnancy Fair
• Self- delivery, %:
reportedvalidat Results Source of information on
NR Regression of current
ed by hospital exposure, outcomes, and
records Episiotomy, %: weight on total number of confounders:
NR pregnancies showed a Poor
1.3kg/pregnancy increase
Other maternal in current weight (P = 0.03) Followup:
outcomes: with no difference between Fair
NA G1 and G2 (P = 0.60) Analysis comparability:
Other infant Maternal weight gain was Poor
outcomes: significantly greater in G2
NA Analysis of outcomes:
than G1 for the first Fair
pregnancy only (P < 0.05)
Interpretation:
G2 had a net weight Fair
retention after the first
pregnancy of 4.0 kg Sum of Good/Fair/Poor:
greater than G1 at 6 weeks 1 Good, 6 Fair, 2 Poor
postpartum
Final Quality Score:
G2 averaged 1.6 kg/ Fair
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

C-459
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Linne et al., 2004 • Cohort NR White
• Prospective G1: 59.8 (7.9) NR
Country and setting: G2: 58.5 (6.3) kg,
Sweden, Stockholm Total Study N: G3: 74.4 (7.6) kg Black
Pregnancy and Weight 563 G4: 58.3 (7.8) NR
Development study G5: 59.4 (7.7)
Group Description: Hispanic
Enrollment Period: G1: Total G6: 61.8 (7.7) P < 0.001 NR
1 and 15 year followup G2: Normal weight Pregravid BMI:
of women recruited in Asian/Pacific Islander
group (BMI < 25) G1: 21.5 (2.4) kg/m2
1984-85 NR
G3: Overweight group G2: 21.0 (1.7)kg/m2,
(> 25) G3: 26.3 (1.1) Other
Funding:
G4: Low weight gain G4: 21.4 (2.7) NR
NR
< 12kg G5: 21.2 (2.1)
Study Objective: G5: Intermediate weight Smoking,%:
G6: 21.9 (2.4 )P < 0.05 G1: 25%
Aim of this study was to gain 12-15.6kg
evaluate how well G6: High weight gain > Imputed: G2: NR
prepregnancy BMI, 15.6kg • No Diabetes mellitus,%:
gestational weight gain, NR
Group N: Categorized:
and postpartum weight
G1: 563 • WHO International Hypertension,%:
retention predict
G2: 514 Taskforce NR
retention of weight 15
G3: 45
years later among Age (mean, yrs): Additional characteristics:
parous women Inclusion criteria: NR G1: diet advice 61%
Time frame: • Participants in G2: NR
Parity:
1 and 15 year followup Stockholm G3:
NR
of women recruited in Pregnancy and
Weight Additional characteristics:
1984 to 1985 NR
Development study
Duration of the study: in 1984 and 1985
15 years 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

C-460
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: NR G1: NR Postpartum weight Good
G2: NR G2: 3,269 (509) retention
G3: 3,507 (482) Sample selection:
Total weight gain: G4: 3,628 (492) Groups Fair
G1: NR P < 0.001 Maternal weight gain was
G2: 9.8 (1.9) used a continuous Definition of maternal
G3: 14.0 (0.9) Gestational diabetes, measure (kg): weight gain:
G4: 18.8 (2.3) %: Poor
P < 0.001 NR Results
G1: Pregravid BMI ≤ 25 Definition of outcomes:
G5: At 12 months, Good
gained 1.1 +/- Cesarean delivery, %: G2: Pregravid BMI > 25
0.4 kg from NR G2 had significantly Source of information on
prepregnancy greater weights at exposure, outcomes,
Instrumental delivery, prepregnancy, delivery, 1
weight %: and confounders:
G6: At 12 months, year postpartum, and 15 Fair
NR years postpartum
gained 1.2 +/- Followup:
0.5 kg P = 0.64 Episiotomy, %: compared to G1
NR (P < 0.001); however, G2 Fair
Categorized: did not have a higher risk Analysis comparability:
• Tertiles based Other maternal of postpartum retention
outcomes: Fair
on weight gain than G1
during • At 15-year follow- Analysis of outcomes:
up, overweight Maternal confounders Fair
pregnancy and
women had a and effect modifiers
defined as low Interpretation:
mean waist accounted for in
weight gain (< Fair
circumference of analysis:
12.0 kg),
intermediate 81 +/- 9.3 cm, and • Alcohol use Sum of Good/Fair/Poor:
weight gain normal weight • Smoking 2 Good, 6 Fair, 1 Poor
(between12 women had a • Number of
and 15.6 kg), mean waist pregnancies since Final Quality Score:
and high circumference of index child Fair
weight gain (> 77 +/- 9.1 cm • Employment area
15.6 kg) (P = 0.73). Hip
circumference was Infant and child
Collected from: 101.1 +/- 8.4 cm in confounders and effect
• Collected by overweight women modifiers accounted for
study and 98 +/- 8.5 cm in analysis:
investigators in normal weight NR
details of inital women (P = 0.28).
SPAWN study 2.
methods NR • At 6 months
here postpartum, normal
Ascertained by: weight women had
retained 1.4 +/- 3.1
• NR
kg from
prepregnancy
weight, and
overweight women
had retained 2.0
+/- 6.7 kg
(P < 0.40).

C-461
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Linne et al., 2004
(continued)

C-462
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
• At 15-year follow-
up, 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 follow-
up. It is evident
that weight
before pregnancy
and weight at 1
year were most
strongly
correlated with
body weight at
15-year follow-
up. 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-463
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Linne et al., 2003 • Cross-sectional • Routine pre-natal care White
• Combination: • Maternity records from NR
Country and setting:
retrospective for original study
Stockholm, Pregnancy Black
factors occurring
and Women’s Nutrition Pregravid BMI: NR
prior to/during
study
pregnancy and Imputed: Hispanic
Enrollment Period: prospective for • No NR
15 year follow-up of weight gain
women who delivered following pregnancy Categorized: Asian/Pacific Islander
infants in 1984-85 • Continuous NR
Total Study N:
Funding: 563 Age (mean, yrs): Other
NR NR NR
Group Description:
Study Objective: Parity: Smoking,%:
Group N: NR NR
To investigate women
NR
who participated in Diabetes mellitus,%:
Stockholm Pregnancy Inclusion criteria: NR
Weight Development • Women who took
study 15 years later, Hypertension,%:
part in Stockholm
focusing on women NR
Pregnancy and
whose weight Weight Additional characteristics:
trajectories changed Development NR
after their pregnancies Study, 1984 to
and in particular those 1985
women who were
normal weight (BMI ≤ Exclusion criteria:
25) before • BMI > 47 (n = 1)
• First child at age 49
Time frame: (n = 1)
15 year follow-up of • Women who were
women who delivered overweight at both
infants in 1984 to 1985 time points
Duration of the study: (prepreg and 15y
Questionnaires followup) (n = 33)
administered at 2.5, 6, and women who
and 12 months and at were overweight
15 years postpartum and who lost weight
(inital questionnaires and regained a BMI
given to women who in normal range at
delivered children in 15y (n = 10) were
1984 to 1985) excluded from
analysis

C-464
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Postpartum weight Good
Total weight gain: retention
Gestational Sample selection:
Categorized: diabetes, %: Groups Fair
• Continuous NR G1: Women with normal
BMI (20-25) at Definition of maternal
Collected from: Cesarean delivery, weight gain:
• Routine pre- prepregnancy and 15
%: years postpartum Fair
natal care or NR
maternity G2: Women with normal Definition of outcomes:
records Instrumental BMI at prepregnancy Good
delivery, %: who had overweight
Ascertained by: NR BMI (> 25) at 15 years Source of information on
• Based on last postpartum exposure, outcomes, and
clinically Episiotomy, %: confounders:
measured NR Results Fair
weight prior to G1: Mean (SD) maternal
Other maternal weight gain, 13.6 (3.7) kg Followup:
delivery outcomes: Good
G2: Mean (SD) maternal
NR weight gain, 15.4 (4.4) kg Analysis comparability:
Other infant t-Test: P < 0.001 Poor
outcomes: Maternal confounders
NR Analysis of outcomes:
and effect modifiers Fair
accounted for in
analysis: Interpretation:
NR Fair
Infant and child Sum of Good/Fair/Poor:
confounders and effect 3 Good, 5 Fair, 1 Poor
modifiers accounted for
Final Quality Score:
in analysis:
Fair
NR

C-465
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Muscati et al., 1996 • Cohort Family physicians’ records White
• Retrospective G1: 62.8 +/- 16.0 kg NR
Country and setting: G2: NR
Canada, public health Total Study N: Black
department 371 Pregravid BMI: NR
Enrollment Period: Group Description: Imputed: Hispanic
1979 to 1989 G1: Total • No NR
G2: NR
Funding: Categorized: Asian/Pacific Islander
NR Group N: • Pregravid weight status NR
G1: 371 categorized into 3
Study Objective: Other
G2: NR groups as a percentage
To examine association NR
of standard weight:
of extent and timing of Inclusion criteria: underweight < 90%, Smoking,%:
pregnancy weight gain • White, low income, normal 90-120%, and NR
with infant birth weight non-smoking overweight > 120%
and postpartum weight women Diabetes mellitus,%:
retention • Pregnant women Age (mean, yrs): NR
G1: 24.5 +/- 5.6
Time frame: Exclusion criteria: Hypertension,%:
G2: NR
1979 to 1989 • Prematurity < 37 NR
weeks Parity:
Duration of the study: Additional characteristics:
• Adolescents < 16 G1: Primiparous 52%
Pregnancy through 6 G1: PPWR: 5.3 +/- 5.7 kg
years G2: NR
weeks postpartum G2: NR
• Women > 40 years
• Maternal health Additional characteristics:
problems NR
• Women who
consume alcohol or
drugs
• Pregnancy
complications such
as proteinuria,
hypertension,
diabetes, negative
weight gain,
missing values

C-466
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Postpartum weight retentin Good
Total weight gain:
G1: 16.1 +/- 6.4 kg Gestational diabetes, Groups Sample selection:
G2: NR %: Maternal weight gain categories: Fair
NR G1: Weight gain <= week 20 (kg)
Categorized: G2: Weight gain weeks 21-30 Definition of
• Continuous Cesarean delivery, %: (kg) maternal weight
NR gain:
Collected from: Results Fair
• Collected by Instrumental delivery, Regression model of weight
study %: retention (kg) at 6 weeks Definition of
investigators NR postpartum as the dependent outcomes:
variable and G1-G5 as Fair
Ascertained by: Episiotomy, %:
• Based on last NR independent variables: Source of
clinically G1: β = 0.86 (SE: 0.05) information on
Other maternal P < 0.001 exposure,
measured outcomes:
weight prior to G2: β = 0.68 (SE: 0.07) outcomes, and
From Table 1: Pearson’s P < 0.001 confounders:
delivery Correlation Coefficient G3: β = 0.49 (SE: 0.07) Fair
and determination P < 0.001
coefficient of maternal G4: β = 0.58 (0.13) Followup:
weight gain with PP P=NR Poor
weight retention and G5: β = 0.77 (0.04)
Infant BW. Maternal PP Analysis
P = NR comparability:
weight retention and
Preg weight gain: [Total Among women with AGA infants, Fair
amount r = 0.808, R women with 6 week postpartum Analysis of
square 65.3%, P < weights greater than the median outcomes:
0.001], [Up to week 20 r value (6.2kg, underweight; 5.7kg, Good
= 0.682, R square normal weight; 3.1kg,
46.5%, P < 0.001], overweight) had significantly Interpretation:
[Weeks 21-30 r = 0.411, greater total weight gains and Poor
R square 16.9%, P < weight gains during the first 20
Sum of
0.001], [Week 31 - term r weeks’ gestation compared to
Good/Fair/Poor:
= 0.414, R square women with 6 week postpartum
2 Good, 5 Fair, 2
17.1%, P < 0.001] weights of the median value or
Poor
lower
Other infant outcomes: Final Quality Score:
Pregnancy Weight Gain Maternal confounders and
Fair
and Infant Birth Weight effect modifiers accounted for
(from Table 1): [Total in analysis:
amount r = 0.216, R • Standard weight for height
square 4.7%, P < 0.001], (based on 1983 Metropolitan
[Up to week 20 r = Life Insurance Tables)
0.114, R-square 1.3%, • Pregravid weight above
P < 0.05], [Weeks 21-30 standard (difference
r = 0.157, R square between actual weight and
2.5%, P < 0.01], [Week standard weight)
31 - term r = 0.160, R • Parity
square 2.6%, P < 0.01]
Infant and child confounders
and effect modifiers accounted
for in analysis:
• Gestational age
• Infant sex

C-467
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ohlin and Rossner, • Cohort • Self-reported White
1990 • Combination: G1: 59.6kg (8.5) NR
retrospectively G2: NR
Country and setting: Black
during pregnancy
Sweden, maternity Pregravid BMI: NR
and prospectively
clinics G1: 21.5 (2.8)
up to 1 year after Hispanic
G2: NR
Enrollment Period: delivery NR
NR Imputed:
Total Study N: Asian/Pacific Islander
1,423 at 1 year • No
Funding: NR
NR postpartum Categorized:
Other
Study Objective: Group Description: • WHO International NR
To make a survey of G1: Total group Taskforce
weight changes after entering study Smoking,%:
Age (mean, yrs): NR
pregnancy; to analyze if G2: NR G1: 29.5 (4.8)
and how different G2: NR Diabetes mellitus,%:
Group N:
factors, such as parity, NR
G1: 2295 Parity:
age, body weight, and
G2: NR NR Hypertension,%:
lactation, correclate to
post partum weight Inclusion criteria: NR
retention; and to • Women coming to Additional characteristics:
analyze if any of these maternity clinic for NR
factors could be used as last routine control
predictors fo (6-15 weeks after
Time frame: delivery)
NR Exclusion criteria:
Duration of the study: • Twin births
Pregnancy through 1 • Insulin use during
year postpartum pregnancy
• Gastrointestinal
problems with
severe energy
losses (heavy
vomiting or
diarrhea)
• Missing
prepregnancy
weight.
• Drop out frequency
1 year postpartum
= 38%

C-468
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Bivariate Outcomes from
Gain Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 2295 G1: 3442 (522) Postpartum weight Good
G2: NR G2: NR retention
Sample selection:
Total weight gain: Gestational diabetes, %: Groups Good
G1: 14.1kg (4.3) NR Maternal weight gain
G2: NR categories: Definition of maternal
Cesarean delivery, %: G1: Continuous weight gain weight gain:
Categorized: NR (kg) Fair
• Continuous G2: Weight change (kg),
Instrumental delivery, %: Definition of outcomes:
Collected from: NR defined as the Good
• Routine pre- difference between
Episiotomy, %: prepregnancy and 1 Source of information on
natal care or
NR year postpartum exposure, outcomes, and
maternity
weights confounders:
records Other maternal outcomes: Fair
Mean Change in body weight Results
Ascertained by:
from prepregnancy weight to 1 Regression model for G2 Followup:
• Based on last year postpartum (n = 1423) = Good
clinically as the dependent variable
1.5kg (SD 3.6)P < 0.001. and G1 as the independent
measured Overweight women (BMI > 23.8, Analysis comparability:
weight prior to variable: Fair
n = 190) tended to retain more B = 0.32
delivery weight after the index time - P < 0.001 Analysis of outcomes:
1.9kg +/- 5.3kg than lighter Fair
women (BMI < 23.9, n = 1233) - Maternal confounders
1.5kg +/- 3.2kg (NS). There was and effect modifiers Interpretation:
a highly significant correlation accounted for in Fair
between weight change and analysis:
Sum of Good/Fair/Poor:
pregnancy weight gain (r = 0.36, • Lactation score 4 Good, 5 Fair, 0 Poor
P < 0.001). This correlation was • Age
slightly lower when using the first • Prepregnancy BMI Final Quality Score:
and last weight recorded in the • Parity Fair
maternity clinic (vs. self reported
prepregnancy weight), but still Infant and child
significant (r < 0.29, P < 0.001). confounders and effect
Women gaining in the highest modifiers accounted for
decentile (16.5kg) had a mean in analysis:
weight change of 3.3 +/- 3.9 kg NR
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

C-469
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Parham et al., 1990 • Other observational: • Self-reported White
pregnant women vs G1: ~50
Country and setting: Pregravid BMI: G2: ~50
non pregnant
USA, prenatal clinics
selected from the Imputed: Black
Enrollment Period: same clinic • No G1: ~25
NR • Retrospective
Categorized: G2: ~25
Funding: Total Study N: • < 20 (underweight), 20- Hispanic
NR 260 (158 pregnant + 102 25 (acceptable), > 25 NR
non pregnant (overweight)
Study Objective: Asian/Pacific Islander
To explore relationship Group Description: Age (mean, yrs): NR
between pregnancy G1: Prenatal patients G1: 23
weight gain and G2: Control G2: 23 Other
postpartum weight and NR
Group N: Parity:
to identify variables
G1: 158 NR Smoking,%:
associated with return to
G2: 102 NR
prepregnancy weight
Inclusion criteria: Diabetes mellitus,%:
Time frame:
NR • Prenatal patients in NR
2 clinics serving low-
Duration of the study: Hypertension,%:
income patients ;
Entry into PNC up to 9 NR
singleton births
months postpartum • Non pregnant Additional characteristics:
women who also NR
had weight info
during a 12 month
period of time
Exclusion criteria:
• Incomplete or
unusable data on
weight changes
during pregnancy
and postpartum
periods

C-470
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Bivariate Outcomes from
Gain Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 158 G1: 3,299 g (SD 628) Postpartum weight Good
G2: NR G2: NR retention, percent change
in BMI category between Sample selection:
Total weight gain: Gestational diabetes, %: prepregnancy and 1-3 Fair
G1: 12.9 kg (SD NR months postpartum
5.8) Definition of maternal
G2: NR Cesarean delivery, %: Groups weight gain:
NR Maternal weight gain for Fair
Categorized: population in tertiles, mean
Instrumental delivery, %: Definition of outcomes:
• < 9.1kg, 9.1- (se):
NR Poor
13.6, and > G1: 3.7 (2.9)
13.6kg Episiotomy, %: G2: 9.4 (1.3) Source of information on
NR G3: 16.0 (3.7) exposure, outcomes, and
Collected from:
confounders:
• Routine pre- Other maternal outcomes: Results Fair
natal care or Mean maternal weight gain G1, G2: 83% No change;
maternity was 9.7kg (“maternal weight 7% Desirable change Followup:
records gain” in this study is weight (i.e. underweight Fair
at delivery minus baby’s women becoming
Ascertained by: Analysis comparability:
BW). Lower third of maternal normal weight); 10%
• Based on last weight gains ranged from - Poor
clinically Undesirable change
7.1 to 6.7 kg, with a mean of (~5% had an increase Analysis of outcomes:
measured 3.7 [+ or -] 2.9 kg; middle
weight prior to in BMI category and Fair
third had a range of 6.8 to ~5% had a decrease in
delivery 11.9 kg (mean = 9.4 [+ or -] Interpretation:
BMI category)
1.3 kg); and the upper third Poor
G3: 42% no change; 19%
had a range of 11.9 to 32.8 desirable change; 39% Sum of Good/Fair/Poor:
kg (mean = 16.0 [+ or -]3.7). 1 Good, 5 Fair, 3 Poor
Three maternal weight gain Undesirable change (all
categories differed increases in BMI category) Final Quality Score:
significantly in initial BMI Poor
Maternal confounders
(P = .03). Residual weight I and effect modifiers
was significantly correlated accounted for in
with maternal weight gain (r analysis:
= .84, NR
P < .001) and with
prepregnancy BMI (r = .14, Infant and child
P = .05). Residual weight II confounders and effect
was also significantly modifiers accounted for
correlated with maternal in analysis:
weight gain (r = .68, P < NR
.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

C-471
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Soltani and Fraser, • Cohort • Measured during first White
2000 • Prospective prenatal visit NR
G1: 73.0 (16.8)
Country and setting: Total Study N: Black
G2: 60.8 (5.6)
UK, hospital 77 NR
G3: 72.0 (5.9)
Enrollment Period: Group Description: G4: 93.0 (10.6) Hispanic
NR G1: Total sample NR
Pregravid BMI:
G2: Normal weight G1: 27.4 (5.9)
Funding: Asian/Pacific Islander
G3: Overweight G2: 22.7 (1.3)
NR NR
G4: Obese G3: 27.7 (1.4)
Study Objective: G4: 34.5 (3.54) Other
Group N:
To investigate pattern of NR
G1: 77 Imputed:
changes in weight gain
G2: 29 • No Smoking,%:
and fat distribution
G3: 23 G1: 24%
during pregnancy and
G4: 25 Categorized: G2: NR
postpartum and whether
this differed by maternal • IOM guidelines
Inclusion criteria: Diabetes mellitus,%:
BMI measured in first • Women attending Age (mean, yrs): NR
trimester first prenatal visit at G1: 26.71 (4.77)
G2: 26.44 (5.32) Hypertension,%:
Time frame: Northern General
Hospital G3: 26.91 (4.50) NR
NR
G4: 27.68 (3.83) Additional characteristics:
Duration of the study: Exclusion criteria:
NR Parity: Fat mass (kg) at first visit:
First prenatal visit to 6 G1: 24.5 (9.9)
months postpartum G1: 0.78 (0.86)
G2: 0.55 (0.87) G2: 16.5 (3.6)
G3: 0.81 (0.75) G3: 24.6 (3.9)
G4: 1.00 (0.96) 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-472
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 77 G1: 3443.0 Postpartum weight retention Good
G2: 29 (589.60)
G3: 25 G2: 3331.5 (481.7) Groups Sample selection:
G3: 3423.7 (543.2) Pregravid BMI categories: Fair
Total weight gain: G4: 3670.4 (489.5) G1: Normal Weight
G1: 13-36 weeks: G2: Underweight Definition of maternal
10.8 (4.7) Gestational G3: Overweight weight gain:
G2: 11.0 (3.2) diabetes, %: G4: Obese Fair
G3: 11.9 (6.4) NR Definition of outcomes:
G4: 9.7 (4.3) Results
Cesarean delivery, G1: Patterns of changes in Good
Categorized: %: body weight (kg) and fat Source of information on
• Continuous NR mass follow a monotonous exposure, outcomes, and
trend; body weight and confounders:
Collected from: Instrumental fatness increased during
delivery, %: Good
• Collected by gestation, decreased
study NR substantially at 6 weeks Followup:
investigators postpartum, and then Fair
Episiotomy, %:
Ascertained by: NR stayed the same or slightly Analysis comparability:
• NR decreased until 6 months Fair
Other maternal postpartum
outcomes: G2: Showed similar pattern to Analysis of outcomes:
NR G1. Fair
Other infant G3: Divergent pattern of weight
Interpretation:
outcomes: gains and losses; body fat
Fair
NR mass changes show a very
scattered pattern Sum of Good/Fair/Poor:
G4: Divergent pattern of both 3 Good, 6 Fair, 0 Poor
weight and fat mass gains
and losses; heavier and Final Quality Score:
greater fat masses at 6 Fair
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

C-473
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Walker et al., 2004 • Cohort • Self-reportedOther- White
• Prospective please explain! G1: 29.6
Country and setting: G2: NR
G1: NR
USA, hospital Total Study N: G2: 65.44 (15.82) kg
382 Black
Enrollment Period: G3: 67.96 (13.99)
G1: 26.2
1999 to 2001 Group Description: G4: 67.26 (15.24)
G2: NR
G1: Total cohort Pregravid BMI:
Funding: Hispanic
G2: White G1: NR
National Instituted of G1: 44.2
G3: African American G2: 24.23 (5.78);
Nursing Research G2: NR
G4: Hispanic Underwt% 18.75;
Study Objective: Normal wt% 53.57; Asian/Pacific Islander
Group N:
Longitudinal analysis of Overwt% 11.61; NR
G1: 382
behavioral and Obese % 16.07
G2: 113
psychosocial correlates G3: 25.39 (5.40); Other
G3: 100
of weight trends during Under 11.34%; NR
G4: 169
first postpartum year Normal 56.7%; Smoking,%:
Inclusion criteria: Over 9.28%;
Time frame: NR
1999 to 2001 • Women with Obese 22.68%
healthy, term, G4: 26.75 (6.19); Diabetes mellitus,%:
Duration of the study: singleton Under 7.78%; NR
Initiation of prenatal pregnancies with Normal 48.5%;
care to 12 months Hypertension,%:
prenatal care Over 13.77%;
postpartum funded through NR
Obese 29.94%
Medicaid Additional characteristics:
• Parity ≤ 3 Imputed: NR
• English speaking • No
• ≥ 18 years free of Categorized:
prenatal • Continuous IOM
complications guidelines
(hypertension or
diabetes) Age (mean, yrs):
G1: NR
Exclusion criteria: G2: 22.79 (4.72)
• NA G3: 22.40 (3.75)
G4: 21.89 (3.36)
Parity:
G1: NR
G2: Parity = 1 (%): 45.13
G3: 35.00%
G4: 30.77%

C-474
Evidence Table 34. Gestational weight gain and postpartum weight retention (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 113 NR Postpartum weight Good
G2: 100 retention
G3: 169 Gestational Sample selection:
diabetes,%: Groups Good
Total weight gain: NR Continuous maternal
G1: kg 16.44 weight gain (kg) Definition of maternal
(6.51); below Cesarean weight gain:
IOM rec delivery,%: Results Fair
16.07%; within G1: 10.62 Each kg of maternal weight
G2: 15.00 gain was associated with Definition of outcomes:
IOM rec Good
30.36%; more G3: 16.57 0.314 kg/m2 of postpartum
than IOM rec BMI Source of information on
Instrumental (P < 0.001)
53.57% delivery,%: exposure, outcomes, and
G2: kg 15.20 NR Maternal confounders confounders:
(7.88); below and effect modifiers Poor
IOM rec Episiotomy,%: accounted for in
NR Followup:
25.53%; within analysis: Good
IOM rec Other maternal • Ethnicity
17.02%; more outcomes: • Time Analysis comparability:
than IOM rec NA • Interaction of ethnicity Fair
57.45% and time
Other infant Analysis of outcomes:
G3: kg 14.87 • Pregravid BMI
outcomes: Good
(7.76); below
• Weight-related
IOM rec NA Interpretation:
distress
22.29%; within Fair
• Energy intake
IOM rec
Sum of Good/Fair/Poor:
Infant and child
Categorized: 5 Good, 3 Fair, 1 Poor
confounders and effect
• Continuous
modifiers accounted for Final Quality Score:
according to
in analysis: Fair
IOM
NR
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

C-475
Evidence Table 35. Gestational weight gain and premenopausal breast cancer
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hilakivi-Clarke et al., • Case-control • Self-reported White
2005 • Retrospective NR
Pregravid BMI:
Country and setting: Total Study N: Black
Finland, primary care Imputed: NR
490
• No
Enrollment Period: Group Description: Hispanic
Apr 1990-Dec 1993 G1: Cases Categorized: NR
G2: Controls • Change in BMI < 3.5,
Funding: 3.5 to 7, > 7 units Asian/Pacific Islander
Supported by grants Group N: NR
from National Cancer G1: 98 Age (mean, yrs):
Institute, Susan G. G1: 46.7 Other
G2: 392
Komen Breast Cancer G2: 46.7 NR
Research Foundation, Inclusion criteria:
Parity: Smoking,%:
and Breast Cancer • Cases of reported NR
breast cancer per NR
Research Foundation
survey, for each Diabetes mellitus,%:
Study Objective: case- 4 controls NR
To investigate whether matched for age
excessive maternal Hypertension,%:
and Mirena status
weight gain alters a chosen randomly NR
woman’s risk of from cohort Additional characteristics:
developing Family history of breast
premenopausal breast Exclusion criteria:
cancer:
cancer • Missing info on
G1: 9.4%
birth year,
Time frame: G2: 5.7%
nulliparous women,
Apr 1990 to Dec 1993 development of
Duration of the study: breast cancer
3 to 6 years after before pregnancy
insertion of IUD
Quality:
Fair

C-476
Evidence Table 35. Gestational weight gain and premenopausal breast cancer (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 98 NR • AOR for Premenopausal breast cancer Good
G2: 392 (95% CI)
Gestational Sample
Total weight gain: diabetes, %: Groups: selection:
G1: < 10 kg 23.4% NR weight gain (kg) Fair
10-15 47.9% G1: < 10kg
16-20 21.3% Cesarean delivery, Definition of
G2: 10-15 kg
20+ 7.5% %: maternal weight
G1: 16-20 kg
G2: < 10 kg 22.2% NR gain:
G2: >20 kg
10-15 50.3% Fair
Instrumental
16-20 19.4% Results:
delivery, %: Definition of
20+ 8.2% G1: 1.0 reference
NR outcomes:
G2: 0.8 (0.44,1.47)
Categorized: Good
Episiotomy, %: G2: NR
• Categorical: NR G3: 1.0 (0.47, 2.04) Source of
< 10kg, 10-15, G4: 0.8 (0.27, 2.13) information on
16-20, > 20 Other maternal exposure,
outcomes: Maternal confounders and effect modifiers
outcomes, and
Collected from: NR accounted for in analysis:
confounders:
• Self-reported • Education
Other infant Poor
data collected • Age at menarche
on weight gain outcomes:
• Age at first birth Followup:
during any NR Poor
• Family history of breast cancer
pregnancy - • Pregnancy weight gain
not first or last Analysis
• Change in BMI during adult life comparability:
specified
Infant and child confounders and effect Fair
Ascertained by: modifiers accounted for in analysis: Analysis of
• Self-reported NR outcomes:
Fair
Interpretation:
Fair
Sum of
Good/Fair/Poor:
2 Good, 5 Fair, 2
Poor
Final Quality
Score:
Fair

C-477
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference for
To compare pregnancy
G1: 613 women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and to Inclusion criteria: G1: 27.5
determine effect of Smoking,%:
• Singleton pregnancy G2: 28.7 (P = NS) NR
gestational weight gain on • Age 20 to 34 years
pregnancy outcome in Parity: Diabetes mellitus,%:
morbidly obese women Exclusion criteria: % multiparous: G1: 14.2%
• Multiple gestations G1: 66.7% G2: 4.3% (P < 0.01)
Time frame: • Extremes of age G2: 44.8% (P < 0.01)
NR • BMI between 27 and Hypertension,%:
Duration of the study: 34 G1: 5.4%
• Missing height G2: 0.3% (P < 0.01)
1988 to 1995
• Missing Additional characteristics:
prepregnancy weight % college education:
G1: 37.1%
G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-478
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Distribution of GDM,%: Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample
Total weight gain: Maternal weight gain categories among morbidly obese selection:
G1: 20 (16.2) Gestational (BMI > 35): Fair
G2: 31.4 (11.5) diabetes, %: G1: Weight loss/no change
G1: 14.2% Definition of
Categorized: G2: 1-15 lbs maternal
G2: 4.3% (P < 0.01) G3: 16-25 lbs
Only calculated for weight gain:
morbidly obese: Cesarean G4: 26-35 lbs Poor
0 or weight loss, 1-15 delivery,%: G5: > 35 lbs
lbs, 16-25 lbs, 26-35 G1: 31.3% Definition of
lbs, >35 lbs G2: 15.9% Results outcomes:
G1: 15.7 Good
Collected from: Instrumental G2: 15.0 Source of
• Routine pre-natal delivery,%: G3: 14.4 information on
care or maternity NR G4: 13.4 exposure,
records G5: 12.5
Episiotomy,%: outcomes, and
Ascertained by: NR P = NS confounders:
• Not stated - from Poor
Other maternal
medical records Maternal confounders and effect modifiers
outcomes Followup:
• Preeclampsia accounted for in analysis: Fair
Race, parity, clinic service, substance abuse, preexisting
• Placental
medical condition Analysis
abruption
comparability:
• Meconium Infant and child confounders and effect modifiers Poor
• Failure to accounted for in analysis:
progress NR Analysis of
• Shoulder outcomes:
dystocia Fair
• Postpartum Interpretation:
hemorrhage Poor
• Endomyometritis
• Wound infections Sum of
Good/Fair/Poo
Other infant r:
outcomes 2 Good, 3 Fair,
• Fetal growth 4 Poor
restriction
• Preterm delivery Final Quality
• Fetal demise Score:
• Fetal distress Poor

C-479
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal weight G1: NR
To compare pregnancy
G1: 683 (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal weight Age (mean, yrs):
women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight change normal weight women
identified from Parity: Other
Time frame: NR G1: NR
1997-1993 pregnancy and
delivery summary G2: NR
Duration of the study: records (normal G3: 4.0 (Total sample)
1997-1993 weight matched to Smoking,%:
obese by race, age, NR
parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-480
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 Percent with Gestational Diabetes by weight group Good
G2: 660 G2: 3285 P ≤ 0.001
Groups Sample
Total weight gain: Gestational Obese BMI > 29 (kg): selection:
G1: 9.5 diabetes,%: G1: Lost weight/no change Fair
G2: 14.5 P ≤ 0.001 NR G2: 0.5-6.5 Definition of
Categorized: Cesarean G3: 7-11.5 maternal
• According to IOM delivery,%: G4: 12-16 weight gain:
G1: 25.6 G5: > 16 Fair
Collected from: G2: 9.1 P < 0.001
• Routine pre-natal Normal weight BMI 19.8-26 Definition of
care or maternity Instrumental G6: < 11.5 outcomes:
records delivery,%: G7: 11.5-16 Fair
Episiotomy,%: G8: > 16 Source of
Ascertained by:
• Based on last information on
Other maternal Results exposure,
clinically outcomes: Gestational diabetes,% outcomes, and
measured weight NA G1: 13.3 confounders:
prior to delivery
G2: 24.3 Fair
Other infant
G3: 11.9
outcomes: Followup:
G4: 16.7
NA Fair
G5: 17.3
P for linear trend (G1-G5) = 0.554
Analysis
comparability:
G6: 2.3
Good
G7: 3.3
G8: 2.9 Analysis of
P for linear trend (G6-G8) = 0.759 outcomes:
Fair
Maternal confounders and effect modifiers Interpretation:
accounted for in analysis: Good
None
Sum of
Infant and child confounders and effect modifiers Good/Fair/Poo
accounted for in analysis: r:
None 3 Good, 6 Fair,
0 Poor
Final Quality
Score:
Fair

C-481
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Saldana et al., 2006 • Cohort • Self-reported White
• Prospective G1: 58%
Country and setting: Pregravid BMI: G2: 73%
United States, hospital Total Study N: G1: 25 (0.24) G3: 69%
952 G2: 28 (1.1)
Enrollment period: Black
G3: 30 (0.82)
August 1,1995 through Group Description: G1: 42%
May 31, 2000 G1: Normal Glucose Imputed: G2: 27%
Tolerance • No G3: 31%
Funding:
G2: Impaired Glucose
Supported in part by Categorized: Hispanic
Tolerance
National Institute of • IOM guidelines NR
G3: GDM
General Medical Sciences
(Grant R25GM55336), Group N: Age (mean, yrs): Asian/Pacific Islander
National Institute of Child G1: 809 G1: 26 (0.22) NR
Health and Development G2: 48 G2: 29 (0.91)
(Grant 28684), and North G3: 28 (0.59) Other
G3: 95
Carolina Clinical Nutrition NR
Inclusion criteria: Parity:
Research (Grant G1: 0.9 (0.04) Smoking,%:
DK56350) • Singleton pregnancy G1: 25%
G2: 1.1 (0.16)
• More than 16 years of G2: 26%
Study Objective: G3: 0.9 (0.10)
age G3: 25%
Objective of study to • English speaking
examine weight and its • Access to phone Diabetes mellitus,%:
relationship to glucose • Planned to continue NR
intolerance during care at 1 of study
pregnancy Hypertension,%:
sites NR
Time frame: Exclusion criteria:
August 1,1995 through Additional characteristics:
• From non-white or Weight gain ratio
May 31, 2000
non-black racial (observed/recommended[com
Duration of the study: group pared with IOM range])
Entry into prenatal care • Having a second G1:: 1.43 (0.04)
through end of second pregnancy in cohort G2: 1.48 (0.21)
trimester • Pre-existing diabetes G3: 1.88 (0.15)
• No glucose screening
data Additional characteristics:
• High screen without NR
an oral glucose
tolerance test

C-482
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Mean and adjusted odds ratio (95% CI) for weight Good
Groups (N): gain
NR Gestational Sample selection:
diabetes, %: Groups Good
Total weight gain: NR
G1: 9.1 (0.19) G1: Normal glucose tolerance Definition of
G2: 8.1 (0.90) Cesarean G2: Impaired glucose tolerance maternal weight
G3: 9.4 (0.62) delivery,%: G3: Gestational diabetes mellitus gain:
NR BMI IOM Good
Categorized:
• 2 weight gain Instrumental Results Definition of
variables were delivery,%: Mean (SE) weight gain ratio (defined as obeserved outcomes:
created. Weight NR weight gain/IOM recommended weight gain): Good
gain was G1: 1.43 (0.04)
Episiotomy,%: Source of
calculated by G2: 1.48 (0.21)
NR information on
subtracting G3: 1.88 (0.15) exposure,
prepregnancy Other maternal P < 0.05 outcomes, and
weight from outcomes: AOR for weight gain ratio confounders:
weight at end of NR G1: 1.0 (reference) Fair
second trimester G3: 1.2 (0.9-1.4)
(G2 weeks). Other infant Followup:
Weight gain ratio outcomes: Good
calculated as Maternal confounders and effect modifiers
ratio of observed accounted for in analysis: Analysis
weight gain to Race, age comparability:
recommended Good
Infant and child confounders and effect modifiers
Collected from: accounted for in analysis: Analysis of
• Routine pre-natal Gestational age outcomes:
care or maternity Fair
records Interpretation:
Ascertained by: Good
• NR Sum of
Good/Fair/Poor:
7 Good, 2 Fair, 0
Poor
Final Quality
Score:
Good

C-483
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Thorsdottir et al., 2002 • Cohort • Self-reported White
• Retrospective G1: 63.1 (6.2) NR
Country and setting:
G2: 62.0 (5.6) P = 0.059
Maternity records, Total Study N: Black
G3: 61.7 (4.8) P = 0.174
Department of Obstetrics 614 NR
G4: 62.2 (6.1) P = 0.274
and Gynecology at
Landspitali University Group Description: Hispanic
Pregravid BMI:
Hospital, Iceland G1: No complication NR
G1: 22.2
G2: Complications in G2: 22.4 )1.6) P = 0.270
Enrollment Period: Asian/Pacific Islander
pregnancy or delivery G3: 22.4 (1.5) P = 0.338 NR
G3: Complications in G4: 22.3 P = 0.584
Funding:
pregnancy Other
NR
G4: Complications in Imputed: NR
Study Objective: delivery • No
To investigate relation Smoking,%:
Group N: Categorized: NR
between gestational
weight gain in women of
G1: 452 • Continuous
G2: 162 Diabetes mellitus,%:
normal prepregnant Age (mean, yrs): NR
G3: 56
weight and complications G1: 29
G4: 106 Hypertension,%:
during pregnancy and G2: 29 P = 0.857
delivery in a population Inclusion criteria: NR
G3: 29 P = 0.404
with high gestational • Women of normal G4: 29 P = 0.398 Additional characteristics:
weight gain and birth prepregnancy weight Proportional weight gain, %:
weight randomly selected Parity:
G1: 26.0
Time frame: within 1 year (1998) NR G2: 28.0 P = 0.018
NR • No history of G3: 30.0 P = 0.005
diabetes, G4: 27.0 P = 0.546
Duration of the study: hypertension, CVD,
1998 or thyroid problems Additional characteristics:
• Singleton births NR
• 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

C-484
Evidence Table 36. Gestational weight gain with reference to IOM recommendations and gestational diabetes
(continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 452 G1: 3789 (469) Gestational diabetes,% Good
G2: 162 G2: 3749 (565) P = 0.389
G3: 56 G3: 3643 (526) P = 0.032 Groups Sample
G4: 106 G4: 3806 (578) P = 0.529 Maternal weight gain categories (kg): selection:
G1: < 11.5 Fair
Total weight gain: Gestational diabetes, %: G2: 11.5-16.0
G1: 16.6 (4.9) NR Definition of
G3: 16.1-20.0 maternal weight
G2: 17.4 (5.1) P = G4: > 20.0
Cesarean delivery, %: gain:
0.080
G3: 18.4 (5.1) P = NR Poor
Results
0.013 Instrumental delivery, Gestational diabetes,% Definition of
G4: 16.9 (5.1) P = %: G1: 2.9 outcomes:
0.887 NR G2: 0 Fair
Categorized: Episiotomy, %: G3: 0 Source of
• According to IOM < NR G4: 0 information on
11.5, 11.-16.0, ≥ P for trend < 0.015 exposure,
16.1, also quintiles Other maternal outcomes, and
< 12.5, 12.5-15.5, outcomes: Maternal confounders and effect modifiers confounders:
15.6-17.8, 17.9- NA Fair
accounted for in analysis:
20.8, > 20.8 Other infant outcomes: None Followup:
Collected from: NA Good
Infant and child confounders and effect
• Routine pre-natal modifiers accounted for in analysis:
care or maternity Analysis
None comparability:
records
Good
Ascertained by:
Analysis of
• Based on last
outcomes:
clinically measured
Good
weight prior to
deliverynot stated - Interpretation:
based on records? Good
Sum of
Good/Fair/Poor:
5 Good, 3 Fair, 1
Poor
Final Quality
Score:
Fair

C-485
Evidence Table 37. Gestational weight gain with reference to IOM recommendations and hypertension
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference for
To compare pregnancy
G1: 613 women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and to Inclusion criteria: G1: 27.5
determine effect of Smoking,%:
• Singleton pregnancy G2: 28.7 (P = NS) NR
gestational weight gain on • Age 20 to 34 years
pregnancy outcome in Parity: Diabetes mellitus,%:
morbidly obese women Exclusion criteria: % multiparous: G1: 14.2%
• Multiple gestations G1: 66.7% G2: 4.3% (P < 0.01)
Time frame: • Extremes of age G2: 44.8% (P < 0.01)
NR • BMI between 27 and Hypertension,%:
Duration of the study: 34 G1: 5.4%
• Missing height G2: 0.3% (P < 0.01)
1988 to 1995
• Missing Additional characteristics:
prepregnancy weight % college education:
G1: 37.1%
G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-486
Evidence Table 37. Gestational weight gain with reference to IOM recommendations and hypertension
(continued)
Maternal Weight Outcomes from Quality
Gain Bivariate Analysis Outcomes from Multivariate Analysis Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Pregnancy-induced hypertenstion Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups: Sample
Total weight gain: G1: Weight loss or 0 lbs selection:
G1: 20 (16.2) Gestational G2: 1-15 lbs Fair
G2: 31.4 (11.5) diabetes, %: G3: 16-25 lbs
G1: 14.2% G4: 26-35 lbs Definition of
Categorized: G2: 4.3% (P < 0.01) G5: >35 lbs maternal
Only calculated for weight gain:
morbidly obese: Cesarean Results: Poor
0 or weight loss, 1-15 delivery,%: G1: 11.8%
G1: 31.3% G2: 13.7% Definition of
lbs, 16-25 lbs, 26-35
lbs, >35 lbs G2: 15.9% G3: 13.7% outcomes:
G4: 12.4% Good
Collected from: Instrumental G5: 21.3% (P = NS) Source of
• Routine pre-natal delivery,%:
care or maternity NR Maternal confounders and effect modifiers accounted information
for in analysis: on exposure,
records
Episiotomy,%: NR outcomes,
Ascertained by: NR and
• Not stated - from Infant and child confounders and effect modifiers confounders:
Other maternal accounted for in analysis: Poor
medical records
outcomes NR
• Preeclampsia Followup:
• Placental Fair
abruption
Analysis
• Meconium comparability
• Failure to :
progress Poor
• Shoulder
dystocia Analysis of
• Postpartum outcomes:
hemorrhage Fair
• Endomyometritis Interpretation
• Wound infections :
Other infant Poor
outcomes Sum of
• Fetal growth Good/Fair/Po
restriction or:
• Preterm delivery 2 Good, 3 Fair,
• Fetal demise 4 Poor
• Fetal distress
Final Quality
Score:
Poor

C-487
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Devader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained from G1: 79.7
Country and setting: G2: 85.6
mother during postpartum
United States, birth Total Study N: G3: 85.2
hospital stay
certificate data 94,696
Pregravid BMI: Black
Enrollment period: Group Description: G1: 15.7
NR
1999 to 2001 G1: Gained less than 25 G2: 10.8
lbs Imputed: G3: 12.1
Funding:
NR
G2: Gained 25 to 35 lbs • No
G3: Gained more than 35 Hispanic
Study Objective: lbs Categorized: NR
To investigate relationship NR
Group N: Asian/Pacific Islander
between gestational Age (mean, yrs): NR
G1: 16,852
weight gain and adverse G1: Maternal age (y)
G2: 37,292
pregnancy outcomes 18 to 24*: 42.3% Other
G3: 40,552
among women with 25 to 30: 36.2% G1: 4.6
normal prepregnancy BMI Inclusion criteria: 31 to 35: 21.5% G2: 3.5
• All mothers with G2: Maternal age (y) G3: 2.7
Time frame:
1999 to 2001 normal prepregnancy 18 to 24*: 36.7% Smoking,%:
BMI (19.8 –26.0 25 to 30: 39.5% G1: 20.5
Duration of the study: kg/m2) who were 18 31 to 35: 23.8% G2: 14.9
Entry into prenatal care to 35 years of age at G3: Maternal age (y) G3: 17.4
through delivery time of delivery and 18 to 24*: 44.7%
who delivered full- 25 to 30: 35.9% Diabetes mellitus,%:
term (37 weeks or 31 to 35: 19.4% NR
more) singleton infant
Hypertension,%:
during period January Parity:
1, 1999, to December NR NR
31, 2001 Additional characteristics:
Exclusion criteria: NR
• Women aged
younger than 18
years and older than
35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-488
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR AOR (95% CI) for preeclampsia Good
Total weight gain: Gestational diabetes, Groups Sample
NR %: Maternal weight gain categories (lbs): selection:
NR G1: < 25 Fair
Categorized:
• According to IOM Cesarean delivery,%: G2: 25-35 Definition of
NR G3: > 35 maternal weight
Collected from: gain:
• Routine pre-natal Instrumental Results Fair
care or maternity delivery,%: G1: 0.56 (0.49-0.64)
records NR G2: 1.00 (reference) Definition of
G3: 1.88 (1.74-2.04) outcomes:
Ascertained by: Episiotomy,%: Good
NR NR Maternal confounders and effect modifiers
accounted for in analysis: Source of
Other maternal information on
outcomes: • Age
• Race exposure,
• Figures 1 to 3 plot outcomes, and
risk for each • Education
confounders:
adverse pregnancy • Income
Fair
outcome by 10-lb • Alcohol use
increments in • Height Followup:
gestational weight • Prior pregnancy Fair
gain. Women who • Inadequate prenatal care use Analysis
gained 25 to 34 lbs • Smoking comparability:
during their
Infant and child confounders and effect Fair
pregnancy had
lower risks for most modifiers accounted for in analysis: Analysis of
outcomes when • Child's gender outcomes:
balancing risk for • Birth year Fair
SGA status and
other adverse Interpretation:
pregnancy Fair
outcomes Sum of
• Women who Good/Fair/Poor:
gained 15 to 24 lbs 2 Good, 7 Fair, 0
had lowest risks for Poor
most outcomes, but
increased their risk Final Quality
of having an SGA Score:
infant from 9.6% to Fair
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%

C-489
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Devader et al., 2007
(combined)

C-490
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Other infant
outcomes:
NR

C-491
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal weight G1: NR
To compare pregnancy
G1: 683 (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal weight Age (mean, yrs):
women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight change normal weight women
identified from Parity: Other
Time frame: NR G1: NR
1997-1993 pregnancy and
delivery summary G2: NR
Duration of the study: records (normal G3: 4.0 (Total sample)
1997-1993 weight matched to Smoking,%:
obese by race, age, NR
parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-492
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 Preeclampsia Good
G2: 660 G2: 3285 P ≤ 0.001
Groups Sample
Total weight gain: Gestational Obese BMI > 29 (kg): selection:
G1: 9.5 diabetes,%: G1: Lost weight/ no change Fair
G2: 14.5 P ≤ 0.001 NR G2: 0.5-6.5 Definition of
Categorized: Cesarean G3: 7-11.5 maternal
• According to IOM delivery,%: G4: 12-16 weight gain:
G1: 25.6 G5: > 16 Fair
Collected from: G2: 9.1 P < 0.001
• Routine pre-natal Normal weight BMI 19.8-26: Definition of
care or maternity Instrumental G6: < 11.5 outcomes:
records delivery,%: G7: 11.5-16.0 Fair
Episiotomy,%: G8: > 16.0 Source of
Ascertained by:
• Based on last information on
Other maternal Results exposure,
clinically outcomes: G1: 10.7 outcomes, and
measured weight NA G2: 7.7 confounders:
prior to delivery
G3: 8.3 Fair
Other infant
G4: 7.9
outcomes: Followup:
G5: 16.5
NA Fair
P for linear trend (for G1-G5) = 0.076
Analysis
G6: 2.8
comparability:
G7: 2.9
Good
G8: 6.6
P for linear trend (for G6-G8) = 0.048 Analysis of
outcomes:
Fair
Maternal confounders and effect modifiers accounted
for in analysis: Interpretation:
None Good
Infant and child confounders and effect modifiers Sum of
accounted for in analysis: Good/Fair/Poo
None r:
3 Good, 6 Fair,
0 Poor
Final Quality
Score:
Fair

C-493
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
Categorized: NR
Study Objective: (BMI 35–39.9) (n =
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight change G3: Obese Class III Age (mean, yrs): NR
on pregnancy outcomes in (BMI 40 and More) (n G1: <26: 46%
obese women = 19,025) 26-35: 47% Other
Older than 35: 8% G1: 22
Time frame: Group N:
1990 to 2001 NR G2: <26: 44% Smoking,%:
26-35: 48% NR
Duration of the study: Inclusion criteria: Older than 35: 8%
Entry into prenatal care • Obese women G3: <26: 40% Diabetes mellitus,%:
through delivery residing in Missouri 26-35: 52% NR
who delivered (at 37 Older than 35: 9%
Hypertension,%:
or more weeks of
Parity: NR
gestation) liveborn,
singleton infants Nulliparous:
Additional characteristics:
during 1990–2001 G1: 34%
G2: 33% NR
Exclusion criteria: G3: 32%
• NR

C-494
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Odds ratios (95% CI) for preeclampsia Good
LGA:13%
Total weight gain: (P < 0.05) Groups Sample
G1: GWG (lb) G2: SGA: 7% Maternal weight gain categories stratified by selection:
Less than 2: 3% LGA:16% prepregnancy obesity status, Obese Class I (BMI Fair
2 to 14: 15% (P < 0.05) 30–34.9), Obese Class II (BMI 35–39.9), Obese Definition of
15 to 25: 26% G3: SGA: 6% Class III (BMI ≥ 40):
More than 25: 56% maternal weight
LGA:18% G1: ≤ -10lbs gain:
G2: GWG (lb) (P < 0.05) G2: -2 to -9 lbs
Less than 2: 8% Fair
G3: No change
2 to 14: 22% Gestational diabetes, %: G4: 2-9 lbs Definition of
15 to 25: 27% NR G5: 10-14 lbs outcomes:
More than 25: 43% G6: 15-25 lbs Good
G3: GWG (lb)Less than Cesarean delivery,%: G7: 26-35 lbs
2: 15% G1: 28 Source of
G2: 34 G8: > 35 lbs information on
G3: 41 exposure,
Categorized: Results outcomes, and
Instrumental delivery,%: For Obese Class I: OR (95% CI) for preeclampsia confounders:
• 10-lb or less loss
NR were significantly lower (< 1.00, G6 was
2 to 9 lbs loss, no Fair
weight change, Episiotomy,%: reference) for G2-G5 and significantly higher for
2 to 9 lbs gain, NR G7-G8. Followup:
10 to 14 lbs gain, Fair
15–25 lb gain, For Obese Class II: OR (95% CI) for
Analysis
26–35 lb gain, and preeclampsia were significantly greater (> 1.00,
comparability:
greater than 35 lb G6 was reference) for G1 and G3- G5 and
Fair
gain significantly lower for G8.
Analysis of
Collected from: For Obese Class III: OR (95% CI) for outcomes:
• Routine pre-natal preeclampsia were significantly greater (> 1.00, Fair
care or maternity G6 was reference) for G1-G3 and G5 and
records significantly lower for G7-G8 Interpretation:
Poor
Ascertained by: Maternal confounders and effect modifiers
NR accounted for in analysis: Sum of
• Age Good/Fair/Poor:
2 Good, 6 Fair, 1
• Race
Poor
• Parity
• Education Final Quality
• Poverty (enrollment in Medicaid, WIC, food Score:
stamp programs) Fair
• Tobacco use
• Chronic hypertension
Infant and child confounders and effect
modifiers accounted for in analysis:
NR

C-495
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-496
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Outcomes from Bivariate
Maternal Weight Gain 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-497
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Thorsdottir et al., 2002 • Cohort • Self-reported White
• Retrospective G1: 63.1 (6.2) NR
Country and setting:
G2: 62.0 (5.6) P = 0.059
Maternity records, Total Study N: Black
G3: 61.7 (4.8) P = 0.174
Department of Obstetrics 614 NR
G4: 62.2 (6.1) P = 0.274
and Gynecology at
Landspitali University Group Description: Hispanic
Pregravid BMI:
Hospital, Iceland G1: No complication NR
G1: 22.2
G2: Complications in G2: 22.4 )1.6) P = 0.270
Enrollment Period: Asian/Pacific Islander
pregnancy or delivery G3: 22.4 (1.5) P = 0.338 NR
G3: Complications in G4: 22.3 P = 0.584
Funding:
pregnancy Other
NR
G4: Complications in Imputed: NR
Study Objective: delivery • No
To investigate relation Smoking,%:
Group N: Categorized: NR
between gestational
weight gain in women of
G1: 452 • Continuous
G2: 162 Diabetes mellitus,%:
normal prepregnant Age (mean, yrs): NR
G3: 56
weight and complications G1: 29
G4: 106 Hypertension,%:
during pregnancy and G2: 29 P = 0.857
delivery in a population Inclusion criteria: NR
G3: 29 P = 0.404
with high gestational • Women of normal G4: 29 P = 0.398 Additional characteristics:
weight gain and birth prepregnancy weight Proportional weight gain, %:
weight randomly selected Parity:
G1: 26.0
Time frame: within 1 year (1998) NR G2: 28.0 P = 0.018
NR • No history of G3: 30.0 P = 0.005
diabetes, G4: 27.0 P = 0.546
Duration of the study: hypertension, CVD,
1998 or thyroid problems Additional characteristics:
• Singleton births NR
• 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

C-498
Evidence Table 38. Gestational weight gain with reference to IOM recommendations and pre-eclampsia
(continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 452 G1: 3789 (469) Maternal weight gain categories (kg): Good
G2: 162 G2: 3749 (565) P = 0.389
G3: 56 G3: 3643 (526) P = 0.032 G1: < 11.5 Sample
G4: 106 G4: 3806 (578) P = 0.529 G2: 11.5-16.0 selection:
G3: 16.1-20.0 Fair
Total weight gain: Gestational diabetes, %: G4: > 20.0
G1: 16.6 (4.9) NR Definition of
G2: 17.4 (5.1) P = maternal weight
Cesarean delivery, %: Preeclampsia,% gain:
0.080 G1: 1.4
G3: 18.4 (5.1) P = NR Poor
G2: 2.3
0.013 Instrumental delivery, G3: 5.4 Definition of
G4: 16.9 (5.1) P = %: G4: 4.4 outcomes:
0.887 NR P for trend = 0.262 Fair
Categorized: Episiotomy, %: Source of
• According to IOM < NR Maternal confounders and effect modifiers information on
11.5, 11.-16.0, ≥ accounted for in analysis: exposure,
16.1, also quintiles Other maternal outcomes, and
outcomes: None
< 12.5, 12.5-15.5, confounders:
15.6-17.8, 17.9- NA Infant and child confounders and effect Fair
20.8, > 20.8 Other infant outcomes: modifiers accounted for in analysis:
None Followup:
Collected from: NA Good
• Routine pre-natal
care or maternity Analysis
records comparability:
Good
Ascertained by:
Analysis of
• Based on last
outcomes:
clinically measured
Good
weight prior to
delivery, not stated Interpretation:
- based on records Good
Sum of
Good/Fair/Poor:
5 Good, 3 Fair, 1
Poor
Final Quality
Score:
Fair

C-499
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: • Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: • Imputed: • Hispanic
Funding:
G1: Obese • No NR
NR
G2: Controls
Study Objective: • Categorized: • Asian/Pacific
Group N: • NHANES II reference Islander
To compare pregnancy
G1: 613 for women 20 to 29 NR
outcomes between
G2: 11,313
morbidly obese and Age (mean, yrs): • Other
nonobese women and Inclusion criteria: G1: 27.5 NR
to determine effect of • Singleton G2: 28.7 (P = NS)
gestational weight gain pregnancy Smoking,%:
on pregnancy outcome • Age 20 to 34 years Parity: NR
in morbidly obese % multiparous:
Exclusion criteria: Diabetes mellitus,%:
women G1: 66.7%
G1: 14.2%
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: G2: 4.3% (P < 0.01)
• Extremes of age
NR • BMI between 27 Hypertension,%:
Duration of the study: and 34 G1: 5.4%
1988 to 1995 • Missing height G2: 0.3% (P < 0.01)
• Missing
Additional characteristics:
prepregnancy
% college education:
weight
G1: 37.1%
G2: 63.1% (P < 0.01)
• Preexisting
diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-500
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Cesarean delivery Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: wt loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lb
G2: 31.4 (11.5) diabetes, %: G3: 16-25 lb Definition of maternal
G1: 14.2% G4: 26-35 lb weight gain:
• Categorize G2: 4.3% (P < 0.01) G5: >35 lb Poor
d:
Cesarean Results Definition of outcomes:
Only calculated for
delivery,%: G1: 25.5% Good
morbidly obese:
0 or weight loss, 1- G1: 31.3% G2: 26.8% Source of information on
15 lbs, 16-25 lbs, G2: 15.9% G3: 28.8% exposure, outcomes, and
26-35 lbs, >35 lbs G4: 35.0% confounders:
Instrumental G5: 33.8%
delivery,%: Poor
• Collected (P = NS)
from: NR No significant difference Followup:
• Routine pre- Episiotomy,%: among morbidly obese Fair
natal care or NR women by weight gain Analysis comparability:
maternity categories.
Other maternal Poor
records
outcomes OR for Cesarean Analysis of outcomes:
• Ascertaine • Preeclampsia comparing morbidly to Fair
d by:
• Placental nonobese =2.3 (1.9, 2.8)
• Not stated - abruption Interpretation:
from medical Maternal confounders Poor
• Meconium
records and effect modifiers
• Failure to Sum of Good/Fair/Poor:
progress accounted for in
2 Good, 3 Fair, 4 Poor
analysis:
• Shoulder
Macrosomia Final Quality Score:
dystocia
Poor
• Postpartum Infant and child
hemorrhage confounders and effect
• Endomyometritis modifiers accounted for
• Wound infections in analysis:
NR
Other infant
outcomes
• Fetal growth
restriction
• Preterm delivery
• Fetal demise
• Fetal distress

C-501
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
DeVader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained G1: 79.7
Country and setting: G2: 85.6
from mother during
United States, birth Total Study N: G3: 85.2
postpartum hospital stay
certificate data 94,696
Pregravid BMI: • Black
Enrollment period: Group Description: NR G1: 15.7
1999 to 2001 G1: Gained less than 25 G2: 10.8
Funding:
lbs • Imputed: G3: 12.1
G2: Gained 25 to 35 lbs • No
NR
G3: Gained more than • Hispanic
Study Objective: 35 lbs • Categorized: NR
To investigate NR
relationship between
Group N: • Asian/Pacific
G1: 16,852 Age (mean, yrs): Islander
gestational weight gain G1: Maternal age (y)
G2: 37,292 NR
and adverse pregnancy 18 to 24*: 42.3%
G3: 40,552
outcomes among 25 to 30: 36.2% • Other
women with normal Inclusion criteria: 31 to 35: 21.5% G1: 4.6
prepregnancy BMI • All mothers with G2: Maternal age (y) G2: 3.5
Time frame: normal 18 to 24*: 36.7% G3: 2.7
1999 to 2001 prepregnancy BMI 25 to 30: 39.5%
(19.8 –26.0 kg/m2) Smoking,%:
31 to 35: 23.8%
Duration of the study: who were 18 to 35 G1: 20.5
G3: Maternal age (y)
Entry into prenatal care years of age at time G2: 14.9
18 to 24*: 44.7%
through delivery of delivery and who G3: 17.4
25 to 30: 35.9%
delivered full-term 31 to 35: 19.4% Diabetes mellitus,%:
(37 weeks or more) NR
singleton infant Parity:
during period NR Hypertension,%:
January 1, 1999, to NR
December 31, 2001 Additional characteristics:
Exclusion criteria: NR
• Women aged
younger than 18
years and older
than 35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-502
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Bivariate Outcomes from
Gain Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR AOR for cesarean delivery Good
(additionally controlled for
Total weight gain: Gestational diabetes, %: LGA and cephalopelvic Sample selection:
NR NR disproportion) Fair
• Categorize Cesarean delivery,%: Groups Definition of maternal
d: NR G1: Gained less than 25 weight gain:
• According to lbs Fair
Instrumental delivery,%:
IOM G2: Gained 25 to 35 lbs
NR Definition of outcomes:
• Collected G3: Gained more than 35 Good
Episiotomy,%: lbs
from: NR Source of information on
• Routine pre- • Results exposure, outcomes, and
natal care or Other maternal outcomes: G1: 0.82 (0.78–0.87) confounders:
maternity • Figures 1 to 3 plot risk for G2: 1.0 Fair
records each adverse pregnancy G3: 1.35 (1.29–1.40)
outcome by 10-lb Followup:
• Ascertaine increments in gestational Maternal confounders Fair
d by: weight gain. Women who and effect modifiers
NR accounted for in Analysis comparability:
gained 25 to 34 lbs
analysis: Fair
during their pregnancy
had lower risks for most Age, race, education, Analysis of outcomes:
outcomes when income, alcohol use, Fair
balancing risk for SGA height, prior pregnancy,
status and other adverse inadequate prenatal care Interpretation:
pregnancy outcomes use, smoking Fair
• Women who gained 15 Sum of Good/Fair/Poor:
to 24 lbs had lowest risks Infant and child 2 Good, 7 Fair, 0 Poor
for most outcomes, but confounders and effect
increased their risk of modifiers accounted for Final Quality Score:
having an SGA infant in analysis: Fair
from 9.6% to 14.3% Child's gender, birth year
• 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

C-503
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period:
• Black
1997-1993 Group Description: • Imputed: G1: NR
Funding:
G1: Obese • No G2: NR
G2: Normal Weight G3: 21.0 (Total sample)
NR • Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese • Hispanic
Group N: (> 29) and normal G1: NR
To compare pregnancy
G1: 683 weight (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal Age (mean, yrs):
weight women and their Inclusion criteria: G1: 27.1
associations with • Asian/Pacific
• Obese women and G2: 25.4 Islander
gestational weight normal weight
change Parity: NR
women identified
from pregnancy NR • Other
Time frame:
1997-1993 and delivery G1: NR
summary records G2: NR
Duration of the study: (normal weight G3: 4.0 (Total sample)
1997-1993 matched to obese
by race, age, parity) Smoking,%:
• Singleton deliveries NR
• Live births Diabetes mellitus,%:
NR
Exclusion criteria:
• Missing data Hypertension,%:
• Fetal deaths NR
Additional characteristics:
NR

C-504
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 Cesarean delivery Good
G2: 660 G2: 3285 P ≤ 0.001
Groups Sample selection:
Total weight gain: Gestational Obese Fair
G1: 9.5 diabetes,%: G1: wt loss or 0 lbs
G2: 14.5 P ≤ 0.001 NR G2: 1-14 lb Definition of
G3: 15-25 lb maternal weight
• Categorize Cesarean G4: 26-35 lb gain:
d: delivery,%: G5: >35 lb Fair
• According to G1: 25.6
Definition of
IOM G2: 9.1 P < 0.001 • Normal weight
outcomes:
G1:<25 lb
• Collected Instrumental Fair
G2: 25-35 lb
from: delivery,%:
G3: >35 lb Source of
• Routine pre- Episiotomy,%: information on
natal care or Results
exposure, outcomes,
maternity Other maternal Obese
and confounders:
records outcomes: G1: 30.7%
Fair
NA G2: 21.6%
• Ascertaine G3: 23.8% Followup:
d by: Other infant G4: 26.2% Fair
• Based on last outcomes: G5: 30.1%
clinically NA Analysis
measured • Normal weight comparability:
weight prior to G1:5.7% Good
delivery G2:12.1%
G3: 8.6% Analysis of
outcomes:
• No significant Fair
difference in rates of cesarean
Interpretation:
delivery by IOM weight gain
Good
categories for normal weight or
obese women Sum of
Good/Fair/Poor:
• Obese women AOR
3 Good, 6 Fair, 0 Poor
=3.2 (2.3,4.4) for cesarean
delivery Final Quality Score:
Fair
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

C-505
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Jain et al, • Cohort • Self-reported NR
2007 • Retrospective
Pregravid BMI: Smoking,%:
Country and setting: Total Study N: • NR NR
United States, hospitals 7661
• Imputed: Diabetes mellitus,%:
Enrollment period: Group Description: • No NR
2002-2005 NR
• Categorized: Hypertension,%:
Funding: Group N: • IOM guidelines NR
Not reported NR
Age (mean, yrs):
Study Objective: Inclusion criteria: NR
To analyze risks of • Term (> 37 weeks)
cesarean section, and singleton for Parity:
macrosomia, and macrosomia and NR
breastfeeding at 10 breastfeeding
weeks postpartum using
logistic regression to Exclusion criteria:
estimate independent • Cesarean analysis
effects of prepregnancy limited to to women
BMI and gestational with cephalic
weight gain presentation-
records with
Time frame: missing data
2002-2005 excluded
Duration of the study:
Entry into prenatal care
to 10 weeks postpartum

C-506
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Cesarean delivery Fair
Total weight gain: Gestational Groups Sample selection:
• NR diabetes, %: G1: ≤ 15 lbs Poor
NR G2: 16 - < 25 lbs
• Categorize G3: 25 - < 35 lbs Definition of maternal
d: Cesarean G4: ≥ 35 lbs weight gain:
• ≤ 15 lbs delivery,%: G5: interaction term overwt/obese and Poor
• 15-25 lbs NR gaining 25-35 Definition of outcomes:
• 25-35 lbs Instrumental Fair
• 35+ lbs Results
delivery,%: Primipara (AOR, 95% CI)
NR Source of information on
• Collected G5: 0.71 (0.43-1.19) exposure, outcomes, and
from: Episiotomy,%: confounders:
• Not outlined NR Multipara Fair
G5: 0.77 (1.37-1.59)
• Ascertaine Other maternal Followup:
d by: outcomes: Maternal confounders and effect Fair
• Birth certificate NR modifiers accounted for in analysis:
Pre-gravid BMI, parity Analysis comparability:
Other infant Fair
outcomes: Infant and child confounders and
NR effect modifiers accounted for in Analysis of outcomes:
analysis: Fair
NR Interpretation:
Fair
Sum of Good/Fair/Poor:
0 Good, 7 Fair, 2 Poor
Final Quality Score:
Fair

C-507
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kaiser and Kirby, 2001 • Cohort • Self-reported White
• Retrospective • Used measured weight G1: 14.9
Country and setting: G2: NR
at first prenatal visit (if
USA, university nurse- Total Study N: less than 12 weeks
midwifery system 1,881 • Black
gestation) if women did
G1: 77.1
Enrollment Period: Group Description: not know
G2: NR
1994 to 1998 G1: Total cohort Pregravid BMI:
G2: NR G1: NR • Hispanic
Funding:
BMI G1: 6.6
NR Group N: G2: NR
G1: 1881 • ≤ 19.7: 13.2%
Study Objective:
G2: NR • 19.8-26.0: 50.7% • Asian/Pacific
To determine whether
• 26.1-28.9: 12.0% Islander
low risk maternity Inclusion criteria:
patients in a nurse- • ≥ 29.0: 24.0% G1: 1.4
• Healthy women G2: NR G2: NR
midwifery service with who met criteria for
prepregnant BMI > 29.0 nurse-midwifery • Imputed: • Other
are at increased risk for care according to • No NR
cesarean delivery practice’s
guidelines • Categorized: Smoking,%:
Time frame: • IOM guidelines NR
1994 to 1998 • Women who
delivered preterm Age (mean, yrs): Diabetes mellitus,%:
Duration of the study: or attempted trials G1: 21.1 (4.7) NR
First prenatal visit to of labor G2: NR
delivery • All pregnancies Hypertension,%:
were included for Parity: NR
women who G1: % primiparous: 36.5 Additional characteristics:
delivered more than G2: NR G1: married: 9.4
once within study G2: NR
period
Additional characteristics:
Exclusion criteria: NR
• 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

C-508
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1881 NR Odds ratios (95% CI) for Good
G2: NR cesarean delivery
Gestational Sample selection:
Total weight gain: diabetes,%: Groups Fair
NR G1: Below IOM
• Categorize G2: within IOM Definition of maternal
d: Cesarean weight gain:
• G3: Above IOM
• Study by delivery,%: Poor
Weight gain below IOM
Parker and G1: 5.1
recommendations Definition of outcomes:
Abrams-weight G2: NR
Good
gain cut offs Results
Instrumental
are different Crude OR Source of information on
delivery, %:
G1: 0.82 (0.49, 1.36) exposure, outcomes, and
• Collected NR
G3:1.0 (0.62, 1.63) confounders:
from: Episiotomy, %: Fair
• Routine pre- • AOR for weight
NR
natal care or gain above IOM Followup:
maternity Other maternal recommendations: Fair
records outcomes: 2.04 (95% CI 1.02, 4.05)
NR Analysis comparability:
• Ascertaine Maternal confounders Fair
d by: Other infant and effect modifiers
outcomes: accounted for in Analysis of outcomes:
• Based on last Fair
clinically NR analysis:
measured • Age Interpretation:
weight prior to • Race Fair
delivery: • Pre-gravid BMI
Sum of Good/Fair/Poor:
difference • Pre-eclampsia
2 Good, 6 Fair, 1 Poor
between • Height
prepregnant • Previous live births Final Quality Score:
weight and • Failure to progress Fair
prenatal visit • Breech presentation
closest to • Birth weight
delivery (not
longer than 3 Infant and child
weeks from confounders and effect
delivery) modifiers accounted for
in analysis:
Birth weight

C-509
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% • Black
Enrollment period: Group Description: Class III obese: 16% G1: 22
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = • Imputed: G3: 27
Funding:
NR
70,536) • No
G2: Obese Class II • Hispanic
Study Objective: (BMI 35–39.9) (n = • Categorized: NR
To examine effect of 30,609) • NIH guidelines
gestational weight G3: Obese Class III • Asian/Pacific
Age (mean, yrs): Islander
change on pregnancy (BMI 40 and More) G1: <26: 46%
outcomes in obese (n = 19,025) NR
26-35: 47%
women Older than 35: 8% • Other
Group N:
Time frame: NR G2: <26: 44% G1: 22
1990 to 2001 26-35: 48%
Inclusion criteria: Smoking,%:
Older than 35: 8%
Duration of the study: • Obese women NR
G3: <26: 40%
Entry into prenatal care residing in Missouri 26-35: 52% Diabetes mellitus,%:
through delivery who delivered (at Older than 35: 9% NR
37 or more weeks
of gestation) Parity: Hypertension,%:
liveborn, singleton Nulliparous: NR
infants during G1: 34%
G2: 33% Additional characteristics:
1990–2001 NR
G3: 32%
Exclusion criteria:
• NR

C-510
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Risk of cesarean delivery Good
LGA:13%
Total weight gain: (P < 0.05) Groups Sample selection:
G1: GWG (lb) G2: SGA: 7% G1: wt loss > 10 lbs Fair
Less than 2: 3% LGA:16% G2: wt loss 2-9 lb
2 to 14: 15% G3: no change Definition of maternal
(P < 0.05) weight gain:
15 to 25: 26% G3: SGA: 6% G4: 2-9 lb
More than 25: G5: 10-14 lb Fair
LGA:18%
56% (P < 0.05) G6: 15-25 lb Definition of outcomes:
G2: GWG (lb) G7: 26-35 lb Good
Less than 2: 8% Gestational diabetes, G8: >35 lb
2 to 14: 22% %: Source of information on
15 to 25: 27% NR Results exposure, outcomes, and
More than 25: For all three classes of confounders:
43% Cesarean delivery,%: obese women, risks of Fair
G3: GWG (lb)Less G1: 28 cesarean delivery rise
G2: 34 above an OR of 1 when Followup:
than 2: 15% Fair
G3: 41 weight gain exceeds 25
pounds Analysis comparability:
Instrumental
• Categorized: Fair
delivery,%: Maternal confounders
• 10-lb or less loss
NR and effect modifiers Analysis of outcomes:
2 to 9 lbs loss, no
accounted for in Fair
weight change, Episiotomy,%: analysis:
2 to 9 lbs gain, NR Interpretation:
• Age
10 to 14 lbs gain, Poor
15–25 lb gain, • Race
26–35 lb gain, • Parity Sum of Good/Fair/Poor:
and greater than • Education 2 Good, 6 Fair, 1 Poor
35 lb gain • Poverty (enrollment in
medicaid Final Quality Score:
• Collected • WIC Fair
from: • Food stamp programs)
• Routine pre-natal • Tobacco use
care or maternity • Chronic hypertension
records
Infant and child
• Ascertained confounders and effect
by: modifiers accounted for
NR in analysis:
NR

C-511
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-512
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Bivariate Outcomes from
Gain Analysis 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-513
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Parker and Abrams, • Cohort • Self-reported White
1992 • Retrospective G1: 56.8 kg(SD 11.0) G1: 44.0
G2: NR G2: NR
Country and setting: Total Study N:
USA, hospital 6,690 Pregravid BMI: • Black
G1: Underweight: 27.7%, G1: 8.3
Enrollment Period: Group Description: Normal weight 61.8%, G2: NR
Sept 1980 to Dec 1988 G1: Overall Overweight: 5.6%,
G2: NR Obese 4.9% • Hispanic
Funding:
G2: NR G1: 9.4
UC Committee on Group N: G2: NR
Research & MCH and G1: 6,690 • Imputed:
Resources G2: NR • Asian/Pacific
Development, Health • No
Islander
Resources and Services Inclusion criteria:
• Categorized: G1: 21.4
Administration • Consecutive live G2: NR
• IOM guidelines
singleton births at
Study Objective: Moffitt Hospital Age (mean, yrs): • Other
To test whether gains between G1: 27.7 (5.5) G1: 12.0
outside IOM reference September 1980 G2: NR G2: NR
ranges were associated and December
with increased risks of 1988 with Parity: Smoking,%:
suboptimal pregnancy gestational ages of Primiparous: G1: 12.0
outcome (SGA, LGA, 37 to 42 weeks G1: 58.8% G2: NR
cesarean delivery) and G2: NR
Exclusion criteria: Diabetes mellitus,%:
to determine whether NR
locally developed • Maternal transfers
ranges were more or transports and Hypertension,%:
applicable to study deliveries NR
population complicated by fetal
malformations, Additional characteristics:
Time frame: maternal diabetes, NR
Sept 1980 to Dec 1988 or maternal
Duration of the study: hypertension
From entry into prenatal
care until delivery

C-514
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 6690 G1: 3408g (462) Risks for cesarean delivery Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational G1: Below IOM Fair
G1: 15.2kg (5.2) diabetes, %: G2: Above IOM
G2: NR NR Definition of maternal
Results weight gain:
• Categorize Cesarean delivery, AOR for all women weight Fair
d: %: gain >IOM (G2) =1.48
NR (1.25,1.76) Definition of outcomes:
• According to
Good
IOM Weight
Instrumental • For overweight
gain ranges Source of information on
delivery, %: women, there was no
based on exposure, outcomes, and
NR significant association
percentiles confounders:
between cesarean delivery
from previous Episiotomy, %: Fair
and weight gain (AOR =
study of UC NR
0.71 (0.40-1.26). Followup:
population with
good Other maternal Fair
• For non-overweight
pregnancy outcomes:
women, the association Analysis comparability:
outcomes: 25th NR
between cesarean delivery Fair
-75th, 10-90th Other infant and weight gain in non-
percentiles. For outcomes: overweight women was 1.45 Analysis of outcomes:
25-75th, weight NR (1.21 - 1.73) Good
gain range = Interpretation:
12-17kg for Maternal confounders and
effect modifiers Poor
underweight
women (BMI < accounted for in analysis: Sum of Good/Fair/Poor:
19.8); • Age 3 Good, 5 Fair, 1 Poor
• Race
• Collected • Parity Final Quality Score:
from: Fair
• Pre-gravid BMI
• Routine pre- • Height
natal care or • Maternal high and low
maternity weight gain
records
• Smoking
• Ascertaine Infant and child
d by: confounders and effect
• Based on last modifiers accounted for in
clinically analysis:
measured • Gestational age
weight prior to
• Birth weight
delivery

C-515
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2004 • Cohort • Self-reported White
• Retrospective • Not stated - records G1: 45
Country and setting: G2: 50
USA, university hospital Total Study N: Pregravid BMI: G3: 43
9,788 G4: 37
Enrollment Period: • Imputed:
Not stated Group Description: • No • Black
G1: All weight gain G1: 11
Funding: • Categorized:
categories G2: 11
Grant HD01262, • IOM guidelines
G2: Women gaining > G3: 9
Women’s Reproductive
IOM guidelines Age (mean, yrs): G4: 14
Health Research
G3: Women gaining G1: 26.6
Scholar
within IOM G2: 26.5 • Hispanic
Study Objective: guidelines G3: 26.8 G1: 10
To examine how G4: Women gaining < G4: 26.2 G2: 10
association between IOM guidelines G3: 9
excessive weight gain Parity: G4: 10
Group N: NR
and cesarean birth is
modified by infant birth
G1: 9,788 • Asian/Pacific
G2: 4,675 Islander
weight in nondiabetic
G3: 3,479 G1: 19
women
G4: 1,634 G2: 15
Time frame: G3: 24
Inclusion criteria:
Not stated G4: 24
• Singleton
Duration of the study: • Term • Other
During pregnancy until G1: 11
deliver Exclusion criteria: G2: 10
• Multiple gestation G3: 12
• Preterm birth (< 37 G4: 12
completed weeks)
• Birth weight less Smoking,%:
than 2500g NR
• Multiparity Diabetes mellitus,%:
• Noncephalic NR
presentation
• Gestational or Hypertension,%:
pregestational NR
diabetes Additional characteristics:
• Placenta previa NR
• Active herpes at
delivery
• Abdominal cerclage
• Fetal anomaly
requiring cesarean
delivery
• Missing data on
maternal
prepregnancy bmi
• Missing data on
gestational weight
gain

C-516
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 9788 G1: 3437 Cesarean delivery Good
G2: 4675 G2: 3562
G3: 3479 G3: 3360 Groups Sample selection:
G4: 1634 G4: 3242 G1: Below IOM Fair
G2: Above IOM
Total weight gain: Gestational Definition of maternal
diabetes, %: Results weight gain:
• Categorize NR AOR with birth weight in Poor
d: model
Cesarean delivery, G1: 0.99 (0.82,1.19) Definition of outcomes:
• According to
%: G2 :1.40 (1.22,1.59) Fair
IOM
NR Source of information on
• Collected • BMI <19.8
Instrumental exposure, outcomes, and
from: G1 =0.96 (0.67,1.37)
delivery, %: confounders:
• Routine pre- G2 =1.93 (1.45,2.53)
NR Poor
natal care or
• BMI 19.8-26
maternity Episiotomy, %: Followup:
G1 =1.04 (0.81,1.33)
records NR Fair
G2 =1.26 (1.06,1.50)
• Ascertaine Other maternal Analysis comparability:
• BMI >26 Fair
d by: outcomes: G1 =0.74 (0.38,1.44)
• Based on last NA G2 =1.21 (0.83,1.78) Analysis of outcomes:
clinically Fair
measured Other infant Maternal confounders and
weight prior to outcomes: effect modifiers Interpretation:
delivery: NA accounted for in analysis: Fair
measured as • Age
Sum of Good/Fair/Poor:
(1) difference • Race
1 Good, 6 Fair, 2 Poor
between • Pre-gravid BMI
prepregnancy • Year of delivery Final Quality Score:
weight and last • Smoking Fair
measurement
prior to delivery Infant and child
and (2) confounders and effect
absolute GWG modifiers accounted for in
= subtraction of analysis:
infant birth • Gestational age
weight and • Birth weight
placental • Infant sex
weight from
total maternal
weight

C-517
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Thorsdottir et al., 2002 • Cohort • Self-reported White
• Retrospective G1: 63.1 (6.2) NR
Country and setting:
G2: 62.0 (5.6) P = 0.059
Maternity records, Total Study N: G3: 61.7 (4.8) P = 0.174 • Black
Department of 614 NR
G4: 62.2 (6.1) P = 0.274
Obstetrics and
Gynecology at Group Description: Pregravid BMI: • Hispanic
Landspitali University G1: No complication G1: 22.2 NR
Hospital, Iceland G2: Complications in G2: 22.4 )1.6) P = 0.270
pregnancy or • Asian/Pacific
G3: 22.4 (1.5) P = 0.338 Islander
Enrollment Period: delivery G4: 22.3 P = 0.584 NR
G3: Complications in
Funding:
pregnancy • Imputed: • Other
NR
G4: Complications in • No NR
Study Objective: delivery
To investigate relation • Categorized: Smoking,%:
Group N: • Continuous NR
between gestational
G1: 452
weight gain in women of Age (mean, yrs): Diabetes mellitus,%:
G2: 162
normal prepregnant G1: 29 NR
G3: 56
weight and G2: 29 P = 0.857
G4: 106
complications during G3: 29 P = 0.404 Hypertension,%:
pregnancy and delivery Inclusion criteria: G4: 29 P = 0.398 NR
in a population with high • Women of normal
Parity: Additional characteristics:
gestational weight gain prepregnancy
NR Proportional weight gain, %:
and birth weight weight randomly G1: 26.0
Time frame: selected within 1 G2: 28.0 P = 0.018
NR year (1998) G3: 30.0 P = 0.005
• No history of G4: 27.0 P = 0.546
Duration of the study: diabetes,
1998 hypertension, CVD, Additional characteristics:
or thyroid problems NR
• 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

C-518
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and cesarean delivery
(continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 452 G1: 3789 (469) Percent cesarean Good
G2: 162 G2: 3749 (565) P = 0.389 deliveries
G3: 56 G3: 3643 (526) P = 0.032 Sample selection:
G4: 106 G4: 3806 (578) P = 0.529 Groups Fair
G1 <11.5 kg
Total weight gain: Gestational diabetes, %: G2 11.5-16 kg Definition of maternal
G1: 16.6 (4.9) NR G3 16.1-20 kg weight gain:
G2: 17.4 (5.1) P = 0.080 G4 >20 kg Poor
G3: 18.4 (5.1) P = 0.013 Cesarean delivery, %:
NR Results Definition of outcomes:
G4: 16.9 (5.1) P = 0.887 Fair
G1: 17.4%
Instrumental delivery,
• Categorized: G2: 9.5% Source of information on
%: G3: 12.9 %
• According to IOM exposure, outcomes, and
NR G4: 13.1%
< 11.5, 11.-16.0, confounders:
≥ 16.1, also quintiles Episiotomy, %: Fair
• No significant
< 12.5, 12.5-15.5, NR
differences in cesarean Followup:
15.6-17.8, 17.9-20.8,
Other maternal delivery rates by IOM Good
> 20.8
outcomes: weight gain categories in
normal weight women Analysis comparability:
• Collected from: NA
Good
• Routine pre-natal Maternal confounders
Other infant outcomes:
care or maternity and effect modifiers Analysis of outcomes:
NA
records accounted for in Good
• Ascertained by: analysis: Interpretation:
• Based on last • Age Good
clinically measured • Parity
• Height Sum of Good/Fair/Poor:
weight prior to
5 Good, 3 Fair, 1 Poor
delivery, not stated -
Infant and child
based on records? Final Quality Score:
confounders and effect
modifiers accounted for Fair
in analysis:
• Gestational age
• Birth weight

C-519
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
Study Design
Patient Population
Inclusion/ Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hickey et al., 1995 • Cohort • Self-reported White
• Prospective G1: 55.8 (8.4) NR
Country and setting:
G2: 54.1 (7.9)
USA Total Study N: Black
university prenatal 1518 Pregravid BMI: NR
clinics G1: < 19.8: 37.7%
Group Description: Hispanic
19.8-26.0: 62.3%
Enrollment Period: G1: Black women NR
G2: < 19.8: 43.3%
Dec 1985 to Oct 1988 G2: White women 19.8-26.0: 57.7% Asian/Pacific Islander
Funding: Group N: NR
Imputed:
NIH G1: 677 • No Other
MCH grant G2: 338
NR
Categorized:
Study Objective: Inclusion criteria:
To examine relationship • IOM guidelines Smoking,%:
• Low income G1: 34.6
between prenatal weight • Multiparous women Age (mean
gain and spontaneous G2: 75.7
• Must have at least
preterm delivery using yrs): Diabetes mellitus,%:
1 risk factor: > 2
IOM guidelins G1: 24.8 (4.4) NR
spontaneous
G2: 24.4 (4.4)
Time frame: abortions
Hypertension,%:
Dec 1985 to Oct 1988 • previous Parity: NR
stillborn/neonatal G1: 1: 58.9%; 2: 41.1%
Duration of the study: death G2: 1: 68.6%; 2: 31.4% Additional characteristics:
Entry into prenatal care • previous birth < 37 NR
until delivery 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

C-520
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Outcomes from Outcomes from Multivariate
Maternal Weight Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: First trimester: 353 NR Odds ratio(95% CI) for Good
Second trimester: 474 spontaneous preterm; and
Third trimester: 615 Gestational diabetes pattern of weight gain Sample selection:
G2: First trimester: 175 Fair
%:
Second trimester: 244 NR Definition of maternal
Third trimester: 301 Groups
G1: Low rate of weight gain weight gain:
Cesarean delivery Fair
Total weight gain: first trimester-
G1: First trimester: %: underweight (BMI < 19.8) & < Definition of
Low BMI -2.61 (2.91); NR 2.3 kg and normal weight (BMI outcomes:
Normal BMI- 2.54 (3.68); Instrumental 19.8-26)& < 1.6 kg Good
Second trimester: delivery
Low BMI: 0.49 (0.19) G2: Low rate of weight gain in Source of information
Normal BMI: 0.46 (0.21) %: second trimester (Underwt & < on exposure,
Third trimester: NR 0.38 kg/wk or normal wt & < outcomes, and
Low BMI- 0.46 (0.27) 0.37 kg/wk) confounders:
Episiotomy Fair
Normal BMI-0.45 (0.27)
G2: First trimester: low BMI - %: G3: Low rate of weight gain in Followup:
2.93 (3.39); normal NR third trimester (Underwt & < Fair
0.38 kg/wk or normal wt & <
Categorized: Other maternal 0.37 kg/wk) Analysis
• According to IOMweight outcomes: comparability:
gain by trimester • Low first Results Fair
trimester weight OR (95% CI) for Spontaneous
Collected from: Preterm Analysis of outcomes:
gain: < 2.3kg for
• Routine pre-natal care low BMI women G1 1.27 (0.7 Fair
or maternity records and < 1.6kg for 2.3)
Interpretation:
Ascertained by: normal BMI G2 1.23 (0.7
Fair
• Based on last clinically women 2.18)
measured weight prior • Low second and G3 2.46 (1.53 Sum of
to delivery: using weight low third 3.92) Good/Fair/Poor:
measured at last visit trimester weight 2 Good, 7 Fair, 0 Poor
Pattern of weight gain
prior to delivery gain: < G1 only 2.94 (0.73 Final Quality Score:
0.38kg/wk for low 11.98) Fair
BMI women and G2 only 1.08 (0.1
< 0.37 kg/wk for 11.23)
normal BMI G3 only 11.54 (2.93
women 45.28)
Other infant G1 & G2 4.89 (0.85
outcomes: 28.14)
• Spontaneous G1 & G3 4.49 (0.96
preterm birth: 20.96)
12.4% in black G2 & G3 7.37 (1.66
women and 8.0% 32.76)
in white women All trimesters 4.18 (0.75
23.35)

C-521
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
Study Design
Patient Population
Inclusion/ Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year:
Hickey et al., 1995
(continued)

C-522
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Outcomes from Outcomes from Multivariate
Maternal Weight Gain Bivariate Analysis 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-523
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Study Design
Patient Population
Inclusion/ Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, Year: Design: Pregravid weight: Race,%:
Schieve et al., 2000 • Cohort • Self-reported White
• Combination: G1: 67.1%
Country and setting: Pregravid BMI: G2: 81.1%
medical charts but
USA
then women were Imputed:
National Maternal and Black
asked to self report • No
Infant Health Survey G1: 20.9%
info after pregnancy
Categorized: G2: 9.1%
Enrollment Period:
Total Study N: • IOM guidelines
1988 Hispanic
3,511
Age (mean G1: 12.1%
Funding: G2: 9.8%
Group Description:
NR yrs):
G1: Preterm
G1: Age at delivery (y): Asian/Pacific Islander
Study Objective: G2: Term
15–19 12.5%* NR
To examine
Group N: 20–29 56.0%
associations between Other
rate of pregnancy Inclusion criteria: 30–50 31.6% NR
weight gain and preterm • Singleton births G2: Age at delivery (y)
delivery among women 15–19 8.3% Smoking,%:
delivered between G1: 38.2
of varying prepregnancy 28 and 43 weeks’ 20–29 60.3%
body mass indices 30–50 31.4% G2: 32.4
gestation wtih data
(BMI) available for 3 or Parity: Diabetes mellitus,%:
Time frame: more prenatal Parity 0 G1: 6.4
1988 weight G1: 49.9% 1 31.8% 2 or G2: 4.4
measurements more 18.3%
Duration of the study: Hypertension,%:
between 14 and 28 G2: 47.7%1 30.8%2 or more
From initiation of G1: 10.9
weeks’ gestation 21.6%
prenatal care to delivery G2: 6.6
Exclusion criteria:
Additional characteristics:
• Women with weight
Marital status:
gain per week of >
G1: Married 72.1%
5.0 lb. or less than -
Not married 27.9%
2.5lb. Women
G2: Married 84.2%
missing data for
Not married 15.8%
prepregnancy
weight or height 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-524
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Adjusted odds ratio for Good
Total weight gain: preterm birth
Gestational Sample selection:
Categorized: diabetes Groups Fair
• According to G1: Low < 0.5 less/week;
IOM pounds %: G2: Average 0.5-1.5 Definition of maternal
per week: Low G1: 6.4 lb/week weight gain:
- 0.5 or G2: 4.4 G3: High > 1.5 lb/week Fair
less/week;
Cesarean Results Definition of outcomes:
average 0.5-
delivery,%: Low BMI: Good
1.5 lb/week;
high > 1.5 Instrumental G1=6.7 (1.1 Source of information on
lb/week delivery 40.6) exposure, outcomes, and
G2=0.8 (0.4 confounders:
Collected from: %: 1.4) Good
• Routine pre- NR G3=1.0 (0.4
natal care or 2.6) Followup:
maternity Episiotomy Fair
records %: Average BMI:
G1=3.6 (1.6 Analysis comparability:
Ascertained by: NR Good
8.0)
• Based on last Other maternal G2 (Reference) Analysis of outcomes:
clinically outcomes: G3=1.0 (0.6 Good
measured NR 1.9)
weight prior to Interpretation:
deliveryNR Other infant High BMI: Good
outcomes: G1=1.6 (0.7
NR 3.5) Sum of Good/Fair/Poor:
G2=1.1 (0.6 6 Good, 3 Fair, 0 Poor
2.1)
Final Quality Score:
G3=0.1 (0.03
Good
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

C-525
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Study Design
Patient Population
Inclusion/ Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, Year: Design: Pregravid weight: Race,%:
Siega-Riz et al., 1994 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
USA Total Study N: G1: Underweight: 12%; Black
public health clinics 5854 Normal weight: 60%; NR
Overweight: 17.7%;
Enrollment Period: Group Description: Hispanic
Obese: 10.5%
1983 to 1986 G1: Total cohort G1: 80
G2: NR
G2: NR G2: NR
Funding:
Imputed:
March of Dimes Group N: Asian/Pacific Islander
• Yes
NIGMS-predoc grant NR
Inclusion criteria: Categorized:
Study Objective: • Women attending 8 Other
To describe gestational • IOM guidelines NR
public health clinics
weight gain patterns by in West Los Age (mean
prepregnancy weight Smoking,%:
Angeles area NR
and trimester of yrs):
• Only included first
pregnancy G1: 24.3 Diabetes mellitus,%:
pregnancy for
and to examine risk of G2: NR NR
which women
preterm birth associated received care Parity:
with prepregnancy Hypertension,%:
Primiparous: NR
weight and gestational Exclusion criteria:
G1: 35%
weight gain using • Women who left
G2: NR Additional characteristics:
various definitions of prenatal care
Married:
adequacy based on setting after at least
G1: 61%
IOM 2 visits with no birth
G2: NR
outcome available
Time frame: • Mismatched Less than 12 years of
1983 to 1986 prenatal and education:
Duration of the study: outcome files G1: 71%
Entry into prenatal care • Erroneous G2: NR
up to delivery gestational age
• Pregnancy
complications
(diabetes
• hypertension
• Stillbirths
• Multiple
pregnancies
• Implausible values

C-526
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 3424 Risk of preterm birth Good
Total weight gain: G2: NR
G1: Underweight Groups Sample selection:
women: Gestational Total weight gain Fair
14.3kg; diabetes expressed as a ratio of
Normal weight: observed: expected based Definition of maternal
13.7 kg; %: on the IOM weight gain:
Overweight: NR recommendation for a Fair
12kg; Cesarean delivery given gestational age Definition of outcomes:
Obese: 11.7kg Good
G2: NR %: Results- outcomes by
NR groups Preterm birth (< 37 Source of information on
Categorized: weeks) exposure, outcomes, and
• According to Instrumental • Adequacy of weight confounders:
IOM delivery gain in the third Fair
%: trimester was
Collected from: predictive of preterm Followup:
• Routine pre- NR Good
birth - the data
natal care or Episiotomy suggested a threshold
maternity Analysis comparability:
%: effect for all weight Poor
records status groups with a
NR Analysis of outcomes:
Ascertained by: marked decrease in
Other maternal risk at 90-110% of the Good
• Based on last
clinically outcomes: IOM recommendation Interpretation:
measured NA • With the rate of weight Poor
weight prior to gain less than 60% of
Other infant Sum of Good/Fair/Poor:
delivery the IOM value
outcomes: 4 Good, 3 Fair, 2 Poor
• women in all four
NA
groups had more than
Final Quality Score:
double the risk of
Fair
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

C-527
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Study Design
Patient Population
Inclusion/ Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, Year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Perinatal data base • Self-reporteddata base White
review NR
Country and setting: Pregravid BMI:
• Retrospective
USA G1: Low 29.6%; Normal Black
academic medical Total Study N: 70.4% NR
center 15,101 G2: Low25.9%; Normal
Hispanic
74.1%
Enrollment Period: Group Description: NR
G3: Low 23.0%; Normal
1976 to 2001 G1: Total 77% Asian/Pacific Islander
G2: White G4: Low 19%; Normal 81%
Funding: NR
G3: African American G5: Low 42.2%; 57.9%
NIH
G4: Latina Other
Study Objective: G5: Asian Imputed: NR
To study how • No
Group N: Smoking,%:
relationship between
G1: 15,101 Categorized: G1: 10.9%
gestational weight gain
and spontaneous
G2: 6,513 • IOM guidelines G2: 14.5%
G3: 1,533 Low (< 19.8) G3: 21.4%
preterm birth interacts
G4: 1,614 Normal (19.8-25.9) but G4: 6.7%
with maternal race or
G5: 3,440 this is not explicitly G5: 4.5%
ethnicity and previous
preterm birth status stated
Inclusion criteria: Diabetes mellitus,%:
Time frame: • Women of low or Age (mean NR
1976 to 2001 normal
yrs): Hypertension,%:
prepregnancy BMI
Duration of the study: G1: 28.19 NR
delivering singleton
From entry into prenatal during study period G2: 29.43
G3: 24.25 Additional characteristics:
care until delivery with complete data Previous preterm birth (%)
(actually used a on all variables G4: 26.17
G1: NR
perinatal data base and considered G5: 29.10
G2: 4.4
looked at info) Parity: G3: 4.1
Exclusion criteria:
Nulliparous G4: 8.3
Quality: • Multiple gestations
Fair G1: 53.8% G5: 5.58
• Hypertension
G2: 57.5 G6: 2.91
• Diabetes G3: 48.0
• Delivery before 24 Additional characteristics:
G4: 49.0
weeks of gestation G5: 52.9 NR
• Congenital
anomalies
• Missing data on
any key variables
• Prepregnancy BMI
of 26 or greater
• Transport from
another hospital

C-528
Evidence Table 40. Gestational weight gain with reference to IOM recommendations and preterm birth
(continued)
Outcomes from
Bivariate Outcomes from
Maternal Weight Gain Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 15,101 NR Odds ratio of spontaneous Good
G2: 6,513 preterm birth
G3: 1,533 Gestational Sample selection:
G4: 1,614 diabetes Groups Good
G5: 3,440 G1: low rate of weight gain
%: <.27 kg/wk Definition of maternal
Total weight gain: NR G2: ref 0.27-0.52 kg/wk weight gain:
G1: Below IOM: 20.5; G3: high rate of weight gain Fair
Cesarean
% Within IOM delivery >0.52 kg/wk Definition of outcomes:
39.1%; Good
Above 40.4% %: Results
P < .001 NR Crude OR Source of information on
G2: Below 15.5%; G1: 2.6 (95% CI 2.1–3.2) exposure, outcomes, and
Instrumental G3: 1.0 (95% CI 0.8–1.2) confounders:
Within 38.5%; delivery
above 46.1% AOR Fair
P < .001 %: G1: 2.5 (95% CI 2.0–3.1) Followup:
G3: Below 16.9%; NR G3: 1.0 (95% CI 0.8–1.3) Fair
Within 30.9%;
Episiotomy No differences in results by Analysis comparability:
Above 41.2%
P < .001 %: parity combined with Hx Fair
G4: Below 21.1%; NR PTB
Analysis of outcomes:
Within 37.4%;
Other maternal Slightly higher risks for Af Fair
Above 41.5%
P < .001 outcomes: Am and high wt gain close Interpretation:
G5: Below 25.4%; • Spontaneous to sign for Af Am Good
Within PTB for
Maternal confounders Sum of Good/Fair/Poor:
• All women
Categorized: and effect modifiers 4 Good, 5 Fair, 0 Poor
4.0%
• Continuous accounted for in
• White 3.6% Final Quality Score:
• According to IOM3- analysis:
• Blacks 6.8% Fair
way categorical • Age
• Latinas 4.4%
variable • Race-EMM
• Asians 3.6%
• low (less than 0.27 • Parity-EMM
kg/wk) Other infant • Pre-gravid BMI
• normal outcomes: • History of previous
(between0.27 and NR PTB
0.52 kg/wk) • Year of delivery
• and high (greater • Number of days
than 0.52kg/wk) between last weighing
and DOB
Collected from: • Smoking
• Rate of weight gain
was determined Infant and child
by:total weight gain confounders and effect
divided by GA modifiers accounted for
minus 2 weeks in analysis:
NR
Ascertained by:
• Based on last
clinically measured
weight prior to
delivery

C-529
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 58.8 (7.1) (P < 0.05) G2: 57.3% (P < 0.01)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
G1: Obese • No
NR
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
To compare pregnancy
Group N: • NHANES II reference
G1: 613 for women 20 to 29
outcomes between Smoking,%:
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Diabetes mellitus,%:
• Singleton G2: 28.7 (P = NS) G1: 14.2%
gestational weight gain pregnancy
on pregnancy outcome Parity: G2: 4.3% (P < 0.01)
• Age 20 to 34 years
in morbidly obese % multiparous: Hypertension,%:
women Exclusion criteria: G1: 66.7% G1: 5.4%
• Multiple gestations G2: 44.8% (P < 0.01) G2: 0.3% (P < 0.01)
Time frame: • Extremes of age
NR • BMI between 27 Additional characteristics:
Duration of the study: and 34 % college education:
1988 to 1995 • Missing height G1: 37.1%
• Missing G2: 63.1% (P < 0.01)
prepregnancy Preexisting diabetes:
weight G1: 7.3%
G2: 1.6% (P < 0.01)

C-530
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) Increase in birthweight Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: Weight loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: Definition of maternal weight
G3: 16-25 lbs gain:
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P < Poor
Only calculated for G5: >35 lbs
0.01) Definition of outcomes:
morbidly obese:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 3,302 Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 3,192 exposure, outcomes, and
G2: 15.9% G3: 3,337 confounders:
Collected from: G4: 3,506 Poor
• Routine pre- Instrumental G5: 3,453
natal care or delivery,%: (P < 0.05) Followup:
maternity NR Fair
records Maternal confounders and
Episiotomy,%: effect modifiers accounted Analysis comparability:
Ascertained by: NR for in analysis: Poor
• Not stated - NR
Other maternal Analysis of outcomes:
from medical
outcomes Infant and child confounders Fair
records
• Preeclampsia and effect modifiers
• Placental Interpretation:
accounted for in analysis:
abruption Poor
NR
• Meconium Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-531
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hickey et al., 1997 • Cohort • Self-reported White
• Retrospective G1: 70.8 (19.6) NR
Country and setting:
G2: 65.8 (17.6)
USA, public health Total Study N: Black
programs 5198 Pregravid BMI: NR
G1: 26.6 (7.1)
Enrollment Period: Group Description: Hispanic
G2: 24.8 (6.3)
Jan 1993 to Dec 1994 G1: Black NR
G2: White Imputed:
Funding: Asian/Pacific Islander
• No
MCH grant, University Group N: NR
of Alabama School of G1: 2219 Categorized:
Public Health/NIH Smoking,%:
G2: 3699 • IOM guidelines G1: 9.2
Intamural Basic
Sciences Research Inclusion criteria: Age (mean, yrs): G2: 35.1
grant • Women enrolled in G1: 23.7 (5.0) Diabetes mellitus,%:
Medicaid Maternity G2: 23.4 (4.6) NR
Study Objective: Waiver programs
Examine differences in operated in 24 Parity: Hypertension,%:
birth weight among term counties by Alabama NR
infants of black and Department of
white women with Additional characteristics:
Public Health during
weight gains in upper or study period NR
lower half of
recommended ranges Exclusion criteria:
• Delivered before 37
Time frame: weeks or after 42
Jan 1993 to Dec 1994 weeks
Duration of the study: • Maternal age ≤ 17
From first visit to years
delivery • 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

C-532
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Outcomes from
Maternal Weight Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Birth Weight (gms) by IOM Categories Good
Total weight gain:
Gestational Groups Sample
Categorized: diabetes, %: selection:
• According to G1: Below IOM Range
NR G2: Lower end of IOM Range Good
IOMgain below
range (for Cesarean G3: Upper end of IOM range Definition of
pregravid BMI), delivery, %: G4: Gain above IOM range maternal weight
gain in lower NR gain:
range, gain in Results Poor
Instrumental
upper range, BMI < 19.8
delivery, %: Definition of
gain above
NR G1: outcomes:
range
Black: 2840 Good
Episiotomy, %:
Collected from: White: 3002
NR Source of
• Routine pre-
G2: information on
natal care or Other maternal
Black: 2995 exposure,
maternity outcomes:
White: 3151 outcomes, and
records NA confounders:
Ascertained by: Other infant G3: Fair
• Based on last outcomes: Black: 3017
White: 3200 Followup:
clinically NA Good
measured G4:
weight prior to Black: 3163 Analysis
delivery White: 3353 comparability:
Fair
BMI19.8-26.0
G1: Analysis of
Black: 3052 outcomes:
White: 3176 Good

G2: Interpretation:
Black: 3105 Fair
White: 3199 Sum of
G3: Good/Fair/Poor:
Black: 3180 5 Good, 3 Fair, 1
White: 3307 Poor

G4: Final Quality

Black: 3228 Score:
White: 3389 Fair

BMI > 26.0

G1:
Black: 3126
White: 3385
G2:
Black: 3192
White: 3376
G3:
Black: 3312
White: 3402
G4:
Black: 3300
White 3504

C-533
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Hickey et al., 1997
(continued)

C-534
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis 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-535
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hickey et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 55.2 (9.0) NR
Country and setting:
G2: 53.8 (7.7)
USA, university prenatal Total Study N: Black
clinics 415 Pregravid BMI: NR
G1: < 19.8: 42.9%
Enrollment Period: Group Description: Hispanic
19.8-26.0: 57.1%
Dec 1985 to Oct 1988 G1: Black NR
G2: < 19.8: 41.4%
G2: White 19.8-26.0: 58.6%
Funding: Asian/Pacific Islander
Maternal and Child Group N: NR
Imputed:
Health grant G1: 275 • No Smoking,%:
G2: 140
Study Objective: G1: 35.6
Categorized:
To examine association Inclusion criteria: G2: 77.9
between prenatal weight • IOM guidelines
• Women who Diabetes mellitus,%:
gain patterns and birth identified as black or Age (mean, yrs):
weight using IOM NR
white, were G1: 25.8 (4.2)
guidelines nonobese, and were G2: 25.2 (4.3) Hypertension,%:
Time frame: para 1 or 2 and who G1: 0.7
enrolled in prenatal Parity: G2: 0.0
Dec 1985 to Oct 1988 G1: 1: 61.4%; 2: 38.6%
care clinic with at
Duration of the study: G2: 1: 68.6%; 2: 31.4% Additional characteristics:
least one or more of
During prenatal care to NR
following risk factors:
delivery > 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

C-536
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 415 NR Birth weight Good
G2: 415
G3: 275 Gestational Groups Sample selection:
G4: 275 diabetes, %: G1: First Trimester <2.6 kg Good
G5: 140 NR for underwt & <1.6 kg
for normal wt Definition of maternal
G6: 140 Cesarean delivery, weight gain:
G2: Second Trimester
Total weight gain: %: <0.38 kg/wk for Fair
G1: First trimester: 2.6 (3.2) NR underwt & <0.37 kg/wk Definition of outcomes:
Second trimester: 0.50 (0.17) Instrumental for normal wt Fair
Third trimester: 0.47 (0.24) delivery, %: G3: <0.38 kg/wk for
G2: First trimester: 2.4 (3.5) NR underwt & <0.37 kg/wk Source of information on
Second trimester: 0.49 (0.22) for normal wt exposure, outcomes, and
Third trimester: 0.46 (0.26) Episiotomy, %: confounders:
G3: Total weight gain: 14.2 (4.4) NR Results Fair
First trimester: 2.4 Association of low trimester
Other maternal gain with birthweight Followup:
Categorized: outcomes: G1: All women -18 g p=.65 Good
• According to IOM • First trimester Black -15 g P = .76 Analysis comparability:
weight gain (kg) White -42 g P = .53
Collected from: Fair
was compared to G2: All women -166g
• Routine pre-natal care or IOM guideline for p=<.001 Analysis of outcomes:
maternity records low BMI women Black -164 g P = .005 Good
= 2.3kg and White -158 g P = .05
Ascertained by: Interpretation:
normal BMI G3: All women -111g
• Based on last clinically Fair
women = 1.6kg p=.008
measured weight prior to
• Second and third Black -77 g P =.14 Sum of Good/Fair/Poor:
delivery
trimester weight White -194 g P =.004 4 Good, 5 Fair, 0 Poor
gain (kg/wk) was
compared to IOM No association with low Final Quality Score:
guideline for low weight gain in only the first Fair
BMI women = or second trimester.
0.49 kg/wk and G3: All -164 g P = .01
normal BMI Black -80 g P = .38
women = 0.44 White -300 g P =.005
kg/wk Association with low weight
Other infant gain during more than one
outcomes: trimester
NA 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

C-537
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: • Prenatal weight
Hickey et al., 1996 observations that
(continued) did not fall within
time frames
specified at
beginning and end
of all 3 trimesters

C-538
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis 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-539
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hickey et al., 1993 • Cohort • Self-reported White
• Combination, G1: 63.9 (17.1) NR
Country and setting:
perinatal database G2: 61.0 (16.0)
USA, prenatal clinics Black
Total Study N: Pregravid BMI: NR
Enrollment Period:
1,168 G1: < 19.8: 27.5%
December 1985 to Hispanic
19.8-26.0: 43.6%
October 1998 Group Description: NR
> 26.0-29.0: 10.5%
G1: black > 29.0: 18.4%
Funding: Asian/Pacific Islander
G2: white G2: < 19.8: 32.3%
NIH, Maternal and Child NR
Health Department, and Group N: 19.8-26.0: 46.0%
Agency for Health care > 26.0-29.0: 8.0% Other
G1: 803
policy and research > 29.0: 13.7% NR
G2: 365
grants Smoking,%:
Inclusion criteria: Imputed:
Study Objective: • No G1: 37.1
At least 1 of following risk
To examine association G2: 73.4
factors: Categorized:
of prenatal weight gain • History of more than Diabetes mellitus,%:
below, within, and • IOM guidelines
2 spontaneous G1: 5.8
above IOM guidelines abortions Age (mean, yrs): G2: 9.6
with birth weight and • Previous fetal or G1: 25.2 (4.4)
fetal growth restriction Hypertension,%:
neonatal death G2: 24.8 (4.4)
among low income, high G1: 2.7
• Previous live birth
risk black and white Parity: G2: 1.1
before 37 weeks’
women Para 1:
gestation Additional characteristics:
G1: 1: 59.3%
Time frame: • Previous infant G2: 1: 68.2% Married:
December 1985 to weighing less than G1: 24.9%
October 1998 2750g G2: 65.6%
• Maternal height less
Duration of the study: than 157cm
Entry to prenatal care • Prepregnancy
until delivery 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)

C-540
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 803 G1: 3227 (440) Adjusted birthweight Good
G2: 365 G2: 3358 (467)
Groups Sample selection:
Total weight gain: Gestational BMI ≤ 29 Good
diabetes, %: G1: gain < range
Categorized: G1: 5.8 G2: gain in the range Definition of maternal
• According to G2: 9.6 G3: gain > range weight gain:
IOM Fair
Cesarean BMI >29
Collected from: delivery,%: G4: gain <6.0 kg Definition of outcomes:
• Collected by NR G5: gain >6.0 kg Good
study
Instrumental Results Source of information on
investigators
delivery,%: G1 Black 3027 White 3246 exposure, outcomes, and
Ascertained by: NR G2 Black 3177 White 3233 confounders:
• Based on last G3 Black 3293 White 3523 Fair
clinically Episiotomy,%: G4 Black 3214 White 3500
NR Followup:
measured G5 Black 3553 White 3596 Good
weight prior to Other maternal
delivery: Maternal confounders and Analysis comparability:
outcomes: effect modifiers
difference NA Fair
between self accounted for in analysis:
Other infant • Maternal height Analysis of outcomes:
report and last
outcomes: • Education Fair
measure
weight (76,4% NA • Parity Interpretation:
made within 2 • Marital status Good
weeks prior to • Smoking
delivery) Sum of Good/Fair/Poor:
• Alcohol use
5 Good, 4 Fair, 0 Poor
• Hypertension
• GDM Final Quality Score:
• Gestational age at Good
delivery
• SES
• Time between last
weight and delivery
Infant and child
confounders and effect
modifiers accounted for in
analysis:
• Gestational age
• Infant sex

C-541
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Luke et al., 1996 • Cohort • Self-reported White
• Prospective G1: 47.9 (5.1) NR
Country and setting:
G2: 58.7 (6.3)
USA, clinic Total Study N: Black
G3: 83.9 (16.9)
487 G1: 48.1
Enrollment Period: G2: 48.8
Pregravid BMI:
March 1, 1974 to June Group Description: G3: 63.5
G1: 18.3 (1.0)
15, 1979 G1: BMI < 19.8 G2: 22.6 (1.7)
G2: BMI 19.8-26.0 Hispanic
Funding: G3: 31.7 (5.3)
G3: BMI > 26.0 NR
NR
Imputed:
Group N: Asian/Pacific Islander
Study Objective: • No
G1: 104 NR
Reanalysis of original
G2: 268 Categorized:
data to examine Other
contribution of maternal
G3: 115 • IOM guidelines NR
weight gain to infant Inclusion criteria: Age (mean, yrs):
birth weight and Smoking,%:
• Referred for G1: 23.1 (5.5) G1: 17.3
retained maternal nutrition counseling G2: 23.8 (5.5)
weight in immediate G2: 15.3
• > 37- < 43 weeks G3: 27.4 (6.2) G3: 13.0
postpartum period, and gestation
effect of weight gains Parity: Diabetes mellitus,%:
• Singleton
below, at, and above % primipara: NR
pregnancy
IOM guidelines on both G1: 60.6
infant birt Exclusion criteria: G2: 48.1 Hypertension,%:
• Women with history G3: 27.0 NR
Time frame: of or concurrent
March 1, 1974 to June Additional characteristics:
metabolic disease, NR
15, 1979 such as diabetes,
Duration of the study: seizure disorder,
Prenatal visit through 2 hypertension,
days postpartum cardiac disease,
asthma, or drug
dependence
• Women developing
antepartum
complications such
as preeclampsia,
GDM, or multiple
gestation

C-542
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 104 G1: 3,067 (44) Adjusted birthweight Good
G2: 268 P < 0.05
G3: 115 significantly Groups Sample selection:
different from G1: Gain <IOM Fair
Total weight gain: mean for normal G2: gain equal to IOM
G1: 12.6 (0.7) G3: gain > IOM Definition of maternal
BMI weight gain:
G2: 13.2 (0.4) G2: 3308 (27)
G3: 11.7 (0.7) Results Fair
G3: 3300 (43) G1: BMI <19.8 2873g*
Significantly Definition of outcomes:
different from mean Gestational BMI 19.8-26.0 3157 g*
BMI >26 3138 g Good
for normal BMI diabetes, %:
group at P < 0.05 NR G2: BMI <19.8 3190 g Source of information on
BMI 19.8-26 3298g exposure, outcomes, and
Categorized: Cesarean delivery, BMI >26 3338g confounders:
• According to %: G3 BMI <19.8 3489g* Fair
IOM NR BMI 19.8-26 3494g*
BMI >26 3347g Followup:
Collected from: Instrumental * significantly different from Fair
• Routine pre- delivery, %: gains within range within
natal care or NR Analysis comparability:
each BMI grouping Good
maternity
Episiotomy, %: Maternal confounders
records Analysis of outcomes:
NR and effect modifiers
Ascertained by: Fair
Other maternal accounted for in
• Based on last outcomes: analysis: Interpretation:
clinically • Maternal age Poor
• Net gain (kg): 9.5
measured • Parity
(0.6), 9.9 (0.4), Sum of Good/Fair/Poor:
weight prior to • Black ethnicity
7.8 (0.6) 3 Good, 5 Fair, 1 Poor
delivery: total
significantly • Smoking
weight gain: Final Quality Score:
different from • Gestational duration
difference Fair
mean for normal
between last Infant and child
BMI group at P <
measurement confounders and effect
0.05
and pregravid modifiers accounted for
• Retained weight
weight; net in analysis:
(kg): 6.6 (0.6),
weight gain: • fetal sex
6.6 (0.4), 4.2
difference
(0.6) significantly
between
different from
pregravid
mean for normal
weight and last
BMI group at
measured
P < 0.05
weight minus
infant birth • Percent retained
weight 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

C-543
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
May, 2007 • Cohort • Self-reported White
• Retrospective G1: 70.3kg (20.4) G1: 58.8
Country and setting:
United States, WIC Total Study N: Pregravid BMI: Black
clinics 233 G1: 26.7kg (7.0) G1: NR
Enrollment period: Group Description: • Imputed: Hispanic
As of February 2001 G1: Total • No G1: 31.8
NR
Funding: • Categorized: Asian/Pacific Islander
NR Group N: • IOM guidelines G1: NR
G1: 233
Study Objective: Age (mean, yrs): Other
NR
Study was designed to G1: 24.7 (5.3) G1: 9.4
test predictors of infant Inclusion criteria:
birth weight based on Parity: Smoking,%:
• Singleton live birth G1: 23.6%
categories of with gestation G1: 29.2% Primipara
prepregnancy BMI, length between 36 Diabetes mellitus,%:
GWG, and smoking to 44 weeks NR
Time frame: Exclusion criteria: Hypertension,%:
As of February 2001 NR NR
Duration of the study: Additional characteristics:
NR NR

C-544
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR Birthweight Beta’s from Good
multiple linear regression
Total weight gain: Gestational Sample selection:
NR diabetes, %: Groups Fair
NR G1: Below IOM
Categorized: G2: Greater IOM Definition of maternal
• According to Cesarean weight gain:
IOM delivery,%: Results Poor
NR G1: -162 g
Collected from: G2: -153 g Definition of outcomes:
• Routine pre- Instrumental Fair
natal care or delivery,%: Maternal confounders
NR and effect modifiers Source of information on
maternity
accounted for in exposure, outcomes, and
records
Episiotomy,%: analysis: confounders:
Ascertained by: NR Poor
• Maternal BMI
• Self-reported Other maternal • Smoking Followup:
outcomes: Fair
Infant and child
NR
confounders and effect Analysis comparability:
Other infant modifiers accounted for Fair
outcomes: in analysis:
Analysis of outcomes:
NR • Gestational age
Fair
Interpretation:
Fair
Sum of Good/Fair/Poor:
1 Good, 6 Fair, 2 Poor
Final Quality Score:
Fair

C-545
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Nielsen et al., 2006 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
USA, clinic Total Study N: G1: 18.3 (1.1) Black
815 G2: 22.4 (1.6) G1: 100
Enrollment Period: G2: 100
G3: 30.9 (4.6)
1990 to 2000 Group Description: G3: 100
G1: BMI < 19.8 Imputed:
Funding: Hispanic
G2: BMI 19.8-26.0 • Yes
NR NR
G3: BMI > 26.0
Categorized:
Study Objective: Asian/Pacific Islander
To examine whether
Group N: • IOM guidelines
G1: 193 NR
such weight gains Age (mean, yrs):
G2: 431
improve birth outcomes G1: mean age at infant birth Other
G3: 191
in a cohort of (SD): 16.9 (1.2) NR
disadvantaged African Inclusion criteria: G2: 16.8 (1.1)
American adolescents Smoking,%:
• Adolescents ≤ 17 G3: 17.0 (1.1) G1: 11.4
Time frame: years at conception G2: 9.7
Parity:
1990 to 2000 • African American G3: 10.5
% primiparous:
pregnancies
Duration of the study: G1: 83.9 Diabetes mellitus,%:
First prenatal care visit Exclusion criteria: G2: 85.2 NR
to delivery • NA G3: 74.9
Hypertension,%:
NR
Additional characteristics:
NR

C-546
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 193 G1: 2899 (595) Adjusted birthweight in Good
G2: 431 G2: 3083 (645) grams
G3: 191 P < 0.005 Sample selection:
compared to BMI < Groups Fair
Total weight gain: 19.8 G1: <IOM
G1: < IOM: 30.3%; G2: lower half IOM range Definition of maternal
G3: 3181 (673) weight gain:
lower half of P < 0.005 G3: Upper half IOM range
IOM: 18.1%; G4: >IOM Good
compared to BMI <
upper half of 19.8 Definition of outcomes:
IOM: 21.9%; > Results
Adjusted birthweight <19.8 Good
IOM: 29.7% Gestational
G2: < IOM: 31.3%; diabetes, %: grams Source of information on
lower half of NR G1: 2986 g exposure, outcomes, and
IOM: 16.1%; G2: 3167 g confounders:
upper half of Cesarean delivery, G3:3198 g Fair
IOM: 17.6%; > %: G4:3277 g
NR All significantly different Followup:
IOM: 35.0% Good
G3: < IOM: 16.5%; from each other except G2
Instrumental & G3
lower half of delivery, %: Analysis comparability:
IOM: 9.4%; NR Adjusted birthweight 19.8 to Good
upper half of 26 grams
Episiotomy, %: Analysis of outcomes:
IOM: 10.6%; > G1: 3018 g
NR Fair
IOM: 63.5 G2: 3166 g
Other maternal G3: 3255 g Interpretation:
Categorized:
outcomes: G4: 3318 g Good
• According to
NA All significantly different
IOM Sum of Good/Fair/Poor:
from each other
Other infant 6 Good, 3 Fair, 0 Poor
Collected from:
outcomes: Adjusted birthweight >26
• Routine pre- Final Quality Score:
• Size for grams
natal care or Good
gestational age G1: 3127 g
maternity
(small, G2: 3351 g
records
average, large) G3: 3384 g
Ascertained by: • Birth weight G4: 3434 g
• Based on last category G1 significantly different
clinically (suboptimal from the others, G2 ,G3 &
measured < 3000g, G4 not significantly different
weight prior to optimal 3000- from each other
delivery: 4000g, above Maternal confounders and
difference optimal effect modifiers
between final > 4000g) accounted for in analysis:
recorded
• Parity
weight within 4
• Pre-gravid BMI
weeks delivery
and self- • Pre-eclampsia
reported • Time between last
prepregnancy weight measure and
weight delivery
• Height
• Smoking
Infant and child
confounders and effect
modifiers accounted for in
analysis:
• Infant sex

C-547
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ogunyemi et al., 1999 • Other observational • Self-reported White
: 582 women NR
Country and setting: Pregravid BMI:
consecutive women
USA, hospital Black
who delivered Imputed: G1: 100
Enrollment Period: • Retrospective • No G2: 100
1990 to 1995 G3: 100
Total Study N: Categorized:
Funding: 582 • IOM guidelines G4: 100
NR Hispanic
Group Description: Age (mean, yrs):
Study Objective: G1: Underweight G1: 20.3 NR
To test IOM guidelines G2: Normal G2: 22.1 Asian/Pacific Islander
in a predominantly rural G3: Overweight G3: 23.7 NR
black population G4: Obese G4: 25.4 (P < 0.01)
Other
Time frame: Group N: Parity: NR
1990 to 1995 G1: 78 G1: # nulliparous: 53
G2: 223 G2: 54 Smoking,%:
Duration of the study: G3: 78 NR
582 women who G3: 42
G4: 203 G4: 26 (P < 0.01)
delivered and then their Diabetes mellitus,%:
medical record was Inclusion criteria: G1: n = 0
abstracted • Single child G2: n = 4
• > 37 weeks G3: n = 3
gestation G4: n = 8 (P = 0.02)
• Black
Hypertension,%:
• Registration for G1: n = 1
prenatal care within G2: n = 2
first trimester of G3: n = 4
pregnancy G4: n = 14 (P < 0.01)
Exclusion criteria: Additional characteristics:
• Difference between NR
recalled pregravid
weight and
measured first
trimester weight
was ≥ 10%

C-548
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 196 G1: 3,029 Birthweight Fair
G2: 181 G2: 3,210
G3: 205 G3: 3,283 (P < Groups Sample selection:
0.01) G1: Low <IOM Poor
Total weight gain: G2: Normal =IOM
Gestational G3: High >IOM Definition of maternal
Categorized: diabetes, %: weight gain:
• According to G1: n = 0 Results Good
IOM G2: n = 4 G1: 3,029
G2: 3,210 Definition of outcomes:
Collected from: G3: n = 3 Good
G4: n = 8 G3: 3,283
• Routine pre- P < 0.01
(P = 0.02) Source of information on
natal care or
Maternal confounders and exposure, outcomes, and
maternity Cesarean
effect modifiers confounders:
records delivery,%:
accounted for in analysis: Fair
Ascertained by: G1: n = 20
G2: n = 10 NR Followup:
• Based on last Fair
clinically G3: n = 17 Infant and child
measured (P = 0.02) confounders and effect Analysis comparability:
weight prior to Instrumental modifiers accounted for in Good
delivery: weight delivery,%: analysis:
NR Analysis of outcomes:
at last prenatal
Episiotomy,%: Fair
visit
Interpretation:
Other maternal Fair
outcomes: Sum of Good/Fair/Poor:
• Asthma, 3 Good, 5 Fair, 1 Poor
preeclampsia
• Vomiting Final Quality Score:
• C-section Fair

Other infant
outcomes:
• Low birth
weight
• Fetal distress
• NICU

C-549
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Scholl et al., 1995 • Cohort • Self-reported White
• Prospective G1: 8.5
Country and setting: Pregravid BMI: G2: 10.9
USA, Camden Study Total Study N: G3: 10.4
Imputed:
274
Enrollment Period: • No Black
September 1985 to May Group Description: G1: 61.0
1990 G1: Low rate of GWG Categorized:
• IOM guidelines G2: 59.4
G2: Moderate rate of G3: 62.3
Funding:
GWG Age (mean, yrs):
NIH Hispanic
G3: Excessive rate of NR
Study Objective: GWG G1: 30.5
To determine whether Parity: G2: 29,7
Group N: NR G3: 27.3
risk of maternal
G1: 59
overweight associated Asian/Pacific Islander
G2: 138
with an excessive rate NR
G3: 77
of gestational weight
gain needs to be Inclusion criteria: Smoking,%:
balanced against risk of • Women with G1: 30.5
impaired fetal growth pregravid BMI 19.8- G2: 26.8
associated with low rate 26.0 G3: 26.9
of gain • Enrolled before Diabetes mellitus,%:
Time frame: January 1988 NR
September 1985 to May Exclusion criteria:
1990 Hypertension,%:
• Missing information NR
Duration of the study: from delivery to 6
During pregnancy months postpartum Additional characteristics:
through 6 months • Pregravid under or NR
postpartum over weight

C-550
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 59 G1: 3,049 (56.94) Birthweight (g) Good
G2: 138 P < 0.05, low
G3: 77 vs. moderate Groups Sample selection:
plus excessive Rate between 20-36 wks Fair
Total weight gain: weight gain G1: low rate <0.34 kg/wk
G1: Gestation G2: moderate rate 0.34- Definition of maternal
G2: 3,208 (36.33) weight gain:
duration (wk)38.5 G3: 39.4 (0.24) 0.68 kg/wk
(0.28) P < 0.05, low G3: Excessive rate >0.68 Fair
vs. moderate plus Gestational kg/wk Definition of outcomes:
excessive weight diabetes, %: Good
gain NR Results
G2: 39.2 (0.17) G1: 3049 (56.94) Source of information on
G3: 39.4 (0.24) Cesarean delivery, P < 0.05, low vs. moderate exposure, outcomes, and
%: plus excessive weight gain confounders:
Categorized: NR G2: 3208 (36.33) Fair
• According to G3: 39.4 (0.24)
Instrumental Followup:
IOM rate of
delivery, %: Maternal confounders Fair
gestational
NR and effect modifiers
weight gain Analysis comparability:
accounted for in
measured Episiotomy, %: Fair
analysis:
between 20 to NR NR Analysis of outcomes:
36 weeks: low
GWG = < Other maternal Infant and child Fair
0.34kg/wk; outcomes: confounders and effect
NA Interpretation:
moderate modifiers accounted for Fair
GWG = 0.34- Other infant in analysis:
0.68 kg/wk; outcomes: NR Sum of Good/Fair/Poor:
excessive NA 2 Good, 7 Fair, 0 Poor
GWG = > 0.68
kg/wk Final Quality Score:
Fair
Collected from:
• Collected by
study
investigators
Ascertained by:
• NR

C-551
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stevens-Simon and • Cohort • Self-reported White
McAnarney, 1992 • Prospective G1: 58.6 (11.1) NR
G2: 160.9 (7.0)
Country and setting: Total Study N: Black
G3: 163.9 (5.5)
USA, adolescent 141 (107 included in NR
maternity program postpartum analyses) Pregravid BMI:
Hispanic
G1: 23.1 (3.5)
Enrollment Period: Group Description: NR
G2: 23.5 (4.4)
1986 to 1989 G1: Slow gainers G3: 23.5 (4.2) Asian/Pacific Islander
G2: Average gainers
Funding: NR
G3: Rapid gainers • Imputed:
Grant from Bureau of
Maternal and Child • No Other
Group N:
Health NR
G1: 28 • Categorized:
G2: 66 • Continuous Smoking,%:
Study Objective:
G3: 47 NR
To clarify advantages Age (mean, yrs):
and disadvantages of Inclusion criteria: G1: 16.9 Diabetes mellitus,%:
large gestational weight • Consecutively G2: 16.6 NR
gain among pregnant enrolled poor, G3: 16.2
adolescents Hypertension,%:
black, 12-19 year
olds Parity: NR
Time frame: NR
1986 to 1989 • Prenatal care prior Additional characteristics:
to 2third week NR
Duration of the study: gestation
Entry into prenatal care • No chronic disease
through 6 weeks PP • No regular
check up medications
• No known uterine
anomalies
• Live birth
• Singletons
Exclusion criteria:
• NA

C-552
Evidence Table 41. Gestational weight gain with reference to IOM recommendations and infant birth weight
(continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28 G1: 2745 (694) Birth weight Good
G2: 66 G2: 3097 (457)
G3: 47 G3: 3351 (482) Groups Sample selection:
P < 0.0001 G1: slow <0.23 kg/wk Poor
Total weight gain: G2: average 0.23-4 kg/wk
G1: 7.7 (average Gestational G3: rapid >0.4 kg/wk Definition of maternal
rate 0.2 kg/wk) diabetes, %: weight gain:
G2: 12.4 (average NR Results Fair
rate 0.3 kg/wk) G1: 2745 (694)
Cesarean delivery, G2: 3097 (457) Definition of outcomes:
G3: 19.8 (average Good
rate 0.5 kg/wk) %: G3: 3351 (482) P < 0.0001
NR No difference in pre-gravid Source of information on
Categorized: by weight gain groups exposure, outcomes, and
Instrumental
• According to confounders:
delivery, %: Maternal confounders
IOMslow gain: Fair
NR and effect modifiers
< 0.23kg/wk;
accounted for in Followup:
average gain: Episiotomy, %: analysis: Fair
0.23- NR NR
0.4kg/week; Analysis comparability:
rapid gain: > Other maternal Infant and child
outcomes: Fair
0.4kg/week confounders and effect
NA modifiers accounted for Analysis of outcomes:
Collected from: Good
Other infant in analysis:
• Routine pre-
outcomes: NR Interpretation:
natal care or
maternity NA Poor
records Sum of Good/Fair/Poor:
Ascertained by: 3 Good, 4 Fair, 2 Poor
• Based on last Final Quality Score:
clinically Fair
measured
weight prior to
delivery

C-553
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-554
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) LBW (%) Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: Weight loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: Definition of maternal weight
G3: 16-25 lbs gain:
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P < Poor
Only calculated for G5: >35 lbs
0.01) Definition of outcomes:
morbidly obese:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 2.0 Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 11.1 exposure, outcomes, and
G2: 15.9% G3: 8.3 confounders:
Collected from: G4: 5.2 Poor
• Routine pre- Instrumental G5: 3.8
natal care or delivery,%: Followup:
maternity NR Maternal confounders and Fair
records effect modifiers accounted
Episiotomy,%: for in analysis: Analysis comparability:
Ascertained by: NR NR Poor
• Not stated -
Other maternal Infant and child confounders Analysis of outcomes:
from medical
outcomes and effect modifiers Fair
records
• Preeclampsia accounted for in analysis:
• Placental Interpretation:
NR
abruption Poor
• Meconium Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-555
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bracero and Byrne, 1997 • Cohort • Self-reported White
• Retrospective G1: 92.1
Country and setting: Pregravid BMI: G2: NR
Hospital charts - Total Study N: G1: median BMI = 23.19
Maimonides Medical 20,971 (range 14.46-40.07) Black
Center, Brooklyn, NY G2: NR G1: 4.2
Group Description: G2: NR
Enrollment Period: G1: Total population Imputed:
G2: NR • No Hispanic
Funding: NR
NR Group N: Categorized:
G1: 20,971 • IOM guidelines Asian/Pacific Islander
Study Objective: G1: 0.9
G2: NR
To determine optimal Age (mean, yrs): G2: NR
weight gain in singleton Inclusion criteria: G1: % < 15 years: < 0.1;
pregnancy and evaluate • Delivery at 15-19 yrs: 4.8; Other
current recommendations Maimonides Medical 20-24: 25.1; G1: 2.1
Center 25-29: 31.1; G2: NR
Time frame:
• Singleton pregnancy 30-34: 24.3; Smoking,%:
Duration of the study: • No documentation of 35-39: 11.8; NR
Jan 1, 1987 to Jan 1, congenital anomaly, 40-44: 2.8;
1993 pregnancy was not 45-49: 0.1; Diabetes mellitus,%:
terminated by > 50: < 0.1 NR
abortion G2: NR
Hypertension,%:
• Documentation on Parity: NR
chart of prepregnancy % primigravida:
maternal weight, Additional characteristics:
G1: 25.1
amount of maternal G2: NR % married:
weight gain during G1: 12.4
pregnancy, and G2: NR
gender of infant
Additional characteristics:
Exclusion criteria: Type of service:
• Infants with any type G1: Ward, 22.5%
of congenital anomaly Private: 77.5%
(international G2: NR
classification of
Additional characteristics:
diseases (ICD-9-CM)
NR
codes 740.0-759.9

C-556
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: r = .210 Percentage of LBW by weight gain categories Fair
Total weight gain: correlation with
G1: % weight gain: maternal weight gain Groups Sample
lost weight, 0.4; G2: NR Maternal weight gain categories: selection:
1 to 5lbs, 0.9; G1: Maternal weight gain under the IOM Fair
6 to 10, 2.3; Gestational guidelines
diabetes, %: Definition of
11 to 15, 5.4; G2: Maternal weight gain within the IOM
16 to 20, 12.0; NR maternal weight
guidelines gain:
21 to 25, 17.2; G3: Maternal weight gain over the IOM
26 to 30, 21.1; Cesarean delivery, Fair
%: guidelines
31 to 35, 14.8; G4: Optimal weight gain (36-40 lbs for BMI < Definition of
36 to 40, 11.5; NR
19.8; 31-40 lbs for BMI 19.8-26.0; 26-30 lbs outcomes:
41 to 45, 6.1; Instrumental for BMI > 26.0) Good
≥ 46, 8.3 delivery, %: G5: Suboptimal weight gain (< 36 lbs for BMI
G2: NR NR Source of
< 19.8; < 31 lbs for BMI 19.8-26.0; < 26 lbs for information on
Categorized: Episiotomy, %: BMI > 26.0) exposure,
• According to IOM NR outcomes, and
ordinal Results confounders:
categories in 5 Other maternal G1: 10.1% Fair
pound intervals outcomes: G2: 3.3%
Optimal weight gain G3: 2.5% (P < 0.001 comparing G1-G3) Followup:
Collected from: defined as 36 to 40 G4: 4.9% Fair
• Routine prenatal pounds for G5: 1.8% (P < 0.001 vs. G4)
care or maternity underweight women, Analysis
records 31 to 40 pounds for Maternal confounders and effect modifiers comparability:
women of ideal accounted for in analysis: Fair
Ascertained by: NA
prepregnancy weight, Analysis of
• Based on last 26 to 30 pounds for Infant and child confounders and effect outcomes:
clinically overweight women modifiers accounted for in analysis: Fair
measured weight
prior to delivery: Other infant NA
Interpretation:
using last outcomes: Fair
measurement Adverse outcomes:
obtained as an • Still birth Sum of
outpatient • Neonatal death Good/Fair/Poor:
1 Good, 8 Fair, 0
• Preterm
Poor
delivery/low birth
weight Final Quality
• Perinatal Score:
morbidity Fair

C-557
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cogswell et al., 1994 • Cohort • Self-reported White
• Retrospective G1: 75.1
Country and setting: Pregravid BMI: G2: 72.4
USA, Pregnancy Nutrition Total Study N: G3: 74.5
Surveillance System Imputed:
53,541
• No Black
Enrollment Period: Group Description: G1: 13.8
1990-1991 G1: Average weight Categorized:
• IOM guidelines G2: 14.1
G2: Overweight G3: 16.1
Funding:
G3: Very overweight Age (mean, yrs):
NR Hispanic
Group N: G1: 11-17 yr: 11.9%
Study Objective: 18-34yr: 85.0% G1: 11.1
G1: 33,809 G2: 13.5
To determine association 35-54 yr: 3.1%
G2: 7,661 G3: 9.4
between increased G2: 11-17 yr: 6.9%
G3: 12,071
gestational weight gain 18-34yr: 88.7% Asian/Pacific Islander
and birth weight outcomes Inclusion criteria: 35-54 yr: 4.4% NR
for low income women • White, black and G3: 11-17 yr: 4.0%
hispanic women who 18-34yr: 90.1% Other
Time frame: NR
1990-1991 delivered single, 35-54 yr: 6.0%
liveborn, term infants Smoking,%:
Duration of the study: Parity:
Exclusion criteria: NR G1: 29.9
Women in WIC but G2: 28.3
everything is self reported • Low or high values
G3: 25.7
so it is when they were for; birth weight,
first enrolled in WIC until prepregnancy BMI, or Diabetes mellitus,%:
delivery weight gain during NR
pregnancy
• Missing data on one Hypertension,%:
or more study NR
variables
Additional characteristics:
• Underweight women NR
• Only 1 infant was
used in analysis for
women who delivered
more than once
during study period

C-558
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 33,809 G1: < 2500g: 2.7% AOR (95% CI) for low birth weight Good
G2: 7,661 2500-4000g: 87.5%
G3: 12,071 > 4000-4500: 8.5% Groups Sample selection:
> 4500g: 1.4% Maternal weight gain categories (lbs) Fair
Total weight gain: G2: < 2500g: 2.5% stratified by pregravid BMI:
G1: < 15 lb: 6.2% Definition of
2500-4000g: 83.9% Normal weight (BMI 19.8-26.0): maternal weight
15-19: 5.8% > 4000-4500: 11.7% G1: < 15
20-24: 11.2% gain:
> 4500g: 2.0% G2: 15-19 Fair
25-29: 14.4% G3: < 2500g: 2.1% G3: 20-24
30-34: 17.1% 2500-4000g: 81.1% G4: 25-29 Definition of
35-39: 13.9% > 4000-4500: 13.2% G5: 30-34 outcomes:
≥ 40: 31.4% > 4500g: 3.6% G6: 35-39 Good
G2: < 15 lb: 11.4% G7: ≥ 40
15-19: 7.8% Gestational diabetes, %: Overweight (BMI > 26.0-29.0): Source of
20-24: 13.0% NR information on
G8: < 15 exposure,
25-29: 12.7% G9: 15-19
Cesarean delivery, %: outcomes, and
30-34: 15.9% G10: 20-24
35-39: 11.2% NR confounders:
G11: 25-29 Poor
≥ 40: 28.1% Instrumental delivery, G12: 30-34
G3: < 15 lb: 25.1% %: G13: 35-39 Followup:
15-19: 10.1% NR G14: > = 40 Fair
20-24: 1 Obese (BMI > 29.0):
Episiotomy, %: Analysis
Categorized: NR G15: < 15
comparability:
• 4 lbs increments G16: 15-19
Fair
starting at 15 lbs Other maternal G17: 20-24
outcomes: G18: 25-29 Analysis of
Collected from: NA outcomes:
• Self-reported Results Good
Other infant outcomes:
G1: 2.1 (1.6-2.6)
Ascertained by: NA Interpretation:
G2: 1.4 (1.1-1.8)
• Self-reported Good
G3: 1.0 (0.8-1.3)
G4: 1.0 (reference) Sum of
G5: 0.8 (0.6-1.0) Good/Fair/Poor:
G6: 0.6 (0.5-0.8) 4 Good, 4 Fair, 1
G7: 0.5 (0.4-0.6) Poor

G8: 1.1 (0.7-1.9) Final Quality

G9: 1.0 (reference) Score:
G10: 0.7 (0.4-1.2) Fair
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

C-559
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year: Design: Pregravid weight: Race,%:

Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal weight G1: NR
To compare pregnancy
G1: 683 (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal weight Age (mean, yrs):
women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight change normal weight women
identified from Parity: Other
Time frame: NR G1: NR
1997-1993 pregnancy and
delivery summary G2: NR
Duration of the study: records (normal G3: 4.0 (Total sample)
1997-1993 weight matched to Smoking,%:
obese by race, age, NR
parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-560
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 Percentage of LBW by weight gain categories Good
G2: 660 G2: 3285 P ≤ 0.001
Groups Sample
Total weight gain: Gestational Maternal weight gain categories (kg) selection:
G1: 9.5 diabetes,%: Obese BMI > 29: Fair
G2: 14.5 P ≤ 0.001 NR G1: Lost weight/no change Definition of
Categorized: Cesarean G2: 0.5-6.5 maternal weight
• According to IOM delivery,%: G3: 7-11.5 gain:
G1: 25.6 G4: 12-16 Fair
Collected from: G2: 9.1 P < 0.001 G5: > 16
• Routine pre-natal Definition of
care or maternity Instrumental Normal BMI 19.8-26 outcomes:
records delivery,%: G6: < 11.5kg Fair
Episiotomy,%: G7: 11.5-16 Source of
Ascertained by:
G8: > 16kg information on
• Based on last Other maternal
clinically exposure,
outcomes: Results outcomes, and
measured weight NA G1:12.8% confounders:
prior to delivery
G2: 8.9% Fair
Other infant
G3: 7.9%
outcomes: Followup:
G4: 6.8%
NA Fair
G5: 8.7%
P (for G1-G5) = 0.405
Analysis
comparability:
G6: 8.5%
Good
G7: 5.6%
G8: 8.9% Analysis of
P (for G6-G8) = 0.183 outcomes:
Fair
AOR (95%CI) for birthweight < 2500g among
obese women (BMI> 29.0): Interpretation:
G3: 1.0 (reference) Good
G1: 4.2 (0.9-19.6) Sum of
Maternal confounders and effect modifiers Good/Fair/Poor:
accounted for in analysis: 3 Good, 6 Fair, 0
• Age Poor
• Parity Final Quality
• Pre-gravid BMI Score:
• GDM Fair
• Pregnancy induced hypertension
• Prenatal adequacy
• Alcohol use
• Drug use
• Smoking
Infant and child confounders and effect
modifiers accounted for in analysis:
Gestational age

C-561
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hellerstedt et al., 1997 • Cohort • Self-reported White
• Retrospective G1: 103.5 kg (13.7) G1: 68.8
Country and setting: G2: 69.1
G2: 61.1kg (5.9)
United States, medical Total Study N:
center 1,343 Pregravid BMI: Black
G1: 38.3 (4.6) G1: 20.4
Enrollment Period: Group Description: G2: 20.6
G2: 22.8 (1.6)
1977-1993 G1: Obese
G2: Normal weight Imputed: Hispanic
Funding: G1: 6.6
• No
NR Group N: G2: 6.5
G1: 683 Categorized:
Study Objective: Asian/Pacific Islander
To examine association
G2: 660 • IOM guidelines
G1: Native Am: 3.8
between infant birth Inclusion criteria: Age (mean, yrs): G2: Native Am: 3.2
outcomes and maternal • Obese and normal- G1: NR
pregravid obesity, weight women • 16-34 years: 91% Other
gestational weight gain, delivering singleton • ≥ 35 years: 8.8% NR
and prenatal smoking during study period G2: NR Smoking,%:
Time frame: Exclusion criteria: • 16-34 years: 93.5% G1: 26.4
1977 to 1993 • Missing data • ≥ 35 years: 5.8% G2: 26.2
Duration of the study: • Siblings Parity: Diabetes mellitus,%:
Entry into prenatal care • Fetal deaths G1: NR NR
until delivery • 0: 31.8%
• 1-3: 64.7% Hypertension,%:
• ≥ 4: 3.5% NR
G2: NR Additional characteristics:
• 0: 33.3% NR
• 1-3: 64.9%
• ≥ 4: 1.8%

C-562
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Percentage of LBW by weight gain categories Good
Total weight gain: and smoking status
Gestational Sample
Categorized: diabetes, %: selection:
• According to IOM NR Groups
Maternal weight gain categories stratified by Fair
Collected from: Cesarean delivery, pregravid BMI and smoking status: Definition of
• Routine pre-natal %: maternal weight
care or maternity NR Obese (BMI > 29.0): gain:
records G1: Smokers, < IOM Fair
Instrumental G2: Smokers, within IOM
Ascertained by: delivery, %: Definition of
G3: Smokers, > IOM
• Based on last NR outcomes:
clinically Good
G4: Nonsmokers, < IOM
measured weight Episiotomy, %:
G5: Nonsmokers, within IOM Source of
prior to delivery NR
G6: Nonsmokers, > IOM information on
Other maternal exposure,
outcomes: Normal weight (BMI 19.8-26.0): outcomes, and
NR G7: Smokers, < IOM confounders:
G8: Smokers, within IOM Fair
Other infant
G9: Smokers, > IOM
outcomes: Followup:
NR Fair
G10: Nonsmokers, < IOM
G11: Nonsmokers, within IOM
Analysis
G12: Nonsmokers, > IOM
comparability:
Good
Obese:
G13: Lost/no gain Analysis of
G14: 0.5-6.5 kg outcomes:
G15: 7-11.5 kg Good
G16: 12-16 kg
G17: > 16 kg Interpretation:
Good
Normal weight: Sum of
G18: < 11.5kg Good/Fair/Poor:
G19: 11.5-16kg 5 Good, 4 Fair, 0
G20: > 16kg Poor

Results Final Quality

G1: 17.3% Score:
G2: 10.0% Good
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%

C-563
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Hellerstedt et al., 1997
(continued)

C-564
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain 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-565
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hickey et al., 1997 • Cohort • Self-reported White
• Retrospective G1: 70.8 (19.6) NR
Country and setting:
G2: 65.8 (17.6)
USA, public health Total Study N: Black
programs 5198 Pregravid BMI: NR
G1: 26.6 (7.1)
Enrollment Period: Group Description: Hispanic
G2: 24.8 (6.3)
Jan 1993 to Dec 1994 G1: Black NR
G2: White Imputed:
Funding: Asian/Pacific Islander
• No
MCH grant, University of Group N: NR
Alabama School of Public G1: 2219 Categorized:
Health/NIH Intamural Other
G2: 3699 • IOM guidelines NR
Basic Sciences Research
grant Inclusion criteria: Age (mean, yrs): Smoking,%:
• Women enrolled in G1: 23.7 (5.0) G1: 9.2
Study Objective: Medicaid Maternity G2: 23.4 (4.6)
Examine differences in G2: 35.1
Waiver programs
birth weight among term operated in 24 Parity: Diabetes mellitus,%:
infants of black and white counties by Alabama NR
women with weight gains Department of Public
in upper or lower half of Hypertension,%:
Health during study
recommended ranges NR
period
Time frame: Additional characteristics:
Exclusion criteria:
Jan 1993 to Dec 1994 NR
• Delivered before 37
Duration of the study: weeks or after 42
From first visit to delivery 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

C-566
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Adjusted odds ratio (95% CI) for LBW by weight Good
Total weight gain: gain categories
Gestational Sample
Categorized: diabetes, %: selection:
• According to Groups
NR Maternal weight gain categories stratified by race: Good
IOMgain below
range (for Cesarean delivery, Black Women: Definition of
pregravid BMI), %: G1: Below range (< 12.5kg for BMI< 19.8; < 13.9kg maternal weight
gain in lower NR for BMI 19.8-26.0; < 7.0kg for BMI > 26.0) gain:
range, gain in G2: In lower range (12.5-15.2kg for BMI< 19.8; Poor
Instrumental 11.5-13.8kg for BMI 19.8-26.0; 7.0-9.2kg for BMI >
upper range,
delivery, %: 26.0) Definition of
gain above range
NR G3: In upper range (15.3-18kg for BMI< 19.8; 13.9- outcomes:
Collected from: 16.0kg for BMI 19.8-26.0; 9.3-11.5kg for BMI Good
Episiotomy, %:
• Routine pre-natal > 26.0)
NR Source of
care or maternity
information on
records Other maternal Results exposure,
outcomes: G1: 2.6 (1.2-5.6) outcomes, and
Ascertained by:
NA G2: 1.0 (reference) confounders:
• Based on last
G3: 1.2 (0.4-3.3) Fair
clinically Other infant
G4: 1.4 (0.6-3.6)
measured weight outcomes: Followup:
G5: 1.5 (0.8-2.6)
prior to delivery NA Good
G6: 1.0 (reference)
G7: 0.4 (0.2-0.9)
Analysis
G8: 0.7 (0.3-1.2)
comparability:
Maternal confounders and effect modifiers Fair
accounted for in analysis:
Analysis of
• Age outcomes:
• Education Good
• Height
• Drug use Interpretation:
• Alcohol use Fair
• Time between last prenatal weight observation Sum of
and delivery Good/Fair/Poor:
• Smoking 5 Good, 3 Fair, 1
Infant and child confounders and effect Poor
modifiers accounted for in analysis: Final Quality
• Gestational age Score:
• Infant sex Fair

C-567
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hulsey et al., 2005 • Cross-sectional • Self-reported White
• Retrospective G1: 56.3
Country and setting: Pregravid BMI: G2: 18.6
USA, birth certificates Total Study N: NR G3: 55.7
linked to PRAMS data 87,293 G4: 10.9
Imputed:
Enrollment Period: Group Description: • No G5: 19.2 (P < 0.0001)
1998 to 1999 G1: Total Black
G2: BMI < 19.8 (U-BMI) Categorized:
Funding: • IOM guidelines G1: 43.7
G3: BMI 19.8-26 (N-BMI) G2: 11.9
NR
G4: BMI 26.1-29.0) Age (mean, yrs): G3: 49.3
Study Objective: OW-BMI NR G4: 14.3
To describe proportion of G5: BMI > 29.0 (O-BMI) G5: 24.6
low birth weight that could Parity:
Group N: NR Hispanic
be potentially prevented
G1: 87,293 (100%) NR
by programs focusing on
G2: 16.2% (Note:
maternal prepregnant BMI Asian/Pacific Islander
corrected
and/or weight gain during NR
Discrepency between
pregnancy
Table 1 values and
Other
Time frame: Results text/Table
NR
1998 to 1999 2&3 values)
G3: 52.6%(Note: Smoking,%:
Duration of the study: corrected NR
Cross-sectional women Discrepency between
surveyed after delivery Table 1 values and Diabetes mellitus,%:
(PRAMS) Results text/Table G1: 4.1
2&3 values) G2: 3.7
G4: 11.5%(Note: correcte G3: 36.4
G4: 21.1
Inclusion criteria: G5: 38.8 P < 0.09
• Ddata consist of birth
Hypertension,%:
certificates linked to
G1: 4.8
PRAMS for South
G2: 7.8
Carolina resident
G3: 36.4
women delivering in
G4: 15.2
South Carolina during
G5: 40.6 (P < 0.56)
1998 and 1999
Exclusion criteria: Additional characteristics:
NR
• BW < 500 g

C-568
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Outcomes from Bivariate Outcomes from Multivariate
Maternal Weight Gain Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Adjusted odds ratio for low birth weight Good
Total weight gain: by categories of weight gain
G1: NR Gestational diabetes, %: Sample selection:
• Adequate: 72.3% G1: 4.1 Groups Poor
• Less than adequate: 27.7 G2: 3.7 Pregravid BMI and gestational weight
G3: 36.4 Definition of
G2: NR gain categories:
G4: 21.1 maternal weight
• Adequate: 14.9% G1: BMI < 19.8 and < IOM gain:
• Less than adequate: 19.6 G5: 38.8 P < 0.09 G2: BMI 19.8-26.0 and < IOM Fair
G3: Cesarean delivery,%: G3: BMI 19.8-26.0 and within IOM
• Adequate: 52.1% NR G4: BMI 26.1-29.0 and < IOM Definition of
• Less than adequate: 53.9 G5: BMI > 29.0 and < IOM outcomes:
G4: Instrumental delivery, %: G6: BMI > 29.0 and within IOM Good
• Adequate: 13.6% NR
Source of
• Less than adequate: 5.9 Episiotomy, %: Results information on
G5: NR AOR (95% CI) for very low birth weight exposure,
• Adequate: 19.4% (500-1,499g): outcomes, and
• Less than adequate: 20.7Other maternal outcomes: G1: 2.06 (1.26-2.87) confounders:
NR G2: 1.82 (1.22-2.29) Poor
Categorized: G3: 1.00 (reference)
• According to IOMLTA = Other infant outcomes: Followup:
G4: 2.05 (0.90-4.44)
less than adequate; AWG NR G5: 1.25 (0.61-1.61) Fair
= adequate weight gain G6: 1.74 (1.23-2.42)
Analysis
comparability:
AOR (95% CI) for moderately low birth
Fair
weight (1500-2499g):
G1: 4.83 (2.98-7.83) Analysis of
G2: 1.77 (1.23-2.60) outcomes:
G3: 1.00 (reference) Fair
G4: 0.28 (0.11-1.83)
G5: 1.09 (0.67-2.13 Interpretation:
Poor
Maternal confounders and effect
modifiers accounted for in analysis: Sum of
Ethnicity, intendedness of pregnancy, Good/Fair/Poor:
Medicaid status, WIC status, prenatal 2 Good, 4 Fair, 3
care, diabetes, hypertension Poor

Infant and child confounders and Final Quality

effect modifiers accounted for in Score:
analysis: Poor
NR

C-569
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Hulsey et al., 2005
(continued)

C-570
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Outcomes from Bivariate
Maternal Weight Gain 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 U-
BMI; 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 U-
BMI, 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-571
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year: Design: Pregravid weight: Race,%:

Nida et al., 1996 • Cohort • Self-reported White
• Prospective G1: 84.7 (79.9-89.7)
Country and setting: Pregravid BMI: G2: 85.1 (82.5-87.6)
United States, multi- Total Study N: G3: 75.5 (71.0-80.0)
center Imputed:
NR. PRAMS data in OK
collects data on 200 • No Black
Enrollment Period: G1: 9.8 (5.5 - 14.1)
mothers/month. Report Categorized:
April 1988 to March 1995 G2: 5.8 (4.0-7.6)
reflects data with 71% • IOM guidelines
Funding: response rate G3: 11.4 (7.7-15.1)
Funding for the PRAMS Age (mean, yrs):
Group Description: G1: Age Hispanic
Program is providedin part NR
G1: Low BMI/less than < 20: 21.2% (15.5-26.9)
by the Centers for
recommended weight gain 20-24: 35.5% (29.2-41.8)
Disease Control and Asian/Pacific Islander
G2: Normal BMI/within 25-29: 24.2% (18.7-29.7)
Prevention, Atlanta, GA NR
recommended weight gain 30-34: 15.2% (10.9-19.5)
(Grant No.
G3: High BMI/over 35+: 3.9% (1.7-6.1) Other
U50/CCU602873-07), and
recommended wt gain [numbers in () are 95% CI] G1: Native Am 3.9 (1.4-6.5)
Maternal and Child Health
Bureau, Department of G2: Age G2: Native Am 7.5 (5.7-9.3)
Group N:
Health and Human < 20: 10.9% (8.5-13.3) G3: Native Am 12.6 (9.3-15.9)
Services Inclusion criteria: 20-24: 30.0% (26.9-33.1) Smoking,%:
• New mothers of 25-29: 31.6% (28.7-34.5) G1: Prenatal smoking: 26.2%
Study Objective: singleton births from 30-34: 19.2% (16.7-21.8)
To examine pre- (20.5-31.9)
state’s live birth 35+: 8.3% (6.5-10.1) G2: 19.5 % (16.8-22.2)
pregnancy weight, registry G3: Age
prenatal weight gain and G3: 21.6 (17.2-26.0)
< 20: 12.5% (8.7-16.2)
their relationship to low Exclusion criteria: 20-24: 33.9% (29.0-38.8) Diabetes mellitus,%:
(< 2,500 grams) birth NR 25-29: 29.2% (24.7-33.7) NR
weight 30-34: 17.5% (14.0-21.0)
Hypertension,%:
Time frame: 35+: 6.9% (4.6-9.3)
NR
April 1988-March 1995 Parity:
Additional characteristics:
Duration of the study: NR
G1: Education
Entry into prenatal care < 12 years: 21.7% (15.6-
through delivery 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-572
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: Percent LBW: • LBW by smoking status by BMI and Poor
Total weight gain: 10.2%/ 6%/ 4.7% prenatal weight gain
G2: 8.4%/ 3.9%/ Sample selection:
Categorized: Poor
4.5% Groups:
• According to IOM G1: Low BMI/less than recommended
G3: 6.1%/ 3.8%/ Definition of
Collected from: 5.1% weight gain
maternal weight
• Self-reported G2: Normal BMI/within recommended
Gestational gain:
weight gain
Ascertained by: diabetes, %: Fair
G3: High BMI/over recommended wt gain
• Self-reported NR Definition of
Results:
Cesarean delivery, outcomes:
%: Low BMI: less than rec weight gain Fair
NR G1: 16.9 (12.2-21.6)
Source of
G2: 7.7 (6.1-9.3)
Instrumental information on
delivery, %: Low BMI: within recommended exposure,
NR G1: 12.7 (9.4-16.0) outcomes, and
G2: 4.2 (3.4-5.0) confounders:
Episiotomy, %: Poor
NR Low BMI: more than recommended
G1: 6.5 (14.3-8.7) Followup:
Other maternal G2: 3.6 (2.8-4.4) Fair
outcomes:
NR Normal BMI: less than recommended Analysis
G1: 12.9 (9.6-16.2) comparability:
Other infant G2: 6.9 (5.7-8.1) Poor
outcomes:
NR Normal BMI: within recommended Analysis of
G1: 6.9 (5.3-8.5) outcomes:
G2: 3.2 (2.8-3.6) Fair
Normal BMI; more than recommended Interpretation:
G1: 8.9 (7.1-10.7) Poor
G2: 3.3 (2.9-3.7)
Sum of
High BMI: less than recommended Good/Fair/Poor:
G1: 7.7 (4.0-11.4) 0 Good, 4 Fair, 5
G2: 5.4 (3.8-7.0) Poor
High BMI: within recommended Final Quality
G1: 4.6 (2.6-6.6) Score:
G2: 3.4 (2.6-4.2) Poor
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

C-573
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Ogunyemi et al., 1999 • Other observational : • Self-reported White
582 women NR
Country and setting: Pregravid BMI:
consecutive women
USA, hospital Black
who delivered Imputed: G1: 100
Enrollment Period: • Retrospective • No G2: 100
1990 to 1995 G3: 100
Total Study N: Categorized:
Funding: 582 • IOM guidelines G4: 100
NR Hispanic
Group Description: Age (mean, yrs):
Study Objective: G1: Underweight G1: 20.3 NR
To test IOM guidelines in G2: Normal G2: 22.1 Asian/Pacific Islander
a predominantly rural G3: Overweight G3: 23.7 NR
black population G4: Obese G4: 25.4 (P < 0.01)
Other
Time frame: Group N: Parity: NR
1990 to 1995 G1: 78 G1: # nulliparous: 53
G2: 223 G2: 54 Smoking,%:
Duration of the study: G3: 78 NR
582 women who delivered G4: 203 G3: 42
and then their medical G4: 26 (P < 0.01) Diabetes mellitus,%:
record was abstracted Inclusion criteria: G1: n = 0
• Single child G2: n = 4
• > 37 weeks gestation G3: n = 3
• Black G4: n = 8 (P = 0.02)
• Registration for Hypertension,%:
prenatal care within G1: n = 1
first trimester of G2: n = 2
pregnancy G3: n = 4
Exclusion criteria: G4: n = 14 (P < 0.01)
• Difference between Additional characteristics:
recalled pregravid NR
weight and measured
first trimester weight
was ≥ 10%

C-574
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 196 G1: 3,029 Adjusted odds ratio for low birth weight by Fair
G2: 181 G2: 3,210 weight gain categories
G3: 205 G3: 3,283 (P < 0.01) Sample selection:
Groups Poor
Total weight gain: Gestational Maternal weight gain categories:
diabetes, %: Definition of
Categorized: G1: < IOM maternal weight
G1: n = 0 G2: Within IOM
• According to IOM G2: n = 4 gain:
G3: > IOM Good
Collected from: G3: n = 3
• Routine pre-natal G4: n = 8 (P = 0.02) BMI IOM Definition of
care or maternity Cesarean outcomes:
records delivery,%: Results Good
G1: n = 20 AOR (95% CI) for very low birth weight: Source of
Ascertained by:
G2: n = 10 G1: 1.8 (0.6-4.7) information on
• Based on last
G3: n = 17 (P = 0.02) G2: 1.1 (0.4-4.7) exposure,
clinically
G3: 1.0 (Reference) outcomes, and
measured weight Instrumental
prior to delivery: delivery,%: Maternal confounders and effect confounders:
weight at last modifiers accounted for in analysis: Fair
prenatal visit Episiotomy,%: • Age Followup:
Other maternal • Parity Fair
outcomes: • Pregravid BMI
asthma,preeclampsia • Pre-eclampsia Analysis
, vomiting, c-section • C-section comparability:
Good
• Previous cesarean
Other infant
• Tobacco use Analysis of
outcomes:
• Previous fetal death outcomes:
low birth weight, fetal
distress, NICU • Hypertension Fair
• Asthma
Interpretation:
• Previous LBW Fair
• Vomiting
• NICU Sum of
Good/Fair/Poor:
Infant and child confounders and effect 3 Good, 5 Fair, 1
modifiers accounted for in analysis: Poor
NR
Final Quality
Score:
Fair

C-575
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year: Design: Pregravid weight: Race,%:

Schieve, 1998 • Cohort • Self-reported White
• Retrospective • NR NR
Country and setting:
Pregnancy Nutrition Total Study N: Pregravid BMI: Black
Surveillance System - 173,066 • NR NR
data from WIC clinics
(99%) from Indiana, Group Description: Imputed: Hispanic
Kansas, Massachusetts, NR • No NR
Minnesota, Nebraska, Group N: Categorized: Asian/Pacific Islander
North Dakota, New York, NR IOM Guidelines NR
Tennessee, and Vermont
Inclusion criteria: Age (mean, yrs): Other
Enrollment period: • White, black, and NR NR
Funding: hispanic women who Smoking,%:
visited WIC clinics Parity:
NR NR NR
prenatally and
Study Objective: subsequently Diabetes mellitus,%:
To examine associations delivered liveborn, NR
between pregnancy singleton infants
weight gain outside and Hypertension,%:
• Delivered between 39
within ranges NR
and 41 weeks
recommended by IOM Additional characteristics:
and birth weight by both Exclusion criteria: NR
prepregnant BMI and race • Missing data for
ethnicity infant birth weight
(n = 4223)
Time frame: • Prepregnant BMI
NR (n = 31477)
Duration of the study: • Pregnancy weight
1990 to 1993 gain (n = 7542)
• Maternal age
(n = 43)
• Maternal education
(n = 3819)

C-576
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 112,524 NR Good
G2: 33,101 Distribution of LBW,%:
G3: 27,441 Gestational Sample selection:
diabetes, %: Groups Poor
Total weight gain: NR Maternal weight gain categories stratified by pregravid
G1: 32.5 BMI (IOM underweight, normal weight, overweight, and Definition of
G2: 30.5 Cesarean obese) and race (non-Hispanic white, non-Hispanic maternal weight
G3: 30.2 delivery,%: black, and Hispanic): gain:
NR Fair
Categorized: G1: > = 10 lbs below IOM
According to IOM >10 Instrumental Definition of
delivery,%: G2: 1-9 lbs below IOM outcomes:
pounds below lower G3: Lower half of IOM
bound of IOM NR Good
G4: Upper half of IOM
recommended range Episiotomy,%: G5: 1-9 lbs above IOM Source of
for woman's NR information on
prepregnant BMI, 1-9 G6 > = 10lbs above IOM exposure,
pounds below lower Other maternal outcomes, and
outcomes Results
bound of IOM lower confounders:
bound, in lower half • NA 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) Fair
of IOM recommended Other infant
range, in upper half of G2: 3.2 (2.1-5.1), 2.8 (1.9-4.2), 1.0, 1.3 (0.8-2.1), 0.5 Followup:
outcomes (0.2-1.03), 0.7 (0.4-1.5) Fair
IOM range, 1-9 • NA
pounds above IOM 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 Analysis
range, >10 pounds comparability:
above IOM upper (1.4-5.4); 7.3 (4.0-13.2)
G5: no data for first category Fair
bound
0.6 (0.05-5.6); 1.0; 0.7 (0.06-7.3); 1.8 (0.3-13.2); Analysis of
Collected from: 10.8 (2.3-51.4) outcomes:
• Self-reported G6: no data for first category;0.8 (0.1-4.9); 1.0; 1.8 Good
(0.4-8.0); 3.3 (0.8-14.1); 6.1 (1.6-24.1)
Ascertained by: Group: average BMI: ≥ 10 lb< IOM, 1-9 lb< IOM, lower Interpretation:
• Self-reported IOM, upper IOM, 1-9 lb >IOM, ≥ 10 lb>IOM Poor
G1: 2.5 (2.0-3.0); 1.5 (1.3-1.8); 1.0; 0.8 (0.6-0.9); 0.6
Sum of
(0.5-0.7); 0.3 (0.3-0.4)
Good/Fair/Poor:
G2: 2.5 (1.9-3.3); 1.7 (1.3-2.2); 1.0; 0.7 (0.5-1.03); 0.7
3 Good, 4 Fair, 2
(0.5-1.03); 0.6 (0.4-0.9)
Poor
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) Final Quality
G4: 0.5 (0.3-0.9); 0.7 (0.5-0.9); 1.0; 1.7 (1.3-2.2); 2.3 Score:
(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 Fair
(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)

C-577
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year:
Schieve, 1998
(continued)

C-578
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain 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-579
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year:
Schieve, 1998
(continued)

C-580
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain 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-581
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year:
Schieve, 1998
(continued)

C-582
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain 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-583
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stevens-Simon and • Cohort • Self-reported White
McAnarney, 1992 • Prospective G1: 58.6 (11.1) NR
G2: 160.9 (7.0)
Country and setting: Total Study N: Black
G3: 163.9 (5.5)
USA, adolescent 141 (107 included in NR
maternity program postpartum analyses) Pregravid BMI:
Hispanic
G1: 23.1 (3.5)
Enrollment Period: Group Description: NR
G2: 23.5 (4.4)
1986 to 1989 G1: Slow gainers G3: 23.5 (4.2) Asian/Pacific Islander
G2: Average gainers
Funding: NR
G3: Rapid gainers Imputed:
Grant from Bureau of
• No Other
Maternal and Child Health Group N:
NR
G1: 28 Categorized:
Study Objective:
To clarify advantages and
G2: 66 • Continuous Smoking,%:
G3: 47 NR
disadvantages of large Age (mean, yrs):
gestational weight gain Inclusion criteria: G1: 16.9 Diabetes mellitus,%:
among pregnant • Consecutively G2: 16.6 NR
adolescents enrolled poor, black, G3: 16.2
Hypertension,%:
Time frame: 12-19 year olds
Parity: NR
1986 to 1989 • Prenatal care prior to
NR
2third week gestation Additional characteristics:
Duration of the study: • No chronic disease NR
Entry into prenatal care • No regular
through 6 weeks PP medications
check up • No known uterine
anomalies
• Live birth
• Singletons
Exclusion criteria:
• NA

C-584
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28 G1: 2745 (694) Distribution of LBW,%: Good
G2: 66 G2: 3097 (457)
G3: 47 G3: 3351 (482) Groups Sample
P < 0.0001 Maternal weight gain categories (kg/wk): selection:
Total weight gain: G1: < 0.23 Poor
G1: 7.7 (average rate Gestational G2: 0.23-0.40
diabetes, %: Definition of
0.2 kg/wk) G3: > 0.40
G2: 12.4 (average NR maternal weight
gain:
rate 0.3 kg/wk) Results
G3: 19.8 (average Cesarean delivery, Fair
%: G1: 21.4
rate 0.5 kg/wk) G2: 10.6 Definition of
NR
Categorized: G3: 4.3 outcomes:
Instrumental P = NS Good
• According to
delivery, %:
IOMslow gain: Source of
NR
< 0.23kg/wk; Maternal confounders and effect modifiers information on
average gain: Episiotomy, %: accounted for in analysis: exposure,
0.23-0.4kg/week; NR NA outcomes, and
rapid gain: confounders:
> 0.4kg/week Other maternal Infant and child confounders and effect modifiers Fair
outcomes: accounted for in analysis:
Collected from: NA NA Followup:
• Routine pre-natal Fair
care or maternity Other infant
records outcomes: Analysis
NA comparability:
Ascertained by: Fair
• Based on last
Analysis of
clinically
outcomes:
measured weight
Good
prior to delivery
Interpretation:
Poor
Sum of
Good/Fair/Poor:
3 Good, 4 Fair, 2
Poor
Final Quality
Score:
Fair

C-585
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Strauss and Dietz, 1999 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
USA, National Total Study N: G1: 22.8 (4.1) Black
Collaborative Perinatal Total = 10,756 G2: 22.7 (3.6) G1: 30
Project and Child Health NCPP = 5,403 G2: 16 sig dif from NCPP
and Development Study Imputed: P < 0.001
CHDS = 5,353
• No
Enrollment Period: Group Description: Hispanic
NCPP: 1959 to 1976 G1: NCPP Categorized: NR
CHDS: 1959 to 1973 G2: CHDS • Continuous
• WHO International Asian/Pacific Islander
Funding: Group N: Taskforce < 20, ≥ 20 - NR
Grants from NIH and G1: 4,771 < 25, ≥ 25
Massachusetts Dept of Other
G2: 5,333
Public Health Age (mean, yrs): NR
Inclusion criteria: G1: 25.2 (5.8)
Study Objective: Smoking,%:
• Women enrolled in G2: 27.4 (5.7) sig dif from G1: 39
To examine relationship NCPP or CHDS NCPP P < 0.001
between maternal weight • G2: 28 sig dif from NCPP
Patients enrolled P < 0.001
gain and risk of within 14 weeks of Parity:
intrauterine growth last menstrual period G1: % primiparous: 28 Diabetes mellitus,%:
retardation G2: 38 sig dif from NCPP P < NR
Exclusion criteria: 0.001
Time frame: • Women with missing Hypertension,%:
NCPP: 1959 to 1976 trimester weight gain NR
CHDS: 1959 to 1973 data
Additional characteristics:
Duration of the study: G1: % single mothers: 10.4
First visit (prior to 14 G2: 2.1 sig dif from NCPP
weeks since LMP) to P < 0.001
delivery

C-586
Evidence Table 42. Gestational weight gain with reference to IOM recommendations and low birth weight
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4771 G1: 3287 (469) Adjusted odds ratios(95% CI) for < 2500g: Good
G2: 5333 G2: 3401 (470) P <
0.001 Groups Sample
Total weight gain: Maternal weight gain categories stratified by pregravid selection:
G1: 10.4 (4.5) Gestational BMI: Fair
G2: 11.5 (4.6) P < diabetes, %: BMI < 20.0:
NR Definition of
0.001 G1: Low 1st trimester gain (< 0.1kg/wk) maternal weight
Categorized: Cesarean delivery, G2: Low 2nd trimester gain (< 0.3kg/wk) gain:
• According to IOM %: G3: Low 3rd trimester gain (< 0.3kg/wk) Fair
low weight gain NR
BMI 20.0-25.0: Definition of
in first trimester:
Instrumental G4: Low 1st trimester gain outcomes:
< 0.1kg/wk; low
delivery, %: G5: Low 2nd trimester gain Good
weight gain in
NR G6: Low 3rd trimester gain
second and third Source of
trimesters: < Episiotomy, %: information on
0.3kg/wk; low NR BMI > 25.0: exposure,
pregnancy G7: Low 1st trimester gain outcomes, and
weight gain: < Other maternal G8: Low 2nd trimester gain confounders:
6.8 kg outcomes: G9: Low 3rd trimester gain Fair
• First trimester
Collected from: weight gain Results Followup:
• Collected by (kg/wk): in AOR (95% CI) for < 2500g: Good
study NCPP, 0.14 G1: 0.88 (0.50-1.57)
investigators Analysis
(0.23); in CHDS, G2: 2.68 (1.46-4.94)
comparability:
0.19 (0.24) G3: 2.07 (1.22-3.51)
Ascertained by: Fair
• Second trimester G4: 1.31 (0.88-1.95)
• Based on last
weight gain G5: 1.92 (1.29-2.87) Analysis of
clinically
(kg/wk): in G6: 2.12 (1.48-3.04) outcomes:
measured weight
NCPP, 0.36 G7: 1.02 (0.50-2.08) Fair
prior to delivery
(0.17); in CHDS, G8: 1.88 (1.03-3.43)
first trimester Interpretation:
0.41 (0.16) G9: 1.53 (0.86-2.74)
weight gain: Fair
prepregnancy to • Third trimester
weight gain Reference group-normal rate of weight gain in the Sum of
13 to 16 wk since
(kg/wk): in trimester Good/Fair/Poor:
LMP; second
trimester: end of NCPP, 0.27 3 Good, 6 Fair, 0
first trimester to (0.20); in CHDS, Poor
Maternal confounders and effect modifiers
26-29 wk since 0.30 (0.16)
accounted for in analysis: Final Quality
LMP; third Other infant Race, GDM, toxemia, smoking Score:
trimester: end of outcomes: Fair
second trimester Infant and child confounders and effect modifiers
% IUGR: in NCPP,
to delivery accounted for in analysis:
4.5%; in CHDS, 2.2%
NR

C-587
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-588
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 613 G1: 3352 (598) LGA (%) Good
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups Sample selection:
Total weight gain: G1: Weight loss or 0 lbs Fair
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: Definition of maternal weight
G3: 16-25 lbs gain:
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P < Poor
Only calculated for G5: >35 lbs
0.01) Definition of outcomes:
morbidly obese:
0 or weight loss, 1- Cesarean Results Good
15 lbs, 16-25 lbs, delivery,%: G1: 12.0 Source of information on
26-35 lbs, >35 lbs G1: 31.3% G2: 11.8 exposure, outcomes, and
G2: 15.9% G3: 18.8 confounders:
Collected from: G4: 25.8 Poor
• Routine pre- Instrumental G5: 23.8
natal care or delivery,%: P < 0.01 Followup:
maternity NR Fair
records
Episiotomy,%: Maternal confounders and Analysis comparability:
Ascertained by: NR effect modifiers accounted Poor
• Not stated - for in analysis:
Other maternal Analysis of outcomes:
from medical NR
outcomes Fair
records
• Preeclampsia Infant and child confounders
• Placental Interpretation:
and effect modifiers
abruption Poor
accounted for in analysis:
• Meconium NR Sum of Good/Fair/Poor:
• Failure to 2 Good, 3 Fair, 4 Poor
progress
• Shoulder Final Quality Score:
dystocia Poor
• Postpartum
hemorrhage
• Endomyometrit
is
• Wound
infections
Other infant
outcomes
• Fetal growth
restriction
• Preterm
delivery
• Fetal demise
• Fetal distress

C-589
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Caulfield et al., 1998 • Cohort • Self-reported White
• Retrospective G1: 13.3 (5.7) NR
Country and setting:
G2: 14.6 (5.1)
USA, hospital obstetric Total Study N: Black
G3: 13.6 (6.7)
database 3,870 NR
G4: 15.3 (5.4)
Enrollment Period: Group Description: G5: 12.4 (7.7) Hispanic
1987 to 1989 G1: BMI < 19.8 Black G6: 14.5 (7.3) NR
G2: BMI < 19.8 White Pregravid BMI:
Funding: Asian/Pacific Islander
G3: BMI 19.8 to 26.0 Black G1: 18.4 (1.0)
NR NR
G4: BMI 19.8 to 26.0 White G2: 18.5 (1.0)
Study Objective: G5: BMI > 26.0 Black G3: 22.7 (1.8) Other
To examine relation G6: BMI > 26.0 White G4: 22.1 (1.8) NR
between gestational
Group N: Imputed: Smoking,%:
weight gain and risk of
G1: 523 • No G1: 32.8
delivering a small for
G2: 267 G2: 20.6
gestational age and large
G3: 1,479 Categorized: G3: 35.4
for gestational age infant
by race
G4: 796 • IOM guidelines G4: 20.0
G5: 615 G5: 28.8
Time frame: G6: 190 Age (mean, yrs): G6: 25.4
1987-1989 G1: 21.7 (4.8)
Inclusion criteria: G2: 27.1 (6.6) Diabetes mellitus,%:
Duration of the study: • Singleton pregnancies G3: 22.7 (5.3) NR
Entry into pn care until • White or black ethnicity G4: 29.8 (5.8)
delivery Hypertension,%:
• At least 28 weeks’ G5: 24.9 (6.0)
G6: 28.2 (5.5) G1: 4.3
gestation
G2: 3.0
• One delivery per Parity: G3: 6.0
woman (randomly G1: % primiparous: 52.4 G4: 5.7
chosen) G2: 55.4 G5: 11.9
• Information on G3: 50.1 G6: 17.0
anthropometric data G4: 48.0
G5: 36.9 Additional characteristics:
Exclusion criteria: NR
• Missing data G6: 46.9
• Improbable data
• Non-black or non-white
ethnicity

C-590
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR • AOR for LGA (95% CI) Good
Total weight gain: Gestational Groups: Sample selection:
G1: 13.3 (5.7) diabetes, %: G1: Underweight, BMI< 19.8 Fair
G2: 14.6 (5.1) NR G2: Normal weight, BMI 19.8-26.0
G3: 13.6 (6.7) Definition of maternal
G3: Overweight, BMI> 26.0
G4: 15.3 (5.4) Cesarean delivery, weight gain:
G5: 12.4 (7.7) %: Fair
Black women:
G6: 14.5 (7.3) NR
G4: No weight gain < IOM Definition of
Instrumental G5: No weight gain > IOM outcomes:
Categorized:
delivery, %: Good
• According to IOM White women:
NR
G6: No weight gain < IOM Source of information
Collected from:
Episiotomy, %: G7: No weight gain > IOM on exposure,
• Routine pre-natal
NR outcomes, and
care or maternity Results: confounders:
records Other maternal AOR (95%CI) for LGA and rate of weight gain Fair
outcomes: (per 50 g/wk):
Ascertained by:
NR G1: 1.25 (1.11-1.41) Followup:
• Based on last Good
clinically Other infant G2: 1.14 (1.08-1.20)
measured weight outcomes: G3: 1.13 (1.07-1.20) Analysis
prior to delivery: NR comparability:
difference Expected Absolute Change (as % of baseline) Good
between in Incidence of LGA associated with modifiable
risk factor (G4-G7): Analysis of outcomes:
selfreport
G4: +1.28 (+26) Good
prepregnancy
weight and last G5: -0.77 (-16) Interpretation:
recorded weight G6: +2.58 (+17) Good
G7: -2.87 (-19)
Sum of
Maternal confounders and effect modifiers Good/Fair/Poor:
accounted for in analysis: 6 Good, 3 Fair, 0 Poor
• Age
• Race Final Quality Score:
• Parity Good
• Pre-gravid BMI
• Height
• Hypertension
• Provider type
• Smoking
Infant and child confounders and effect
modifiers accounted for in analysis:
Female infant

C-591
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Devader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained from G1: 79.7
Country and setting: G2: 85.6
mother during postpartum
United States, birth Total Study N: G3: 85.2
hospital stay
certificate data 94,696
Pregravid BMI: Black
Enrollment period: Group Description: G1: 15.7
NR
1999 to 2001 G1: Gained less than 25 G2: 10.8
lbs Imputed: G3: 12.1
Funding:
NR
G2: Gained 25 to 35 lbs • No
G3: Gained more than 35 Hispanic
Study Objective: lbs Categorized: NR
To investigate relationship NR
Group N: Asian/Pacific Islander
between gestational Age (mean, yrs): NR
G1: 16,852
weight gain and adverse G1: Maternal age (y)
G2: 37,292
pregnancy outcomes 18 to 24*: 42.3% Other
G3: 40,552
among women with 25 to 30: 36.2% G1: 4.6
normal prepregnancy BMI Inclusion criteria: 31 to 35: 21.5% G2: 3.5
• All mothers with G2: Maternal age (y) G3: 2.7
Time frame:
1999 to 2001 normal prepregnancy 18 to 24*: 36.7% Smoking,%:
BMI (19.8 –26.0 25 to 30: 39.5% G1: 20.5
Duration of the study: kg/m2) who were 18 31 to 35: 23.8% G2: 14.9
Entry into prenatal care to 35 years of age at G3: Maternal age (y) G3: 17.4
through delivery time of delivery and 18 to 24*: 44.7%
who delivered full- 25 to 30: 35.9% Diabetes mellitus,%:
term (37 weeks or 31 to 35: 19.4% NR
more) singleton infant
Hypertension,%:
during period January Parity:
1, 1999, to December NR NR
31, 2001 Additional characteristics:
Exclusion criteria: NR
• Women aged
younger than 18
years and older than
35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-592
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR AOR for Women With Normal Good
Prepregnancy BMI (19.8 –26.0
Total weight gain: Gestational diabetes, kg/m2) by GWG Category, Sample selection:
NR %: Missouri Birth Certificates, 1999– Fair
NR 2001 (95% CI)
Categorized: Definition of maternal weight
• According to IOM Cesarean delivery,%: Groups: gain:
NR G1: Gained less than 25 lbs Fair
Collected from:
• Routine pre-natal Instrumental G2: Gained 25 to 35 lbs Definition of outcomes:
care or maternity delivery,%: G3: Gained more than 35 lbs Good
records NR
Source of information on
Ascertained by: Episiotomy,%: Results: exposure, outcomes, and
NR NR AOR (95%CI) for LGA: confounders:
G1: 0.40 (0.37-0.44) Fair
Other maternal G2: 1.00 (reference)
outcomes: G3: 2.43 (2.30-2.56) Followup:
• Figures 1 to 3 plot Fair
risk for each
Maternal confounders and Analysis comparability:
adverse pregnancy
effect modifiers accounted for Fair
outcome by 10-lb
increments in in analysis: Analysis of outcomes:
gestational weight • Age Fair
gain. Women who • Race
gained 25 to 34 lbs • Education Interpretation:
during their • Income Fair
pregnancy had • Alcohol use Sum of Good/Fair/Poor:
lower risks for most • Height 2 Good, 7 Fair, 0 Poor
outcomes when • Prior pregnancy
balancing risk for • Inadequate prenatal care use Final Quality Score:
SGA status and Fair
• Smoking
other adverse
pregnancy Infant and child confounders
outcomes and effect modifiers accounted
• Women who for in analysis:
gained 15 to 24 lbs • Child's gender
had lowest risks for Birth year
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%

C-593
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hellerstedt et al., 1997 • Cohort • Self-reported White
• Retrospective G1: 103.5 kg (13.7) G1: 68.8
Country and setting: G2: 69.1
G2: 61.1kg (5.9)
United States, medical Total Study N:
center 1,343 Pregravid BMI: Black
G1: 38.3 (4.6) G1: 20.4
Enrollment Period: Group Description: G2: 20.6
G2: 22.8 (1.6)
1977-1993 G1: Obese
G2: Normal weight Imputed: Hispanic
Funding: G1: 6.6
• No
NR Group N: G2: 6.5
G1: 683 Categorized:
Study Objective: Asian/Pacific Islander
To examine association
G2: 660 • IOM guidelines
G1: Native Am: 3.8
between infant birth Inclusion criteria: Age (mean, yrs): G2: Native Am: 3.2
outcomes and maternal • Obese and normal- G1: NR
pregravid obesity, weight women • 16-34 years: 91% Other
gestational weight gain, delivering singleton • ≥ 35 years: 8.8% NR
and prenatal smoking during study period G2: NR Smoking,%:
Time frame: Exclusion criteria: • 16-34 years: 93.5% G1: 26.4
1977 to 1993 • Missing data • ≥ 35 years: 5.8% G2: 26.2
Duration of the study: • Siblings Parity: Diabetes mellitus,%:
Entry into prenatal care • Fetal deaths G1: NR NR
until delivery • 0: 31.8%
• 1-3: 64.7% Hypertension,%:
• ≥ 4: 3.5% NR
G2: NR Additional characteristics:
• 0: 33.3% NR
• 1-3: 64.9%
• ≥ 4: 1.8%

C-594
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR LGA (%) Good
Total weight gain:
Gestational Groups Sample
Categorized: diabetes, %: selection:
• According to IOM NR Maternal weight gain categories stratified by
pregravid BMI and smoking status: Fair
Collected from: Cesarean delivery, Definition of
• Routine pre-natal %: Obese (BMI > 29.0): maternal weight
care or maternity NR G1: Smokers, < IOM gain:
records G2: Smokers, within IOM Fair
Instrumental G3: Smokers, > IOM
Ascertained by: delivery, %: Definition of
• Based on last NR outcomes:
G4: Nonsmokers, < IOM
clinically Good
G5: Nonsmokers, within IOM
measured weight Episiotomy, %:
G6: Nonsmokers, > IOM Source of
prior to delivery NR
information on
Other maternal Normal weight (BMI 19.8-26.0): exposure,
outcomes: G7: Smokers, < IOM outcomes, and
NR G8: Smokers, within IOM confounders:
G9: Smokers, > IOM Fair
Other infant
outcomes: Followup:
G10: Nonsmokers, < IOM
NR Fair
G11: Nonsmokers, within IOM
G12: Nonsmokers, > IOM
Analysis
comparability:
Obese:
Good
G13: Lost/no gain
G14: 0.5-6.5 kg Analysis of
G15: 7-11.5 kg outcomes:
G16: 12-16 kg Good
G17: > 16 kg
Interpretation:
Normal weight: Good
G18: < 11.5kg Sum of
G19: 11.5-16kg Good/Fair/Poor:
G20: > 16kg 5 Good, 4 Fair, 0
Poor
Results
Frequencies of LGA, %: Final Quality
G1: 5.3 Score:
G2: 10.0 Good
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

C-595
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Hellerstedt et al., 1997
(continued)

C-596
Evidence Table 39. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from
Gain 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-597
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
(BMI 35–39.9) (n = Categorized: NR
Study Objective:
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight change G3: Obese Class III Age (mean, yrs): NR
on pregnancy outcomes in (BMI 40 and More) (n G1: <26: 46%
obese women = 19,025) 26-35: 47% Other
Older than 35: 8% G1: 22
Time frame: Group N:
1990 to 2001 NR G2: <26: 44% Smoking,%:
26-35: 48% NR
Duration of the study: Inclusion criteria: Older than 35: 8%
Entry into prenatal care • Obese women G3: <26: 40% Diabetes mellitus,%:
through delivery residing in Missouri 26-35: 52% NR
who delivered (at 37 Older than 35: 9%
Hypertension,%:
or more weeks of
Parity: NR
gestation) liveborn,
singleton infants Nulliparous:
G1: 34% Additional characteristics:
during 1990–2001 NR
G2: 33%
Exclusion criteria: G3: 32%
• NR

C-598
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Absolute risk and OR (95% CI) of pregnancy Good
LGA:13% outcomes for various classes of obese
Total weight gain: (P < 0.05) women (class I, II, III) Sample
G1: GWG (lb) G2: SGA: 7% selection:
Less than 2: 3% LGA:16% Groups: Fair
2 to 14: 15% (P < 0.05) Maternal weight gain categories stratified by
15 to 25: 26% prepregnancy obesity status, Obese Class Definition of
G3: SGA: 6% maternal weight
More than 25: 56% LGA:18% I(BMI 30–34.9), Obese Class II (BMI 35–
G2: GWG (lb) 39.9), Obese Class III (> = BMI 40): gain:
(P < 0.05) Fair
Less than 2: 8% G1: < = -10lbs
2 to 14: 22% Gestational diabetes, %: G2: -2 to -9 lbs Definition of
15 to 25: 27% NR G3: No change outcomes:
More than 25: 43% G4: 2-9 lbs Good
G3: GWG (lb)Less than Cesarean delivery,%: G5: 10-14 lbs
2: 15% G1: 28 G6: 15-25lbs Source of
G2: 34 G7: 26-35lbs information on
G3: 41 G8: > 35 lbs exposure,
Categorized: outcomes, and
Instrumental delivery,%:
• 10-lb or less loss Result: confounders:
NR For Obese Class I: OR (95% CI) for LGA
2 to 9 lbs loss, no Fair
weight change, Episiotomy,%: were significantly lower (< 1.00, G6 was
2 to 9 lbs gain, NR reference) for G1- G5 and significantly higher Followup:
10 to 14 lbs gain, for G7-G8. Fair
15–25 lb gain, Analysis
26–35 lb gain, and For Obese Class II: OR (95% CI) for LGA comparability:
greater than 35 lb were significantly lower (< 1.00, G6 was Fair
gain reference) for G1- G5 and significantly higher
for G7-G8. Analysis of
Collected from: outcomes:
• Routine pre-natal For Obese Class III:OR (95% CI) for LGA Fair
care or maternity were significantly lower (< 1.00, G6 was
records Interpretation:
reference) for G1- G4 and significantly higher
Poor
Ascertained by: for G7-G8
NR Sum of
Maternal confounders and effect
Good/Fair/Poor:
modifiers accounted for in analysis:
2 Good, 6 Fair, 1
• Age Poor
• Race
• Parity Final Quality
• Education Score:
• Poverty (enrollment in Medicaid, WIC, Fair
food stamp programs)
• Tobacco use
• Chronic hypertension
Infant and child confounders and effect
modifiers accounted for in analysis:
NR

C-599
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Kiel et al., 2007
(continued)

C-600
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Outcomes from Bivariate
Maternal Weight Gain 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-601
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Parker and Abrams, 1992 • Cohort • Self-reported White
• Retrospective G1: 56.8 kg(SD 11.0) G1: 44.0
Country and setting: G2: NR
G2: NR
USA, hospital Total Study N:
6,690 Pregravid BMI: Black
Enrollment Period: G1: 8.3
G1: Underweight: 27.7%,
Sept 1980 to Dec 1988 Group Description: G2: NR
Normal weight 61.8%,
G1: Overall Overweight: 5.6%,
Funding: Hispanic
G2: NR Obese 4.9%
UC Committee on G1: 9.4
Research & MCH and Group N: G2: NR
G2: NR
Resources Development, G1: 6,690
Imputed:
Health Resources and G2: NR Asian/Pacific Islander
• No
Services Administration G1: 21.4
Inclusion criteria: Categorized: G2: NR
Study Objective: • Consecutive live
To test whether gains • IOM guidelines Other
singleton births at
outside IOM reference Moffitt Hospital Age (mean, yrs): G1: 12.0
ranges were associated between September G1: 27.7 (5.5) G2: NR
with increased risks of 1980 and December G2: NR
suboptimal pregnancy Smoking,%:
1988 with gestational G1: 12.0
outcome (SGA, LGA, ages of 37 to 42 Parity:
cesarean delivery) and to Primiparous: G2: NR
weeks
determine whether locally G1: 58.8% Diabetes mellitus,%:
developed ranges were Exclusion criteria: G2: NR NR
more applicable to study • Maternal transfers or
population transports and Hypertension,%:
deliveries NR
Time frame: complicated by fetal
Sept 1980 to Dec 1988 Additional characteristics:
malformations,
NR
Duration of the study: maternal diabetes, or
From entry into prenatal maternal
care until delivery hypertension

C-602
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 6690 G1: 3408g (462) • AOR for LGA (95% CI) Good
G2: NR G2: NR
Groups: Sample
Total weight gain: Gestational G1: < IOM range selection:
G1: 15.2kg (5.2) diabetes, %: G2: Within IOM range Fair
G2: NR NR G3: > IOM
Definition of
Categorized: Cesarean delivery, maternal
• According to IOM %: Results: weight gain:
Weight gain NR AOR (95% CI) for LGA: Fair
ranges based on G3: 1.92 (1.52-2.43)
Instrumental Definition of
percentiles from G2: 1.00 (reference)
delivery, %: outcomes:
previous study of
NR Good
UC population Incidence of LGA in nonobese women, %:
with good Episiotomy, %: G1: 3.25 Source of
pregnancy NR G2: 6.14 information on
outcomes: 25th - G3: 13.11 exposure,
75th, 10-90th Other maternal outcomes, and
percentiles. For outcomes: Incidence of LGA in obese women, %: confounders:
25-75th, weight NR G1: 5.88 Fair
gain range = 12- Other infant G2: 17.53
17kg for Followup:
outcomes: Fair
underweight NR AOR for LGA and high weight gain
women (BMI < UCSF 25-75 Analysis
19.8); 1.89 (1.51-2.37) comparability:
UCSF 10-90 Fair
Collected from: 1.87 (1.39-2.52)
• Routine pre-natal IOM Analysis of
care or maternity 1.92 (1.52-2.43) outcomes:
records Good
Ascertained by: Interpretation:
• Based on last Maternal confounders and effect modifiers Poor
clinically accounted for in analysis:
measured weight Sum of
• Age Good/Fair/Poo
prior to delivery • Race r:
• Parity 3 Good, 5 Fair,
• Pre-gravid BMI 1 Poor
• Height
• Maternal high and low weight gain Final Quality
• Smoking Score:
Fair
Infant and child confounders and effect modifiers
accounted for in analysis:
• Gestational age
Birth weight

C-603
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stevens-Simon and • Cohort • Self-reported White
McAnarney, 1992 • Prospective G1: 58.6 (11.1) NR
G2: 160.9 (7.0)
Country and setting: Total Study N: Black
G3: 163.9 (5.5)
USA, adolescent 141 (107 included in NR
maternity program postpartum analyses) Pregravid BMI:
Hispanic
G1: 23.1 (3.5)
Enrollment Period: Group Description: NR
G2: 23.5 (4.4)
1986 to 1989 G1: Slow gainers G3: 23.5 (4.2) Asian/Pacific Islander
G2: Average gainers
Funding: NR
G3: Rapid gainers Imputed:
Grant from Bureau of
• No Other
Maternal and Child Health Group N:
NR
G1: 28 Categorized:
Study Objective:
To clarify advantages and
G2: 66 • Continuous Smoking,%:
G3: 47 NR
disadvantages of large Age (mean, yrs):
gestational weight gain Inclusion criteria: G1: 16.9 Diabetes mellitus,%:
among pregnant • Consecutively G2: 16.6 NR
adolescents enrolled poor, black, G3: 16.2
Hypertension,%:
Time frame: 12-19 year olds
Parity: NR
1986 to 1989 • Prenatal care prior to
NR
2third week gestation Additional characteristics:
Duration of the study: • No chronic disease NR
Entry into prenatal care • No regular
through 6 weeks PP medications
check up • No known uterine
anomalies
• Live birth
• Singletons
Exclusion criteria:
• NA

C-604
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28 G1: 2745 (694) Distribution of LGA,%: Good
G2: 66 G2: 3097 (457)
G3: 47 G3: 3351 (482) Groups Sample
P < 0.0001 Maternal weight gain categories (kg/wk): selection:
Total weight gain: G1: < 0.23 Poor
G1: 7.7 (average rate Gestational G2: 0.23-0.40
0.2 kg/wk) diabetes, %: Definition of
G3: > 0.40 maternal weight
G2: 12.4 (average NR
rate 0.3 kg/wk) gain:
Cesarean delivery, Results Fair
G3: 19.8 (average G1: 3.6
rate 0.5 kg/wk) %:
NR G2: 4.5 Definition of
Categorized: G3: 12.8 outcomes:
Instrumental P = NS Good
• According to
delivery, %:
IOMslow gain: Maternal confounders and effect modifiers Source of
NR
< 0.23kg/wk; accounted for in analysis: information on
average gain: Episiotomy, %: NA exposure,
0.23-0.4kg/week; NR outcomes, and
rapid gain: > Infant and child confounders and effect modifiers confounders:
0.4kg/week Other maternal accounted for in analysis: Fair
outcomes: NA
Collected from: NA Followup:
• Routine pre-natal Fair
care or maternity Other infant
records outcomes: Analysis
NA comparability:
Ascertained by: Fair
• Based on last
Analysis of
clinically
outcomes:
measured weight
Good
prior to delivery
Interpretation:
Poor
Sum of
Good/Fair/Poor:
3 Good, 4 Fair, 2
Poor
Final Quality
Score:
Fair

C-605
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Cohort • Self-reported White
• Retrospective G1: 16.2
Country and setting: Pregravid BMI: G2: 35.8
USA, university hospital Total Study N: G1: < 19.8: 25.8% G3: 48.0
20465 19.8-26.0: 19.4%
Enrollment Period: Black
26.1-29.0: 9.2%
1980 to 2001 Group Description: G1: 25.5
> 29.0: 20.6%
G1: Gain below IOM G2: < 19.8: 49.1% G2: 29.4
Funding:
recommendations 19.8-26.0: 34.8% G3: 45.1
NR
G2: Gain within IOM 26.1-29.0: 23.3%
Study Objective: recommendations Hispanic
> 29.0: 25.5%
To examine relationship G3: Gain above IOM G1: 19.2
G3: < 19.8: 25.0%
between gestational recommendations G2: 34.8
19.8-26.0: 45.8%
weight gain and adverse G3: 46.0
Group N: 26.1-29.0: 67.5%
neonatal outcomes > 29.0: 53.9% Asian/Pacific Islander
G1: 4,114
among infants born at P < 0.001 G1: 24.3
G2: 7,490
term (37 weeks or more) G2: 43.3
G3: 8,861 Imputed:
Time frame: G3: 32.4
Inclusion criteria: • No
1980 to 2001 Other
• Singleton Categorized:
Duration of the study: G1: 21.7
Exclusion criteria: • IOM guidelines G2: 37.9
Entry into PN care up till
delivery • Pregnancies Age (mean, yrs): G3: 40.4
complicated by G1: < 20 years: 23.4% P for all race categories <
multiple gestations, 20-29 years: 19.3% 0.001
congenital anomalies, 30-39 years: 19.9%
chronic hypertension, Smoking,%:
> 40 years: 25.3% G1: 23.5
gestational or G2: < 20 years: 31.3%
pregestational G2: 30.8
20-29 years: 36.6% G3: 45.8 P < 0.001
diabetes 30-39 years: 37.6%
• Birth before 37 weeks > 40 years: 36.3% Diabetes mellitus,%:
• Maternal transport G3: < 20 years: 45.4% NR
• Missing data on any 20-29 years: 44.0%
of variables Hypertension,%:
30-39 years: 42.5%
considered in > 40 years: 38.4% NR
multivariable analysis P < 0.001 Additional characteristics:
Parity: NR
% Nulliparous:
G1: 17.3
G2: 36.2
G3: 46.6
P < 0.001

C-606
Evidence Table 43. Gestational weight gain with reference to IOM recommendations and large for gestational
age (continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4114 G1: %SGA: 36.1; %AGA: • Risk of adverse neonatal outcomes by Good
G2: 7490 20.2; %LGA: 8.5 gestational weight gain by IOM guidelines,
G3: 8861 G2: %SGA: 39.4; %AGA: Sample
adjusted ORs compared to women with GWG
37.5; %LGA: 26.5 selection:
within IOM guidelines and risk of adverse
Total weight gain: G3: %SGA: 24.5; %AGA: Fair
neonatal outcomes by extremes of GWG
Categorized: 42.4; %LGA: 65.1 compared to women with weight gain 11.5- Definition of
• According to P < 0.001 16.0kg maternal weight
IOMpercentiles Gestational diabetes,%: gain:
Groups:
and dichotomous NR Fair
G1: < IOM
Collected from: G2: Within IOM Definition of
Cesarean delivery,%:
• Routine pre-natal G1: 14.7 G3: > IOM outcomes:
care or maternity G2: 32.1 G4: < 7kg Good
records G5: > 18kg
G3: 53.2 Source of
Ascertained by: Results: information on
Instrumental delivery,%:
• Based on last Unadjusted Rates of LGA: exposure,
Operative vaginal delivery:
clinically G1: 3.85 P< 0.001 vs. G2 outcomes, and
G1: 18.0%
measured weight G2: 37.5% G2: 6.62 confounders:
prior to delivery G3: 44.5% G3:13.76 P< 0.001 vs. G2 Fair
G4: 5.26
Episiotomy,%: G5: 14.60 P< 0.05 vs. G2 Followup:
NR Fair
AOR (95% CI) for LGA: Analysis
Other maternal G1: 0.58 (0.47-0.72)
outcomes: comparability:
G2: 1.00 (reference) Fair
NA G3: 1.98 (1.74-2.25)
Other infant outcomes: G4: 0.50 (0.33-0.78) Analysis of
G5: 2.28 (2.00-2.62) outcomes:
• Birth trauma
Fair
• 5 min Apgar score less
than 7 Maternal confounders and effect modifiers Interpretation:
• Aassisted ventilation accounted for in analysis: Good
• SGA • Age Sum of
• LGA • Race Good/Fair/Poor:
• NICU admission • Parity 3 Good, 6 Fair, 0
• SCN admission • Pre-gravid BMI Poor
• Neonatal infection • Pregnancy induced hypertension
• Seizure • Date of delivery Final Quality
• Hypoglycemia • Mode of delivery Score:
• Polycythemia Fair
• Length of first stage of labor
• MAS • Length of second stage of labor
• RDS • Smoking
• Tachypnea
• Hospital stay > 5 days Infant and child confounders and effect
modifiers accounted for in analysis:
• Hospital stay > 10
days • Gestational age
Birth weight

C-607
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Cogswell et al., 1994 • Cohort • Self-reported White
• Retrospective G1: 75.1
Country and setting: Pregravid BMI: G2: 72.4
USA, Pregnancy Nutrition Total Study N: G3: 74.5
Surveillance System Imputed:
53,541
• No Black
Enrollment Period: Group Description: G1: 13.8
1990-1991 G1: Average weight Categorized:
• IOM guidelines G2: 14.1
G2: Overweight G3: 16.1
Funding:
G3: Very overweight Age (mean, yrs):
NR Hispanic
Group N: G1: 11-17 yr: 11.9%
Study Objective: 18-34yr: 85.0% G1: 11.1
G1: 33,809 G2: 13.5
To determine association 35-54 yr: 3.1%
G2: 7,661 G3: 9.4
between increased G2: 11-17 yr: 6.9%
G3: 12,071
gestational weight gain 18-34yr: 88.7% Asian/Pacific Islander
and birth weight outcomes Inclusion criteria: 35-54 yr: 4.4% NR
for low income women • White, black and G3: 11-17 yr: 4.0%
hispanic women who 18-34yr: 90.1% Other
Time frame: NR
1990-1991 delivered single, 35-54 yr: 6.0%
liveborn, term infants Smoking,%:
Duration of the study: Parity:
Exclusion criteria: NR G1: 29.9
Women in WIC but G2: 28.3
everything is self reported • Low or high values
for; birth weight, G3: 25.7
so it is when they were
first enrolled in WIC until prepregnancy BMI, or Diabetes mellitus,%:
delivery weight gain during NR
pregnancy
• Missing data on one Hypertension,%:
or more study NR
variables
Additional characteristics:
• Underweight women NR
• Only 1 infant was
used in analysis for
women who delivered
more than once
during study period

C-608
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description:
G1: 33,809 G1: < 2500g: 2.7% AOR (95% CI) for high birth weight
G2: 7,661 2500-4000g: 87.5%
G3: 12,071 > 4000-4500: 8.5% Groups
> 4500g: 1.4% Maternal weight gain categories (lbs)
Total weight gain: G2: < 2500g: 2.5% stratified by pregravid BMI:
G1: < 15 lb: 6.2% 2500-4000g: 83.9% Normal weight (BMI 19.8-26.0):
15-19: 5.8% > 4000-4500: 11.7% G1: < 15
20-24: 11.2% > 4500g: 2.0% G2: 15-19
25-29: 14.4% G3: < 2500g: 2.1% G3: 20-24
30-34: 17.1% 2500-4000g: 81.1% G4: 25-29
35-39: 13.9% > 4000-4500: 13.2% G5: 30-34
≥ 40: 31.4% > 4500g: 3.6% G6: 35-39
G2: < 15 lb: 11.4% G7: ≥ 40
15-19: 7.8% Gestational diabetes, %: Overweight (BMI > 26.0-29.0):
20-24: 13.0% NR G8: < 15
25-29: 12.7% G9: 15-19
Cesarean delivery, %:
30-34: 15.9% G10: 20-24
35-39: 11.2% NR
G11: 25-29
≥ 40: 28.1% Instrumental delivery, G12: 30-34
G3: < 15 lb: 25.1% %: G13: 35-39
15-19: 10.1% NR G14: > = 40
20-24: 1 Obese (BMI > 29.0):
Episiotomy, %:
Categorized: NR G15: < 15
• 4 lbs increments G16: 15-19
starting at 15 lbs Other maternal G17: 20-24
outcomes: G18: 25-29
Collected from: NA
• Self-reported Results
Other infant outcomes:
AOR (95% CI) for high birth weight:
Ascertained by: NA
G1: 1.0 (0.5-2.0)
• Self-reported
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-609
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Cogswell et al., 1994
(continued)

C-610
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Maternal Weight Outcomes from
Gain 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-611
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal weight G1: NR
To compare pregnancy
G1: 683 (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal weight Age (mean, yrs):
women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight change normal weight women
identified from Parity: Other
Time frame: NR G1: NR
1997-1993 pregnancy and
delivery summary G2: NR
Duration of the study: records (normal G3: 4.0 (Total sample)
1997-1993 weight matched to Smoking,%:
obese by race, age, NR
parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-612
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 • Birthweight ≥ 4000g Good
G2: 660 G2: 3285 P ≤ 0.001
Sample
Groups:
Total weight gain: Gestational selection:
Maternal weight gain categories (kg) Obese > 29:
G1: 9.5 diabetes,%: Fair
G1: Lost weight/no change
G2: 14.5 P ≤ 0.001 NR
G2: 0.5-6.5 Definition of
Categorized: Cesarean G3: 7-11.5 maternal weight
• According to IOM delivery,%: G4: 12-16 gain:
G1: 25.6 G5: > 16 Fair
Collected from: G2: 9.1 P < 0.001 Normal BMI 19.8-26
• Routine pre-natal G6: < 11.5kg Definition of
care or maternity Instrumental G7: 11.5-16 outcomes:
records delivery,%: G8: > 16kg Fair
Ascertained by: Episiotomy,%: Source of
Results: information on
• Based on last Other maternal Birthweight > = 4000g, %: exposure,
clinically outcomes: G1:12.0 outcomes, and
measured weight NA G2: 12.5 confounders:
prior to delivery
Other infant G3: 13.3 Fair
outcomes: G4: 15.4
G5: 24.4 Followup:
NA Fair
P (for G1-G5) = 0.026
Analysis
G6: 5.7 comparability:
G7: 6.6 Good
G8: 16.9
P (for G6-G8) < 0.001 Analysis of
outcomes:
Fair
AOR (95%CI) for birthweight> = 4000g among obese
women (BMI> 29.0): Interpretation:
G3: 1.0 (reference) Good
G8: 2.8 (1.4-5.6) Sum of
Good/Fair/Poor:
AOR (95%CI) for birthweight> = 4000g among normal 3 Good, 6 Fair, 0
weight women (BMI 19.8-26.0): Poor
G7: 1.0 (reference)
G8: 2.4 (1.3-4.7) Final Quality
Score:
Fair
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

C-613
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hedderson et al., 2006 • Case-control • Self-reported in some cases White
• Retrospective used measured weight G1: 54.0
Country and setting: G2: 67.8
recorded in chart closes to
USA, Kaiser Permanente Total Study N: G3: 47.6
woman’s last menstrual
Medical Care Program 45,245 G4: 42.6
period but no more than 12
Enrollment Period: Group Description: months before her last
Black
January 1, 1996 - June G1: Controls menstrual period
G1: 10.0
31, 1998 G2: Macrosomia G2: 5.1
Pregravid BMI:
G3: Hypoglycemia G1: < 19.8: 13.5% G3: 11.3
Funding:
G4: Hyperbilirubinemia
19.8-24.9: 56.4% G4: 4.4
R01 DK 54834 from
National Institute of Group N: 25.0-29.0: 12.4%
Hispanic
Diabetes and Digestive G1: 652 > 29.0: 17.6%
G1: 17.2
and Kidney Diseases, G2: 391 G2: < 19.8: 5.1%
G2: 15.1
grant from American G3: 328 19.8-24.9: 51.2%
G3: 20.4
Diabetes Association and G4: 432 25.0-29.0: 16.6%
G4: 15.5
Kaiser Community Benefit > 29.0: 27.1%
research support Inclusion criteria: G3: < 19.8: 10.1% Asian/Pacific Islander
• Singleton livebirth 19.8-24.9: 50.0% G1: 8.1
Study Objective: 25.0-29.0: 17.1% G2: 3.6
To examine whether Exclusion criteria:
> 29.0: 22.9% G3: 6.7
pregnancy weight gains • No pregestational
G4: < 19.8: 13.9% G4: 20.1
outside IOM diabetes or history of
19.8-24.9: 57.9%
recommendations and gestational diabetes Other
25.0-29.0: 13.2%
rates of maternal weight (screened at 24-28 G1: 10.7
> 29.0: 57.1%
gain are associated with weeks gestation - G2: 8.4
neonatal complications meeting National Imputed: G3: 14.0
Diabetes Data Group • No G4: 17.4
Time frame: criteria for GDM)
January 1, 1996 to June Categorized: Smoking,%:
31, 1998 • IOM guidelines G1: %nonsmoking during
pregnancy: 92.0; %smoked
Duration of the study: Age (mean, yrs): but quit: 4.2; %smoked 3.9
First prenatal care visit to G1: < 25 years: 22.1% G2: %nonsmoking during
30 days post delivery 25-29: 24.2% pregnancy: 90.8; %smoked
30-34: 33.6% but quit: 5.3; %smoked 4.0
≥ 35: 20.1% G3: %nonsmoking during
G2: < 25 years: 15.9% pregnancy: 92.6; %smoked
25-29: 28.0% but quit: 1.5; %smoked 5.8
30-34: 31.7% G4: %nonsmoking during
≥ 35: 24.3% pregnancy: 94.2; %smoked
G3: < 25 years: 24.1% but quit: 4.9; %smoked 1.0
25-29: 25.3%
30-34: 26.8% Diabetes mellitus,%:
≥ 35: 23.8% NR
G4: < 25 years: 17.1%
Hypertension,%:
25-29: 29.4%
NR
30-34: 32.6%
≥ 35: 20.8% Additional characteristics:
Parity: Screening glucose value less
than 140:
% primiparous:
G1: 56.9 G1: 85.0%: > 140: 15.0%
G2: 81.6%: > 140: 18.4%
G2: 31.2
G3: 50.0 G3: 81.4%: > 140: 18.6%
G4: 83.3%: > 140: 16.7%
G4: 59.3

C-614
Evidence Table 48. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • AOR for birthweight>4500g (95% CI) Good
Total weight gain:
Gestational Groups: Sample selection:
Categorized: diabetes, %: Good
G1: < IOM recommendations
• According to IOM NR G2: Within IOM recommendations
Definition of
Collected from: G3: > IOM recommendations
Cesarean delivery, maternal weight
• Routine pre-natal %: Results: gain:
care or maternity NR % Distribution of maternal weight gain Fair
recordsrate of categories among women with macrosomia:
maternal weight Instrumental G1: 4.0
Definition of
gain was delivery, %: outcomes:
G2: 16.3
calculated as NR Good
G3: 79.7 P< 0.05 (compared to controls)
total pregnancy
Episiotomy, %: Source of
weight gain AOR (95% CI) for macrosomia:
NR information on
minus infant birth G1: 0.38 (0.20-0.70) exposure,
weight divided by Other maternal G2: 1.00 reference outcomes, and
weeks of outcomes: G3: 3.05 (2.19-4.26) confounders:
gestation when NA
Fair
last weight was OR (95% CI) for macrosomia:
measured; rate Other infant Underweight women (BMI < 19.8) Followup:
of maternal outcomes: Fair
NA G2: 1.00 (reference)
weight gain G3: 2.70 (0.83-8.61)
before the third Analysis
trimester was comparability:
Normal weight women(BMI 19.8-26.0) Good
calculated using G2: 1.00 (reference)
the weight G3: 3.60 (2.27-5.83) Analysis of
measured at or outcomes:
before the Overweight/obese women (BMI > 26.0) Fair
screening test for G2: 1.00 (reference)
GDM (24-28 wks Interpretation:
G3: 2.00 (1.14-3.47) Good
of gestation)
minus Maternal confounders and effect modifiers Sum of
prepregnancy accounted for in analysis: Good/Fair/Poor:
weight divided by • Age 5 Good, 4 Fair, 0
weeks of • Race Poor
gestation • Parity
• Pre-gravid BMI Final Quality
Ascertained by: Score:
• Based on last • Screening glucose value from 1 hour after
50g oral glucose challenge test Good
clinically
measured weight • Difference between age at delivery and
prior to delivery: gestational age at last weight measured
difference Infant and child confounders and effect
between final modifiers accounted for in analysis:
recorded weight NR
at last prenatal
visit (within 2
weeks of delivery
date) and
prepregnancy
weight

C-615
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year: Design: Pregravid weight: Race,%:

Kabali, C and Werler, MM, • Cohort • Self-reported White
2007 • Retrospective G1: (67.7)
Pregravid BMI:
Country and setting: Total Study N: NR Black
Canada and United 815 G1: (11.3)
States, multicenter Imputed:
Group Description: • No Hispanic
Enrollment period: G1: Total Study G1: (16.2)
1996 to 2002 Categorized:
Group N: • IOM guidelines Asian/Pacific Islander
Funding: G1: 815 NR
National Instituteof Dental Age (mean, yrs):
and Craniofacial Inclusion criteria: G1: <24 years 208 (25.5%) Other
Research, grant # • Controls were 24 to 34 years 478 (58.7%) G1: (4.8)
DE11393 selected by pediatric 35 to 45 years 129 (15.8%) Smoking,%:
practice (or one of G1: throughout pregnancy -
Study Objective: similar size and Parity:
To establish whether G1: Primaparae (56.2%) yes: 8.2%
location) of each case
excessive pre-pregnancy by identifying next Diabetes mellitus,%:
weight as measured by four children seen in NR
BMI, excessive PWG, or practice whose ages
their combined effects are Hypertension,%:
were within 2 months
risk factors for delivering of case's age. NR
large babies Additional characteristics:
Exclusion criteria:
Time frame: NR
• Diabetic women
1996 to 2002 • Multiple gestations
Duration of the study: • Missing weight,
Entry into prenatal care height, or weight gain
through pregnancy data
• Women with outlying
data

C-616
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description:
NR NR OR for maternal BMI and weight gain in
relation to risk of macrosomia (95% CI)
Total weight gain: Gestational diabetes, %:
NR NR Groups:
G1: < IOM
Categorized: Cesarean delivery,%: G2: Within IOM
• According to IOM NR G3: > IOM
Collected from: Instrumental delivery,%:
• NR NR Results:
Ascertained by: Episiotomy,%: AOR
• Self-reported NR G1: 1.0 (0.4, 1.9)
G2: ref
Other maternal outcomes: G3: 1.5 (0.7, 2.5)
NR
Other infant outcomes: 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-617
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rode et al., 2007 • Cohort • Self-reported White
• Prospective NR
Country and setting: Pregravid BMI:
Smoke-free Newborn Total Study N: • NR Black
Study, University Hospital, 2248 NR
Denmark Imputed:
Group Description: • No Hispanic
Enrollment period: G1: BMI < 19.8 NR
November 1996 to G2: BMI 19.8-26.0 Categorized:
October 1998 IOM Guidelines Asian/Pacific Islander
G3: BMI 26.1-29.0
NR
G4: BMI > 29.0 Age (mean, yrs):
Funding:
NR G1: Less than 25:15.3% Other
Group N:
25-30: 45.7% NR
G1: 385
Study Objective: 30-35: 33.5%
G2: 1,531 Smoking,%:
To investigate association >35: 5.5%
G3: 177 %nonsmokers:
between maternal weight G2: Less than 25:17.5%
G4: 385 G1: 58.3
gain and birthweight 25-30: 36.7% G2: 65.5
Inclusion criteria: 30-35: 34.5%
Time frame: G3: 61.1
November 1996 to • Women who >35: 11.3% G4: 67.3
October 1998 answered G3: Less than 25:15.3%
questionnaire at both 25-30: 45.7% Diabetes mellitus,%:
Duration of the study: 12 to 18 weeks and 30-35%: 33.5% NR
12 to 18 weeks gestation 37 weeks gestation >35: %
through delivery G4: Less than 25: 20.0% Hypertension,%:
Exclusion criteria: 25-30: 39.4% NR
• Multiple gestation 30-35: 29.7% Additional characteristics:
• Women who >35: 11.0% P < 0.001 % married/cohabiting:
delivered prior to 37
Parity: G1: 92.3
weeks
G2: 91.4
% nulliparous:
G1: 52.2 G3: 94.2
G2: 58.6 G4: 92.7
G3: 51.4 Additional characteristics:
G4: 49.0 P = 0.02 NR

C-618
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 385 G1: less than 2500g: 1.8% • AOR for birthweight ≥ 4000g (95% CI) Good
G2: 1,531 2500-2999: 10.9%
G3: 177 3000-3999: 72.7% Groups: Sample
G4: 385 4000-4499: 11.4% Maternal weight gain categories stratified by selection:
≥ 4500: 3.1% pregravid BMI status: Fair
Total weight gain: G2: less than 2500g: 1.1% BMI less than 19.8
G1: < 1kg: 0% Definition of
2500-2999: 7.1% G1: < IOM
1-5:0.5% maternal weight
3000-3999: 69.6% G2: Within IOM
gain:
6-10: 16.1% 4000-4499: 18.2% G3: > IOM
11-15: 45.7% Fair
≥ 4500: 4.0%
16-20: 30.1% G3: less than 2500g: 2.3% BMI 19.8–26.0 Definition of
>20: 7.5% 2500-2999: 4.5% G4: < IOM outcomes:
G2: < 1kg: 0.3% 3000-3999 G5: Within IOM Good
1-5: 1.6% G6: > IOM
6-10: 16.9% Gestational diabetes, %: Source of
11-15: 41.5% NR BMI 26.1–29.0 information on
16-20: 29.1% G7: < IOM exposure,
>20: 10.5% Cesarean delivery,%: outcomes, and
G8: Within IOM
G3: < 1kg: 1.7% NR confounders:
G9: > IOM
1-5: 4.5% Instrumental delivery,%: Poor
6-10: 24.9% Results:
NR Followup:
11-15: 40.1% AOR (95%CI) for birthweight > = 4000g:
Episiotomy,%: G1: 0.8 (0.4-1.6) Good
16-20: 24.3%
>20: 4.5% NR G2: 1.0 (reference) Analysis
G4: G3: 1.7 (0.8-3.6) comparability:
Other maternal outcomes
NR Good
Categorized: G4: 0.7 (0.5-0.999)
AccordinG to IOM Other infant outcomes G5: 1.0 (reference) Analysis of
G6: 1.9 (1.5-2.5) outcomes:
Collected from: • Birthweight
Good
• Self-reported G7: 0.6 (0.1-3.1) Interpretation:
Ascertained by: G8: 1.0 (reference) Good
• Self-reported G9: 1.8 (0.8-3.9)
Sum of
G10: 0.8 (0.4-1.7) Good/Fair/Poor:
G11: 1.0 (reference) 6 Good, 2 Fair, 1
G12: 0.9 (0.4-2.0) Poor
Maternal confounders and effect Final Quality
modifiers accounted for in analysis: Score:
• Pre-eclampsia Fair
• Caffeine consumption
• Smoking
Infant and child confounders and effect
modifiers accounted for in analysis:
Gestational age

C-619
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)

Author, year: Design: Pregravid weight: Race,%:

Schieve, 1998 • Cohort • Self-reported White
• Retrospective • NR NR
Country and setting:
Pregnancy Nutrition Total Study N: Pregravid BMI: Black
Surveillance System - 173,066 • NR NR
data from WIC clinics
(99%) from Indiana, Group Description: Imputed: Hispanic
Kansas, Massachusetts, NR • No NR
Minnesota, Nebraska, Group N: Categorized: Asian/Pacific Islander
North Dakota, New York, NR IOM Guidelines NR
Tennessee, and Vermont
Inclusion criteria: Age (mean, yrs): Other
Enrollment period: • White, black, and NR NR
Funding: hispanic women who Smoking,%:
visited WIC clinics Parity:
NR NR NR
prenatally and
Study Objective: subsequently Diabetes mellitus,%:
To examine associations delivered liveborn, NR
between pregnancy singleton infants
weight gain outside and Hypertension,%:
• Delivered between 39
within ranges NR
and 41 weeks
recommended by IOM Additional characteristics:
and birth weight by both Exclusion criteria: NR
prepregnant BMI and race • Missing data for
ethnicity infant birth weight
(n = 4223)
Time frame: • Prepregnant BMI
NR (n = 31477)
Duration of the study: • Pregnancy weight
1990 to 1993 gain (n = 7542)
• Maternal age
(n = 43)
• Maternal education
(n = 3819)

C-620
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Outcomes Description:
Groups (N): Birth weight: Macrosomia (>4500g) Background:
G1: 112,524 NR Good
G2: 33,101 Groups
G3: 27,441 Gestational Sample selection:
diabetes, %: Maternal weight gain categories stratified by pregravid Poor
Total weight gain: NR BMI (IOM underweight, normal weight, overweight, and
G1: 32.5 obese) and race (non-Hispanic white, non-Hispanic Definition of
G2: 30.5 Cesarean black, and Hispanic): maternal weight
G3: 30.2 delivery,%: gain:
NR G1: > = 10 lbs below IOM Fair
Categorized: G2: 1-9 lbs below IOM
According to IOM >10 Instrumental Definition of
delivery,%: G3: Lower half of IOM outcomes:
pounds below lower G4: Upper half of IOM
bound of IOM NR Good
G5: 1-9 lbs above IOM
recommended range Episiotomy,%: G6 > = 10lbs above IOM Source of
for woman's NR information on
prepregnant BMI, 1-9 Results exposure,
pounds below lower Other maternal Within every BMI-race ethnicity stratum, the odds of outcomes, and
bound of IOM lower outcomes delivering a > 4500g infant tended to increase as confounders:
bound, in lower half • NA weight gain increased. This trend was statistically Fair
of IOM recommended significant for all strata; however, the trend
Other infant Followup:
range, in upper half of diminished with decreasing BMI. Women in G6
outcomes
IOM range, 1-9 were 2.2–10.8 times more likely to deliver a > 4500 Fair
• NA g infant compared to women in G3, irrespective of
pounds above IOM Analysis
range, >10 pounds BMI status.
comparability:
above IOM upper Fair
bound Maternal confounders and effect modifiers
Analysis of
Collected from: accounted for in analysis:
outcomes:
• Self-reported • Age Good
• Height
Ascertained by: • Education Interpretation:
• Self-reported • Trimester of the Special Supplemental Nutrition Poor
Program for Women, Infants, and Children Sum of
Infant and child confounders and effect modifiers Good/Fair/Poor:
accounted for in analysis: 3 Good, 4 Fair, 2
NR Poor
Final Quality
Score:
Fair

C-621
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Thorsdottir et al., 2002 • Cohort • Self-reported White
• Retrospective G1: 63.1 (6.2) NR
Country and setting:
G2: 62.0 (5.6) P = 0.059
Maternity records, Total Study N: Black
G3: 61.7 (4.8) P = 0.174
Department of Obstetrics 614 NR
G4: 62.2 (6.1) P = 0.274
and Gynecology at
Landspitali University Group Description: Hispanic
Pregravid BMI:
Hospital, Iceland G1: No complication NR
G1: 22.2
G2: Complications in G2: 22.4 )1.6) P = 0.270
Enrollment Period: Asian/Pacific Islander
pregnancy or delivery G3: 22.4 (1.5) P = 0.338 NR
G3: Complications in G4: 22.3 P = 0.584
Funding:
pregnancy Other
NR
G4: Complications in Imputed: NR
Study Objective: delivery • No
To investigate relation Smoking,%:
Group N: Categorized: NR
between gestational
weight gain in women of
G1: 452 • Continuous
G2: 162 Diabetes mellitus,%:
normal prepregnant Age (mean, yrs): NR
G3: 56
weight and complications G1: 29
G4: 106 Hypertension,%:
during pregnancy and G2: 29 P = 0.857
delivery in a population Inclusion criteria: NR
G3: 29 P = 0.404
with high gestational • Women of normal G4: 29 P = 0.398 Additional characteristics:
weight gain and birth prepregnancy weight Proportional weight gain, %:
weight randomly selected Parity:
G1: 26.0
Time frame: within 1 year (1998) NR G2: 28.0 P = 0.018
NR • No history of G3: 30.0 P = 0.005
diabetes, G4: 27.0 P = 0.546
Duration of the study: hypertension, CVD,
1998 or thyroid problems Additional characteristics:
• Singleton births NR
• 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

C-622
Evidence Table 44. Gestational weight gain with reference to IOM recommendations and macrosomia
(continued)
Outcomes from Outcomes from
Maternal Weight Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 452 G1: 3789 (469) Birthweight > 4500g Good
G2: 162 G2: 3749 (565) P = 0.389
G3: 56 G3: 3643 (526) P = 0.032 Groups: Sample selection:
G4: 106 G4: 3806 (578) P = 0.529 Maternal weight gain Fair
categories:
Total weight gain: Gestational diabetes, %: Definition of maternal
G1: 16.6 (4.9) NR G1: < 11.5 kg weight gain:
G2: 17.4 (5.1) P = G2: 11.5-16.0 kg Poor
0.080 Cesarean delivery, %: G3: 16.1-20.0 kg
NR Definition of outcomes:
G3: 18.4 (5.1) P = G4: > 20.0 kg Fair
0.013 Instrumental delivery,
G4: 16.9 (5.1) P = %: G5: 12.5-15.5kg Source of information on
0.887 NR G6: > 17.8-20.8 kg exposure, outcomes, and
confounders:
Categorized: Episiotomy, %: Fair
• According to IOM < NR Results:
11.5, 11.-16.0, ≥ Birth weight > 4500g, % Followup:
16.1, also quintiles Other maternal G1: 4.3 Good
< 12.5, 12.5-15.5, outcomes: G2: 4.1 (P< 0.05 between
NA Analysis comparability:
15.6-17.8, 17.9- groups) Good
20.8, > 20.8 Other infant outcomes: G3: 9.1 (P< 0.05 between
NA groups) Analysis of outcomes:
Collected from: G4: 10.2 (P< 0.05 between Good
• Routine pre-natal groups)
care or maternity Interpretation:
P for trend< 0.015
records Good

Ascertained by: RR (95%CI) for > 4500g: Sum of Good/Fair/Poor:

• Based on last G5: 1.00 (reference) 5 Good, 3 Fair, 1 Poor
clinically measured G6: 3.54 (1.26-9.97)
Final Quality Score:
weight prior to Maternal confounders and Fair
delivery 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-623
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bianco et al., 1998 • Cohort • Routine pre-natal care White
• Retrospective G1: 104.7 (16.2) G1: 17.7%
Country and setting: G2: 57.3% (P < 0.01)
G2: 58.8 (7.1) (P < 0.05)
Mount Sinai Medical Total Study N:
Center, New York City 613 morbidly obese Pregravid BMI: Black
11,313 nonobese • NR NR
Enrollment period:
Group Description: Imputed: Hispanic
Funding: NR
NR
G1: Obese • No
G2: Controls
Categorized: Asian/Pacific Islander
Study Objective: NR
Group N: • NHANES II reference
To compare pregnancy
G1: 613 for women 20 to 29
outcomes between Other
G2: 11,313
morbidly obese and Age (mean, yrs): NR
nonobese women and Inclusion criteria: G1: 27.5
to determine effect of Smoking,%:
• Singleton G2: 28.7 (P = NS) NR
gestational weight gain pregnancy
on pregnancy outcome • Age 20 to 34 years Parity: Diabetes mellitus,%:
in morbidly obese % multiparous: G1: 14.2%
women Exclusion criteria: G1: 66.7% G2: 4.3% (P < 0.01)
• Multiple gestations G2: 44.8% (P < 0.01)
Time frame: • Extremes of age Hypertension,%:
NR • BMI between 27 G1: 5.4%
Duration of the study: and 34 G2: 0.3% (P < 0.01)
1988 to 1995 • Missing height Additional characteristics:
• Missing % college education:
prepregnancy G1: 37.1%
weight G2: 63.1% (P < 0.01)
Preexisting diabetes:
G1: 7.3%
G2: 1.6% (P < 0.01)

C-624
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description:
G1: 613 G1: 3352 (598) SGA (%)
G2: 11,313 G2: 3269 (532)
(P < 0.05) Groups
Total weight gain: G1: Weight loss or 0 lbs
G1: 20 (16.2) Gestational G2: 1-15 lbs
G2: 31.4 (11.5) diabetes, %: G3: 16-25 lbs
G1: 14.2% G4: 26-35 lbs
Categorized: G2: 4.3% (P <
Only calculated for G5: >35 lbs
0.01)
morbidly obese:
0 or weight loss, 1- Cesarean Results
15 lbs, 16-25 lbs, delivery,%: G1: 4
26-35 lbs, >35 lbs G1: 31.3% G2: 3.9
G2: 15.9% G3: 5.6
Collected from: G4: 3.1
• Routine pre- Instrumental G5: 3.8
natal care or delivery,%:
maternity NR Maternal confounders and
records effect modifiers accounted
Episiotomy,%: for in analysis:
Ascertained by: NR NR
• Not stated -
Other maternal Infant and child confounders
from medical
outcomes and effect modifiers
records
• Preeclampsia accounted for in analysis:
• Placental NR
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

C-625
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Study Design, Patient
Population, Baseline Characteristics
Study Description Inclusion/Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Caulfield et al., 1998 • Cohort • Self-reported White
• Retrospective G1: 13.3 (5.7) NR
Country and setting:
G2: 14.6 (5.1)
USA, hospital obstetric Total Study N: Black
G3: 13.6 (6.7)
database 3,870 NR
G4: 15.3 (5.4)
Enrollment Period: Group Description: G5: 12.4 (7.7) Hispanic
1987 to 1989 G1: BMI < 19.8 Black G6: 14.5 (7.3) NR
G2: BMI < 19.8 White Pregravid BMI:
Funding: Asian/Pacific Islander
G3: BMI 19.8 to 26.0 Black G1: 18.4 (1.0)
NR NR
G4: BMI 19.8 to 26.0 White G2: 18.5 (1.0)
Study Objective: G5: BMI > 26.0 Black G3: 22.7 (1.8) Other
To examine relation G6: BMI > 26.0 White G4: 22.1 (1.8) NR
between gestational
Group N: Imputed: Smoking,%:
weight gain and risk of
G1: 523 • No G1: 32.8
delivering a small for
G2: 267 G2: 20.6
gestational age and
G3: 1,479 Categorized: G3: 35.4
large for gestational
age infant by race
G4: 796 • IOM guidelines G4: 20.0
G5: 615 G5: 28.8
Time frame: G6: 190 Age (mean, yrs): G6: 25.4
1987-1989 G1: 21.7 (4.8)
Inclusion criteria: G2: 27.1 (6.6) Diabetes mellitus,%:
Duration of the • Singleton pregnancies G3: 22.7 (5.3) NR
study: • White or black ethnicity G4: 29.8 (5.8)
Entry into pn care until • Hypertension,%:
At least 28 weeks’ gestation G5: 24.9 (6.0)
delivery G6: 28.2 (5.5) G1: 4.3
• One delivery per woman G2: 3.0
(randomly chosen) Parity: G3: 6.0
• Information on G1: % primiparous: 52.4 G4: 5.7
anthropometric data G2: 55.4 G5: 11.9
Exclusion criteria: G3: 50.1 G6: 17.0
• Missing data G4: 48.0
G5: 36.9 Additional characteristics:
• Improbable data NR
• Non-black or non-white G6: 46.9
ethnicity

C-626
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR • AOR for SGA (95% CI) Good
Total weight gain: Gestational Groups: Sample selection:
G1: 13.3 (5.7) diabetes, %: G1: Underweight, BMI< 19.8 Fair
G2: 14.6 (5.1) NR G2: Normal weight, BMI 19.8-26.0
G3: 13.6 (6.7) Definition of
G3: Overweight, BMI> 26.0
G4: 15.3 (5.4) Cesarean delivery, maternal weight
G5: 12.4 (7.7) %: gain:
Black women:
G6: 14.5 (7.3) NR Fair
G4: No weight gain < IOM
Instrumental G5: No weight gain > IOM Definition of
Categorized:
delivery, %: outcomes:
• According to IOM White women:
NR Good
Collected from: G6: No weight gain < IOM
Episiotomy, %: G7: No weight gain > IOM Source of
• Routine pre-natal
NR information on
care or maternity Results: exposure,
records Other maternal AOR (95%CI) for SGA and Rate of weight gain (per outcomes, and
outcomes: 50 g/wk): confounders:
Ascertained by:
NR G1: 0.87 (0.78-0.97) Fair
• Based on last
clinically Other infant G2: 0.90 (0.84-0.96)
G3: 0.93 (0.86-1.01) Followup:
measured weight outcomes: Good
prior to delivery: NR
difference Expected Absolute Change (as % of baseline) in Analysis
between Incidence of SGA associated with modifiable risk comparability:
selfreport factors (G4-G7): Good
prepregnancy G4: -1.17 (-16)
G5: +0.97 (+13) Analysis of
weight and last
G6: -0.44 (-11) outcomes:
recorded weight
Good
G7: +0.60 (+15)Maternal confounders and effect
modifiers accounted for in analysis: Interpretation:
• Age Good
• Race Sum of
• Parity Good/Fair/Poor:
• Pre-gravid BMI 6 Good, 3 Fair, 0
• Height Poor
• Hypertension
• Provider type Final Quality
Score:
• Smoking
Good
Infant and child confounders and effect modifiers
accounted for in analysis:
Female infant

C-627
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-
gestational age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Devader et al., 2007 • Cohort • Routine pre-natal care White
• Retrospective • If missing, obtained from G1: 79.7
Country and setting: G2: 85.6
mother during postpartum
United States, birth Total Study N: G3: 85.2
hospital stay
certificate data 94,696
Pregravid BMI: Black
Enrollment period: Group Description: G1: 15.7
NR
1999 to 2001 G1: Gained less than 25 G2: 10.8
lbs Imputed: G3: 12.1
Funding:
NR
G2: Gained 25 to 35 lbs • No
G3: Gained more than 35 Hispanic
Study Objective: lbs Categorized: NR
To investigate relationship NR
Group N: Asian/Pacific Islander
between gestational Age (mean, yrs): NR
G1: 16,852
weight gain and adverse G1: Maternal age (y)
G2: 37,292
pregnancy outcomes 18 to 24*: 42.3% Other
G3: 40,552
among women with 25 to 30: 36.2% G1: 4.6
normal prepregnancy BMI Inclusion criteria: 31 to 35: 21.5% G2: 3.5
• All mothers with G2: Maternal age (y) G3: 2.7
Time frame:
1999 to 2001 normal prepregnancy 18 to 24*: 36.7% Smoking,%:
BMI (19.8 –26.0 25 to 30: 39.5% G1: 20.5
Duration of the study: kg/m2) who were 18 31 to 35: 23.8% G2: 14.9
Entry into prenatal care to 35 years of age at G3: Maternal age (y) G3: 17.4
through delivery time of delivery and 18 to 24*: 44.7%
who delivered full- 25 to 30: 35.9% Diabetes mellitus,%:
term (37 weeks or 31 to 35: 19.4% NR
more) singleton infant
Hypertension,%:
during period January Parity:
1, 1999, to December NR NR
31, 2001 Additional characteristics:
Exclusion criteria: NR
• Women aged
younger than 18
years and older than
35 years
• Non-Missouri
residents
• Preterm deliveries
• Multiple gestations

C-628
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR AOR for SGA for Women With Normal Good
Prepregnancy BMI (19.8 –26.0 kg/m2) by
Total weight gain: Gestational diabetes, GWG Category, Missouri Birth Certificates, Sample
NR %: 1999–2001 (95%CI) selection:
NR Fair
Categorized: Groups:
• According to IOM Cesarean delivery,%: G1: Gained less than 25 lbs Definition of
NR G2: Gained 25 to 35 lbs maternal weight
Collected from: gain:
• Routine pre-natal Instrumental G3: Gained more than 35 lbs
Fair
care or maternity delivery,%: Results:
records NR G1: 2.14 (2.01–2.27) Definition of
G2: 1.0 outcomes:
Ascertained by: Episiotomy,%: Good
NR NR G3: 0.48 (0.45–0.50)
Maternal confounders and effect Source of
Other maternal information on
outcomes: modifiers accounted for in analysis:
exposure,
• Figures 1 to 3 plot • Age
outcomes, and
risk for each • Race
confounders:
adverse pregnancy • Education Fair
outcome by 10-lb • Income
increments in • Alcohol use Followup:
gestational weight • Height Fair
gain. Women who • Prior pregnancy Analysis
gained 25 to 34 lbs • Inadequate prenatal care use comparability:
during their • Smoking Fair
pregnancy had
lower risks for most Infant and child confounders and effect Analysis of
outcomes when modifiers accounted for in analysis: outcomes:
balancing risk for • Child's gender Fair
SGA status and Birth year
other adverse Interpretation:
pregnancy Fair
outcomes Sum of
• Women who Good/Fair/Poor:
gained 15 to 24 lbs 2 Good, 7 Fair, 0
had lowest risks for Poor
most outcomes, but
increased their risk Final Quality
of having an SGA Score:
infant from 9.6% to Fair
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%

C-629
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year:
Devader et al., 2007
(combined)

C-630
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Other infant
outcomes:
NR

C-631
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Edwards et al., 1996 • Cohort • Self-reported White
• Retrospective G1: 103.5 G1: NR
Country and setting: G2: NR
G2: 61
USA, hospital Total Study N: G3: 69.0 (Total sample)
1,443 Pregravid BMI:
Enrollment Period: Black
1997-1993 Group Description: Imputed: G1: NR
G1: Obese • No G2: NR
Funding:
G2: Normal Weight G3: 21.0 (Total sample)
NR Categorized:
G3: total sample
Study Objective: • IOM guidelinesobese Hispanic
Group N: (> 29) and normal weight G1: NR
To compare pregnancy
G1: 683 (BMI 19.8-26.0) G2: NR
course and outcomes in
G2: 660 G3: 7.0 (Total sample)
obese and normal weight Age (mean, yrs):
women and their Inclusion criteria: G1: 27.1 Asian/Pacific Islander
associations with • Obese women and G2: 25.4 NR
gestational weight change normal weight women
identified from Parity: Other
Time frame: NR G1: NR
1997-1993 pregnancy and
delivery summary G2: NR
Duration of the study: records (normal G3: 4.0 (Total sample)
1997-1993 weight matched to Smoking,%:
obese by race, age, NR
parity)
• Singleton deliveries Diabetes mellitus,%:
• Live births NR
Exclusion criteria: Hypertension,%:
• Missing data NR
• Fetal deaths Additional characteristics:
NR

C-632
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 683 G1: 3420 • SGA Good
G2: 660 G2: 3285 P ≤ 0.001
Sample selection:
Total weight gain: Gestational Groups: Fair
G1: 9.5 diabetes,%: Maternal weight gain categories (kg) Obese >
G2: 14.5 P ≤ 0.001 NR Definition of
29:
maternal weight
G1: Lost weight/no change
Categorized: Cesarean gain:
G2: 0.5-6.5
• According to IOM delivery,%: G3: 7-11.5
Fair
G1: 25.6
Collected from: G4: 12-16 Definition of
G2: 9.1 P < 0.001
• Routine pre-natal G5: > 16 outcomes:
care or maternity Instrumental Normal BMI 19.8-26 Fair
records delivery,%: G6: < 11.5kg
G7: 11.5-16 Source of
Ascertained by: Episiotomy,%: G8: > 16kg information on
• Based on last exposure,
Other maternal Results: outcomes, and
clinically outcomes:
measured weight % SGA for Obese confounders:
NA G1: 10.7% Fair
prior to delivery
Other infant G2: 6.6%
G3: 6.0% Followup:
outcomes: Fair
NA G4: 4.0%
G5: 5.3% Analysis
P = 0.11 comparability:
Good
For Normal weight
G6: 15.9% Analysis of
G7: 7.5% outcomes:
G8: 5.7% Fair
P = 0.001 Interpretation:
Good
AOR (95%CI)
Obese Sum of
G1 vs G3 2.9 (1.1, 8.4) Good/Fair/Poor:
Normal weight 3 Good, 6 Fair, 0
G6 vs G7 1.7 (0.9,3.4) Poor
Maternal confounders and effect modifiers Final Quality
accounted for in analysis: Score:
• Age Fair
• 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

C-633
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-
gestational age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hellerstedt et al., 1997 • Cohort • Self-reported White
• Retrospective G1: 103.5 kg (13.7) G1: 68.8
Country and setting: G2: 69.1
G2: 61.1kg (5.9)
United States, medical Total Study N:
center 1,343 Pregravid BMI: Black
G1: 38.3 (4.6) G1: 20.4
Enrollment Period: Group Description: G2: 20.6
G2: 22.8 (1.6)
1977-1993 G1: Obese
G2: Normal weight Imputed: Hispanic
Funding: G1: 6.6
• No
NR Group N: G2: 6.5
G1: 683 Categorized:
Study Objective: Asian/Pacific Islander
To examine association
G2: 660 • IOM guidelines
G1: Native Am: 3.8
between infant birth Inclusion criteria: Age (mean, yrs): G2: Native Am: 3.2
outcomes and maternal • Obese and normal- G1: NR
pregravid obesity, weight women • 16-34 years: 91% Other
gestational weight gain, delivering singleton • ≥ 35 years: 8.8% NR
and prenatal smoking during study period G2: NR Smoking,%:
Time frame: Exclusion criteria: • 16-34 years: 93.5% G1: 26.4
1977 to 1993 • Missing data • ≥ 35 years: 5.8% G2: 26.2
Duration of the study: • Siblings Parity: Diabetes mellitus,%:
Entry into prenatal care • Fetal deaths G1: NR NR
until delivery • 0: 31.8%
• 1-3: 64.7% Hypertension,%:
• ≥ 4: 3.5% NR
G2: NR Additional characteristics:
• 0: 33.3% NR
• 1-3: 64.9%
• ≥ 4: 1.8%

C-634
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR SGA (%) Good
Total weight gain:
Gestational Groups Sample selection:
Categorized: diabetes, %: Fair
• According to IOM NR Maternal weight gain categories stratified by
pregravid BMI and smoking status: Definition of
Collected from: Cesarean delivery, maternal weight
• Routine pre-natal %: Obese (BMI > 29.0): gain:
care or maternity NR G1: Smokers, < IOM Fair
records G2: Smokers, within IOM
Instrumental G3: Smokers, > IOM Definition of
Ascertained by: delivery, %: outcomes:
• Based on last NR Good
G4: Nonsmokers, < IOM
clinically
G5: Nonsmokers, within IOM
measured weight Episiotomy, %: Source of
G6: Nonsmokers, > IOM information on
prior to delivery NR
exposure,
Other maternal Normal weight (BMI 19.8-26.0): outcomes, and
outcomes: G7: Smokers, < IOM confounders:
NR G8: Smokers, within IOM Fair
G9: Smokers, > IOM
Other infant Followup:
outcomes: Fair
G10: Nonsmokers, < IOM
NR
G11: Nonsmokers, within IOM
Analysis
G12: Nonsmokers, > IOM
comparability:
Good
Obese:
G13: Lost/no gain Analysis of
G14: 0.5-6.5 kg outcomes:
G15: 7-11.5 kg Good
G16: 12-16 kg
G17: > 16 kg Interpretation:
Good
Normal weight: Sum of
G18: < 11.5kg Good/Fair/Poor:
G19: 11.5-16kg 5 Good, 4 Fair, 0
G20: > 16kg Poor

Results Final Quality

Frequencies of SGA, %: Score:
G1: 13.3 Good
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

C-635
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year:
Hellerstedt et al., 1997
(continued)

C-636
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain 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-637
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Kiel et al., 2007 • Cohort • Self-reported White
• Retrospective G1: 78
Country and setting: Pregravid BMI: G2: 77
United States, birth Total Study N: G1: Total: G3: 73
registry 120,170 Class I obese: 59%
Class II obese: 25% Black
Enrollment period: Group Description: G1: 22
Class III obese: 16%
1990 to 2001 G1: Obese Class I G2: 23
(BMI 30–34.9) (n = Imputed: G3: 27
Funding:
70,536) • No
NR Hispanic
G2: Obese Class II
(BMI 35–39.9) (n = Categorized: NR
Study Objective:
To examine effect of 30,609) • NIH guidelines
Asian/Pacific Islander
gestational weight change G3: Obese Class III Age (mean, yrs): NR
on pregnancy outcomes in (BMI 40 and More) (n G1: <26: 46%
obese women = 19,025) 26-35: 47% Other
Older than 35: 8% G1: 22
Time frame: Group N:
1990 to 2001 NR G2: <26: 44% Smoking,%:
26-35: 48% NR
Duration of the study: Inclusion criteria: Older than 35: 8%
Entry into prenatal care • Obese women G3: <26: 40% Diabetes mellitus,%:
through delivery residing in Missouri 26-35: 52% NR
who delivered (at 37 Older than 35: 9%
Hypertension,%:
or more weeks of
gestation) liveborn, Parity: NR
singleton infants Nulliparous:
G1: 34% Additional characteristics:
during 1990–2001 NR
G2: 33%
Exclusion criteria: G3: 32%
• NR

C-638
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Outcomes from
Maternal Weight Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: SGA: 7 Absolute risk and OR (95% CI) of pregnancy Good
LGA:13% outcomes for various classes of obese women
Total weight gain: (P < 0.05) (class I, II, III) Sample
G1: GWG (lb) G2: SGA: 7% selection:
Less than 2: 3% LGA:16% Groups: Fair
2 to 14: 15% (P < 0.05) Maternal weight gain categories stratified by
15 to 25: 26% prepregnancy obesity status, Obese Class Definition of
G3: SGA: 6%
More than 25: 56% LGA:18% I(BMI 30–34.9), Obese Class II (BMI 35–39.9), maternal weight
G2: GWG (lb) Obese Class III (> = BMI 40): gain:
(P < 0.05) Fair
Less than 2: 8% G1: < = -10lbs
2 to 14: 22% Gestational diabetes, %: G2: -2 to -9 lbs Definition of
15 to 25: 27% NR G3: No change outcomes:
More than 25: 43% G4: 2-9 lbs Good
G3: GWG (lb)Less than Cesarean delivery,%: G5: 10-14 lbs
2: 15% G1: 28 G6: 15-25lbs Source of
G2: 34 G7: 26-35lbs information on
G3: 41 G8: > 35 lbs exposure,
Categorized: outcomes, and
Instrumental delivery,%:
• 10-lb or less loss Result: confounders:
NR For Obese Class I: AOR (95% CI) for SGA
2 to 9 lbs loss, no Fair
weight change, Episiotomy,%: were significantly greater (> 1.00, G6 was
2 to 9 lbs gain, NR reference) for G1- G5 and significantly lower for Followup:
10 to 14 lbs gain, G7-G8. Fair
15–25 lb gain, Analysis
26–35 lb gain, and For Obese Class II: AOR (95% CI) for SGA comparability:
greater than 35 lb were significantly greater (> 1.00, G6 was Fair
gain reference) for G1- G5 and significantly lower for
G7-G8 Analysis of
Collected from: outcomes:
• Routine pre-natal For Obese Class III: AOR (95% CI) for SGA Fair
care or maternity were significantly greater (> 1.00, G6 was
records Interpretation:
reference) for G1 and G3 and significantly
Poor
Ascertained by: lower for G7-G8
NR Sum of
Maternal confounders and effect modifiers
Good/Fair/Poor:
accounted for in analysis:
2 Good, 6 Fair, 1
• Age Poor
• Race
• Parity Final Quality
• Education Score:
• Poverty (enrollment in Medicaid, WIC, food Fair
stamp programs)
• Tobacco use
• Chronic hypertension
Infant and child confounders and effect
modifiers accounted for in analysis:
NR

C-639
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-
gestational age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Nielsen et al., 2006 • Cohort • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
USA, clinic Total Study N: G1: 18.3 (1.1) Black
815 G2: 22.4 (1.6) G1: 100
Enrollment Period: G2: 100
G3: 30.9 (4.6)
1990 to 2000 Group Description: G3: 100
G1: BMI < 19.8 Imputed:
Funding: Hispanic
G2: BMI 19.8-26.0 • Yes
NR NR
G3: BMI > 26.0
Categorized:
Study Objective: Asian/Pacific Islander
To examine whether such
Group N: • IOM guidelines
G1: 193 NR
weight gains improve birth Age (mean, yrs):
G2: 431
outcomes in a cohort of G1: mean age at infant birth Other
G3: 191
disadvantaged African (SD): 16.9 (1.2) NR
American adolescents Inclusion criteria: G2: 16.8 (1.1) Smoking,%:
Time frame: • Adolescents ≤ 17 G3: 17.0 (1.1) G1: 11.4
1990 to 2000 years at conception G2: 9.7
Parity:
• African American G3: 10.5
Duration of the study: % primiparous:
pregnancies
First prenatal care visit to G1: 83.9 Diabetes mellitus,%:
delivery Exclusion criteria: G2: 85.2 NR
• NA G3: 74.9
Hypertension,%:
NR
Additional characteristics:
NR

C-640
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 193 G1: 2899 (595) • SGA Good
G2: 431 G2: 3083 (645)
G3: 191 P < 0.005 compared Groups: Sample
to BMI < 19.8 G1: BMI < 19.8 selection:
Total weight gain: G3: 3181 (673) G2: BMI 19.8-26.0 Fair
G1: < IOM: 30.3%; P < 0.005 compared G3: BMI > 26.0
lower half of IOM: to BMI < 19.8 Definition of
18.1%; upper half maternal
G4: < IOM recommendation
of IOM: 21.9%; Gestational weight gain:
G5: Lower half of IOM recommendation
> IOM: 29.7% diabetes, %: Good
G6: Upper half of IOM recommendation
G2: < IOM: 31.3%; NR G7: > IOM recommendation Definition of
lower half of IOM: outcomes:
16.1%; upper half Cesarean delivery, Good
of IOM: 17.6%; %: Results:
> IOM: 35.0% NR SGA, %: Source of
G3: < IOM: 16.5%; G1: 22.3 information on
Instrumental
lower half of IOM: delivery, %: G2: 15.6 exposure,
9.4%; upper half NR G3: 11.5 outcomes, and
of IOM: 10.6%; P < 0.01 for G1-G3 confounders:
> IOM: 63.5 Episiotomy, %: Fair
NR AOR (95%CI) for SGA:
Categorized: G4: 2.31 (1.22-4.37) Followup:
• According to IOM Other maternal G5: 1.00 (reference) Good
outcomes: G6: 0.88 (0.41-1.89)
Collected from: NA Analysis
G7: 0.68 (0.34-1.35) comparability:
• Routine pre-natal P < 0.01 for G4-G7
care or maternity Other infant Good
records outcomes: Maternal confounders and effect modifiers Analysis of
• Size for accounted for in analysis:
Ascertained by: outcomes:
gestational age • Parity Fair
• Based on last (small, average, • Pre-gravid BMI
clinically large) Interpretation:
• Pre-eclampsiatime between last weight measure
measured weight • Birth weight Good
and delivery
prior to delivery: category
• Height Sum of
difference (suboptimal
between final • Smoking Good/Fair/Poo
< 3000g, optimal
recorded weight 3000-4000g, r:
Infant and child confounders and effect modifiers
within 4 weeks above optimal 6 Good, 3 Fair,
accounted for in analysis:
delivery and self- > 4000g) 0 Poor
Infant sex
reported Final Quality
prepregnancy Score:
weight Good

C-641
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Parker and Abrams, 1992 • Cohort • Self-reported White
• Retrospective G1: 56.8 kg(SD 11.0) G1: 44.0
Country and setting: G2: NR
G2: NR
USA, hospital Total Study N:
6,690 Pregravid BMI: Black
Enrollment Period: G1: 8.3
G1: Underweight: 27.7%,
Sept 1980 to Dec 1988 Group Description: G2: NR
Normal weight 61.8%,
G1: Overall Overweight: 5.6%,
Funding: Hispanic
G2: NR Obese 4.9%
UC Committee on G1: 9.4
Research & MCH and Group N: G2: NR
G2: NR
Resources Development, G1: 6,690
Imputed:
Health Resources and G2: NR Asian/Pacific Islander
• No
Services Administration G1: 21.4
Inclusion criteria: Categorized: G2: NR
Study Objective: • Consecutive live
To test whether gains • IOM guidelines Other
singleton births at
outside IOM reference Moffitt Hospital Age (mean, yrs): G1: 12.0
ranges were associated between September G1: 27.7 (5.5) G2: NR
with increased risks of 1980 and December G2: NR
suboptimal pregnancy Smoking,%:
1988 with gestational G1: 12.0
outcome (SGA, LGA, ages of 37 to 42 Parity:
cesarean delivery) and to Primiparous: G2: NR
weeks
determine whether locally G1: 58.8% Diabetes mellitus,%:
developed ranges were Exclusion criteria: G2: NR NR
more applicable to study • Maternal transfers or
population transports and Hypertension,%:
deliveries NR
Time frame: complicated by fetal
Sept 1980 to Dec 1988 Additional characteristics:
malformations,
NR
Duration of the study: maternal diabetes, or
From entry into prenatal maternal
care until delivery hypertension

C-642
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 6690 G1: 3408g (462) • SGA Good
G2: NR G2: NR
Groups: Sample
Total weight gain: Gestational G1: < IOM range selection:
G1: 15.2kg (5.2) diabetes, %: G2: Within IOM range Fair
G2: NR NR G3: > IOM
Definition of
Categorized: Cesarean delivery, maternal weight
• According to IOM %: Results: gain:
Weight gain NR AOR (95% CI) for SGA: Fair
ranges based on G1: 1.78 (1.39-2.27)
Instrumental Definition of
percentiles from G2: 1.00 (reference)
delivery, %: outcomes:
previous study of
NR Good
UC population Incidence of SGA in nonobese women, %:
with good Episiotomy, %: G1: 3.25 Source of
pregnancy NR G2: 6.14 information on
outcomes: 25th - G3: 13.11 exposure,
75th, 10-90th Other maternal outcomes, and
percentiles. For outcomes: Incidence of SGA in obese women, %: confounders:
25-75th, weight NR G1: 11.76 Fair
gain range = 12- Other infant G2: 3.09
17kg for Followup:
outcomes: Fair
underweight NR AOR of SGA and low weight gain
women (BMI UCSF 25-75 Analysis
< 19.8); 2.06 (1.62-2.63) comparability:
UCSF 10-90 Fair
Collected from: 1.82 (1.35-2.47)
• Routine pre-natal IOM Analysis of
care or maternity 1.78 (1.39-2.27) outcomes:
records Good
Ascertained by: Maternal confounders and effect modifiers Interpretation:
• Based on last accounted for in analysis: Poor
clinically • Age
measured weight Sum of
• Race Good/Fair/Poor:
prior to delivery
• Parity 3 Good, 5 Fair, 1
• Pre-gravid BMI Poor
• Height
• Maternal high and low weight gain Final Quality
• Smoking Score:
Fair
Infant and child confounders and effect modifiers
accounted for in analysis:
• Gestational age
Birth weight

C-643
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-
gestational age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stevens-Simon and • Cohort • Self-reported White
McAnarney, 1992 • Prospective G1: 58.6 (11.1) NR
G2: 160.9 (7.0)
Country and setting: Total Study N: Black
G3: 163.9 (5.5)
USA, adolescent 141 (107 included in NR
maternity program postpartum analyses) Pregravid BMI:
Hispanic
G1: 23.1 (3.5)
Enrollment Period: Group Description: NR
G2: 23.5 (4.4)
1986 to 1989 G1: Slow gainers G3: 23.5 (4.2) Asian/Pacific Islander
G2: Average gainers
Funding: NR
G3: Rapid gainers Imputed:
Grant from Bureau of
• No Other
Maternal and Child Health Group N:
NR
G1: 28 Categorized:
Study Objective:
To clarify advantages and
G2: 66 • Continuous Smoking,%:
G3: 47 NR
disadvantages of large Age (mean, yrs):
gestational weight gain Inclusion criteria: G1: 16.9 Diabetes mellitus,%:
among pregnant • Consecutively G2: 16.6 NR
adolescents enrolled poor, black, G3: 16.2
Hypertension,%:
Time frame: 12-19 year olds
Parity: NR
1986 to 1989 • Prenatal care prior to
NR
2third week gestation Additional characteristics:
Duration of the study: • No chronic disease NR
Entry into prenatal care • No regular
through 6 weeks PP medications
check up • No known uterine
anomalies
• Live birth
• Singletons
Exclusion criteria:
• NA

C-644
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28 G1: 2745 (694) Distribution of SGA,%: Good
G2: 66 G2: 3097 (457)
G3: 47 G3: 3351 (482) Groups Sample
P < 0.0001 Maternal weight gain categories (kg/wk): selection:
Total weight gain: G1: < 0.23 Poor
G1: 7.7 (average rate Gestational G2: 0.23-0.40
0.2 kg/wk) diabetes, %: Definition of
G3: > 0.40 maternal weight
G2: 12.4 (average NR
rate 0.3 kg/wk) gain:
Cesarean delivery, Results Fair
G3: 19.8 (average G1: 7.1
rate 0.5 kg/wk) %:
NR G2: 9.1 Definition of
Categorized: G3: 2.1 outcomes:
Instrumental P = NS Good
• According to
delivery, %:
IOMslow gain: Maternal confounders and effect modifiers Source of
NR
< 0.23kg/wk; accounted for in analysis: information on
average gain: Episiotomy, %: NA exposure,
0.23-0.4kg/week; NR outcomes, and
rapid gain: > Infant and child confounders and effect modifiers confounders:
0.4kg/week Other maternal accounted for in analysis: Fair
outcomes: NA
Collected from: NA Followup:
• Routine pre-natal Fair
care or maternity Other infant
records outcomes: Analysis
NA comparability:
Ascertained by: Fair
• Based on last
Analysis of
clinically
outcomes:
measured weight
Good
prior to delivery
Interpretation:
Poor
Sum of
Good/Fair/Poor:
3 Good, 4 Fair, 2
Poor
Final Quality
Score:
Fair

C-645
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-
gestational age (continued)
Study Design, Patient
Population,
Inclusion/Exclusion Baseline Characteristics
Study Description Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Cohort • Self-reported White
• Retrospective G1: 16.2
Country and setting: Pregravid BMI: G2: 35.8
USA, university hospital Total Study N: G1: < 19.8: 25.8% G3: 48.0
20465 19.8-26.0: 19.4%
Enrollment Period: Black
26.1-29.0: 9.2%
1980 to 2001 Group Description: G1: 25.5
> 29.0: 20.6%
G1: Gain below IOM G2: < 19.8: 49.1% G2: 29.4
Funding:
recommendations 19.8-26.0: 34.8% G3: 45.1
NR
G2: Gain within IOM 26.1-29.0: 23.3%
Study Objective: recommendations Hispanic
> 29.0: 25.5%
To examine relationship G3: Gain above IOM G1: 19.2
G3: < 19.8: 25.0%
between gestational recommendations G2: 34.8
19.8-26.0: 45.8%
weight gain and adverse G3: 46.0
Group N: 26.1-29.0: 67.5%
neonatal outcomes > 29.0: 53.9% Asian/Pacific Islander
G1: 4,114
among infants born at P < 0.001 G1: 24.3
G2: 7,490
term (37 weeks or more) G2: 43.3
G3: 8,861 Imputed:
Time frame: G3: 32.4
Inclusion criteria: • No
1980 to 2001 Other
• Singleton Categorized:
Duration of the study: G1: 21.7
Exclusion criteria: • IOM guidelines G2: 37.9
Entry into PN care up till
delivery • Pregnancies Age (mean, yrs): G3: 40.4
complicated by G1: < 20 years: 23.4% P for all race categories <
multiple gestations, 20-29 years: 19.3% 0.001
congenital anomalies, 30-39 years: 19.9%
chronic hypertension, Smoking,%:
> 40 years: 25.3% G1: 23.5
gestational or G2: < 20 years: 31.3%
pregestational G2: 30.8
20-29 years: 36.6% G3: 45.8 P < 0.001
diabetes 30-39 years: 37.6%
• Birth before 37 weeks > 40 years: 36.3% Diabetes mellitus,%:
• Maternal transport G3: < 20 years: 45.4% NR
• Missing data on any 20-29 years: 44.0%
of variables Hypertension,%:
30-39 years: 42.5%
considered in > 40 years: 38.4% NR
multivariable analysis P < 0.001 Additional characteristics:
Parity: NR
% Nulliparous:
G1: 17.3
G2: 36.2
G3: 46.6
P < 0.001

C-646
Evidence Table 45. Gestational weight gain with reference to IOM recommendations and small-for-gestational
age (continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4114 G1: %SGA: 36.1; %AGA: • Risk of adverse neonatal outcomes by Good
G2: 7490 20.2; %LGA: 8.5 gestational weight gain by IOM guidelines,
G3: 8861 G2: %SGA: 39.4; %AGA: Sample
adjusted ORs compared to women with GWG
37.5; %LGA: 26.5 selection:
within IOM guidelines and risk of adverse
Total weight gain: G3: %SGA: 24.5; %AGA: Good
neonatal outcomes by extremes of GWG
Categorized: 42.4; %LGA: 65.1 compared to women with weight gain 11.5- Definition of
• According to P < 0.001 16.0kg maternal
IOMpercentiles Gestational diabetes,%: weight gain:
Groups:
and dichotomous NR Fair
G1: < IOM
Collected from: G2: Within IOM Definition of
Cesarean delivery,%:
• Routine pre-natal G1: 14.7 G3: > IOM outcomes:
care or maternity G2: 32.1 G4: < 7kg Good
records G5: > 18kg
G3: 53.2 Source of
Ascertained by: Instrumental delivery,%: information on
• Based on last Results: exposure,
Operative vaginal delivery:
clinically Unadjusted Rates of SGA: outcomes, and
G1: 18.0%
measured weight G2: 37.5% G1: 11.74 P< 0.001 vs. G2 confounders:
prior to delivery G3: 44.5% G2: 7.05 Fair
G3:3.70 P< 0.001 vs. G2
Episiotomy,%: G4: 13.99 P< 0.05 vs. G2 Followup:
NR G5: 3.87 P< 0.05 vs. G2 Fair

Other maternal Analysis

AOR (95% CI) for SGA: comparability:
outcomes: G1: 1.66 (1.44-1.92)
NA Fair
G2: 1.00 (reference)
Other infant outcomes: G3: 0.51 (0.44-0.59) Analysis of
G4: 2.26 (1.76-2.90) outcomes:
• Birth trauma
Fair
• 5 min Apgar score less G5: 0.50 (0.42-0.60)
than 7 Maternal confounders and effect modifiers Interpretation:
• , Aassisted ventilation accounted for in analysis: Good
• SGA • Age Sum of
• LGA • Race Good/Fair/Poo
• NICU admission • Parity r:
• SCN admission • Pre-gravid BMI 4 Good, 5 Fair,
• Neonatal infection • Pregnancy induced hypertension 0 Poor
• Seizure • Date of delivery
• Hypoglycemia • Mode of delivery Final Quality
• Polycythemia Score:
• Length of first stage of labor
• MAS Fair
• Length of second stage of labor
• RDS • Smoking
• Tachypnea
• Hospital stay > 5 days Infant and child confounders and effect
modifiers accounted for in analysis:
• Hospital stay > 10
days • Gestational age
• Birth weight

C-647
Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Nixon et al., 1998 • Cohort • Self-reported White
• Retrospective G1: 138 (31) NR
Country and setting:
G2: 158 (36) (P < 0.0001)
USA, county nurse- Total Study N: Black
midwifery services 2,228 Pregravid BMI: NR
G1: 24 (5)
Enrollment Period: Group Description: Hispanic
G2: 26 (5.8) (P < 0.0001)
January 1991 to G1: 2500 - 3999g NR
December 1994 G2: ≥ 4000g Imputed:
Asian/Pacific Islander
• No
Funding: Group N: NR
American College of G1: 1906 Categorized:
Nurse Midwives Other
G2: 322 • Continuous IOM NR
Study Objective: guidelines
Inclusion criteria:
Smoking,%:
To compare outcomes of • Gestational age ≥ 37 Age (mean, yrs):
term infants of average NR
weeks G1: 25 (6)
birth weight with • Birth weight ≥ 2500g G2: 27.5 (6) (P < 0.0001) Diabetes mellitus,%:
outcomes of large infants • Live infant at onset of NR
using computer database Parity:
labor
% parous: Hypertension,%:
Time frame: • Birth occurred in G1: 56.3 NR
January 1991 to hospital G2: 69.9 (P < 0.00001)
December 1994 Additional characteristics:
Exclusion criteria: % shoulder dystocia:
Duration of the study: • Women with G1: 0.6
First prenatal visit through gestational diabetes G2: 5.9 (P < 0.001)
birth collected that required insulin
retrospectively therapy % NICU:
G1: 4.3
G2: 6.6 (P = ns)

C-648
Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 1906 NR Apgar scores < 7 Good
G2: 322
Gestational Groups: Sample selection:
Total weight gain: diabetes, %: NR Fair
G1: 30.7+/-15 NR
G2: 37.2+/-15 Outcomes Set 2: Definition of maternal
Cesarean delivery, Gestational weight gain not a predictor of weight gain:
(P < 0.0001)
%: Apgar scores < 7 (details NR) Fair
Categorized: NR
Maternal confounders and effect Definition of outcomes:
• Continuous
Instrumental modifiers accounted for in analysis: Good
According to IOM
delivery, %: NR
NR Source of information on
Collected from:
Infant and child confounders and effect exposure, outcomes, and
• Routine pre-natal
Episiotomy, %: modifiers accounted for in analysis: confounders:
care or maternity
NR NR Fair
records
Other maternal Followup:
Ascertained by:
outcomes: Good
• Based on last NA
clinically Analysis comparability:
measured weight Other infant Fair
prior to delivery outcomes:
Analysis of outcomes:
• Apgar scores
Fair
Interpretation:
Fair
Sum of Good/Fair/Poor:
3 Good, 6 Fair, 0 Poor
Final Quality Score:
Fair

C-649
Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stevens-Simon and • Cohort • Self-reported White
McAnarney, 1992 • Prospective G1: 58.6 (11.1) NR
G2: 160.9 (7.0)
Country and setting: Total Study N: Black
G3: 163.9 (5.5)
USA, adolescent 141 (107 included in NR
maternity program postpartum analyses) Pregravid BMI:
Hispanic
G1: 23.1 (3.5)
Enrollment Period: Group Description: NR
G2: 23.5 (4.4)
1986 to 1989 G1: Slow gainers G3: 23.5 (4.2) Asian/Pacific Islander
G2: Average gainers
Funding: NR
G3: Rapid gainers Imputed:
Grant from Bureau of
• No Other
Maternal and Child Health Group N:
NR
G1: 28 Categorized:
Study Objective:
To clarify advantages and
G2: 66 • Continuous Smoking,%:
G3: 47 NR
disadvantages of large Age (mean, yrs):
gestational weight gain Inclusion criteria: G1: 16.9 Diabetes mellitus,%:
among pregnant • Consecutively G2: 16.6 NR
adolescents enrolled poor, black, G3: 16.2
Hypertension,%:
Time frame: 12-19 year olds
Parity: NR
1986 to 1989 • Prenatal care prior to
NR
2third week gestation Additional characteristics:
Duration of the study: • No chronic disease NR
Entry into prenatal care • No regular
through 6 weeks PP medications
check up • No known uterine
anomalies
• Live birth
• Singletons
Exclusion criteria:
• NA

C-650
Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28 G1: 2745 (694) Distribution of 1- and 5-minute Apgar scores,%: Good
G2: 66 G2: 3097 (457)
G3: 47 G3: 3351 (482) Groups Sample
P < 0.0001 Maternal weight gain categories (kg/wk): selection:
Total weight gain: G1: < 0.23 Poor
G1: 7.7 (average rate Gestational G2: 0.23-0.40
diabetes, %: Definition of
0.2 kg/wk) G3: > 0.40
G2: 12.4 (average NR maternal
weight gain:
rate 0.3 kg/wk) Results
G3: 19.8 (average Cesarean delivery, Fair
%: Distribution of 1 minute Apgar score < = 4, %:
rate 0.5 kg/wk) G1: 25.0 Definition of
NR
Categorized: G2: 4.5 outcomes:
Instrumental G3: 14.9 Good
• According to
delivery, %: P = 0.02 for G1 vs. G2 or G3
IOMslow gain: Source of
NR
< 0.23kg/wk; information on
average gain: Episiotomy, %: Distribtution of 5 minute Apgar score < = 4, %: exposure,
0.23-0.4kg/week; NR G1: 3.5 outcomes, and
rapid gain: > G2: 0 confounders:
0.4kg/week Other maternal G3:0 Fair
outcomes: P = NS
Collected from: NA Followup:
• Routine pre-natal Maternal confounders and effect modifiers Fair
care or maternity Other infant accounted for in analysis:
records outcomes: NA Analysis
NA comparability:
Ascertained by: Infant and child confounders and effect modifiers Fair
• Based on last accounted for in analysis:
NA Analysis of
clinically
outcomes:
measured weight
Good
prior to delivery
Interpretation:
Poor
Sum of
Good/Fair/Poo
r:
3 Good, 4 Fair,
2 Poor
Final Quality
Score:
Fair

C-651
Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Cohort • Self-reported White
• Retrospective G1: 16.2
Country and setting: Pregravid BMI: G2: 35.8
USA, university hospital Total Study N: G1: < 19.8: 25.8% G3: 48.0
20465 19.8-26.0: 19.4%
Enrollment Period: Black
26.1-29.0: 9.2%
1980 to 2001 Group Description: G1: 25.5
> 29.0: 20.6%
G1: Gain below IOM G2: < 19.8: 49.1% G2: 29.4
Funding:
recommendations 19.8-26.0: 34.8% G3: 45.1
NR
G2: Gain within IOM 26.1-29.0: 23.3%
Study Objective: recommendations Hispanic
> 29.0: 25.5%
To examine relationship G3: Gain above IOM G1: 19.2
G3: < 19.8: 25.0%
between gestational recommendations G2: 34.8
19.8-26.0: 45.8%
weight gain and adverse G3: 46.0
Group N: 26.1-29.0: 67.5%
neonatal outcomes > 29.0: 53.9% Asian/Pacific Islander
G1: 4,114
among infants born at P < 0.001 G1: 24.3
G2: 7,490
term (37 weeks or more) G2: 43.3
G3: 8,861 Imputed:
Time frame: G3: 32.4
Inclusion criteria: • No
1980 to 2001 Other
• Singleton Categorized:
Duration of the study: G1: 21.7
Exclusion criteria: • IOM guidelines G2: 37.9
Entry into PN care up till
delivery • Pregnancies Age (mean, yrs): G3: 40.4
complicated by G1: < 20 years: 23.4% P for all race categories <
multiple gestations, 20-29 years: 19.3% 0.001
congenital anomalies, 30-39 years: 19.9%
chronic hypertension, Smoking,%:
> 40 years: 25.3% G1: 23.5
gestational or G2: < 20 years: 31.3%
pregestational G2: 30.8
20-29 years: 36.6% G3: 45.8 P < 0.001
diabetes 30-39 years: 37.6%
• Birth before 37 weeks > 40 years: 36.3% Diabetes mellitus,%:
• Maternal transport G3: < 20 years: 45.4% NR
• Missing data on any 20-29 years: 44.0%
of variables Hypertension,%:
30-39 years: 42.5%
considered in > 40 years: 38.4% NR
multivariable analysis P < 0.001 Additional characteristics:
Parity: NR
% Nulliparous:
G1: 17.3
G2: 36.2
G3: 46.6
P < 0.001

C-652
Evidence Table 46. Gestational weight gain with reference to IOM recommendations and Apgar scores
(continued)
Maternal Weight Outcomes from Bivariate
Gain Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4114 G1: %SGA: 36.1; %AGA: • Risk of adverse neonatal outcomes by Good
G2: 7490 20.2; %LGA: 8.5 gestational weight gain by IOM guidelines,
G3: 8861 G2: %SGA: 39.4; %AGA: Sample
adjusted ORs compared to women with GWG
37.5; %LGA: 26.5 selection:
within IOM guidelines and risk of adverse
Total weight gain: G3: %SGA: 24.5; %AGA: Fair
neonatal outcomes by extremes of GWG
Categorized: 42.4; %LGA: 65.1 compared to women with weight gain 11.5- Definition of
• According to P < 0.001 16.0kg maternal weight
IOMpercentiles Gestational diabetes,%: gain:
Groups:
and dichotomous NR Fair
G1: < IOM
Collected from: G2: Within IOM Definition of
Cesarean delivery,%:
• Routine pre-natal G1: 14.7 G3: > IOM outcomes:
care or maternity G2: 32.1 G4: < 7kg Good
records G5: > 18kg
G3: 53.2 Source of
Ascertained by: Instrumental delivery,%: information on
• Based on last Results: exposure,
Operative vaginal delivery:
clinically Unadjusted Rates of 5 minute Apgar score < 7: outcomes, and
G1: 18.0%
measured weight G2: 37.5% G1: 1.94 confounders:
prior to delivery G3: 44.5% G2: 1.58 Fair
G3: 2.14 (P< 0.05, G3 vs. G2)
Episiotomy,%: Followup:
NR G4: 2.39 Fair
G5: 2.16 (P< 0.05, G5 vs. G2) Analysis
Other maternal
outcomes: comparability:
AOR (95% CI) for 5 minute Apgar score < 7: Fair
NA G1: 1.18 (0.84-1.66)
Other infant outcomes: G2: 1.00 (reference) Analysis of
G3: 1.33 (1.01-1.76) outcomes:
• Birth trauma
Fair
• 5 min Apgar score less G4: 1.29 (0.70-2.39)
than 7 G5: 1.30 (0.95-1.77) Interpretation:
• , Aassisted ventilation Maternal confounders and effect modifiers Good
• SGA accounted for in analysis: Sum of
• LGA • Age Good/Fair/Poor:
• NICU admission • Race 3 Good, 6 Fair, 0
• SCN admission • Parity Poor
• Neonatal infection • Pre-gravid BMI
• Seizure • Pregnancy induced hypertension Final Quality
• Hypoglycemia • Date of delivery Score:
• Polycythemia • Mode of delivery Fair
• MAS • Length of first stage of labor
• RDS • Length of second stage of labor
• Tachypnea • Smoking
• Hospital stay > 5 days
Infant and child confounders and effect
• Hospital stay > 10
modifiers accounted for in analysis:
days
• Gestational age
Birth weight

C-653
Evidence Table 47. Gestational weight gain with reference to IOM recommendations and perinatal mortality
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bracero and Byrne, 1997 • Cohort • Self-reported White
• Retrospective G1: 92.1
Country and setting: Pregravid BMI: G2: NR
Hospital charts - Total Study N: G1: median BMI = 23.19
Maimonides Medical 20,971 (range 14.46-40.07) Black
Center, Brooklyn, NY G2: NR G1: 4.2
Group Description: G2: NR
Enrollment Period: G1: Total population Imputed:
G2: NR • No Hispanic
Funding: NR
NR Group N: Categorized:
G1: 20,971 • IOM guidelines Asian/Pacific Islander
Study Objective: G1: 0.9
G2: NR
To determine optimal Age (mean, yrs): G2: NR
weight gain in singleton Inclusion criteria: G1: % < 15 years: < 0.1;
pregnancy and evaluate • Delivery at 15-19 yrs: 4.8; Other
current recommendations Maimonides Medical 20-24: 25.1; G1: 2.1
Center 25-29: 31.1; G2: NR
Time frame:
• Singleton pregnancy 30-34: 24.3; Smoking,%:
Duration of the study: • No documentation of 35-39: 11.8; NR
Jan 1, 1987 to Jan 1, congenital anomaly, 40-44: 2.8;
1993 pregnancy was not 45-49: 0.1; Diabetes mellitus,%:
terminated by > 50: < 0.1 NR
abortion G2: NR
Hypertension,%:
• Documentation on Parity: NR
chart of prepregnancy % primigravida:
maternal weight, G1: 25.1 Additional characteristics:
amount of maternal G2: NR % married:
weight gain during G1: 12.4
pregnancy, and G2: NR
gender of infant
Additional characteristics:
Exclusion criteria: Type of service:
• Infants with any type G1: Ward, 22.5%
of congenital anomaly Private: 77.5%
(international G2: NR
classification of
Additional characteristics:
diseases (ICD-9-CM)
NR
codes 740.0-759.9

C-654
Evidence Table 47. Gestational weight gain with reference to IOM recommendations and perinatal mortality
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: r = .210 • Perinatal mortality and adverse perinatal outcome Fair
Total weight gain: correlation with
G1: % weight gain: maternal weight gain Groups: Sample selection:
lost weight, 0.4; G2: NR Maternal weight gain in relation to IOM Fair
1 to 5lbs, 0.9; recommendations:
6 to 10, 2.3; Gestational Definition of
G1: Under 17.6%
diabetes, %: maternal weight
11 to 15, 5.4; G2: Within 56.9%
16 to 20, 12.0; NR gain:
G3: Over 25.5%
21 to 25, 17.2; Fair
26 to 30, 21.1; Cesarean delivery,
%: Definition of
31 to 35, 14.8; Results:
NR outcomes:
36 to 40, 11.5; Adverse perinatal outcome %
Good
41 to 45, 6.1; G1: 14.4
Instrumental
≥ 46, 8.3 G2: 8.4 Source of
delivery, %:
G2: NR G3: 8.5 P < 0.001 information on
NR
exposure,
Categorized: Birthweight < 2500 %
Episiotomy, %: outcomes, and
G1: 10.1
• According to IOM NR confounders:
ordinal G2: 3.3
Fair
Other maternal G3: 2.5 P < 0.001
categories in 5
pound intervals outcomes: Followup:
Perinatal mortality %
Optimal weight gain Fair
G1: 1.1
Collected from: defined as 36 to 40
G2: 0.4 Analysis
• Routine prenatal pounds for
G3: 0.4 P < 0.001 comparability:
care or maternity underweight women,
records 31 to 40 pounds for Fair
Maternal confounders and effect modifiers
women of ideal accounted for in analysis: Analysis of
Ascertained by:
prepregnancy weight, NR outcomes:
• Based on last 26 to 30 pounds for Fair
clinically overweight women Infant and child confounders and effect modifiers
measured weight accounted for in analysis: Interpretation:
prior to delivery: Other infant NR Fair
using last outcomes: G4: 0.7 P = 0.298
measurement Adverse outcomes: G5: 0.6 Sum of
obtained as an • Still birth G6: 0.2 P < 0.001 Good/Fair/Poor:
outpatient • Neonatal death 1 Good, 8 Fair, 0
• Preterm Poor
delivery/low birth Final Quality
weight Score:
• Perinatal Fair
morbidity

C-655
Evidence Table 48. Gestational weight gain with reference to IOM recommendations and hypoglycemia
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hedderson et al., 2006 • Case-control • Self-reported in some White
• Retrospective cases used measured G1: 54.0
Country and setting: G2: 67.8
weight recorded in chart
USA, Kaiser Permanente Total Study N: G3: 47.6
closes to woman’s last
Medical Care Program 45,245 G4: 42.6
menstrual period but no
Enrollment Period: Group Description: more than 12 months
Black
January 1, 1996 - June G1: Controls before her last menstrual
G1: 10.0
31, 1998 G2: Macrosomia period
G2: 5.1
G3: Hypoglycemia Pregravid BMI: G3: 11.3
Funding:
G4: Hyperbilirubinemia G1: < 19.8: 13.5% G4: 4.4
R01 DK 54834 from
National Institute of Group N: 19.8-24.9: 56.4%
Hispanic
Diabetes and Digestive G1: 652 25.0-29.0: 12.4%
G1: 17.2
and Kidney Diseases, G2: 391 > 29.0: 17.6%
G2: 15.1
grant from American G3: 328 G2: < 19.8: 5.1%
G3: 20.4
Diabetes Association and G4: 432 19.8-24.9: 51.2%
G4: 15.5
Kaiser Community Benefit 25.0-29.0: 16.6%
research support Inclusion criteria: > 29.0: 27.1% Asian/Pacific Islander
• Singleton livebirth G3: < 19.8: 10.1% G1: 8.1
Study Objective: 19.8-24.9: 50.0% G2: 3.6
To examine whether Exclusion criteria:
25.0-29.0: 17.1% G3: 6.7
pregnancy weight gains • No pregestational
> 29.0: 22.9% G4: 20.1
outside IOM diabetes or history of
G4: < 19.8: 13.9%
recommendations and gestational diabetes Other
19.8-24.9: 57.9%
rates of maternal weight (screened at 24-28 G1: 10.7
25.0-29.0: 13.2%
gain are associated with weeks gestation - G2: 8.4
> 29.0: 57.1%
neonatal complications meeting National G3: 14.0
Diabetes Data Group Imputed: G4: 17.4
Time frame: criteria for GDM) • No
January 1, 1996 to June Smoking,%:
31, 1998 Categorized: G1: %nonsmoking during
• IOM guidelines pregnancy: 92.0; %smoked
Duration of the study: but quit: 4.2; %smoked 3.9
First prenatal care visit to Age (mean, yrs): G2: %nonsmoking during
30 days post delivery G1: < 25 years: 22.1% pregnancy: 90.8; %smoked
25-29: 24.2% but quit: 5.3; %smoked 4.0
30-34: 33.6% G3: %nonsmoking during
≥ 35: 20.1% pregnancy: 92.6; %smoked
G2: < 25 years: 15.9% but quit: 1.5; %smoked 5.8
25-29: 28.0% G4: %nonsmoking during
30-34: 31.7% pregnancy: 94.2; %smoked
≥ 35: 24.3% but quit: 4.9; %smoked 1.0
G3: < 25 years: 24.1%
25-29: 25.3% Diabetes mellitus,%:
30-34: 26.8% NR
≥ 35: 23.8%
G4: < 25 years: 17.1% Hypertension,%:
NR
25-29: 29.4%
30-34: 32.6% Additional characteristics:
≥ 35: 20.8% Screening glucose value less
Parity: than 140:
G1: 85.0%: > 140: 15.0%
% primiparous:
G1: 56.9 G2: 81.6%: > 140: 18.4%
G3: 81.4%: > 140: 18.6%
G2: 31.2
G4: 83.3%: > 140: 16.7%
G3: 50.0
G4: 59.3

C-656
Evidence Table 48. Gestational weight gain with reference to IOM recommendations and neonatal
hypoglycemia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR • AOR for neonatal hypoglycemia (95% CI) Good
Total weight gain:
Gestational Groups: Sample selection:
Categorized: diabetes, %: Good
G1: Rate of maternal weight gain (kg/wk): -0.26-
• According to IOM NR 0.21
Definition of
Collected from: G2: Rate of maternal weight gain (kg/wk): 0.22-
Cesarean delivery, maternal weight
• Routine pre-natal %: 0.31
gain:
care or maternity NR G3: Rate of maternal weight gain (kg/wk): 0.32-
Fair
recordsrate of 0.39
maternal weight Instrumental G4: Rate of maternal weight gain (kg/wk): 0.40- Definition of
gain was delivery, %: 1.03 outcomes:
calculated as NR Good
Results:
total pregnancy G1: 0.87 (0.57-1.32)
Episiotomy, %: Source of
weight gain G2: 1.00
NR information on
minus infant birth G3: 0.74 (0.49-1.14) exposure,
weight divided by Other maternal G4: 1.91 (1.33-2.82) outcomes, and
weeks of outcomes: confounders:
gestation when NA Below IOM recommendations Fair
last weight was 0.91 (0.59-1.41)
measured; rate Other infant Within IOM recommendations Followup:
of maternal outcomes: Fair
NA 1.00
weight gain Above IOM recommendations
before the third Analysis
1.39 (1.02-1.90) comparability:
trimester was
calculated using Maternal confounders and effect modifiers Good
the weight accounted for in analysis: Analysis of
measured at or • Age outcomes:
before the • Race Fair
screening test for • Parity
GDM (24-28 wks • Pre-gravid BMI Interpretation:
of gestation) Good
• Screening glucose value from 1 hour after
minus 50g oral glucose challenge test Sum of
prepregnancy • Difference between age at delivery and Good/Fair/Poor:
weight divided by gestational age at last weight measured 5 Good, 4 Fair, 0
weeks of Poor
gestation Infant and child confounders and effect
modifiers accounted for in analysis: Final Quality
Ascertained by: NR Score:
• Based on last Good
clinically
measured weight
prior to delivery:
difference
between final
recorded weight
at last prenatal
visit (within 2
weeks of delivery
date) and
prepregnancy
weight

C-657
Evidence Table 48. Gestational weight gain with reference to IOM recommendations and neonatal
hypoglycemia (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Cohort • Self-reported White
• Retrospective G1: 16.2
Country and setting: Pregravid BMI: G2: 35.8
USA, university hospital Total Study N: G1: < 19.8: 25.8% G3: 48.0
20465 19.8-26.0: 19.4%
Enrollment Period: Black
26.1-29.0: 9.2%
1980 to 2001 Group Description: G1: 25.5
> 29.0: 20.6%
G1: Gain below IOM G2: < 19.8: 49.1% G2: 29.4
Funding:
recommendations 19.8-26.0: 34.8% G3: 45.1
NR
G2: Gain within IOM 26.1-29.0: 23.3%
Study Objective: recommendations Hispanic
> 29.0: 25.5%
To examine relationship G3: Gain above IOM G1: 19.2
G3: < 19.8: 25.0%
between gestational recommendations G2: 34.8
19.8-26.0: 45.8%
weight gain and adverse G3: 46.0
Group N: 26.1-29.0: 67.5%
neonatal outcomes > 29.0: 53.9% Asian/Pacific Islander
G1: 4,114
among infants born at P < 0.001 G1: 24.3
G2: 7,490
term (37 weeks or more) G2: 43.3
G3: 8,861 Imputed:
Time frame: G3: 32.4
Inclusion criteria: • No
1980 to 2001 Other
• Singleton Categorized:
Duration of the study: G1: 21.7
Exclusion criteria: • IOM guidelines G2: 37.9
Entry into PN care up till
delivery • Pregnancies Age (mean, yrs): G3: 40.4
complicated by G1: < 20 years: 23.4% P for all race categories <
Quality: multiple gestations, 20-29 years: 19.3% 0.001
Fair congenital anomalies, 30-39 years: 19.9%
chronic hypertension, Smoking,%:
> 40 years: 25.3% G1: 23.5
gestational or G2: < 20 years: 31.3%
pregestational G2: 30.8
20-29 years: 36.6% G3: 45.8 P < 0.001
diabetes 30-39 years: 37.6%
• Birth before 37 weeks > 40 years: 36.3% Diabetes mellitus,%:
• Maternal transport G3: < 20 years: 45.4% NR
• Missing data on any 20-29 years: 44.0%
of variables Hypertension,%:
30-39 years: 42.5%
considered in > 40 years: 38.4% NR
multivariable analysis P < 0.001 Additional characteristics:
Parity: NR
% Nulliparous:
G1: 17.3
G2: 36.2
G3: 46.6
P < 0.001

C-658
Evidence Table 48. Gestational weight gain with reference to IOM recommendations and neonatal
hypoglycemia (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4114 G1: %SGA: 36.1; %AGA: AOR for neonatal hypoglycemia (95% CI) Good
G2: 7490 20.2; %LGA: 8.5
G3: 8861 G2: %SGA: 39.4; %AGA: Groups: Sample
37.5; %LGA: 26.5 G1: Below IOM guidelines selection:
Total weight gain: G3: %SGA: 24.5; %AGA: G2: Within IOM guidelines Fair
42.4; %LGA: 65.1 G3: Above IOM guidelines
Categorized: Definition of
• According to P < 0.001 maternal
IOMpercentiles Gestational diabetes,%: Results weight gain:
and dichotomous NR Hypoglycemia Fair
G1: 1.02 (0.64–1.62)
Collected from: Cesarean delivery,%: G2: 1.0 Definition of
• Routine pre-natal G1: 14.7 G3: 1.52 (1.06–2.16) outcomes:
care or maternity G2: 32.1 Good
records G3: 53.2 Maternal confounders and effect modifiers
accounted for in analysis: Source of
Ascertained by: information on
Instrumental delivery,%: • Age
• Based on last Operative vaginal exposure,
• Race
clinically delivery: outcomes, and
• Parity confounders:
measured weight G1: 18.0%
• Pre-gravid BMI Fair
prior to delivery G2: 37.5%
• Pregnancy induced hypertension
G3: 44.5% • Date of delivery Followup:
Episiotomy,%: • Mode of delivery Fair
NR • Length of first stage of labor Analysis
• Length of second stage of labor comparability:
Other maternal • Smoking
outcomes: Fair
NA Infant and child confounders and effect Analysis of
modifiers accounted for in analysis: outcomes:
Other infant outcomes:
• Gestational age Fair
• Birth trauma Birth weight
• 5 min Apgar score Interpretation:
less than 7 Good
• Assisted ventilation
Sum of
• SGA
Good/Fair/Poo
• LGA
r:
• NICU admission 3 Good, 6 Fair,
• SCN admission 0 Poor
• Neonatal infection
• Seizure Final Quality
• Hypoglycemia Score:
• Polycythemia Fair
• MAS
• RDS
• Tachypnea
• Hospital stay > 5
days
• Hospital stay > 10
days

C-659
Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to
neonatal intensive care
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stevens-Simon and • Cohort • Self-reported White
McAnarney, 1992 • Prospective G1: 58.6 (11.1) NR
G2: 160.9 (7.0)
Country and setting: Total Study N: Black
G3: 163.9 (5.5)
USA, adolescent 141 (107 included in NR
maternity program postpartum analyses) Pregravid BMI:
Hispanic
G1: 23.1 (3.5)
Enrollment Period: Group Description: NR
G2: 23.5 (4.4)
1986 to 1989 G1: Slow gainers G3: 23.5 (4.2) Asian/Pacific Islander
G2: Average gainers
Funding: NR
G3: Rapid gainers Imputed:
Grant from Bureau of
• No Other
Maternal and Child Health Group N:
NR
G1: 28 Categorized:
Study Objective:
To clarify advantages and
G2: 66 • Continuous Smoking,%:
G3: 47 NR
disadvantages of large Age (mean, yrs):
gestational weight gain Inclusion criteria: G1: 16.9 Diabetes mellitus,%:
among pregnant • Consecutively G2: 16.6 NR
adolescents enrolled poor, black, G3: 16.2
Hypertension,%:
Time frame: 12-19 year olds
Parity: NR
1986 to 1989 • Prenatal care prior to
NR
2third week gestation Additional characteristics:
Duration of the study: • No chronic disease NR
Entry into prenatal care • No regular
through 6 weeks PP medications
check up • No known uterine
anomalies
• Live birth
• Singletons
Exclusion criteria:
• NA

C-660
Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to
neonatal intensive care (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28 G1: 2745 (694) • Admission to NICU (%) Good
G2: 66 G2: 3097 (457)
G3: 47 G3: 3351 (482) Groups: Sample
P < 0.0001 Maternal weight gain categories (kg/wk): selection:
Total weight gain: G1: < 0.23 (slow gainers) Poor
G1: 7.7 (average rate Gestational G2: 0.23-0.40 (average gainers)
diabetes, %: Definition of
0.2 kg/wk) G3: > 0.40 (ra[od gainers)
G2: 12.4 (average NR maternal
Results: weight gain:
rate 0.3 kg/wk)
G3: 19.8 (average Cesarean delivery, G1: 28.6 Fair
%: G2: 15.2
rate 0.5 kg/wk) Definition of
NR G3: 8.5 P = 0.1 for infants of slow gainers vs. all other
Categorized: outcomes:
infants
Instrumental Good
• According to
delivery, %: Maternal confounders and effect modifiers
IOMslow gain: Source of
NR accounted for in analysis:
< 0.23kg/wk; information on
average gain: NA
Episiotomy, %: exposure,
0.23-0.4kg/week; NR Infant and child confounders and effect modifiers outcomes, and
rapid gain: > accounted for in analysis: confounders:
0.4kg/week Other maternal Fair
NA
outcomes:
Collected from: NA Followup:
• Routine pre-natal Fair
care or maternity Other infant
records outcomes: Analysis
NA comparability:
Ascertained by: Fair
• Based on last
Analysis of
clinically
outcomes:
measured weight
Good
prior to delivery
Interpretation:
Poor
Sum of
Good/Fair/Poo
r:
3 Good, 4 Fair,
2 Poor
Final Quality
Score:
Fair

C-661
Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to
neonatal intensive care (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stotland et al., 2006 • Cohort • Self-reported White
• Retrospective G1: 16.2
Country and setting: Pregravid BMI: G2: 35.8
USA, university hospital Total Study N: G1: < 19.8: 25.8% G3: 48.0
20465 19.8-26.0: 19.4%
Enrollment Period: Black
26.1-29.0: 9.2%
1980 to 2001 Group Description: G1: 25.5
> 29.0: 20.6%
G1: Gain below IOM G2: < 19.8: 49.1% G2: 29.4
Funding:
recommendations 19.8-26.0: 34.8% G3: 45.1
NR
G2: Gain within IOM 26.1-29.0: 23.3%
Study Objective: recommendations Hispanic
> 29.0: 25.5%
To examine relationship G3: Gain above IOM G1: 19.2
G3: < 19.8: 25.0%
between gestational recommendations G2: 34.8
19.8-26.0: 45.8%
weight gain and adverse G3: 46.0
Group N: 26.1-29.0: 67.5%
neonatal outcomes > 29.0: 53.9% Asian/Pacific Islander
G1: 4,114
among infants born at P < 0.001 G1: 24.3
G2: 7,490
term (37 weeks or more) G2: 43.3
G3: 8,861 Imputed:
Time frame: G3: 32.4
Inclusion criteria: • No
1980 to 2001 Other
• Singleton Categorized:
Duration of the study: G1: 21.7
Exclusion criteria: • IOM guidelines G2: 37.9
Entry into PN care up till
delivery • Pregnancies Age (mean, yrs): G3: 40.4
complicated by G1: < 20 years: 23.4% P for all race categories <
multiple gestations, 20-29 years: 19.3% 0.001
congenital anomalies, 30-39 years: 19.9%
chronic hypertension, Smoking,%:
> 40 years: 25.3% G1: 23.5
gestational or G2: < 20 years: 31.3%
pregestational G2: 30.8
20-29 years: 36.6% G3: 45.8 P < 0.001
diabetes 30-39 years: 37.6%
• Birth before 37 weeks > 40 years: 36.3% Diabetes mellitus,%:
• Maternal transport G3: < 20 years: 45.4% NR
• Missing data on any 20-29 years: 44.0%
of variables Hypertension,%:
30-39 years: 42.5%
considered in > 40 years: 38.4% NR
multivariable analysis P < 0.001 Additional characteristics:
Parity: NR
% Nulliparous:
G1: 17.3
G2: 36.2
G3: 46.6
P < 0.001

C-662
Evidence Table 49. Gestational weight gain with reference to IOM recommendations and admission to
neonatal intensive care (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 4114 G1: %SGA: 36.1; %AGA: • Risk of adverse neonatal outcomes by Good
G2: 7490 20.2; %LGA: 8.5 gestational weight gain by IOM
G3: 8861 G2: %SGA: 39.4; %AGA: Sample
guidelines, adjusted ORs compared to
37.5; %LGA: 26.5 selection:
women with GWG within IOM guidelines
Total weight gain: G3: %SGA: 24.5; %AGA: Good
and risk of adverse neonatal outcomes
Categorized: 42.4; %LGA: 65.1 by extremes of GWG compared to Definition of
• According to P < 0.001 women with weight gain 11.5-16.0kg maternal
IOMpercentiles Gestational diabetes,%: weight gain:
Groups:
and dichotomous NR Fair
G1: < IOM
Collected from: G2: Within IOM Definition of
Cesarean delivery,%:
• Routine pre-natal G1: 14.7 G3: > IOM outcomes:
care or maternity G2: 32.1 G4: < 7kg Good
records G5: > 18kg
G3: 53.2 Source of
Ascertained by: Instrumental delivery,%: information on
• Based on last Results: exposure,
Operative vaginal
clinically AOR (95% CI) for NICU admission: outcomes, and
delivery:
measured weight G1: 18.0% G1: 0.66 (0.46-0.96) confounders:
prior to delivery G2: 37.5% G2: 1.03 (0.79-1.35) Fair
G3: 0.50 (0.23-1.12)
G3: 44.5% Followup:
Episiotomy,%: G4: 0.66 (0.46-0.96) Fair
NR G5: 1.03 (0.79-1.35) Analysis
Other maternal comparability:
outcomes: Maternal confounders and effect Fair
NA modifiers accounted for in analysis: Analysis of
• Age outcomes:
Other infant outcomes:
• Race Fair
• Birth trauma
• Parity
• 5 min Apgar score Interpretation:
• Pre-gravid BMI
less than 7 Good
• Pregnancy induced hypertension
• , Aassisted ventilation
• Date of delivery Sum of
• SGA
• Mode of delivery Good/Fair/Poo
• LGA
• Length of first stage of labor r:
• NICU admission 4 Good, 5 Fair,
• Length of second stage of labor
• SCN admission 0 Poor
• Smoking
• Neonatal infection
• Seizure Infant and child confounders and effect Final Quality
• Hypoglycemia modifiers accounted for in analysis: Score:
• Polycythemia • Gestational age Fair
• MAS • Birth weight
• RDS
• Tachypnea
• Hospital stay > 5
days
• Hospital stay > 10
days

C-663
Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight
status
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Oken et al., 2007 • Cohort • Self-reported White
• Prospective G1: 74%
Country and setting: Pregravid BMI:
Reported elsewhere Total Study N: G1: 24.6 (SD 5.0) Black
1,044 G1: 11%
Enrollment period: Imputed:
NR Group Description: • No Hispanic
G1: Total G1: 6%
Funding: Categorized:
Supported by grants from Group N: • IOM guidelines Other
US National Institutes of G1: 1,044 G1: 10%
Health (HD 34568, HL Age (mean, yrs):
64925, HL68041, HD Inclusion criteria: G1: 15-24: 6% Smoking,%:
44807), the Robert Wood Women delivering live 25-34: 62% G1: Never: 67%
Johnson Foundation, singleton infant and 35-44: 32% Quit before pregnancy 20%
Harvard Medical School, enrolled for continuation Smoked in early pregnancy 10%
and Harvard Pilgrim of study beyond 6 months Parity:
G1: Nulliparous: 48% Diabetes mellitus,%:
Health Care Foundation after delivery
Parous: 52% G1: 4%
Study Objective: Exclusion criteria:
Purpose of study to • Missing information
examine associations of on prepregnancy
gestational weight gain weight, parental BMI,
with child adiposity or infant birthweight,
or who did not have a
Time frame: weight recorded
NR within 4 weeks
Duration of the study: preceding delivery
Entry to prenatal care thru
delivery

C-664
Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight
status (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR NR • Association of MWG with Good
child adiposity-related
Total weight gain: Gestational Sample selection:
outcomes at age 3 years,
G1: 15.6 kg (5.4) diabetes, %: Fair
before and after adjustment
G1: 4%
Categorized: for potential confounding Definition of maternal weight
• Continuous Cesarean and pathway variables. gain:
According to IOM delivery,%: Effect increments are for Fair
G1: 23% IOM weight gain categories
Collected from: G2: 12% Definition of outcomes:
• Routine pre-natal G3: 35% Groups: Good
care or maternity G4: 53% G1: Inadequate gestational
weight gain Source of information on
records
Instrumental G2: Adequate weight gain exposure, outcomes, and
Ascertained by: delivery,%: G3: Excessive weight gain confounders:
• Based on last NR Good
clinically Results:
Followup:
measured weight Episiotomy,%: AOR of having overweight Fair
prior to delivery NR (< 95th percentile) child
Other maternal G1: 1.0 Analysis comparability:
outcomes: G2: 3.77 (1.38, 10.27) Fair
NR G3: 4.35 (1.69, 11.24) Analysis of outcomes:
Other infant AOR of having child between Fair
outcomes: 85-94th percentile Interpretation:
NR G1: 1.0 Good
G2: 2.09 (1.12, 3.92)
G3: 2.03 (1.11, 3.72) Sum of Good/Fair/Poor:
4 Good, 5 Fair, 0 Poor
AOR of having child between
50th-84th percentile Final Quality Score:
G1: 1.0 Fair
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

C-665
Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight
status (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Oken et al., 2007
continued

C-666
Evidence Table 50. Gestational weight gain with reference to IOM recommendations and childhood weight
status (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Infant and child confounders
and effect modifiers
accounted for in analysis:
• Birth length
• Sex
• Child diet
• Child television viewing

C-667
Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation
performance
Study Design, Patient
Population, Inclusion/ Baseline Baseline Characteristics
Study Description Exclusion Criteria Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Baker et al, • Cohort • Self-reported NR
2007 • Prospective •
Smoking,%:
Country and setting: Total Study N: Pregravid BMI: G1: 18.0 (37,430)
Denmark, birth registry 37,459 • G1: 23.6 +/ 4.2 Diabetes mellitus,%:
Enrollment period: Group Description: Imputed: NR
4 years - 1999 to 2002 NR • No Hypertension,%:
Funding: Group N: Categorized: NR
Data analysis supported G1: 37,459 • WHO International
by Hatch Taskforce
grantNYC399405 (to Inclusion criteria:
KMR) and a grant from • Delivered of liveborn, Age (mean, yrs):
the Einaudi Center at singleton infant G1: 30.5 (4.22)
CornellUniversity (to Exclusion criteria: Parity:
JLB). JLB was • Subjects who were G1: 46.7 % primiparous
supported by National aged 18 y or 45 y (n 40) (37,429)
Institutes of
• Preexisting or
Healthtraining grant
gestational diabetes (n:
HD07331 (to KMR).
554)
Study Objective: • Chose to not breastfeed
To determine whether (n: 745)
this association was • Used alternative
stronger with increasing breastfeeding method
maternal obesity, was (e.g., breast pump only
modified by gestational or feeding infant banked
weight gain, and still human milk; n: 14),
existed when there was whose infant was born
greater preterm (gestation 259
social support for d; n: 1,316) or at a very
breastfeeding low birth weight (2000
g; n: 29)
Time frame:
• Infant had birth defect,
4 years - 1999 to 2002
severe illness, or other
Duration of the study: condition that might
Entry into prenatal care preclude successful
through 18 months breastfeeding (as
postpartum 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

C-668
Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 37 459 G1: 3.64 +/ 0.49 Any breastfeeding or full Good
breastfeeding
Total weight gain: Gestational Sample selection:
G1: 15.1kg +/ 6.0 diabetes, %: Groups Good
NR G1:<8 kg
Categorized: G2:8-15.9 kg Definition of maternal
• < 8 kg Cesarean G3:>=16 kg weight gain:
• 8-15.9 kg delivery,%: Fair
• ≥ 16 kg NR Results
Overall higher risk of Definition of outcomes:
Collected from: Instrumental terminating full or any Good
• Self-reported delivery,%: breastfeeding with higher
NR Source of information on
Ascertained by: pregravid BMI. exposure, outcomes, and
• Self-reported Episiotomy,%: Unadjusted RR full BF confounders:
NR G1:1.13 (95%1.08, 1.18) Poor
Other maternal G2: NR Followup:
outcomes G3:1.05 (1.03, 1.08) Good
• GWG Any BF Analysis comparability:
increased G1:RR 1.16 (1.11, 1.22) Good
odds of G2: NR
termination of G3:1.05 (1.03, 1.08). Analysis of outcomes:
breastfeeding GWG not a predictor of full Good
inconsistently. or any when BMI was in the
Significant for Interpretation:
model. Good
termination of
full Maternal confounders and Sum of Good/Fair/Poor:
breastfeeding effect modifiers 7 Good, 1 Fair, 1 Poor
at 1 (P 0.0001), accounted for in analysis:
16 (P < 0.05), • Pre-gravid BMI Final Quality Score:
and 20 (P < Fair
0.05) wk. Infant and child
Significant for confounders and effect
termination of modifiers accounted for in
any analysis:
breastfeeding • NR
only at 16 and
20 wk (P
0.0001 for
both)
Other infant
outcomes
NR

C-669
Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Li et al., 2003 • WIC mother and Self-reported White
child data sets that G1: 69.9%
Country and setting: Pregravid BMI: G2: NR
were linked
USA, WIC clinics G1: BMI before pregnancy
• Retrospective
(in kg/m2) Black
Enrollment Period: Underweight (< 19.8) G1: 17.9
Total Study N:
1996 to 1998 7591 (14.8%) G2: NR
51,329
Funding: Normal (19.8¨C26.0)
Group Description: 24417 (47.6%) Hispanic
Conducted by staff at G1: 9.7
G1: Total Group Overweight (>
CDC G2: NR
(multiple logistic 26.0¨C29.0) 6836
Study Objective: regression) (13.3%) Asian/Pacific Islander
To test hypothesis that G2: NR Obese (> 29.0) 12485 NR
women who are obese (24.3%)
Group N:
before pregnancy or G2: NR Other
G1: 51329
who gain excessive G1: 2.5
G2: NR Imputed:
weight during G2: NR
pregnancy are less Inclusion criteria: • No
likely to initiate and Smoking,%:
• Low income US Categorized: G1: 27.1
maintain breast-feeding women and • IOM guidelines G2: NR
than are their normal- children
weight counterparts participating in Age (mean, yrs): Diabetes mellitus,%:
federally funded G1: Maternal age NR
Time frame:
public health < 20 y 9631 (18.8%)
1996 to 1998 Hypertension,%:
programs such as 20¨C24 y 18 256
Duration of the study: WIC (35.6%) NR
From entry into WIC for 25¨C29 y 13 251 Additional characteristics:
mom until 1 yr Exclusion criteria: (25.8%) NR
postpartum or she stops • Multiple births ¡Ý30 y 10 191 (19.9%)
BF • Records with G2: NR
missing data for
pregravid BMI, Parity:
gestational weight G1: Multiparous 27897
gain, characteristics (54.3%) Primiparous 23432
of children, (45.7%)
characteristics of G2: NR
mother,
breastfeeding
initiation
information
• Biologically
implausible values
for BW, gestational
age, maternal BMI,
maternal age, parity

C-670
Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 51329 G1: Low (< 2500 g) Adjusted OR for failure to Good
G2: NR 3432 (6.7%) initiate breast feeding by
Normal (¡Ý2500 g) BMI Sample selection:
Total weight gain: 47897 (93.3%) Fair
G1: Gestational G2: NR Groups
weight gain G1:<IOM Definition of maternal
Below IOM 15888 Gestational G2: within IOM weight gain:
(31.0%) diabetes, %: G3:>IOM BMI before Poor
Within IOM 13634 NR pregnancy: Underweight < Definition of outcomes:
(26.6%) 19.8 Good
Above IOM 21 807 Cesarean delivery,
(42.5%) %: Results Source of information on
G2: NR NR Under, normal and exposure, outcomes, and
overweight G1 groups had a confounders:
Categorized: Instrumental significant increased odds of
delivery, %: Poor
• According to failure to initiate BF
NR compared to G2 within BMI Followup:
IOM
Episiotomy, %: strata. Obese women Good
Collected from: regardless of weight gain
NR Analysis comparability:
• Self- had increased odds of
reportedself- Other maternal Fair
failure to initiate compared
reported by outcomes: to normal wt G2. Analysis of outcomes:
subjects at the NR Fair
postpartum Adjusted mean duration of
visit Other infant BF (p<0.01)* Interpretation:
outcomes: G1:12.9 wk* Good
Ascertained by: NR G2:13.6 wk (ref)
• Self-reported Sum of Good/Fair/Poor:
G3:12.8wk*
4 Good, 3 Fair, 2 Poor
Maternal confounders and
Final Quality Score:
effect modifiers
Fair
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

C-671
Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rasmussen et al., 2002 • Cohort • Routine pre-natal care White
• Retrospective NR
Country and setting: Pregravid BMI:
USA, hospital Total Study N: Black
Imputed: NR
2,494
Enrollment Period: • No
Jan 1988 ti Dec 1997 Group Description: Hispanic
Categorized: NR
Funding: Group N: • IOM guidelines
NR Asian/Pacific Islander
Inclusion criteria: Age (mean, yrs): NR
Study Objective: • 19 to 40 year old NR
To examine how women delivering Other
gestational weight gain singleton infants at Parity: NR
might modify Mary Imogene NR
association between Smoking,%:
Bassett Hospital in NR
prepregnant bmi and Cooperstown, NY
lactational performance who attempted to Diabetes mellitus,%:
Time frame: BF at delivery and NR
Jan 1988 to Dec 1997 for whom complete
Hypertension,%:
data were available
Duration of the study: NR
Entry into prenatal care Exclusion criteria:
Additional characteristics:
through child’s second • Contraindications
NR
year for BF, gestational
DM, underweight
(BMI < 19.8) at
conceptioni or lost
weight during
pregnancy

C-672
Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Maternal Weight Outcomes from Outcomes from
Gain Bivariate Analysis Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR OR unsuccessful initiation of Good
Total weight gain: BF (normal wt G2 ref)
Gestational Sample selection:
Categorized: diabetes, %: Groups Fair
• According to NR G1:<IOM
IOM G2 within IOM Definition of maternal
Cesarean delivery, G3:>IOM weight gain:
Collected from: %: Fair
• Routine pre- NR Results
natal care or Underweight: no significant Definition of outcomes:
maternity Instrumental diff Poor
records delivery, %: Normal wt: G3 1.66
NR Source of information
Ascertained by: (1.05,2.63) on exposure,
• Based on last Episiotomy, %: Overwt: no significant diff outcomes, and
clinically NR Obese: G3 2.89 (1.78, 4.69) confounders:
measured Hazard OR discontinuing Fair
Other maternal
weight prior to outcomes: exclusive BF Followup:
delivery: weight NR (normal wt G2 ref) Good
at delivery Underwt G3 1.39 (1.01, 1.92)
minus Other infant Normal wt-no signif Analysis
prepregnancy outcomes: differences comparability:
weight NR Overwt G3 1.27 (1.03, 1.56) Fair
Obese G1:1.37 (1.01, 1.84), Analysis of outcomes:
G2 1.50 (1.11, 2.03), G3:1.78 Fair
(1.48, 2.14)
Interpretation:
Hazard OR discontinuing any Poor
BF
(normal wt G2 ref) Sum of
Underwt-no sign difference Good/Fair/Poor:
Normal wt-no sign difference 2 Good, 5 Fair, 2 Poor
Overwt- no sign difference
Final Quality Score:
Obese G2 1.57 (1.14, 2.18),
Fair
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

C-673
Evidence Table 51. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hilson et al., 2006 • Cohort Self-reported White
• Retrospective G1: 51.2 +/-4.9 NR
Country and setting: G2: 61.5 +/-6.8
USA, hospital Total Study N: G3: 73.9 +/- 6.5 Black
2,783 G4: 90.4 +/-13.6 NR
Enrollment Period:
Jan 1988 to Dec 1997 Group Description: G5: 66.8(17.9)/ 63.2(13.1) Hispanic
G1: Underweight BMI < G6: 70.2(14.7) NR
Funding:
19.8 Pregravid BMI:
NIH and USDA-Hatch Asian/Pacific Islander
G2: Normal BMI 19.8- G1: 18.6 +/- 0.9 NR
Study Objective: 26.0 G2: 22.7 +/-1.7
To determine whether G3: Overweight 26.1- G3: 27.4 +/- 0.9 Other
GWG was 29.0 G4: 33.7 +/- 4.1 NR
independently G4: Obese > 29.0 G5: 24.9(6.4) / 23.4(4.5)
associated with initiation G5: < IOM/ Within IOM Smoking,%:
G6: 25.8(5.2) Before pg:
and continuation of BF G6: > IOM
and whether GWG Imputed: G1: 22.2%
Group N: • No G2: 18.5
modified previously
G1: 364 G3: 20.3
observed association
G2: 1522 Categorized: G4: 19.9
between high
G3: 354 • IOM guidelines G5: 24.0/18.8
prepregnant BMI and
G4: 543 G6: 18.4
these outcomes Age (mean, yrs):
G5: 520/ 877
G6: 1386 G1: 27.3 +/- 5.1 Diabetes mellitus,%:
Time frame:
G2: 28.5 +/- 5.1 NR
Jan 1988 to Dec 1997
Inclusion criteria: G3: 28.0 +/-4.8
Hypertension,%:
Duration of the study: • Mother-infant dyads G4: 27.9 +/-4.9
From entry into PNC in which BF was G5: 27.8(5.0) / 28.9 (5.0) NR
through 1 year of life but ever attempted and G6: 27.9 (5.0) Additional characteristics:
all based on medical to those thought to Vaginal delivery:
Parity:
record info have a low potential G1: 93.1%
G1: Nulliparous (%) 44.6
for G2: 90.2%
G2: Nulliparous (%) 37.6
contraindications to G3: 85.9%
G3: Nulliparous (%) 39.4
BF G4: 80.5%
G4: Nulliparous (%) 34.1
• Mothers also had to G5: 91.7/89.7
G5: 29.1%/33.9%
be 19–49 y old and G6: 85.8
G6: 44.1%
free of gestational
diabetes Additional characteristics:
• Singleton births NR
• Had information for
all key variables
analysed in present
study
Exclusion criteria:
See above

C-674
Evidence Table 50. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 364 G1: 3469 g (SD 462) • The predicted duration of EBF was Good
G2: 1,522 G2: 3602 P < 0.01 from 1 wk shorter for underweight and
G3: 354 underweight group Sample selection:
overweight women whose GWG
G4: 543 G3: 3662 P < 0.01 from Good
was above IOM recommendations
G5: 520/877 underweight and 3 wk shorter for obese women Definition of maternal
G6: 1,386 G4: 3703 P < 0.01 from whose GWG was above IOM weight gain:
underweight group; P recommendation (Fig. 2) Fair
Total weight gain: < 0.01 from normal • For obese women, predicted
G1: 15.7 +/-4.7 G5: 3413 g(462)/ 3571 Definition of
duration of ABF was 17 wk shorter
G2: 15.8 +/- 3.4 g(455) P < 0.01 outcomes:
among those who gained within
G3: 15.0 +/- 6.1 G6: 3713 ( Good
IOM recommendation and 20 wk
G4: 11.6 +/-7.2
shorter among those who gained Source of information
P < 0.01 from Gestational diabetes, %:
above IOM recommendation than on exposure,
underweight NR
among women in reference group outcomes, and
group; P < 0.01
Cesarean delivery, %: (Fig. 2) confounders:
from normal;
P < 0.01 from NR Fair
Groups:
overweight Instrumental delivery, G1: Underweight BMI < 19.8 Followup:
group %: G2: Normal BMI 19.8-26.0 Good
G5: 7.5 (4.1)/13.1 NR G3: Overweight 26.1-29.0
(2.6) P < 0.01) G4: Obese > 29.0 Analysis
G6: 18.7 (5.0) Episiotomy, %: G5: < IOM/ Within IOM comparability:
P < 0.01 NR G6: > IOM Fair
Categorized: Other maternal Results: Analysis of outcomes:
• According to outcomes: Good
IOM • Initiated BF,%: Underweight BMI
Underweight 89, G1: 1.21 (0.53, 2.76) Interpretation:
Collected from: Normal 90.1, G2: 1.59 (0.82, 3.07) Good
• Routine pre- Overweight 88.4, G3: 1.88 (0.91, 3.92) Sum of
natal care or Obese 82.58 G4: 1.31 (0.995, 1.71) Good/Fair/Poor:
maternity (P < .05, P < 0.01 G5: 1.04 (0.82, 1.31) 6 Good, 3 Fair, 0 Poor
records from normal weight G6: 1.39 (1.01, 1.92)
group), < IOM 87.9, Final Quality Score:
Ascertained by: Normal weight BMI Good
Within IOM 91.1, >
• Based on last G1: 1.69 (0.99, 2.88)
IOM 86.7 P < 0.01
clinically G2: 1.0
from women who
measured G3: 1.66 (1.05, 2.63) P < 0.05)
gained within IOM
weight prior to G4: 1.19 (0.981, 1.44)
delivery Other infant outcomes: G5: 1.0
Macrosomic, %: G6: 1.14 (0.969, 1.33)
• Underweight 11.5 Overweight
• Normal 20.08 (P < G1: 2.96 (0.90, 9.79)
0.01 from G2: 1.47 (0.61, 3.53)
underweight group) G3: 1.62 (0.90, 2.91)
• Overweight 23.48 G4: 1.59 (0.94, 2.68)
(P < 0.01 from G5: 1.13 (0.81, 1.58)
underweight group) 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

C-675
Evidence Table 50. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Hilson et al., 2006
(continued)

C-676
Evidence Table 50. Gestational weight gain with reference to IOM recommendations and lactation
performance (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
• Overweight G1: Hazard ratio (HR) of
23.48(P < 0.01 discontinuing Any BF: < IOM
from underweight G2: Hazard ratio (HR) of
group) discontinuing Any BF: Within IOM
• Obese 28.08 (P < G3: Hazard ratio (HR) of
0.01 from discontinuing Any BF: > IOM
underweight
Underweight BMI
group, P < 0.01
G1: 1.21 (0.89, 1.64)
from normal
G2: 0.95 (0.73, 1.24)
weight group, <
G3: 1.34 (0.95, 1.88)
IOM 10.0%
• Within IOM 17.4 Normal Weight
(P<0.01), >IOM G1: 1.09 (0.88, 1.35)
27.4% P<0.01 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-677
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Butte et al., 2003 • Cohort • Measured by study White
• Prospective investigators G1: 77
Country and setting: G2: NR
USA, children’s nutrition Total Study N: Pregravid BMI:
center 63 Black
Imputed: G1: 10
Enrollment Period: Group Description: • No G2: NR
NR G1: Total cohort
G2: NR Categorized: Hispanic
Funding: • IOM guidelines G1: 10
US Department of Army Group N: G2: NR
and US Department of G1: 63 Age (mean, yrs):
Agriculture/Agriculture G2: NR G1: 31 (4) Asian/Pacific Islander
Research Service G2: NR G1: 3
Inclusion criteria: G2: NR
Study Objective: • Nonsmokers Parity:
To evaluate how changes • NR Other
18-40 years
in gestational weight and • parity ≤ 4 NR
body composition affect • Physically active (20 Smoking,%:
infant birth weight and to 30 minutes of
maternal fat retention after NR
moderate exercise at
delivery in underweight, least 3 times/week) Diabetes mellitus,%:
normal weight and • No long term NR
overweight women medicine use Hypertension,%:
Time frame: • No alcohol/drug NR
NR abuse
Additional characteristics:
Duration of the study: Exclusion criteria: NR
Prior to preg through pp • Multiparous
• Preterm deliveries
• Miscarriage
• Preeclampsia

C-678
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Fat retention Good
Total weight gain:
G1: 15.0 (3.8) kg Gestational Groups: Sample
G2: 14.5 (4.5) kg diabetes, %: BMI groups, low, normal, high selection:
G3: 17.9 (5.4) kg NR Fair
Categorized: Cesarean delivery, Results: Definition of
• Continuous %: • After adjustment for gestational duration, gravidity, maternal
NR and ethnicity, gestational weight gain and net weight gain:
Collected from: gestational weight gain (GWG-birth weight) were Fair
• Collected by Instrumental
significantly lower in normal BMI group than in high
study delivery, %: Definition of
BMI group (P = 0.04) - GWG and net GWG in low
investigators NR outcomes:
BMI group was not significantly different from women
Good
Ascertained by: Episiotomy, %: in normal and high BMI groups
• NR NR • On average weight gain was 42% fat mass and 58% Source of
fat free mass information on
Other maternal
• Weight gain was linearly correlated with gains in TBW exposure,
outcomes: outcomes, and
(r = 0.39, P = 0.003), TBK (r = 0.49, P = 0.001),
NA confounders:
protein (r = 0.49, P = 0.001), Fat free mass (r = 0.50,
Other infant P = 0.001), and FM (r = 0.76, P = 0.001) Good
outcomes: • Mean gestational weight gain (14.4kg) of women who
Followup:
• Birth weight gained within IOM recommendations was associated
Poor
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 Analysis
3.44kg comparability:
• Changes in body weight differed among BMI groups in Fair
first trimester (normal BMI < high BMI group, P =
0.004) and third trimester (low BMI < normal and high Analysis of
BMI group, P < 0.01) outcomes:
Fair
• No effect of breast feeding on body weight and
composition Interpretation:
• Birth weight correlated significantly with GWG (r = Fair
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 = Sum of
0.39, P = 0.003) but not with FM Good/Fair/Poo
• Partitioning GWG into FFM and FM showed that FFM r:
gain accounted for effect on birth weight (not FM) 3 Good, 5 Fair,
1 Poor
• Maternal FFM gains in first (P = 0.008), second (P =
0.005), and third trimesters (P = 0.005) were shown Final Quality
to make independed contributions to birth weight Score:
• Total gestational gains in maternal weight, TBW, TBK, Fair
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-679
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Butte et al., 2003
(continued)

C-680
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
(continued)
Maternal Weight Outcomes from
Gain 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-681
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Lederman et al., 1997 • Cohort • Self-reported White
• Prospective G1: 63.4 (12.9) NR
Country and setting:
G2: NR
USA, clinics Total Study N: Black
196 Pregravid BMI: NR
Enrollment Period:
Jan 1991-Aug 1993 Group Description: Imputed: Hispanic
G1: study cohort • NR NR
Funding:
G2: NR
Grant from Maternal and Categorized: Asian/Pacific Islander
Child Health Bureau and Group N: • IOM guidelines NR
Department of Health and G1: 196
Human Services Age (mean, yrs): Other
G2: NR
G1: 26.0 (4.8) NR
Study Objective: Inclusion criteria: G2: NR
To determine fat Smoking,%:
• 18 to 35 years of age NR
deposited during Parity:
• Non-smokers
pregnancy in women G1: 0.8 (1.0) Diabetes mellitus,%:
• Self-identified as
according to G2: NR NR
Hispanic, black, or
recommendations of IOM white
and relationship of weight Hypertension,%:
• Expecting singleton NR
gain to fat gain in women birth
of different starting • Able to schedule their Additional characteristics:
weights classified by BMI first body composition NR
Time frame: laboratory visit before
Jan 1991 to Aug 1993 16th week of
gestation
Duration of the study: • Free of medical
From first visit through illnesses requiring
delivery 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

C-682
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
(continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 196 G1: 3,449 (433) • Fat gain between pregnancy weeks 14-37 Good
G2: NR G2: NR
Groups: Sample
Total weight gain: Gestational < IOM, within IOM, > IOM, for BMI groups for three selection:
G1: 13.6 (6.1) diabetes, %: outcomes: Good
G2: NR NR G1: Body weight gain
Definition of
G2: Body water gain
Categorized: Cesarean delivery, maternal
G3: Fat gain
• According to IOM %: weight gain:
NR Results: Fair
Collected from:
• Collected by Instrumental BMI < 19.8: all women (n = 21) Definition of
study delivery, %: G1: 12.6 (4.4) outcomes:
investigators NR G2: 6.1 (2.4) Good
G3: 4.8 (3.8)
Ascertained by: Episiotomy, %: Source of
• Based on last NR BMI < 19.8: less than recommended; recommended; information on
clinically more than recommended exposure,
Other maternal outcomes, and
measured weight G1: 7.9 (1.6); 12.6 (2.4); 16.1 (3.9)
outcomes: confounders:
prior to delivery: G2: 6.4 (3.7); 5.9 (1.6); 6.1 (2.2)
Study investigators Fair
difference G3: 0.6 (1.9); 6.0 (2.6); 6.9 (3.5)
measured body
between weight, body density Followup:
BMI19.8-26.0: all women (n = 118)
measurement at by Poor
G1: 12.2 (4.0)
week 37+ and hydrodensitometry, G2: 7.0 (2.7)
prepregnancy and deuterium Analysis
G3: 3.9 (3.7)
dilution volume twice comparability:
during pregnancy (at BMI19.8-26.0: less than recommended; recommended; Poor
weeks 12-16 and at more than recommended
Analysis of
37+ weeks) G1: 8.6 (1.9); 12.1 (3.4); 15.2 (3.4)
outcomes:
G2: 6.2 (2.1); 6.9 (2.7); 7.6 (3.0)
Other infant Fair
G3: 1.3 (3.0); 3.8 (3.5); 6.0 (3.1)
outcomes: Interpretation:
NA BMI > 26.0-29.0: all women (n = 29)
Fair
G1: 11.0 (4.6)
G2: 7.8 (3.5) Sum of
G3: 2.8 (5.4) Good/Fair/Poo
r:
3 Good, 4 Fair,
2 Poor
Final Quality
Score:
Fair

C-683
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
(continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Lederman et al., 1997
(continued)

C-684
Evidence Table 52. Gestational weight gain with reference to IOM recommendations and fat retention
(continued)
Maternal Weight Outcomes from
Gain 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-685
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Luke et al., 1996 • Cohort • Self-reported White
• Prospective G1: 47.9 (5.1) NR
Country and setting:
G2: 58.7 (6.3)
USA, clinic Total Study N: Black
G3: 83.9 (16.9)
487 G1: 48.1
Enrollment Period: G2: 48.8
Pregravid BMI:
March 1, 1974 to June 15, Group Description: G3: 63.5
G1: 18.3 (1.0)
1979 G1: BMI < 19.8 G2: 22.6 (1.7)
G2: BMI 19.8-26.0 Hispanic
Funding: G3: 31.7 (5.3)
G3: BMI > 26.0 NR
NR
Imputed:
Group N: Asian/Pacific Islander
Study Objective: • No
G1: 104 NR
Reanalysis of original data
G2: 268 Categorized:
to examine contribution of Other
maternal weight gain to
G3: 115 • IOM guidelines NR
infant birth weight and Inclusion criteria: Age (mean, yrs):
retained maternal weight • Smoking,%:
Referred for nutrition G1: 23.1 (5.5) G1: 17.3
in immediate postpartum counseling G2: 23.8 (5.5)
period, and effect of G2: 15.3
• > 37- < 43 weeks G3: 27.4 (6.2) G3: 13.0
weight gains below, at, gestation
and above IOM guidelines • Parity: Diabetes mellitus,%:
Singleton pregnancy
on both infant birt % primipara: NR
Exclusion criteria: G1: 60.6
Time frame: • Women with history G2: 48.1 Hypertension,%:
March 1, 1974 to June 15, of or concurrent G3: 27.0 NR
1979 metabolic disease, Additional characteristics:
Duration of the study: such as diabetes, NR
Prenatal visit through 2 seizure disorder,
days postpartum hypertension, cardiac
disease, asthma, or
drug dependence
• Women developing
antepartum
complications such
as preeclampsia,
GDM, or multiple
gestation

C-686
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 104 G1: 3,067 (44) Mean retained weight Good
G2: 268 P < 0.05
G3: 115 significantly Groups Sample selection:
different from Maternal weight gain < IOM Fair
Total weight gain: mean for normal recommendations:
G1: 12.6 (0.7) Definition of maternal weight
BMI G1: BMI < 19.8 gain:
G2: 13.2 (0.4) G2: 3308 (27) G2: BMI 19.8-26.0
G3: 11.7 (0.7) Fair
G3: 3300 (43) G3: BMI > 26.0
Significantly different Definition of outcomes:
from mean for normal Gestational Maternal weight gain within Good
BMI group at P < 0.05 diabetes, %: IOM recommendations:
NR Source of information on
Categorized: G4: BMI < 19.8 exposure, outcomes, and
• According to IOM Cesarean delivery, G5: BMI 19.8-26.0 confounders:
%: G6: BMI > 26.0 Fair
Collected from: NR
• Routine pre-natal Maternal weight gain > IOM Followup:
care or maternity Instrumental recommendations: Fair
records delivery, %: G7: BMI < 19.8
NR Analysis comparability:
G8: BMI 19.8-26.0
Ascertained by: Good
Episiotomy, %: G9: BMI > 26.0
• Based on last
NR Analysis of outcomes:
clinically Results
Fair
measured weight Other maternal Mean (SEM) retained weight
prior to delivery: outcomes: (defined as 2-day postpartum Interpretation:
total weight gain: weight minus pregravid weight, Poor
• Net gain (kg): 9.5
difference kg):
(0.6), 9.9 (0.4), Sum of Good/Fair/Poor:
between last G1: 3.2 (0.5) P < 0.05
7.8 (0.6) 3 Good, 5 Fair, 1 Poor
measurement compared to G4
significantly
and pregravid G2: 0.8 (0.4) P < 0.05 Final Quality Score:
different from
weight; net compared to G5 Fair
mean for normal
weight gain: G3: -5.0 (0.7) P < 0.05
BMI group at P <
difference compared to G6
0.05
between
• Retained weight
pregravid weight G4: 8.2 (0.7)
(kg): 6.6 (0.6),
and last G5: 7.0 (0.4)
6.6 (0.4), 4.2
measured weight G6: 1.4 (0.8)
(0.6) significantly
minus infant birth
different from
weight G7: 15.5 (0.9) P < 0.05
mean for normal
compared to G4
BMI group at
G8: 12.9 (0.4) P < 0.05
P < 0.05
compared to G5
• Percent retained
G9: 9.5 (0.5) P < 0.05
weight (%): 11.4
compared to G6
(0.9), 9.4 (0.5),
4.4 (0.8)
significantly Maternal confounders and
different from effect modifiers accounted
mean for normal for in analysis:
BMI group at Age, parity, race, smoking,
P < 0.05 gestation duration, fetal sex
Other infant Infant and child confounders
outcomes: and effect modifiers
NA accounted for in analysis:
NR

C-687
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Scholl et al., 1995 • Cohort • Self-reported White
• Prospective G1: 8.5
Country and setting: Pregravid BMI: G2: 10.9
USA, Camden Study Total Study N: G3: 10.4
Imputed:
274
Enrollment Period: • No Black
September 1985 to May Group Description: G1: 61.0
1990 G1: Low rate of GWG Categorized:
• IOM guidelines G2: 59.4
G2: Moderate rate of G3: 62.3
Funding:
GWG Age (mean, yrs):
NIH Hispanic
G3: Excessive rate of NR
Study Objective: GWG G1: 30.5
To determine whether risk Parity: G2: 29,7
Group N: NR G3: 27.3
of maternal overweight
G1: 59
associated with an Asian/Pacific Islander
G2: 138
excessive rate of NR
G3: 77
gestational weight gain
needs to be balanced Inclusion criteria: Other
against risk of impaired • Women with NR
fetal growth associated pregravid BMI 19.8-
with low rate of gain Smoking,%:
26.0 G1: 30.5
Time frame: • Enrolled before G2: 26.8
September 1985 to May January 1988 G3: 26.9
1990 Exclusion criteria: Diabetes mellitus,%:
Duration of the study: • Missing information NR
During pregnancy through from delivery to 6
6 months postpartum months postpartum Hypertension,%:
• Pregravid under or NR
over weight Additional characteristics:
NR

C-688
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 59 G1: 3,049 (56.94) Mean change in weight Good
G2: 138 P < 0.05, low
G3: 77 vs. moderate Groups Sample
plus excessive Maternal weight gain categories (kg/wk): selection:
Total weight gain: weight gain G1: ≤ 0.34 Fair
G1: Gestation G2: 3,208 (36.33) G2: > 0.34-0.68 Definition of
duration (wk)38.5 G3: 39.4 (0.24) G3: > 0.68
(0.28) P < 0.05, low maternal
weight gain:
vs. moderate plus Gestational Results
excessive weight diabetes, %: Fair
Mean (SEM) change in weight (kg) from pregravid to 6 weeks
gain NR postpartum: Definition of
G2: 39.2 (0.17) G1: 3.1 (0.80) outcomes:
G3: 39.4 (0.24) Cesarean delivery,
%: G2: 3.9 (0.51) Good
Categorized: NR G3: 9.4 (0.70) P < 0.001, G3 vs. G1,G2 Source of
• According to Maternal confounders and effect modifiers accounted for information on
Instrumental
IOM rate of in analysis: exposure,
delivery, %:
gestational Age, parity, race, height, lactation status, smoking outcomes, and
NR
weight gain confounders:
measured Episiotomy, %: Infant and child confounders and effect modifiers Good
between 20 to NR accounted for in analysis:
36 weeks: low NR Followup:
GWG = < Other maternal Fair
0.34kg/wk; outcomes:
NA Analysis
moderate comparability:
GWG = 0.34- Other infant Fair
0.68 kg/wk; outcomes:
excessive NA Analysis of
GWG = > 0.68 outcomes:
kg/wk Fair

Collected from: Interpretation:

• Collected by Fair
study Sum of
investigators Good/Fair/Poo
Ascertained by: r:
• NR 3 Good, 6 Fair,
0 Poor
Final Quality
Score:
Fair

C-689
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Stevens-Simon and • Cohort • Self-reported White
McAnarney, 1992 • Prospective G1: 58.6 (11.1) NR
G2: 160.9 (7.0)
Country and setting: Total Study N: Black
G3: 163.9 (5.5)
USA, adolescent 141 (107 included in NR
maternity program postpartum analyses) Pregravid BMI:
Hispanic
G1: 23.1 (3.5)
Enrollment Period: Group Description: NR
G2: 23.5 (4.4)
1986 to 1989 G1: Slow gainers G3: 23.5 (4.2) Asian/Pacific Islander
G2: Average gainers
Funding: NR
G3: Rapid gainers Imputed:
Grant from Bureau of
• No Other
Maternal and Child Health Group N:
NR
G1: 28 Categorized:
Study Objective:
To clarify advantages and
G2: 66 • Continuous Smoking,%:
G3: 47 NR
disadvantages of large Age (mean, yrs):
gestational weight gain Inclusion criteria: G1: 16.9 Diabetes mellitus,%:
among pregnant • Consecutively G2: 16.6 NR
adolescents enrolled poor, black, G3: 16.2
Hypertension,%:
Time frame: 12-19 year olds
Parity: NR
1986 to 1989 • Prenatal care prior to
NR
2third week gestation Additional characteristics:
Duration of the study: • No chronic disease NR
Entry into prenatal care • No regular
through 6 weeks PP medications
check up • No known uterine
anomalies
• Live birth
• Singletons
Exclusion criteria:
• NA

C-690
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 28 G1: 2745 (694) Short-term weight retention; adjusted odds ratio for Good
G2: 66 G2: 3097 (457) subsequent maternal obesity
G3: 47 G3: 3351 (482) Sample
P < 0.0001 Groups selection:
Total weight gain: Maternal weight gain categories (kg/wk): Poor
G1: 7.7 (average rate Gestational G1:< 0.23
diabetes, %: Definition of
0.2 kg/wk) G2: 0.23-0.40
G2: 12.4 (average NR maternal
G3: > 0.40 weight gain:
rate 0.3 kg/wk)
G3: 19.8 (average Cesarean delivery, Fair
%: Results
rate 0.5 kg/wk) Short term weight retention (2-11 weeks postpartum), total Definition of
NR
Categorized: kg: outcomes:
Instrumental G1: -1.7 (SD 2.9) Good
• According to
delivery, %: G2: 2.9 (SD 2.9)
IOMslow gain: < Source of
NR G3: 9.6 (SD 5.6)
0.23kg/wk; information on
average gain: Episiotomy, %: P < 0.0001 exposure,
0.23-0.4kg/week; NR outcomes, and
rapid gain: > AOR (95% CI) for subsequent maternal obesity (> 120% confounders:
0.4kg/week Other maternal ideal weight for height): Fair
outcomes: G3: 190.94 (7.55-4,779.02)
Collected from: NA Followup:
• Routine pre-natal Maternal confounders and effect modifiers accounted Fair
care or maternity Other infant for in analysis:
records outcomes: • Age Analysis
NA • Pregravid BMI comparability:
Ascertained by: • Level of physical activity Fair
• Based on last • Timing of first prenatal and postpartum visits Analysis of
clinically • Substance use outcomes:
measured weight • Body habitus Good
prior to delivery
Infant and child confounders and effect modifiers Interpretation:
accounted for in analysis: Poor
NR
Sum of
Good/Fair/Poo
r:
3 Good, 4 Fair,
2 Poor
Final Quality
Score:
Fair

C-691
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Walker et al., 2004 • Cross-sectional • Self-reported White
• Combination: G1: 66.9 (15.1) G1: 30.3
Country and setting: G2: NR
recruited at delivery- G2: NR
USA, Austin New Mothers
they filled out
Study Pregravid BMI: Black
questionniares and
G1: 25.6 (6.0) G1: 24.1
Enrollment Period: then got some info
G2: NR
G2: NR
1999-2001 from medical records
Imputed: Hispanic
Funding: Total Study N:
G1: 45.6
419 • No
National Institute of G2: NR
Nursing Research grant Categorized:
Group Description:
• IOM guidelines since few Asian/Pacific Islander
Study Objective: G1: Total cohort
NR
To assess proportion of G2: NR underweight and
women attaining overweight women 2 Other
Group N: groups were made:
prepregnant weight and to NR
G1: 419 underweight/normal and
ascertain predictors of
G2: NR overweight/obese Smoking,%:
amount of retained weight
at 6 weeks postpartum in NR
Inclusion criteria: Age (mean, yrs):
a tri-ethnic low income • Low income women G1: 22.2 (3.8) Diabetes mellitus,%:
population • Term infants G2: NR NR
Time frame: • Singletons
Parity: Hypertension,%:
1999 to 2001 • Low-risk pregnancies G1: 1.0 (0.0) NR
• At least 18 years G2: NR
Duration of the study: • Perinatal care funded Additional characteristics:
Delivery to 6 weeks was by Medicaid NR
prospective nature-
retrospectively they Exclusion criteria:
obtained info from medical • Women who reported
record weighing less at end
of pregnancy than
before (n = 4)
• Missing weight data
(n = 137)

C-692
Evidence Table 53. Gestational weight gain with reference to IOM recommendations and short-term weight
retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 419 G1: 3377 (424) Mean weight retention; percentage of women with Good
G2: NR G2: NR retained weight, correlation and multiple regression
analysis Sample
Total weight gain: Gestational selection:
G1: 15.8 (7.1) diabetes,%: Groups Fair
G2: NR NR Maternal weight gain categories: Definition of
Categorized: Cesarean G1: < IOM maternal weight
• According to IOM delivery,%: G2: Within IOM gain:
G1: 14.3 G3: > IOM Fair
Collected from: G2: NR
• Self-reported Mean (SD) weight (kg) retained at 6 weeks postpartum: Definition of
Instrumental G1: -0.34 (3.44) outcomes:
Ascertained by: delivery,%: Good
G2: 3.86 (3.45)
• Based on last
Episiotomy,%: G3: 10.55 (6.14) Source of
clinically
P = 0.000 information on
measured weight Other maternal
prior to delivery outcomes: exposure,
% Women who attained pregravid weight at 6 weeks outcomes, and
NA postpartum: confounders:
G1: 48.8 Fair
Other infant
G2: 14.3
outcomes: Followup:
G3: 2.3
NA Good
Correlation of gestational weight gain, excluding infant
Analysis
weight, (continuous variable) and weight retained at 6
comparability:
weeks postpartum: r = 0.90 P = 0.000
Fair
Multiple regression analysis predicted a mean increase Analysis of
in retained weight of 0.88 kg for each 1 kg increase in outcomes:
maternal weight gain (B = 0.88, SE = 0.02, P = 0.000) Fair
Interpretation:
Maternal confounders and effect modifiers Fair
accounted for in analysis:
• Race Sum of
Good/Fair/Poor:
• Parity
3 Good, 6 Fair, 0
• Pregravid BMI
Poor
• Gestational weight gain
Final Quality
Infant and child confounders and effect modifiers Score:
accounted for in analysis: Fair
• Gestational age

C-693
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Amorim et al., 2007 • Cohort Self-reported White
• Combination: In NR
Country and setting: Pregravid BMI:
maternity unit, staff
Sweden, hospital G1: 21.5 (2.4) Black
invited women to
NR
Enrollment period: take part in study at Imputed:
Study comprised follow- first control visit • No Hispanic
up period from delivery after delivery. Up to NR
(1984 to 1985) to 15 that point, study Categorized:
years postpartum (1999 was retrospective in • Continuous Asian/Pacific Islander
to 2000). that information NR
Age (mean, yrs):
about weight G1: 30.0 (4.6) Other
Funding: development during
Study supported by NR
pregnancy was Parity:
Brazilian Foundation for collected from G1: Primiparous 52% Smoking,%:
training of researchers obstetrics records. NR
in Doctoral Exchange Women were then
Programe (CAPES) (to Diabetes mellitus,%:
prospectively NR
A.R.A.)and by monitored up to 1
Arbeitsmarknadens year postpartum Hypertension,%:
Forsakrings-och and15 years later NR
Aktiebolag(AFA) (to
M.N.) Total Study N: Additional characteristics:
483 NR
Study Objective:
Explore effect of GWG Group Description:
according to IOM G1: Total
recommendations on
Group N:
long-term BMI,
NR
accounting for several
potentially confounding Inclusion criteria:
factors, including • Women who
postpartum weight delivered children
changes and pre- in 1984 to 1985 in
pregnancy BMI 14 maternity units
Time frame: in Stockholm,
Study comprised follow- Sweden
up period from delivery Exclusion criteria:
(1984 to 1985) to 15 NR
years postpartum (1999
to 2000).
Duration of the study:
Entry into prenatal care
through 15 years after
childbirth

C-694
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: 3506 (470) g Time and weight gain Good
interaction
Total weight gain: Gestational Sample selection:
G1: 14.2 (4.1) kg diabetes, %: Groups Fair
NR Maternal weight gain
Categorized: Definition of maternal
• According to Cesarean categories: weight gain:
IOM delivery,%: < IOM Fair
NR Within IOM
Collected from: >IOM Definition of outcomes:
• Routine pre- Instrumental Good
natal care or delivery,%: Results
NR Source of information on
maternity A mixed ANOVA with one exposure, outcomes, and
records repeated measures factor
Episiotomy,%: confounders:
NR (weight before pregnancy, 6 Poor
Ascertained by:
months, 1, and 15 years) and
NR
Other maternal one between-subjects factor Followup:
outcomes: (< IOM, within IOM, > IOM) Good
NR showed a main effect of time
Analysis comparability:
[F (9.024) = 113.7, P = 0.000]
Other infant Fair
and a significant time group
outcomes:
interaction [F(6,12) = 77.23, P Analysis of outcomes:
NR
= 0.000] Good

The weight of women who Interpretation:

gained excessive during Good
pregnancy was significantly Sum of Good/Fair/Poor:
greater at each time-point 5 Good, 3 Fair, 1 Poor
[main effect of group: F
(10.55) = 870.0, P = 0.000] Final Quality Score:
Fair
Maternal confounders and
effect modifiers accounted
for in analysis:
Pre-gravid BMI
Infant and child
confounders and effect
modifiers accounted for in
analysis:
NR

C-695
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Keppel and Taffel, 1993 • Cross-sectional • Self-reported White
• Retrospective NR
Country and setting: Pregravid BMI:
USA, 1988 National Total Study N: Black
Maternal and Infant Imputed: NR
2,944
Health Survey • No
Group Description: Hispanic
Enrollment Period: NR Categorized: NR
1988 • IOM guidelines
Group N: Asian/Pacific Islander
Funding: NR Age (mean, yrs): NR
National Center for NR
Health Statistics Inclusion criteria: Other
• Live births Parity: NR
Study Objective: NR
• Singletons Smoking,%:
To examine implications • Women interviewed
of compliance with IOM NR
10-18 months
guidelines for following delivery Diabetes mellitus,%:
postpartum weight • Births at ≥ 37 NR
retention weeks gestation Hypertension,%:
Time frame: • White or black NR
1988 women
• ≥ 15 years of age Additional characteristics:
Duration of the study: NR
NA, cross-sectional Exclusion criteria:
• Obese women, BMI
> 29.0

C-696
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Weight retention by postpartum time Good
Total weight gain:
Gestational Groups Sample
Categorized: diabetes, %: selection:
• According to Categories of amount of weight retained (lbs) at 10-18
NR months postpartum: Fair
IOM
Cesarean delivery, G1: Lost weight Definition of
Collected from: %: G2: 0-3 maternal
• Self-reported NR G3: 4-8 weight gain:
G4: 9-13 Fair
Ascertained by: Instrumental G5: ≥ 14
• Self-reported delivery, %: Definition of
NR Results outcomes:
The percent distribution of women in G1-G5 stratified Good
Episiotomy, %:
NR by maternal weight gain categories showed that both Source of
black and white women who gained < IOM or within the information on
Other maternal IOM guidelines retained less weight (10-18 months exposure,
outcomes: postpartum) than women who gained > IOM outcomes, and
NA recommendations. Irrespective of maternal weight gain, confounders:
black women retained more weight than white women Poor
Other infant
outcomes: Followup:
NA Maternal confounders and effect modifiers Good
accounted for in analysis:
None Analysis
comparability:
Infant and child confounders and effect modifiers Poor
accounted for in analysis:
None Analysis of
outcomes:
Fair
Interpretation:
Poor
Sum of
Good/Fair/Poor
:
3 Good, 3 Fair,
3 Poor
Final Quality
Score:
Poor

C-697
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued) (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Olson et al., 2003 • Cohort • Measured at first prenatal White
• Prospective visit G1: 96
Country and setting: G2: NR
USA, hospital and primary Total Study N: Pregravid BMI:
care clinic system 540 G1: < 19.8: 8.9%; 19.8-26.0: Black
50.6%; > 29.0: 25.2% NR
Enrollment Period: Group Description: G2: NR
Mid 1990s G1: Total cohort Hispanic
G2: NR Imputed: NR
Funding:
• Yes
NIH grants Group N: Asian/Pacific Islander
G1: 540 Categorized: NR
Study Objective:
To describe importance of
G2: NR • IOM guidelines Other
GWG, postpartum Inclusion criteria: Age (mean, yrs): NR
exercise, food intake and • ≥ 18 years G1: < 20y: 3.9%
breastfeeding to weight Smoking,%:
• Singleton infants 20-40y: 93.5% NR
change from eary > 40y: 2.6%
pregnancy to 1 year post Exclusion criteria: G2: NR Diabetes mellitus,%:
partum and to identify • No 1 year weight NR
subgroups of women at available Parity:
greatest risk for major • Invalid 1 year weight G1: Nulliparous: 41.2% Hypertension,%:
weight gain surrounding • Pregnant at 1 year G2: NR NR
child bearing • Serious postpartum Additional characteristics:
illness affecting body % married:
Time frame:
weight G1: 92.8%
Mid 1990s
• Last prenatal weight G2: NR
Duration of the study: taken more than 6
Women were followed weeks prior to
from early pregnancy to delivery
one year postpartum
(specific dates are not
mentioned)

C-698
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Maternal Weight Outcomes from Outcomes from Multivariate
Gain Bivariate Analysis Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description:
G1: 540 NR Pregnancy weight versus
G2: NR postpartum weight
Gestational
Total weight gain: diabetes, %: Groups
G1: Less than NR Maternal weight gain
recommended: categories:
Cesarean delivery,
20.4%; G1: < IOM
recommended: %:
NR G2: Within IOM
37.8%; more than G3: > IOM
recommended: Instrumental G4: Interaction for > IOM and
41.9% delivery, %: income ≤ 185% federal poverty
G2: NR NR line
Categorized: Episiotomy, %:
• According to IOM NR Results
Regression coefficient (SE) for
Collected from: Other maternal weight change from early
• Routine pre-natal outcomes: pregnancy to 1 year postpartum
care or maternity • At 1 year (kg):
records postpartum, G1: -1.50 (0.62) P = 0.016
women were on G2: reference
Ascertained by:
average 1.51 G3: 0.32 (0.65) P = 0.621
• Based on last
(5.95) kg heavier G4: 3.41 (0.91) P < 0.001
clinically
than they were in
measured weight
early pregnancy AOR (95% CI) for major weight
prior to delivery:
gain (≥ 10 lbs) at 1 year
difference Other infant
postpartum:
between first outcomes:
G1: 0.33 (0.13-0.83)
trimesters weight NR
G2: 1.00 (reference)
and last weight
G3: 1.47 (0.73-2.94)
measured
G4: 3.23 (1.25-9.08)
(usually within 1
week of delivery)
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-699
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rooney et al., 2002 • Cohort • weight at first pn visit White
• Prospective G1: 97%
Country and setting: Pregravid BMI: G2: NR
USA, hospital Total Study N: G1: 25.0
540 G2: NR Black
Enrollment Period: NR
10 year followup of Group Description: Imputed:
study from Apr 1989 to G1: Group Studied • No Hispanic
March 1990 (Continued Care) NR
G2: NR Categorized:
Funding: • IOM guidelines Asian/Pacific Islander
Gundersen Lutheran Group N: NR
Medical Center G1: 540 Age (mean, yrs):
G1: 28.6 Other
G2: NR
Study Objective: G2: NR NR
To estimate impact of Inclusion criteria:
excess pregnancy Parity: Smoking,%:
• Convenience NR
weight gain and failure sample of women NR
to lose weight by 6 with uncomplicated Diabetes mellitus,%:
months postpartum on pregnancies NR
excess weight 8 to 10 receiving care at
years later Hypertension,%:
Gundersen Clinic
from April first 1989 NR
Time frame:
10 year followup of to March 30 1990 Additional characteristics:
study from Apr 1989 to Exclusion criteria: NR
March 1990 • Women who
Duration of the study: discontinued care
April 1, 1989 to 1999 at clinic or did not
(10 years) have a weight
Entry into prenatal care available 5-10
up to 10 years years after their
postpartum study pregnancy

C-700
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 540 NR Weight change Good
G2: NR
Gestational Groups Sample
Total weight gain: diabetes, %: Maternal weight gain categories: selection:
G1: 13.1 kg (mean) NR G1: < IOM Fair
G2: NR G2: Within IOM
Cesarean delivery, Definition of
Categorized: %: G3: > IOM maternal weight
• According to NR gain:
IOM BMI IOM Fair
Instrumental
Collected from: delivery, %: Results Definition of
• Routine pre- NR Average weight change between prepregnancy and 6 outcomes:
natal care or months postpartum (kg): Good
Episiotomy, %:
maternity G1: -0.61
NR Source of
records G2: 1.8 information on
Other maternal G3: 4.2 exposure,
Ascertained by:
outcomes: P = 0.01 outcomes, and
• Based on last
• Mean retained confounders:
clinically
maternal Regression coefficient (95% CI) for weight at 6 months Good
measured
weight (kg) postpartum:
weight prior to Followup:
was 1.7kg G1: -1.53 (-3.36–0.30)
delivery: Study Poor
• 66% retained G2: Reference
investigators
pregnancy G3: 1.24 (-0.63–3.11)
measured Analysis
weight at 6
weight at comparability:
months follow
delivery Maternal confounders and effect modifiers Fair
up
accounted for in analysis:
• 26% gained Analysis of
Duration of breastfeeding, postpartum aerobic
less than outcomes:
exercise, weight loss by 6 months
recommended Good
(IOM) amount Infant and child confounders and effect modifiers
Interpretation:
of weight accounted for in analysis:
Fair
during NR
pregnancy, Sum of
50% gained Good/Fair/Poor:
recommended 4 Good, 4 Fair, 1
amount, and Poor
24% gained
more than Final Quality
recommended Score:
Fair
Other infant
outcomes:
NR

C-701
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Scholl et al., 1995 • Cohort • Self-reported White
• Prospective G1: 8.5
Country and setting: Pregravid BMI: G2: 10.9
USA, Camden Study Total Study N: G3: 10.4
Imputed:
274
Enrollment Period: • No Black
September 1985 to May Group Description: G1: 61.0
1990 G1: Low rate of GWG Categorized:
• IOM guidelines G2: 59.4
G2: Moderate rate of G3: 62.3
Funding:
GWG Age (mean, yrs):
NIH Hispanic
G3: Excessive rate of NR
Study Objective: GWG G1: 30.5
To determine whether Parity: G2: 29,7
Group N: NR G3: 27.3
risk of maternal
G1: 59
overweight associated Asian/Pacific Islander
G2: 138
with an excessive rate NR
G3: 77
of gestational weight
gain needs to be Inclusion criteria: Other
balanced against risk of • Women with NR
impaired fetal growth pregravid BMI 19.8-
associated with low rate Smoking,%:
26.0 G1: 30.5
of gain • Enrolled before G2: 26.8
Time frame: January 1988 G3: 26.9
September 1985 to May Exclusion criteria:
1990 Diabetes mellitus,%:
• Missing information NR
Duration of the study: from delivery to 6
During pregnancy months postpartum Hypertension,%:
through 6 months • Pregravid under or NR
postpartum over weight Additional characteristics:
NR

C-702
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 59 G1: 3,049 (56.94) Change in weight, risk for becoming overweight Good
G2: 138 P < 0.05, low
G3: 77 vs. moderate Groups Sample
plus excessive Maternal weight gain categories (kg/wk): selection:
Total weight gain: weight gain G1: ≤ 0.34 Fair
G1: Gestation G2: 3,208 (36.33) G2: > 0.34-0.68
duration (wk)38.5 Definition of
G3: 39.4 (0.24) G3: > 0.68 maternal
(0.28) P < 0.05, low
vs. moderate plus Gestational weight gain:
Results Fair
excessive weight diabetes, %: Mean (SEM) change in weight (kg) from pregravid to 6
gain NR months postpartum: Definition of
G2: 39.2 (0.17) G1: 3.2 (0.95) outcomes:
G3: 39.4 (0.24) Cesarean delivery,
%: G2: 3.8 (0.61) Good
Categorized: NR G3: 7.9 (0.83) P < 0.001, G3 vs. G1, G2 Source of
• According to information
Instrumental Mean (SEM) change in weight (kg) from 6 weeks to 6
IOM rate of on exposure,
delivery, %: months postpartum:
gestational outcomes,
NR G1: 0.13 (0.64)
weight gain and
measured Episiotomy, %: G2: -0.05 (0.41) confounders:
between 20 to NR G3: -1.48 (0.56) P < 0.05, G3 vs. G1, G2 Fair
36 weeks: low
GWG = < Other maternal AOR (95% CI) for becoming overweight (BMI > 26.0) at Followup:
0.34kg/wk; outcomes: 6 months postpartum: Fair
moderate NA G1, G2: 1.0 (reference)
Analysis
GWG = 0.34- G3: 2.89 (1.36-6.00)
Other infant comparability
0.68 kg/wk; outcomes: Maternal confounders and effect modifiers :
excessive NA accounted for in analysis: Fair
GWG = > 0.68 Age, race, parity, pregravid BMI, lactation, height,
kg/wk Analysis of
smoking
outcomes:
Collected from: Infant and child confounders and effect modifiers Fair
• Collected by accounted for in analysis:
study Interpretation:
NR
investigators Fair

Ascertained by: Sum of

• NR Good/Fair/Po
or:
2 Good, 7 Fair,
0 Poor
Final Quality
Score:
Fair

C-703
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Walker, 1996 • Cohort • Self-reported White
• Combination: G1: 98%
Country and setting: Pregravid BMI: G2: NR
Prospective on
USA, multicounty
outcomes, Imputed:
community Black
retrospective on • No G1: NR
Enrollment Period: pregravid weight
Categorized: G2: NR
NR
Total Study N: • IOM guidelines Hispanic
Funding: 88
Age (mean, yrs): NR
Biomedical Research
Group Description: G1: 26.4
Support Grant; Luci B. Asian/Pacific Islander
G1: Total G2: NR
Johnson Centennial NR
G2: NR
Professorship in Parity:
Nursing Other
Group N: G1: 41% primiparae NR
G1: 88 G2: NR
Study Objective:
G2: NR Smoking,%:
To test contributions of
life-style and stress to NR
Inclusion criteria:
postpartum weight gain • Women identified Diabetes mellitus,%:
after controlling for through newspaper NR
sociodemographic and birth
reproductive influences Hypertension,%:
announcements
NR
Time frame: were sent
NR questionnaires in Additional characteristics:
mail NR
Duration of the study:
Pregravid Exclusion criteria:
(retrospective) through • Hypertensive or
18 months postpartum 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

C-704
Evidence Table 54. Gestational weight gain with reference to IOM recommendations and weight retention
during the first year postpartum (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 88 G1: 3544 Maternal weight gain and postpartum weight Good
G2: NR G2: NR
Groups Sample selection:
Total weight gain: Gestational Maternal weight gain categories: Fair
G1: 16.4 kg (SD diabetes,%: G1: < IOM
7.2) NR Definition of
G2: Within IOM maternal weight
G2: NR G3: > IOM
Cesarean gain:
Categorized: delivery,%: Fair
• According to G1: 81% vaginal Results
births Mean weight retention at 6 months postpartum, lbs: Definition of
IOM
G2: NR G1: 0.4 outcomes:
Collected from: G2: 3.7 Good
• Self-reported Instrumental G3: 13.5
delivery,%: Source of
P < 0.001 information on
Ascertained by:
• Self-reported Episiotomy,%: exposure,
Maternal weight gain was significantly related to outcomes, and
Other maternal weight at 6 months postpartum: r = 0.60, P < 0.001 confounders:
outcomes: Mean weight retention at 18 months postpartum, Poor
GWG was lbs:
significantly related G1, G2: 0.7 Followup:
to weight gain at 6 G3: 11.0 Good
(r[86] = 0.60, P < P < 0.01
0.001) and 18 Analysis
months (r[73] = comparability:
Maternal weight gain was significantly related to
0.49, P < 0.001) Fair
weight at 18 months postpartum: r = 0.49, P < 0.001
Other infant Analysis of
Maternal confounders and effect modifiers
outcomes: outcomes:
accounted for in analysis:
NR Good
Mode of delivery, infant sex, breastfeeding, infant
birth weight, pregravid BMI Interpretation:
Fair
Infant and child confounders and effect Sum of
modifiers accounted for in analysis: Good/Fair/Poor:
NR 4 Good, 4 Fair, 1
Poor
Final Quality
Score:
Fair

C-705
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Amorim et al., 2007 • Cohort Self-reported White
• Combination: In NR
Country and setting: Pregravid BMI:
maternity unit, staff
Sweden, hospital G1: 21.5 (2.4) Black
invited women to
NR
Enrollment period: take part in study at Imputed:
Study comprised follow- first control visit • No Hispanic
up period from delivery after delivery. Up to NR
(1984 to 1985) to 15 that point, study Categorized:
years postpartum (1999 was retrospective in • Continuous Asian/Pacific Islander
to 2000). that information NR
Age (mean, yrs):
about weight G1: 30.0 (4.6) Other
Funding: development during
Study supported by NR
pregnancy was Parity:
Brazilian Foundation for collected from G1: Primiparous 52% Smoking,%:
training of researchers obstetrics records. NR
in Doctoral Exchange Women were then
Programe (CAPES) (to Diabetes mellitus,%:
prospectively NR
A.R.A.)and by monitored up to 1
Arbeitsmarknadens year postpartum Hypertension,%:
Forsakrings-och and15 years later NR
Aktiebolag(AFA) (to
M.N.) Total Study N: Additional characteristics:
483 NR
Study Objective:
Explore effect of GWG Group Description:
according to IOM G1: Total
recommendations on
Group N:
long-term BMI,
NR
accounting for several
potentially confounding Inclusion criteria:
factors, including • Women who
postpartum weight delivered children
changes and pre- in 1984 to 1985 in
pregnancy BMI 14 maternity units
Time frame: in Stockholm,
Study comprised follow- Sweden
up period from delivery Exclusion criteria:
(1984 to 1985) to 15 NR
years postpartum (1999
to 2000).
Duration of the study:
Entry into prenatal care
through 15 years after
childbirth

C-706
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR G1: 3506 (470) g Weight change across postpartum years Good
Total weight gain: Gestational Groups Sample selection:
G1: 14.2 (4.1) kg diabetes, %: G1: < IOM Fair
NR G2: Within IOM
Categorized: Definition of
• According to Cesarean G3: > IOM maternal weight
IOM delivery,%: gain:
NR Results Fair
Collected from: Mean (SD) change in weight at 15 years
• Routine pre- Instrumental postpartum, kg: Definition of
natal care or delivery,%: G1: 6.2 (6.8) outcomes:
maternity NR G2: 6.7 (6.8) Good
records G3: 10.3 (8.5)
Episiotomy,%: Source of
NR P = 0.000 information on
Ascertained by:
NR exposure,
Other maternal Mean (SD) BMI at 15 years postpartum: outcomes, and
outcomes: G1: 23.5 (3.7) confounders:
NR G2: 23.6 (3.0) Poor
G3: 25.9 (3.9)
Other infant Followup:
P = 0.000
outcomes: Good
NR
Multiple regression coefficient, B (95% CI) for 15
Analysis
year BMI status:
comparability:
G1: 0.01 (-0.56-0.59)
Fair
G2: Reference
G3: 0.72 (0.15-1.30) Analysis of
P = 0.033 outcomes:
Good
Multiple regression coefficient (95% CI) for
change in BMI status between pregravid and 15 Interpretation:
years postpartum: Good
G1: 0.02 (-0.56-0.59) Sum of
G2: Reference Good/Fair/Poor:
G3: 0.68 (0.11-1.24) 5 Good, 3 Fair, 1
P = 0.042 Poor
Maternal confounders and effect modifiers Final Quality
accounted for in analysis: Score:
Education, lactation, weight retention at 6 Fair
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

C-707
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Gunderson et al., 2000 • Cohort • Self-reported White
• Retrospective G1: 53.3
Country and setting: Pregravid BMI: G2: NR
USA, university hospital Total Study N: G1: < 19.8: 28.3%
1,300 19.8-26.0: 59.5% Black
Enrollment Period: G1: 10.5
> 26-29.0: 6.6%
1980-1990 Group Description: G2: NR
> 29.0: 5.6%
G1: Total cohort G2: NR
Funding: Hispanic
G2: NR
Grants from California G1: 12.4
Imputed:
Dietetic Association, Group N: G2: NR
• No
Zellmer Grant, Dowdle G1: 1300
Endowment and G2: NR Categorized: Asian/Pacific Islander
Grossman Medical • IOM guidelines G1: 23.8
Research Funds, NIH, Inclusion criteria: G2: NR
University at California, • White, black, Age (mean, yrs):
Berkeley Hispanic, and Asian G1: 27 (5) Other
adult women who G2: NR NR
Study Objective: delivered two
To assess relationships Parity: Smoking,%:
consecutive NR
between gestational singleton births G1: % nulliparous: 72.4
weight gain, G2: NR Diabetes mellitus,%:
race/ethnicity, Exclusion criteria: NR
reproductive history, • < 18 years
age, education, and risk • Adoptions Hypertension,%:
of becoming overweight • Pregnancy NR
after pregnancy complications Additional characteristics:
• Medical conditions G1: % married: 77%
Time frame: which could modify
1980 to 1990 G2: NR
gestational weight
Duration of the study: gain or retention Additional characteristics:
2 pregnancies; weight NR
gain in first up to second
pregnancy

C-708
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
NR Adjusted odds ratio (95% CI) for becoming Good
Total weight gain: overweight between baseline (pregravid weight at
G1: 16.1kg Gestational start of index pregnancy) and start of second study Sample
G2: NR diabetes, %: pregnancy (median interval time = 1.5 years): selection:
NR Fair
Categorized:
• According to Cesarean delivery, Groups Definition of
IOM %: G1: < IOM/ within IOM maternal
NR G2: > IOM weight gain:
Collected from: Fair
• Routine pre- Instrumental Results
natal care or delivery, %: G1: Reference Definition of
maternity NR G2: 2.95 (1.67-5.24) outcomes:
records Good
Episiotomy, %:
Ascertained by: NR Maternal confounders and effect modifiers Source of
• Based on last accounted for in analysis: information on
Other maternal exposure,
clinically outcomes: Smoking, PIH, education, parity, marital status, age
measured at menarche, interval to first birth outcomes, and
• 6.4% (n = 72)of confounders:
weight prior to
women became Infant and child confounders and effect Fair
delivery:
overweight by modifiers accounted for in analysis:
difference Followup:
second NR
between self Good
pregnancy (all
reported weight
perviously normal
and weight at Analysis
weight except for
last prenatal comparability:
1 underweight
visit (average Good
woman)
of 0.9 weeks
• Mean weight Analysis of
prior to
increase from outcomes:
delivery)
baseline Good
(pregravid weight
at index Interpretation:
pregnancy) until Good
start of second Sum of
pregnancy = Good/Fair/Poor
10.4 (5.2) kg :
among women 6 Good, 3 Fair,
who became 0 Poor
overweight
compared with Final Quality
1.6 (3.6) kg Score:
among women Good
who did not
become
overweight (P <
0.001)
Other infant
outcomes:
NA

C-709
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rooney et al., 2002 • Cohort • weight at first pn visit White
• Prospective G1: 97%
Country and setting: Pregravid BMI: G2: NR
USA, hospital Total Study N: G1: 25.0
540 G2: NR Black
Enrollment Period: NR
10 year followup of Group Description: Imputed:
study from Apr 1989 to G1: Group Studied • No Hispanic
March 1990 (Continued Care) NR
G2: NR Categorized:
Funding: • IOM guidelines Asian/Pacific Islander
Gundersen Lutheran Group N: NR
Medical Center G1: 540 Age (mean, yrs):
G1: 28.6 Other
G2: NR
Study Objective: G2: NR NR
To estimate impact of Inclusion criteria:
excess pregnancy Parity: Smoking,%:
• Convenience NR
weight gain and failure sample of women NR
to lose weight by 6 with uncomplicated Diabetes mellitus,%:
months postpartum on pregnancies NR
excess weight 8 to 10 receiving care at
years later Hypertension,%:
Gundersen Clinic
from April first 1989 NR
Time frame:
10 year followup of to March 30 1990 Additional characteristics:
study from Apr 1989 to Exclusion criteria: NR
March 1990 • Women who
Duration of the study: discontinued care
April 1, 1989 to 1999 at clinic or did not
(10 years) have a weight
Entry into prenatal care available 5-10
up to 10 years years after their
postpartum study pregnancy

C-710
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 540 NR Change in weight or BMI across postpartum time Good
G2: NR
Gestational Groups Sample selection:
Total weight gain: diabetes, %: G1: < IOM Fair
G1: 13.1 kg (mean) NR G2: within IOM
G2: NR Definition of
Cesarean delivery, G3: > IOM maternal weight
Categorized: %: gain:
• According to IOM NR Results Fair
Average weight change between prepregnancy and
Collected from: Instrumental ~8.5 years postpartum (kg): Definition of
• Routine pre-natal delivery, %: G1: 4.1 outcomes:
care or maternity NR G2: 6.5 Good
records G3: 8.4
Episiotomy, %: Source of
NR P = 0.01 information on
Ascertained by:
• Based on last exposure,
Other maternal Regression coefficients (95% CI) for BMI at ~8.5 years outcomes, and
clinically outcomes: postpartum: confounders:
measured weight
• Mean retained G1: -3.86 (-5.56 - -2.16) Good
prior to delivery:
maternal weight G2: Reference
Study Followup:
(kg) was 1.7kg G3: -0.70 (-2.13-0.74)
investigators Poor
• 66% retained
measured weight Maternal confounders and effect modifiers
pregnancy
at delivery accounted for in analysis: Analysis
weight at 6
Duration of breastfeeding, postpartum aerobic exercise, comparability:
months follow up
weight loss by 6 months Fair
• 26% gained less
than Infant and child confounders and effect modifiers Analysis of
recommended accounted for in analysis: outcomes:
(IOM) amount of NR Good
weight during
Interpretation:
pregnancy, 50%
gained Fair
recommended Sum of
amount, and Good/Fair/Poor:
24% gained 4 Good, 4 Fair, 1
more than Poor
recommended
Final Quality
Other infant Score:
outcomes: Fair
NR

C-711
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Rooney et al., 2005 • Cohort • Measured at first White
• Prospective prenatal visit (average NR
Country and setting:
of 10.3 weeks gestation)
USA, medical center Total Study N: Black
484 Pregravid BMI: NR
Enrollment Period:
G1: 24.2
1988 to 2004 Group Description: Hispanic
G2: NR
G1: Cohort (at NR
Funding:
beginning of study) Imputed:
Gundersen Luterhan Asian/Pacific Islander
G2: NR • No
Medical Foundation NR
Group N: Categorized:
Study Objective: Other
To estimate impact of
G1: 484 • IOM guidelines NR
G2: NR
perinatal weight change Age (mean, yrs):
on obesity, weight gain, Smoking,%:
Inclusion criteria: G1: 28.6
and development of NR
• NA G2: NR
obesity related illnesses Diabetes mellitus,%:
15 years after Exclusion criteria: Parity: NR
pregnancy • Multiple births % primiparous:
• Missing weight G1: 39% Hypertension,%:
Time frame: measurements G2: NR NR
1988 to 2004 • Deceased Additional characteristics:
Duration of the study: Retained weight at 6 months
Original study postpartum:
conducted April 12, G1: 1.7kg
1988 to October 12, G2: NR
1990 followed up until
15 years later (2004) % married:
G1: 90
Quality: G2: NR
Fair

C-712
Evidence Table 55. Gestational weight gain with reference to IOM recommendations and long-term weight
retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis Quality Rating
Groups (N): Birth weight: Outcomes Description: Background:
G1: 484 G1: 13.0 kg Change in weight or BMI Good
G2: NR G2: NR
Groups Sample
Total weight gain: Gestational G1: < IOM selection:
diabetes, %: G2: within IOM Poor
Categorized: NR
• According to G3: > IOM Definition of
IOM Cesarean delivery, maternal
%: Results weight gain:
Collected from: NR Multivariable regression coefficient (95% CI) for BMI at Fair
• Routine pre- 15 years postpartum:
natal care or Instrumental G1: -0.57 (-0.57-1.21) Definition of
maternity delivery, %: G2: reference outcomes:
records NR G3: 1.69 (0.79-2.58) Good
Ascertained by: Episiotomy, %: Source of
NR Multivariable regression coefficient (95% CI) for change information
• Based on last
in weight between baseline and 15 years postpartum: on exposure,
clinically Other maternal G1: 0.43 (-1.87-2.73) outcomes,
measured outcomes: G2: reference and
weight prior to NA G3: 4.19 (1.88-6.51) confounders:
delivery
Other infant Maternal confounders and effect modifiers Good
outcomes: accounted for in analysis: Followup:
NA Marital status at delivery, change in marital status, Good
current parity, insurance status at delivery, current
insurance status, baseline BMI, weight gain at index Analysis
pregnancy, retained weight at 6 months postpartum, comparability
participation in postpartum aerobic exercise, duration of :
breastfeeding Fair
Infant and child confounders and effect modifiers Analysis of
accounted for in analysis: outcomes:
NR Fair
Interpretation:
Fair
Sum of
Good/Fair/Po
or:
4 Good, 4 Fair,
1 Poor
Final Quality
Score:
Fair

C-713
Evidence Table 56. Anthropometrics of maternal weight retention
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bartha, 2007 • Cohort • 64.01 kg NR
• Prospective
Country and setting: Pregravid BMI: Smoking,%:
Spain, tertiary referral Total Study N: NR
university center Imputed:
30
• Yes 24.4 Diabetes mellitus,%:
Enrollment Period: Group Description: NA
NR NA Categorized:
Hypertension,%:
Funding: 10 women were overweight NR
Consejeria de Salud Group N: BMI > 25
Additional characteristics:
30 Age (mean, yrs):
Study Objective: NR
29.07 years
to study the relationships
Inclusion criteria: Parity:
between ultrasound
estimated visceral fat and • 11-14 weeks of NR
metabolic risk factors gestation
during early pregnancy. Exclusion criteria:
Time frame: • NR
NA
Duration of the study:
NR
Quality:

C-714
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Decriptions
Metabolic risk factors as a function of visceral fat
Total weight gain: Gestational thickness (VFT) versus subcutaneous fat thickness
• NR diabetes, %: (SFT)
Groups
Cesarean NA
delivery,%:
NR Results
VFT significantly correlated with
Instrumental
• Diastolic blood pressure (r= 0.37, p= 0.04)
delivery, %:
• Glycemia (r= 0.37, p =0.04)
NR
• Insulinemia (r= 0.59, p = 0.001)
Episiotomy, %: • Insulin sensitivity (HOMA; r = 0.59, p= 0.001),
NR Triglycerides (r = 0.58, p =0.03)
• HDL-C (r=0.39, p = 0.03)
Other maternal
outcomes: • Total cholesterol/HDL-C ratio (p = 0.002)
NR
SFT significantly correlated with
Other infant • Diastolic blood pressure (p _ 0.03).
outcomes:
NR 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-715
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Bo et al., 2003 • Cohort • Self-reported White
• Prospective G1: 100
Country and setting: Pregravid BMI: G2: 100
Italy, university clinic Total Study N: G1: 21.2 G3: 100
700 G2: 29.9 G4: 100
Enrollment Period:
G3: 21.5
April 1999 to February Group Description: Black
G4: 29.9
2001 G1: Normal wieight, NR
normal OGTT Imputed:
Funding: Hispanic
G2: Overweight/Obese, • No
NR NR
normal OGTT
Categorized:
Study Objective: G3: Normal Weight,
Asian/Pacific Islander
IGT/GDM NR
To evaluate pregnancy NR
outcomes in cohort of G4: Overweight/Obese, Age (mean, yrs):
caucasian pregnant IGT/GDM G1: 31.7 Other
women in relation to BMI G2: 31.1 NR
Group N:
and glucose toleranc G3: 32.9
G1: 333 Smoking,%:
status; role of central fat G4: 32.6
G2: 117 G1: 11.4
distribution, as indicated
G3: 133 Parity: G2: 15.4
by waist to hip
G4: 117 G1: Nulliparous (%): 63.7 G3: 15.0
circumference ratio also
considered G2: 53.0 G4: 18.8
Inclusion criteria:
G3: 62.4
Time frame: • Caucasian pregnant Diabetes mellitus,%:
G4: 51.3
April 1999 to February women attending NR
2001 Gynecological and
Hypertension,%:
Obstetrical
Duration of the study: G1: 1.2
Department of
G2: 10.3
Screened during University of Torino
pregnancy at 24 to 28 G3: 4.5
screened with 50g
G4: 11.1
weeks, recall data on oral glucose test at
pregravid weight 24 to 28 weeks Additional characteristics:
gestation Waist-to-hip ratio:
Exclusion criteria: G1: 0.86
G2: 0.87
• Women known to
G3: 0.89
have preexistent
G4: 0.90
diabetes mellitus, a
disease affecting Additional characteristics:
glucose metabolism, Preterm delivery (%):
or hypertension 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-716
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
G1: 333 G1: 3271+/-446 Explanation of multivariate models:
G2: 117 (P < 0.05 vs. G2) • OR for hypertension in pregnancy and obesity -
G3: 133 G2: 3413+/-589 adjusted for age, gestational age, weight gain,
G4: 117 (P < 0.01 vs. G3) and gestational hypergylcemia
G3: 3186+/-578 • OR for cesarean sections included gestational
Total weight gain: (P < 0.01 vs. G4) hyperglycemia, gestational weight gain, age,
G1: 13.2+/-4.1 G4: 3389+/-447 obesity
(P < 0.01 vs. G2) (P < 0.05 vs. G1)
G2: 10.5+/-6.1 • OR for LGA included obesity (BMI ≥ 30),
(overall P = 0.001) gestational weight gain, age, gestational
G3: 11.8+/-5.7
(P < 0.05 vs. G2, Gestational hyperglycemia, and smoking
P < 0.05 vs. G4) diabetes,%: • OR for LGA/cesarean sections and WHR
G4: 9.5+/-6.8 NR adjusted for age, gestational age, weight gain,
(P < 0.01 vs. G1) gestational hyperglycemia, obesity, smoking
(overall P < 0.0001) Cesarean habits
delivery,%: • Prepregnancy weight was not associated with
Categorized: G1: 30.5 adverse outcomes, also height and parity not
• Continuous G2: 38.1 significantly associated with any pregnancy
G3: 39.2 outcomes
Collected from: G4: 44.3 (P < 0.01
• Gains during vs. G1) (overall P = Groups:
pregnancy not 0.044) G1: Normal wieight, normal OGTT
collected G2: Overweight/Obese, normal OGTT
Instrumental G3: Normal Weight, IGT/GDM
Ascertained by: delivery,%: G4: Overweight/Obese, IGT/GDM
• Not explained by NR
researchers, may Results:
be difference Episiotomy,%: Per kg increase in gestational weight gain
between NR G1: 1.06 (1.02 - 1.10)
prepregnancy G2: 1.08 (1.03 - 1.12)
Other maternal
weight and outcomes: Gestational hyperglycemia
weight measured
• Height G1: 1.78 (1.21 - 2.62)
at 24 to 28
• Parental G2: ns
weeks gestation
diabetes
Age
• Waist
G1: NS
• Systolic bp
G2: NS
• Diastolic bp
• Hypertension Obesity
• Triglycerides G1: NS
• HDL G2: 4.48 (2.30 - 8.71)

Other infant Smoking

outcomes: G1: NR
• Weeks of G2: NS
delivery Waist to hip ratio > .90
• SGA G1: 1.51 (1.02 - 2.24)
• Neonatal G2: 1.81 (1.12- 2.93)
pathologies
Height
G1: ns
G2: ns
Parity
G1: ns
G2: ns

C-717
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Bo et al., 2003
(continued)

C-718
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain 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-719
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Butte et al., 2003 • Cohort • Measured by study White
• Prospective investigators G1: 77
Country and setting: G2: NR
USA, children’s nutrition Total Study N: Pregravid BMI:
center 63 Black
Imputed: G1: 10
Enrollment Period: Group Description: • No G2: NR
NR G1: Total cohort
G2: NR Categorized: Hispanic
Funding: • IOM guidelines G1: 10
US Department of Army Group N: G2: NR
and US Department of G1: 63 Age (mean, yrs):
Agriculture/Agriculture G2: NR G1: 31 (4) Asian/Pacific Islander
Research Service G2: NR G1: 3
Inclusion criteria: G2: NR
Study Objective: • Nonsmokers Parity:
To evaluate how changes • NR Other
18-40 years
in gestational weight and • parity ≤ 4 NR
body composition affect • Physically active (20 Smoking,%:
infant birth weight and to 30 minutes of
maternal fat retention after NR
moderate exercise at
delivery in underweight, least 3 times/week) Diabetes mellitus,%:
normal weight and • No long term NR
overweight women medicine use Hypertension,%:
Time frame: • No alcohol/drug NR
NR abuse
Additional characteristics:
Duration of the study: Exclusion criteria: NR
Prior to preg through pp • Multiparous
• Preterm deliveries
• Miscarriage
• Preeclampsia

C-720
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
NR Fat retention
Total weight gain:
G1: 15.0 (3.8) kg Gestational Groups:
G2: 14.5 (4.5) kg diabetes, %: BMI groups, low, normal, high
G3: 17.9 (5.4) kg NR
Categorized: Cesarean delivery, Results:
• Continuous %: • After adjustment for gestational duration, gravidity,
NR and ethnicity, gestational weight gain and net
Collected from: gestational weight gain (GWG-birth weight) were
• Collected by Instrumental
significantly lower in normal BMI group than in high
study delivery, %:
BMI group (P = 0.04) - GWG and net GWG in low
investigators NR
BMI group was not significantly different from women
Ascertained by: Episiotomy, %: in normal and high BMI groups
• NR NR • On average weight gain was 42% fat mass and 58%
fat free mass
Other maternal
• Weight gain was linearly correlated with gains in TBW
outcomes:
(r = 0.39, P = 0.003), TBK (r = 0.49, P = 0.001),
NA
protein (r = 0.49, P = 0.001), Fat free mass (r = 0.50,
Other infant P = 0.001), and FM (r = 0.76, P = 0.001)
outcomes: • Mean gestational weight gain (14.4kg) of women who
• Birth weight 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-721
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Butte et al., 2003
(continued)

C-722
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain 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-723
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Hediger et al., 1994 • Cohort • Self-reported White
• Prospective G1: 56.00 (0.84) kg G1: 7.6
Country and setting: G2: 9.2
G2: 59.95 (0.82)
USA, setting NR Total Study N: G3: 8.8
G3: 60.91 (0.82)
608
Enrollment Period: Black
Pregravid BMI:
1985 Group Description: G1: 69.5
G1: 21.81 (0.30)
G1: Teenagers 13-15 years G2: 23.02 (0.29) G2: 57.5
Funding:
G2: Teenagers 16-18 years G3: 23.18 (0.29) G3: 61.8
NICHD grant
G3: Adults 19-29
Study Objective: Imputed: Hispanic
Group N: • No G1: 22.8
To study relationship
G1: 197 G2: 33.3
between changes in
G2: 207 Categorized: G3: 29.4
maternal subcutaneous
fat and infant birth weight
G3: 204 • Continuous
Asian/Pacific Islander
Inclusion criteria: Age (mean, yrs): NR
Time frame:
1985 • Primigravid and G1: 14.49 (0.14)
multigravid teenagers G2: 17.41 (0.13) Other
Duration of the study: (< 19 years) with first G3: 22.63 (0.14) NR
Initiation of prenatal care pregnancy at < 16 y Smoking,%:
Parity:
to 4 to 6 weeks • Older women ages 18 G1: 20.8
postpartum % primiparous:
to 29 years at first G2: 34.8
G1: 93.9
pregnancy G3: 40.2
G2: 37.2
Exclusion criteria: G3: 36.3 Diabetes mellitus,%:
• History of serious NR
nonobstetric problems
(seizure disorders, Hypertension,%:
leukemia or drug or NR
alcohol abuse)
Additional characteristics:
• Fetal demise Mean change in arm muscle
• Multiple pregnancy area, cm2:
• Missing data on study G1: 2.19 (0.44)
variables G2: 1.78 (0.38)
• Women who breast fed G3: 2.00 (0.39)
after delivery or who
were still breastfeeding Change in arm fat area, cm2:
at 4 to 6 weeks G1: -0.46 (0.48)
postpartum 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-724
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
G1: 197 NR • r = 0.21, P < 0.001 for infant birth weight and
G2: 207 arm fat area at 28 wk gestation
G3: 204 Gestational diabetes,
• r = 0.16, P < 0.001 for infant birth weight and
%:
arm muscle area at 28 wk gestation
Total weight gain: NR
G1: 14.85 (0.54) kg • Question 54: Shows multiple linear regression
G2: 13.82 (0.47) Cesarean delivery, %: analysis of infant birth weight (g) - model
G3: 14.12 (0.48) NR included: gestation (wk), maternal age (y), low
pregravid weight, maternal height, prior poor
Categorized: Instrumental delivery,
outcome, primiparity, infant sex, race, smoking
%:
• Continuous • Question 67: Shows pattern of pregnancy
NR
weight gain, birth weight, and weight retention
Collected from: by arm fat area changes (28 weeks to the
Episiotomy, %:
• Routine pre-natal postpartum period)
NR
care or maternity • * designates model was adjusted for maternal
records Other maternal age, parity, ethnicity, low pregravid weight,
outcomes: height, smoking, length of gestation or iterval
Ascertained by:
• Anthropometric (wk) to the 4-6 wk postpartum visit
• Based on last
measurements • ** designates model was adjusted for length of
clinically
taken were: mid- gestation, maternal age, parity, ethnicity, low
measured weight
upper arm pregravid weight, height, smoking, total weight
prior to delivery
circumference, gain, prior poor outcome, infant sex
triceps, and
• *** designates model was adjusted for length
subscapular
of gestation, maternal age, parity, ethnicity,
skinfold thickness
low pregravid weight, height, smoking, total
from left side of
weight gain, prior poor outcome, infant sex -
body - upper arm
but not significantly different from zero
muscle and fat
area Groups:
G1: Teenagers 13 to 15 years
Other infant
G2: Teenagers 16 to 18 years
outcomes:
G3: Adults 19-29
NA
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-725
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Hediger et al., 1994
(continued)

C-726
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain 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-727
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Hediger et al., 1994
(continued)

C-728
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain 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-729
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Javanovic-Peterson • Observational • Self-reported NR
1993 • Prospective
Pregravid BMI: Smoking,%:
Country and setting: Total Study N: NR
USA, hospitals affiliated Imputed:
20
with medical schools • No Diabetes mellitus,%:
Group Description: 100%
Enrollment Period: NA Categorized:
1959 to 1966 • No Hypertension,%:
NR
Funding: Group N: Age (mean, yrs):
NR Additional characteristics:
20 28.8 years NR
Study Objective: Parity:
Inclusion criteria: NR
to investigate with MRI the
relationship between • Women with GDM at
maternal weight, fat 36 to 38 weeks'
distribution, and glucose gestation
levels and neonatal Exclusion criteria:
birthweight ratio, percent • NR
fat, and infant outcome in
pregnancies complicated
by gestational diabetes.
Time frame:
NR
Duration of the study:
NA

C-730
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Decription:
Maternal body composition measures, infant birthweight and
Total weight gain: Gestational neonatal morbidity
• NR diabetes, %:
0% Groups:
NA
Cesarean
delivery,%:
NR Results:
• Maternal body composition was related to maternal
Instrumental
weight (p=0.012, r=0.54)
delivery, %:
• Maternal arm fat was related to maternal weight (p=0.05,
NR
r=0.60)
Episiotomy, %: • Maternal arm fat correlated with trunk fat
NR • Maternal trunk fat not correlated with wegith (NS)
• Maternal hemoglobin correlated with maternal weight
Other maternal
(p=0.05, r=0.43)
outcomes:
NR • Maternal hemoglobin not correlated with infant birth
weight
Other infant • Infant birth weight ratio predicted by MRI (p<0.001,
outcomes: r=0.88)
NR • 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-731
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Larciprete et al., 2003 • Cohort • Routine pre-natal care White
• Prospective G1: 66.73 (1.39) kg NR
Country and setting:
G2: NR
Italy, obstetrics Total Study N: Black
ambulatory clinic 170 Pregravid BMI: NR
G1: 24.15 (0.48)
Enrollment period: Group Description: Hispanic
G2: NR
NR G1: Total sample NR
G2: NR Imputed:
Funding: Asian/Pacific Islander
• No
NR Group N: NR
G1: 170 Categorized:
Study Objective: Other
To evaluate changes in
G2: NR • Continuous NR
maternal body Inclusion criteria: Age (mean, yrs): Smoking,%:
composition and normal • Women with G1: 32.06 (0.50)
ranges of maternal body NR
singleton healthy G2: NR
components during pregnancy were Diabetes mellitus,%:
various periods of consecutively Parity: NR
pregnancy recruited for a
Hypertension,%:
Time frame: longitudinal study at
NR
NR early gestation
Additional characteristics:
Duration of the study: Exclusion criteria:
NR
First prenatal visit to • Did not complete
delivery 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

C-732
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
G1: 170 G1: 3472.75 (42.35) • analysis of correlations
G2: NR G2: NR • TBW and ECW significantly increase during second and
third trimester of gestation - progressive decrease in
Total weight gain: Gestational
resistance provides indirect proof of TBW and ECW
diabetes, %:
Categorized: expansion at mid-gestation and term gestation, since
NR
• Continuous inverse relationship between first and last 2 parameters
Cesarean delivery, is well known
Collected from: %: • Reactance undergoes a progressive rise during entire
• Collected by NR gestation, following maternal weight gain - this result
study demonstrates that even fat mass deposition and not only
investigators Instrumental
fluid retention is responsible for GWG, since reactance
delivery, %:
Ascertained by: is an indirect parameter in estimating fat mass amount
NR
• NR • Intracellular water slightly enhances during course of
Episiotomy, %: gestation with a peak in late third trimester - this
NR observation may be explained by water filling need of
some tissues, occurring at term gestation to guarantee
Other maternal correct development of labor, delivery, and puerperium
outcomes:
NR Groups:
G1: Total sample
Other infant G2: NR
outcomes:
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-733
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Lederman et al., 1997 • Cohort • Self-reported White
• Prospective G1: 63.4 (12.9) NR
Country and setting:
G2: NR
USA, clinics Total Study N: Black
196 Pregravid BMI: NR
Enrollment Period:
Jan 1991-Aug 1993 Group Description: Imputed: Hispanic
G1: study cohort • NR NR
Funding:
G2: NR
Grant from Maternal and Categorized: Asian/Pacific Islander
Child Health Bureau and Group N: • IOM guidelines NR
Department of Health and G1: 196
Human Services Age (mean, yrs): Other
G2: NR
G1: 26.0 (4.8) NR
Study Objective: Inclusion criteria: G2: NR Smoking,%:
To determine fat • 18 to 35 years of age
deposited during Parity: NR
• Non-smokers
pregnancy in women G1: 0.8 (1.0) Diabetes mellitus,%:
• Self-identified as
according to G2: NR NR
Hispanic, black, or
recommendations of IOM white
and relationship of weight Hypertension,%:
• Expecting singleton NR
gain to fat gain in women birth
of different starting • Able to schedule their Additional characteristics:
weights classified by BMI first body composition NR
Time frame: laboratory visit before
Jan 1991 to Aug 1993 16th week of
gestation
Duration of the study: • Free of medical
From first visit through illnesses requiring
delivery 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

C-734
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
G1: 196 G1: 3,449 (433) • Fat gain between pregnancy weeks 14-37
G2: NR G2: NR
Groups:
Total weight gain: Gestational < IOM, within IOM, > IOM, for BMI groups for three
G1: 13.6 (6.1) diabetes, %: outcomes:
G2: NR NR G1: Body weight gain
G2: Body water gain
Categorized: Cesarean delivery,
G3: Fat gain
• According to IOM %:
NR Results:
Collected from:
• Collected by Instrumental BMI < 19.8: all women (n = 21)
study delivery, %: G1: 12.6 (4.4)
investigators NR G2: 6.1 (2.4)
G3: 4.8 (3.8)
Ascertained by: Episiotomy, %:
• Based on last NR BMI < 19.8: less than recommended; recommended;
clinically more than recommended
Other maternal
measured weight G1: 7.9 (1.6); 12.6 (2.4); 16.1 (3.9)
outcomes:
prior to delivery: G2: 6.4 (3.7); 5.9 (1.6); 6.1 (2.2)
Study investigators
difference G3: 0.6 (1.9); 6.0 (2.6); 6.9 (3.5)
measured body
between weight, body density BMI19.8-26.0: all women (n = 118)
measurement at by G1: 12.2 (4.0)
week 37+ and hydrodensitometry, G2: 7.0 (2.7)
prepregnancy and deuterium G3: 3.9 (3.7)
dilution volume twice
during pregnancy (at BMI19.8-26.0: less than recommended; recommended;
weeks 12-16 and at more than recommended
37+ weeks) 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)
Other infant G3: 1.3 (3.0); 3.8 (3.5); 6.0 (3.1)
outcomes:
NA 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-735
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Lederman et al., 1997
(continued)

C-736
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain 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-737
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Paxton et al., 1998 • Cohort • Self-reported White
• Prospective G1: 63.2 ± 12.8 G1: 21%
Country and setting: G2: NR
G2: NR
USA, prenatal clinics Total Study N:
200 Pregravid BMI: Black
Enrollment Period: G1: 25%
G1: Maternal prepregnancy
Jan 1991 to Jan 1994 Group Description: G2: NR
weight classification:
G1: All Underweight (BMI < 19.8)
Funding: Hispanic
G2: NR 10.5%Normal weight (BMI
Supported by grant MCJ- G1: 55%
360601 from Maternal and Group N: 19.8–26.0) 61.5%Overweight
G2: NR
Child HealthBureau (Title G1: 200 (BMI > 26 to 29.0)
V, SSA), HRSA, DHHS G2: NR 14.5%Obese (BMI > 29) Asian/Pacific Islander
13.5% NR
Study Objective: Inclusion criteria: G2: NR
To accurately estimate fat • Black, Hispanic, and Other
without making extensive white women 18-35 Imputed: NR
assumptions regarding years of age with • No
composition of lean tissue Smoking,%:
singleton pregnancy, Categorized: NR
in pregnant women, free of major illness
authors developed a 4- • IOM guidelines
Diabetes mellitus,%:
compartment model Exclusion criteria: Age (mean, yrs): NR
(weight, water, bone • Smoker during G1: 26 ± 4.8
mineral mass, and body pregnancy G2: NR Hypertension,%:
density) as standard, • Regular drug or NR
tested 4 exist alcohol use during Parity:
G1: 0.8 ± 1.0 Additional characteristics:
pregnancy
Time frame: G2: NR NR
• Delivered before
Jan 1991 to Jan 1994 second measurement
Duration of the study: visit
From week 14 to week 37
of pregnancy

C-738
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
G1: 200 G1: 3451 ± 439g • Traditional anthropometric measures
G2: NR G2: NR • Comparisons between new anthropometric
model and 4-compartment model
Total weight gain: Gestational
G1: 13.6 kg ± 4.5 diabetes, %: Groups:
G2: NR NR G1: Anthropometric equation for fat at 37 weeks
G2: Four compartment model for fat at 37 weeks
Categorized: Cesarean delivery,
G3: Anthropometric equation for change in fat mass
• (classified as < 5, %:
from 14- 37 weeks
5 to < 10, 10 to < NR
G4: Four-compartment model for change in fat mass
15, and ³ 15 kg),
Instrumental from 14- 37 weeks
Collected from: delivery, %:
• Collected by NR G5: Weight and body-composition changes during
study gestation
Episiotomy, %:
investigators
NR
Ascertained by: Results:
Other maternal GWG (wks 14 to 37) < 5 kg
• NR outcomes: G1: 27.83 ± 13.51
• Existing G2: 23.55 ± 13.00
anthropometric G3: – 4.17 ± 1.99
measures varied G4: – 5.66 ± 4.01 (no significant differences based
from each other, on repeated-measures)
with 4-
compartment GWG (wks 14 to 37) 5 to < 10 kg
model providing G1: 22.00 ± 6.96
lowest estimate G2: 21.46 ± 7.69
of weight gain G3: 0.24 ± 1.16
• Change in fat G4: 0.96 ± 2.36 (no significant differences based on
and fat mass repeated-measures)
estimate from GWG (wks 14 to 37) 10 to < 15 kg
weeks 14 to 37 G1: 23.14 ± 6.09
or at week 37 G2: 22.90 ± 6.91
from new G3: 3.87 ± 1.38
anthropometric G4: 4.36 ± 2.80 (no significant differences based on
model was not repeated-measures)
significantly
different from GWG (wks 14 to 37) ≥ 15 kg
estimate from G1: 30.93 ± 10.08
4-compartment G2: 31.55 ± 10.33
model (weight, G3: 9.73 ± 2.17
water, bone G4: 8.70 ± 2.73 (no significant differences based on
mineral mass, repeated-measures)
and body
density)
Change in weight (prepregnancy to week 14
Other infant Prepregnancy to week 14)
outcomes: G5: 2.1 ± 4.5 (–9.5, 26.9)
NR
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-739
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Paxton et al., 1998
(continued)

C-740
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain 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-741
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Sohlstrom et al., 1993 • Cohort • NR White
• Prospective G1: 62.6 (9.7) kg NR
Country and setting:
G2: NR
Sweden, setting NR Total Study N: Black
10 Pregravid BMI: NR
Enrollment Period:
G1: 22.4 (2.7)
not stated Group Description: Hispanic
G2: NR
G1: Total sample NR
Funding:
G2: NR Imputed:
NR Asian/Pacific Islander
• No
Group N: NR
Study Objective:
G1: 10 Categorized:
To validate and assess Other
precision of MRI method;
G2: NR • Continuous NR
to estimate changes in Inclusion criteria: Age (mean, yrs): Smoking,%:
amount of TBF and FF NR G1: 28 (5)
body weight during NR
G2: NR
pregnancy and throughout Exclusion criteria:
Diabetes mellitus,%:
first year post partum in a NR Parity: NR
group of healthy Swedish NR
women; to study how Hypertension,%:
distribution of TBF is NR
affected during pregnancy Additional characteristics:
and throughout the first % total body fat prepregnancy:
year post partum G1: 25.7 (4.8)
Time frame: G2: NR
Not stated
Duration of the study:
First visit during
pregnancy to 1 year
postpartum

C-742
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
G1: 10 G1: 3700 (620) g • During first 6 and 12 months postpartum women
G2: NR G2: NR mobilized 2.6 (3.6) and 3.2 (3.2)kg body fat,
respectively
Total weight gain: Gestational
• Correlations - indicates that women who retained
G1: 19.0 (7.9) kg diabetes, %:
more fat during pregnancy also were those who
G2: NR NR
mobilized more fat post partum
Categorized: Cesarean delivery, • On average, 84% of fat retained during pregnancy
• Continuous %: was placed subcutaneously - amount of
NR subcutaneous fat decreased during whole year post
Collected from: partum while non subcutaneous fat did not change
• Collected by Instrumental
or even tended to increase during this period of time
study delivery, %:
• 44% of fat retained during pregnancy was place in
investigators NR
lower trunk, 30% in upper trunk, 1% in thighs, 4% in
Ascertained by: Episiotomy, %: upper arms, 2% in calves, and 1% in forearms
• NR NR • During first 2 months postpartum fat was mainly
mobilized from lower trunk, most of fat retained in
Other maternal thighs was mobilized during first year post partum
outcomes: while fat which still remained after 1 year mainly
net weight gain was found in upper and lower trunk
during pregnancy:
9.8 (6.3)kg - 5.5 Groups:
(3.2)kg was TBF G1: Total sample
and 4.3 (3.7)kg was
Results:
fat free body weight
Fat mobilized at 6 months postpartum
Other infant G1: r = -0.66 P < 0.05
outcomes:
Fat mobilized at 12 months postpartum
NR
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-743
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year: Design: Pregravid weight: Race,%:
Soltani and Fraser, 2000 • Cohort • Measured during first White
• Prospective prenatal visit NR
Country and setting:
G1: 73.0 (16.8)
UK, hospital Total Study N: Black
G2: 60.8 (5.6)
77 NR
Enrollment Period: G3: 72.0 (5.9)
NR Group Description: G4: 93.0 (10.6) Hispanic
G1: Total sample NR
Funding: Pregravid BMI:
G2: Normal weight G1: 27.4 (5.9)
NR Asian/Pacific Islander
G3: Overweight G2: 22.7 (1.3) NR
Study Objective: G4: Obese G3: 27.7 (1.4)
To investigate pattern of G4: 34.5 (3.54) Other
Group N:
changes in weight gain NR
G1: 77 Imputed:
and fat distribution during
G2: 29 • No Smoking,%:
pregnancy and
G3: 23 G1: 24%
postpartum and whether
G4: 25 Categorized: G2: NR
this differed by maternal
BMI measured in first • IOM guidelines
Inclusion criteria: Diabetes mellitus,%:
trimester • Women attending first Age (mean, yrs): NR
Time frame: prenatal visit at G1: 26.71 (4.77)
Hypertension,%:
NR Northern General G2: 26.44 (5.32)
NR
Hospital G3: 26.91 (4.50)
Duration of the study: G4: 27.68 (3.83) Additional characteristics:
First prenatal visit to 6 Exclusion criteria:
Parity: Fat mass (kg) at first visit:
months postpartum NR
G1: 0.78 (0.86) G1: 24.5 (9.9)
G2: 0.55 (0.87) G2: 16.5 (3.6)
G3: 0.81 (0.75) G3: 24.6 (3.9)
G4: 1.00 (0.96) 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-744
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain Bivariate Analysis Outcomes from Multivariate Analysis
Groups (N): Birth weight: Outcomes Description:
G1: 77 G1: 3443.0 (589.60) • Pattern of weight changes during pregnancy and
G2: 29 G2: 3331.5 (481.7) up to 6 months postpartum follow a monotonous
G3: 25 G3: 3423.7 (543.2) trend in normal weight women, all seem to
G4: 3670.4 (489.5) increase weight during pregnancy and a
Total weight gain:
considerable weight loss is obeserved at 6
G1: 13-36 weeks: Gestational
weeks post partum - from then until 6 months
10.8 (4.7) diabetes, %:
postpartum, they either tend to reduce slightly or
G2: 11.0 (3.2) NR
stay at the same level
G3: 11.9 (6.4)
Cesarean delivery, • Normal weight women follow a comparatively
G4: 9.7 (4.3)
%: monotonous pattern of changes in fat mass
Categorized: NR • Overweight women show a divergent pattern -
• Continuous women with maximum weight gain and also
Instrumental
maximum weight loss are seen in this -
Collected from: delivery, %:
overweight women show a very scattered
• Collected by NR
pattern of changes in fat mass
study • Majority of obese women seem to be
Episiotomy, %:
investigators considerably heavier at 6 months postpartum in
NR
Ascertained by: comparison with 13 weeks gestation
Other maternal • Obese women mostly have higher values of fat
• NR outcomes: mass at 6 months postpartum than early
NR pregnancy
Other infant • Underweight women showed a similar trend of
outcomes: change as normal weight women
NR
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-745
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Study Design, Patient
Population, Inclusion/ Baseline Characteristics
Study Description Exclusion Criteria Baseline Characteristics (continued)
Author, year:
Soltani and Fraser, 2000
(continued)

C-746
Evidence Table 56. Anthropometrics of maternal weight retention (continued)
Maternal Weight Outcomes from
Gain 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

C-747
Appendix D. List of Excluded Studies
 Exclusion Codes
Code Criteria N
Article is not concerned with topics relevant to maternal weight gain or the 80
X-1 measurement of body fat
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

D-1
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Appendix E. Acknowledgments
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

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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

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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

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