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McKoy JN, Hartmann KE, Jerome RN, et al. Future Research Needs for Outcomes of Weight Gain in Pregnancy [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Nov. (Future Research Needs Papers, No. 6.)

Cover of Future Research Needs for Outcomes of Weight Gain in Pregnancy

Future Research Needs for Outcomes of Weight Gain in Pregnancy [Internet].

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Appendix CPrioritization Tools and Results

Snowballing Tool (PDF, 318K)

Maternal Weight Gain Ranking Survey Results

Participants were asked to rank the measures with 1 being the most important and 12 as the least important. The ranking scores were added together so that the measure with the highest score was the least important. Our goal was to eliminate at least one-third (4) of the measures so the highlighted measures will not be used for the next ranking.

Measures of maternal weight gain

MeasureTotal Score
Total weight gain from prepregnancy to end of pregnancy73
Total weight gain from first trimester to end of pregnancy89
Prepregnancy baseline weight/BMI93
Pattern of weight gain across pregnancy as a statistical trend line or function93
Pattern of weight gain across trimesters94
Rate of weight gain101
Change in BMI from prepregnancy to end of pregnancy106
Change in body/body fat composition107
Early pregnancy baseline weight/BMI110
Change in BMI from first trimester to end of pregnancy116
Body/body fat composition by caliper, impedence, “BodPod” or other measure118
Anthropomorphic groupings149

Participants were asked to rank the outcomes with 1 being the most important and 8 as the least important. The ranking scores were added together so that the outcome with the highest score was the least important. Our goal was to eliminate at least one-third (3) of the outcomes so the highlighted outcomes will not be used for the next ranking.

Outcomes of interest related to maternal weight gain

OutcomesTotal Score
Development of gestational diabetes46
Child health outcomes56
Fetal outcomes67
Infant health outcomes70
Maternal postpartum outcomes75
Intrapartum outcomes79
Neonatal outcomes79
Maternal antepartum outcomes84

We used a two-step process to identify questions for elimination. The proportion of 9 or 10 votes cast for each domain was first calculated. Next, the proportion of 9–10 votes assigned for clinical utility, feasibility of the research, and potential to advance the science were averaged. This left two measures: the proportion of 9–10 votes assigned for overall importance for each question and the average proportion of 9–10 votes for the additional three domains combined. Questions highlighted in red below received fewer than 30 percent of 9–10 level votes by each measure.

General evidence gaps

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance scienceOverall AverageAverage (3 items)
What factors confound the relationship between [weight gain in pregnancy] and [outcomes]?46.7%20.0%20.0%26.7%28.3%22.2%
Does nutrient content of the diet confound the relationship between [weight gain in pregnancy] and [outcomes]?27%13.3%13.3%33.3%21.7%20.0%
Does physical activity [metabolic expenditure] confound the relationship between [weight gain in pregnancy] and [outcomes]?50%35.7%42.9%50.0%44.6%42.9%
Does socioeconomic status confound the relationship between [weight gain in pregnancy] and [outcomes]?20%13.3%20.0%6.7%15.0%13.3%
Does pregravid health status confound the relationship between [weight gain in pregnancy] and [outcomes]?33%33.3%6.7%13.3%21.7%17.8%
Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?53%26.7%46.7%33.3%40.0%35.6%
What physiologic or clinical factors modify the relationship between [weight gain in pregnancy] and [outcomes]?40%33.3%13.3%26.7%28.3%24.4%
Does maternal age modify the relationship between [weight gain in pregnancy] and [outcomes]?20%13.3%26.7%13.3%18.3%17.8%
Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?47%46.7%40.0%40.0%43.3%42.2%
Does weight at menarche modify the relationship between [weight gain in pregnancy] and [outcomes]?0%0.0%6.7%0.0%1.7%2.2%
Does use of insulin or other diabetes medications modify the relationship between [weight gain in pregnancy] and [outcomes]?20%40.0%26.7%33.3%30.0%33.3%
Does gestational weight gain above targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?40%46.7%40.0%40.0%41.7%42.2%
Does gestational weight gain below targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?40%46.7%40.0%40.0%41.7%42.2%
Does race modify the relationship between gestational weight gain above (or below) thresholds defined in the 2009 IOM weight gain and complications?20%20.0%33.3%20.0%23.3%24.4%
Does maternal age modify the relationship between gestational weight gain above (or below) thresholds defined in the 2009 IOM weight gain and complications?13%26.7%40.0%20.0%25.0%28.9%
What are the harms and benefits of offering standardized weight gain recommendations to all pregnant women?60%66.7%26.7%53.3%51.7%48.9%
Which anthropometric tools are most appropriate for determining adiposity in pregnant women?47%33.3%33.3%33.3%36.7%33.3%
What are the strengths and weaknesses of measuring adiposity for the clinical management of weight gain during pregnancy?27%20.0%6.7%26.7%20.0%17.8%
What are the strengths and weaknesses of measuring adiposity for the evaluation of the relationship between weight gain and outcomes of pregnancy?27%26.7%20.0%33.3%26.7%26.7%
What is the general health literacy (i.e., the level of knowledge, attitudes and self-efficacy) of women regarding gestational weight gain?33%13.3%33.3%13.3%23.3%20.0%
Does weight gain during pregnancy influence lactation initiation and maintenance?20%20.0%6.7%13.3%15.0%13.3%
Does parity influence the relationship of weight gain and pregnancy outcomes?13%13.3%20.0%13.3%15.0%15.6%
Do the mother’s or father’s genetic factors influence the relationship between weight gain and pregnancy outcomes?27%6.7%6.7%26.7%16.7%13.3%
Is there an interaction between mother’s stature and weight gain during pregnancy that affects the outcomes of the pregnancy?20%13.3%13.3%13.3%15.0%13.3%
What is the relative impact of total weight gain vs. rate of weight gain vs. timing of weight gain (by trimester) on pregnancy outcomes?53%40.0%33.3%46.7%43.3%40.0%
What is the effect of gestational weight gain on infant (beyond birthweight) and childhood outcomes?80%46.7%33.3%73.3%58.3%51.1%
What are the optimal gestational weight gains for women with varying degrees of prepregnancy obesity?60%53.3%26.7%40.0%45.0%40.0%
What research studies and databases are available to describe the distribution of maternal weight gain (prior to, during and after pregnancy) among different populations of women in the US?40%13.3%26.7%20.0%25.0%20.0%
What research studies and databases are available to inform our understanding of the effects of different weight patterns (including underweight and overweight) during pregnancy on maternal and child health outcomes?33%6.7%20.0%20.0%20.0%15.6%

Interventions

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance scienceOverall AverageAverage (3 items)
Do prenatal care providers have the necessary knowledge, attitudes, and skills to provide appropriate weight gain guidance to women?40%60.0%46.7%13.3%40.0%40.0%
Do women receive weight gain guidance from their prenatal clinicians? If so, is the guidance consistent with the 2009 IOM/NRC Gestational Weight Gain publication?27%40.0%40.0%6.7%28.3%28.9%
What methods are effective for helping women acquire knowledge and understanding of the goals for weight gain, and skills for controlling weight gain?53%60.0%33.3%20.0%41.7%37.8%
What research has been conducted to describe the individual, community, and health care system factors that impede or foster adherence to recommended gestational weight gain guidelines?33%46.7%46.7%33.3%40.0%42.2%
What interventions are effective for the outcome of maternal weight gain within the recommended range(s)?73%73.3%26.7%60.0%58.3%53.3%
How does physical activity affect maternal weight gain?47%33.3%33.3%33.3%36.7%33.3%
How does total caloric intake, and dietary composition of caloric intake affect maternal weight gain?40%26.7%20.0%40.0%31.7%28.9%

Statistical issues

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance scienceOverall AverageAverage (3 items)
In conducting analyses on weight gain in pregnancy, how should one define outliers in pregravid weight, gestational weight gain, postpartum weight, and maternal height?27%20.0%13.3%13.3%18.3%15.6%
How should outliers in pregravid weight, gestational weight gain, postpartum weight, and maternal height be handled analytically?27%0.0%20.0%6.7%13.3%8.9%
What is the need for standardization of research measures to advance the field of research related to weight gain in pregnancy?40%33.3%33.3%33.3%35.0%33.3%
How much variability is there in measurement of factors associated with maternal weight gain and pregnancy outcomes such as definition of diet composition, measurement of maternal and neonatal body composition and agreement on ideal neonatal weight and body composition?20%0.0%13.3%13.3%11.7%8.9%
Is there a lack of standardization in current research in terms of maternal weight gain measures?40%20.0%33.3%26.7%30.0%26.7%
Is there a lack of standardization in current research in terms of birth, maternal, and infant outcomes?20%13.3%26.7%26.7%21.7%22.2%

Policy

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance scienceAverageAverage (3 items)
How accurate is self-reported compared to measured weight (prepregnancy, in pregnancy, and postpartum) in all populations and among women of varying pregravid weights and gestational ages?7%6.7%46.7%20.0%20.0%24.4%
How reliable is self-reported prepregnancy weight in pregnancy by age, parity, and BMI?20%13.3%26.7%20.0%20.0%20.0%
What opportunities exist for Title V maternal and child health programs to assist childbearing women in achieving and maintaining recommended weight?13%13.3%13.3%6.7%11.7%11.1%
What future research and data collection efforts could improve the efforts of Title V programs to support women from different racial and ethnic backgrounds in their efforts to meet recommended weight guidelines and to improve their maternal health?13%6.7%13.3%6.7%10.0%8.9%

Measurement

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance scienceOverall AverageAverage (3 items)
Is rate of weight gain, change in BMI, adequacy of rate of weight gain, or total weight gain superior for predicting adverse birth, maternal, and infant outcomes?40%40.0%20.0%33.3%33.3%31.1%
What are the preferred anthropometric measurements for predicting birth, maternal, and infant outcomes?33%33.3%13.3%33.3%28.3%26.7%
Does direct measurement of body fat (prepregnancy, in pregnancy, postpartum) and other body composition factors and biomarkers (for example, blood lipids) contribute to the understanding of birth, maternal, and infant outcomes?27%33.3%13.3%26.7%25.0%24.4%
Would a direct measure of body fat prior to pregnancy be more closely related to pregnancy outcomes such as infant birthweight than prepregnancy BMI?27%26.7%20.0%26.7%25.0%24.4%

Maternal Weight Gain Ranking Survey Results—Round 2

In the first round of ranking (see results above) we were able to eliminate the lowest ranking responses. In the second round of ranking participants were asked to rank the remaining eight measures with 1 being the most important and 8 as the least important. The ranking scores were added together so that the measure with the highest score was the least important.

Measures of maternal weight gain

MeasureTotal
Total weight gain from prepregnancy to end of pregnancy47
Prepregnancy baseline weight/BMI63
Change in body/body fat composition65
Pattern of weight gain across pregnancy as a statistical trend line or function79
Total weight gain from first trimester to end of pregnancy82
Pattern of weight gain across trimesters82
Rate of weight gain84
Change in BMI from prepregnancy to end of pregnancy88

Total weight gain from prepregnancy to end of pregnancy was the most important measure of maternal weight gain, followed by prepregnancy baseline weight/BMI and change body/body fat composition.

Participants were asked to rank the five remaining outcomes with 1 being the most important and 5 as the least important.

Outcomes of interest related to maternal weight gain

OutcomesTotal
Maternal postpartum outcomes43
Child health outcomes46
Infant health outcomes47
Development of gestational diabetes52
Fetal outcomes52

Participants ranked maternal postpartum and child health outcomes as the most important outcomes related to maternal weight gain.

In the first round of ranking we used the percentage of 9’s or 10’s as our elimination standard. However, for the second round of ranking the ranking scores were multiplied by the number of responses and these scores were added together so that the measure with the highest score was the most important. For example, if out of 5 participants 3 ranked the question as 5 out of 10 in importance and 2 ranked the question as 10 out of 10, that question would receive a score of (5*3) + (2*10) =35. These scores were then compared across questions.

General Evidence Gaps

The table below is the score totals across the four domains, overall importance, clinical utility, feasibility, and potential to advance science.

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance Science
What factors confound the relationship between [weight gain in pregnancy] and [outcomes]?117106101107
Does physical activity [metabolic expenditure] confound the relationship between [weight gain in pregnancy] and [outcomes]?114108107112
Does pregravid health status confound the relationship between [weight gain in pregnancy] and [outcomes]?10910183107
Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?119112114117
What physiologic or clinical factors modify the relationship between [weight gain in pregnancy] and [outcomes]?1161029611
Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?123117109115
Does use of insulin or other diabetes medications modify the relationship between [weight gain in pregnancy] and [outcomes]?102110110109
Does gestational weight gain above targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?113117110112
Does gestational weight gain below targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?110117110112
What are the harms and benefits of offering standardized weight gain recommendations to all pregnant women?11011185105
Which anthropometric tools are most appropriate for determining adiposity in pregnant women?1049999105
What is the general health literacy (i.e., the level of knowledge, attitudes and self-efficacy) of women regarding gestational weight gain?106103109101
What is the relative impact of total weight gain vs. rate of weight gain vs. timing of weight gain (by trimester) on pregnancy outcomes?10810999106
What is the effect of gestational weight gain on infant (beyond birthweight) and childhood outcomes?124112100122
What are the optimal gestational weight gains for women with varying degrees of prepregnancy obesity?11411497112
What research studies and databases are available to describe the distribution of maternal weight gain (prior to, during and after pregnancy) among different populations of women in the US?1029311796
What research studies and databases are available to inform our understanding of the effects of different weight patterns (including underweight and overweight) during pregnancy on maternal and child health outcomes?928710895

In overall importance the top three questions were:

  1. What is the effect of gestational weight gain on infant (beyond birthweight) and childhood outcomes?
  2. Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?
  3. Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?

The top three questions by averaging all four scores were:

  1. Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?
  2. Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?
  3. What is the effect of gestational weight gain on infant (beyond birthweight) and childhood outcomes?

Interventions

The table below is the score totals across the four domains, overall importance, clinical utility, feasibility, and potential to advance science.

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance Science
Do prenatal care providers have the necessary knowledge, attitudes, and skills to provide appropriate weight gain guidance to women?10411310495
What methods are effective for helping women acquire knowledge and understanding of the goals for weight gain, and skills for controlling weight gain?93958682
What research has been conducted to describe the individual, community, and health care system factors that impede or foster adherence to recommended gestational weight gain guidelines?89889785
What interventions are effective for the outcome of maternal weight gain within the recommended range(s)?108107101104
How does physical activity affect maternal weight gain?11111097102
How does total caloric intake, and dietary composition of caloric intake affect maternal weight gain?99967898

In overall importance the top three questions were:

  1. How does physical activity affect maternal weight gain?
  2. What interventions are effective for the outcome of maternal weight gain within the recommended range(s)?
  3. Do prenatal care providers have the necessary knowledge, attitudes, and skills to provide appropriate weight gain guidance to women?

The top three questions by averaging all four scores were:

  1. How does physical activity affect maternal weight gain?
  2. What interventions are effective for the outcome of maternal weight gain within the recommended range(s)?
  3. Do prenatal care providers have the necessary knowledge, attitudes, and skills to provide appropriate weight gain guidance to women?

Statistical issues

The table below is the score totals across the four domains, overall importance, clinical utility, feasibility, and potential to advance science.

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance Science
What is the need for standardization of research measures to advance the field of research related to weight gain in pregnancy?90769584
Is there a lack of standardization in current research in terms of maternal weight gain measures?70628272

“What is the need for standardization of research measures to advance the field of research related to weight gain in pregnancy?” was the question that was the most important overall by overall importance score and also by averaging all four scores.

Measurement

The table below is the score totals across the four domains, overall importance, clinical utility, feasibility, and potential to advance science.

QuestionOverall ImportanceClinical UtilityFeasibilityAdvance Science
Is rate of weight gain, change in BMI, adequacy of rate of weight gain, or total weight gain superior for predicting adverse birth, maternal, and infant outcomes?86877684
What are the preferred anthropometric measurements for predicting birth, maternal, and infant outcomes?90867891

“What are the preferred anthropometric measurements for predicting birth, maternal, and infant outcomes?” was the question that was most important overall by overall importance score and also by averaging all four scores.

Across all of the categories the most important questions by overall importance were:

  1. What is the effect of gestational weight gain on infant (beyond birthweight) and childhood outcomes?
  2. Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?
  3. Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?
  4. What factors confound the relationship between [weight gain in pregnancy] and [outcomes]?
  5. What physiologic or clinical factors modify the relationship between [weight gain in pregnancy] and [outcomes]?

The questions with the most clinical utility were:

  1. Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?
  2. Does gestational weight gain above targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
  3. Does gestational weight gain below targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
  4. What are the optimal gestational weight gains for women with varying degrees of prepregnancy obesity?
  5. Do prenatal care providers have the necessary knowledge, attitudes, and skills to provide appropriate weight gain guidance to women?

The questions that were scored as the most feasible were:

  1. What research studies and databases are available to describe the distribution of maternal weight gain (prior to, during and after pregnancy) among different populations of women in the US?
  2. Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?
  3. Does gestational weight gain above targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
  4. Does gestational weight gain below targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
  5. Does use of insulin or other diabetes medications modify the relationship between [weight gain in pregnancy] and [outcomes]?

The questions that had the greatest potential to advance science were:

  1. What is the effect of gestational weight gain on infant (beyond birthweight) and childhood outcomes?
  2. Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?
  3. Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?
  4. What physiologic or clinical factors modify the relationship between [weight gain in pregnancy] and [outcomes]?
  5. Does physical activity [metabolic expenditure] confound the relationship between [weight gain in pregnancy] and [outcomes]?
  6. Does gestational weight gain above targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
  7. Does gestational weight gain below targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
  8. What are the optimal gestational weight gains for women with varying degrees of prepregnancy obesity?

The top five questions by highest average score across all four domains were:

  1. Does prepregnancy BMI or prepregnancy weight modify the relationship between [weight gain in pregnancy] and [outcomes]?
  2. Does prepregnancy BMI or prepregnancy weight confound the relationship between [weight gain in pregnancy] and [outcomes]?
  3. What is the effect of gestational weight gain on infant (beyond birthweight) and childhood outcomes?
  4. Does gestational weight gain above targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
  5. Does gestational weight gain below targets defined in the 2009 IOM weight gain guidelines contribute to complications (including antepartum, postpartum longer term maternal and infant complications)?
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